Every finding on record at Autumn Lake Healthcare at Perring Parkway

Based on medical record review, observation and interview, it was determined that the facility staff failed to identify and consistently evaluate the contributing factors to a resident fall and ensure appropriate interventions were implemented to prevent future occurrences. This was evident for 1 of 2 (#6) residents reviewed for falls and resulted in harm to Resident #6. The findings include: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. Person-centered care: means to focus on the resident as the locus of control and support the resident in making their own choices and having control over their daily lives.The medical record for Resident #6 was reviewed on 6/16/26 at 8:21 AM regarding complaint 303105, that Resident #6 had repeated falls without interventions and was hospitalized multiple times.A review of the hospital discharge summary from 5/18/26 prior to this initial admission, documented that it was the 5th hospitalization secondary to falls for this resident prior to coming to the facility with discharge recommendations including 24/7 supervision from the physical therapy and occupational therapy team at the hospital secondary to the residents falls and debilitated condition.An initial admission baseline care plan was established on 5/18/2026 during the admission assessment completed with Resident #6. This noted that Resident #6 had a history of falls, and documented staff orientated the resident to the call bell as the intervention for fall prevention.Continued review of the medical record on 6/16/26 showed that less than 24 hours after initial admission on [DATE], Resident #6 fell on 5/19/26 with superficial injuries on the back and the resident also reported hitting his/her head lightly. On 5/22/26, Resident #6 fell on with no injuries noted, resident attempted to stand independently and was placed back in bed, and on 5/28/26 an assisted fall occurred during a transfer with staff, resident again was placed in bed and given the call light with the bed lowered. During this medical record review, there was no root cause analysis or documented change in the resident plan of care as to the cause of the repeated falls in this short time frame. Then on 5/30/26 resident was found on the floor in the bathroom with injuries noted to the resident back and forehead and a resulting abnormal neurological exam including an abnormal left pupil. Resident #6 developed a subdural hematoma from that unwitnessed fall when the resident attempted to self toilet. On 5/30/26 Resident #6 was sent to the hospital secondary to a fall, the 5th fall since 5/18/26 admission to the facility. Resident #6 could not recall the incident or if s/he hit their head, however, Resident #6's neurological exam was abnormal, so s/he was sent to the emergency room. S/he was diagnosed with a subdural hematoma (a life-threatening collection of blood that builds up between the surface of the brain and the dura mater).Upon readmission to the facility on 5/31/26, Resident #6 was moved to a bed closer to the nursing station to prevent falls according to a nursing note completed on 5/31/26 at 6:40 PM by RN #5. However, there was nothing in the care plan noting this intervention was in place and multiple observations over the course of the survey from 6/16/26 through 6/19/26, Resident #6 was noted in his/her room with the door closed, or if the door was open, the curtain was pulled so the residents' activities were still not visible to the staff in the hall or sitting at the nurses station. This surveyor noted Resident #6 awake during these time frames. This surveyor spoke to him/her on 6/17/26 at 7:00 AM when the curtain was noted closed and remained closed until morning cares were finally completed after 10AM.The care plan that was initiated upon the residents return on 5/31/26 noted one for poor safety awareness and falls, with interventions for physical therapy, proper footwear and orienting the resident to the call bell. During this survey and review, Resident #6 was no longer in physical therapy and was noted with the wrong size foot wear during care observations on 6/17/26. S/he did have the call bell, however, no other interventions or changes were added to the residents plan of care since the previous falls for the prevention of further falls and injuries. After the hospitalization for the fall that resulted in the subdural hematoma, Resident #6 fell again on 6/2/26 out of the wheelchair at the nurses station with abrasion documented to left knee.Attending #21 was interviewed on 6/18/26 at 11:11 AM. Her notes, the contents and the resident status at the time the notes were written were reviewed with her as she concurrently reviewed the same notes from 6/1/26 specific to Resident #6's readmission and a 6/17/26 note. She stated that she was aware of the incident with the subdural hematoma with Resident #6. She further stated that her notes were incorrect as she noted Resident #6 had 'no initial acute injury,' and that a subdural hematoma is a major injury. Further the expectations of 24/7 supervision in her notes were explained. She expected staff to have the resident visual, either at the nursing station or visually monitoring him/her. This surveyor reported to her that the surveyors were arriving prior to 7:00 AM over the past few mornings and since the start of observations on 6/16/26, the surveyors have observed Resident #6's door closed, even after breakfast was served in the morning, the curtain was pulled so the resident was not visible. Attending #21 verbalized at this time that that was a concern. The lack of actual orders in place for safety measures related to Resident #6's falls was discussed at this time.A general progress note completed on 6/3/26 stated that an IDT meeting was held and recommended Resident #6 to have physical and occupational therapy. However, 2 days later on 6/5/26 Resident #6 was released from therapy secondary to insurance reasons. No further interventions were put in place for the prevention of falls for Resident #6.The identified concerns were brought to the attention of the NHA throughout the survey. She stated on 6/18/26 at 8:48 AM that IDT meets on Wednesdays and it is up to the individual disciplines i.e. nursing, dietary, social work, to update their respective care plans. The concern that the care plan when established failed to address the specific individualized needs of the resident was reviewed at this time.When the DON was notified of the concern on 6/18/26 at approximately 1:00 PM she stated that she thought there was communication from the family about leaving the door closed. However, as of 6/24/26 this was not provided to the survey team and was not reflected in the resident's plan of care. The concern that a resident was admitted to the facility with a known history of falls with injuries and the facility failed to have appropriate individualized interventions in place for said resident who continued to have multiple falls resulting in an actual injury was reviewed with the facility on 6/18/26 and again on 6/22/26.

Based on observation and interview, it was determined that facility staff failed to maintain the facility in a homelike environment. This was evident for 3 of 3 observations of unit 1 and unit 2. The findings include: 1. On 6/16/26 at 7:05 AM the following observations were made on station 2 nursing unit: Inside room [ROOM NUMBER] there was a trashcan on the left that had a pair of discarded gloves lying beside the trashcan. There were pieces of food scattered in the hallway throughout the unit and beside the facility's sign in the lobby area near the elevator. There was a discarded mask in the hallway sitting on top of a personal protective equipment cart. There was a kitchenette with double doors, that were open and across the hallway was a napkin, straw papers and crumbs scattered in front of resident's room doors. To the right of the kitchen doors was a cart that had dirty dishes piled on it. There were 2 linen carts in the hallway with blue covers. On top of the covers were items such as briefs and an open box of gloves and on the other one were briefs, wipes, trash bags, and large gloves. These items were lying in disarray. 2. On 6/16/26 at 7:09 AM the following observations were made on Station 1 nursing unit: There were gloves found on the floor in room [ROOM NUMBER] and in room [ROOM NUMBER]. The floor in the hallway leading up to room [ROOM NUMBER] was observed to have several blackened areas appearing to look as though something was dripping on the floor. These areas were observed again on 6/17/26 at 8:06 AM and on 6/18/26 at 7:45 AM. On 6/18/26 at 7:44 AM the environmental services District Manager Staff #20 was observed in the hallway using a floor buffer machine on the floor on Station 1 unit. During an interview with Staff #20, he and the surveyor observed the floor outside room [ROOM NUMBER] and it was wet and the stains that were observed on 6/16/26, 6/17/26, and 6/18/26 were gone. He reported that he had placed a more aggressive pad on the buffer machine this morning. The concerns were reviewed with him. He reported that environmental staff were on duty during the day and evening. However, was unable to speak to why the facility was unkempt. The manager of housekeeping had been transferred to another facility. 3. During the initial entrance, at 7:07 AM on 6/16/26 this surveyor observed a pair of gloves on the floor at the entrance to room [ROOM NUMBER] on the 2nd floor. LPN/Supervisor #8 was observed at this time entering the room, stepping over the pair of gloves, then moments later exiting the room, again stepping over the gloves and leaving them on the floor. The tour and observations continued on Unit 1 at 7:18 AM on 6/16/26 a black cart was observed sitting in front of room [ROOM NUMBER] with 2 trays on top of it. The trays contained 2 plates of partially eaten food, dirty dishes, silverware and exposed food. On 6/18/26 at 7:35 AM continued tours of the facility and observations of resident care and interactions with staff. A black cart was observed in front of room [ROOM NUMBER]. There were 2 plates on it with exposed food from the prior dinner meal. Tour again at 8:25 am on 6/18/26 the black cart was still there in front of room [ROOM NUMBER] with the prior days' meal on it. These identified concerns were brought to the attention of the environmental services District manager #20 on 6/18/26 at 7:44 AM as noted above.

Based on record review and interview, it was determined that the facility failed to have a process in place to ensure residents/resident representatives had the right to a grievance process. This was evident for 1 (#1) of 6 residents reviewed for complaints. The findings include:On 6/17/26 at 12:00 PM a review of the facility's policy titled, Resident and Family Grievances dated 12/23/22 with the last review on 11/3/25 revealed they failed to enter the name and title of the grievance officer and contact information as indicated on the policy. The policy stated that a resident or family member may voice grievances with respect to care and treatment and other concerns regarding their stay at the facility. In addition, it was noted that a person may use the following forum to voice a grievance verbal complaint to a staff member or grievance official. The staff member receiving the grievance will record the nature and specifics of the grievance on the designated grievance form or assist the resident or family member to complete the form. Then forward the grievance form to the grievance officer as soon as practicable. Upon review of complaint #2791591 for Resident #1 on 6/16/26 at 10:40 AM it was revealed that the complainant reported that they had sent emails to facility staff regarding their concerns and received no response to resolve the concerns. An interview with the complainant on 6/16/26 at 10:41 AM revealed that facility staff failed to inform them of their right to a grievance process when they had a concern. The complainant reported that they continued to have concerns about the resident not receiving the full meal as stated on their meal ticket. An interview with the Director of Nursing (DON) on 6/22/26 at 11:35 AM revealed that when she received a verbal complaint about a resident's care she would not complete a grievance right off the bat When asked if she had received care complaints regarding Resident #1 multiple times over a few months she stated she had, but they were mostly about food. She reported an incident where the resident had not received a sandwich that they were supposed to get extra with their meal. She stated, we had the peanut butter and the bread, so we made [the resident] a sandwich. She further stated that she did not interview the resident or staff to attempt to find out the root cause and determine a solution because it was a food concern. When asked why she had not completed a grievance form when food concerns were continuously being reported to her, she stated that food was not her category and that should be taken care of by the Nursing Home Administrator (NHA). When asked if she had received any emails regarding concerns about Resident #1's care, she reported that she had received 2 emails, however, could not recall what the concerns were. She reported later that she was unable to find the emails to review and discuss with the surveyor. On 6/22/26 at 1:31 PM the concerns were reviewed with the NHA. Although the complainant reported they included the NHA in the emails, she offered no rationale as to why the complainant had not been afforded their right to file a grievance and have a resolution for their concerns.

Based on observation, record review, and interview, it was determined that facility staff failed to ensure that a resident was treated with dignity. This was evident for 1 (#5) of 3 residents observed during the complaint survey,The findings include:An observation of Resident #5 on 6/17/26 at 1:23 PM revealed the resident was in a hospital gown. A review of complaint #3034879, regarding Resident #5, on 6/16/26 at 10:40 AM revealed the complainant alleged the resident was not receiving assistance with his/her personal care needs. On 6/17/26 at 1:24 PM the certified nursing assistant (Aid) #22, who was assigned to Resident #5 the day of the observation, was interviewed. She reported that she had given the resident a bed bath, mouth care, and applied lotion on his/her skin. When asked if the resident had family who provided clothes for him/her, Aid #22 reported that the resident had clothes. However, she reported there was no reason she had not assisted the resident to dress in their clothes instead of a hospital gown.The concerns were reviewed with the Director of Nursing (DON) and the Nursing Home Administrator on 6/22/26 at 1:18 PM. They offered no rationale for the deficient practice.

