Every finding on record at Autumn Lake Healthcare at Overlea

Based on observation and staff interviews, it was determined that the facility failed to maintain a safe and functional environment for residents, staff and visitors. This deficient practice was evident for 3 (Residents #63, #74, and #76) out of 32 residents reviewed for the physical environment and during a observation of the resident's smoking area conducted during the annual survey.The findings include: 1) At 1:30 PM on 6/30/2026 the surveyor observed the blinds opened to the three (3) windows in Resident room G-5. In the middle window looking out to the facility's parking lot was a large crack that extended from the top right-hand corner of the window which curved diagonally to the left-hand side towards the bottom 1/3 of the window. The crack in the middle window appeared to be on the inside panel of the double-panel window as surveyor touched a chip of glass in the cracked window. Residents #63, #74 and #76 occupied room G-5. Interview with the Nurse Manager #5 at 1:35 PM on 6/30/2026 revealed that she was not aware of the cracked window and she notified the Licensed Nursing Home Administrator (LNHA) and the Maintenance Director. Nurse Manager #5, Maintenance Director and LNHA observed the cracked window in room G-5. LNHA and Maintenance Director were not aware of the cracked window. LNHA stated that the window would be repaired. On 7/2/2026 at 12:25 PM the surveyor followed up on the large crack in the middle window of Resident room G-5 and the crack in the middle window remained visible with clear heavy tape on the crack. At 4:00 PM on 7/2/2026 the LNHA provided the surveyor with a copy of the proposal dated 7/1/2026 from [NAME] Brothers Inc. Glass Company for repair of the cracked window. 2) On 7/02/2026 at 10:30 AM the surveyor conducted an observation of residents who smoked on the smoking porch. Observation of the designated smoking porch revealed large areas with water pooling on the floor and water actively dripping from the top of the ceiling. The area which was slightly carved inwards measured approximately 2.5 feet long. The floor of the entire porch also had areas with multiple cracks located throughout exposing the concrete underneath. Most of the residents smoking on the porch were wheelchair bound while some ambulated with walkers. About 11 residents were out smoking at the time. The smoking porch is also where non-smokers can routinely come out for fresh air, socialize or hang out with visitors. On 7/02/2026 at11:46 AM The Nursing House Administrator (NHA) was made aware of the unsafe condition of the Porch with water pooling on the floor and cracks everywhere exposing the concrete underneath. He confirmed that it needed to be fixed and is a fall risk for the residents. He stated that he will go up with the maintenance director to take a look. On 7/02/2026 at 12:06 PM The NHA came back to say that they have roped off the areas with exposed holes/concrete with tapes and cones and that maintenance will start working on them.

Based on record review and staff interviews it was determined that the facility failed to comply with employee training for staff related to Resident Rights. This was evident for 6 (Staff #16, # 17, #18, #19, #20 and #21) of 6 staff records reviewed during the annual survey.The findings include: On 07/01/2026 at 11:00 AM Staff #13, the Human Resource Director (HR), was interviewed and ask for employee records for Staff #16, # 17, #18, #19, #20 and #21. HR stated those records would be with the Nursing Home Administrator, (NHA). On 07/01/2026 at 1:45 PM the NHA provided employee training for Staff # 16, #17, #18, #19, #20 and #21 for Abuse, Dementia, Infection Control, and Quality Assurance Program Improvement (QAPI) but no employee training for Resident Rights. The NHA then provided a packet dated 3/17/2026 for Resident Rights however, the attached in-service sign-in sheet was titled, Be mindful of the conversations and language used in patient care areas and hallways, rather than Resident Rights. Later that day at 2:10 PM, the NHA provided a second Resident Rights packet that lacked a defined topic. The first page was dated 11/3/2025, while the second page was undated. Neither page included documentation identifying the trainer or topic. It remained unclear what the training was and who the trainer was.On 07/02/2026 at 9:47 AM a review of the facility records revealed that in the facility's Facility Assessment for Staffing training/education and competencies confirmed that Resident rights and facility responsibilities is listed as the primary education requirement, alongside Abuse, Neglect, Exploitation, Dementia, Behavioral Health, Customer service, Infection Control, Cultural competency, Disaster planning, and Health Insurance Portability and Accountability Act (HIPAA). No additional documentation regarding Resident Rights training was provided by the time of exit.

Number of residents sampled: Number of residents cited: Based on record review and staff interviews, it was determined that facility staff failed to verify whether an existing advance directive was in place at the time of admission for residents who lacked decision making capacity. This deficient practice was evident for 4 (Resident #2, Resident #13, Resident #114, and Resident #141) of 6 residents reviewed for advance directives during the annual survey.The findings include:An Advance Directive is a legal document that states a person's wishes about receiving medical care if that person is no longer able to make medical decisions because of a serious illness. An advance directive may also give a person (such as spouse, relative, or friend) authority to make medical decisions.On 06/29/2026 at 10:13 AM, a review of Resident #2's medical record revealed the resident was admitted to the facility in February 2024 with multiple diagnoses, including dementia. At the time of admission, the resident was identified as lacking decision-making capacity. Further review of the medical record revealed documentation dated 02/09/2024, indicating that an advance directive was currently in place. However, the medical records failed to include a copy of the advance directive or documented evidence that facility staff made attempts to obtain the existing advance directive. On 06/29/2026, a review of Resident #13's medical record revealed the resident was admitted to the facility in February 2024 with multiple diagnoses, including dementia. At the time of admission, the resident was identified as lacking decision-making capacity. Further review of the medical record revealed documentation dated 02/26/2024, indicating that an advance directive was currently in place. However, the medical records failed to include a copy of the advance directive or documented evidence that facility staff made attempts to obtain the existing advance directive. On 06/29/2026 at 10:13 AM, a review of Resident #114's medical record revealed the resident was admitted to the facility in June 2024 with multiple diagnoses, including dementia. At the time of admission, the resident was identified as lacking decision-making capacity. Further review of the medical record revealed documentation indicating no advance directive document. The remaining advance directive screening questions were left blank. The medical records failed to document evidence that facility staff made attempts to determine if an advance directive existed.During an interview on 06/30/2026 at 9:08 AM, the Director of Social Services (DSS) #6 explained that, upon admission, advance directives are reviewed with the resident and/or the resident's representative. If a resident has an existing advance directive, she requests a copy and documents the request in the resident's medical record. For residents who lack decision-making capacity, she stated that she contacts the resident's family member to determine whether an advance directive exists. If a resident lacking decision-making capacity does not have an advance directive, she informs the family that a surrogate decision maker affidavit must be completed.At 9:19 AM, the surveyor requested documented evidence of the existing advance directives for Resident #2, Resident #13, and Resident #114, as well as documented attempts made by the facility to obtain the required advance directive records.On 06/30/2026 at 10:45 AM, the DSS #6 stated she was unable to locate the resident's advance directives or documentation of attempts to obtain existing advance directives. The Administrator #1 stated the facility identified concerns related to advance directives and conducted a facility wide audit in March 2026. He explained that residents without a completed advance directive were screen for decision making capacity and if they lacked capacity, family members were asked to complete a surrogate decision maker affidavit. When asked whether the facility first contacted family members to determine if an existing advance directive was already in place, the Administrator #1 was unable to provide an answer.On 07/06/2026 at 11:29 AM, a review of Resident #141's medical record revealed the resident was admitted to the facility in May 2026 with multiple diagnoses, including Alzheimer's disease. On 05/12/2026, the resident was identified as lacking decision-making capacity. Further review of the medical record revealed an advance directive screening was completed on 05/14/2026 indicating the resident was unable to participate in the screening. Further review of the resident's medical record failed to show evidence the facility made attempts to determine if the resident had an existing advance directive.On 07/06/2026 at 12:43 PM, the surveyor inquired about Resident #141's advance directive. The DSS #6 stated there is no documented evidence that the resident's family member were asked about an existing advance directive.On 07/06/2026, the Administrator was informed of the concern on multiple occasions throughout the survey.

Based on observation, clinical record review and interviews, it was determined that the facility failed to apply a hand splint on a resident as ordered by the physician. This was evident in 1 (Resident #43) of 1 resident reviewed for hand splints during the survey.The findings include:Resident #43's diagnoses include Hemiplegia and Hemiparesis following Cerebral Infarction affecting Right Dominant Side and Contracture of Muscle, Right Hand.On 06/29/26 at 8:56 AM during the initial tour, the surveyor observed Resident #43 sitting in a wheelchair watching Television (TV) in their room. The resident's right hand was visibly contracted with the fingers curved towards the palm. The resident was not wearing a hand splint.A review of the resident's clinical record on 06/30/26 at 09:10 AM revealed a physician's order as follows: Patient to wear Resting Hand splint on right hand and wrist at least 8 hours daily: ON: after AM care and OFF: Before PM care. Please notify OT if skin breakdown is observed. Splint cover must be washed and dried when soiled. Order Date: 04/24/26On 07/01/26 at 11:20 AM the surveyor again observed Resident #43 sitting in their room watching TV without a hand splint. A further review of the resident's clinical record on 07/01/26 at 11:20AM revealed the Treatment Administration Record (TAR) signed on 07/01/26 indicating that the splint was applied and in place on the resident's right hand.The surveyor brought the concerns to the attention of the Unit Manager LPN#11 (UM #11) on 07/01/26 at 11:33AM. UM #11 accompanied the surveyor to the resident's room where she observed the splint was not applied to the resident's hand. The splint was observed hanging on the wall over the resident's nightstand, in transparent bag. UM #11 reviewed the TAR and expressed concern that the nurse had signed the TAR indicating that the splint was applied to Resident #11's right hand when it was not.In an interview on 07/01/2026 at 1:00 PM the Director of Nursing was notified of the surveyor's concerns and she stated, If they are signing for the splint and not putting it on that is a problem.

Number of residents sampled: Number of residents cited: Based on record review and staff interviews, it was determined that the facility staff failed to ensure consent for psychotropic medications was obtained and maintained in the resident's medical records. This deficient practice was evident for 1 (Resident #2) of 5 residents reviewed for psychotropic medications during the annual survey.The findings include:Psychotropic medication is any drug that affects brain activities associated with mental processes and behavior.On 07/01/2026 at 9:49 AM, a review of Resident #2's medical record revealed the facility identified the resident's family member as a surrogate decision maker in January 2026. In April 2026, two physicians certified that the resident lacked decision-making capacity due to cognitive impairment. In May 2026, the resident's dosage of psychotropic medication Seroquel (Quetiapine) increased. Further review of the records failed to show documented evidence that the resident's surrogate decision maker provided consent for the increased dosage of the psychotropic medication.On 07/01/2026 at 12:47 PM, the surveyor presented the psychotropic medication consent concern for Resident #2 to the Director of Nursing (DON) #2 and regional staff. The DON #2 stated that she reviewed the resident's medical records and was unable to locate documentation showing that the resident's surrogate decision maker provided informed consent for the increased dosage of the psychotropic medication.

Based on record review and staff interview, it was determined that facility staff failed to identify a surrogate decision maker who is authorized to exercise the rights of a resident that lacks decision making capacity in a timely manner. This deficient practice was evident for 2 (, Resident #13, Resident #114) of 4 resident's reviewed for representative rights during the annual survey.The findings include:On 06/29/2026 at 10:13 AM, a review of Resident #114's medical record revealed the resident was admitted to the facility in June 2024 with multiple diagnoses, including dementia. At the time of admission, the resident was identified as lacking decision-making capacity. Further review of the records identified the resident's children as the resident's point of contact, however, the records failed to indicate who is responsible for making health care decisions.On 06/29/2026, a review of Resident #13's medical record revealed the resident was admitted to the facility in February 2024 with multiple diagnoses, including dementia. At the time of admission, the resident was identified as lacking decision-making capacity. Further review of the records identified the resident's child and two other family members has the point of contact, however, the records failed to indicate who is responsible for making health care decisions.On 06/30/2026 at 9:08 AM, the Director of Social [NAME] (DSS) #6 stated that advance directives are reviewed with the resident or the resident's representative upon admission. For residents who lack decision-making capacity, she contacts the family to determine whether an advance directive exists. If no advance directive is in place, the family is informed, a surrogate decision maker affidavit must be completed.At 9:19 AM, the surveyor informed the DSS #6 that the medical records for Resident #13 and Resident #114 did not clearly identify the family member authorized to make healthcare decision on behalf of the resident. The DSS #6 stated she would review the records and follow up with the surveyor.On 07/02/2026 at 12:06 PM, the DSS #6 provided a copy of surrogate decision maker affidavit forms for Resident #13 and Resident #114. Review of the records revealed that Resident #13's family member signed the affidavit in March 2026, approximately two years after the resident's admission to the facility. Further review showed that Resident #114's family member signed the affidavit in May 2026, nearly two years after the resident was admitted .The surveyor asked the DSS #6 how staff determined who was authorized to participate in care plan meetings and make healthcare decisions for residents who did not have a completed surrogate decision maker affidavit. The DSS#6 stated that staff contacted the individual listed as the resident's primary emergency contact or the first family member listed in the resident's contact information.On 07/02/2026, the Administrator was informed of the concern on multiple occasions throughout the survey.

