Every finding on record at Autumn Lake Healthcare at Silver Spring

Based on record review and interview, it was determined that the social services department failed to ensure that a resident received medically related social services. This was evident for 1 (#1) of 1 resident reviewed for discharge.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. On 4/23/26 at 12:44 PM a medical record review for Resident #1 was conducted. According to the progress notes, the resident had an initial care plan on 3/27/26 with a family member present and the note was authored by the Social Services Director. In the discharge planning section, the Social Services Director failed to document the resident's plans for discharge. The admission minimum data set (MDS) documented that the resident had no cognitive impairment and no impairment with communication. According to section GG, Resident #1 required staff assistance with most ADLs (activities of daily living such as toileting, dressing, bathing, personal hygiene) and was wheelchair bound.A note dated 4/14/26 from the Social Services Director Staff #2 stated the resident's insurance coverage was ending and the resident agreed to go home on 4/15/26. Then later that day Staff #2 wrote that the resident wanted to appeal the decision. On 4/16/26, the resident was visited by Nurse Practitioner (NP) #1 and she wrote the resident was admitted for generalized muscle weakness. The resident had mobility and ADL dysfunction and was at risk for functional impairment without pain control and physical and occupation therapy services. The attending physician wrote a note on 4/16/26, stating the resident was in extensive need of therapy and was not ready to be discharged to his/her home.On 4/23/26 at 12:08 PM an interview with Resident #1 revealed he/she asked to be transferred to another facility the same day of admission because he/she did not feel the facility was able to meet his/her needs. Resident #1 reported he/she spoke with the Social Services Director staff #5 regarding this transfer during the care plan meeting. When asked what Staff #5 had done after the request was made, Resident #1 stated that he did nothing and stated that the stress caused by the facility had affected his/her ability to heal.On 4/23/26 at 1:31 PM this was confirmed by the resident's family member who had attended the care plan meeting.An interview with the Social Services Director staff #5 on 4/27/26 at 10:22 AM revealed he had not completed the discharge planning section on the care plan note dated 3/27/26 because he stated the resident wanted to be transferred to another facility. When asked what he had done to assist the resident with the transfer to another facility, he stated that he had asked the Social Services Assistant to take care of it. Staff #5 confirmed he had not sent any referrals to attempt to find another facility per the resident's request.The Social Services Assistant staff #6 was interviewed on 4/27/26 at 11:30 AM. She reported she was on leave when the resident had a care plan meeting on 3/27/26 and had not returned until the following Saturday (April 4,2026). When asked if she was asked by the Social Services Director to assist Resident #1 with transferring to another facility, she reported she had not. She stated when she returned from her leave that she knew the resident had asked for be transferred but was not involved. She stated that the resident approached her in the hallway at the end of the day on 4/12/26 and stated he/she wanted to be transferred to another facility. Staff #6 stated that she did not want to discuss this information in the hallway and made arrangements with the resident to meet the following day. She provided evidence that she contacted another facility for a possible transfer. This was 18 days after the resident had requested the transfer and the resident had to request the transfer a second time. An interview with Resident #1 on 4/23/26 at 12:08 PM revealed he/she was being discharged that day but was concerned because Resident #1 was not able to walk yet. Resident #1 stated they asked to stay at the facility to receive more therapy so they could walk before going home. When asked if the facility had set up therapy services for him/her at home, Resident #1 stated that they had not told him/her if they did.An interview with Resident #1's family member with the resident was present was conducted on 4/23/26 at 1:31 PM. The family member reported he was there to take the resident home. However, he voiced concerns about taking the resident home because s/he was unable to get around on their own. When asked what the home situation was like, they reported that the resident had to walk across about 4 feet of grass to the steps and then up 4 steps to the porch to enter the house. The house was one level inside except for a few steps to go to the laundry room. The resident was going to be home during the day alone. They reported the resident wanted to go home because the insurance was not going to cover services at the facility. They stated they were not aware of any in-home services that had been set up by the facility and were unaware that this was an option.On 4/27/26 at 9:00 AM a medical record review for Resident #1 revealed the resident had refused to discharge unless home health services had been set up. It was documented the resident was being charged private pay while staying at the facility. An interview with Physical Therapist (PT) #9 on 4/27/26 at 12:00 PM revealed Resident #1 had not met his/her therapy goals and was not able to discharge home safely without continued physical therapy services.An interview on 4/27/26 at 10:22 AM with the Social Services Director Staff #5 revealed he was not at the facility on 4/23/26 and had not set up home health services or therapy services for the resident. He stated that he referred this to the Social Services Assistant Staff #6. He confirmed that he provided oversight for Staff #6, however had not ensured that everything was in place for Resident #1 prior to the discharge date . During an interview with the Social Services Assistant Staff #6 on 4/27/26 at 11:30 AM, she provided a utilization review sent to the facility by the insurance company. On that paperwork dated 4/17/26, it noted the resident was eligible for home health and in-home therapy services. When asked if she had set up those services for the planned discharge on [DATE], she stated that she had notified a home health provider on 4/23/26 around 12 noon. However, the evidence she provided showed she had not sent a request until 4/23/26 at 3:26 PM which was during the discharge meeting with the resident. She reported she was unaware she could set up the services prior to the discharge date . She reported that the resident was not discharged because they were unable to find a home health provider that accepted the resident's insurance although there was a list of providers on the utilization review paperwork she presented during the interview.An interview with the Ombudsman on 4/28/26 at 11:46 AM revealed that Resident #1's family member called her on 4/24/26 and put her on speaker during a discharge meeting. She stated that until she asked for social services to be present, they had not been at the meeting. She confirmed that the facility had not secured home health and therapy services for Resident #1's discharge home. She stated she informed them that the home health provider they were trying to secure was not listed on the utilization review dated 4/17/26.The Nursing Home Administrator (NHA) was not available during the survey. The concerns were reviewed with the Corporate Compliance Officer on 4/28/26 at 2:30 PM and she acknowledged the concerns.

Based on record review and interview, it was determined the facility failed to report allegations of abuse to the State Agency (SA) within the required timeframe. This was evident for 1 (#2) of 1 resident reviewed for an abuse allegation.The findings include:On 4/28/26 at 1:40 PM review of a grievance form dated as received on 4/15/26 at 4:30 PM revealed that Resident #2 reported to the facility an allegation of abuse. The form read that the resident reported on 4/14/26 around 8:30 PM that the assigned geriatric nursing assistant (GNA) came into their room to assist them to go to bed. When Resident #2 told the GNA s/he was not ready to go to bed, the GNA continued to urge him/her to go to bed and then threatened to slap the resident if they did not go to bed. The form was signed by Registered Nurse (RN) #7.A review of the facility's investigation file for the facility reported incident #298941 on 4/27/26 at 1:28 PM revealed on the initial report form that the facility was alleging they were not aware of the allegation of abuse until 4/17/26 at 2:30 PM. It was documented that the Ombudsman reported the allegation of abuse to the Nursing Home Administrator (NHA). The allegation read that Resident #2 alleged that an assigned GNA had hit him/her. However, on a witness statement form completed by RN #7 and the Assistant Director of Nursing (ADON) revealed that the resident's allegation was the same as the incident s/he reported to the facility on 4/15/26.An interview with the Activity Director #4 on 4/28/26 at 1:18 PM revealed Resident #2 reported the allegation of abuse on 4/15/26 during a resident council meeting. She stated that the resident informed the group that she was threatened by a staff member who stated she would slap him/her if she did not go to bed. She stated she left the meeting immediately and verbally reported it to the Nursing Home Administrator (NHA) and the she told the Assistant Director of Nursing (ADON).Surveyor was unable to interview the NHA because she was unavailable during the survey.An interview with the ADON on 4/28/26 at 1:32 PM revealed she was approached by the Activity Director on 4/15/26 about Resident #2's allegation of abuse. She stated she went to the NHA who told her to write it on a grievance form and start an investigation. She confirmed she had not reported it to the SA because they were just investigating it at that time. She stated that the resident alleged it occurred on 4/14/26 in the evening, however, she pointed out GNA #8 who had not been on duty that evening. When shown the schedule and that GNA #8 had not worked on 4/14/26, but had worked on 4/13/26, she stated she had not noticed that during the investigation. Furthermore, because the resident reported the wrong date, GNA #8 was allowed to continue to work on 4/15/26 and was assigned to Resident #2. When asked why the allegation was not reported as an allegation of abuse on 4/15/26, but was reported after the Ombudsman reported it to the NHA, she stated that she was not sure because it was the same allegation that they had already investigated on 4/15/26 and 4/16/26.The concerns were reviewed with Corporate Compliance Officer on 4/28/26 at 2:30 PM.Cross Reference: F610