Based on record review and interview, it was determined that the facility failed to have a process in place to ensure that allegations of abuse were reported to the State Agency within the required timeframe. This was evident for 4 of 4 abuse allegations reported to staff for Resident #3. The findings include:1) On 6/16/26 at 10:08 AM a review of the facility's Abuse, Neglect, and Exploitation Policy dated 11/13/23 and last reviewed on 10/17/25 revealed in section VII (7) titled, Reporting/Response that staff were to report all allegations of abuse to the Nursing Home Administrator (NHA) and to the State Agency (SA). A review of the facility's investigation file for the facility reported incident #2982477 on 6/17/26 at 9:23 AM revealed the facility documented that they became aware of the allegation of abuse on 4/13/26 at 3:00 PM when another family member of the resident reported it to the NHA. Further review revealed that Certified Nursing Assistant II (Aid) #10 wrote in her statement that Resident #3 had reported the allegation of abuse to her while she was providing care to the resident. However, according to the email confirmation, facility staff failed to report the allegation of abuse to the SA until 4/13/26 at 5:12 PM. On 6/17/26 at 10:33 AM an interview with Aid #10 revealed that while providing care for Resident #3 after dinner on 4/12/26, the resident reported that she had been beaten by 6 women. She reported that she told the nurse on duty about the allegation of abuse. An interview with the NHA on 6/17/26 at 11:35 AM revealed that she was aware that allegations of abuse were to be reported to the SA within the 2-hour timeframe. She reported she was unaware that the resident had reported the allegation of abuse to Aid #10 on 4/12/26. The concerns were reviewed at this time. 2) A medical record review for Resident #3 revealed a progress note that the resident's representative wanted the resident discharged on 6/2/26. Based on another progress note written by Nurse Practitioner (NP) #24 on 6/2/26 revealed the resident was supposed to discharge on [DATE]. Upon review of complaint #3034284 dated 6/4/26, Resident #3 was taken to the local hospital emergency department (ED) and there was an allegation that the resident was abused at the facility. On 6/16/26 at 1:34 PM a review of the hospital records for the ED visit on 6/2/26 revealed photos of bruising on both sides of Resident #3's neck, a bruise to the right knee, and a bruise on the elbow. The ED physician documented that there was an allegation of abuse and the forensic nurse was notified and the police. He further noted that it was reported the abuse occurred at the facility the resident was residing at and that the complainant brought the resident straight to the ED. An interview with the Director of Social Services on 6/17/26 at 9:40 AM confirmed that the resident was discharged 2 days earlier. She reported she was not present when the resident discharged , but that it was handled by the Director of Nursing (DON).During an interview with the DON on 6/22/26 at 9:28 AM, she reported that the resident representative had some concerns that day and had called 911. When asked specifically what the concerns were she stated she would need to look at her notes.A subsequent interview with the DON on 6/22/26 at 10:00 AM revealed she had not spoken to the daughter or the resident on 6/2/26 but had been approached by the responding police officers. She stated that they told her a family member had concerns about a staff member talking rudely to her [the family member]. They reportedly told her the resident refused to answer their questions. The DON stated she told the police officers that the facility could discharge the resident that day if the family member wanted them to. She stated that the police officer went back and informed the family member who agreed to the discharge. An interview with the NHA on 6/22/26 at 10:50 AM revealed the family member had called her cellphone directly. She was unable to reach the family member when she attempted to call back, so she called the nurses' station. She attempted to ask the family member what was wrong, but she refused to tell her. She reported that the resident's nurse told her the resident was fine, but when the family member arrived, they called the police. She reported that when the police officers talked to the DON, she was on speaker phone and they reported that the concerns were not about something that happened that day. On 6/22/26 at 12:18 PM an interview with Certified Nursing Assistant II (Aid) #25 revealed that he was assigned to Resident #3 on 6/2/26. Aid #25 reported that when he arrived to the unit the resident was up in their wheelchair, so he provided care and put the resident back in bed. When the family member arrived and saw him in the resident's room, the family came out in the hallway accusing Aid #25 of abusing the resident and throwing things in the room. When asked if anyone else had witnessed the family member coming out into the hallway, he stated that the nurse assigned to the resident that day. He reported that he told Supervisor #26 about it. Aid #25 explained further that earlier this year the family member was watching him feed the resident and was upset about a comment he made to the resident. This was reported to facility staff and the next time the Aid worked he was asked by Unit Manager (UM) #9 to write a statement about what happened. The Aid #25 further reported that facility staff had not told him that he was not to be assigned the resident in the future and this was the reason the family member was upset. An interview with UM #9 on 6/22/26 at 12:33 PM revealed that she was unable to recall the incident when the family reported Aid #25 and she asked him to write a statement. She stated she recalled another incident where the resident accused someone of pulling his/her arm and she reported that to the DON via email. She reported that she puts everything into an email, so she has a electronic paper trail. She was asked to look review the emails and report back to the surveyors. However, she failed to do so by the conclusion of the survey. On 6/22/26 at 12:46 PM the DON was asked about the 2 incidents, and she reported she was unaware of either of them. She was asked to check to see if they had reported either allegation of abuse to the State Agency (SA). She was made aware that there was an allegation of abuse for Resident #3 on 6/2/26 that facility staff failed to report to her. The concerns that allegations of abuse were not reported to the SA as required were reviewed with the DON and NHA on 6/22/26 at 1:19 PM.Cross Reference: F610

Based on record review and interview, it was determined that the facility failed to have a process in place to ensure that all allegations of abuse were investigated and appropriate interventions put into place to ensure resident were free of abuse. This was evident for 3 of 4 allegations of abuse reported regarding Resident #3.The findings include:A medical record review for Resident #3 revealed a progress note that the resident's representative wanted the resident discharged on 6/2/26. Based on another progress note written by Nurse Practitioner (NP) #24 on 6/2/26 revealed the resident was supposed to discharge on [DATE]. Upon review of complaint #3034284 dated 6/4/26, Resident #3 was taken to the local hospital emergency department (ED) and there was an allegation that the resident was abused at the facility. On 6/16/26 at 1:34 PM a review of the hospital records for the ED visit on 6/2/26 revealed photos of bruising on both sides of Resident #3's neck, a bruise to the right knee, and a bruise on the elbow. The ED physician documented that there was an allegation of abuse and the forensic nurse was notified and the police. He further noted that it was reported the abuse occurred at the facility the resident was residing at and that the complainant brought the resident straight to the ED. An interview with the Director of Nursing (DON) on 6/22/26 at 10:00 AM revealed she was aware that Resident #3's family member called 911 on 6/2/26 because she was at the facility when it happened. She spoke to police who told her the concerns were not recent. She asked the nurse who was assigned to the resident what was wrong but was told everything was ok. However, she reported she did not assess the resident or talk with the family to find out what was wrong. She offered to discharge the resident that day if the family wished to do so.An interview with the NHA on 6/22/26 at 10:50 AM revealed she attempted to talk to the family member over the phone but was unable to find out what was wrong. She reported that she was on speaker phone when the police talked with the DON. On 6/22/26 at 12:18 PM an interview with Certified Nursing Assistant II (Aid) #25 revealed that he was assigned to Resident #3 on 6/2/26. Aid #25 reported the family member went into the hallway and was alleging he abused the resident. He reported that the nurse assigned to the resident and that he told Supervisor #26 what the resident's family member said. However, no one took action to remove the alleged perpetrator from access to the resident and other vulnerable residents or conduct a thorough investigation of the allegation of abuse. During this interview, Aid #25 reported that the same family member previously reported to staff that he made an inappropriate comment while feeding the resident. He stated that he found out when he returned to work at the facility because UM #9 asked him to write a statement about what happened. There was no evidence that this allegation was reported to the SA and a thorough investigation was completed to ensure the residents were free of abuse. While interviewing UM #9 on 6/22/26 at 12:33 PM it was reported that she did not recall the incident reported by Aid #25 with the inappropriate comment but recalled another allegation of abuse. She stated that the resident reported that someone had pulled on his/her arm and that it was hurting. She recalled writing a statement and sending it to the DON. She reported she kept everything in her emails to ensure it was not lost. However, she failed to report back to the surveyor. The facility failed to show that this allegation of abuse was reported, and a thorough investigation competed to ensure the safety of their residents from abuse. On 6/22/26 at 12:46 PM the DON was asked about the 2 incidents, and she reported she was unaware of either of them. She was asked to check to see if they had reported either allegation of abuse to the State Agency (SA). She was made aware that there was an allegation of abuse for Resident #3 on 6/2/26 that facility staff failed to report to her. The DON was asked to check to see if they had any documentation regarding the allegations of abuse and if they were investigated. There was no additional evidence provided at the time of the conclusion of the survey.During an interview with the DON and NHA on 6/22/26 at 1:19 PM they reported they had no knowledge of these incidents. They were informed that if they found additional evidence to the contrary to provide it to the SA. Cross Reference: F609

Based on record review and interview, it was determined that the facility failed to have a process in place to ensure that residents were appropriately discharged from the facility. This was evident for 1 (#3) of 1 discharge reviewed. The findings include:MDS (Minimum Data Set) - is a complete assessment of the resident which provides the facility information necessary to develop a plan of care, provide the appropriate care and services to the resident, and to modify the care plan based on the resident's status. Care plan - 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. Person-centered care: means to focus on the resident as the locus of control and support the resident in making their own choices and having control over their daily lives. A paper record review for Resident #3 on 6/16/26 at 1:11 PM revealed 2 provider certifications dated 2/25/26 and 3/3/26 deeming the resident incapable of making decisions due to the diagnosis of dementia. An electronic medical record review for Resident #3 on 6/16/26 at 8:23 AM revealed a history and physical was completed on 2/25/26 that documented the resident had dementia, left side weakness after a stroke, and ambulatory dysfunction. The notes revealed the resident was at the facility for rehabilitation (rehab) services. A review of the care plan for the focus of the resident discharging home when the rehabilitation stay was completed that was initiated on 3/9/26. The goal was that the resident will be discharged when they had reached their rehab/self-care goals. The following interventions were initiated on 3/9/26: assess future placement setting to ensure the resident's needs can be met; complete post-discharge plan, review with resident, and provide a copy; discuss with resident/rep discharge process. The interventions were not resident-centered. There was no evidence on the care plan that staff documented an ongoing discharge planning process that included the IDT (Interdisciplinary Team consisting of nursing, providers, therapy, dietary, and social services). They failed to include the discharge needs of the resident; show there was regular re-evaluations to identify changes in the discharge needs and reflect changes that were made; show that the considered caregiver/support person availability and ability to provide the care/support; show there was input from the resident representative; address the resident's goals of care and treatment preferences; document the resident had been asked about their interest in receiving information regarding returning to the community; and document the referrals for community resources and medical equipment referrals and update the care plan with their responses. A review of the progress notes revealed that on 3/12/26 the Social Services Director Staff #12 wrote that the resident representative was considering long-term care for the resident, however this was not reflected on the discharge care plan. On 4/30/26 Staff #12 wrote a note that she spoke with the resident's representative about completing the Medicaid application timely if the plan was for the resident to stay long-term. On 6/17/26 at 9:40 AM an interview with Staff #12 revealed she had ordered the durable medical equipment for the resident and made a referral to the home health agency. She stated that the resident went home 2 days early, but that the discharge was completed prior to the date she left. She reported she had no concerns with the discharge. During subsequent interview with Staff #12 on 6/22/26 at 10:30 AM she reported that she was not aware of the regulatory requirements for discharging a resident from the facility. She could not recall if she had or had not received training at the time she was hired. The concerns were reviewed with her. On 6/22/26 at 1:19 PM the concerns were reviewed with the Director of Nursing and the Nursing Home Administrator.