Based on observations and staff interviews it was determined that the facility failed to maintain a safe, clean, comfortable and homelike environment for Residents. This finding was found to be evident in review of the physical environment of the facility during the annual recertification survey. The findings include: 1) On 06/29/2026 at 9:10 AM, during an initial observation, Resident #146's three-drawer bedside table was observed with a large tear in the top veneer. The tear was significant enough for the resident's entire hand to fit underneath. On 06/30/2026 at 10:35 AM, the Maintenance Director (Staff #4) was interviewed regarding the facility's process for reporting damaged items. Staff #4 stated that staff are instructed to use TELS, an electronic system for reporting broken or damaged equipment. Once a request is entered into TELS, the maintenance department receives the notice on their computer and addresses the issue. On 06/30/2026 at 1:30 PM, a follow-up observation was conducted with a Licensed Practical Nurse, (LPN) Staff #11, who was shown the condition of the bedside table. At that time, the torn section of the veneer had fallen behind the nightstand, and a large, dark area—which appeared to be mold—was visible on top of the table. Staff #11 put on gloves and retrieved the loose piece of veneer. Staff #11, LPN stated they would coordinate with the Nursing Home Administrator to ensure the bedside table is replaced and removed the large loose piece of veneer. 2) In Resident room G-7 at 8:27 AM on 6/29/2026 the surveyor observed a clock on the wall above the sink that indicated 2:30. Resident #10 stated that the clock needed batteries. Nursing staff on the unit were notified of the clock without the correct time and stated that they would notify Maintenance department. Licensed Nursing Home Administrator (LNHA) was notified of Resident #10's concern at 11:20 AM on 6/30/2026. On tour of the Ground-TCU Nursing Unit on 6/29/2026 at 8:53 AM the surveyor observed a ceiling vent without an attached cover/panel at the nursing station. Observed in the ceiling vent was an opening. At 2:20 PM on 7/2/2026 the Regional Licensed Nursing Home Administrator (LNHA) was notified of the ceiling vent without cover at the nursing station on Ground-TCU nursing unit. Regional LNHA stated that he was aware of this and that it was not a vent, but a heater in the ceiling and he had been unable to locate a cover that would fit the heater.

Based on record review and staff interviews, it was determined that the facility staff failed to document the action taken to address medication regimen review irregularity. This deficient practice was evident for 1 (Resident #5) resident reviewed for medication regimen review during the annual survey.The findings include:Medication Regimen Review (MRR) or Drug Regimen Review is a thorough evaluation of the medication regimen of a resident, with the goal of promoting positive outcomes and minimizing adverse consequences and potential risks associated with medication. The MRR includes review of the medical record in order to prevent, identify, report, and resolve medication-related problems, medication errors, or other irregularities. The MRR also involves collaborating with other members of the IDT, including the resident, their family, and/or resident representative.On 07/01/2026, a review of Resident #5's medical records revealed that a monthly MRR was completed in June 2026. The pharmacist's progress note stated, see report for comments and recommendations. At 1:37 PM, the surveyor requested a copy of the June 2026 MRR report from the Director of Nursing (DON) #2.At 3:35 PM, The DON #2 provided the June 2026 MRR report. Review of the report revealed a recommendation to consider increasing the resident's Methimazole dose and to monitor the thyroid stimulating hormone level in six weeks and every 6 months thereafter or clinically indicated.The Family Nurse Practitioner (FNP) #14 response on the report stated, I accept the recommendation above with the following modifications. However, the section designated to document the modification was left blank. The surveyor then reviewed Resident #5's medical record with the DON. No progress notes or other documentation describing the modifications or actions taken in response to the recommendation were found. The DON #2 stated she would further investigate the MRR recommendation and follow up with the surveyor.On 07/02/2026 at 8:24 AM, the DON #2 followed up with the surveyor and reported that she had spoken with the FNP. According to the DON #2, the FNP stated that he failed to document the rationale for his modification on the MRR form and also failed to document a rationale in the resident's medical record.

Based on observations, staff interviews, and surveyor record reviews, it was determined that the facility staff failed to follow professional standards of practice for oxygen administration and oxygen safety. This finding was found to be evident in 2 (Resident #10 and #99) out of 3 Residents reviewed for respiratory care and services.The findings include:Oxygen concentrator is a medical device that pulls ambient air, removes nitrogen, and delivers concentrated oxygen to individuals with respiratory conditions. The purified oxygen is delivered directly to the user via a nasal cannula.At 8:25 AM on 6/29/2026 the surveyor observed Resident #10 lying in bed, in no distress with oxygen therapy in use. Resident #10 had an oxygen concentrator at the bedside and a portable emergency tank of oxygen (etank) standing on the floor at the head of the bed. The etank was not secured in a cart, stand or bracket. Surveyor notified the Nurse Manager #5 who observed the etank in Resident #10's room that was not secured in a cart or stand and removed the etank from Resident room indicating that the etank should have been in a stand. Additionally, there was not an oxygen in use signage on the Resident room door.On 6/29/2026 at 9:00 AM surveyor observed Resident #99 sitting in bed, in no distress with oxygen therapy in use with an oxygen concentrator. There was not an oxygen in use signage on the Resident room door. The surveyor conducted a record review of the facility's policy and procedure for Oxygen Safety and Oxygen Administration on 6/30/2026 at 12:30 PM. Review of the policy revealed that No Smoking signs will be utilized to clearly identify oxygen is in use before connecting the oxygen supply and will remain in place until oxygen administration has been discontinued; oxygen warning signs must be placed on the door of the Resident's room where oxygen is in use. At 4:00 PM on 7/2/2026 Licensed Nursing Home Administrator (LNHA) and Regional LNHA were notified of the concerns with oxygen storage and administration.

Based on observation, clinical record review and interviews, it was determined that the facility failed to ensure that dependent residents' grooming needs were met. This was evident in 2 (Resident #11 and #43) of 3 residents reviewed for Activities of Daily Living during the survey.The findings include: On 06/29/26 At 8:50 AM Resident #11 was observed lying in bed. Fingernails were noted to be long and jagged with black material present underneath. At 8:56 AM Resident #43 was observed sitting in a wheelchair. The resident has a known contracture to the right hand. Fingernails on the right hand were observed to be long and curved towards the palm.On 6/29/26 at 12:00PM a review of Resident #11 and Resident #43's clinical record revealed that the residents were dependent on staff for personal hygiene. On 07/01/26 at 11:33 AM the surveyor again observed both Resident #11and #43 with their fingernails in the same condition as observed on 06/29/26.In an interview on 07/01/26 at 11:33 AM the Unit Manager LPN#11 stated that they do not have a schedule for nail care, however the Geriatric Nursing Assistants are required to provide nail care on shower days and as needed. She accompanied the surveyor to the residents' rooms, examined the residents' hands and stated that she would arrange for the residents to have their nails trimmed.The Director of Nursing was notified of the surveyor's findings on 07/01/26 at 1:00PM. She stated that she was notified by the nurse and would address the concern.

Based on observations, staff interviews, and surveyor record review it was determined that the facility failed to install a handrail in the hall on the Ground-TCU Nursing Unit. This finding was found to be evident in review of the physical environment during the annual recertification survey.The findings include:The surveyor observed at 12:25 PM on 7/2/2026 on the Ground-TCU Nursing Unit a gap/space in the handrail on the wall on the right side of the hall. The gap/space was observed to be approximately 30 long, and there were four (4) holes in the wall which appeared to be from a missing piece of the handrail. The gap/space was located between the utility room and medication room and across from Resident room G-9. Residents were observed to be ambulatory, using walkers and wheelchairs. At 12:35 PM on 7/2/2026 the surveyor notified the Nurse Manager #5 of the missing handrail. Nurse Manager #5 observed gap/space in the handrail on the wall with the four (4) holes between the utility room and medication room. Nurse Manager #5 indicated that she would notify Maintenance. Environmental Services staff in the hall stated that there used to be a water fountain in that space.Record review at 1:00 PM on 7/2/2026 revealed that the Resident census on Ground-TCU nursing unit was 15, and capacity was 17. At 2:10 PM on 7/2/2026 the surveyor notified the Regional Licensed Nursing Home Administrator (LNHA) of concern with the handrail on the Ground-TCU Nursing Unit. Regional LNHA observed the gap/space and the four (4) holes in the wall. Regional LNHA stated that there used to be a water fountain on the wall that was removed and indicated that he was aware that a handrail needed to be installed in that space.On 7/2/2026 at 4:00 PM the Licensed Nursing Home Administrator (LNHA) provided the surveyor with an email time stamped at 2:46 PM on 7/2/2026 to an individual at inprocorp.com that indicated a request to order a handrail that was needed to be replaced in the facility.

Based on interviews, observations, and record reviews, it was determined that facility staff failed to assist a resident in arranging follow up for dental care in a timely manner. This deficient practice was evident for 1 (Resident #5) of 2 residents reviewed for dental services during the annual survey.The findings include:On 06/29/2026 at 9:08 AM, during an interview, Resident #5 stated, they were to have their remaining teeth removed but were hospitalized for a month. Since returning to the facility in October 2025, there has been no follow up on the extraction. During the interview, the surveyor observed that the resident had only two small tooth fragments remaining. A review of the resident's medical records on 06/30/26 at 10:03 AM revealed an August 2025 dental consult recommending extraction of remaining root tips. The resident returned from the hospital in October 2025. Records failed to show documented evidence of follow up.On 06/30/26 at 11:16 AM, the Director of Nursing (DON) #2 explained that that after dental appointments, follow up instructions are given to medical records staff to arrange further appointments. The surveyor informed the DON #2 of the missing follow up since August 2025. The DON #2 stated she would review the records and follow up with the surveyor.On 06/30/2026, the Medical Record (MR) #8 staff presented a email dated 05/05/2026 related to the following up for the extraction. When asked about the follow up from August 2025 consult, she stated that follow ups were made, however, there was no documented evidence she could provide. The surveyor presented the concerns to the DON #2 who acknowledged the concern.

Based on clinical record review and interviews, it was determined that the facility failed to provide adequate side effects monitoring for a resident on anticoagulant therapy. This was evident for 1 (Resident #11) of 6 residents reviewed for monitoring of side effects.The findings include:On 07/02/26 at 8:39 AM a review of Resident #11's clinical record revealed that the resident was receiving anticoagulant medication, Eliquis from 12/03/25. The Physician Order stated as follows:Eliquis Oral Tablet 5 mg (Apixaban) Give 1 tablet via PEG-tube two times a day DVT Prophylaxis Order Date 12/03/25.Further review of the record failed to reveal a process for monitoring side effects associated with anticoagulant therapy.On 07/02/26 at 1:32 PM during an interview Unit Manager LPN#11 (UM #11) stated that it was the practice for the facility to monitor residents for side effects and document the monitoring on the resident's Medication Administration Record or Treatment Administration Record. UM #11 reviewed the clinical record and stated I do not see any monitoring or care plans for anticoagulant, it is not here, I will take care of itThe Director of nursing was notified of the surveyor's concerns and during an interview on 07/02/26 at 3:15 PM, she provided the surveyor with a copy of a physician's order dated 07/02/26 at 1:39 PM for monitoring of side effects for Resident #11. The surveyor noted that order was initiated after the surveyor's intervention.