Based on record review and interview, it was determined that the facility failed to ensure that a staff member was removed from the resident care area following an allegation of abuse to ensure the safety of all residents until an investigation was completed. This was evident for 1 (#2) of 1 resident reviewed for abuse allegation.The findings include:On 4/28/26 at 1:40 PM review of a grievance form dated as received on 4/15/26 at 4:30 PM revealed that Resident #2 reported to the facility an allegation of abuse. The form read that the resident reported on 4/14/26 around 8:30 PM that the assigned geriatric nursing assistant (GNA) came into their room to assist them to go to bed. When Resident #2 told the GNA s/he was not ready to go to bed, the GNA continued to urge him/her to go to bed and then threatened to slap the resident if they did not go to bed. The form was signed by Registered Nurse (RN) #7.An interview with the ADON on 4/28/26 at 1:32 PM revealed she was approached by the Activity Director on 4/15/26 about Resident #2's allegation of abuse. She stated that she and the evening shift supervisor RN #7 worked on an investigation that evening and into the next day (4/16/26). She reported that they asked the GNA who was assigned to the resident on 4/14/26 during the evening shift to come to the facility on 4/15/26. When the resident saw her, the resident stated that it was not her and pointed out GNA # 8 and see if that was who the resident was talking about. The Activity Director stated she went to the NHA who told her to write it on a grievance form and start an investigation. She confirmed she had not reported it to the SA because they were just investigating it at that time. She stated that the resident alleged it occurred on 4/14/26 in the evening, however, she pointed out GNA #8. The ADON reported she had not asked GNA #8 to leave the resident care area because she was not working on the day the resident alleged the incident happened. She was shown the schedules and that GNA #8 had not worked on 4/14/26, but had worked on 4/13/26, she stated she had not noticed that during the investigation. She agreed that the resident may not have had the right date but she had clearly identified the GNA #8 who threatened her. An interview with the Ombudsman on 4/28/26 at 11:43 AM revealed she had visited Resident #2 on 4/16/26 around 5:00 PM. The resident reported the allegation of abuse to her and when GNA #8 came in the room, the resident stated that it was her who had threatened the resident. A review of the facility's investigation file for the facility reported incident #298941 on 4/27/26 at 1:28 PM revealed a witness statement dated 4/17/26, that RN #7 wrote that Resident #2 had pointed out GNA #8 as the alleged perpetrator that day.A review of the time stamps for GNA #8 on 4/28/26 at 1:37 PM revealed she worked the evening shift 4/15/26 - 4/24/26. Even though the allegation was reported a second time to the NHA on 4/17/26 by the Ombudsman who reported to her that the resident identified GNA #8 as the alleged perpetrator.The surveyor was unable to interview the NHA because she was unavailable during the survey.The concerns were reviewed with Corporate Compliance Officer on 4/28/26 at 2:30 PM.Cross Reference: F609

Based on record review and interview, it was determined that the facility failed to provide their residents with rehabilitation services based on their plan of care as required. This was evident for 1 (#1) of 1 resident reviewed for rehabilitation services. 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. 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. On 4/23/26 at 12:44 PM a medical record review for Resident #1 was conducted. A review of the resident's care plan revealed on 3/25/26 a focus for rehabilitation (rehab) services was initiated on 3/25/26 with a goal to improve current level of function with therapy services. There was an intervention to provide therapy services as per the physician's orders. The admission minimum data set (MDS) documented that the resident had no cognitive impairment and no impairment with communication. According to section GG, the resident required staff assistance with most ADLs (activities of daily living such as toileting, dressing, bathing, personal hygiene) and was wheelchair bound.A note dated 4/14/26 from the Social Services Director Staff #2 stated the resident's insurance coverage was ending and the resident agreed to go home on 4/15/26. Then later that day Staff #2 wrote that the resident wanted to appeal the decision. On 4/16/26, the resident was visited by Nurse Practitioner (NP) #1 and she wrote the resident was admitted for generalized muscle weakness. The resident had mobility and ADL dysfunction and was at risk for functional impairment without pain control and physical and occupation therapy services. The attending physician wrote a note on 4/16/26, stating the resident was in extensive need of therapy and was not ready to be discharged to his/her home. A review of therapy notes for the resident revealed s/he had not had therapy since 4/16/26.An interview with Resident #1 on 4/23/26 at 12:08 PM revealed s/he was scheduled to go home that day. The resident reported s/he had concerns about going home because they felt they needed more therapy to be safe at home and had appealed the insurance decision to send them home. The resident reported that they were granted an extended stay, but had not received any more therapy since 4/16/26.The Social Services Director Staff #5 was interviewed on 4/27/26 at 10:22 AM and confirmed that the resident was supposed to discharge on [DATE], but had been granted additional days and then the resident appealed that decision and was granted to stay until 4/22/26. Physical Therapist (PT) #9 was interviewed on 4/27/26 at 12:00 PM and she reported that Resident #1 had participated in therapy but had not reached his/her goals. She stated that the resident needed to improve his/her navigation of steps before going home. PT #9 reported that even though the resident had been approved for services until 4/23/26 sometimes the insurance would stop the services. An interview with the Rehab Director #10 on 4/27/26 at 12:12 PM confirmed that Resident #1 had not had services since 4/16/26 and that she was aware the resident had been appealing the insurance decision to discharge. She stated that when the resident was extended it was for custodial reasons based on abnormal labs which was why she had not extended the resident's therapy services. However, she wanted to look at some paperwork and get back to the surveyor. On 4/27/26 at 12:40 PM Rehab Director #10 came back and reported Resident #1 had met his/her therapy goals for skilled nursing services and so the insurance company felt the resident could continue therapy services at home. When asked why they had not continued to provide therapy through the appeal processes she stated it was back and forth with this resident and she was not sure what was going on with the discharge. She reported that the resident would experience a physical decline without therapy services for 11 days and that they were going to start services again until the resident was discharged . The surveyor was unable to interview the Nursing Home Administrator because she was unavailable. The concerns were reviewed with the Corporate Compliance Officer on 4/28/26 at 2:30 PM and she acknowledged the concerns.

Based on observation and interview, it was determined facility dietary staff failed to maintain proper infection control procedures by using serving warming plates and cloches that had been wet nesting and were still wet with standing water when the residents' plates of food were placed in them. Wet nesting is a sanitation hazard occurring when recently washed, wet, or damp items (like plates, pots, or bowls) are stacked together. This practice restricts airflow, creating a dark, moist environment that promotes rapid bacterial growth and mold.During the survey observation of the lunch plating, it was observed that the warming plates and cloches that were being used were very wet with the warming plates having standing water in them. This was observed when the warming plates were being set on the warming charger and the water in the them began to boil with obvious bubbles. The surveyor discussed the wet nesting situation with Employee #31 who directed the kitchen staff to run the warming plates and cloches back through the dishwasher and allow them to air dry.

