Every finding on record at Autumn Lake Healthcare at Patuxent River

Based on medical record review and staff interview it was determined that the facility staff failed to administer medications according to the physician orders. This was evident for 2 out 3 Resident (#16 and #7) reviewed during the complaint survey regarding medication administration.The findings include:Documentation is an integral part of medication administration. Documentation communicates the timing, dosing, and effect of any medications received by a patient. In the setting of skilled nursing care, residents are often prescribed multiple medications for significant medical conditions. They are also often more vulnerable to medication errors and more prone to changes in conditions that require review and adjustment of their medication regimen. Inaccurate medication documentation has the potential to place residents at significant risk of medication error, provide incomplete or inaccurate information for providers and care givers to evaluate, and represents a failure of basic medication administration principles.Late documentation is a form of inaccurate documentation and is worsened if the documentation does not document when medications were actually given. 'Late administration' is defined as giving medication greater than 1 hour after a medication is due. 'Late documentation' is defined as not documenting immediately after administration. 1. Secondary to a complaint, the medical record for Resident #16 was reviewed. The complaint alleged that insulin was administered late or after meals. The family was further concerned, as the resident was admitted with a wound and they reported the surgeon was adamant about glucose control.Review of the medical record for Resident #16 on 4/7/26 at 8:50 AM revealed admission to the facility for strict diabetic monitoring secondary to wound healing.On admission, according to the hospital discharge instructions, Resident #16, was to be administered Novolog flex pen 7 units prior to meals, ordered at 630, 1130, 1630 and 2000, additionally, on 3/27/26 Resident #16 was placed on a sliding scale schedule before meals and at bedtime, 630, 1130, 1630 and 2000 to coincide with the Novolog flex pen 7 units.A closer review of the administration times of the medication on 4/8/26 at 7:35 AM revealed:Novolog Flex pen for 3/20/26 4:30 PM signed off at 7:23 PM,Novolog signed flex pen and sliding scale signed off on 3/30/26 for 11:30 AM at 1:02 PM,4/1/26 for 11:30 AM flex pen signed off at 1:12 PM and sliding scale signed off at 2:40 PM, 8:00 PM signed off at 9:31 PM,4/2/26 for 11:30 AM both flex pen and sliding scale signed off at 1:00 PM,4/3/26 8:00 PM sliding scale signed off at 10:00 PM,4/4/26 6:30 AM both flex pen and sliding scale signed off at 8:17 AM, 11:30 AM both signed off at 2:45 PM, 4:30 PM AND 8:00 PM sliding scale signed off at 10:03 PM,4/5/26 11:30 AM both flex pen and sliding scale signed off at 1:32 PM.A review of Resident #16's documented blood glucose from 3/15-4/9/26 ranged from 70 mg/dl to 349mg/dl. The identified concerns were reviewed with the DON starting on 4/7/26 and throughout the survey. 2. A review of Resident #7's medical record was completed on 4/10/26 at 12:15 PM secondary to a facility reported incident. The family had concerns with the care provided on 1/11/26.A review of the available documentation of nursing notes, vital signs, and ordered medication revealed multiple inconsistencies. According to the residents vital signs column in the electronic medical record, at 10:38 AM his/her blood pressure was 90/60 mm/Hg, the next recorded was at 2:06 PM was 122/71 mm/Hg.Review of the medication administration record (MAR) revealed that the order was for the blood pressure to be checked at 8AM-12PM-4PM-8PM. It is checked with the concurrent administration of Midodrine (treats low blood pressure).Further review of the administration of the Midodrine and blood pressure checks since admission noted for the ordered 1/8/26 8:00 AM was signed off at 10:07 AM, 1/9/26 8:00 AM was signed off at 12:03 PM which was 4 hours after the scheduled dose. Resident #7 was sent to the emergency room on 1/11/26 secondary to hypotension.The identified concerns were reviewed with the DON on 4/13/26 and the facility Administrator during exit on 4/13/26.

Based on medical record review, observation and interview it was determined that the facility failed to complete accurate assessments of a resident related to the functional use of extremities on the quarterly and annual minimum data set (MDS). This was determined during the review of an injury of unknown origin for 1 of 3 residents (Resident #1)The findings included:The Minimum Data Set (MDS) is a federally mandated assessment tool used by nursing home staff to gather information on each Resident's strengths and needs. Information collected drives resident care planning decisions. MDS assessments must be accurate to ensure that each resident receives the care they need. The medical record of Resident #1 was reviewed on 4/10/26 at 7:48 AM related to a report of injury of unknown origin. This review identified a healed treated wound on the inside of a bed bound residents' leg, with interventions put in place. The facility MDS coordinator was interviewed on 4/10/26 at 10:10 AM. She was asked specifically about Resident #1's assessment and stated that 'if I am able to move it, its coded no impairment though its passive, the resident can't follow directions to move on their own.' It was reviewed at this time that on the 2/26/25, 5/30/25 and 8/28/25 MDS assessments, all were coded as Resident #1 had bilateral impairments to the lower extremities.On the 11/24/25 and 3/4/26 MDS assessments the bilateral lower extremities were coded as no impairment. Staff # 3 was asked what the change was, or why she coded differently. She stated that she just codes what is presented at the time. Surveyor observed the healed area on Resident #1's leg with the assigned nurse LPN #11 on 4/10/26 at 11:55 AM. LPN #11 attempted to reposition the residents' legs and they were difficult to move. At this time this surveyor requested the MDS nurse to come to the resident's room. At 12:00 PM she arrived at the resident room with the facility DON. She was asked to show how she performed her assessments to properly code the resident's status on the MDS.MDS staff #3 then proceeded to flex Resident #1's left ankle back and forth. This surveyor asked if staff #3 thought that that was full flexion, and she stated that 'it's moving.' This surveyor looked at the DON and stated that this would be reviewed with the office MDS coordinator. These concerns were reviewed again during exit on 4/13/26 with the facility Administrator and DON.

Based on record review and interview it was determined that facility staff failed to ensure that physician visits notes were available in the medical record for each resident. This was evident for 1 (#15) of 8 residents reviewed for complaints. The findings include:A medical record review for Resident #15 on 4/9/26 at 11:45 AM revealed the last attending physician note found was dated 11/30/25. The last physician visit note was requested on 4/10/26 at 1:00 PM.A review of the documentation provided by the Director of Nursing (DON) on 4/10/26 at 8:30 AM revealed they had not included the last physician provider note. The DON was made aware on 4/10/26 at 8:38 AM. She confirmed that the last attending physician note on the medical record was dated 11/30/25. She stated that she was going to investigate what happened because the new attending physician #16 started on 3/23/26 and she thought the resident was seen. On 4/10/26 at 11:37 AM the DON brought evidence that Resident #15 had been seen by attending physician #16 on 3/26/26 but the note was not available in the medical record.

Based on random observations, interviews and medical record review, it was determined that the facility failed to ensure infection control orders were followed and consistent throughout the facility. This was evident for 1 (Resident #12) of 20 residents reviewed during the complaint survey.The findings include:1) On 4/13/26 at 12:07 PM during an observation of Resident #12, Geriatric Nursing Assistant (GNA) #14 was observed in the resident's room without a gown on. He was carrying a basin of water to the bathroom. There was a sign on the door that indicated the resident was on enhanced barrier precautions (EBP) and the resident's name tag was highlighted orange. There was a linen cart sitting in the doorway of the resident's room with the blue cover pulled up and the linen was exposed. Inside the room there were linens lying directly on the floor and a plastic bag with linen lying next to them. An interview with GNA #14 on 4/13/26 at 12:12 PM revealed he was in the room providing incontinent care. He reported he was wearing a gown but took it off, before he finished providing care, because it was in his way. When asked about the EBP he reported he was to wear a gown and gloves during care, but he was not sure which resident the sign was for. When asked about the linens on the floor and the linen cart outside the doorway and open, he agreed that he should not have done that due to contamination. On 4/13/26 at 12:19 PM Licensed Practical Nursing (LPN) #15 was interviewed. He looked up Resident #12's physician's orders and stated the resident was on EBP. He went with the surveyor and observed the laundry cart sitting outside the room door and agreed that it should have been covered. Reviewed the observation and concerns and he acknowledged the concerns. On 4/13/26 at 12:35 PM the concerns were reviewed with the Director of Nursing (DON) and Nursing Home Administrator (NHA) and they reported that the orange highlighted name tag did mean that it was that resident who was on EBP. However, they did not think Resident #12 was on EBP. However, they agreed that if a staff member saw the signage and the orange highlighted tag, they should have followed the signage. Acknowledged the other concerns.