Based on interviews and record reviews, it was determined that the facility staff failed to code Minimum Data Set (MDS) assessments accurately for a resident, and failed to accurately code a resident's dental status on the admission assessment. This deficent practice was evident for 2 (Resident #14, Resident #5) out of 8 residents reviewed for tube feeding, nutrition services, and dental during the annual survey. The findings include: Minimum Data Set (MDS) is a federally mandated standardized assessment tool that measures health status in nursing home Residents including functional, medical, psychosocial and cognitive status. MDS assessments are completed on admission, quarterly, annually, and upon significant changes in Resident conditions. MDS assessment is designed to collect data to guide care planning and monitoring for Residents in long term care settings. The data is used to compute indicators of care quality. MDS assessments are completed by the clinical interdisciplinary team and coordinated by a Registered Nurse (RN) in the nursing facility. Care Plan is a personalized document that summarizes a Resident's health conditions, specific care needs and current treatments. Developed by the clinical interdisciplinary team, the care plan maps out targeted interventions to achieve specific, measurable goals for the Resident in the long-term care facility. Medication Administration Record (MAR) is a critical tool that ensures safety and accuracy for Residents in healthcare settings. MAR is used to document medications that Residents receive, including dosage and time, and it provides a comprehensive, organized record of each medication administered to a Resident. This vital document supports healthcare providers by tracking doses, preventing errors, and providing a clear record of care. Intravenous therapy (IV) is a way to give fluids, medicine, nutrition, or blood directly into the bloodstream through a vein. IV therapy uses a type of tiny plastic tubing (cannula) that goes into the vein, a needle, and plastic tubing that connects the set-up to a bag of fluid. A percutaneous endoscopic gastrostomy (PEG) is a feeding tube that allows a patient to receive enteral nutrition through the stomach. A PEG is placed if a Resident has difficulty swallowing or cannot receive all the nutrition needed by mouth. 1) The surveyor conducted a record review of Resident #14's medical record at 6:45 AM on 7/2/2026 who was admitted to the facility on [DATE]. Review of the physician orders revealed that Resident #14 had a PEG tube and received a therapeutic enteral diet. Review of the medication administration records revealed that Resident #14 received intravenous (IV) therapy for hydration on 3/4/2026, 3/5/2026, 3/9/2026, 3/10/2026 and 3/11/2026. Review of the 3/10/2026 Annual MDS assessment for Resident #14 revealed that Section K (Nutritional Approaches) was coded for IV feeding and feeding tube (PEG) while a Resident, however, therapeutic diet was not coded while a Resident. Also, Section O (IV Access) was coded as No while a Resident, however, Resident #14 had an IV for hydration during that assessment period. Further review of the medical record revealed that Section K (Nutritional Approaches) of the 6/12/2026 Quarterly MDS assessment revealed that Resident #14 was coded Yes for feeding tube and therapeutic diet while a Resident. Additionally, review of Resident #14's comprehensive care plan revealed care plans for IV hydration and PEG tube. In an interview with the RN MDS Coordinator #22 at 8:50 AM on 7/2/2026 and a follow up interview at 10:20 AM on 7/2/2026 the surveyor conveyed to RN #22 regarding the inaccurate coding on the 3/10/2026 admission MDS assessment for Section K (therapeutic diet) and Section O (IV access). RN #22 acknowledged the surveyor and stated that she would review the coding on the 3/10/2026 admission MDS assessment for Section K (therapeutic diet) and Section O (IV access) with the Regional MDS Director. At 11:15 AM on 7/2/2026 in a follow up interview with RN #22 she indicated that the coding on the 3/10/2026 admission MDS assessment for Section K (therapeutic diet) and Section O (IV access) was inaccurate and a modification (correction) had been initiated for this MDS assessment. The surveyor at 3:55 PM on 7/2/2026 conducted a follow-up record review of Resident #14's 3/10/2026 admission MDS assessment. Review revealed that the RN MDS Coordinator #22 completed a modification/correction to Section K (therapeutic diet) and Section O (IV access) at 3:16 PM on 7/2/2026. Therapeutic diet while a Resident under Section K was now coded and IV Access while a Resident under Section O was now coded as Yes. Licensed Nursing Home Administrator (LNHA) and Regional LNHA were notified at 4:00 PM on 7/2/2026 of the inaccurate coding on the MDS assessment. 2) On 06/29/2026 at 9:08 AM, during an interview, Resident #5 stated, they were to have their remaining teeth removed but were hospitalized for a month. The resident stated they returned to the facility in October 2025, and there has been no follow up regarding the extraction. During the interview, the surveyor observed that the resident had only two small tooth fragments remaining in the mouth. On 07/01/2026 at 3:35 PM, a review of Resident #5's medical record revealed a dental care plan initiated in July 2024 that identified cracked teeth as a dental concern. Further review of the records revealed an August 2025 dental consult recommending extraction of the resident's remaining root tips. The resident was hospitalized in September 2025 and readmitted to the facility in October 2025. A review of the 10/22/2025 admission [NAME] Data Set (MDS) revealed that MDS coordinator documented that the resident was remitted without dental issues. On 07/02/2026 at 9:40 AM, during an interview with MDS Coordinator #22 at 9:00AM she explained, at the time of admission she interviewed Resident #5. The resident did not report dental concerns such as pain or discomfort. The surveyor asked if she conducted an oral exam of the resident mouth. She stated, if the resident allows it; sometimes the resident refuses. On 07/02/2026, the surveyor presented the dental concern to the Director of Nursing (DON) #2. The DON #2 stated she understood why the issue was a concern and that she would investigate the matter further.

Based on record review and interviews, it was determined that the facility staff failed to implement and develop comprehensive care plans for residents. This deficient practice was evident in 3 (Resident #4, Resident #11, and Resident #5) of 5 residents reviewed for comprehensive care plans during the annual survey. The findings include: 1). Resident #4 diagnoses include Dementia, Major Depressive Disorder Mood Disturbance and Anxiety. On 07/02/26 at 3:36 PM a review of Resident #4's clinical record revealed a Quarterly Activity Review dated 5/19/26 which referenced an existing Activities care plan. The document stated that the goals, interventions and approaches were effective in keeping with that care plan. However, further review of Resident #4's clinical record failed to reveal an active Activities care plan existed. On 07/06/26 at 8:23 AM during an interview, the Activities Director reviewed Resident #4's clinical record and stated that she could not find an Activities Care Plan I cannot find one, I do not know why (resident) does not have one. During an interview on 07/06/26 at 10:35 AM the Director of Nursing (DON) provided the surveyor with a copy of Resident #4's Activities care plan which stated that the Goals and Interventions were RESOLVED. There was no date on the document. When asked if there was an active care plan in place for Resident #4 the DON responded, this is what we have on record. 2). On 07/02/26 at 8:39 AM a review of Resident #11's clinical record revealed that the resident had an active physician's order dated 12/03/25 for anticoagulant medication, Eliquis. The resident's medication administration record confirmed that the resident was receiving the medication. The clinical record failed to reveal a care plan on the risks and interventions associated with anticoagulation therapy. On 07/02/26 at 1:32 PM during an interview with Unit Manager #11 (UM#11), the surveyor asked whether there was a care plan for anticoagulant therapy for Resident #11. UM#11 reviewed the clinical record and stated, I do not see any monitoring or care plans for anticoagulant, it is not here, I will take care of it. On 07/02/2026 at 1:44 PM the DON who was made aware of the surveyor's findings. 2.) On 06/29/2026 at 9:08 AM, during an interview, Resident #5 stated, they were recommended to have their remaining teeth removed in August 2025 but were hospitalized for a month. During the interview, the surveyor observed that the resident had only two small tooth fragments remaining. On 06/30/2026 at 3:35 PM, a review of Resident #5's medical record revealed a dental care plan initiated in July 2024 that identified cracked teeth as a dental concern. The dental care plan directed staff to coordinate and arrange dental care, including transportation as needed, and as ordered. Further review of the medical records revealed that, in August 2025 a Doctor of Dental Medicine ordered preoperative lab testing and extraction of remaining root tips under general anesthesia. The medical records failed to show evidence of dental care coordination. During an interview with Medical Record (MR) #8 staff on 06/30/2026, she provided an email dated 05/05/2026 regarding follow up for the resident's tooth extraction. When asked about follow up attempts from August 2025 through the present, she stated that follow up had occurred; however, she was unable to provide documented evidence. The surveyor presented the concerns to the Director of Nursing, who acknowledged the findings.

Based on staff interviews and surveyor record reviews it was determined that the facility staff failed to update and revise a comprehensive care plan for a Resident. This finding was found to be evident in 1 (Resident #30) out of 7 Residents reviewed for care plans.The findings include: Care Plan is a personalized document that summarizes a Resident's health conditions, specific care needs and current treatments. Developed by the clinical interdisciplinary team, the care plan maps out targeted interventions to achieve specific, measurable goals for the Resident in the long-term care facility. Care plans are updated and revised as Resident's condition warrants and at least quarterly.Medication Administration Record (MAR) is a critical tool that ensures safety and accuracy for Residents in healthcare settings. MAR is used to document medications that Residents receive, including dosage and time, and it provides a comprehensive, organized record of each medication administered to a Resident. This vital document supports healthcare providers by tracking doses, preventing errors, and providing a clear record of care. Diuretic (water pill) is a medication that helps the body eliminate salt and water through the urine. Diuretics are primarily prescribed to treat high blood pressure, heart failure, and edema (swelling) by reducing fluid volume in the bloodstream. The surveyor conducted a record review of Resident #30's medical record on 7/1/2026 at 7:15 AM who admitted to the facility on [DATE]. Review of Resident #30's comprehensive care plan revealed a plan of care for diuretic therapy, The Resident is on diuretic therapy related to edema, initiated on 9/24/2025 with a target date of 4/8/2026. Review of the physician orders for Resident #30 did not reveal an active order for a diuretic medication. Review of the discontinued physician orders revealed that diuretic therapy (Lasix/Furosemide) was discontinued on 10/1/2025 for Resident #30. Review of the medication administration records (MARs) for September 2025, and October of 2025 revealed that Resident #30 received diuretic therapy (Lasix/Furosemide) and that the last dose was received on 10/1/2025.In an interview with the Director of Nursing (DON) at 10:35 AM on 7/1/2026 the surveyor conveyed that Resident #30 was no longer receiving diuretic therapy (Lasix/Furosemide) as the medication was discontinued on 10/1/2025. Surveyor further conveyed that there was a plan of care on Resident #30's comprehensive care plan which indicated that Resident was on diuretic therapy. Surveyor stated that Resident #30's care plan was not revised and updated when diuretic therapy was discontinued on 10/1/2025.DON acknowledged the surveyor and indicated that she would review and follow-up. At 11:15 AM on 7/2/2026 DON provided surveyor with copies of Resident #30's physician orders (active and discontinued), MARs (September 2025 and October 2025), and care plan and confirmed that Resident was no longer receiving diuretic medication.Licensed Nursing Home Administrator (LNHA) and Regional Administrator were notified at 4:00 PM on 7/2/2026 of the concern with care plan update and revision.

Based on observation, staff interviews, and surveyor record review it was determined that the facility failed to maintain services that meet professional standards of care. This finding was found to be evident in 1 (Resident #10) out of 3 Residents reviewed for oxygen administration.The findings include:The surveyor observed Resident #10 in bed, in no distress at 8:25 AM on 6/29/2026 with oxygen therapy in use.Resident #10 was observed at 6:55 AM on 6/30/2026 in bed, in no distress with oxygen in use.Care Plan is a personalized document that summarizes a Resident's health conditions, specific care needs and current treatments. Developed by the clinical interdisciplinary team, the care plan maps out targeted interventions to achieve specific, measurable goals for the Resident in the long-term care facility.At 10:55 AM on 6/30/2026 the surveyor conducted a record review of Resident #10's medical record. Record review revealed that Resident #10 did not have a current physician order for oxygen usage. Review of Resident #10's comprehensive care plan revealed an intervention, give oxygen therapy as ordered by the physician with a date initiated 5/15/2026.In an interview with Nurse Manager #5 at 11:05 AM on 6/30/2026 surveyor reviewed with Nurse Manager #5 that Resident #10 was receiving oxygen and that there was no physician order for oxygen therapy. Nurse Manager #5 stated that Resident has been on oxygen since admission and confirmed that Resident did not have a physician order for oxygen. Resident #10 was admitted to the facility on [DATE]. Licensed Nursing Home Administrator (LNHA) was notified at 11:20 AM on 6/30/2026 of oxygen therapy in use for Resident #10 without a physician order.The surveyor reviewed the facility's policy for Oxygen Administration at 12:20 PM on 6/30/2026. The policy indicated that oxygen is administered to Residents who need it, consistent with professional standards of practice; under orders of a physician, except in the case of an emergency, and orders for oxygen are obtained as soon as practicable when the situation is under control.LNHA and Regional LNHA were notified of the oxygen administration concerns at 4:00 PM on 7/2/2026.