Based on review of employee files and interviews with facility staff, it was determined that the facility failed to conduct required performance reviews of Geriatric Nursing Assistants (GNAs) at least once every 12 months. This was evident for 4 (GNA #17, #19, #20, #5) out of 5 GNAs' employee files reviewed during the Sufficient and Competent Nursing Staffing portion of the facility's recertification survey. The findings include:Performance reviews are to be completed for each GNA at least every 12 months to identify specific, in-service education based on the outcome of those individual performance reviews. On 3/24/26 at 10:02 AM the surveyor requested the complete employee files for GNA #17, GNA #18, GNA #19, GNA #20, and GNA #5. An interview was conducted with the Human Resources Director (HRD #21) on 3/24/26 at 10:50 AM. During the interview, she verified and confirmed that the employee files provided were the complete files and included all documents related to the employees except for their health files. On 3/24/26 at 10:54 AM review of GNA #17's employee file revealed she was hired on 2/8/18; however, failed to reveal a performance review from 2025.On 3/24/26 at 11:06 AM review of GNA #18's employee file revealed she was hired on 11/30/16; however, failed to reveal a performance review from 2025.On 3/24/26 at 11:14 AM review of GNA #19's employee file revealed she was hired on 3/11/25; however, failed to reveal a performance review from 2025.On 3/24/26 at 11:18 AM review of GNA #20's employee file revealed she was hired on 10/15/24; however, failed to reveal a performance review from 2025.On 3/24/26 at 11:23 AM review of GNA #5's employee file revealed she was hired on 1/14/15; however, failed to reveal a performance review from 2025.On 3/24/26 at 11:48 AM in an interview with the Assistant Director of Nursing /Staff Educator (ADONSE #8) when asked if performance reviews were conducted for the GNAs, she stated yes. When asked how often, she said, Every year. When asked who conducted them, she stated the supervisors, managers or Director of Nursing (DON). When asked where they were stored, she stated, I'm not sure, maybe with HRD #21 or the Director of Nursing.On 3/24/26 at 12:10 PM in an interview with ADONSE #8 she stated, I talked to HRD #21 and for the GNA performance evaluations, we're in the process of putting it together.On 3/25/26 at 9:05 AM in an interview with ADONSE #8, when asked about the GNA performance reviews, she stated, If they were not in the employee file then they were not completed, but we are going to get a process in place. On 3/26/26 at11:08 AM during an interview with ADONSE #8, she stated Performance reviews, we dropped the ball on that because of all the changes and changes in ownerships. The surveyor shared this was a concern and the ADONSE #8 acknowledged understanding of the concern.On 3/27/26 at 10:00 AM the Nursing Home Administrator (NHA) provided 11 GNA performance reviews that she said they had located. Review of the performance reviews revealed 1 GNA's [GNA #18] out of the 5 GNAs reviewed for Staffing was included. On 3/27/26 at 11:27 AM the NHA provided 9 additional GNA performance reviews; however, they were all from 2024. When asked where these reviews were located, she stated she had to let the previous Human Resources go because she was just stacking paperwork and not filing it. During the interview, she stated, The first stack was found in HRD #21's office and the second stack was found in the DON's office. Additionally, she stated that they were supposed to be in the employees' files. The surveyor shared the concern that only 1 of 5 GNAs reviewed had a performance review completed. The NHA acknowledged understanding of the concern.

Based on observations, interviews, and record review, it was determined that the facility failed to implement appropriate infection control practices as evidenced by 1) failing to ensure oxygen tubing and humidification bottles were dated to indicate timely replacement, 2) not stocking enough Personal Protective Equipment (PPE) outside resident rooms, and 3) using appropriate infection control practice during urinary catheter maintenance. This was found to be evident for 9 (Residents #3, #9, #22, #116, #157, #158, #23, #30, and #155) of 47 residents investigated during the recertification survey. The findings include: PPE includes specialized clothing or gear, such as gloves, gowns, and masks, worn to create a physical barrier between a person and infectious materials. Contact Precautions require staff to wear a gown and gloves for every entry into a patient's room to prevent the spread of germs through direct or indirect touch. Enhanced Barrier Precautions (EBP) are a more targeted approach used in nursing homes, requiring gown and glove use only during high-contact care activities—like bathing, dressing, or wound care. A urinary catheter bag is a sterile container that collects urine from the bladder via a flexible tube. The catheter bag should never touch the floor to prevent contamination and the risk of infection. 1) On 03/23/2026 at 8:03 AM, observation revealed Resident #157 with oxygen tubing and a humidification bottle that were not dated. At 8:11 AM, Resident #22 was observed with undated oxygen tubing and humidification bottle. At 8:29 AM, Resident #9 was observed with undated oxygen tubing and humidification bottle. At 8:42 AM, Resident #116 was observed with undated oxygen tubing and humidification bottle. On 03/26/2026 at 12:16 PM, the surveyor requested the facility policy regarding oxygen tubing and humidification bottles, including the frequency of changes. The Assistant Director of Nursing (ADON) stated they would check to clarify. At this time, the surveyor shared the information about the four residents that were observed without dates on the oxygen tubing or humidification bottles. At 12:25 PM, the facility policy was provided, which indicated that humidification bottles are to be changed every 72 hours. The absence of dates on the oxygen tubing and humidification bottles prevented verification that the equipment was changed in accordance with facility policy. 2) On 3/23/2026 at 8:51 AM, multiple rooms on the 1st floor unit were observed to have contact or EBP signs attached to doors outside of resident rooms. On 3/23/2026 at 8:51 AM, Registered Nurse (RN) #12 stated during an interview that PPE should be located outside of resident rooms in carts if they are on EBP or contact precautions. The following was observed on 3/23/2026: At 8:54 AM, contact precaution sign observed on Resident #3's door, PPE cart outside room did not have gloves or gowns stocked, no PPE observed inside resident room. At 8:59 AM, EBP sign observed on Resident #158's door, PPE cart outside room did not have gloves or gowns stocked, no PPE observed inside resident room. At 9:05 AM, EBP sign observed on Resident #23's door, PPE cart outside room did not have gloves stocked, no PPE observed inside resident room. At 9:06 AM, EBP sign observed on Resident #30's door, PPE cart outside room did not have gowns stocked, no PPE observed inside resident room. At 9:07 AM, contact precaution sign observed on Resident #155's door, no PPE cart was observed outside of room, no PPE was observed inside resident room. On 3/23/2026 at 9:40 AM, previously mentioned PPE carts were observed to be fully stocked. On 3/23/2026 at 10:41 AM, a PPE cart was observed outside of Resident #155's room. On 3/24/2026 at 10:33 AM, concerns were addressed with the ADON. The ADON stated it's the facility's expectation the PPE carts are stocked with the necessary supplies and that it is the night shift supervisor's responsibility to ensure the carts are stocked and outside resident rooms. 3) On 3/23/2026 at 8:54 AM, Resident #3's catheter drainage bag was observed hanging from their bed but touching the floor. This again was observed at 10:07 AM. On 3/24/2026 at 10:30 AM, Resident #3's catheter drainage bag was observed not hung from their bed and laying directly on the floor. The ADON observed the catheter drainage bag with surveyor on 3/24/2026 at 10:33 AM. The ADON stated it's the facility's expectation that the drainage bag is not on the floor and stated they would immediately switch out the bag with a new one and ensure it was hung properly from the bed frame.

Based on medical record review and facility staff interview it was determined that the facility failed to ensure that Resident #33's personal belongings were secured. This was evident for 1 out of 1 residents observed. During a complaint investigation it was discovered that the facility could not account for some of Resident #33's belonging. The complaint alleged that the resident was missing a phone charger, 3 white tee shirts, 3 ball caps, and a pair of sweatpants. The medical record and the paper chart were reviewed for an inventory sheet for the resident, and none was found. A copy of the facility's policy for Resident's Personal Belongings was requested and acquired. This policy clearly stated that All resident personal items will be inventoried at the time of admission and documentation shall be retained in the medical record. Addition possessions brought in during the duration of the individual's stay shall be added to the existing personal belongings inventory listing.During an interview with the facility Administrator, a copy of Resident 33's inventory sheet was requested. The Administrator stated that a search for the inventory sheet was done of both the electronic and the paper medical record for Resident #33 and no inventory sheet was found. The Administrator further stated that they would contact Resident #33's Responsible Party (RP) and ascertain what items were missing and the facility would replace them.