Based on observation and staff interview it was determined that the facility staff failed to ensure a resident had access to their call bell plunger. This was evident for 1 (Resident #8) out 8 residents that were part of the survey sample during the complaint survey.The findings include:This surveyor went to Resident #8's room on 10/16/25 at 12:15 PM. The resident's call bell plunger (handheld part used to sound an alarm alerting staff the resident needed assistance) was observed to be on the floor on the right side of the bed. This surveyor left the room and told the nurse (Staff #20). She came to the room, put on gloves, and picked up the plunger. She then put the plunger on the bed.This surveyor went to Resident #8's room on 10/17/25 at 9:10 AM. The call bell plunger was observed to be hanging down from the bed near the top of the right-side transition rail. The resident was asked if they knew where their call bell was and the resident shook their head no.The Director of Nursing was interviewed on 10/17/25 at 10:35 AM. She was informed of the call bell observations. She responded by saying she would talk to the nursing staff and address it with them.

Based on complaint #2635993, record reviews, observation, and interviews, it was determined that the facility failed to ensure the physician was notified of changes in resident condition. This was evident for 1 (Resident #4) of 6 complaints reviewed during the survey process.The findings included:On 10/16/2025, a review of complaint #2635993 alleged that Resident #4 had rashes that were not being treated.On 10/16/2025 at 11:55 AM, a review of Resident #4's chart revealed that weekly skin evaluations on 9/18/2025 and 9/12/2025 identified no skin issues; however, weekly skin evaluation on 10/9/2025 at 2:48 PM identified a rash and pressure ulcer.On 10/17/2025, a review of Resident #4's care plan, developed on 12/18/2020, revealed that the resident had developed skin rashes and actual skin impairment to the arms, legs, and trunk related to skin dermatitis periodically, and received treatment each time.On 10/17/2025 at 9:25 AM, the resident was observed awake and alert to self, with no observable rashes noted on her face or arms.On 10/17/2025 at 9:27 AM, during an interview with RN #27, he was asked if Resident #4 had any rash on his/her skin. He explained that approximately 3-4 months prior, the resident had a fungal rash on his/her upper back and buttocks. When asked about additional locations, RN #47 explained that the resident also had the rash on his/her face once, but it healed after treatment was administered. He was asked what actions he would take if the known rash worsened, and he stated that he would notify the doctor. When asked about the current status of the resident's skin, he stated that the resident did not have any skin impairment.On 10/17/2025 at 11:21 AM, during an interview with GNA #28, he was asked if Resident #4 had any skin impairment. He stated that the resident had a skin problem on the back and that he had applied a cream to his/her back. The surveyor asked when he first noticed the issue, and he stated that he noticed it approximately a month prior when he started working with the resident. The surveyor accompanied GNA #28 to the resident's room to observe the resident's skin. The surveyor observed a large dry area on the resident's sacrum and upper back with a small open area below the left buttocks. The GNA was asked to show the surveyor what he had been using, and he showed the surveyor a jar of [NAME] butter cream.On 10/17/2025 at 11:45 AM, during an interview with RN #27, the surveyor informed him that the resident had an evident skin impairment and referenced GNA #28's previously mentioned statement.On 10/17/2025 at 11:29 AM, during an interview with LPN #29 (unit manager), she was informed that Resident #4 had skin impairment and that GNA #28 had stated he applied a cream ([NAME] butter cream, identified at bedside). However, the resident's nurse (RN #27) stated he was not aware of Resident #4's skin impairment and that the GNA did not report the issue to him, even though the skin assessment completed on 10/9/2025 by RN #27 revealed that the resident had a skin impairment identified as a rash and pressure ulcer. LPN #29 acknowledged that the [NAME] butter was not appropriate for a rash and stated that she would complete a skin assessment with the resident's nurse and notify the doctor to receive orders for treatment, if necessary.On 10/17/2025 at 12:10 PM, during an interview with the Director of Nursing (DON), the DON was notified of the above-mentioned findings. She stated that the resident had a known skin condition and was treated daily. The medication administration record she presented to the survey showed: Ammonium Lactate Solution (Ammonium Lactate), applied topically to the affected area once a day. The surveyor explained that the daily Ammonium Lactate Solution order was initiated on 03/04/2025. Since that date, weekly skin evaluations completed on 9/12/2025 and 9/18/2025 showed no skin impairments. Therefore, the rash identified on 10/9/2025 was a change in the resident's skin condition and should have been reported to the physician in case additional treatment was required. The DON agreed to provide documentation to support Resident #4's physician was notified, if available; however, no documented evidence was provided to the surveyor.

Based on review of the resident's medical record and interview with resident and facility staff, it was determined that the facility staff failed to maintain accuracy of medical record by not documenting the reason for missed dose of medication in the resident's medical record. This was evident for 1 (Resident #11) of 1 resident reviewed for medication administration during the complaint survey.The findings include:During the investigation of Complaints and Facility Reported Incidents (FRIs) on 10/16/2025 at 1:29 PM, Resident #11 stated that he/she had not received her Vitamin C medication for the past couple days. A medical record review on 10/17/2025 at 11:32 AM revealed an active order written on 5/22/2025 at 09:00 for Vitron-C Oral Tablet 65-125 MG (Iron-Vitamin C), Give 1 tablet by mouth in the morning every other day for anemiaUpon further review of the Medication Administration Record (MAR) for the month of October 1-17, 2025, it was noted on 11 October 2025, the nurse's initials and the number 9.During an interview with the DON on 10/17/2025 at 11:32 AM, when asked what does the 9 mean on the MAR, the DON stated that as per the MAR legend, 9=See Nurse Note. The surveyor asked to see the documented nurse note for the missed medication dose on 11 October 2025.On 10/17/2025 at 11:47 AM, the DON stated that she could not find any documentation as to whether the medication was given and no supporting nurses' notes. The surveyor informed the DON that this was a concern as there were no documentation in the medical record that indicated the reason for the missed dose of medication. The DON agreed and stated that there should have been documentation in the resident's medical record.