Based on complaint, reviews of all pertinent documents and a closed medical record, and interviews with facility staff, it was determined that the facility failed to implement preventative measures to prevent the development and deterioration of a resident's pressure ulcers. This was evident for 1 (Resident #2) out of 4 residents reviewed during a survey. The findings include: On 03/30/26 the Office of Health Care Quality received a complaint with concerns that Resident #2 was not provided with quality of care. The complaint indicated Resident #2 developed pressure wounds that deteriorated during their time in the facility.A review of CMS guidelines to prevent pressure ulcers require nursing facilities to prevent new pressure ulcers unless clinically unavoidable by ensuring proper risk assessment, implementing individualized care plans, providing necessary treatment/services, and turning bed-bound patients at least every two hours. Key measures focus on nutrition, hydration, and using pressure-reducing surfaces. Resident #2 was admitted to the facility from the hospital on [DATE] with diagnoses that include but not limited to septic shock, urinary tract infection, severe cognitive-communication deficits, an indwelling foley catheter, diabetes, anorectal cancer with a history of radiation and chemotherapy treatments, and a pressure area of the Gluteal cleft midline (coccyx area) that was being treated with Santyl ointment daily. Santyl is an FDA-approved prescription medicine used to debride (remove) dead tissue from chronic dermal ulcers and severe burns. It is the only enzymatic debrider that selectively removes necrotic tissue to promote healing. Common side effects include temporary pain, redness, or burning. The hospital staff documented a Braden score of 15 in Resident #2's hospital discharge summary.The Braden Scale is a widely used, evidence-based tool for assessing a patient's risk of developing pressure injuries. It evaluates six subscales-sensory perception, moisture, activity, mobility, nutrition, and friction/shear-with a total score ranging from 6 to 23; lower scores indicate higher risk. Braden Scale Scoring and Risk Levels - 19-23: No Risk, 15-18: Mild Risk, 13-14: Moderate Risk, 10-12: High Risk, less than 9: Severe Risk.Upon admission to the facility, Resident #2 was determined to be capable of understanding medical information and to make medical decisions by his attending physician on 11/04/25. On 11/11/25, Resident #2's was assessed by the staff to have a BIMS score of 12/15. The BIMS (Brief Interview for Mental Status) score is a 0-15 point tool used in healthcare, particularly long-term care, to assess cognitive function, with higher scores indicating better cognition. It evaluates immediate recall, temporal orientation, and short-term memory. A score of 13-15 indicates intact cognition, 8-12 moderate impairment, and 0-7 severe impairment.A review of the facility policy for Pressure Injury Prevention and Management on 04/09/26 revealed the policy was last reviewed by the Medical Director on 11/12/2025. Under the policy explanation and compliance guidelines: 2. The facility shall establish and utilize a system approach for pressure injury prevention and management, including prompt assessment and treatment; intervening to stabilize, reduce or remove underlying risk factors; monitoring the impact of the interventions; and modifying the interventions as appropriate.On 04/09/26, a review of Resident #2's 11/04/25, 10:02 pm nursing admission progress notes revealed Resident #2 was assessed to be cognitively impaired, required two-person physical assistance with transfers and toileting hygiene, and an indwelling foley catheter. On 11/04/25 at 11:50 PM, Resident #2 was assessed by the nurse as having an open area on his sacral area that was noted to be from moisture associated skin damage (MASD). There were no documented measurements of the MASD nor any documentation of an odor, drainage, depth of the wound. A review of Resident #2's admission base line care plan included the nursing intervention: to leave Resident #2's sacral area of MASD ota (open to air). Further review of Resident #2'closed medical record revealed three other Braden Scale assessments dated 11/06/25, 11/14/25, and 11/19/25. Each of these Braden scale assessments determined that Resident #2 had a LOW probability for developing a pressure wound.A pressure ulcer also known as pressure sore or decubitus ulcer is any lesion caused by unrelieved pressure that results in damage to the underlying tissue. Pressure ulcers are staged according the their severity from Stage I (area of persistent redness), Stage II ( superficial loss of skin such as an abrasion, blister or shallow crater), Stage III (full thickness skin loss involving damage to subcutaneous tissue presenting as a deep crater), Stage IV (full thickness skin loss with extensive damage to muscle, bone or tendon) or Unstageable Pressure Ulcer (full thickness tissue loss in which the base of the ulcer is covered by slough and / or eschar in the wound bed).Further review of the nurses progress notes revealed that on 11/23/25 at 3:41 PM and 3:51 PM, Resident #2 was identified with 2 new pressure wounds on the weekly skin evaluation Pressure wound #1 was noted to the coccyx area and Pressure wound #2 was noted to the sacrum. The medical record failed to reveal any nursing documented measurements of the 2 new pressure wounds nor any documentation of an odor, drainage, or depth of the wound. The medical record also failed to reveal that Resident #2's physician was made aware of the 2 new wounds on 11/23/25 at 3:41 PM or 3:51 PM The nursing staff also completed a new Braden Scale assessment on 11/23/25 and determined Resident #2 to have a Braden score of 10 (high risk for pressure wound development). On 11/24/25, Resident #2 was assessed by the facility wound consultant who documented Resident #2 appeared immobile, confused, and in no acute distress but had the following wounds: the first wound was an unstageable sacral full thickness pressure wound that measured 6 cm x 3 cm x unknown depth (due to presence of nonviable tissue and necrosis). The duration of this first wound was listed to be greater than 5 days old by the wound consultant. (A full-thickness wound is a severe injury extending through the epidermis and dermis into subcutaneous tissue, often exposing muscle, tendon, or bone. Common causes include Stage 3/4 pressure injuries. These wounds require extensive healing time, often months, via contraction and epithelialization, frequently needing specialized, moisture-balanced dressings, debridement, or grafting.) Resident #2's first wound was observed with a moderate amount of Serous drainage (Serous drainage is a clear, thin, watery fluid (plasma) that is a normal part of the healing process, commonly seen in, but not limited to, the first few days after surgery or injury. It appears pale yellow or transparent and aids healing by providing nutrients to the tissue.) The wound consultant performed a surgical excisional debridement procedure to Resident #2's first wound on 11/24/25 and then gave detailed instructions to the nursing staff on the daily dressing needs. The wound consultant then documented an estimated time to heal Resident #2's sacral wound of 1-2 months. On 11/24/25, the wound consultant then described Resident #2's second full thickness pressure wound to the left buttock was a Stage 3 wound that measured 0.5 cm x 0.7 cm x 0.2 cm with no signs of infection. The duration of this second wound was listed as being greater than 5 days old by the wound consultant. The wound consultant also estimated the time to heal Resident #2's left buttock wound would be 1-2 months.Further review of Resident #2's physician and nurse practitioner progress notes from 11/04/25 through 11/24/25 failed to reveal and documentation regarding any changes to Resident #2's skin.In an interview with the facility nurse practitioner, CRNP#1, on 04/13/26 at 11:30 am, CRNP#1 stated that the medical staff had not been alerted to any skin issues regarding Resident #2 in November 2025. CRNP#1 stated the first time that they documented any issues with Resident #2's skin was on 12/10/2025. CRNP#1 stated that the facility wound consultant addressed Resident #2's skin issues before that time.In an interview with Resident #2's attending physician on 04/13/26 at 2:21 PM, Resident #2's attending stated that they were unaware of any skin issues after Resident #2 was admitted on [DATE]. Resident #2's physician stated, if the nursing staff calls me about a resident's skin, I will order a treatment and get the wound consultant to see the resident. When asked, Resident #2's physician they did not recall discussing Resident #2's wounds during the monthly Quality Assurance meetings.A further review of Resident #2's care plans and nursing interventions failed to reveal any preventative nursing interventions to assist or to turn and reposition Resident #2 every 2 hours. The CNA staff were documenting yes or no if they turned and repositioned Resident #2. From 11/04/25 through 11/24/25 the CNA staff documented the following: Day shift, 7am to 3 pm, 10 of 20 days the CNA staff documented NO they did not turn and reposition Resident #2.Evening shift, 3 pm to 11 pm, 4 of 20 days the CNA staff documented NO they did not turn and reposition Resident #2.Night shift, 11 pm to 7 am, 4 of 21 days the CNA staff documented NO they did not turn and reposition Resident #2.

Based on observations and interview it was determined that the facility staff failed to ensure that the handrails on the third floor were repaired and safe for the residents to use. This deficient practice was widespread on the third floor. The findings include: On 10/22/25 at 10:22 AM while on the third floor of the facility the surveyor observed multiple handrails with screws that were not flush with the handrail. The screws were sticking out with the potential to injure a resident's hand. The handrail near the elevator was separated by a gap. On 10:23 AM the surveyor observed a nail sticking out of the handrail outside of room [ROOM NUMBER]. The surveyor observed a hole in the handrail outside of room [ROOM NUMBER] & the handrail had a yellow screw that was not flush to the surface. The surveyor observed two screws on separate sides of the handrail outside of the MDS Nurse's office that were not flush to the surface. On 10:26 AM the surveyor observed an unflushed screw in the handrail outside of room [ROOM NUMBER]. The surveyor observed unflushed nails in the handrail between the Storage Room & EVS Room, and the handrail was not secured to the wall. The handrail shook when the slightest pressure was applied. The handrail near the Central Supply Room was loose with a screw that was not flush to the surface. On 10/22/25 at 11:16 AM the surveyor reported to the Administrator That there were multiple broken handrails and handrails that had screws that were not flush with the surface on the third floor. The Administrator verbalized they were trying to secure the handrails with the screws. The surveyor verbalized that the screws are not flush to the surface and has the potential to cause injury to a residents hand while using the handrail.

Based on record review and interviews, it was determined that the facility failed to provide treatments to assure proper care for Residents with suprapubic catheters. This was evident in 2 (Resident #5 and #11) of 2 residents reviewed for suprapubic catheter and Urinary Tract Infection (UTI) during the complaint survey. A suprapubic catheter (SPC) is a surgically created connection between the urinary bladder and the skin in the abdomen used to drain urine through a tube from the bladder to a collection bag in individuals with obstruction of normal urinary flow. The findings included: 1a) On 10/21/25 at 9:15 AM, the surveyor reviewed intake # 329288. The intake alleged that Resident #5's suprapubic catheter (SPC) was not cared for properly. On 10/21/25 at 9:32 AM, the surveyor reviewed Resident #5's medical record. The review revealed Resident #5 had a past medical history of benign prostatic hyperplasia without lower track urinary symptoms and urine retention. On further review, a consultation was placed for a urology (provider that specializes in urinary tract system)/pelvic medicine specialist to see Resident #5 after being hospitalized for blood in the suprapubic tube. The blood was described as occurring after the suprapubic catheter was changed and the nurse flushed the tube later that day. The initial evaluation was completed on 8/13/25. The pelvic specialist recommended that due to frequent clogging more tests should be completed and for the catheter to be flushed with 100cc of fluid twice per day. It also stated that the SPC should be exchanged routinely every 4-6 weeks. Resident #5 was seen by the urology/pelvic medical team with recommendation instructions on 9/6/24, 10/6/24, 10/18/24 and 11/1/24. On these visits the instructions were to flush the catheter twice a day with 100cc of fluid to prevent the catheter from being clogged followed by, urology team would exchange the catheter. On 10/6/25 the progress note documented the procedure for the exchange was performed by the consulting provider. On 9/20/2024, 11/15/24, 12/13/24, 12/27/24 and 1/24/25 the flush recommendations were the same however, the instructions stated, Please perform routine exchange the SPC routinely every 4-6 weeks. On 3/5/25 and 3/26/25 the recommended flush was changed to 50 cc normal saline or sterile water, however the instructions for the exchange were the same as the prior visits. The surveyor next reviewed the Treatment Administration Records (TARs). Resident #5's SPC was documented as changed on 8/13/24,9/20/24, 11/13/24 and 12/28/24. The January 2025 TAR had no changes documented and the TARs to follow had no order for the SPC catheter to be changed. No documentation could be found to indicate if and when the catheter was changed. Further review of the TARs revealed the twice a day 100cc flushing was last documented as completed on 1/7/25 and discontinued on 1/10/25. (The gap correlated with Resident #5's hospitalization stay) No flush was ordered when Resident #5 returned from the hospital on 1/10/25 until 4/15/25, when a flush of 50cc of normal saline every day was started. This was 2.5 months after the urology/pelvic team last evaluated the resident (1/24/25 on return from the hospital and made these recommendations). The surveyor reviewed Resident #5's suprapubic catheter care plan. A care plan intervention was created on 6/28/23 that stated Resident #5's indwelling catheter and draining system should be changed every 30 days. On 10/21/25 at 1:46 PM the surveyor conducted an interview with the Director of Nursing (DON). During the interview the surveyor requested documentation to show Resident #5's SPC flushes were done per recommendation in February, March and second half of April along with documentation of Resident #'s 5 SPC changes for January - May 2025. On 10/21/25 at 2:22 PM, the surveyor conducted a follow-up interview with the DON. During the interview the DON confirmed that no flushes were documented as administered for the later part of January, February, March and half of April 2025 even though the recommendations were to do so. She further stated that during that time different urology consult providers were coming into the building and that they all had different ways of communicating with the facility. She stated that SPC changes were performed when the urology consultation provider came in to do consultation visits. She confirmed that there was no documentation in Resident #5's medical record to indicate the SPC was changed after 12/28/25. The DON stated she would have to reach out to the providers to get documentation that the catheters were changed. On 10/22/25 at 12:18 PM, the surveyor conducted a telephone interview with urology/pelvic consult Provider Staff #6. During the interview Staff #6 indicated that there are only a few reasons why the providers would change the SPC on the consultation visits, such as an initial change after placement or a complicated catheter. He further stated that if the provider changed the catheter, it would be documented in the progress note from that visit. He confirmed that unless the providers indicated they were going to change the catheter then it is the expectation that the facility would change the catheters per the Resident's individual plan of care. At the time of exit no documentation was provided to support that the SPC was changed for Resident #5 for January-May 26 of 2025 (on 5/26/25 hospital records documented it was changed) or flushes were provided February, March and second half of April. Cross reference F842 1b) On 10/22/25 at 9:49 AM, the surveyor reviewed Resident #11's medical record the review revealed Resident #11 had a past medical history of obstructive and reflux uropathy, and overactive bladder. Resident #11 had a suprapubic catheter (SPC). On further review the surveyor noted an order was initiated on 12/30/22 that stated, change suprapubic foley (catheter) every 4 weeks on Friday night shift. Next the surveyor reviewed Resident #11's Treatment Administration Records (TAR)s. November of 2024 Resident #11's catheter was documented as changed on 11/1/24 and 11/29/24. On the December 2024's TAR the order was discontinued on 12/9/24 and on 12/11/24 the order was changed to change as needed. There was no documentation that Resident #11's SPC was being changed in January - July's TARs. The surveyor reviewed Resident #11's urology(provider that specializes in urinary tract system)/pelvic medical team consultation notes from visit on 11/15/24, 12/13/25, 12/27/24, 1/24/25 and 3/26/25. All notes stated, Please perform routine exchange the SPC routinely every 4-6 weeks. Nowhere in the note did it state that the SPC was exchanged. On further review the surveyor reviewed a progress note written on 12/10/24 by Registered Nurse (RN) #12. The note stated that Staff reached out to Resident #11's Resident Representative (RP) after Resident #11 returned to the facility and informed Resident #11's RP that the SPC was changed monthly by the urology staff. The surveyor noted that the urology staff had not seen Resident #11 monthly in 2025. On 10/22/25 at 10:05 AM, the surveyor requested documentation from the Director of Nursing (DON) demonstrating that Resident #11's SPC was changed per recommendations every 4-6 weeks. At the time of exit no documentation was provided to support that the SPC was changed for Resident #11 for January-July of 2025.