Based on medical record review, and facility staff interview, it was determined that the facility staff failed to develop and initiate comprehensive person-centered care plans for residents residing in the facility. This was evident for 2 (#33, #47) of 33 residents reviewed during the recertification survey. A care plan is a guide that addresses the unique needs of each resident. It is used to plan, assess, and evaluate the effectiveness of the resident's care. On 03/26/2026 at 11:25 AM, during a review of the medical record for Resident #47, it was determined that the resident's dental issues were not addressed in their care plan. The contract dental service had been seeing the resident, had identified the resident's dental issues and were working to resolve them by replacing the resident's dentures. The dental services had documented what had been done and what needed to be done but the care plan did not reflect this issue. On 03/27/2026 at 12:18 PM, during a review of the medical record it was discovered that though Resident #33 had been diagnosed by their primary provider with Chronic Kidney Disease (CKD), Stage 3, this diagnosis had not been addressed in the resident's care plan. There was no mention of CKD in either the initial care plan or the current care. The resident's CKD had also been identified by the providers at the acute care hospital during 2 emergency room visits in the last 8 months.On 3/27/2026 at 2:20 PM, during an interview with Employee #8 it was requested that they review the care plans for Residents #33 and #47 to verify that the elements identified during the survey were missing. Employee #8 verified that the residents' care plans were missing the identified elements and stated the care plans would be updated.

Based on observations, medical record review, and interviews, it was determined that the facility failed to follow provider orders. This was found to be evident in 1 (Resident #3) of 47 residents reviewed during the recertification survey.The findings include:A midline intravenous (IV) or midline catheter is a thin, flexible tube inserted into a vein in the upper arm that provides longer-term access than a standard IV, typically lasting up to four weeks. The sterile dressing must be changed regularly-usually once a week-to protect the insertion site from bacteria, moisture, and debris that could cause a serious infection.On 3/23/2026 at 10:07 AM, Resident #3 was observed to have a midline IV in their left arm. The dressing covering the IV site was dated 3/17/2026.On 3/26/2026 at 1:00 PM, Resident #3's midline IV dressing was observed and was dated 3/17/2026.On 3/27/2026 at 9:10 AM, Resident #3's medical record was reviewed which revealed an active order placed by the nursing facility provider dated 3/18/2026 that stated, Change midline insertion site dressing, every evening shift every Thu Label with Initials, Date and Time AND as needed Label with Initials, Date and Time.On 3/27/2026 at 9:43 AM, Resident #3's Treatment Administration Record (TAR) was reviewed. It was documented in the TAR that the order for dressing change was performed on 3/19/2026 and 3/26/2026 by facility staff.On 3/27/2026 at 11:06 AM, Resident #3's midline IV was observed and the dressing was dated 3/17/2026.On 3/27/2026 at 11:11 AM, Registered Nurse (RN) Supervisor #32 observed the midline dressing with surveyor and confirmed it was dated 3/17/2026. RN #32 also reviewed Resident #3's TAR with surveyor and confirmed that it was documented that the dressing was changed on 3/19/2026 and 3/26/2026. RN #32 stated that it's the facility's expectation that orders checked off as performed in the TAR are completed.On 3/27/2026 at 11:25 AM, surveyor concern about the lack of dressing changes and incorrect documentation was addressed with the Nursing Home Administrator.

Based on record reviews and interviews with facility staff, it was determined that the facility failed to ensure monthly Medication Regimen Reviews were completed by a provider and to respond to and address recommendations made by consulting pharmacists in a timely manner. This was evident for 1 (Resident #29) of 5 residents reviewed for unnecessary medications during the facility's recertification survey.The findings include:The Medication Regimen Review (MRR) is a review of the medication regimen (plan) of each resident with the goal of promoting positive outcomes and minimizing adverse (negative) consequences and potential risks associated with medications. The MRR must be completed at least once a month by a licensed pharmacist and includes a review of the medical record to identify, report, and resolve medication-related problems, errors, and/or other irregularities. On 3/24/26 at 12:54 PM review of Resident #29's medical record revealed the 1/8/26 and 2/8/26 MRR documented as See [pharmacist's] report. On 3/24/2026 1:37 PM in an interview with the Assistant Director of Nursing (ADON) when asked the facility's MRR process, she stated, The pharmacist emails it to us and we fix whatever they need us to fix. We give it to the Nurse Practitioner (NP #14) who addresses them all. Some of the MRRs say for the attending and those we give to the Medical Director. During the interview when asked who received the report, she stated, The Medical Director, Attending Physician, Director of Nursing, ADON, Administrator, and Unit Managers (UMs). Everyone gets the email, but I print the recommendations. After I print the recommendations, I hand them all to the NP [#14] and she addresses them and hands them back to me. When asked if the expectation was for the provider to check one of the three boxes (agree, disagree or other) and sign and date it, she stated, yes. When asked who was responsible for discontinuing and/or creating new orders based off the recommendations, she stated, Some of them she [NP #14] makes the changes in PCC (the facility's electronic medical record) and some of them she does not. For the ones she did not address, I give them to the UMs in the morning meeting, and they make the changes in PCC and then they either put them in the MRR binder or give them back to me and I put them in the binder. When asked when the MRRs were to be completed, she stated before the next month's review.On 3/24/2026 at 1:48 PM the surveyor requested the 1/8/26 and 2/9/26 MRR for Resident #29. On 3/25/26 at 8:52 AM the ADON provided the 1/8/26 MRR to the surveyor. When asked where the 2/9/26 MRR was she said she would check.On 3/25/26 at 8:53 AM review of the MRR revealed a recommendation to discontinue the resident's melatonin. The provider had checked agree and signed and dated the MRR; however, the date was 3/3/26 almost 2 months after the pharmacist made the recommendation.On 3/25/26 at 9:00 AM the ADON provided Resident #29's 2/9/26 MRR. Review of the recommendation revealed it was the same recommendation from 1/8/26. In an interview with the ADON she stated, It was the same as the 1/8/26 MRR and they were both missed. During the interview she stated, I was on vacation. During a dual observation, the surveyor pointed out that the [DATE] MRR was not addressed until 3/3/26 and that the 2/9/26 MRR was not addressed at all with no signature, date, or checked box. When asked who the signature was on the 1/8/26 MRR, she stated it was NP #14's. The surveyor shared these were concerns and the ADON verified and acknowledged understanding of the concerns. On 3/25/26 at 9:47 AM review of the facility's policy titled Addressing Medication Regimen Review Irregularities revealed, It is the policy of this facility to provide a Medication Regimen Review (MRR) for each resident in order to identify irregularities and respond to those irregularities in a timely manner to prevent the occurrence of an adverse drug event. Further review of the policy revealed, The facility will utilize a systematic approach for reviewing each resident's medication regimen which preventing, identifying, reporting, and resolving medication-related problems, medication errors, or other irregularities, and collaborating with other members of the interdisciplinary team. Continued review revealed, The pharmacist must report any irregularities to the attending physician, the facility's medical director and Director of Nursing, and the reports must be acted upon. Furthermore, the policy stated, If the pharmacist should identify a non-urgent recommendation the physician shall address the recommendation and the response shall be documented in the resident's medical record or on a form designated by the facility prior to the next scheduled review.

Based on observations and interviews of facility staff it was determined the facility failed to ensure an effective pest control program as flying gnats were observed throughout the first floor of the building. This was found to be evident during the survey. The findings include: During an environmental tour of the first floor unit on 03/23/2026 at 9:47 AM, the surveyor observed a plethora of gnats flying around in the hallway. The surveyor observed a more concentrated amount of flies upon entrance into room [ROOM NUMBER], in comparison to those noted in the hallway. During an interview with one the residents in room [ROOM NUMBER] the surveyor observed more than 20 gnats resting on the resident's right side of the bed and on the resident's privacy curtain. When asked by the surveyor, the resident stated that the flies are always in the room. However, the resident neither confirmed or denied reporting this issue to facility staff. On 3/23/2026 at 10:30 AM the Director of Environmental Services and the surveyor toured the first hallway on the first floor and also room [ROOM NUMBER] together. The Director of Environmental Services confirmed the presence of the gnats and stated that he will coordinate with nursing and environmental staff to take immediate action to clean the room and remove the gnats (when the residents are out of the room).