Based on medical record review, observation and interviews, it was determined that the facility failed to accurately code a residents' active diagnosis and skin conditions on the minimum data set (MDS). This was determined during the review of complaints related to general care in 2 of 4 residents (#6 and #7). 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.1. The medical record for Resident #6 was reviewed on 6/17/26 at 1:32 PM. The comprehensive assessment completed on 5/18/26 and the active diagnosis entered in section 'I' stated that the active diagnosis entered in the comprehensive assessment for 5/18/26 documented that Resident #6 had or was treated within the past 7 days with cancer. A comprehensive review of the medical record including the hospital discharge, failed to note any active treatment for cancer, only a 'history of.'The MDS coordinator staff #18 was interviewed on 6/17/26 at 1:32 PM regarding the identified concerns. After her review she followed up to state that a modification will be done that the 'cancer' diagnosis under active diagnosis was entered incorrectly. 2. Resident #7 was observed in bed on 6/16/26 at 7:07 AM and a wound vac (is a dressing system that uses gentle suction to help a wound heal) that was observed sitting on a chair to the left of the resident's bed connected to tubing protruding out from the left side of the bed. Review of the June quarterly MDS on 6/16/26 at 12:10 PM June Quarterly assessment section 'M' skin conditions, failed to code and document the presence of any wounds for Resident #7. MDS coordinator #18 was interviewed on 6/22/26 at 10:05 AM. Of note, everything on section 'M' was dated 5/15/26, however, under #1 for number of unhealed pressure ulcers, the date was 5/29/26. She was asked about the difference in the dates. She stated she recalled this and that she was audited by her corporate office and was told that there was not enough in the medical record to support the coding of the presence of a pressure ulcer. She stated she would follow up to confirm. An email from the facility nursing home administrator on 6/23/26 confirmed this statement which also correlates with the concerns reported to the DON at 10:15 on 6/22/26 that there were no weekly wound records found for Resident #7.

Based on observation and interview, it was determined that the facility failed to provide the residents with a quality of care and dignity by timely responding to call bells and providing residents with the appropriate adult incontinence briefs. This was evident during random observations and 1 of 1 resident (#6) observed for the use of incontinence briefs. The findings include: 1. During the entrance and initial general observations conducted on 6/16/26 at 7:00 AM, this surveyor walked past room [ROOM NUMBER], heard and saw the call bell going off. A staff member was seen walking in the opposite direction towards the surveyor. This individual proceeded to go past this surveyor, past the call bell still alarming and proceeded pushed the button for the elevator. This surveyor continued down the hall and the 2nd floor nursing station was visualized to the left with 5 staff all seated around the nurses station. The call bell panel was observed up on the wall and there were 3 call bells that were presently lit up on the panel alarming, including room [ROOM NUMBER] that could still be observed from this observational standpoint.This surveyor introduced self and coworker and the purpose for the visit and requested for a supervisor from any of the 5 individuals sitting at the nursing station. One staff, later identified as the evening supervisor, Staff # 8, notified this surveyor that the Director of Nursing's office was downstairs and this surveyor was welcome to go and get her. During this conversation now 7:17 AM, this surveyor noted that there were still at least 3 call bells going off, with the alarm system to the immediate left of LPN/Supervisor #8's head. This surveyor continued to ask the rest of the staff their names, as staff #8 who was later identified as the night supervisor sat there with the call bells going off.The second staff sitting at the nursing station was then asked her name. She initially refused and stated that she was agency and has nothing to do with any of this. She was then asked if she was still on the clock and cared for any residents last night. She then stated, it doesn't matter, to which this surveyor repeated to her to confirm, her statement. This identified agency certified nursing assistant (Aide) #14, looked away and would not answer any further questions. This surveyor proceeded down the nursing station to each employee asking their names. The call bells continued to alarm, and all the staff continued to sit at the nursing station. This surveyor then proceeded around the remainder of the facility.2. Secondary to allegations of double diapering and neglect of Resident #6 and other residents, on 6/17/26 at 9:38 AM, care for Resident #6 was directly observed. Permission was requested and granted from the resident and certified nursing assistant (Aide) staff #10 notified this surveyor when she was starting.This surveyor noted that Aide #10 brought in and prepped a blue brief for the resident. However, when the resident was undressed, a tan/yellow brief was revealed. This surveyor asked Aide #10 about the discrepancy in the brief's colors. Aide #10 looked at this surveyor and stated that they are supposed to go by the resident size/weights when choosing briefs and that this resident should be in a 'L,' however, last night staff placed him in an 'XL.' The brief was noted bunched up around the sides of the resident and between the legs. Aide #10 further stated that unfortunately sometimes staff do this. On 6/18/26 at 6:45 AM this surveyor approached the 1st floor nursing station after reviewing the assignment board, establishing who cared for Resident #6 the night prior and introduced self. Aide #9 was identified as the staff that cared for Resident #6 the night prior. She was asked if she recalled the color brief that was used on [him/her]. She looked at me and said, I think the tan size, the bigger one, I don't know, they are giving him something for [his/her] bowels so. This surveyor tried to clarify how the staff would determine the appropriate size of adult briefs for a resident. Aide #9 looked at this surveyor and stated, why are you asking me, I don't know what I put on [him/her]. The next Aide sitting at the nursing station, Aide # 6, was also asked how she would determine what size goes to what resident, as there are different colored briefs. She replied to this surveyor What she said.The DON was notified of the observations and interactions with the staff on the night shift at 7:17 AM, she stated well you know that's why some people work on the night shift. A tour of the storerooms, one identified on each unit, identified the same items were stocked and available on both floors, the S, M, L, XL briefs were labeled as on the 1st floor but not on the 2nd floor. A look at the individual packages and websites for the current company the facility utilizes revealed that the size of the briefs used for an individual should be based on abdominal circumference not weight. When the identified concerns were reviewed again with the DON on 6/18/26 at 9:37 AM about staff using the wrong size briefs on residents, she stated that they use different brands and colors can change. However, when it comes to briefs and adult diapers it was brought to her attention at this time that the manufacturers go by abdominal circumference, not weights.A review on 6/18/26 at 9:40 AM of Resident #6's medical record failed to reveal any documentation of an abdominal circumference or of a size brief that should be used.Review on 6/22/26 at 11:49 AM of Resident #6's medical record revealed a history of having sacral ulcers and incontinence associated dermatitis (painful skin irritation, caused by chronic exposure to moisture, urine and feces).The overall concern related to the lack of staff response to call bells and placement of inappropriate sized briefs/adult diapers potentially resulting in additional and worsening skin breakdown was reviewed with the facility DON and NHA during exit on 6/22/26.

Based on medical record review and interview with facility staff, it was determined that the physicians failed to have their signed notes in the medical record timely after seeing the resident and ensure their notes were individualized and reflected the status of the resident. This was evident 1 of 2 (Resident #7) residents reviewed during a complaint survey.The findings include: 1. Review of the medical record for Resident #7 on 6/18/26 at 10:29 AM revealed attending notes completed by attending #21 completed on 5/20, a history and physical, 6/1 and 6/17.All 3 notes contained the same information. On 5/31/26 Resident #7 sustained a fall and acquired requiring hospitalization where it was noted that s/he acquired a subdural hematoma. The 6/1/26 readmission note stated that Resident #7 had 'no acute injury.' To plan for 24/7 supervision. Attending #21 was interviewed on 6/18/26 at 11:11 AM. Her notes, their contents and the resident status at the time the notes were written were reviewed with her as she concurrently reviewed her notes. She stated that she was aware of the incident with the subdural hematoma. After reviewing what was brought to her attention by the surveyor, she stated that it was her 'fault,' that it was not a comprehensive note capturing the resident's actual status and that she would be more careful in the future. 2. During the review of these progress notes it was also identified that these progress notes for this resident had a different created and signed date. Review starting on 6/16/26 at 8:21 AM revealed the following:Physicians' notes from 5/20/26 (history and physical) were signed on 5/24. The 6/1/26 (readmission post hospitalization for significant injury) note was not signed until 6/10/26 and the 6/17/26 (readmission post hospitalization for infection) progress note was signed the next morning on 6/18/26. Therefore, had there been any changes or updates to the resident care it would not have been implemented until the signed date, not the day the physician initiated the progress note potentially causing delays in care.

Based on observation and interview it was determined the facility failed to ensure a homelike environment. This was evident for 2 of 2 facility floors of the building during the facility's recertification survey. The findings include: During surveyor initial tour of the facility, upon entering the facility's lobby area on 11/24/2025 at 7:30AM, and again at 7:48AM surveyors noted a malodorous smell was present. Carpeting present within 2 out of 2 of the facility's floors was observed to be in worn condition with areas of the carpet's pattern no longer visible as compared to smaller adjacent areas. Surveyors observed dark grey areas and staining and debris present within the carpeting material. On 11/26/2025 at approximately 11:30AM the survey team noted a malodorous smell was present in the hallway near room [ROOM NUMBER]. On 11/26/2025 at 11:40AM a malodorous smell was found by the surveyor to be present in the hallway near the elevator on the first floor of the facility. On 11/26/2025 at 12:40PM the surveyor observed the front reception area desk with damage present to the front lower portion of the desk in several areas with pieces of the covering chipped and missing with a visible triangular shaped hole present, and the surveyor shared their observation and concerns with Clinical Regional Nurse #14 who acknowledged and confirmed understanding of the concern. On 12/01/2025 at approximately 10:05AM a malodorous smell was again noted to be present by the surveyor in the facility's lobby area. At this time, the concerns were shared with the facility's Administrator and a dual observation of the concerns was conducted with them. At this time, the facility Administrator observed, acknowledged, and confirmed understanding of the concerns. The facility Administrator reported to the surveyor that potentially the odor was due to nearby resident rooms located adjacent to the lobby area. On 12/01/2025 at 11:54AM the surveyor conducted an environmental tour of the facility and noted that despite the carpet having been observed to be cleaned by facility staff, the carpeting continued to be observed in worn condition with staining and debris present. Dark areas of staining were observed to be present in the doorways of multiple resident rooms. On 12/01/2025 at 11:57AM the surveyor observed chipped areas present within the flooring of the elevator. On 12/01/2025 at 11:58AM, after surveyor intervention, the reception area damage was observed to be repaired. On 12/01/2025 at 12:01PM the surveyor observed a partially brown stained ceiling tile adjacent to the air vent in the resident hallway near Resident room [ROOM NUMBER]. The air vent was observed to have black debris along the edges of the adjacent ceiling tiles, and the vent was observed to have thick, grey matter present within it. On 12/01/2025 at 12:03PM the surveyor observed three ceiling tiles above the floor 2 nursing station with brown staining present and surrounding tiles were observed to have debris and grey matter present on them. On 12/01/2025 at 12:04PM the surveyor observed the ceiling vent near room [ROOM NUMBER] with dark grey matter present within it. Ceiling tiles adjacent to the vent were observed to have black debris along the edges and areas of grey matter present on surrounding ceiling tiles. On 12/01/2025 at 12:11PM the surveyor conducted an environmental tour of the facility with the facility's Supervisor of Maintenance #16 and Director of Environmental Services (DES) #15 who observed and acknowledged the surveyor's concerns and confirmed understanding of the concerns. During surveyor interview of DES #15 at this time, they reported to the surveyor that they were in charge of odor control within the facility, and that when staff call to let him know of an odor, he looks in different areas near the odor and usually he had found that it was attributed to dirty incontinence care products in trash cans in the rooms. Supervisor of Maintenance #16 reported they would be cleaning the ceiling vents and was subsequently observed by the surveyor cleaning them.