Based on observation, interview and documentation review, it was determined the facility failed to ensure an effective infection prevention and control program by; 1) failing to implement an effective system to ensure that symptomatic staff could not and did not work during a declared health emergency, 2) failing to ensure that staff followed accepted standards of practice for hand hygiene during the declared health emergency and 3) failing to ensure that staff utilized personal protective equipment (PPE) in a manner that met minimum standards and minimized risk for infectious spread. These interrelated system failures in the infection prevention and control program placed all residents, staff and visitors at increased risk for exposure to COVID-19, and thereby at increased risk for harm and possible death. As a result of these findings, an immediate jeopardy was declared on 7/22/2020 at 1:50 PM for failure to ensure that symptomatic staff could not and did not work during a declared health emergency. The facility submitted a plan of removal at 10:46 PM and it was accepted by the State Agency at 11:08 PM. The immediacy was removed on 7/24/2020 at 12:38 PM after validation that the plan had been implemented. After removal of the immediacy, the deficient practice continued with a scope and severity of F with potential for more than minimal harm for the remaining residents. The findings include: On 3/5/2020 the Governor of the State of Maryland declared that a state of emergency and catastrophic health emergency existed within the entire state of Maryland related to the spread of COVID-19. 1. The facility failed to ensure that symptomatic staff could not and did not work during the declared COVID-19 emergency. On 4/2/2020, The Centers for Medicare and Medicaid Services published COVID-19 Long-Term Care Facility Guidance which provided, that every individual regardless of reason entering a long-term care facility (including residents, staff, visitors, outside healthcare workers, vendors, etc.) should be asked about COVID-19 symptoms and they must also have their temperature checked. On 5/8/2020 the Centers for Disease Control and Prevention (CDC) published updated guidance on COVID-19 symptoms. In addition to fever, cough, and shortness of breath, chills, repeated shaking with chills, muscle pain, headache, sore throat, new loss of taste or smell, persistent pain or pressure in the chest, trouble breathing, new confusion, inability to arouse, and bluish lips or face, the CDC added gastrointestinal symptoms including nausea, vomiting and diarrhea. Review of the CDC website for Coronavirus on 7/20/2020 at 2:50 PM revealed an update on 5/13/2020 for symptoms of Coronavirus which documented, anyone can have mild to severe symptoms. Older adults and people who have severe underlying medical conditions like heart or lung disease or diabetes seem to be at higher risk for developing more serious complications from COVID-19 illness. Watch for symptoms which may appear 2-14 days after exposure to [MEDICAL CONDITION]. Interview of the Nursing Home Administrator (NHA) and Infection Preventionist (IP) on 7/20/2020 at 9:10 AM revealed that the facility was currently experiencing an outbreak of COVID-19 which had begun on or by 6/26/2020. The NHA stated that the outbreak had spread to 32 active cases in the building as of 7/20/2020 and 3 current residents were hospitalized with confirmed COVID-19. In addition, per the NHA on 7/20/2020, 30 employees tested positive and there were 11 resident deaths related to COVID-19 since the 6/26/2020 outbreak. The NHA was asked how the outbreak originated and he stated, Staff #11. When Staff #11 was screened, Staff #11 did not have an elevated temperature. Staff #11 had GI (gastrointestinal) issues and worked 2 days with GI issues. On Friday, 6/26/2020, Staff #11 had a temp and they sent her home, but Staff #11 did not tell anyone she was having symptoms until she got screened with the elevated temp. Staff #11 was interviewed on 7/21/2020 at 10:06 AM and stated that her symptoms started when she got home from work on 6/23/2020. Staff #11 reported that she had GI symptoms, headache, and muscle aches, all of which by 6/23/2020 were symptoms known to be associated with COVID-19. Staff #11 reported that these symptoms continued and that she developed fever in the evening of 6/24/2020 and 6/25/20, however when she woke up her fever was gone. With these symptoms, Staff #11 worked on 6/24/2020 and 6/25/2020. Staff #11 also stated that she had training on COVID-19 and the sick policy back in March or April 2020 and said that staff were told, to make sure you call and tell your supervisor if you have symptoms. Staff #11 stated the facility was always having updates and the IP was always coming around with education. The facility screening process did not identify and enforce that Staff #11 should not work when she reported to the facility with symptoms on 6/24/2020 and 6/25/2020. On 7/20/2020 at 1:15 PM, the surveyor observed the ground floor screening area and reviewed the screening binder. The screening form entitled, Employee and Essential Healthcare Personnel Screening log had 14 columns. The fourth column stated, do you have any of the following symptoms: fever, cough, shortness of breath, sore throat? (yes/no) *if yes, indicate symptoms. The form did not include all symptoms known to be associated with COVID-19 by 6/23/2020, including GI symptoms. The surveyor requested a copy of the form and was told that the IP would have to get the form. On 7/20/2020 at 2:31 PM the IP gave the surveyor a blank Employee and Essential Healthcare Personnel Screening log form and stated, A new screening tool was implemented on 6/23/2020 that had other symptoms on it. We had done mock (survey) and they said there was an update to the screening tool. The literature had stayed the same but there were a couple of changes on that. In the process of getting this uploaded and changed over it wasn't done. The surveyor asked if the form was updated why wasn't it in the screening book. The IP stated that someone needed copies of the tool, so they took the master copy and made copies and used those copies instead of the updated form. The updated form, with the additional symptoms to screen for, was used on 6/23/2020, but was then not used on the days that followed, until nearly a month later when the surveyor requested a copy on 7/20/2020. On 7/20/20, the IP stated, that was fixed today, and I will make sure I check up on that. On 7/20/20 at 2:43 PM the IP gave the surveyor copies of the screening logs dated, 6/23, 6/24, 6/25 and 6/26/2020. Review of the Employee and Essential Healthcare Personnel Screening Log revealed the updated symptoms of fever, cough, shortness of breath, sore throat, chills, rigors, muscle pain, headache, or new loss of taste or smell. On 6/23/2020, Staff #11 answered no to those symptoms. Further review of the Employee and Essential Healthcare Personnel Screening Log documented that Staff #11 did not have a fever, cough, shortness of breath or sore throat on 6/24/2020, 6/25/2020 and 6/26/2020, but the form did not screen for the GI symptoms that Staff #11 was experiencing. The employee answered no to taking fever reducing medications on 6/24 and 6/25, having contact with known COVID-19 in the past 14 day or any exposure to COVID-19. On 6/26/2020 it was documented yes to have taken fever reducing medication and yes to evidence of exposure to COVID-19. The IP stated that she spoke to the nurse that screened Staff #11 on 6/26/2020 and was told Staff #11 didn't look good, so the Director of Nursing (DON) was notified and after Staff #11 said she had someone at home that was sick, they sent her home. Staff #11 also stated she took Tylenol the day before. The IP stated, once I looked at the line listing, I talked to her to see when she started to feel unwell. She said, I got sent home Friday (6/26/2020) and she said that she started 2 days before that with weakness, and stomach upset. First it was muscle aches, headache, and nausea started on 6/23/2020. Staff #11 got tested for COVID-19 on 6/26/2020 and the results of that test were reported as positive on 6/27/2020. Initially she attributed it to yogurt that she and her (family member) ate, that she thought it upset her stomach. When I talked to her the week after and we talked about the symptoms, she was upset about it because she didn't think about it as blatant. Interview of Registered Nurse (RN) #10 on 7/20/20 at 3:00 PM revealed she screened Staff #11 on 6/26/2020 prior to the employee entering the building. RN #10 stated, her eyes looked sleepy, tired and that's when I asked her how she was feeling and probed her a little bit of what was going on. Staff #11 told me a family member had some type of stomach upset and she had it and she did not feel good and was so tired. I made her stay and I called the Director of Nursing and Staff #11 was sent home. Line listings are utilized by Infection Preventionists in healthcare settings to track symptoms of residents, staff and visitors in order to track for common symptoms and promptly isolate any potential evolving outbreak(s). Review of the facility line listing on 7/21/2020 at 9:30 AM, (provided to the surveyor by the IP on 7/20/2020), revealed that Staff #11 started having symptoms on 6/23/2020, was tested for COVID-19 on 6/26/2020 with results obtained on 6/27/2020 indicated Staff #1 was positive for COVID-19. Additionally, it was noted on the line listing that Staff #12 started with a headache on 6/27/2020, was tested for COVID-19 on 6/29/2020 with results obtained on 7/2/2020 which indicated Staff #12 was positive for COVID-19. The IP stated during an interview on 7/21/2020 at 3:10 PM, We called her (Staff #12) on 7/2/2020 with the results and she did not come back to work. Before she came to work on 6/27/2020, she was tired and had a headache. This is the struggle. It's May or June in Maryland, dander, dust/allergies [REDACTED]. Review of education sign-in sheets on 7/21/2020 at 10:30 AM revealed documentation that Staff #11 signed an in-service training sheet dated 3/17/2020 for the topic, COVID-19 Resident Symptoms Update. The overview documented about the new temperature to monitor for was 99.6 Fahrenheit, social distancing, emergency warning signs for COVID-19. A second page included COVID-19 which documented, staff should not report to work if showing signs or symptoms and must call out to a supervisor. The facility screening tool was not updated timely with new symptoms in guidance released on 5/13/2020. After updating the screening tool on 6/23/2020, the old screening tool continued in use for nearly another month. The older screening tool in use did not include the symptoms; nausea, vomiting, diarrhea, fatigue, body aches, congestion or runny nose. On 6/24/2020 and 6/25/2020 Staff #11 worked for 2 days while experiencing GI symptoms and Staff #11 did not report the symptoms prior to working these two days. 2. The facility failed to ensure that staff followed accepted standards of practice for hand hygiene during the declared health emergency. On 4/29/2020, the State of Maryland Health Secretary issued a Directive and Order Regarding Nursing Home Matters pursuant to Executive Order No. 20-04-05-01. This Order required that facilities licensed under Title 19, subtitles 3 and 14 of the Health-General Article and [MEDICAL CONDITION] (nursing homes) shall immediately ensure that they are in full compliance with all U.S. Centers for Disease Control and Prevention (CDC), U.S. Centers for Medicare & Medicaid Services (CMS) and the Maryland Department of Health (MDH) guidance related to COVID-19. On 6/19/2020 in updated Directive and Order Regarding Nursing Home Matters the MDH continued these same requirements. On 5/8/2020 The Centers for Disease Control and Prevention released updated guidance on Hand Hygiene noting that hand hygiene should be performed in the following situations: before resident contact, even if PPE (personal protective equipment) is worn; after contact with the resident; after contact with blood, body fluids, or contaminated surfaces or equipment; before performing aseptic tasks; and after removing PPE. On 7/20/2020 from 10:00 AM to 10:20 AM on the third floor nursing unit Geriatric Nursing Assistant (GNA) #8 was observed carrying a plastic bag with unknown contents out of room [ROOM NUMBER] and then walked into room [ROOM NUMBER]. GNA #8 was wearing a glove on his right hand and the left hand was bare. GNA #8 took the glove off his right hand and threw it in the trash can in room [ROOM NUMBER], then without gloves on took a soiled breakfast tray to the dining room at the end of the hall. GNA #8 had not washed his hands during this observation. GNA #8 then went to the nurse's station, got a hand full of gloves out of the glove box, with his still unwashed bare hands, touched all the gloves as he separated them and put the gloves in his pocket. GNA #8 then walked down the hallway and opened the doorknob to room [ROOM NUMBER], with his bare hands, and entered the room. Still with bare hands GNA #8 picked up the plastic bag that he had placed on the floor and walked into room [ROOM NUMBER], turned on the light switch, and placed the plastic bag on the floor inside the room. GNA #8 then put gloves on both hands and emptied the trash from the roommate in B bed. In the meantime, a resident had walked down the hall and knocked on the door of room [ROOM NUMBER] and opened the door using the doorknob with bare hands. GNA #8 then emptied the trash for A bed with gloves on. GNA #8 took the gloves off and exited the room and went into room [ROOM NUMBER]. GNA #8 had not sanitized his hands. GNA #8 came out of the room, touched the door handle with bare hands and then walked down the hall and opened the linen cart, touched the gowns, pads, and towels and carried that linen back in room [ROOM NUMBER] after touching the door handle with bare hands and shutting the door. The GNA, at no time, sanitized his hands after touching soiled objects. GNA #8 also brought items from one resident room into another resident's room. The NHA and IP were notified of the observation on 7/20/2020 at 12:30 PM. As a result of these findings, a state of immediate jeopardy was declared on 7/22/2020 at 1:50 PM and an IJ summary tool was provided to the facility at that time. The facility submitted the first draft of their plan to remove the immediacy at 6:42 PM and it was not accepted. The facility submitted a second additional draft that was not accepted. The third draft was submitted at 10:46 PM and it was accepted by the state agency at 11:08 PM. The provisions of the plan to remove the immediacy included the following: Education will be completed by Infection Preventionist to department heads on current standard public health emergency guidance regarding working when sick. Education will be completed by the Department heads to their employees on current standard public health emergency guidance regarding working when sick. The Assistant Director of Nursing (ADON) will ensure that all employees receive this training prior to returning to work. This will be monitored by facility education line listing. This education will be completed by 7/23/2020 at 12:00 PM and staff will not be able to return to work until education is completed. Infection Preventionist will continue to follow up with staff who are out with symptoms to determine date of onset and ensure proper reporting, via line listing form, which is submitted to the local health department daily. If any staff reports symptoms prior to last date worked, the QAPI (Quality Assurance and Performance Improvement) team including medical director and clinical consultant will be convened to determine if additional infection prevention measures need to be implemented. The facility has updated its screening tool, including to ask symptoms over the last 24 hours. The facility has added the symptom education to their agency orientation packet to ensure all staff receive additional education. The facility has posted the symptom education at the facility screening table for additional staff opportunity for education. The Immediate Jeopardy was removed on 7/24/2020 at 12:38 PM after validation of the implementation of the plan by the surveyor who was onsite at the facility. 3. The facility failed to ensure that staff utilized personal protective equipment in a manner that met minimum standards and minimized risk for infectious spread. On 4/2/2020, The Centers for Medicare & Medicaid Services published COVID-19 Long-Term Care Facility Guidance which provided for the duration of the state of emergency in their State, all long-term care facility personnel should wear a facemask while they are in the facility. Consistent with the 4/2/2020 CMS guidance, on 6/25/2020, the Centers for Disease Control and Prevention (CDC) published updated guidance (from earlier 3/21/2020, 4/15/2020 and 5/19/2020) entitled Preparing for COVID-19 in Nursing Homes. The CDC directed that healthcare personnel should wear a facemask at all times while they are in the facility. On 4/29/2020, the State of Maryland Health Secretary issued a Directive and Order Regarding Nursing Home Matters pursuant to Executive Order No. 20-04-05-01. This Order required that facilities licensed under Title 19, subtitles 3 and 14 of the Health-General Article and [MEDICAL CONDITION] (nursing homes) shall immediately ensure that they are in full compliance with all U.S. Centers for Disease Control and Prevention (CDC), U.S. Centers for Medicare & Medicaid Services (CMS) and the Maryland Department of Health (MDH) guidance related to COVID-19. On 6/19/2020 in updated Directive and Order Regarding Nursing Home Matters the MDH continued these same requirements. On 7/20/2020 at 8:50 AM, the surveyor observed the facility screening area and process. Without a mask or facial cover, a staff member walked into the building and up to the screening table. The screener took the staff member's temperature via the staff member's forehead. The staff member filled out a paper on the screening table and still with no mask or facial cover on, walked past the screening table, down the hall and went into a room on the right side of the hallway The IP was informed on 7/20/2020 at 12:07 PM of the observation. The IP stated it typically doesn't work that way and that the staff member walked into the room where masks are located. The IP stated, people usually have on a mask when they enter the building. A second observation was made on 7/24/2020 at 8:38 AM. The NHA and the surveyor were standing by the wall at the entrance to the facility watching the screening process. With no mask or facial cover on, Staff #16 walked into the building and proceeded to the screening table where she waited for her temperature to be taken. Staff #16 was screened for symptoms questions. Staff #16 answered questions and then signed a form. At that time the NHA walked over and gave Staff #16 a mask. The NHA was asked if staff were supposed to wear a mask when entering the building and the response was, I prefer it. Observation was made on 7/24/2020 at 8:40 AM of a sign by the front door that stated, masks are required upon entering facility. Facility staff failed to follow the CMS direction, the CDC guidance, or the facility posted instructions. Cross refernce [MEDICAL CONDITION](A)