Based on clinical record review, investigation of intake #2601797, and staff interview it was determined that the facility staff failed to 1) ensure a resident's refusal to receiving showers was addressed and 2) ensure an activity of daily living individualized comprehensive care plan included an intervention for transfer status. This was evident for 2 (Resident #8 and Resident #7) out of 11 resident that were reviewed during the complaint survey. The findings include: The Minimum Data Set (MDS) is a required assessment for all residents in Medicare- or Medicaid-certified nursing homes. It evaluates each resident's health and functional status to help staff identify issues. Assessments are conducted at admission and at regular intervals, following set guidelines. A comprehensive care plan is an individualized and collaboratively developed document outlining a resident's medical, nursing, and psychosocial needs, along with planned treatments and activities. It is used to plan, assess and evaluate the effectiveness of the residents care. Activities of Daily Living (ADLs) are basic self-care tasks like bathing, dressing, eating, toileting, and transferring. Nurses assess ADLs to determine a patient's level of independence and care needs. Transfer assistance levels, as defined by the National Institutes of Health, include: Dependent: Patient needs full assistance; mechanical lift and help from others required. Max Assist: Patient does 25% of the task; caregiver does 75%. Mod Assist: Patient and caregiver each do 50%. Min Assist: Patient does 75%; caregiver helps with 25%.Independent: Patient performs the task safely without help. 1) This surveyor investigated concerns raised as part of intake #2601797 regarding Resident #8 not receiving showers. The resident's clinical record was reviewed on 10/16/25 and 10/17/25. The facility nursing staff documented that the resident often refuses showers. A review of the resident's care plans revealed that there was no care plan that specifically addresses the shower refusals. This surveyor interviewed the Director of Nursing (DON) on 10/17/25 at 10:33 AM. This surveyor asked whether or not the resident received showers. She said the resident was offered weekly but refused most of the showers. She added that the nursing staff then gave bed baths. This surveyor asked if the resident had a care plan. She replied that he/she had one where it says he/she was to be offered two showers each week. This surveyor stated that the care plan did not include interventions to address refusals and then asked why the facility staff did not develop a more robust care plan that addressed the refusals. She said she would review the care plans. 2) On 10/16/2025 at 11:49AM, a review of Resident #7's medical record revealed a facility document dated 07/29/2025 titled, Admit/Readmit Screener, question number 7 addresses Chair/bed-to-chair transfer. The Admit/Readmit screener is where staff document a resident's ability to transfer between a bed and a chair/wheelchair upon admission. The selected response for this assessment was Not assessed/no information. On 10/16/2025 at 11:49AM, continued review of Resident #7's medical record revealed a facility admission MDS assessment completed on 08/01/2025, which indicated that the resident was dependent for chair/bed-to-chair transfers in Section GG, which documents functional abilities. Further review of Section V Care Area Assessments (CAA) Summary #5, ADL Functional/Rehabilitation Potential, revealed the facility staff would develop a care plan to address the care area for Resident #7; however, the ADL care plan dated 07/29/2025, did not incorporate a transfer status or intervention until 09/02/2025. On 10/16/2025 at 11:49AM, review of a Physical Therapy Discharge Summary with a service date from 07/30/2025 through 08/29/2025, indicated changes dated 08/31/2025 at 2:24 PM for goal status revealed the current function changed from transfers: max assist X1 to X 1-2 (one to two person assist). On 10/16/2025 at 11:49AM, continued review of Resident #7's medical record revealed 37 skilled nursing progress notes from August 15 to August 31, 2025. These notes documented the required level of care for Activities of Daily Living (ADLs), including transfers. Seventeen notes indicated extensive assistance, 3 indicated limited assistance, and 2 indicated independence. In 15 instances, the transfer activity did not occur. In summary, the documentation for transfer assistance completed by the Geriatric Nursing Assistants was inconsistent throughout the month of August. Continued review of Resident #7's medical record revealed a care plan, initiated 07/29/2025, that noted an ADL self-care deficit due to limited mobility. Transfer intervention with a date initiated on 09/02/2025 required two staff and use of side rails/slide board. However, the date the intervention for transfer status was initiated was on 09/02/2025, after an incident on 09/01/2025 that resulted in injury related to a transfer from bed to wheelchair. On 10/16/2025 at 1:32 PM, during an interview Staff #7, the Director of Rehab, stated a transfer status for a resident is determined upon admission by a therapy eval or the nursing GG score. Staff #7 noted nursing and therapy may differ on transfer assistance levels (max assist 1-2 people). Staff #7 confirmed therapy always used a slide board for Resident #7 related to his/her leg weakness and the inability of Resident #7 to stand. On 10/17/2025 at 7:42 AM, during an interview, LPN Staff #10 stated that upon admission, a nurse assesses a resident's transfer status. Therapy also evaluates the resident's strength to determine the required level of assistance (1-2 people). This information is then communicated to nursing and documented on the Kardex. Staff #10 confirmed familiarity with Resident #7, noting that Resident #7 required a two-person assist due to lower extremity weakness. On 10/17/2025 at 8:07 AM during an interview, Staff #13 Geriatric Nursing Assistant (GNA) stated a resident's transfer status would be in the Kardex of the electronic medical record. Staff #13 stated she was familiar with Resident #7 and stated that therapy mostly completed the transfers and used a sliding board. Staff #13 stated although she never transferred Resident #7, she would have used a Hoyer lift to transfer Resident # 7 and indicated Resident #7 had no ability to perform any movements. On 10/17/2025 at 8:15 AM during an interview, the Director (DON) stated that upon admission, a resident's transfer status is determined by a nurse's assessment, which utilizes hospital records and physical therapy notes as a baseline. The Unit Manager then completes a comprehensive care plan within 48 to 72 hours. Staff can find care instructions, including transfer status, in the Kardex, which is derived from the ADL care plan. An ADL comprehensive care plan should detail all aspects of daily care, including transfer status. Therapy and nursing may have different transfer statuses. Communication between nursing and rehabilitation typically occurs verbally or through weekly Utilization Review Meetings. On 10/17/2025 at 8:27 AM, in an interview, Staff #14 (MDS Nurse) stated when an admission MDS is completed, a comprehensive care plan is to be developed through an Interdisciplinary Team (IDT) process. Staff #14 also confirmed the transfer status was not implemented into the comprehensive ADL care plan until 09/02/25, after an injury sustained during a bed-to-wheelchair transfer. On 10/17/2025 at 9:21 AM, an interview with Staff #15, Occupational Therapist (OT) indicated that Resident #7 required a sliding board to transfer related to the inability to push up from bed or pivot to a chair, which made the sliding board the safest option. Staff #15 stated that Resident #7 was dependent on assistance for transfers. Staff #15 stated, as a therapist she would have a second person present during Resident #7's transfers due to the resident's lower extremity weakness and inability to move or reposition their legs. The second person's role was to prevent Resident #7's legs from getting caught on things, as this often occurred. On 10/17/2025 at 10:40 AM, an additional interview with Staff #7, the Director of Rehab, stated that Resident #7 showed poor progress in therapy. Additionally, facility staff had not received formal training on the sliding board transfer intervention, which was added to the ADL plan of care on 09/02/2025. On 10/17/2025 at 11:15 AM in an interview, Staff #16 (Nurse Unit manager) stated upon a resident's admission, staff should await a therapy evaluation to determine the resident's transfer status. The transfer status must be included in the Care Plan to appear on the Kardex. On 10/17/2025 at 11:30 AM in an interview, Staff #19 (Registered Nurse (RN) indicated that a resident's transfer status is determined upon admission, and she would refer to physician orders for this information. On 10/17/2025 at 11:50 AM in an interview, Staff #18 (Registered Nurse (RN) stated upon admission, a resident's transfer status is determined through a nursing assessment. The nurse would also utilize the hospital discharge summary for transfer status determination. Staff #18 stated she was familiar with Resident #7, described the resident as weak and unable to stand, requiring two people assistance for safe transfer. On 10/17/2025 at 1:27 PM in an interview, Staff #21 (GNA) stated facility staff use Hoyer lifts for transfers when unsure of a resident's condition or proper technique, as knowing the resident's condition determines the correct transfer status. On 10/17/2025 at 1:34 PM in an interview, Staff #22 (LPN) revealed that this facility operates under a no-lift policy, requiring staff to use a Hoyer lift for residents who are unable to ambulate or stand. However, there was no evidence of a no lift policy provided by the facility. On 10/17/2025 at 1:35 PM in an interview, Staff #23(LPN) stated that if a resident is bedbound, has any weakness, and cannot stand, the staff must use a Hoyer lift. On 10/17/2025 at 1:40 PM, in an interview, Staff #24 (LPN) stated a resident's transfer status is determined upon a nursing assessment and would find the resident's transfer status in the progress notes in the electronic medical record. On 10/17/2025 at 1:42 PM, in an interview, Staff #25 (LPN) admitted to being unsure how to find a resident's transfer status and had not located it in the medical record. While searching the medical record with the Surveyor present, she remarked, I think it is this one on the task list- wait this is for eating, not sure. On 10/17/2025 at approximately 2:30 PM, during a second interview with the Director of Nursing (DON), he/she stated that the facility's nursing staff had not received instructions regarding Resident #7's transfer status. The DON added that the ADL care plan should have included a transfer status to guide staff in providing appropriate care and transfers. On 10/17/2025 at approximately 3:40 PM the Administrator and the DON were made aware of the concern.

Based on record reviews and interviews, it was determined that the facility failed to clarify residents pain medication orders and ensure residents' medications were administered and physician's orders were followed in accordance with professional standards. This was evident for 2 (#14 and #24) residents out of 66 residents investigated during the survey.The findings include: 1. On 07/31/25 at 12:00 PM during Resident #24's medical record review revealed a doctor's order dated 11/06/2024 for oxycodone HCl Oral Tablet 10 MG (Oxycodone HCl) *Controlled Drug* Give 10 mg by mouth every 6 hours as needed for Pain (5-10). Take 10 mg by mouth every 4 hours as needed for Pain (5-10). The orders had two administration frequencies for the same pain level within the order. On 07/31/25 at 12:06 PM during medical record review, it revealed the Medication Administration Record(MAR) dated 7/1/2025 - 7/31/2025, that the medication oxycodne HCl was given to Resident #24 for 17 days of 31 days, on July 1, 2, 3, 4, 5, 6, 10, 11, 12, 14, 15, 16, 17, 18, 20, 23, and 26. On 08/01/25 at 11:00 AM the surveyor conducted an interview with the facility's Nursing Home Administrator (NHA), Staff #01 and Director of Nursing (DON), Staff #02 and shared the concern for the two administration frequencies for the same pain level within a single medication order that was not clarified and subsequently administered to Resident #24 on 17 different days of 31 days for the month of July 2025. When surveyor inquired about the expectation of clarifying medication orders, the NHA #01 and DON #02 stated the expectation is for nursing staff to have had the order clarified. On 08/04/25 at 12:00 PM during interview with NHA #01 and DON #02, they informed the survey team that the above order was discontinued on 08/01/25 after surveyor intervention and discussion. During follow-up medical record review of Resident #24, a facility Order Audit Report revealed the oxycodone HCl medication order was discontinued on 08/01/25 at 17:14 PM. 2. On 07/31/25 at 10:00 AM during medical record review of Resident #14's facility Medication Admin Audit Report for Schedule Date of 07/29/25-07/31/25, it revealed concerns late medication administration and inconsistent daily weight measurement times. Resident #14 had a significant medical history of 'essential primary hypertension, chronic combined systolic (congestive) and diastolic (congestive) heart failure, and lyphemdema'. Review of physician orders revealed Weights Daily - Weigh at same time every day and call MD if increases more than 2 lbs/day or 5 lbs/week every day shift every Mon, Wed, Fri for CHF; The resident was also prescribed cardiac medications such as Losartan, Carvedilol, and Lasix. Continued record review revealed:Weights scheduled for 07:00 AM were done on 07/29/25 at 13:56 PM and then on 07/30/25 at 10:14 AM.Medications were administered as follows:Scheduled on 07/29/25 at 08:00 AM, were documented as given at 13:54 PMScheduled on 07/29/25 at 12:00 PM, were documented as given at 13:56 PMScheduled on 07/30/25 at 08:00 AM, were documented as given at 10:14 AMScheduled on 07/30/25 at 12:00 PM, were documented as given at 13:05 PMScheduled on 07/31/25 at 08:00 AM, were documented as given at 10:06 AMScheduled on 07/31/25 at 12:00 PM, were documented as given at 15:18 PM On 08/01/25 at 11:10 AM the surveyor conducted an interview with the facility's Nursing Home Administrator (NHA), staff #01 and Director of Nursing (DON), staff #02 and shared the concern of late medication administration and inconsistent weight monitoring on Resident #14 with significant CHF history. NHA #1 and DON #2 acknowledged and agreed that the medications and weight monitoring were administered late; and stated, this is not the expectation of medication administration and weight monitoring for residents.