Based on record review and staff interviews, it was determined that the facility failed to ensure a resident's right to formulate an Advanced Directive and maintain accurate documentation within their medical record. This was evident for 4 (Resident #2, #5, #64, and #57) out of 6 residents reviewed for Advanced Directives during the survey.The findings include: Advance directive is a written instruction, such as a living will or durable power of attorney for health care, recognized under State law (whether statutory or as recognized by the courts of the State), relating to the provision of health care when the individual is incapacitated. It is a legal document outlining future healthcare wishes and appointing a healthcare agent. Maryland Medical Orders for Life-Sustaining Treatment (MOLST) is a form which includes medical orders for emergency medical services or other medical personnel regarding CPR (cardiopulmonary resuscitation) and other life-sustaining treatment options. It is a state specific medical document, with signed physician orders. 1. On [DATE] at 11:47 AM, review of the electronic medical record and hard charts for 6 residents revealed that advance directive documentation could not be located for Residents #2 and #5. The surveyor requested assistance locating the documentation from the Director of Nursing. On [DATE] at 10:15 AM, an interview was conducted with Staff #8 and they stated that the MOLST (Maryland Medical Orders for Life-Sustaining Treatment) form was the advance directive. The administrator confirmed that the MOLST form was considered an advance directive. The surveyor informed them at this time that the MOLST form was not considered an advance directive, per CMS regulations. 2. On [DATE] at 1:06PM, the Surveyor discovered an Advanced Directive admission assessment completed on [DATE] which stated Resident #64 has an Advanced Directive currently in place. Further review revealed a Social Service Assessment completed on [DATE] which stated that the resident had an Advanced Directive and the Advanced Directive was on file. On [DATE] at 8:55AM, a review of Resident #64's electronic and paper medical records failed to reveal Advanced Directive documents. The Surveyor requested the Director of Nursing (DON) to provide Advanced Directive documents for the resident. On [DATE] at 10:00AM, the Director of Nursing provided the Surveyor with a copy of the MOLST form for Resident #64, which is not an advanced directive. During an interview with Social Worker (SW) #8 and the Nursing Home Administrator (NHA), the Surveyor expressed the concern that Resident #64 has an Advanced Directive admission assessment completed on [DATE] and a Social Service Assessment completed on [DATE] stating that the resident has an Advance Directive document on file; however, a review of the resident's medical record failed to reveal such documentation. SW #8 stated that Resident #64 has a MOLST and the MOLST was considered the resident's Advance Directive when completing the assessments. The NHA and SW #8 confirmed that they assumed the MOLST was an Advanced Directive. The Surveyor informed the NHA and SW #8, that a MOLST and Advanced Directive are 2 different documents. Therefore, Resident #64 did not have the opportunity to formulate an Advance Directive because the MOLST was considered to be their Advanced Directive. By the exit conference on [DATE], the NHA confirmed that the MOLST was not an Advanced Directive. 3. On [DATE] at 9:02AM, during a review of Resident #57's electronic medical record, the Surveyor discovered a Social Service Assessment completed on [DATE] which stated that the resident was provided with a copy of the Advance Directive for completion. Additionally, a Social Determinants of Health assessment completed on [DATE] by the Social Service department revealed that the resident always needs to have someone help them when they read instructions, pamphlets, or other written material from their doctor or pharmacy. The resident was their own representative. Further review revealed an Advanced Directive admission assessment completed on [DATE] which stated that if the resident does not have an Advanced Directive and wish to create one, the facility can assist you with this process. According to the assessment, Resident #57 did not have an Advance Directive currently in place and was interested in meeting with a member of the Social Work team to discuss steps to implement an Advance Directive. Additional review of Resident #57's electronic and paper medical record failed to reveal completed Advanced Directive documents or documentation that the facility assisted the resident with their wishes to formulate an Advanced Directive. On [DATE] at 10:20AM during an interview with Social Worker (SW) #8 and the Nursing Home Administrator (NHA), the Surveyor expressed the concern that on [DATE], the resident was provided with a copy of an Advance Directive to complete; however, the resident needed physical assistance to complete the form and there was no documentation to verify the SW assisted the resident. The Surveyor also expressed the concern that Resident #57 failed to have an Advanced Directive formulated after communicating an interest on [DATE] and [DATE] to the SW. The NHA informed the Surveyor that SW #8 was employed by the facility in [DATE]. The SW who completed the assessments was no longer employed by the facility. The Surveyor confirmed that Resident #57 does not have an Advanced Directive but has a MOLST form. SW #8 stated that the resident was no longer their own representative and has a resident representative. The Surveyor expressed the concern that the resident should have had the opportunity to formulate Advance directives while they had their own decision-making abilities.

Based on record review and interview with staff, it was determined that the facility failed to ensure residents and/or resident representatives were offered the opportunity to participate in their care planning process by holding timely quarterly care plan meetings. This was evident for 2 (Resident #31 and Resident #57) out of 4 residents reviewed for care planning during the annual survey. The findings include:A care plan is used to summarize a person's health conditions, specific care needs, and current treatments and outlines what needs to be done to plan, assess, and manage care. Care plans are developed, reviewed, and/or revised by the IDT after the completion of a comprehensive MDS assessment (Admission, Annual, Quarterly, Significant Change) to help to evaluate the effectiveness of the resident's care while in the facility.The MDS (Minimum Data Set) is a standardized, comprehensive assessment of a resident's functional, medical, psychosocial, and cognitive status to develop a plan of care based on the resident's individualized needs.On 11/25/2025 at 10:20AM, an interview conducted with Social Worker (SW) #8 and the Nursing Home Administrator (NHA) revealed that initial care plan meetings are held within 7-14 days of admission and are then held quarterly, usually within the timeframe of the MDS assessments. Care plan meetings can also be held with a change in condition or at the request of the resident or the resident representative. The Surveyor requested documentation of Resident #31's and Resident #57's quarterly care plan meetings from January 2024-November 2025On 11/25/2025 at 11:35AM, a review of Resident #31's care plan meeting notes revealed that the resident had care plan meetings on 2/1/2024, 6/20/2024, and 9/18/2025. A review of Resident #31's electronic medical record revealed the facility held a quarterly MDS assessment on 3/8/2024, an annual MDS assessment on 6/14/2024, a quarterly MDS assessment on 9/14/2024, 12/8/2024, and 2/18/2025, an annual MDS assessment on 5/21/2025, and a quarterly MDS assessment on 7/25/2025 and 10/25/2025. Further review failed revealed care plan meetings were held quarterly, during the timeframe of the MDS assessments on 9/14/2024, 12/8/2024, 2/8/2025, 5/21/2025, and 7/25/2025. A review of Resident #57's care plan meeting notes revealed that the resident had care plan meetings on 6/9/2024, 11/22/2024, 2/26/2025, 4/24/2025, and 10/9/2025. A review of Resident #57's electronic medical record revealed the facility held an annual MDS assessment on 3/19/2024, a quarterly MDS assessment on 5/2/2024, 8/3/2024, 11/3/2024, 12/20/2024, an annual MDS assessment on 3/20/2025, and a quarterly MDS assessment on 6/20/2025 and 9/20/2025. Further review failed to reveal care plan meetings were held quarterly, during the timeframe of the MDS assessments on 3/19/2024, 8/3/2024, and 6/20/2025.On 11/25/2025 at 11:50AM, during an interview with the NHA, the Surveyor expressed the concern that the facility failed to ensure timely quarterly care plan meetings were held for Resident #31 from 6/20/2024 until 9/18/2025 and failed to ensure timely quarterly care plan meetings were held for Resident #57 during the timeframe of 3/19/2024, 8/3/2024, and 6/20/2025. The Surveyor requested additional documentation that quarterly care plan meetings were held during that timeframe for those residents. The NHA informed the Surveyor that they completed a care plan meeting audit because they identified an issue with timely care plan meetings and documentation of care plan meeting notes. The entire care plan process was reviewed, and the facility was working on getting caught up.By exit conference, held on 12/1/2025 at 2:27PM and after multiple requests, the NHA was unable to provide the Surveyor with supporting documentation of timely quarterly care plan meetings for Resident #31 and Resident #57.

Based on observation, record review, and interview with staff, it was determined that the facility failed to ensure the baseline care plan was thoroughly completed and included the resident -specific initial goals based on admission orders needed to properly care for the resident immediately upon their admission. This was evident for 1(Resident #99) out of 4 residents reviewed for care planning during the annual survey.The findings include: The facility must develop and implement a baseline care plan for each resident that includes the minimum healthcare information necessary to properly care for each resident immediately upon their admission, which would address resident-specific health and safety concerns to prevent decline or injury with the instructions needed to provide effective and person-centered care of the resident and meet professional standards of quality care.On 11/24/2025 at 8:36AM, during a tour of Station 1, the Surveyor observed Resident #99 in their room lying awake in bed. The Surveyor observed a Care Plan Report completed on 11/23/2025 and Order Summary Report on the end of the over-bed table. The Surveyor reviewed the documents.On 11/25/2025 at 10:30AM, during a review of Resident #99's electronic medical record, the Surveyor discovered the resident was admitted to the facility on [DATE] with diagnoses of, but not limited to, acute and chronic respiratory failure with hypoxia, emphysema, absence of part of the lung, pulmonary hypertension, and major depressive disorder. A review of Resident #99's order summary revealed physician orders for psychotropic medications including diazepam, aripiprazole, duloxetine, and trazadone; a diuretic medication, spironolactone; and opioid medication, oxycodone.On 11/25/2025 at 11:30AM, an interview conducted with Unit Manager (UM) #11 revealed that the baseline care plan should be completed and implemented within 48 hours. The interdisciplinary team will review and complete their sections of the care plan. The nursing staff, including UM #11 are responsible for reviewing the baseline care plan with the resident and/or the resident representative, providing them with a copy of the care plan and their order summary, and answering any questions.On 12/1/2025 at 1:00PM, a review of Resident #99's baseline care plan failed to include the use of psychotropic, diuretic, and opioid medications the resident was currently taking. A resident's baseline care plan should include these medications because they require a clear indication for use, monitoring for effectiveness and side effects, and monitoring of behaviors associated with the use of the medications.During an interview with UM #11 on 12/1/2025 at 1:50PM, the Surveyor expressed the concern that Resident #99's baseline care plan was not thoroughly completed upon admission to include the medications the resident was taking. UM #11 and the Surveyor confirmed that the resident's psychotropic, diuretic, and opioid medications were not included in the baseline care plan and should be because they require specific monitoring and nursing considerations associated with the use of these medications.

Based on observation and interview it was determined the facility failed to ensure dignity was maintained for Resident #24. This was evident for 1 out of 1 Resident (#24) reviewed for dignity during the facility's recertification survey. The findings include: During the surveyor's initial tour of the facility on 11/24/2025 at 8:08AM Resident #24 was observed sitting in their wheelchair in the resident hallway outside of their room with bare feet on the hallway floor and multiple orange stains were observed on the t-shirt they were wearing. On 11/25/2025 at 8:50AM the surveyor observed Resident #24 sitting in their wheelchair in the resident hallway outside of their room wearing the same t-shirt with the same stains on it which was observed by the surveyor the day prior. On 11/25/2025 at 9:05AM the surveyor requested and performed a dual surveyor observation with the facility's Administrator of Resident #24. At this time Resident #24 was observed from the hallway laying in their bed exposed with no clothing on from the waist down. At this time, the surveyor shared the concern with the facility Administrator who acknowledged the concern and asked a Geriatric Nursing Assistant (GNA) to assist the resident with provision of privacy at which time the GNA was observed by the surveyors assisting the resident to cover with a blanket and pulled the privacy curtain for them. On 11/25/2025 at 9:06AM surveyors conducted an interview of Resident #24 with the facility Administrator. Upon entrance to the room a strong odor was present which was acknowledged by the Administrator and linens on the resident's wheelchair were observed to have brown stains on them. The Administrator observed Resident #24 wearing the stained t-shirt with the surveyors and informed Resident #24 of the stains and offered for their shirt to be changed. Resident #24 acknowledged the stains on their t-shirt and stated thank you and accepted the offer to receive a clean shirt. Surveyors reviewed the concerns with the Administrator who acknowledged and confirmed understanding of the concerns and reported they planned to speak with staff taking care of the Resident. Review of Resident #24's medical record on 11/25/2025 at 10:27AM by the surveyor revealed that Resident #24's care plan stated the following information dated as last revised on 10/20/2025: (Resident #24) exhibits ADL Self care deficit as evidenced by need for staff assistance to complete bathing, dressing, toileting, ambulation, bed mobility, and meal set up related to recent illness and subsequent deconditioning, Will be clean, dressed, and well groomed daily to promote dignity and psychosocial wellbeing x 90 days and Assist with daily hygiene, grooming, dressing, oral care and eating as needed.Surveyor concerns were again reviewed during the facility's exit conference on 12/1/2025.