Based on administrative and medical record review and staff interviews it was determined the facility failed to: 1) provide ongoing supervision of Resident #3 after s/he was found to have inappropriately touched Resident #4 in his/her private area; 2) provide ongoing supervision of Resident #3 after s/he touched Resident #20's breast; and 3) ensure that Resident # 2 was free from verbal abuse by Staff #1 who was observed by facility staff using aggressive and profane language during a verbal exchange with Resident #2. This was evident for 3 of 4 residents reviewed for abuse during this complaint survey. The Minimum Data Set (MDS) is a comprehensive assessment of the resident completed by the facility staff. The MDS is a multi-disciplinarian tool that allows many facets of the resident's care (cognition, behavior, mobility, activities of daily living, accidents, activities, weight, pain and medications to name a few) to be addressed. The MDS assessment is part of a broader RAI (Resident Assessment Instrument) process. The RAI process ties the assessment and care plan to the delivery of care to meet the needs of the resident. 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. Brief Interview for Mental Status (BIMS) is an assessment that assists staff in determining a resident's cognitive understanding. A score of 13-15 indicates cognitively intact, 08-12 indicates moderately impaired, and 00-07 indicates severe impairment. The findings include: 1)The facility failed to ensure that Resident #4 was free from sexual abuse. Review of a facility reported incident (MD 292), on 6/20/18, revealed an allegation that on 5/1/18 Resident #3 was observed rubbing Resident #4 between her/his legs. Medical record review on 6/20/18, revealed a care plan for Resident #3, with an initiation date of 5/6/15, that addressed a behavior problem related to [MEDICAL CONDITION] TBI as evidenced by making sexual advances, intrusive and impulsive behavior, and exposing herself/himself. Interventions included but were not limited to anticipate and meet the resident's needs, caregivers were to provide an opportunity for positive interaction, explain all procedures to the resident before starting, allow the resident time to adjust to changes, explain/reinforce why the behavior is inappropriate and/or unacceptable, psychiatric consultation as needed, medication review as needed, and staff were to gently but firmly tell the resident when his/her behavior was inappropriate. Other interventions included staff educated on monitoring and redirecting the resident's inappropriate behavior, the need to maintain consistent, firm boundaries and instructions not to accidentally encourage inappropriate behavior by sending mixed signals such as allowing the behavior one time and then reacting negatively the next time. Medical record review on 6/20/18, revealed Resident #3 was admitted to the facility for long-term care with [DIAGNOSES REDACTED]. The psychiatric Nurse Practitioner noted on 8/17/17 that the resident does not have the capacity to control his/her behavior and on 10/31/17 that the resident was impulsive and not likely to remember rules and limits. Review of the annual MDS assessment dated [DATE] revealed facility staff entered a BIMS score of 2 out of 15 and 3 out of 15 for the quarterly MDS assessment dated [DATE]. The psychiatric Nurse Practitioner noted on 11/16/17 that resident #3 exposed himself/herself to another resident. It was further noted that the resident failed three trails of antidepressant treatment in an attempt to decrease his/her libido. The resident was to start [MEDICATION NAME]. Review of the Medication Administration Records revealed the resident received [MEDICATION NAME] on 11/16/17, 12/17/17, 1/17/18, 2/17/18, 3/17/17, and 4/17/18. [MEDICATION NAME] may be used off-label to decrease sexual desire. [MEDICATION NAME] was discontinued because the resident's insurance would not cover the cost. The psychiatric Nurse Practitioner noted on 4/12/18 that the resident exposed himself/herself in the dining room on 4/11/18 and asked another resident to touch his/her private area. S/he noted the resident's behavior had been improving with [MEDICATION NAME]. On 4/19/18 the psychiatric nurse practitioner noted the resident was more aggressive since antidepressants had been discontinued. New orders for [MEDICATION NAME] (antipsychotic) and [MEDICATION NAME] (antidepressant) were written. The Nurse Practitioner also noted the resident was demonstrating increased sexual activity, was observed masturbating at the nurse's station and the resident's short-term memory was severely impaired. Medical record review, on 6/20/18, revealed Resident #4 is a long-term care resident with [DIAGNOSES REDACTED]. The resident was noted by the psychiatric Nurse Practitioner on 4/26/18 to have poor insight and impaired judgement. Review of the quarterly MDS Assessments dated 3/29/18 and 5/21/18 revealed facility staff entered a BIMs score of 0.0 for Resident #4. Further medical record review revealed a care plan for Resident #4 that addressed impaired cognitive function and thought processes. Interventions included the need for assistance with all decision making and supervision as needed. A Nursing Assessment note dated 5/1/18 and psychiatric Nurse Practitioner's progress note dated 5/1/18 reported Resident #3 was found in his/her room rubbing Resident #4 between the legs attempting to put his/her hands in Resident #4's pants. The psychiatric Nurse Practitioner noted Resident #3 was increasingly aggressive and hypersexual with behaviors that are difficult to control. S/he recommended increasing the [MEDICATION NAME]. The Nurse Practitioner further recommended issuing a 30-day notice of discharge to the resident. The Nurse Practitioner also noted the Medical Director stated the resident's behavior could be controlled with increased staffing. The psychiatric Nurse Practitioner documented, on 5/1/18, that Resident #4 self-propels in her/his wheelchair and often wanders into other residents' rooms. Resident #3 continued to be seen by the psychiatric Nurse Practitioner including visits on 5/15/18 and 5/31/18 when medications were reviewed and the resident's behaviors were discussed with nursing staff. The Nurse Practitioner's recommendations included providing structured socialization. On 6/20/18 at 12:45 PM the surveyor observed Resident #3 in the dining room with 18 other residents without staff supervision. In interview with the surveyor, on 6/20/18 at 1:05 PM, LPN #3 stated staff keep Resident #3 separated from other residents, redirect him/her when necessary and supervise him/her in the dining room. These instructions are not detailed in the resident's care plan. During an interview with the surveyor, on 6/25/18 at 1:28 PM, LPN #4 was asked how staff manage the resident's sexually inappropriate behavior. LPN #4 stated the resident is redirected. S/he further stated Resident #3 is selective about the individuals he/she touches and is redirectable if staff catch him/her in time. In interview with the surveyor, on 6/25/18 at 1:40 PM, GNA #1 stated the resident has days when s/he needs frequent redirection regarding inappropriate touching of residents and staff. Stated s/he makes rounds on residents approximately every 2 hours and confirmed Resident #3 is not on close observation (intervals greater than every 2 hours). Failure to provide ongoing supervision for Resident #3 who has a history of inappropriate sexual behavior created the potential for psychosocial harm for a cognitively impaired resident (Resident #4) who was unable to give his/her consent to Resident #3's sexual advances. 2)The facility failed to ensure that a functionally impaired resident (Resident #20) was free from abuse by Resident #3. Medical record review, on 6/25/18, revealed Resident #20 was admitted to the facility with [DIAGNOSES REDACTED]. Review of the admission MDS assessment dated [DATE] revealed the resident was dependent on staff for Activities of Daily Living. A Nursing Assessment Note, dated 10/25/17, reported Resident #3 appeared to be having increased sexually inappropriate behaviors. Resident #20 reported to nursing staff that while in the dining room Resident #3 rubbed his/her left breast. During an interview with the surveyor, on 6/25/18 at 1:20 PM, Resident #20 and her/his family member confirmed the inappropriate touching that occurred on 10/25/17. The resident's family member stated s/he was notified about the incident. In interview with the surveyor, on 6/25/18 at 1:28 PM, LPN #4 stated Resident #3 is selective about who s/he touches, is redirected when s/he is inappropriate and confirmed the resident is not on close observation. In interview with the surveyor, on 6/25/18 at 1:40 PM, GNA #1 stated the resident has days when s/he needs frequent redirection regarding inappropriate touching of residents and staff. Stated s/he makes rounds on residents approximately every 2 hours and confirmed Resident #3 is not on close observation (intervals greater than every 2 hours). Medical record review and staff interview failed to reveal evidence that Resident #3's care plan was adjusted to reflect the need for increased supervision or other interventions to maintain the safety of vulnerable residents. 3)The facility failed to ensure Resident #2 was free from verbal abuse. Review of facility reported incident MD 786, on 6/21/18, revealed an allegation that Staff #1 verbally threatened Resident #2 on 3/2/18. Review of a written statement from PTA #1 revealed Staff #1 threatened to F k, the resident (Resident #2) up, suggested s/he was confined to the nursing home while s/he (Staff #1) was not and implied Resident #2 would suffer bodily harm if s/he went out on the porch to smoke. PTA #1 confirmed this information based on her/his observation of the interaction during an interview with the surveyor 6/21/18 at 11:59 AM. A written statement submitted by RN #2 noted the Resident reported feeling unsafe after this incident and the police were called. During an interview with the surveyor, on 6/21/18 at 11:49 AM, the Director of Nursing (DON) stated Resident #2 reported feeling unsafe after the abusive exchange with Staff#1. The DON confirmed that the facility substantiated the abuse allegation and reported the matter to the contractor that employed Staff #1. In interview with the surveyor on 6/21/18 at 12:04 PM the Environmental Services Manager stated he/she investigated the matter and based on the facility's and his/her investigative findings the contractor terminated Staff #1's services. The findings regarding abuse were discussed with the Administrator and Director of Nursing on 6/26/18 at approximately 5:00 PM. Refer to F684, F607