Based on review of the medical record and pertinent documentation and interviews with facility staff, it was determined that the facility failed to transmit MDS assessments within 14 days of completion of the assessment. This was evident for 1 (Resident #53) of 1 residents reviewed for resident assessment. The findings include:The Minimum Data Set (MDS) is a federally mandated, standardized assessment tool used to comprehensively evaluate a resident's functional, medical, psychosocial, and cognitive status. It is administered to all residents at admission, quarterly, annually, and whenever a significant change in an individual's condition occurs. It is the foundation for creating an individualized care plan and ensures the appropriate care and services are provided to each resident. Each resident assessment must be encoded within 7 days and transmitted to the Centers for Medicare and Medicaid (CMS) System within 14 days of when an assessment is completed.On 3/27/2026 at 12:00 PM in an interview with the MDS Coordinator (MDSC #33) when asked if she had transmitted any data for Resident #53 in the last 120 days, she stated she would go check. On 3/27/2026 at 12:27 PM in an interview with MDSC #33, she provided a document referencing Resident #53's February 2026 MDS that had documented at the bottom, Message: Record Submitted Late: The submission date is more than 14 days after Z0500B on this new (A0050 equals 1) assessment. When asked if this MDS was submitted late, she pointed to the document and stated, That's what it says. The surveyor shared this as a concern and MDSC #33 acknowledged understanding of the concern. The surveyor requested a copy of the resident's Final Validation Report verifying the exact date the MDS was transmitted. On 3/27/2026 at 12:43 PM in an interview with MDSC #33, she provided a copy of the Final Validation Report which showed the Target Date as 2/13/26 and the Submission Date/Time as 3/19/26 11:54 AM. When asked why it was submitted late, she stated her supervisor submits the MDSs.On 3/27/2026 at 1:03 PM in an interview with the Regional MDS (RMDS #34) when asked why Resident #53's February 2026 MDS was submitted late she stated, I can't remember what happened. During the interview, RMDS #34 verified and confirmed that it was submitted late. The surveyor shared this as a concern and RMDS #34 acknowledged understanding.

Based on random observations of the Arcadia unit, it was determined that the facility failed to ensure the doors exiting the unit were in good repair and created a safe and comfortable environment for residents. The findings include:Observations of the double doors exiting the Arcadia unit revealed plastic kick plates covering the bottom half of both doors. The plastic kick plates were secured to the doors by multiple screws. On the right door, black tape was covering the top of the plastic kick plate and down the right side where the plastic was coming unsecured from the door. There were also many areas with cracks and chips and jagged edges where the plastic has broken around the screws. On 8/4/25 at 12:00 PM Resident #4 was observed standing at the door picking at the top of the plastic kick plate where there was the observed jagged edges with the broken plastic kick plate.The NHA and DON were notified of the concerns and observations at 12:30 PM on 8/4/25.

Based on medical record review and interview with facility staff, it was determined that that facility failed to ensure that care plan meetings were scheduled quarterly and included the resident and representative. This was evident during the review of a complaint and review of 1 of 3 resident (1).The findings include:Review of the complaint #2577970 on 8/4/25 at 6:45 AM revealed concerns related to communication with the facility and involvement in care plans. A review of the medical record for Resident #1 revealed the last care plan meeting occurred on 10/22/24. The last social work note in the system was a 'social determinants of health' completed on 6/14/25. However, that was not a complete official care plan meeting. Interview with the facility social worker, staff #4 at 12:25 PM revealed that she is in communication with the family regularly but there was not a recent care plan meeting. Concerns were reviewed at 12:45 pm with the Director of Nursing and Nursing Home Administrator that there have not been care plan meetings with the family since 10/22/24. This surveyor was notified that a care plan meeting is scheduled for 8/7/25, however, Resident #1 is currently in the hospital, and this is 10 months after the last official care plan meeting.

Based on observation, interview, job description review, document review and policy review, the facility failed to employ sufficient staff with the appropriate competencies and skills sets to carry out the functions of the food and nutrition department having the potential to affect all residents. The facility failed to ensure adequate oversight of dietary/nutrition services from the Registered Dietitian (RD), who worked part time, had not been to the facility since July of 2024. In addition, the facility failed to ensure the Food Service Director (FSD) was qualified. This resulted in failures to provide palatable food, provide food alternates/choices, provide snacks, serve meals without extended timeframes between dinner and breakfast, and provide nutritional interventions to prevent unplanned weight loss. Findings include: Review of the undated Dietitian job description provided by the facility revealed the primary purpose of the position was to, plan, organize, develop, and direct the overall operation of the Dietary Department . to assure that quality nutritional services are provided on a daily basis and that the dietary department is maintained in a clean, safe, and sanitary manner. Duties and responsibilities included, Inspect food storage rooms . Delegate a responsible staff member to act in your behalf when absent from the facility . Participate in facility surveys (inspections) made by authorized government agencies . Participate in maintaining records of the residents' food likes and dislikes . Assist in developing methods for determining quality and quantity of food served . Ensure that residents are offered a nourishing snack at bedtime . Provide substitute foods of similar nutritive value to residents who refuse foods served . Monitor dietary services to assure that all resident's dietary needs are being met. Review of the undated Director of Food Services job description provided by the facility revealed the primary purpose of the position was to, assist the Dietitian in planning, organizing, developing and directing the overall operation of the Dietary Department . Education requirements included, Be a graduate of an accredited course in dietetic training approved by the American Dietetic Association. A request was made on 12/05/24 and 12/06/24 for the Food Service Director's (FSD) qualifications. A ServSafe Certification Food Protection Manager dated 11/14/22 was provided. This certification did not meet the requirement for the FSD position per the facility's job description or federal requirements. During survey from 12/03/24 through 12/06/24 revealed the RD was not onsite. Two attempts were made to interview the RD on 12/06/24 at 11:34 AM and 1:30 PM and no return calls were received. Although the RD's participation via phone was requested of the Administrator on 12/05/24; the RD was not available and/or did not participate in the survey. During an interview on 12/03/24 at 12:22 PM, the Regional Certified Dietary Manager (CDM) confirmed the FSD was not currently qualified for the FSD position. The Regional CDM stated the RD did not come to the facility and completed all her work offsite. During an interview on 12/04/24 at 4:58 PM, the FSD stated there had been no RD coming to facility since July 2024. The FSD stated the RD worked remotely on the weekends. The FSD stated she gathered food preferences and worked with nursing and speech therapy as needed regarding diets and residents' nutritional needs. During an interview on 12/06/24 at 2:30 PM, the Administrator stated the current RD was scheduled to work 24 hours a week remotely. The Administrator stated the RD was available by phone or email during the week; however, the Administrator stated she expected onsite presence from the RD to fulfill the requirements of the position. The Administrator verified the FSD was not qualified for the position. Cross reference tags F804 Food Palatability, F806 Food Substitutes, F809 Mealtimes/Bedtime Snacks, F812 Kitchen Sanitation, and F692 Nutritional Parameters.