Based on observation, interview, and record review, it was determined that the facility failed to provide and document individualized activities to support the physical, mental, and psychosocial well-being of 1 (Resident #6) of 1 resident reviewed for activities.The findings include:On 07/30/2025 at 9:08 AM, Resident #6 was observed lying in bed with no activities occurring in the room or any evidence of engagement in individualized activity.On 08/01/2025 at 9:04 AM, the resident was again observed lying in bed with no materials or indications of participation in any activity.At 9:10 AM, the surveyor requested documentation of activities provided for Resident #6 for the last 30 days from Staff #4. Staff #4 checked the electronic medical record and stated there were no recorded activities for the last 30 days. At 9:22 AM, Staff #4 reported that he was unable to locate any documentation for Resident #6 in the activity department's logbook. Staff #4 stated that musical encounters, involving a musician (typically a guitarist) visiting residents' rooms, occur approximately twice a month. However, there was no documentation to confirm Resident #6's participation in these or any other activities.

Based on record review and interview it was determined the facility failed to ensure the care plan for Resident #117 was comprehensive. This was evident for 1 out of 4 residents reviewed for urinary catheters during the facility's recertification survey. The findings include: Review of the medical record by the surveyor on 8/4/25 at 10:51AM revealed Resident #117 had an active medical order for an indwelling urinary catheter which was dated as beginning on 3/31/25, and diagnoses listed which included urinary tract infection as well as an active medical order dated as beginning on 6/15/25 for contact precautions. On 8/4/25 at 11:00AM the surveyor reviewed the medical record of Resident #117 which revealed their care plan had no documentation of the resident's urinary catheter. Additionally, the enhanced barrier precautions focus on the resident's care plan did not include a catheter as one of the indications that were listed for the precautions, and the care plan did not reflect the active medical order in place dated as beginning on 6/15/25 for contact precautions. Review of Resident #117's baseline care plan by the surveyor on 8/4/25 at 11:16AM revealed the resident was documented as having an indwelling catheter present on 3/31/25 upon their admission to the facility. On 8/4/25 at approximately 12:00PM the surveyor observed Resident #117 had a foley catheter in place. On 8/4/25 at 1:01PM the surveyor shared the concern and conducted an interview with the Director of Nursing (DON) who acknowledged the surveyor's concern and confirmed with the surveyor that the resident's catheter was not care planned and stated to the surveyor: No, it is not on there. The DON further confirmed with the surveyor that the resident currently had a foley catheter in place. At this time, the surveyor offered an opportunity for the facility to provide any and all documentation of the foley catheter having been care planned. On 8/4/25 at 1:20PM the surveyor reviewed the kardex document that the Geriatric Nursing Assistants of the facility utilize to know the care required for the resident, which revealed there was no mention of the resident's urinary catheter on that document. On 8/4/25 at 1:49PM the surveyor provided another opportunity to the DON for any and all further documentation regarding the concern to be provided to the surveyor for review. On 8/4/25 at 1:54PM the DON informed the surveyor that nothing is on the care plan for the resident's catheter. On 8/4/25 at 12:48PM the surveyor conducted an interview with the DON and inquired as to if any action was taken by the facility in response to this surveyor having shared the concern. At this time, the DON reported to the surveyor: We should have that on the care plan now, I'll bring you a copy. On 8/06/2025 at 12:50PM during the surveyor's review of the medical record, the care plan of Resident #117 was observed with the following care plan documentation dated as initiated on 8/5/25: (Resident #117) has an indwelling urinary catheter. Additionally goals and interventions for the care of the catheter and a goal related to urinary infection were now observed by the surveyor to be present on the resident's care plan. On 8/06/2025 at 1:44PM the facility's Administrator and DON provided the surveyor with a copy of the updated care plan.

Based on observations, record reviews, and interviews, it was determined that the facility failed to ensure: 1.) Residents' or family representative's request to implement an Advance Directive was addressed; 2.) Resident's advanced directive was obtained and followed; and 3.) Information regarding advance directives was offered. This was evident for 3 (#10, #117, #106) residents out of 66 residents investigated during the survey.The findings include: 1. On 07/30/2025 12:40 PM during resident medical record review, it revealed an 'Advanced Directive Admission' facility evaluation form completed on 05/26/25 at 11:03 AM indicating that Resident #10 answered 'a. Yes' to the question: 'I am interested in meeting with a member of the Social Work team to discuss steps to implement an Advance Directive.' This surveyor was unable to locate an Advance Directive for Resident #10 that was requested to be formulated. On 07/30/2025 at 12:58 PM during staff interview with Director of Social Work #6 discussed that Resident #10 requested to implement an Advance Directive and unable to locate Advance Directive on chart; Staff #6 stated he/she was unable to locate an Advance Directive on the chart and would determine if an Advance Directive was ever created with and for Resident #10. On 08/01/25 at 1:31 PM during follow-up staff interview with Director of Social Work #6, surveyor was given a completed copy of the Maryland Advance Directive: Planning For Future Health Care Decisions form for Resident #10 dated for 07/30/25. Staff #6 stated this was completed after surveyor intervention regarding Resident #10 request to implement an Advance Directive. 2. On 7/31/25 at 8:53AM the surveyor observed and reviewed the medical record of Resident #117 which revealed they were admitted to the facility in March 2025, and one physician certification of incapacity was present within their medical record signed as completed by Physician #5 dated 6/17/25 in which the section titled: Part 1: Identifying information; Patient: I am certifying information about: failed to include the resident's name. Review of the resident's Maryland Orders for Life Sustaining Treatment (MOLST) Form indicated the resident had a surrogate in place for decision making dated 4/1/25. Review of the advanced directive present in the resident's medical record revealed a power of attorney for a person with a different first name and was not Resident #117's advanced directive. On 8/4/25 at 10:18AM the surveyor conducted an interview with the facility's Administrator who confirmed with the surveyor that Resident #117 was incapable of medical decision making. At this time, the surveyor shared the concern and conducted a dual observation of Resident #117's medical record with the facility Administrator who observed the certification of incapacity, MOLST form, and the power of attorney advanced directive located in the medical record of Resident #117 which was not Resident #117's. On 8/4/25 at 11:00AM the surveyor conducted a review of the medical record of Resident #117 which revealed the following care plan focus dated as initiated on 4/5/25: See MOLST form, (Resident #117) has an advanced directive, and the following intervention: Will review MOLST with resident/POA quarterly and as needed. The surveyor noted that there was no advanced directive of Resident #117 in their medical record. On 8/4/25 at 11:22AM the surveyor conducted an interview with Social Worker (SW) #6 who confirmed with the surveyor that the power of attorney paperwork in the medical record of Resident #117 was not theirs and further stated this was an oversight. SW #6 confirmed with the surveyor that in response to the surveyor having shared concerns, the resident's family member was contacted by them, and they were able to confirm that Resident #117 has a power of attorney which the family member will bring a copy of to the facility the next day. When surveyors inquired as to who the resident's power of attorney currently was, SW #6 stated: I do not know yet who that POA names. SW #6 informed surveyors that the resident has a husband, however, surveyors noted that the facility had a person other than the resident's husband named as the current surrogate who was the person named in the power of attorney which was another person's. SW# 6 reported to surveyors they had made an attempt to call the resident's husband, however, no supporting documentation could be found in the resident's medical record. On 8/4/25 at 11:51AM SW #6 provided the survey team with a second certification of incapacity form for Resident #117 which was observed to have a different person's first name and the same last name as the resident written on it as the person that information was being certified about instead of the resident. On 8/4/25 at 11:53AM the surveyor shared concerns with the facility's Administrator who observed, confirmed, and acknowledged understanding of the concerns. On 8/6/25 at 2:30PM the surveyor reviewed the medical record which revealed the following information: 1.) An advanced directive admission assessment dated [DATE] in which questions regarding advanced directives was blank, 2.) A social service assessment dated [DATE] completed by SW #6 which indicated the resident was married and identified the person's name and under section E of the form titled Health Care Decision Making: 1.) Advanced Directives document: the answer of yes was checked indicating that the resident had an advanced directive. On 8/6/25 at approximately 3:30PM concerns were shared during the facility's exit conference with the facility Administrator, Director of Nursing, and Corporate Compliance Nurse. 3. On 07/31/2025 at 10:44 AM, during review of Resident #106's hard chart and electronic medical record, the surveyor found that a physician had documented the resident was capable of making their own medical decisions. No documented advance directive or evidence that advance directive information had been provided was found. On 08/01/2025 at 10:20 AM, the surveyor requested the documentation from the Director of Nursing (DON). At 11:30 AM, the DON stated that no advance directive or record of an offer being made could be located. At 11:48 AM, the facility's social worker confirmed there was no advance directive on file and no documentation that the resident had been offered information. At 12:57 PM, the surveyor requested documentation showing that advance directive information had been offered that day. At that time, the resident had still not been offered the information. At 1:31 PM, the DON and the social worker again confirmed that the resident had not been offered information regarding advance directives.