Based on observation, record review, and interviews, it was determined that the facility failed to ensure a resident was offered the opportunity to participate in facility sponsored group activities. This was evident for 1 (Resident #54) out of 2 residents reviewed for activities during the annual survey.The findings include:On 11/24/2025 at 12:00PM, during an interview conducted with the resident representative, the Surveyor was informed that Resident #54 was provided with coloring activities in their room but has not observed facility staff offer to take the resident to group activities or observed the resident at group activities. The resident representative stated that that would be nice for the resident to get out of their room and go to group activities because they would really enjoy it. The resident uses a wheelchair and would need staff assistance with transportation around the facility.On 11/25/2025 at 12:30PM, during a review of Resident #54's electronic medical record, the Surveyor discovered that the resident was admitted to the facility on [DATE]. Further review revealed an admission and Annual Activities Assessment completed on 10/24/2025 which stated that the resident's preferred activity setting was small groups, enjoyed crafts, music, watching TV/movies, dogs, likes to play/watch sports, and would like to be invited to church. The Surveyor reviewed the resident's activity care plan created on 10/28/2025 with a focus, [Resident] prefers not to attend group activities due to little motivational interest, a goal [Resident] will adjust positively to facility by participating in either independent or group activities of interest x 90 days, and an intervention to Encourage participation in group activities of interest.During an interview conducted with Activity Director (AD) #12 on 11/25/2025 at 12:49PM, the Surveyor was informed that Resident #54 likes to color, and the activity staff brings the resident coloring packets. AD #12 stated that they were unsure why the resident does not come out of the room for activities. Activity staff should let the residents know what the activities are for the day when they pass out the Daily Chronicle in the morning and offer to take those residents who may need assistance. The Surveyor requested documentation to verify the resident participation in activities.On 11/25/2025 at 1:35PM after a review of Resident #54's activity Participation Log with AD #12 for October 2025 and November 2025, the Surveyor confirmed that the activity staff reviewed the Daily Chronicle with the resident in October and the resident had 2 prayer room visits, reviewed the Daily Chronicle, watched TV, and was provided with coloring activities in November 2025. The facility documented that the resident attended a Veterans Day ceremony on 11/11/2025.On 11/26/2025 at 12:28PM, during an interview conducted with the resident's caregiver, the Surveyor was informed that the resident is very sociable and would love to go to group activities including music entertainment, games, and manicures. The caregiver stated that they visit the facility often, but they can't always get to the facility to take the resident to group activities. The caregiver was unaware that the facility staff can also take the resident to activities.On 11/26/2025 at 1:00PM during an interview with AD #12, the Surveyor expressed the concern that Resident #54 was not offered the opportunity to participate in activities outside of their room.

Based on observation, interview and record review it was determined the facility failed to ensure a resident's dry skin condition was identified and failed to ensure they received intervention to address the condition. This was evident for 1 out of 1 Resident (#24) reviewed for skin conditions during the facility's recertification survey. The findings include: During the surveyor's initial tour on 11/24/2025 at 8:08 AM Resident #24 was observed in their wheelchair in the hallway with no socks or shoes and the surveyor noted the resident's lower extremities appeared to have very dry skin with visible flaking present. On 11/24/2025 at 11:37AM the surveyor observed Resident #24 laying in their bed and noted they continued to have very dry visibly flaky skin on both lower extremities. Review of Resident #24's medical record by the surveyor on 11/25/2025 at 9:41AM revealed there was no documentation present for the Resident's dry flaky skin on their lower extremities having been identified or addressed. Review of Resident #24's diagnoses revealed they had a diagnosis of lymphedema. On 11/25/2025 at 10:06AM the surveyor conducted an interview of Registered Nurse Unit Manager #11 who reported to surveyors that they perform wound rounding for the entire building, and stated that Unit Manager (UM) #17 was the Unit Manager for Resident #24 and regarding the dry skin on Resident #24's legs, I would have to talk to (UM #17) about that, I'm not sure. At this time, the surveyor requested an interview of UM #17. On 11/25/2025 at 10:32AM the surveyor conducted an interview of UM #17 who confirmed they observed Resident #24's lower extremities and the skin condition and stated: it's dry, I would definitely get an order for some lotion. Review of the medical record during the interview revealed that Resident #24 was dependent upon staff for the task of personal hygiene. When the surveyor inquired to UM #17 as to if the skin condition had been addressed prior to surveyor intervention, they stated: No, I have not, I'll have to talk to (Physician #19) about it, the podiatrist has seen him/her. UM #17 acknowledged that Resident #24's dry skin condition was an issue that needed to be addressed, but had not yet been addressed at the time of the interview. Review of the medical record by the surveyor on 11/25/2025 at 10:23AM revealed that the condition of the Resident's lower extremity skin was not present in the progress notes. Review of the medical record by the surveyor on 11/25/2025 at 10:24AM revealed the following care plan problem and intervention dated 10/20/25 for Resident #24: (Resident #24) has a hx (history) of skin breakdown and remains at risk for skin alteration related to: limited mobility, intermittent incontinence, BLE (bilateral/both lower extremities) edema, lymphedema, Observe skin condition with ADL care daily; report abnormalities. After surveyor intervention, review of the medical record by the surveyor on 11/25/25 at 12:23PM revealed the following medical order dated 11/25/25 at 11:28AM was observed to have been placed: Ammonium lactate external cream 12% Apply to bilateral lower legs topically every day and evening shift for dry skin. Review by the surveyor of Resident #24's prior documented assessments on 11/21/25, 11/24/25, 11/29/25, and weekly skin assessments revealed the condition of their skin was not captured.

Based on record review and interview with the resident and the staff, it was determined that the facility failed to ensure a resident receives proper treatment and scheduled follow-up appointments to maintain vision. This was evident for 1 resident (Resident #57) reviewed for vision services during the annual survey.The findings include:On 11/24/2025 at 11:30AM, during an interview with Resident #57, the Surveyor was informed that Resident #57 had cataract surgery on the right eye and was supposed to have cataract surgery on the left eye, but the facility never scheduled the surgery.On 11/24/2025 at 1:26PM, a review of Resident #57's electronic medical record revealed an eye care group note dated 4/22/2024 with a completed assessment that included Cataract, mixed; Bothersome; Both eyes; VA stable, but patient is not satisfied with level of vision and a plan in which Cataract surgery recommended; ophthalmology consult; Follow-up: 4-5 months; Referral: Ophthalmology consult; Please schedule an appointment for this patient the see an outside ophthalmologist such as [Eye Group] for further evaluation and extraction of bothersome cataract-further evaluation to [rule out] [NAME] at that time as well.Further review revealed another eye group note dated 6/27/2025 with a competed assessment that included, Cataract, mixed; [left] eye; Patient had cataract surgery [right] eye months ago and was supposed to return for [left] eye, but was never scheduled according to the patient and a plan in which, Cataract surgery recommended; ophthalmology consult; Follow-up:5-6 months; referral: Ophthalmology consult; Please schedule an appointment for this patient to see an outside ophthalmologist for further evaluation and extraction of bothersome cataracts. Additional review failed to reveal an appointment scheduled for Resident #57 to see the ophthalmologist for cataract surgery on the left after the eye exam conducted on 6/27/2025.On 11/26/2025 at 2:00PM during an interview with the Director of Nursing (DON), the Surveyor was informed that the resident is a patient of [Eye Group]. The Surveyor expressed the concern that the resident had an eye exam on 6/27/2025 with orders recommending cataract surgery and for the facility to schedule an appointment for the resident to see an outside ophthalmologist for further evaluation and extraction of bothersome cataracts of the left eye. A review of the resident's electronic medical record failed to reveal documentation of a scheduled ophthalmology appointment since the eye exam on 6/27/2025 or cataract surgery performed on the left eye as the resident requested and as recommended by the optometrist. The DON stated they would look into the concern.On 12/1/2025 at 12:30PM, the Surveyor was provided with a physician's order dated 12/1/2025 at 10:50AM which stated that Resident #57 had an ophthalmology appointment scheduled for 12/5/2025 at 11:00AM.

Based on observation, interview, and record review it was determined the facility failed to ensure consistent incontinence care was provided. This was evident for 1 out of 1 Resident (#4) reviewed for bowel and bladder incontinence during the facility's recertification survey. The findings include: During the surveyor's initial tour of the facility on 11/24/25 at 8:05AM Resident #4 was observed in their bed wearing a visibly wet, yellow incontinence care product. Review of Resident #4's medical record by the surveyor on 11/24/2025 at 10:42AM revealed Resident was documented consistently by various nursing staff on the Task Documentation Survey Report throughout the month of November 2025 as having total dependence upon staff for toileting needs for incontinence of bowel and bladder. Surveyor review on 12/01/2025 at 11:31AM of Resident #4's incontinence care documentation in the medical record revealed that incontinence care was documented as being provided on the following dates and times: 11/28/25 at 12:35AM and 7:34PM, 11/29/25 at 1:05AM, 9:08AM, and 7:09PM, 11/30/25 at 1:53PM, and 12/1/25 at 10:39AM. The surveyor noted that upon the review of the medical record, there was no evidence found to indicate that Resident #4 was provided with consistent incontinence care each shift. On 12/01/2025 at 11:31AM the surveyor conducted an interview of Unit Manager (UM) #17 who reported to the survey team that all Geriatric Nursing Assistants document on the task list every shift on the care that they provide. UM #17 confirmed Resident #4 was dependent on staff for incontinence care and was incontinent. At this time UM #17 reviewed the incontinence care documentation with the surveyor and stated: It doesn't look like it was documented, our 3-11 shift was at 82% yesterday for documentation. UM #17 reported to the survey team that they determine who the GNA was that did not complete the documentation, and stated: Our supervisor for the weekends is supposed to be looking at that. When the surveyor inquired to UM #17 as to how they know it was a documentation issue and that the care had actually been provided, UM #17 reported: I would ask the nursing staff if I'm not available, but rounds should be made. During the interview, on 12/01/2025 at 11:43AM UM #17 confirmed with the surveyor that every shift all staff are required to document on the tasks. At this time, the surveyor shared their concern with UM #17 who acknowledged the concern and stated: Okay, thank you. The surveyor noted that throughout the facility's recertification survey, all surveyors noted daily odors present within all resident hallways including adjacent areas.

Based on observation, interview and record review it was determined the facility failed to: 1.) ensure respiratory tubing and the humidification saline bottle was dated and timed in accordance with professional standards and ensure a respiratory nebulizer machine, face mask, tubing and saline bottle was stored off of the floor's surface. This was evident for 2 out of 2 Residents (#98, #10) reviewed for respiratory during the facility's recertification survey. The findings include:1.) On 11/24/2025 at 8:09AM the surveyor observed Resident #98 wearing their nasal cannula oxygen tubing which had no label indicating date or time of when it was placed or would expire. On 11/24/2025 at 8:09AM the surveyor observed Resident #98's humidification bottle for their oxygen with no labeling indicating date or time of when it was placed or when it would expire.On 11/24/2025 at 8:09AM the surveyor observed Resident #98's nebulizer machine and face mask directly laying on the floor's surface next to their bed. On 11/24/2025 at 8:10AM the surveyor requested a dual observation of the concerns with Licensed Practical Nurse #10 who observed the concerns and stated to the surveyor: I'm going to throw this tubing and mask away, no it should not be stored on the floor. On 11/26/2025 at 8:58AM the surveyor conducted an interview of the facility's Director of Nursing who reported their expectation was for nursing staff to have respiratory tubing dated and timed with a label and they confirmed with the surveyor that respiratory nebulizer equipment should not be stored on the floor's surface. At this time the surveyor shared their concern with the DON who acknowledged and confirmed understanding of the surveyor's concerns. Review of the medical record of Resident #98 by the surveyor on 11/26/2025 at 9:37AM revealed the November 2025 treatment administration record which documented the following order signed off by various nursing staff dated as beginning on 11/03/2025: Oxygen tubing change weekly label each component with date and initials, every night shift every Mon label each component with date and initials. On 12/01/2025 the concern was again shared by the survey team during the facility's exit conference. 2.) During the surveyor's initial tour of the facility on 11/24/2025 at 8:04AM Resident #10 was observed with no labeling present on their oxygen tubing. Review of the medical record of Resident #10 by the surveyor on 11/26/2025 at 10:43AM revealed the following November 2025 treatment administration record order signed off by nursing staff dated as beginning on 7/23/25: Oxygen tubing change weekly, label each component with date and initials, every night shift every Wed, for SOB label each component with date and initials. On 11/26/2025 at 10:49AM the surveyor conducted an observation of Resident #10's respiratory tubing which was observed to have no label with date or time present and the Resident's humidification bottle was observed sitting directly on the floor's surface attached to the concentrator by extension tubing. On 11/26/2025 at 10:50AM the surveyor conducted an interview of Unit Manager (UM) #17 and requested for them to observe the concern and shared the concern with them. UM #17 acknowledged and confirmed understanding of the concern and stated to the surveyor: Okay I'll go take care of that now. On 11/26/2025 at 10:52AM the surveyor shared the concern with the facility's Administrator who acknowledged and confirmed understanding of the concern and stated to the surveyor: Okay, and you let (Unit Manager #17) know about it? Okay, thank you. On 12/01/2025 the concern was again shared by the survey team during the facility's exit conference.