Based on observations, interview, document review, and policy review, the facility failed to ensure that the kitchen was maintained in a sanitary manner to prevent the potential spread of foodborne illness to 126 out of 129 residents (three residents received nutrition via feeding tubes). Specifically, dietary staff did not adhere to hand hygiene/glove use requirements for ready to eat food and the dishwasher was not operating in accordance with manufacturer's specifications. Findings include: Review of the facility's policy titled, Dishwasher Temperature dated 01/31/23 and provided by the facility revealed, It is the policy of this facility to ensure dishes and utensils are cleaned under sanitary conditions through adequate dishwasher temperatures . Manufacturer's instructions shall be followed for machine washing and sanitizing . For high temperature dishwashers (heat sanitization): The wash temperature shall be 150 - 165 degrees F [Fahrenheit] . The final rinse temperature shall be 180 degrees or above . Review of the facility's policy titled, Dietary Employee Personal Hygiene dated 01/31/23 and provided by the facility revealed, Gloves are to be worn and changed appropriately to reduce the spread of infection . 1. Observations over three days of the survey revealed concerns with the dish machine temperatures as follows: a. During a kitchen observation on 12/03/24 at 11:24 AM, the Regional Certified Dietary Manager (CDM) two dietary staff washing dishes using the dish machine. The manufacturer's data plate affixed to the machine indicated a minimum wash temperature of 160 degrees F and rinse temperature of 180 degrees F were required. The wash temperature read 142 degrees F and the rinse 158 degrees F. The Regional CDM stated the temperatures were not hot enough. Review of the dishwashing log for December 2024 showed all wash temperatures were 160 degrees F, and all rinse temperatures were a minimum of 180 degrees F. During an interview on 12/03/24 at 11:31 AM, the Maintenance Director stated that the dish machine sanitized dishes through the temperature of the rinse cycle water and it would be evaluated since temperatures were not hot enough. Another cycle of the dish machine was run, and the wash temperature was 144 degrees F. On 12/03/24 at 12:06 PM the dish machine wash temperature was 157 degrees F, and the rinse temperature had increased to 193 degrees F. b. During a kitchen observation on 12/04/24 at 4:13 PM, the Regional CDM ran the dish machine, and the wash cycle was 155 degrees F, and the rinse was 162 degrees F. The Regional CDM verified the temperatures were not hot enough per the manufacturer's specifications. The Regional CDM stated Eco Lab came and checked on replacing a heating element in the dish machine and that this was in the works to be repaired. The Regional CDM stated staff had been monitoring the dish machine temperatures since 12/03/24 closely and they had been in acceptable most of the time. c. During a kitchen observation on 12/05/24 at 03:55 PM, the dishwasher was running, and the rinse temperature was 153 degrees F. On 12/05/24 at 4:15 PM, the Regional CDM observed the dishwasher cycle and the rinse temperature was 149 degrees F. The Regional CDM stated the heating element was not working 100% of the time and the rinse temperatures were up and down. Review of the Dishwasher Temperature Log from August 2024 - November 2024 revealed the dish machine temperatures were checked at breakfast, lunch, and dinner every day. Except for a few entries, the wash temperature was recorded as being 160 degrees F and the rinse temperature as being 190 degrees F. 2. Kitchen observations revealed concern with dietary staff's glove use when touching ready to eat foods. Staff touched ready to eat foods with gloved hands and then touched multiple other items such as plates, utensils, counters, tray cards, etc. creating the potential for cross contamination as follows: a. During an observation on 12/03/24 at 12:08 PM, Cook1 was pulling pieces of bread out of a bread bag with gloved hands. She placed the bread on a cutting board and sliced the pieces in half and then placed them into a steamtable pan for meal service. Cook1 touched the bread, plastic wrap on top of the steamtable pan, the cutting board, and knife with the same gloved hand. [NAME] 1 served residents meals on the tray line (observed through 12:31 PM using the same process), placing each slice of bread on a resident's plate with her gloved hand. In between, she touched multiple items such as plates, the counter, and serving utensils without washing her hands in between tasks or changing gloves. b. During a tray line observation in the kitchen on 12/04/24 from 4:13 PM through 4:39 PM, Cook3 used gloved hands to place hamburger buns on residents' plates prior to scooping sloppy joe onto the bottom half of the bun. Afterwards, he used his gloved hand to place the top bun on the sloppy joe/bottom bun. Cook3 touched utensils, the counter, and plates in between touching the hamburger buns without handwashing or changing gloves between tasks. The Regional CDM was present and instructed Cook3 to use tongs for placing the buns on the plates. Cook3 stated the tongs might make a hole in the top of the buns. The Regional CDM verified gloves could be used to touch ready to eat food only when nothing else was touched with the same gloves. Cook3 proceeded to use tongs to place the buns on the plate; however, continued to use his gloved hand to place the top bun on top of the bottom bun/sloppy joe. On 12/04/24 at 4:39 PM, the Regional CDM was notified, and she instructed Cook3 not to touch the buns. c. During an observation on 12/05/24 at 3:54 PM, Dietary Aide (DA)1 was dishing up individual pieces of cake out of a pan and placing them onto individual bread plates for a dessert. DA1 touched the pieces of cake as they were placed onto the plates to position them and then touched other items such as the spatula, plastic wrap, and plates without changing gloves in between tasks or performing handwashing. Review of the undated Dietitian Job Description provided by the facility revealed the primary purpose of the position was to, plan, organize, develop, and direct the overall operation of the Dietary Department . to assure that quality nutritional services are provided on a daily basis and that the dietary department is maintained in a clean, safe, and sanitary manner.

Based on observations, interview, and policy review, the facility failed to maintain the outdoor garbage area in a sanitary manner for three of three days of the survey creating the potential for the harborage of pests which could affect all 129 residents. Findings include: Review of the facility's policy titled, Safe and Homelike Environment dated 01/27/23 and provided by the facility revealed, the facility will provide a safe, clean, comfortable and homelike environment . Sanitary includes, but is not limited to , preventing the spread of disease-causing organisms . 1. Observation and interview of the garbage dumpster/compactor area 12/03/24 at 11:55 PM with the Regional Certified Dietary Manager (CDM) and the Housekeeping Manager revealed a significant amount of garbage strewn around the garbage compactor area extending approximately fifteen feet away. Garbage included pieces of plastic, drink cartons, condiment packets, paper refuse, silverware, pieces of cardboard, garbage bags with trash, a pile of scrambled eggs on the pavement, and disposable gloves. The Regional CDM and Housekeeping Manager (HM) verified the area was not sanitary and needed cleaning up. 2. Observation and interview of the garbage dumpster/compactor area on 12/04/24 at 4:43 PM with the Food Service Director (FSD) revealed there was garbage on the ground around the compactor extending approximately ten feet away including pieces of plastic, pieces of paper, disposable gloves, tin foil, plastic bottles, and cardboard. The FSD stated the garbage would be a sanitation concern if there was food that rodents could access. 3. Observation and interview of the garbage dumpster/compactor area on 12/05/24 at 4:51 PM with the Regional CDM and the HM revealed the same garbage observed on 12/04/24 that was on the ground around the compactor extending approximately ten feet away including pieces of plastic, pieces of paper, disposable gloves, tin foil, plastic bottles, and cardboard. Both the Regional CDM and HM verified the area needed to be cleaned up. The HM stated housekeeping was responsible for keeping the area cleaned up. During an interview on 12/06/24 at 2:30 PM, the Administrator stated she expected housekeeping staff to keep the garbage dumpster area clean and without accumulated garbage.