Based on medical record review, observation and interviews with facility staff, it was determined that the facility staff failed to prevent a resident who was a known elopement risk from eloping, due to multiple failed systems including: 1) wanderguard system malfunction, 2) no documented wanderguard functionality and placement checks and 3) not following their policy of updating their photographic directory of residents identified at risk for elopement (Resident #1). After the elopement occurred on 8/23/17, the facility staff failed to establish a process to maintain an updated photographic directory of residents identified at risk for elopement. This was evident for 5 out of 27 residents that were identified at risk for elopement reviewed during a complaint survey. As result of these findings an Immediate Jeopardy was called at 3:05 PM on 1/29/2018. The Immediate Jeopardy was abated on (MONTH) 29th, (YEAR) at 6:15 PM when the facility staff updated the Residents at Risk for Elopement book to include all residents at risk's photographs, developed a process to keep the book up to date and submitted the plan to the surveyor. After removal of the immediacy, the deficient practice continued at a scope and severity of D with potential for minimal harm for the remaining residents. The findings include: Review of the medical record on 1/29/18 revealed Resident #1 was admitted to the facility on [DATE] with a history of elopement attempts from another facility and was assessed to be elopement risk on 7/31/17. At that time a care plan for elopement risk/wanderer was implemented. Interventions for the elopement risk/wanderer care plan were: 1. to check placement and function of safety monitoring device every shift and 2. wanderguard bracelet as ordered/change as needed. Review of Resident #1's (MONTH) (YEAR) Treatment Administration Record revealed the facility staff failed to document the functionality and placement of the wanderguard every shift. Review of nurses note dated 8/15/17 states, Resident is extremely agitated this am he is exit seeking, aggressive with staff, he removes several wanderguard devices place by staff. On 8/16/17 there was a physician order [REDACTED]. Review of the facility reported incident revealed on 8/23/17 the Resident eloped from the building by telling the receptionist he/she was a visitor and was found uninjured 2 blocks from facility. The Resident was then placed on a 1 to 1 and discharged later that day to another facility. Interview with the facility's receptionist on 1/29/18 at 9:30 AM revealed on 8/23/17 the Resident approached the front desk and stated he/she was a visitor and needed to be let out of the building. The receptionist stated he/she let out the Resident and then worried the person she let out was a resident and not a visitor. The receptionist stated he/she realized that Resident #1 had eloped by looking in the computer for the name of the resident that Resident #1 stated he/she had come to visit. The receptionist then alerted staff. When the surveyor asked the receptionist how he/she identifies residents at risk for elopement he/she showed the surveyor the facility's Residents at Risk for Elopement book. During the interview, the receptionist stated on 8/23/17 Resident #1 was not included on the list or had a photograph in the Residents at Risk for Elopement book. Review of the Residents at Risk for Elopement book on 1/29/18 revealed the book included a list of all residents at risk for elopement and pictures of those residents with a revision date of 12/5/17. The surveyor then compared the list of residents at risk for elopement to the residents' pictures and 5 out of 27 residents (Resident #12, #18, #20, #21, #24) on the list had their names but not their pictures. 1 out of 27 residents (Resident #8) included on the list had been discharged from the facility. Per facility policy for Resident Elopement, with a revision date of (MONTH) 2012, the facility creates a photographic directory of residents identified at risk for elopement. Also included in the facility policy is the facility appoints a staff member responsible for updating the directory/binder as needed. Interview with the Director of Nursing (DON) on 1/29/18 at 2:30 PM revealed residents are identified to be at risk for elopement at weekly risk meeting on Thursdays and at daily morning meetings. The DON also identified the Activities Director is then responsible for updating the Residents at Risk for Elopement book. Interviews with the DON, Administrator, Activities Director and receptionist on 1/29/18 failed to provide a rationale why the book had not been updated timely with an accurate list and with all residents' pictures. The facility staff failed to keep the book up to date therefore putting other residents at risk for elopement. Review of the facility's QAPI plan for elopements dated 8/28/17, submitted to the surveyor, included that the facility developed a plan for wanderguard interventions and documentation. Review on 1/29/18 of two additional residents' medical record (#18 and #20) included in the Residents at Risk for Elopement book revealed wanderguard documentation for functionality and placement complete. Review of the facility investigation did not include any documentation that Resident #1 was wearing a wanderguard at the time of the elopement. Interview with the Regional Manager on 1/29/18 at 5:30 PM revealed the facility discovered during the investigation of the elopement on 8/23/17, a problem with their wanderguard system and addressed it in the QAPI plan dated 8/28/17. Per interview with the Regional Manager testing and drills were conducted to ensure the wanderguard system was working properly. On 1/29/18 during the complaint survey, the surveyor identified no issues with the wanderguard system functionality and documentation. Also included in the facility's QAPI plan was all elopement books were updated at the time of the event, and will be reviewed weekly during at-risk management meeting. The facility's QAPI plan included: The QAPI Committee is responsible for the on-going monitoring for compliance. Interview with the Administrator and DON on 1/29/18 at 2:50 PM confirmed the facility staff failed to keep the photographic directory of residents identified at risk for elopement up to date. See F867

Based on medical record review and interviews, it was determined the facility staff failed to prevent a resident (# 3) from eloping from the facility which resulted in an Immediate Jeopardy-cited past noncompliance. This was evident for 1 of 11 residents selected during the complaint survey. The findings include: Medical record review for Resident # 3 revealed the resident was admitted to the facility with a history of elopement. In the nursing home setting, elopement is considered a type of unsupervised wandering. Specifically, it is unsupervised wandering which results in a resident leaving the nursing home facility. Supervision is a critical component to a safe nursing home facility. After admission to the facility interventions were in place for wandering for Resident # 3: the facility staff placed a wandergaurd bracelet on the resident. The Portable WanderGuard system is a battery-operated door monitor designed to monitor individuals with wandering, flight-risk or aggressive behaviors. The patient wears a WanderGuard wristband signaling device. When he or she attempts to go through the monitored doorway, an alarm sounds at the door and at the remote annunciator. This selective alarm mode allows everyone else to come and go freely. The remote annunciator alerts caregivers to alarms when they're out of hearing range. The facility staff also initiated a care plan to address the elopement risk of Resident # 3- Potential for Safety-exit seeking related to wandering . Care plans provide direction for individualized care of the client. A care plan flows from each patient's unique list of [DIAGNOSES REDACTED]. Continuity of care. The care plan is a means of communicating and organizing the actions of a constantly changing nursing staff. On 10/4/16 Resident # 3 was moved from the ground floor where he/she had been living to the 3rd floor. On 10/18/16 at 9:00 PM the facility staff reported Resident # 3 had eloped from the facility. Review of the Incident Report conducted by the facility staff revealed: Resident had an unassisted leave from the facility. Per staff and Resident # 3 he/she left as a result in medication change and a concern of over medication . It was further noted, while the facility staff was looking for Resident # 3 in the facility, the family of Resident # 3 was on the phone notifying the facility that Resident # 3 was at their house. The resident was returned to the facility with no injuries noted. Tour and observations of the facility on 1/19/17 revealed that the facility consisted of 4 resident floors (Ground-3rd floor). The ground floor had a camera at the ground floor nurses' station that visualized- the immediate inside and outside areas of a locked ground floor door that exits to the outside of the facility. There was no Wanderguard monitor on this door. To enter or exit the facility, on the ground unit a person had to be buzzed in or out. Interview with the receptionist and Director of Nursing on 1/19/17 at 12:00 PM revealed the facility staff uses at the camera at the ground floor nurses' station to determine the validity of buzzing a person in or out. It was further revealed, an intercom is also present at the nurses' station in which questioning could occur if further information is needed. The first floor also had a locked door that exits to the outside. During the day shift, till 8:00 PM, there was a receptionist present at that door. The receptionist could also visualize the camera view on the ground floor. During the day shift, the receptionist would use the camera to buzz staff, visitors, and vendors and accompanied residents in and out of the building from the ground floor exit door. Floors 2 and 3 have no access to the outside of the building. The facility staff determined, upon their investigation of the elopement of Resident # 3- On review of the camera footage, it was seen Resident # 3 was sitting in the back hallway (on the ground floor). The dentist exited. (There is no evidence to the actual time of the dentist departure or the facility staff member that buzzed the dentist out). Resident # 3 got to the door before it closed completely. Resident # 3 then held the door ajar while looking through the window of the door. After a short time, Resident # 3 then opened the door and exited. The resident then explained he/she took 2 buses to arrive at the family member's house. Interview with the receptionist on 1/19/17 at 1:00 PM stated the expectation is the facility staff member who buzzes a person out (regardless of who- staff, visitor, and vendor) is to observe the camera and assure the outside door closes completely. Interviews with staff nurse # 1 and # 2 on 1/19/17 at 1:10 PM verbalized the same expectations. The Director of Nursing also verbalized the expectation of assuring the door is completely closed prior to leaving camera range. Despite the interventions in place for Resident # 3, he/she was able to travel from the 3rd floor to the ground; sit outside of camera range and elope through the exit door prior to its full closure when the dentist exited. The incident of Resident # 3's elopement was a facility reported incident, therefore the facility staff was aware of the elopement. Interview with the Director of Nursing and corporate nurse on 1/19/17 at 12:30 PM revealed the facility staff conducted meetings to prevent the incident from occurring again. On 10/24/16 the facility staff conducted a Safety Meeting with the interventions of: 1. Applying key pad at exit door on the ground floor 2. Installing a set of doors in hall near the side of break room 3. Potentially change the reception area to the ground level (on 1st floor at present) 4. Obtain estimates for key pads and doors In addition to the above interventions, the facility staff also put the following actions in place: 1. Conduct safety meetings- completion date of 10/24/16 2. Audit all residents currently on wander guards- completion date of 10/29/16 3. Obtain estimates for key padding doors, installing doors and possibly changing reception area to ground floor- completion date 11/18/16 4. Review of wander guard Policy and Procedure with staff and vendors- completion date 11/1/16 5. Conduct competency evaluation for Resident # 3-completeion date 10/20/16 6. Obtain new picture of Resident # 3 (for receptionist a front desk for camera observation) completion date 10/26/16 Further review revealed the facility staff mailed a letter to vendors striving the importance of ensuring closure of all doors on exit and entrance. The facility staff also conducted monthly in-services on Wandering and Elopement. The Director of Nursing and corporate nurse was notified on 1/19/17 at 3:40 PM that an Immediate Jeopardy -past non-compliance- had been cited by the Office of Health Care Quality in the failure of the facility staff to prevent the elopement of Resident # 3.