Based on interviews, and medical record reviews it was determined that the facility staff failed to 1) ensure a resident received proper care to prevent the removal of a skin graft which led to the failure of the skin graft procedure and caused harm to Resident #94 by prolonging healing of the wound; 2) administer insulin before meals as ordered and failed to follow the hypoglycemia protocol as ordered which led to harm for Resident #91 when the low glucose incident required Resident #91 to be transferred to the hospital Intensive Care Unit for care; 3) provide wound care to a resident who had a surgical wound (Resident #84). This was evident for 3 of 45 residents selected for review during the survey. The findings include: 1. On 12/15/23 at 1 PM medical record review revealed a hospital discharge summary for Resident #94. On 2/2/22, Resident #94 had excision of right heel and on 2/7/22, placement of bilayer integra skin graft and wound vac with the following discharged orders from the hospital: incision/wound care instructions to the right heel that included the following: wound vac to right heel, set wound vac at 125mmHg continuous suction. Change wound vac every 5 days per integra protocol. There is a contact layer that has been placed above the Integra graft. The contact layer is all that should be removed when removing the dressing. The Integra graft has been sutured to the skin and should not be removed. Further medical records reviewed revealed that Resident #94 was admitted to the facility on [DATE] from an acute hospital stay with a diagnosis of osteomyelitis of the right heel, diabetes with peripheral neuropathy and peripheral arterial disease. On 12/15/23 at 8:35 AM a review of Resident #94's admission skin assessment dated [DATE], revealed the resident had a surgical wound on the right heel and Weekly Skin Evaluation revealed extensive wound but no description of the wound or skin graft. On 02/21/2022 the facility's attending Physician #18 ordered the following: Negative Pressure Therapy to Right foot wound. SET Unit to 125 mmHg, continuously. Cleanse with (NSS/Wound Cleanser/other) black foam into the wound. Apply skin prep to intact skin around the wound Cover with occlusive dressing and secure tubing per manufacturer guide every day shift every Tuesday, Thursday, Saturday for wound care. On 12/18/23 at 7:53 AM, in an interview, Physician #18 was advised the orders that were approved by him/her were different from the hospital discharge orders for wound care. Physician #18 stated I don't put wound orders in, that's not my specialty. The wound team put the orders for wound treatment. The wound team is here every Tuesday. Physician #18 showed the first wound consult on 3/10/22, It is funny I don't see any notes from the wound team until 3/10/22. Physician #18 stated that he does not have time to review every order that he signs and approves, if so, I would have a 35 hour workday. On 12/18/23 at 9:14 AM an interview with the Surgical Physician #20 revealed the intra skin graft was sutured in with nylon sutures at the time of surgery on 2/7/22. He further stated that on 3/2/22 the resident came to his office for a follow-up visit that resulted in finding the sutures in place but the integra skin graft removed. Surgical Physician #20 stated that the removal of the skin graft was a failure of the skin graft procedure, and the resident would experience a delay in the healing process of the right heel. On 12/18/23 at 9:45 in an interview with [Hospital name] vascular Surgery RN #19 he/she stated that he would fax the wound instructions to the facility prior to admission and would also send a copy with the Resident and stated, I include my phone number and am available 24 hours a day for any questions on the care of the wound and graft. The facility staff did not call or leave any messages about the surgical wound care. On 12/18/23 at 8:30 AM, a review of the Resident #94's Treatment Administration Record (TAR) for February and March 2022 revealed the following: Wound Vac Changed per order on 2/22/22, 2/24/22, 2/26/22, 3/1/22 and 3/8/2022. The Surveyor did not find any documentation in the electronic medical record from the nurses, physician or the Wound team in the description, size, appearance of skin graft to the right heel. On 12/15/23 at 2:30 PM, in an interview, the Medical Director revealed that he/she was aware of the incident and had a discussion with Physician #20 about wound care. During an interview on 2/18/23 at 11:45 AM, the Director of Nursing (DON) stated when the resident went for a follow-up appointment on 3/2/22 with Surgical Physician #20 It was at that time the facility was made aware of the missing graft. DON confirmed that the facility had no continuing education at this time on the care and treatment for skin grafts. The DON also confirmed that there was no documentation in the Electronic Medical Record of the size and appearance of the skin graft to the right heel. On 2/19/23 at 1 PM in an interview, Unit Manager/ Wound Round Nurse #7 stated that she/he completed the wound Care course and had been doing weekly wound rounds for the past 4 years. The last wound vac training was completed in 2021. The Unit Manager/Wound team Nurse #7 stated that surgical wounds are not followed up by the wound team unless there is a concern with the surgical wound and that is why the Wound Team did not see Resident #94 until 3/10/22. Wound Round Nurse #7 stated since this occurrence the wound team would make a visual of all surgical wounds and if any surgical wounds have concerns they would follow-up weekly with the wound team. 2. On 12/19/23 at 12pm a review of Resident #91's medical record revealed the resident was transferred to the facility on [DATE], status post hospitalization for PLIF/transforaminal lumbar fusion levels L4-S1. Resident #91 had the following medical diagnoses: diabetes, heart failure, atrial flutter, pulmonary hypertension, and liver disease. A review of the hospital discharge summary on 7/1/23 for Resident #91 included a list of medications to be continued in the facility which included HumuLIN R U-500 (Conc) Kwikpen 500 unit/mL (3 mL) insulin pen, inject 80 units subcutaneously three times a day before meals. The drug company [NAME] Lilly Dosage Guide reads as the following: Humulin R U-500 Dosage Guide: Instruct patients to inject HUMULIN R U-500 subcutaneously, usually two or three times daily approximately 30 minutes before meals. Individualize and titrate the dosage of HUMULIN R U-500 based on the patient's metabolic needs, blood glucose monitoring results, and glycemic control goal. A review of Resident's admitting orders into the facility on [DATE] revealed the physician ordered: HumuLIN R U-500 KwikPen Subcutaneous Solution Pen-injector 500 UNIT/ML (Insulin Regular (Human)), Inject 80 units subcutaneously three times a day for DM and hypoglycemia protocol. The Facility's hypoglycemia protocol instructs if the resident is difficult to arouse or unconscious then hold all diabetic medications including insulin and oral medications. Remain with the resident, monitor vital signs and perform a blood glucose level. If the Blood glucose level is equal to or below 70, immediately administer Glucagon 1mg IM or SQ. The facility Physician did not order the HUMULIN R U-500 as recommended per Hospital discharge summary or the drug company instructions by [NAME] Lilly for 30 minutes before eating a meal. A review of the administration record revealed Humulin R is to be administered 3 times a day at 6AM, 1PM and 9 PM and was signed and approved by the Physician. The facility mealtimes were 7:30 am, 12:30 PM and 5:50 PM. The Nursing Progress note indicated that on 7/4/23 during routine rounds at 4:30 AM the resident was found unresponsive and did not respond to a sternal rub. Nurse #26 recorded the vital signs and Blood pressure was 102/71, pulse was 92 beats per minute and Pulse oxygen was recorded at 85% on room air. Nurse #26 placed oxygen on resident #91 at 10 liters per minute and the Pulse oxygen level increased to 97%. The resident remained unresponsive and 911 was called. No blood glucose levels were obtained per the hypoglycemia protocol. EMS (Emergency Medical System) arrived at the facility. The EMS report confirmed that the resident was unresponsive, and the blood glucose level was 23. Glucagon 1 mg was given, and the resident's condition improved per EMS. The resident was then transported to an area hospital and admitted to the Intensive Care Unit (ICU) for hypoglycemia, unresponsive. On 12/18/23 at 1PM in an interview, the Resident's emergency contact person revealed that he/she spoke to the facility staff on admission but did not remember the staff name. The emergency contact person informed the staff that the Resident's blood sugar needed to be watched closely because the Resident had many episodes of low glucose in the past. On 12/19/23 at 11 AM in an interview, the facility Physician #18 revealed that he/she does not enter the orders in the Electronic Medical record and that the nurses will enter the admitting orders in the system and will contact him/her for approval. Physician #18 agreed that the Humulin R U500 should have been scheduled 30 minutes before meals and the hypoglycemia protocol should have been followed. On 12/19/23 at 1pm in an interview, the facility medical Director stated that he had no additional information to offer. On 12/19/23 at 12PM in an Interview, Nurse #26 revealed that she found the resident unconscious on 7/4/23 at 4:30am and applied a sternal rub without a response from the resident. Nurse #26 obtained vital signs such as blood pressure, pulse, Pulse Oxygen and called 911 and the physician. Nurse #26 did not remember if glucose level was obtained. Nurse #26 stated if she obtained a glucose level it would be documented in the Electronic Medical Record. No glucose level was documented in the medical record for this event. Interview with the Director of Nursing on 12/20/23 at 10:30 AM confirmed the facility staff failed to provide treatment for Resident #91 per the hypoglycemia protocol. 42782 3. On 12/20/23 at 10:41 am a review of Resident #84's electronic medical record (EMR) revealed the resident had a right below the knee amputation wound and was receiving wound care. Review of the treatment administration record (TAR) revealed the wound care order was discontinued on 11/19/23 at 10:43 am. There was no documentation to support the resident's wound care was performed on 11/19/23 although the resident still had the wound. Further review of the TAR revealed there was not another order to resume the resident's wound care. On 12/20/23 at 12:17 pm during an interview with RN Unit Manager #7 when asked if the resident's wound care was discontinued on 11/19/23 at 10:43 am was it his/her expectation for the nurse to have changed the dressing. RN Unit Manager #7 stated, it depended on the nurse/patient ratio the nurse may or may not have had time to change the dressing if medications were still being passed. The Unit Manager was made aware the dressing was last changed on 11/18/23. On 12/20/23 at 1:22 pm RN Unit Manager #7 made the surveyor aware there was no evidence the wound care was done on 11/19/23 - 11/20/23. On 12/22/23 at 10:20 am Director of Nursing #2 reported, the nurse wrote an order on 12/19/23 at 10:55 am for wound care but the order did not transfer to the correct Kardex so the nurses were unable to see the order. The expectation was for the nurses to render care to the ongoing wound.