Based on observation, interview and record review it was determined the facility failed to ensure the accuracy and completeness of Resident #117's medical record. This was evident for 1 out of 10 residents reviewed for advanced directives; and failed to ensure accuracy of room numbers on resident medical records This was evident for 5 out of 32 residents located on the lighthouse nursing unit during the facility's recertification survey.The findings include:1.) On 7/31/25 at 8:53AM the surveyor observed and reviewed the medical record of Resident #117 which revealed one physician's certification of incapacity present within their medical record completed by Physician #5 dated 6/17/25. The surveyor noted that on the certification of incapacity form signed as completed by Physician #5 titled Part 1: Identifying information; Patient: I am certifying information about: this section failed to include the resident's name. On 8/4/25 at 10:18AM the surveyor conducted an interview with the facility's Administrator who confirmed with the surveyor that Resident #117 was incapable of medical decision making. When the surveyor inquired to the Administrator as to how the resident is deemed incapable they stated the following information: Two certifications for incapacity are required for that. At this time, the surveyor shared the concern and conducted a dual observation of Resident #117's medical record with the facility Administrator who observed and confirmed that only one certification of incapacity was present and the power of attorney advanced directive located in the medical record of Resident #117 which was not Resident #117's. When the surveyor inquired to the Administrator as to if there was any other certification of incapacity of the resident they reported the following information: The social worker has further information in her office in case documentation is misplaced or sent to the hospital or something by accident. On 8/4/25 at 11:00AM the surveyor conducted a review of the medical record of Resident #117 which revealed the following care plan focus dated as initiated on 4/5/25: See MOLST form, (Resident #117) has an advanced directive, and the following intervention: Will review MOLST with resident/POA quarterly and as needed. The surveyor noted that there was no second certification of incapacity and no advanced directive of Resident #117 in their medical record.On 8/4/25 at 11:22AM the surveyor conducted an interview with Social Worker (SW) #6. SW #6 confirmed with the surveyor that the power of attorney paperwork in the medical record of Resident #117 was not theirs and further stated this was an oversight. SW #6 confirmed with the surveyor that in response to the surveyor having shared concerns, the resident's family member was contacted by them, and they were able to confirm that Resident #117 has a power of attorney which the family member will bring a copy of to the facility the next day.On 8/4/25 at 11:38AM the surveyor observed the hard copy medical record of Resident #117 in which a second certification of incapacity form dated 6/19/25 was present which had a different person's first name instead of the resident's name on it, indicating incapacitation was being certified for a person other than the resident.On 8/4/25 at 11:51AM SW #6 provided the survey team with the second certification of incapacity form dated 6/19/25 for Resident #117 which was again, observed to have a different person's first name written on it as the person that information was being certified about instead of the resident. The surveyor reviewed documentation provided by the facility and observed an additional copy of the certification of incapacity form which had the resident's name at the top of the form. Part 1 of both of the physician certifications related to medical condition, substitute decision making, and treatment limitations forms was observed to be left blank which was missing the following information: 1.) Patient: I am certifying information about . 2.) Certifying practitioner (check all that apply), and 3.)Time frame: The following certifications are or are not made within 2 hours of examining the individual, however, both forms were observed to be dated 6/19/25 and signed by Physician #8.On 8/4/25 at 11:53AM the surveyor shared concerns with the facility's Administrator who observed, confirmed, and acknowledged understanding of the concerns.On 8/6/25 at approximately 3:30PM concerns were shared during the facility's exit conference with the facility Administrator, Director of Nursing, and Corporate Compliance Nurse.2.) On 8/4/2025 at 10:17AM the surveyor observed the hard copy medical records located at the nursing station on the lighthouse unit which had room numbers labeled on the spine of the records which did not match the room number of the rooms in which the residents were located in, and did not match the room number labeling of the areas they were located in.On 8/4/25 at 10:36AM the surveyor performed a dual observation and shared the concern with the facility Administrator who observed, acknowledged and confirmed understanding of the concern. The surveyor conducted an interview with the Administrator at this time who confirmed that staff refer directly to the hard copy medical records to follow the MOLST in the event of emergencies.On 8/6/25 at 1:44PM the surveyor conducted review of the resident census which revealed 5 hard copy medical records in which the room numbers documented on the spine of the hard chart did not match the room the residents were located in, and the surveyor noted the hard copy of medical records were located in areas labeled with conflicting room numbers.On 8/6/25 at approximately 3:30PM concerns were shared during the facility's exit conference with the facility Administrator, Director of Nursing, and Corporate Compliance Nurse.

Based on record review and interview it was determined the facility failed to ensure a resident's care was reviewed by the physician. This was evident for 1 out of 10 residents reviewed for advanced directives during the facility's recertification survey. The findings include:On 8/4/25 at 11:51AM SW #6 provided the survey team with a second certification of incapacity form dated 6/19/25 for Resident #117. This form was observed to have a different person's first name and the same last name as the resident written on it at the top as the person that information was being certified about instead of the resident. The surveyor reviewed documentation provided by the facility and observed an additional copy of the certification of incapacity form which had the resident's name at the top of the form. Part 1 of both of the physician certifications related to medical condition, substitute decision making, and treatment limitations forms was observed to be left blank which was missing the following information: 1.) Patient: I am certifying information about . 2.) Certifying practitioner (check all that apply), and 3.)Time frame: The following certifications are or are not made within 2 hours of examining the individual, however, both forms were observed to be dated 6/19/25 and signed by Physician #8.On 8/4/25 at 11:53AM the surveyor shared concerns with the facility's Administrator who observed, confirmed, and acknowledged understanding of the concerns.On 8/6/25 at 1:17PM the surveyor conducted an interview with the facility Administrator and Director of Nursing at which time Physician #8 was interviewed via phone at 1:25PM. Physician #8 reported to surveyors that the facility social worker asked them to come into the facility to sign forms left at the desk for them which they did on 8/4/25. On 8/6/25 at 1:30PM the surveyor again shared concerns with the Administrator and Director of Nursing who acknowledged understanding of the concerns. On 8/6/25 at approximately 3:30PM concerns were shared during the facility's exit conference with the facility Administrator, Director of Nursing, and Corporate Compliance Nurse.