Based on record review and staff interview, it was determined that the facility staff failed to recognize a medication order discrepancy, failed to monitor and evaluate the medication regimen as a potential cause of [MEDICAL CONDITION] activity (Resident # 152), thoroughly address a low potassium blood result for a resident (# 115) in a timely manner, failed to obtain a blood pressure with the administration of [MEDICATION NAME] for a resident (# 58), failed to administer the ordered doses of a medication as ordered to a resident (# 109, # 141), failed to identify target behaviors and the continued need for a medication (# 11) and failed to attempt a Gradual Dose Reduction for a resident (# 134). This was evident for 7 of 45 residents selected for review in the stage 2 survey sample. The findings include: 1. The facility staff failed to recognize a medication order discrepancy failed to monitor for efficacy and adverse drug consequences and failed to evaluate the medication regimen as a potential cause of [MEDICAL CONDITION] activity. [MEDICAL CONDITION] is a progressive disorder caused by the loss of [MEDICATION NAME]-producing brain cells affecting mobility and control of the skeletal and muscular system. [MEDICATION NAME] is a chemical messenger that sends information to the parts of the brain that control movement and coordination. When a person is diagnosed with [REDACTED]. Therefore, messages from the brain telling the body how and when to move are delivered much slower leaving the person powerless to initiate and control movements in a normal way. Since [MEDICAL CONDITION] is chronic and progressive, the signs and symptoms worsen over time gradually. Characteristic features include resting tremors, muscle rigidity, balance problems, slowed movement and difficulty walking. There is no cure for [MEDICAL CONDITION]; however, medications provide relief from the crippling and debilitating symptoms. [MEDICATION NAME] is a combination drug of [MEDICATION NAME] and [MEDICATION NAME]. [MEDICATION NAME] is a natural substance found in plants and animals and when given to people with [MEDICAL CONDITION] converts to [MEDICATION NAME] in the brain reversing disabling symptoms and helping to control movement. [MEDICATION NAME] prevents the breakdown of [MEDICATION NAME] in the blood stream allowing more to reach the brain. According to the manufacturers package insert approved by the FDA (Food and Drug Administration), [MEDICATION NAME] is an immediate-release formulation designed to begin release of ingredients within 30 minutes and should be taken at regular intervals as scheduled by the physician. Several doses may be required during the day since the half-life or duration of the drug action is about 1.5 hours. The prescribed dosage regimen must be titrated carefully and most importantly, should not be stopped or reduced abruptly without consulting the physician. [MEDICATION NAME]? CR ([MEDICATION NAME]-[MEDICATION NAME]) is a continuous-release combination of [MEDICATION NAME] and [MEDICATION NAME]. The ingredients are released over a 4-6 hour period and the duration is prolonged because of continuous absorption. The time between doses should be 4-8 hours during the waking day. The daily dosage must be determined by careful titration and monitored closely during the dose adjustment period for the appearance or worsening dyskinesias (unintended, involuntary, uncontrollable movements that include twitches, jerking, twisting or simple restlessness; it does not include tremor). In [MEDICAL CONDITION] the excess movement of dyskinesia is a total contrast to the bradykinesia (slow movement and rigidity) so typical of the disease. Dyskinesias often occur as a side effect of long-term therapy with [MEDICATION NAME]. Review of Resident # 152's medical record revealed the resident was admitted to the facility on [DATE] for rehabilitation. Review of the hospital transfer summary, dated 11/27/13, revealed instructions to administer [MEDICATION NAME] 25/100 ([MEDICATION NAME] 25 mg (milligrams)/[MEDICATION NAME] 100 mgs) by mouth every 2 hours. Review of the physician's orders [REDACTED]. Review of the MAR's (Medication Administration Record) revealed the facility staff administered [MEDICATION NAME]? CR every 2 hours. On 1/7/14 the nursing staff documented the resident fell and had [MEDICAL CONDITION] activity [MEDICATION NAME] 7 minutes. The physician was notified and ordered the resident be sent to the hospital via 911. The resident was evaluated at the hospital and returned to the facility on [DATE]. Review of the hospital discharge summary, dated 1/9/14, revealed the neurology consultation suggested to treat the movement disorder with [MEDICATION NAME]/[MEDICATION NAME], not anti-[MEDICAL CONDITION] medications. The facility staff continued to administer [MEDICATION NAME]? CR q 2 hours as ordered. On 1/12/14 at 2:15 pm, the facility staff documented the resident had "[MEDICAL CONDITION] activity" [MEDICATION NAME] approximately 7 minutes. The physician was notified and ordered the resident be sent to the hospital via 911. The resident returned to the facility later that evening with a [DIAGNOSES REDACTED]. On 1/13/14 the nursing staff documented the resident had [MEDICAL CONDITION] activity with elevated blood pressure [MEDICATION NAME] 2-3 minutes at 11:38 am. The nurse practitioner saw the resident and ordered anti-[MEDICAL CONDITION] medications ([MEDICATION NAME]/[MEDICATION NAME]) and changed the resident's [MEDICATION NAME] CR (controlled release) to regular [MEDICATION NAME] (immediate release). Later that evening at 7:30 pm the nursing staff documented the resident had [MEDICAL CONDITION] activity with elevated blood pressure [MEDICATION NAME] approximately 4 minutes. On 1/14/14 the nursing staff documented the daughter spent the night. At 1 am, the daughter requested the resident be sent to the hospital to see a neurologist. The physician was notified and orders obtained for transfer. The physician saw the resident on 1/14/14 noting "[MEDICATION NAME]/[MEDICATION NAME]-Overdose? or over medicated with side effects?" Interview with the nurse practitioner on 3/10/14 at 2:20 pm, revealed the resident should have received [MEDICATION NAME] 25/100 mg every 2 hours per the hospital transfer summary instructions dated 11/27/13. The order [MEDICATION NAME] was changed on 1/13/14 (48 days later). Interview with the physician on 3/11/14 at 11:16 am, revealed the order for the [MEDICATION NAME]? CR was a "typo" and was corrected when brought to his attention. Further review of the medical record revealed the facility staff administered the [MEDICATION NAME]? CR every 2 hours from 11/17/13 through 1/13/14 (48 days), failed to recognize the medication order discrepancy, failed to monitor for efficacy and adverse drug consequences and failed to evaluate the medication regimen as a potential cause of [MEDICAL CONDITION] activity resulting in the addition of anticonvulsants to treat recent-onset [MEDICAL CONDITION] that can be adverse consequences of medications. Interview with the nursing home administrator, director of nursing and assistant director of nursing on 3/13/14 at 10:34 am, confirmed the facility staff failed to recognize the medication discrepancy, administered [MEDICATION NAME]? CR every 2 hours and failed to evaluate the medication regimen. See F 386 and F 428 2. The facility staff failed to thoroughly address a low potassium level for a resident in a timely manner. Based on review of resident # 115's record it was revealed that on 1/9/14 the facility staff obtained a laboratory blood test with the results of the potassium level at 3.0 (normal 3.5-5.1). At that time, the facility staff notified the nurse practitioner. Record review revealed on 1/9/14 (no time) the nurse practitioner ordered: discontinue [MEDICATION NAME] 5 milligrams by mouth; [MEDICATION NAME] 2.5 milligrams by mouth 3 times a week and repeat BMP (Basic Metabolic Panel) in 1 week; however, there is no evidence that the nurse practitioner address the low potassium at that time. The BMP is a routine blood test that encompasses the potassium level. [MEDICATION NAME], is a medication used to reduce the swelling and fluid retention caused by heart failure or kidney disease. It causes the kidneys to reduce the amount of water and salt in the body by increasing the amount of urine. Normally, at the excretion of urine is increased, so is the excretion of potassium. Potassium ions are necessary for the function of all living cells potassium depletion can result in various cardiac dysfunctions (irregular heart beats). Interview with the physician on 3/10/14 at 8:10 AM revealed that he would have administered a small replacement dose of potassium, added a dietary supplement of potassium (banana or orange juice) and would have repeated the BMP in 48 hours. Interview with the nurse practitioner on 3/11/14 at 1:40 PM revealed that she was more concerned with decreasing the dose of the medication in the expectation that the potassium would level off. Further interview with the nurse practitioner at that time revealed that a small dose of potassium supplement should have been administered. Interview with the director of nursing, assistant director of nursing and administrator on 3/13/14 at 1:00 PM revealed that the facility staff failed to thoroughly assess and intervene for a low potassium level. 3. The facility staff failed to obtain/document blood pressure with the administration of [MEDICATION NAME]. Review of resident # 58's record revealed on 1/4/14 at 3:00 PM the physician ordered: [MEDICATION NAME] .4 milligrams SL (sub-lingual- under the tongue) as needed, may repeat 3 times for complaint of chest pain. Review of the Medication Administration Record [REDACTED]. Relaxation of vascular smooth muscle is the principal pharmacological action of [MEDICATION NAME] which usually causes a significant decrease in the blood pressure. Review of the revealed that the facility staff documented the administration of the [MEDICATION NAME] on 1/12/14 at 4:42 PM, 1/12/14 at 5:29 PM and 1/12/14 at 8: 53 PM; however, there is no evidence that the facility staff obtained the blood pressure. Interview with the director of nursing, assistant director of nursing and administrator on 3/13/14 at 1:00 PM revealed that the facility staff failed to obtain/document the blood pressure when administering a medication to a resident that lowers the blood pressure. 4. The facility staff failed to administer a medicaiton to a resident as ordered by the physician. Review of resident # 109's record revealed on 5/12/13 the physician ordered: [MEDICATION NAME] 250 milligrams-2 tablets by mouth today and 1 tablet (250 milligrams) by mouth every day for 4 days. [MEDICATION NAME] is an antibiotic used to treat infections. Review of the Medication Administration Record [REDACTED]. (Further review of the MAR indicated [REDACTED]. Interview with the director of nursing, assistant director of nursing and administrator on 3/13/14 at 1:00 PM revealed that the facility staff failed to administer a medication as ordered by the physician. 5. The facility staff failed to attempt a Gradual Dose Reduction (GDR) for a resident. Review of resident # 134's record revealed on 4/29/13 the physician ordered: [MEDICATION NAME] .25 mgs 2 times a day for [MEDICAL CONDITION]. [MEDICATION NAME] is in a class of medications called atypical antipsychotics. It works by changing the activity of certain natural substances in the brain. Rispersal is used to treat the symptoms of [MEDICAL CONDITION] (a mental illness that causes disturbed or unusual thinking, loss of interest in life, and strong or inappropriate emotions) in adults. It is also used to treat episodes [MEDICAL CONDITION](frenzied, abnormally excited, or irritated mood) or mixed episodes (symptoms [MEDICAL CONDITION] depression that happen together) in adults. During the first year of use of antipsychotics there must be a gradual dose reduction attempt in two separate quarters, unless clinically contraindicated. The attempts should be at least a month apart and to determine if the use of medication is necessary and to possibly administer the least amount of medication to obtain the desired effects. After the first year, the gradual dose reduction should be attempted at least once a year. If the gradual dose reduction is unsuccessful, further reductions can be considered "clinically contraindicated". Review of the medical record and interview with the assistant director of nursing on 3/12/14 at 12:00 PM revealed no evidence that a GDR had been attempted on the resident with the [MEDICATION NAME]. Interview with the director of nursing, assistant director of nursing and administrator on 3/13/14 at 1:00 PM revealed that the facility staff failed to attempt a GDR for a resident. 6. The nursing staff failed to recognize that [MEDICATION NAME] was not being administered as ordered resulting in the resident receiving extra doses of the medication. [MEDICATION NAME] is a medication used to treat [MEDICAL CONDITION] Disorders. Review of resident # 141's medical record on 3/12/14 at 2 pm, revealed a physician's orders [REDACTED]. Review of the Medication Administration Record [REDACTED]. According to the Medication Administration Record [REDACTED]. Further review of the medical record revealed a Free [MEDICATION NAME] level was ordered on [DATE], results were 2.33. The medication was placed on hold. The [MEDICATION NAME] level in the body is measured through blood tests to ensure an effective dosage is being administered. The normal Free [MEDICATION NAME] level range is from (1.0-2.0). Interview with the charge nurse and the pharmacist on 3/13/13 verified the resident recieved extra doses of the medication. 7. The facility staff failed to identify target symptoms and justify continued use of psychoactive medications. Record review for Resident #11 revealed a failure to clearly identify target symptoms for each psychoactive medication and a rationale for continued use. Review of the Medication Administration Record [REDACTED]. The Behavior flow sheets did not record the demonstration of anxiety symptoms daily. Further review of the record failed to reveal information regarding the frequency and intensity of the symptoms that require the daily administration of [MEDICATION NAME] or individualized interventions to manage the resident's mental health needs, including non-pharmacological techniques. The findings were confirmed with the assistant director of nursing on 3/10/14 at 1:45 PM.

Based on medical record review, staff interview, and observation of the resident and the resident's environment, it was determined that the facility staff failed to implement corrective or preventative measures, in a timely manner, after the resident had fallen from her bed. This was evident for 1 of 34 residents' selected for review in the stage 2 sample. The findings are as follows: Resident # 22 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The resident's fall risk was assessed every 3 months with the last assessment dated [DATE] scoring the resident as an " 8 " (total score of 10 or above represents a high risk for falls). The resident has a care plan to prevent and manage falls and it is updated as required. According to the care plan the resident suffered falls on 1/15/11 and 1/17/11 and did not have a fall since May 2010. Review of the medical record revealed that the resident had a fall on 1/15/11 at 4:55 PM. The "Interdisciplinary Post Fall Review " form " Description of Fall " is as follows: Resident was found stuck between the bed and the wall. According to the RCS (Resident Care Specialist) who found resident states that she found resident between bed and the wall and she was trying to pull resident out and the resident fell and hit her forehead on the floor and sustained bump on the forehead. On the "Change of Condition Report " under the "Situation " section: Things that make the problem/symptom worse are " ________ " (air mattress was written in the space provided). On the " Interdisciplinary Post Fall Review " under the "Conditions That May Contribute " had "change of mattress " was written in the space provided. Under the " Environmental Factors" sections "equipment " is checked and " air mattress" is written in the space provided. The summary of the interdisciplinary team: " Remove air mattress and have maintenance check locks on the bed " . Further review of the medical record revealed that the resident had another fall on 1/17/11 at 6:30 AM. " Description of fall " is as follows: Resident was found sitting in an upright position on the right side of bed on floor mat. Under " Conditions that may contribute " : history of falls and new air mattress placement. The summary of the interdisciplinary team: " Remove air mattress from bed, maintenance to check locks on bed " . Review of the nurses ' notes revealed the following: 1/11/11 " .....adjusting ok to air mattress " . 1/12/11 " ...rolled off air mattress times 3 this AM " . Again on 1/12/11 " ...Also rolled off the air mattress times 1 this shift to the floor matt.... " 1/13/11, written at 7:30 AM " .....Patient keeps rolling out of air mattress times 4 during this shift... " No nurses' note was written on 1/15/11, however, there was a change in condition explaining that the resident was found between the bed and the wall as noted above. On 1/16/11 written at 6:30 AM the nurses ' note states the following " .....Resident continues to roll herself onto fall EZ mat... 1/16/11 at 3 PM the nurses notes states the following " Air mattress not conducive for resident....... " 1/16/11 written at 10 PM the nurses note states the following " ...Air mattress is not comfortable to patient... " Further review of the medical record revealed a physician's orders [REDACTED]. During an interview with the maintenance man on 1/21/11 at 11:00 AM, he stated he exchanged the mattress on 1/17/11 and that the breaks are fine. Observation of the bed confirmed that the brakes are tight and the bed did not move. The resident has physician orders [REDACTED]. No side rails - low bed with protection pad on floor when in bed. Bed against wall to provide safety secondary to dementia and history of self injury related to uncontrollable movement. Observation of the resident on 1/21/11 at 10:40 AM revealed the resident in bed. She was positioned on her back and she extended and flexed both of her legs. She also had her right arm over her head. While observing the resident she had also turned over onto her right side. Observation of the resident's environment on 1/21/11 at 10:40 AM revealed that the resident's bed was a low bed which was close to the floor and it did not have the 1/4 rails raised and that a fall mat was on the right side of the bed. However, the resident's bed was not against the wall as ordered by the physician. Observation of the wall revealed that there was a support beam sticking out from the wall 5 inches which prevented the bed from being against the wall. (This is how the resident was able to be stuck between the mattress and the wall on 1/15/11.) At this time the unit manager was made aware of the surveyor's concerns of the 5 inch gap between the bed and the wall. The unit manager acknowledged the 5 inch gap. Shortly after, the Administrator and the Director of NNursing were seen in the resident's room reviewing the situation. The resident's bed was than repositioned to be perpendicular to the wall and fall mats were placed on both sides of the bed. During an interview with the Director of Nursing on 1/21/11 at 12:15 PM, she acknowledged that the potential for possible entrapment existed until the resident's bed had been repositioned to be perpendicular to the wall. She also acknowledged that the bed was not able to be positioned against the wall as ordered by the physician because of the support beam. The night shift nurse who documented the incident of the resident being stuck between the bed and the wall on 1/15/11 was interviewed on 1/25/11 at 6:55 AM. The surveyor asked the nurse what she had done to assure that the resident would not get stuck again. The nurse responded that she continued to monitor the resident. It was concluded that nothing was done to replace the air mattress other than to document on the Post Fall Review to remove the air mattress. On 1/25/11 at 10:46 AM, the survey team met with the Administrator and the Director of Nursing to inform them the situation described above was considered an immediate jeopardy. The facility staff knew about the situation since 1/12/11 when the resident had rolled off of the air mattress. No corrective action occurred until 1/17/11. At this time the air mattress had been removed, however, since the resident's bed could not be against the wall because of the support beam the resident was still at risk to get stuck between the mattress and the wall. This was corrected after surveyor intervention on 1/21/11. The facility's staff submitted a plan of correction on 1/25/11, and the immediate jeopardy was abated.