Based on observations, interview, record review, and policy review, the facility failed to ensure two of 37 sampled residents (Residents (R) R184 and R19) received nutritional interventions to address significant weight loss. Specifically, these two residents were not served enough food; did not receive prescribed nutritional interventions; were not offered alternates when they did not eat, when they experienced significant unplanned weight losses. Staff documented R19 and R184 eating meals and consuming supplements that they did not eat or consume. Findings include: Review of the facility's Weight Monitoring policy dated 12/15/22 and provided by the facility revealed, Based on the resident's comprehensive assessment, the facility will ensure that all residents maintain acceptable parameters of nutritional status . unless the resident's clinical condition demonstrates that this is not possible . A weight monitoring schedule will be developed upon admission for all residents: . Residents with weight loss - monitor weight weekly . The facility will utilize a systemic approach to optimize a resident's nutritional status. This process includes: . Developing and consistently implementing pertinent approaches . 1. Review of the undated Face Sheet revealed R184 was admitted to the facility on [DATE]; diagnoses included Alzheimer's disease and dysphagia (swallowing impairment). Review of the quarterly Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 10/01/24 in the EMR under the MDS tab revealed R184 was severely impaired in cognition with a Brief Interview for Mental Status (BIMS) score of three out of 15. R184 required set up assistance with meals. R184 experienced a significant weight loss that was not prescribed by the physician, and he received a therapeutic diet. Review of the Weight Summary from 07/10/20 through 12/03/24 in the EMR under the Vitals tab, revealed R184's weight over the previous six months decreased as follows: 55.6 pounds (#) on 06/02/24 150.2# on 06/25/24 150.8# on 07/01/24 146.8# on 07/19/24 144.8# on 07/22/24 133.0# on 08/14/24 135.0# on 08/18/24 137.4# on 09/05/24 136.0# on 09/11/24 130.2# on 09/25/24 125.2# on 10/04/24 119.8# on 11/02/24 122.0# on 11/04/24 117.6# on 12/03/24. Review of the Physician's Orders through 12/06/24 in the EMR under the Orders tab revealed R184 was prescribed a regular diet, chopped texture, and nectar thickened liquids consistency. R184 was to be weighed weekly until his weight was stable. R184 was prescribed a Magic Cup twice a day with lunch and dinner, initiated on 11/14/24. R184 was prescribed as a bedtime snack daily. R184 was prescribed house shakes three times a day at 8:00 AM, 12:00 PM, and 4:00 PM, initiated on 06/26/24. Review of R184's Care Plan dated 10/09/24 in the EMR under the Care Plan tab revealed R184 was at increased nutritional risk due to suboptimal intake and unplanned weight loss. The goal was to avoid significant weight changes. Interventions in total were: Consult dietitian as needed [10/09/24]; Monitor weight, labs and intake as available [10/09/24], Notify MD [medical doctor] and dietitian if resident has any significant weight changes [10/09/24], OT [Occupational Therapy]/ST [Speech Therapy] as needed. Although R184 experienced progressive significant weight loss, she/he was not weighed weekly as directed by Physician's Orders (weekly weights until weight stabilizes) and the facility policy. R184 experienced a significant weight loss of 37.4 pounds, a 24% weight loss in six months (10% or greater is significant in six months), from 155# to 117.6#. Observation of the lunch meal in the Acadia Unit on 12/03/24 from 1:23 PM - 2:01 PM. R184 was served rice with chili on top, bread, creamed corn, yogurt, thickened drinks (water) and coffee. R184 was not served a Magic Cup with lunch or a house shake. Continuous observations were made. R184 refused the meal and ate zero percent. Continuous observations were made and staff did not offer her/him anything else to eat (an alternate) and her/his tray was removed at 2:01 PM. Geriatric Nurse Aide (GNA)3 verified at 2:01 PM that R184 had eaten none of her/his food and an alternate had not been offered. Review of the POC [Point of Care] Response History from 11/07/24 - 12/05/24 in the EMR under the Vitals tab, R184's meal intake was not recorded for lunch on 12/03/24. Review of the Medication Administration Record (MAR) for December 2024 in the EMR under the Orders tab documented R184 consuming the health shake served on 12/03/24 at lunch and eating 25% of the Magic Cup at served at lunch when neither items were served. On 12/05/24 at 1:12 PM, R184 had a lunch meal consisting of chopped meat with gravy, collard greens, a muffin, pureed sweet potatoes, and two thickened beverages. R184 ate zero percent. GNA2 reviewed the contents of R184's tray and compared it to his meal ticket and verified R184 was not served the Magic Cup per the tray card and stated she had not seen Magic Cups come on the trays with meals. R184's tray was removed at 1:23 PM and she/he was not offered an alternative. Registered Nurse (RN)1 was interviewed on 12/05/24 at 1:23 PM and verified R184 ate zero percent of the meal. Review of the POC Response History from 11/07/24 - 12/05/24 in the EMR under the Vitals tab, R184's meal intake for lunch on 12/05/24 was incorrectly documented as 51-75%. Review of the MAR for December 2024 in the EMR under the Orders tab documented R184 ate 50% of the Magic Cup for lunch; no Magic Cup had been served and no Magic Cups were available in the facility. The MAR documented a 2 refused for house shake at lunch on 12/05/24 when a shake had not been served. During an interview on 12/05/24 at 1:23 PM, RN1 stated R184 had not eaten any of the meal and verified she/he was not offered an alternate. RN1 stated the staff had tried chopping R184's food to see if she/he would eat it better. RN1 stated R184 used to receive a regular diet. RN1 stated R184's intake had been poor for months. RN1 stated R184 was sent Magic Cups and supplements from the kitchen at snack times. During an interview on 12/05/24 at 11:39 AM, GNA1 stated R184 used to eat well but now she/he did not and picked at her/his food. GNA1 stated her/his family brought her/him food and she/he would eat it at times, ethnic food from her/his country. GNA1 stated the staff should offer her/him something else to eat if she/he did not eat anything. GNA1 stated she/he would ask for a cookie at times and sometimes the staff sent a supplement on her/his tray that she/he would drink. During an interview on 12/6/24 at 4:17 PM GNA2 who worked on the Acadia Unit stated the staff on Acadia did not offer alternates if a resident did not eat their meal. GNA2 stated if a resident did not eat, this meant they were probably not hungry. GNA2 stated she had not thought of offering something different when residents did not eat. During an observation on 12/05/24 at 1:40 PM, dietary staff delivered the 2:00 PM snacks on Acadia Unit. There was a four ounce Mighty Shake with a label that documented R184's name, Magic Cup and it was dated 12/05/24 10:00 AM. RN1 verified R184 received a Mighty Shake on the snack tray when the label documented Magic Cup and that the labels documented 10:00 AM and not 2:00 PM. All the shakes on the tray for Acadia Unit were frozen solid. RN1 stated she would have to let the shakes thaw out before they could be served. During an interview on 12/6/24 at 4:12 PM, GNA4 stated the nurse aides were responsible for documenting the amount eaten for meals. During an observation in the kitchen on 12/05/24 at 3:59 PM, Dietary aide (DA)1 went into the walk-in refrigerator and freezer with the surveyor. DA1 stated they did not have any Magic Cups in stock today; therefore, none were sent as snacks or with meals to the residents on 12/05/24. DA1 showed the supply (two partial boxes) of Mighty Shakes that were in the freezer. There were no Mighty Shakes thawed or being thawed in the walk-in refrigerator; this was verified by DA1 who stated that some shakes would need to be thawed; he was responsible for making the bedtime snacks and there were shakes on the snack list. All the shakes were currently frozen. During an interview on 12/05/24 at 5:57 PM, the Regional Certified Dietary Manager (CDM) stated the staff on the units should call the kitchen for alternates if the residents did not eat what was served. The Regional CDM verified there were not any alternatives or extra food sent to the units for residents who did not eat what was served. During an interview on 12/06/24 at 2:06 PM, the Director of Nursing (DON) stated the staff had asked R184's family to bring homemade food. She stated sometimes R184 consumed the food they brought. The DON stated the Medical Director stated R184 had end stage dementia and weight loss was part of the decline with dementia. The DON stated documentation regarding snacks and meals should be accurate. 2. Review of R19's Face Sheet in the EMR under the Census tab revealed admitted [DATE] and diagnoses included malignant neoplasm of the right breast, Cerebral Vascular Accident (Stroke), and unspecified protein malnutrition. Review of R19's quarterly MDS with an ARD of 08/29/24 in the EMR under the MDS tab with a BIMS score was 0 out of 15 which indicated R19 cognition was severely impaired. Review of R19's Care Plan dated 06/24/24 under the Care Plan tab revealed a focus area that he/she was at an increased nutritional risk with potential for decreased intakes and unplanned weight loss related to breast cancer. The goal was for the prevention of weight loss, Interventions included to consult the dietitian as needed, monitoring his/her weight, laboratory tests, and food/fluid intake as available. Notify the Medical Doctor and dietitian if resident has any significant weight changes. Observation on 12/03/24 at 11:00 AM revealed R19 had three cartons of Mighty Shake on his/her overbed table labeled as a 12/03/24 at 10:00 AM snack and a Magic Cup with the same directions. The cartons were unopened and there were no straws or glasses available. The Magic Cup was also not opened and there was no spoon available. The supplements were not within R19's reach. During an interview on 12/3/24 at 2:00 PM, Certified Nurse Aide (CNA) 1 stated R19 was able to feed herself. If he/she had wanted to drink the supplements he/she would. Sometimes he/she would push them away. She agreed the supplements from 10:00 AM were still on his/her overbed table and were not opened for him/her. She agreed there was no spoon for R19 to eat the Magic Cup supplement. Observation on 12/04/24 at 9:38 AM of his/her breakfast tray revealed he/she had taken one bite of a hashbrown patty. He/She had not taken any hot cereal, juice, or milk. Observations on 12/05/24 at 2:30 PM revealed R19 had three cartons of Mighty Shake on his/her overbed table with the date and time of 120/5/24 at 10:00 AM and were still fully frozen. On 12/05/24 at 3:00 PM, the 2:00 PM snack was delivered which was one Mighty Shake and was still frozen. On 12/05/24 at 6:10 PM, the two 10:00 AM Mighty Shakes that were still unopened and on his/her overbed table. HIs/Her overbed table was not within reach for him/her to have access to them. There was a frozen Mighty Shake with the date 12/05/24 at 2:00 PM on the overbed table and it was partially frozen. Review of R19's weights under the Vital Signs tab in the EMR revealed: On 04/04/24, R19 weighed 124.8 pounds (lbs.). On 12/05/24, he/she weighed 108.2 lbs., which was a 13.30 % loss. During an interview on 12/04/24 at 4:58 PM, the Food Service Director(FSD) stated the Registered Dietitian (RD) had not been to the facility since July 2024. The FSM stated the RD worked remotely on weekends. The FSM stated the RD did the clinical assessments and wrote progress notes and she (FSD) managed the kitchen. The FSD stated snacks were sent to the units at 10:00 AM, 2:00 PM, and 6:00 PM. During an interview on 12/06/24 at 2:30 PM, the Administrator stated the RD worked on the weekends up to 24 hours a week remotely. The Administrator stated the RD could not fulfill all her job responsibilities without coming to the facility. During an interview on 12/6/24 at 2:32 PM, the DON stated that weight loss was discussed every Wednesdays during the interdisciplinary risk meeting.