Based on record reviews and interviews the facility failed to ensure that a resident must be seen by a physician at least once every 60 days after the first 90 days after admission. This was evident for 1 (#24) resident out of 8 residents investigated during the facility's annual survey.The findings include:On 07/31/25 at 12:00 PM during medical record review of Resident #24, it revealed an MD General Note for date of service of 01/10/2025 at 21:15 PM created by Physician #08; and no other MD General Notes for any subsequent dates of services during this review.On 08/01/25 at 11:30 AM the surveyor conducted an interview with the facility's Nursing Home Administrator (NHA), staff #01 and Director of Nursing (DON), staff #02 and shared the concern for lack of physician visit at least once every 60 days after the first 90 days after admission.On 08/06/25 at 14:10 PM during follow-up interview after surveyor discussion and intervention, NHA #1 and DON #02 provided the surveyor with a Late Entry MD General Note for date of service 05/14/25 at 18:32 PM created by Physician #08 on 08/04/25 14:34 PM. The 05/14/25 physician visit was 124 days from last physician visit on 01/10/25. When NHA #01 and DON #02 asked did they agree this timeframe was outside of the regulation, both stated yes, the physician visit was late.

Based on observations, record reviews, and interviews, it was determined that the facility failed to: 1.) maintain infection prevention designed to prevent the development and transmission of communicable diseases and infections. This was evident for 1 (Resident #1) of 2 residents reviewed for Trach Care; 2.) maintain proper infection control practices to prevent cross-contamination with Foley catheters. This was evident for 1 (Resident #7) of 3 residents reviewed for Foley Care; and 3.) ensure infection control precautions were followed. This was evident for 2 residents (Resident #117, and Resident #125) of 2 residents reviewed for infection control precautions during the survey.The findings include: 1. On 07/30/25 at 7:57 AM the surveyor observed Resident #1 supine in bed with Trach Collar intact to neck and Trach Collar Oxygen mask, dated 07/23/25 laying lateral to the left side of the resident bed on the floor. On 07/30/25 at 8:16 AM during follow-up observation rounds of Resident #1 with LPN Unit Manager staff #03, the resident remained supine in bed with Trach Collar intact and Trach Collar Oxygen mask, dated 07/23/25, again observed on the floor lateral to the left side of the resident bed. On 07/30/25 at 8:18 AM the surveyor conducted an interview with Unit Manager #03 who confirmed with the surveyor that Resident #1 Trach Collar Oxygen mask was found on floor. The surveyor shared the concern for the importance of maintaining infection prevention to prevent the development and transmission of potential infections. After surveyor discussion and intervention, Unit Manager #03 stated that the Trach Collar Oxygen mask would be replaced. The surveyor observed Unit Manager #03 remove the Trach Collar Oxygen mask from the floor. 2. On 8/1/25 at 11am, during a follow-up observation of Resident #7's room, a used Foley catheter with visible urine in the drainage tubing and collection bag was observed placed directly on the bedside table next to personal care items. The Foley catheter was not contained in a biohazard bag or other appropriate receptacle for contaminated medical waste. An interview was conducted at the time of the observation with the Registered Nurse (RN) staff #17 who stated, I meant to come back and throw it away after I finished with the resident, but I forgot. Staff #17 acknowledged that placing a contaminated Foley catheter on a bedside table was against infection control policy and could expose the resident and others to harmful pathogens. A review of the facility’s Infection Prevention and Control Program Policy, updated last 2019, revealed staff are to immediately discard used medical equipment, including Foley catheters, into appropriate biohazard receptacles after use to prevent contamination of the resident’s environment. In an interview on 8/6/25 at 1pm, the Infection Preventionist (IP) and the DON (Director of nursing) confirmed that used Foley catheters should never be left on bedside tables and should be discarded immediately following use. The IP stated that leaving the contaminated catheter in the resident's environment was a direct violation of infection control protocols and posed a risk of infection spread. 3. On 7/30/25 at 9:02AM the surveyor observed the following signage on the door to the room of Resident #117: Stop, Contact Precautions, Everyone must: Clean their hands, including before entering and when leaving the room, Providers and staff must also: put on gloves before room entry, discard gloves before room exit, put on gown before room entry, discard gown before room exit, do not wear the same gown and gloves for the care of more than one person, use dedicated or disposable equipment, clean and disinfect reusable equipment before use on another person. The trach tubing connected to Resident #117 was observed by the surveyor to be laying directly on the facility floor surface. On 7/30/25 at 9:02AM the surveyor observed Geriatric Nursing Assistant (GNA) #9 walk past the contact precautions signage on the door to the room of Resident #117 and enter the room with no hand hygiene performed and no personal protective equipment (PPE) donned, and they proceeded to walk over to the resident's bed and pick a towel up off of the floor from underneath the bed with their bare hands, and then carried it out of the room with no hand hygiene or ppe and retrieved a trash bag and placed the towel into the trash bag. At this time, the surveyor conducted an interview with GNA #9 and Registered Nurse Supervisor (RN) #10. GNA #9 and RN #10 visualized the contact precaution signage on the door and the trach tubing laying on the floor with the surveyor and confirmed that the resident was to be on contact precautions. GNA #9 stated to the surveyor during the interview that PPE should be worn when in the resident's room. At this time, the surveyor shared their concern and GNA #9 acknowledged understanding of the concern. RN #10 acknowledged and confirmed understanding of the surveyor's concern and stated to the surveyor that Gown and gloves have to be worn for contact precautions. RN #10 further stated to the surveyor that they did not know why Resident #117 was on contact precautions. On 7/30/2025 at 9:03AM the surveyor conducted an interview with Licensed Practical Nurse (LPN) #11 who was assigned care of the resident who stated to the surveyor that the resident was to be on contact precautions and confirmed there was an active medical order for contact precautions for Resident #117. The surveyor shared their concerns with LPN #11, and after surveyor intervention, they responded, performed hand hygiene, donned ppe, and addressed the resident's trach tubing. On 7/30/2025 at 11:20AM the surveyor shared the concerns with the facility Administrator who acknowledged and confirmed understanding of the concerns. On 8/6/25 at 11:50AM the surveyor conducted an interview with the Director of Nursing (DON) and Infection Preventionist (IP) #12. During the interview, the DON reported their expectation of staff for adhering to contact precautions was for them to perform hand hygiene and gather items needed items before going into the room, to gown and glove prior to entering the room, and if they are on contact precautions then they need to use that PPE. The DON and IP #12 confirmed with the surveyor that Resident #117 required contact precautions. At this time, all infection control concerns were shared by the surveyor and both the DON and IP #12 acknowledged the surveyor's concerns. 4. On 8/5/25 at 9:17AM the surveyor observed following signage on the door to the room of Resident #125: Stop, Contact Precautions, Everyone must: Clean their hands, including before entering and when leaving the room, Providers and staff must also: put on gloves before room entry, discard gloves before room exit, put on gown before room entry, discard gown before room exit, do not wear the same gown and gloves for the care of more than one person, use dedicated or disposable equipment, clean and disinfect reusable equipment before use on another person. During the surveyor's review of medication administration, Licensed Practical Nurse (LPN) #13 was observed walking past the contact precautions signage posted on the door to the room of Resident #125 and entered the room to pass medications with no personal protective equipment (PPE) donned and was standing against the side of the bed with their clothing touching the resident's bed linens as they passed medications. On 8/5/25 at 9:21AM Geriatric Nursing Assistant (GNA) #14 was observed walking past the contact precautions signage on the door to the room of Resident #125 and entered the room without performing hand hygiene or donning PPE, performed a task in the resident's bathroom and then re-entered the resident's room before exiting the room. At this time, the surveyor conducted an interview and shared the concern with GNA #14 who reported the following information to the surveyor: Yes, I have to have PPE on when providing care. On 8/5/25 at 9:26AM the surveyor conducted an interview with LPN #13 who observed the contact precautions signage on the resident's door with the surveyor and stated to the surveyor that PPE only needed to be worn when providing care. When the surveyor further inquired as to what contact precautions meant, LPN #13 further stated: I wear PPE if I am changing a dressing for a wound. When the surveyor asked LPN #13 what reason the resident had been placed on contact precautions for, they reported they did not know what the reason was for the contact precautions in place for Resident #125. Review of the medical record with LPN #13 revealed the resident required contact precautions for more than one multi drug resistant organism. On 8/5/25 at 9:31AM the surveyor conducted an interview and shared concerns with Registered Nurse Supervisor, Unit Manager (RN UM) #15 who confirmed that Resident #125 was to be on contact precautions and acknowledged understanding of the surveyor's concerns. When the surveyor inquired as to what their expectation was for staff when caring for a resident on contact isolation they reported their expectation was that the signage was there on the room so the staff can follow it and use the PPE that is there in the cart. After surveyor intervention, RN UM #15 stated the following to the surveyor: I am going to do an in-service right away. On 8/6/25 at 11:50AM all infection control concerns were shared by the surveyor with both the DON and IP #12 who acknowledged the surveyor's concerns.