Based on medical record review and interview, the facility staff failed to prevent a resident from being placed in involuntary seclusion (Resident #1). This was evident for 1 out of 3 residents reviewed during a complaint survey. The findings include: Review of Resident #1's medical record revealed the Resident was admitted to the facility on [DATE] from the hospital with a [DIAGNOSES REDACTED]. Further review of the resident's medical record revealed [REDACTED]. An admission assessment was completed by the facility staff on 9/3/19. The facility staff documented on 9/3/19 a BIMS (Brief Interview for Mental Status) could not be conducted because Resident #1 is rarely/never understood. Review of facility reported Incident MD 291 revealed the facility reported on 10/31/19 to OHCQ (Office of Health Care Quality) that on 10/28/19 Resident #2 observed Resident #1's door handle tied to the hallway railing. Review of Resident #1 and #2's Controlled Substance Medication Log revealed Resident #2's pain medication was signed out by Nurse #3 on 10/28/19 at 1:15 AM and Resident #1's pain medication was signed out by the Nurse #3 on 10/28/19 at 1:20 AM. During interview with the Administrator on 11/8/19 at 9:17 AM, she stated that on 10/30/19 at approximately 4:45 PM - 5:00 PM Resident #2 came to her office and stated a few nights ago Resident #1 was having a hard night and was up and down the hallway a lot. Resident #2 stated that around 1 AM when he/she went to get pain medication, he/she noticed Resident #1's door handle tied to the hall railing. The Administrator then stated she reviewed the weekend staffing and interviewed GNA #3 and GNA #4, who were working, on 10/30/19 at the facility. The Administrator stated GNA #2 stated Resident #1 was in his/her room, the Resident's door was closed, and she could hear the Resident banging on the door. GNA #2 then stated Nurse #3 asked her to get linen and GNA #2 stated she brought back linen to Nurse #3, then saw Nurse #3 tie the Resident's door shut. The Administrator stated she attempted to interview Nurse #3, but the Nurse was not available on 10/30/19. Review of the facility staff interviews on 10/31/19 of alert and oriented residents that were on the unit on 10/28/19 revealed Resident #3 stated, I was about to get in bed, and I heard somebody beating on the door and screaming very loudly. I heard the nurse say she's trying to fight me. The surveyor interviewed Resident #3 on 11/8/19 at 9:40 AM and he/she stated I was in my room and heard a lot of commotion and yelling. I heard someone saying she is trying to fight me. It lasted for about 5 minutes and then went silent. The surveyor asked Resident #3 if they went in hallway and observed anything and the Resident stated no, he/she stayed in the room. During interview of Resident #1's spouse on 11/8/19 at 9:40 AM, he/she stated they were made aware by the facility staff that the Resident was locked in his/her room by the facility staff for about 20 minutes about a week ago. The Resident's spouse stated he/she believes the Resident was up and down the hallways that night because of pain. The surveyor attempted to interview Resident #1 on 11/8/19 at 9:50 AM with the Resident's spouse present. The Resident was unable to answer to answer any questions about the incident on 10/28/19. When the surveyor asked the Resident if he/she recalled the incident, he/she shook head no. The surveyor attempted to interview Resident #2 on 11/8/19 at 9:35 AM and 11:43 AM but the Resident refused to talk to the surveyor. During phone interview with Nurse #3 on 11/8/19 at 11:17 AM with the Administrator present, Nurse #3 stated when she started shift on 10/27/19 at 11:00 PM, Resident #1 was in bed. Nurse #3 stated after getting shift report the Resident started going up and down the hallway towards the exit and refusing to go back to his/her room. Nurse #3 stated she was trying to redirect him/her but was unsuccessful and thought the Resident may have been in pain due to hospitalization last week for a kidney stone. Nurse #3 stated she eventually got Resident #1 to go to his/her room and put the medication cart in front of Resident's door to prevent the Resident from leaving his/her room. Nurse #3 then stated the Resident began to push the medication cart and everything on it. Nurse #3 stated, so I thought the next thing was to tie the door closed so the he/she couldn't escape while I got the medication. I used one sheet to tie the doorknob to railing in hall. Then Resident #2 came in the hallway to get his/her pain medication. I gave Resident #2 his/her pain medication and then prepared Resident #1's pain medication. I was able to give Resident #1 his/her medication through the PEG tube while he/she was lying in bed. The surveyor asked Nurse #3 about how long the door was tied shut, she stated 20 to 30 minutes. During phone interview of GNA #2 on 11/8/19 at 11:25 AM with the Administrator present, GNA #2 stated on 10/28/19 Resident #1 was trying to leave the facility by going to the elevator and I was trying to calm him/her down. GNA #2 stated, Nurse #3 was trying to give medications and asked me to get a sheet. GNA #2 stated, I saw Nurse #3 tie the sheet on the door handle to railing in hallway. I kept checking on the Resident by going in room [ROOM NUMBER]'s bathroom and saw the Resident was laying in bed. The surveyor asked about how long the door was tied closed, GNA #2 stated about 60 minutes. During interview with the Director of Nursing on 11/8/19 at 12:38 PM, the surveyor asked the Director of Nursing what she would have expected Nurse #3 to do on 10/28/19 when Resident #1's behavior escalated. The Director of Nursing stated she would have expected Nurse #3 to ask for assistance from another nurse working in the facility and if needed more assistance to call the Director of Nursing. The Director of Nursing also stated she would have expected Nurse #3 to place the Resident on a 1 to 1 until the Resident's behaviors deescalated and notify the physician of the Resident's behaviors on 10/28/19. During interview with the Administrator on 11/8/19 at 12:38 PM, the Administrator stated no staff can work until they are reeducated on abuse. Interview with the Administrator and Director of Nursing on 11/8/19 at 2:15 PM confirmed the facility staff failed to protect a resident from involuntary seclusion. Cross reference F 580 and F 609

Based on observation, review of the medical record, and staff interviews, it was determined that the facility staff failed to honor a resident's (#104) written directions not to have cardiopulmonary resuscitation administered and to allow death to occur naturally. This resulted in an immediate jeopardy for the facility. This was evident for 1 of 29 residents reviewed in the Stage 2 survey sample. The findings include: On [DATE] Resident #104 elected to enter a Hospice program. Hospice is a program in which the individual recognizes they have a life-limiting illness and treatment has changed from curative to palliative. On [DATE] Resident #104 was admitted to the facility from the hospital under the care of a Hospice. On [DATE] the resident's physician wrote Resident #104 has adequate decision making capacity including decisions about life-sustaining treatments. On [DATE] Resident #104 completed a Maryland Medical Orders for Life-Sustaining Treatment (MOLST), along with their physician. Maryland MOLST is a portable and enduring medical order form covering options for cardiopulmonary resuscitation and other life-sustaining treatments. The medical orders are based on a resident's directions about medical treatments. The completed MOLST form dated [DATE] indicated resident #104 selected No Cardio-Pulmonary Resuscitation (CPR) Option A-2, Do Not Intubate (DNI). DNI (Do Not Intubate) is the insertion of a tube into the lungs for breathing. The no CPR/DNI is a medical order written by the physician to prevent a person from undergoing CPR/DNI if their heart were to stop or they were to stop breathing. The no CPR/DNI request is usually made by the patient or health care power of attorney and allows the medical teams taking care of them to respect the end of life directive. On [DATE] at 4:55 PM Resident #104 was found unresponsive with no pulse or respirations by Nurse #1. Nurse #2, the supervisor, arrived and initiated CPR despite the physician orders [REDACTED].#104's wishes. Emergency Medical Services (EMS) was called and CPR continued after their arrival until the resident was pronounced deceased at 5:20 PM. Interview with Nurse #2 on [DATE] at 11:46 AM revealed Nurse #2 had the medical record with the MOLST form in Resident #104's room and read and understood that Resident #104 was a no CPR/DNI and still initiated CPR. Nurse #1 interviewed on [DATE] at 9:57 AM also reviewed the MOLST form and understood that Resident #104 was a no CPR/DNI. The facility failed to honor Resident #104's wishes and the physician's end of life orders. The facility responded with training for Review/understanding MOLST Directions and Conclusive signs of irreversible death on [DATE] and [DATE] but did not complete the training for all facility registered nurses and all licensed practical nurses. Nurse #1 was not included in the training and Nurse #2's training was done via the telephone.

Based on medical records review, facility policy and interview with facility staff, it was determined that the facility failed to have a system in place to ensure safe resident handling during Activities of Daily Living (ADL) care. This was evident for 1 out of the 30 Residents (# 70) reviewed, during stage two of the survey. The findings include: The surveyor observed that resident #70 had been provided a specialty mattress that inflated such that the mattress was above the top of the bed side-rails. The medical record revealed that no care plans, that were in place, addressed safety needs of resident #70 when he/she received ADL care with this specialty mattress in place. The ADL care planning documentation also failed to specify the number of staff that needed to be with resident #70 during ADL care. Medical record review on 10/14/15 revealed that Resident # 70 fell from bed on 9/20/15 at 11:30 AM, while AM care was being performed by only one GNA. Interview with the Director of Nursing on 10/14/15 at 9:00 AM, revealed that the Geriatric Nursing Assistant (GNA) who was providing ADL care on 9/20/15, stated that she had placed the resident on his/her side with the bed in a high position, and then left the resident to call the nurse to perform a treatment to the resident ' s sacrum. While the GNA was away from the resident, the resident fell , and the fall was unwitnessed by staff. The medical record revealed that about five hours after the fall, the resident ' s family came in to visit around 4:30 PM. The family noted that the resident had slurred speech therefore requested that the Resident be sent to the hospital. A care plan evaluation note written on 9/22/15 at 9:56 AM revealed that the resident was sent out to the hospital at 5:00 PM when he/she had been noted with slurred speech. Hospital discharge documentation revealed that the resident had suffered two major injuries. The 9/25/15 hospital discharge summary revealed that the resident had suffered a right parietotemporal subdural hematoma status [REDACTED]. Review of the facility ' s investigation of the fall revealed that the facility did identify that the use of the specialty mattress had contributed to the fall, yet no changes were communicated to staff through the care planning process as required. The medical record revealed that Resident #70 returned to the facility on [DATE]. A comprehensive MDS assessment was conducted with an assessment reference date of 10/8/15. Review of the comprehensive MDS screening assessment revealed that during the MDS assessment window of 10/1/15 through 10/8/15, the resident scored an aggregate MDS score for requiring 2 staff assisting with bed mobility. From the MDS screening, the care area for falls also triggered. Once the care area triggered the facility was required to complete a comprehensive falls Care Area Assessment (CAA) to ensure an appropriate and effective care plan was in place. The CAA did not identify or review the recent fall and the care plan was not updated with any new interventions related to the use of a specialty mattress and the specific risks that mattress created for this completely dependent resident. On 10/14/15 at 10:10 AM, two surveyors observed one GNA providing care to this same resident. The resident was observed on the specialty mattress that inflates the bed surface higher than the bed rails, meaning that the bed rails cannot contain the resident in the bed during ADL care. The resident was observed on her right side (same position when she fell on [DATE]) and only one staff was with the resident providing care. The mattress was not deflated prior to starting ADL care and no staff was covering the opposite side of the bed during care to protect the resident from another potential fall. On 10/14/15 at 10:10AM, the GNA was asked by one of the surveyor observing care, whether he/she was aware that the resident had fallen from the bed before. The GNA stated that he/she was aware the resident had a fall but was not aware of the details surrounding the fall. The GNA further stated that he/she was not on duty on the day the resident fell . On 10/14/15 at 11:14 AM, the charge nurse who was on duty the day the resident fell stated that because the staff were working short, he/she had asked the GNA to call him/her to perform the residents wound treatments. The charge further stated that he/she observed the GNA in the hallway, outside the resident ' s room, requesting that he/she (the charge nurse) come down to the resident ' s room. The charge nurse stated that upon entering the room, the resident was observed on the floor by the bed on his/her back. The charge nurse then said that the resident ' s family came in to visit in the afternoon about 3:30 PM and noted that the resident had slurred speech; subsequently they requested that the resident be sent out to the hospital. Even after the fall and after conducting the comprehensive MDS screening, the facility failed to assess the individualized needs of this resident who was at high risk for falls and failed to then revise the care plan to ensure care provided met the individualized needs of the resident and that care provided was safe. Follow up interview with the Director of Nursing and the Regional Clinical Nurse Consultant, on 10/14/15, at 11:38 AM confirmed that the facility staff failed to prevent the resident from the fall.