Based on observation, interview, and record review, the facility failed to maintain the dignity of 2 of 3 residents (Residents #7 and #50) reviewed for dignity. The findings include: 1. Observation of Resident #7's room, on 07/30/25 at 8:42 a.m., revealed a brown clothing bin with the top missing and two drawers underneath the missing top. Clothing was observed under an empty milk carton. Also observed were a black plastic bowl with old food stuck in it and a clear plastic bag containing used disposable dinnerware.On 08/01/25 at 11:30 a.m., during a follow-up observation, the resident was not in bed. The clothing bin was covered with a clean towel; however, the empty milk carton, the black plastic bowl with old food stuck in it, and the clear plastic bag with used disposable dinnerware remained on top of the resident's clothing. On 08/01/2025 at 12:15 PM, Geriatric Nursing assistant Staff 18 # (GNA) stated the clothing bin has been like that for a while and that she was unsure who was responsible for putting the items there.On 08/01/2025 at 12:30 PM, the Unit Manager (staff #15) stated staff should ensure residents' rooms remain clean and organized, and that personal items should be stored appropriately to maintain dignity. The Unit Manager confirmed the items should have been removed after the initial observation.2. Observation of Resident #50, on 07/30/25 at 9:00 a.m., revealed the resident's Foley catheter bag was observed to contain approximately 600 cc of cloudy yellow urine and was resting directly on the floor. The Unit Manager (staff #15) was notified, she removed the bag from the floor, and emptied it.On 08/01/25 at 11:00 a.m., the Foley bag was observed lying on the bedside table with approximately 100 cc of urine. When asked if the Foley had been discontinued, the resident pulled back the covers and revealed a urinary leg Foley, which was nearly full.

Based on review of complaints, tray tickets, observation, and interview, it was determined the facility failed to serve residents food that was palatable and appealing and failed to follow the selections residents had chosen. This was evident for 13 (#10, #65, #63, #61, #68, #67, #66, #58, #70, #64, #62, #17, #71) of 73 residents reviewed during a complaint survey. The findings include: Review of complaints MD00202967, MD00206399, and MD00201718 alleged, inferior quality of food that was tasteless, cold, and often old. Badly cooked food without any nutrition or nourishment. Food was cooked raw with blood in it. I have been forced to order food regularly for my mother. They give patients a food menu and it's not what they have on their tray. 1) On 4/15/25 at 8:30 AM Resident #10 was observed sitting in the dining room. Resident #10 was asked how the food was, and the reply was, it is ok, but I don't like biscuits and that is what they sent me instead of toast. Observation of Resident #10's breakfast plate revealed a hard-boiled egg yolk sitting on the plate along with a biscuit. Review of Resident #10's tray ticket documented the resident was supposed to get white toast 1 slice. The resident stated he/she did not receive toast. The tray ticket also said apple juice, but the resident stated they served orange juice. 2) On 4/15/25 at 8:40 AM Resident #65's breakfast tray ticket did not match what was on the tray. Resident #65's tray ticket stated banana and 2% milk. Observation of the breakfast tray revealed whole milk instead of 2% milk and there was no banana. 3) On 4/15/25 at 8:43 AM Resident #63's tray ticket documented hard cooked egg. Review of the breakfast tray had scrambled eggs. There was no bread, however the tray ticket said 1 slice of bread. There was no coffee or hot tea, no assorted yogurt cup, and no house shake. According to the cook there was a certain person on the line that made the error. 4) On 4/15/25 at 8:50 AM Resident #61's tray ticket and breakfast tray were observed. Resident #61 stated, they gave me oatmeal and I don't eat oatmeal. There was milk on the tray and the resident stated he/she doesn't drink milk. The tray ticket indicated 2 eggs, however the resident only received 1 egg. The tray ticket said banana; however, the resident did not receive a banana. Resident #61 stated he/she got a muffin and that it wasn't on the ticket and jelly was on the ticket but did not get jelly. 5) On 4/15/25 at 12:20 PM Resident #66's tray ticket stated coffee or hot tea. Observation of the lunch tray revealed no hot beverage. Resident #66 stated, it would be good to have it. 6) On 4/15/25 at 12:22 PM Resident #58's ticket said coffee or tea. Resident #58 did not receive coffee or tea. The resident was served cranberry juice, and he/she said it tasted watered down. Resident #58 was interviewed about food and stated that there were many times when the tray ticket did not match what was served. Resident #58 complained that he/she was served bread with mold. 7) On 4/15/25 at 12:23 PM Resident #67's tray ticket stated house shake and frozen nutritional treat. There was no house shake or frozen nutritional treat on Resident #67's lunch tray. 8) On 4/15/25 at 12:24 PM Resident #61 stated they gave him/her a salad with no egg. There was no hot tea and no cookie. 9) On 4/15/25 at 12:26 PM Resident #70's lunch ticket stated chopped sliced peaches, but the resident received mandarin oranges. The ticket stated 1 slice of bread and LPN #33 confirmed that the resident did not receive bread 10) On 4/15/25 at 12:28 PM Resident #68's tray ticket for lunch said house shake, however there was no house shake and no coffee. 11) On 4/15/25 at 12:28 PM Resident #64 had ground peaches on the tray ticket but received applesauce. Resident #64 stated, I wanted the peaches. I get applesauce almost every day and it tastes sour. 12) On 4/15/25 at 12:30 PM Resident #62 did not have coffee or hot tea or 2% milk on the tray even though it was on the ticket. Resident #62 stated there were times that he/she did not get what he/she asked for. 13) On 4/16/25 at 12:31 PM Resident #70's tray ticket stated 5/14/25 instead of 4/16/25. The ticket stated open-faced roast pork sandwich. Resident #70 complained that the meat was thick, and they did not send a knife. Resident #70 kept a knife from yesterday because that happened frequently. Resident #70's tray ticket stated Frozen Nutritional Treat, Chocolate. The resident was served vanilla. Resident #70 stated, they do it all the time. I prefer chocolate. On 4/18/25 at 8:58 AM Staff #48, cook and Staff #4, dietary manager were interviewed and stated, we get food delivery on Tuesday and typically it is not until the afternoon. We run out of the house shakes or they are on back order. We probably only had a few of the house shakes. We normally have them but it's Tuesday and that is when the truck comes so it may have been an oops. Staff #48 stated that this happens with the bananas too. When asked if the geriatric nursing assistants (GNAs) look at the tray ticket and see what isn't on the tray, what happens. The cook stated, if they come and tell us we can make sure they get it. There is a lot of miscommunications around here. The surveyor went through each tray ticket with Staff #4 and Staff #48. Staff #48 stated that the person that was on the food line that day was excused off the line due to the amount of mistakes she was making. They also stated that they are not responsible for the juices and the hot drinks. They stated they send a cart out with the beverages on the cart and the GNAs are responsible to make sure the residents receive the drinks. Staff #4 was told about the vanilla and chocolate frozen nutritional treat situation. He stated, most people don't like chocolate, so we don't order it as much. We just give them the vanilla. The surveyor stated, even though they requested chocolate. Staff #4 shook his head. Both Staff #4 and Staff #48 were told about the numerous tray tickets that did not match what was sent to the residents. They both stated that they had problems with a few staff and have since removed them from the tray line. 14) On 4/18/25 at 12:45 PM the lunch tray was served to Resident #17. The resident looked at the salad and said, I don't like romaine lettuce. It is supposed to be iceberg lettuce. The resident then looked at the 1 small piece of broccoli and then looked at the surveyor and wrinkled up her nose. The broccoli was mushy and surrounded by some white object that was mushy. The presentation of the plate was a piece of bread cut in half, mushy broccoli, and half of a shriveled up baked potato. The resident also complained about the food and said the other day he/she got syrup but no pancake and received rice and mashed potatoes for lunch with no meat. Resident #17 stated he/she told someone, and they were going to get him/her something else but never did. At that time the surveyor went to get the Nursing Home Administrator (NHA) to view the lunch tray. The NHA came to the resident's room and confirmed that the chef's salad was made with Romaine lettuce and the tray ticket said iceberg lettuce in bold print. The NHA confirmed that it was half a potato but stated that it may be due to portion size. (Note: the resident was prescribed a regular diet). The tray ticket said regular diet. The resident complained the ice cream was melted so the NHA took that and said she would get another one. The NHA confirmed that the lunch did not look appealing. The surveyor and NHA then went to the roommate, Resident #71 and with his/her permission took off the lid off the plate. There was half of a small baked potato that had 2 small scoops out of it. The resident stated, why didn't I get a whole potato. The baked chicken breast was half eaten as the resident stated it was rubbery, and the bread was half eaten and the tossed salad was not touched. Again, the NHA admitted the meal did not look appealing. The surveyor discussed with the NHA that even after having a conversation with Staff #4 earlier in the day, the tray tickets still did not match what was sent to the residents.

Based on review of a complaint, observation of resident wheelchairs, and interviews, it was determined the facility failed to provide maintenance services necessary to keep all wheelchairs in a sanitary, comfortable, and well maintained condition. This was evident on 2 of 3 nursing units observed. The findings include: On 4/15/25 at 8:30 AM a review of complaint MD00203718 alleged wheelchairs in the facility were in disrepair. On 4/15/25 at 8:50 AM observation was made of Resident #60 sitting in the dining area eating breakfast. The vinyl was missing on the right front wheelchair armrest approximately 1 inch. The vinyl on the left wheelchair armrest was missing vinyl and the remaining vinyl was cracked. On 4/15/25 at 1:15 PM Resident #59 was observed sitting in the hallway in a wheelchair. The vinyl on the left wheelchair armrest was cracked along the edge and missing 1 inch of vinyl in the front. On 4/18/25 at 10:49 AM Resident #56 was observed sitting in a wheelchair. The left armrest was missing vinyl. Resident #56 was interviewed and stated that the armrest had been like that for a while. On 4/18/25 at 10:51 AM Resident #55 was observed sitting in a wheelchair. The vinyl on the left wheelchair armrest was cracked and missing about 1 inch of vinyl in the front and along the outer edge of the armrest. The right armrest was in the same condition. Resident #55 was interviewed and stated, this is how they gave it to me. Yesterday they tightened the right armrest. The surveyor asked Resident #55 if they said anything about replacing the armrest and the resident stated, no. On 4/18/25 at 10:55 AM Resident #57 was observed sitting in a wheelchair. The vinyl on the right armrest was missing at the front of the armrest and in 2 other places on the armrest. On 4/18/25 at 11:18 AM an interview was conducted with the Director of Maintenance, Staff #25. Staff #25 stated he did audits weekly of the wheelchairs. He audited the brakes, backrests, armrests, wheels, and leg rests. At that time Staff #25 was informed of the observations. On 4/21/25 at 1:45 PM the Nursing Home Administrator was informed of the concern.

Based on medical record review, documentation review and interview it was determined the facility failed to report allegations of abuse, neglect, or an injury of unknown origin within 2 hours of the allegation to the regulatory agency, the Office of Health Care Quality (OHCQ) (Resident #7, #8). This was evident for 2 of 24 residents reviewed for allegations of abuse, neglect or an injury of unknown origin during a complaint survey. The findings include: 1. Review of Resident #7's medical record review on 4/16/25 revealed the Resident was admitted to the facility in January 2023. Further review of the Resident's medical record revealed a nurse's note on 3/31/23 at 2:38 PM that stated, Patient noted with swelling on right thumb. On assessment there is dark discoloration noted, which is tender and warm to the touch. Patient voiced pain on assessment on the scale of 3 out of 10. Review of the facility reported incident the facility staff submitted to OHCQ on 3/31/23 revealed Resident #7 had an injury of unknown origin. Further review of the facility's investigation documentation revealed, Staff #15 gave a statement that stated, Upon resumption of my shift on 3/30/23, I noticed some bruises on both his/her arms and I went to the nursing station with an intention to tell the nurse, but she was busy with another resident. Interview with the Administrator on 4/16/25 at 1:00 PM confirmed the facility staff failed to report bruising of unknown origin for Resident #7 on 3/30/23 to OHCQ. 31145 2. On 4/16/25 at 10:40 AM a review of facility reported incident MD00191025 alleged that Resident #8's visitor stated that Resident #8 had been inappropriately touched. The facility became aware of the alleged incident on 4/5/23 at 5:25 PM. Review of the facility's investigation revealed an email confirmation that documented the initial report was sent to OHCQ on 4/6/23 at 6:00 PM. The allegation of potential abuse was not reported within 2 hours of notification. On 4/16/25 at 11:05 AM an interview was conducted with the Nursing Home Administrator(NHA). The NHA confirmed that the incident was not reported timely. The NHA stated she was not employed at the facility at the time.

Based on medical record review and interview with facility staff, it was determined that a resident with a noted change in condition and documented pain for a fracture, was not medicated with ordered pain medication or hospitalized timely. This was evident for 1 of 1 Resident (#119) reviewed during the investigative portion of the survey. The findings include: Review of the medical record for Resident #119 on 4/25/2022 at 9:31 AM revealed admission on 4/30/2021 including nondisplaced intertrochanteric fracture of the left femur admitted for routine healing and with a documented history of falling. Further review revealed that Resident #119 had 6 falls during his/her stay in the facility with the 6th fall occurring on 1/19/2022. This fall was not documented as occurring until 1/28/2022 when a late entry was entered into the electronic health record by the unit manager (UM) RN staff # 28. Review of the progress notes on 4/25/2022 at 10:26 AM for Resident #119 revealed a note written by UM staff #28 on 1/25/2022. The note documented that she told RN staff # 29 to order an x-ray to rule out a fracture for Resident #119. There was no other documentation before this note to potentially identify that an incident had occurred with Resident #119 to warrant an x-ray. On 1/26/2022 UM staff #28 wrote another note in the progress notes for Resident #119 that she was notified around 4:45 PM that Resident #119 was showing signs of pain due to his/her facial expressions, and s/he was unable to move his/her right leg. UM staff #28 notified the Nurse Practitioner (NP) on 1/26/2022 of Resident #119's status and an x-ray was ordered. The x-ray was finally completed on 1/27/2022 at 3:25 PM, 24 hours later, according to nursing documentation. The results were returned at 11:19 PM on 1/27/2022 and confirmed that Resident #119 has a fracture involving the right trochanteric femur with displacement and a fracture involving the proximal tibia with mild displacement. According to the nursing progress notes, the assigned nurse RN staff #29 sent an electronic notification to the on-call physician about the x-ray results at 11:19 PM on 1/27/2022. A progress note completed on 1/28/2022 from Nurse Practitioner (NP), staff #30, documented that she came in and assessed Resident #119 and ordered for Resident #119 to be sent to the hospital for treatment. There is no nursing documentation regarding the transfer, treatment or timing of the transfer. The NP note initiated on 1/28/22 at 3:36 PM, that was marked as a late entry and not signed until 2/7/22, included vital signs from 7:58 PM for 1/28/22 and noted the plan to send the resident to the hospital for a fracture. A review of Resident #119's Medication Administration Record [MEDICAL RECORD OR PHYSICIAN ORDER] . According to the MAR indicated [MEDICAL RECORD OR PHYSICIAN ORDER] . On 4/26/2022 at 1:15 PM surveyor interviewed UM staff # 28 regarding the notes she put in about Resident #119. She stated that RN staff #29 was the one that was caring for the patient, and we concurrently reviewed the notes. She was surprised that medication besides the ordered Tylenol was not admin and stated 'sorry.' She was not aware that the nurse had not followed through with her directions to medicate the resident. On 4/29/2022 at 11:40 AM surveyor interviewed NP staff #30. She stated that she was aware of Resident #119's fracture and that the RN staff, #29 was notified on the evening of 1/27/2022 to send the resident out to the hospital by the attending. NP staff # 30 presented to the survey team copies of the orders from 1/27/2022 to send the resident to the hospital. There was an electronic order time stamped 1/27/2022 at 7:57 PM to send Resident #119 to the hospital from the attending to RN staff #29. Survey team met with the Administrator and the DON on 4/29/2022 at 1:02 PM to review the identified concerns related; to the facilities failure to medicate a resident with new documented pain, lack of treatment for [MEDICAL RECORD OR PHYSICIAN ORDER] . According to the DON during this meeting, on 1/26 and 1/27/2022 it was reported to the UM, staff # 28 by the RCS (resident care specialist/geriatric nurse assistant) that Resident #119 appeared to be in pain on the right side. UM Staff #28 had given directions to staff RN #29 as identified in her progress notes. As far as the x-ray results, on 1/27 and 1/28 the attending physician had responded to the staff RN #29, however, the nurse failed to follow up and respond to the physician. On 1/28/2022 the attending came in for his regular visits, saw that the resident was still in the facility and ordered for him/her to be sent out. The NP staff #30's notes were reviewed at that time as there were vital signs for Resident #119 from the night of 1/28/2022. The DON stated that she would contact emergency medical services (EMS) to get the time that the resident was transferred out. At 1:11 PM on 4/29/2022 the DON reported to the survey team that Resident #119 was transferred to the hospital on 1/28/2022 at 11:30 AM. The concerns related to the failure to treat the resident for pain when it was identified and transfer to the hospital timely was reviewed at that time and again during exit on 5/6/2022.