Based on reviews of the medical record, the facility's investigation and transfer policy and procedure, interviews with the resident, the complainant, and facility staff, and observations of residents and staff, it was determined that the facility failed to safely transfer 2 residents as assessed. As a result, one resident sustained [REDACTED]. After the surveyor reviewed the facility policy and procedure, observed and interviewed additional residents and facility staff, it was evident that another resident had not been transferred as assessed for safe transfer. The findings resulted in an actual harm to the resident with the fracture and an immediate jeopardy for the potential harm to the remainder of the residents requiring safe transfer techniques. The findings include: Hoyer lifts and mechanical lifts are used in nursing facilities to transfer immobile residents to a bed or a chair. They are also used to lift residents who are too heavy to move manually. The residents are seated on slings that act as a seat when raised and carries the person securely while he or she is being moved. The slings have bars and hooks that attach to the lift for safety and stability. Hoyer slings come in different types and sizes. A size chart helps determine the right size for the weight of the patient. The slings that were used in the facility were canvas with colored piping around the edge. The canvas hooks and fabric extensions had many loops with different colors inside. The hooks attached to the mechanical lift by sliding metal hooks through the appropriate loop and hooking the sling to the lift. The system used by the facility was color coded by matching the color of the piping around the sling to the assessed size deemed safe for each resident as well as letters and numbers denoting the type of lift and number of people needed. On [DATE], the facility failed to transfer resident #1 with the method she had been assessed to need for a safe transfer, a Hoyer lift. GNA #11 transferred the resident by herself without the Hoyer lift. This resulted in the resident falling and twisting her right ankle. Her right ankle became swollen and painful. She was diagnosed with [REDACTED]. The surveyor reviewed her medical record on [DATE]. By way of history, she had been in the hospital from [DATE] until [DATE]. Her chief complaint, according to her hospital summary, was a fall at home. Her other [DIAGNOSES REDACTED]. She had fallen at home while transferring form a commode to a walker in the kitchen. She complained of severe low back pain and her family was not able to assist her up from the floor and called emergency medical services. She was transferred to the hospital and started on oxygen for hypoxia. Her past medical history included: a stroke in 1996 without residual deficits; osteoarthritis; right hip fracture, and [DIAGNOSES REDACTED]. She had surgical correction of the right hip. The only medications she took at home were aspirin and multi vitamins. She was assessed at the hospital to be alert and oriented to person, place, and time. She had recurrent falls and severe low back pain. The falls were thought to be related to her poor vision and hearing. She was to have physical and occupational therapy to evaluate her for rehabilitation protocol. The resident had been admitted to the facility on [DATE]. On [DATE], the resident had been evaluated for safe lift/ transfer /repositioning technique, by RN #13. The resident was assessed as not being able to bear weight on either leg and a total lift was required by 2 people. Her weight was 152.8 pounds. She was under 170 pounds so a Medium / purple - the color of the binding / piping around the sling - size was noted. The surveyor reviewed the resident's printed physician orders [REDACTED]. Her [DIAGNOSES REDACTED]. Her functional level noted that she was dependent for bathing, dressing, eating, mobility, and continence. On [DATE], a change in condition form had been completed. It noted an "accident / fall which was witnessed". At 11:30 AM, the resident had a fall and during the fall the resident had twisted her ankle. The resident had been assessed to require a Hoyer lift and 2 staff members for safe transfers but GNA #11 had transferred the resident from the bed to the chair independently without the lift. On [DATE], a change in condition form was completed. The resident was noted to be experiencing pain and swelling of the right foot and an X-ray was ordered to rule out a fracture. At 4:50 PM, an X-ray of the right ankle to rule out a fracture because of severe pain and swelling was ordered. At 6:58 PM, the X-ray of the right ankle and foot was done. The resident was diagnosed with [REDACTED]. A bimalleolar fracture is a fracture of the ankle that involves the lateral malleolus and the medial malleolus. Malleolus is the bony prominence on each side of the ankle. Each leg is supported by two bones, the tibia on the inner side (medial) of the leg and the fibula on the outer side (lateral) of the leg. The medial malleolus is the prominence on the inner side of the ankle, formed by the lower end of the tibia. The lateral malleolus is the prominence on the outer side of the ankle, formed by the lower end of the fibula. One of the more common causes of a bimalleolar ankle fracture is simply twisting your ankle. Due to the awkward nature of this type of rotation, the bones located on either side of your ankle may sustain a break. It usually affects the lateral malleolus of your fibula (which is located on the outside of your ankle) and the medial malleolus of the tibia (the protrusion on the inside of your ankle), but it may also cause a problem along the distal portion of your tibia instead. With this type of injury, it's also quite possible to sustain a strain or tear within the ligament of your ankle during the course of the awkward rotation, further exacerbating the severity of the injury. On [DATE], GNA #11 was interviewed by the facility regarding the independent transfer of Resident #1. She provided a witness statement. She was noted to state that she was putting the resident in her wheel chair, her foot went on top of hers, her legs bent and she went to the floor. At 11:00 AM, the incident / accident investigation was done. The contributing factors included transfer assistance, visual and hearing deficits and altered mobility. The cause was that the resident twisted her ankle during a fall on [DATE]. Immediate actions to prevent further incidents / injuries included staff education and Hoyer lifted transfers. At 12:20 PM, Ibuprofen " NOW " was ordered as well as Tramadol three times per day and Tylenol and Ibuprofen as needed for pain management. GNA #11 was again interviewed by the facility. She was noted to state that she was putting the resident tin the wheel chair when her leg started to bend and she lowered her to the floor. She noted that the resident was fighting with her while she was putting her in the chair. She said that in the past she had been afraid of the Hoyer lift, she knew the resident was doing well in PT, so she transferred her without the Hoyer, alone to the wheel chair. On [DATE], the surveyor reviewed a complaint sent to the Office of Health Care and Quality on [DATE]. The allegations included that the resident had been transferred by a GNA and had fallen on the floor and fractured her ankle. The complainant was concerned that the resident had not been transferred safely which resulted in a fall and fracture. The complainant was interviewed and shared concerns regarding the transfer and fracture. The surveyor interviewed the administrator (ADM) and director of nursing (DON) and asked if the resident had a fall at the facility resulting in a fracture. The response was affirmative. The fall occurred on [DATE] and they provided the surveyor with the accident / investigation. The ADM stated that the fall / fracture had not been reported as an injury of unknown origin because they knew the origin. At 10:40 AM, the surveyor interviewed and observed resident #1. She was dressed, lying on her bed, and had a Hoyer sling beneath her. She offered no complaints at that time. At 1:30 PM, the surveyor interviewed GNA #11 about the transfer of resident #1 on [DATE]. The GNA stated that she transferred the resident from the bed to the chair by herself because the resident didn' t like the Hoyer lift, she got nervous. The resident lost her balance and she was lowered to the floor. She said that she had used the Hoyer lift to get her off of the floor and back to bed. She added that she heard the next day that the resident had a broken leg. She said she knew the Hoyer was what she should have used for a safe transfer to the chair. She said that she would check the sign on the door next time and double check with the nurse before changing anything. The GNA described a letter, number, color coded sticker system on the resident's doors used to identify the safe transfer technique for each resident. The surveyor looked for the stickers on the door and asked how this information was confirmed. The ADM told the surveyor that there were books used by the GNAs. The surveyor looked at resident #1's information in the nursing kardex book on the counter at the nursing station. The kardex that correlated with resident #1's room had another resident's name and information about her care on it. The surveyor interviewed LPN #8 and was told that the resident listed had expired. The information on the nursing Kardex in the book on the counter was inaccurate. The administrator began to look for another book which he stated supported the sticker on the door frame. He, ward clerk #9 and LPN #8 were unable to locate the book. The ADM asked the corporate nurse, acting ADON on that unit how the system worked for assuring the residents were transferred per the assessment used to determine safest transfer technique for each resident. He provided the surveyor with a color coding system used in the facility. He added that the other homes in the corporation also used the system. The safe resident handling program guidelines noted that the resident would be assessed at the time of admission, any significant change, and quarterly. The assessment results were to be clearly documented on the GNA / ADL sheet as well as other areas. The facility staff was not able to locate or provide the surveyor with this sheet / book. There was a coding system using stickers placed next to or below the resident's names next to the door jam. There were letters, numbers, and colors noting the type of lift, number of staff required, and the piping / binding color around the Hoyer sling. The transfer system was reviewed by the surveyor. The surveyor observed resident #1's sticker. She had a purple "TA2" on her door as an indication of her safe transfer method. This would indicate that the resident would be a Hoyer transfer with 2 persons and the color of the piping / binding around the Hoyer sling should be purple due to her weight. The resident was seated on a sling with blue piping / binding not purple. The Acting ADON toured with the surveyor and confirmed the stickers on the doors with the color coding. They observed the following: Resident #1, as noted above, had the fall with injury on [DATE]. She had a purple Hoyer sling listed on her door as her method of safe transfer. She was seated in her Geri Chair on a blue sling, not the color noted for her weight for the safest transfer. Resident #5's door reflected the need for a gait belt " GB " for safe transfers. The resident was seated in a Geri chair in the hallway on a Hoyer sling with green piping. The safest assessed method for him had been a Gait belt, per the sticker. A gait belt is a belt like device used around the resident's waist during transfers for support. Roommates resident #6 and #7's door noted 2 person purple Hoyer slings. The residents were seated in their chairs on green and blue piped slings, respectively. They were not on the sling assessed to be safest for their weight. Roommates resident #10 and #11 were noted on the door to need purple and green piped sling, respectively. Resident #10 was on a green sling, not the sling assessed to be safest for her weight and resident #11 was in bed. Roommates resident #8 and #9's door noted purple slings for both of them. Resident #8 was seated on a blue piped sling and Resident #9 had nothing beneath her in her wheel chair. Resident #8 was seated on a sling not assessed to be safest for her weight and resident #9 was seated without a sling. The surveyor interviewed the Assistant ADM about how the resident had been transferred from bed. She stated she would call the GNA that had transferred her on the day shift and interview her. Resident #1 had a fall when transferred using a method that did not match her assessment for safe transfers. This resulted in pain, swelling, and a fractured right foot. When the surveyor reviewed the facility system for safe transfers and then the facility implementation of the practice with the residents the following was observed: ,[DATE] residents observed were transferred using the incorrect color or type of lift and resident #9 was not on a sling as needed for safe transfer. At 5:00 PM, while awaiting a return call form the GNA that had transferred resident #9, the surveyor interviewed GNA#12 about the color coded lift safe transfer system. She noted that the color of the hooks in the sides of the slings were what the color referred to on the stickers on the doors. The facility system noted the colors indicated the piping / border not the colors in the cloth hooks on the 4 sides of the Hoyer sling pad. The GNA failed to have a clear understanding of the color coding system. The Assistant ADM was able to reach GNA, #5, that had transferred resident #9 that day by telephone. The GNA, during interview, stated that she stood the resident and pivoted her to the chair by herself. The surveyor reviewed resident #9's current safe lift /transfer / evaluation dated [DATE]. She had been assessed as unable to bear weight on either leg and require a total lift. The resident's functional level noted she was dependent for mobility. This was the same thing that had occurred with resident #1 on [DATE] which had resulted in a fracture. At approximately 5:30 p.m. on [DATE], an immediate jeopardy was called and the administrator was notified. On [DATE] at 6:30 PM, the surveyor reviewed the " Safe handling plan of correction " provided by the administrator. The immediate jeopardy was abated. In summary, the facility staff failed to safely transfer a resident in the method she had been assessed. During the transfer, Resident #1 twisted her ankle which resulted in pain, swelling and a fracture. Nearly one year later, the surveyor reviewed the safe transfer system used by the facility and found that the staff failed to use the method of transfer noted to be safe for another resident and that 7 other residents, including the resident with the transfer which resulted in a fracture, were not transferred with the size sling they had been assessed to need for safety. This resulted in actual harm and immediate jeopardy.

Based on the review of the resident's medical record, the facility's investigation, and interviews with the resident and facility staff, it was determined that the facility staff failed to transfer the resident using the standard of practice following a fall with hip injury which resulted in pain. Record review revealed that on 1/5/11 at 5:15 PM, resident #1 got out of bed and fell . The facility staff's initial assessment noted pain and a decrease in the range of motion in the resident's right hip. These symptoms indicated that the resident may have a fractured right hip. During a transfer with a Hoyer lift, a sling is placed beneath the resident and attached to a standing mechanical lift. Once the sling is attached, the sling/resident is lifted off the floor using the mechanical lift. The resident would be transported from the fall area to over the bed while the sling was suspended in the air. Once the resident is over the bed, the sling would be lowered. The sling would then be removed from beneath the resident. During the transfer the resident's legs would be flexed and adducted, which would increase pressure on the resident's hips. During surveyor interview on 10/24/11, the resident and the facility staff described the resident having pain during the transfer. The resident was X-rayed on 1/6/11 at 1 AM and diagnosed with [REDACTED]. When the facility staff assessed the resident with a change in her range of motion and pain in the right hip, the transfer should have been done keeping in mind the possibility of a [MEDICAL CONDITION]. The standard of practice for the transfer of a resident with a suspected [MEDICAL CONDITION] includes immobilization of the hip to prevent further injury and pain. On 10/24/11 at 2 PM, during surveyor interview, the resident stated that she remembered being transferred to her bed after the fall. She said that she screamed because of the pain, passed out, and didn't remember anything until she was in the hospital. On 10/24/11, during surveyor interview with the facility staff present during the transfer, Nurse #1, #3, and geriatric nursing assistant (GNA) #4, noted that the resident screamed out in pain and stated that her hip was broken. The facility staff failed to transfer the resident using the standard of practice following a fall with a suspected hip injury that resulted in pain to the resident.