Based on observations, interview, record review, document review and policy review, the facility failed to ensure the food was palatable for 13 out of 37 sampled residents (Resident (R)88, R84, R46, R99, R123, R338, R21, R85, R60, R101, R7, R121, and R18). The food was not appetizing, prepared according to standards/recipes, or hot when residents received their meals. This created the potential for dissatisfaction and weight loss. Findings include: Review of the facility's policy titled, Standardized Menus dated 02/2023 and provided by the facility revealed, The facility shall provide nourishing, palatable meals to meet the nutritional needs of the residents . The facility will make reasonable efforts to provide food that is appetizing . 1. Residents' comments about the food were as follows: a. During an interview on 12/04/24 at 10:05 AM, R101 stated the food tasted bad. R101 stated she/he did not like the meat. Review of the undated Face Sheet in the Electronic Medical Record (EMR) under the Profile tab revealed R101 was admitted to the facility on [DATE]. Review of the quarterly Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 09/18/24 in the EMR under the MDS tab revealed R101 was intact in cognition with a Brief Interview for Mental Status (BIMS) score of 15 out of 15. b. During an interview on 12/03/24 at 12:48 PM, R7 stated the food was terrible. Review of the undated Face Sheet in the EMR under the Profile tab revealed R7 was admitted to the facility on [DATE]. Review of the admission MDS with an ARD of 10/21/24 in the EMR under the MDS tab revealed R7 was intact in cognition with a BIMS score of 15 out of 15. c. During an interview on 12/03/25 at 12:55 PM, R121 stated the food was unappetizing, bland and it needed seasoning. Review of the undated Face Sheet in the EMR under the Profile tab revealed R121 was admitted to the facility on [DATE]. Review of the admission MDS with an ARD of 10/28/24 in the EMR under the MDS tab revealed R121 was intact in cognition with a BIMS score of 15 out of 15. d. During an interview on 12/04/24 at 4:46 PM, R18 stated he/she was heating up his/her own food in the facility's microwave because, I don't want that dog food (facility's food). It is nasty as hell. During a subsequent interview on 12/06/24 at 11:30 AM, R18 stated the food was, Not good and food was the main concern that was repeatedly discussed in resident council meetings. Review of the undated Face Sheet in the EMR under the Profile tab revealed R18 was admitted to the facility on [DATE]. Review of the quarterly MDS with an ARD of 09/02/24 in the EMR under the MDS tab revealed R18 was intact in cognition with a BIMS score of 15 out of 15. During a Group meeting in the dining room on 12/05/24 at 11:00 AM, R46 stated, The food is so cold and nasty and so tough that I feed it to the squirrels outside. Nothing ever gets done when you complain. Everyone says I'll look into or work on it. R84 stated, They mix all the vegetables together and it's always the same kind. We hardly ever get fruit. The food is always cold and not a good flavor. I like to try to fix it up with pepper, but they only give me one packet of pepper every time. They gave me cereal this morning too, but no milk for it. I asked for it, but they never brought it back to me.R88 stated, The food is always cold and sometimes it feels like it just came right from the freezer. They gave me cereal this morning and no milk to drink or put on my cereal. Fruit would be nice. We never get fruit.R99 stated, The food isn't good about 80% of the time. e. Review of R46's undated Admission Record in the Profile tab of the EMR revealed an admitted [DATE] and diagnosis of chronic obstructive pulmonary disease. Review of R46's annual MDS with ARD of 09/13/24, located in the EMR MDS tab, revealed a BIMS score of 15 out of 15 which indicated R46 was cognitively intact. f, Review of R84's undated Admission Record in the Profile tab of the EMR revealed an admitted [DATE] and diagnosis of chronic obstructive pulmonary disease with exacerbation. Review of R84's quarterly MDS with an ARD of 09/30/24, located in the EMR MDS tab, revealed a BIMS score of 15 out of 15 which indicated R84 was cognitively intact. g. Review of R88's undated Admission Record in the Profile tab of the EMR revealed an admitted [DATE] and diagnosis of cerebral infarction. Review of R88's quarterly MDS with an ARD of 10/18/24, located in the EMR MDS tab, revealed a BIMS score of 15 out of 15 which indicated R88 was cognitively intact. h. Review of R99's undated Admission Record in the Profile tab of the EMR revealed an admitted [DATE] and diagnosis of seizures and alcohol dependence with uncomplicated withdrawals. Review of R99's admission MDS with an ARD of 09/06/24, located in the EMR MDS tab, revealed a BIMS score of three out of 15 which indicated R99 was severely cognitively impaired. i. During an interview on 12/03/24 at 10:54 AM, R338 stated that he/she only ate his/her meals in his/her room and when his/her meals were delivered to his/her room, the food was cold. The food has been cold since he/she was admitted on [DATE]. He/She does ask for it to be warmed. Review of R338's admission MDS with an ARD in the EMR under the MDS tab with a BIMS score of 15 out of 15 which indicated resident cognition was intact j. During a joint interview on 12/03/24 at 11:41 AM, R60 and R85 stated that they preferred to eat their meals in their rooms, the food was not always hot, and the dietary department did not answer the phone so they could order from the optional menu. The only way to get any food from the optional menu was to ask the nurse to call the dietary department. R60 stated she/he had asked for a hamburger and got a cold hot dog. The menu for supper on 12/02/24, was supposed to get kielbasa but received a hot dog. Review of R60's EMR under the census tab revealed admitted [DATE]. Review of R60's annual MDS with an ARD of 09/14/24 in the EMR under the MDS tab revealed a BIMS score of 15 out of 15 which indicated resident's cognition was intact. Review of R85's EMR under the census tab revealed admitted [DATE]. Review of R85's quarterly MDS with an ARD of 09/16/24 in the EMR under the MDS tab revealed a BIMS score of 8 out of 15 which showed he had moderate cognitive impairment. k. During an interview on 12/04/24 at 10:39 AM, R123 stated that the food comes up from the dietary department at different times. At times breakfast was not delivered until after 10:00 AM and lunch after 2:00 PM. The food was cold. The broccoli served was just the stalks. What was listed on the menu was not what was served. Condiments were not served with the meals, for example no tartar sauce with fish. The bread served was stale. The dietary department did not answer the phone if a substitute was wanted. Review of R123's EMR revealed under the census tab revealed admitted [DATE]. Review of R123's admission MDS in the EMR under the MDS tab revealed a BIMS score of 12 out of 15, which indicated moderate cognitive impairment. 2. During an observation and interview in the kitchen on 12/03/24 from 11:51 AM through 12:31 PM, Cook1 was setting up the tray line for meal service. There was a steamtable pan with a brown creamy food and Cook1 stated it was, creamed corn. When asked why it was brown, Cook1 stated she added cinnamon and brown sugar to the corn. Tray line meal service was observed and the bread slices were served plain without margarine as directed by the menu. Review of the Fall/Winter Week-At-A-Glance, Week 2 menu revealed a packet of margarine was to be served with the slice of bread. The recipe for creamed corn for lunch on 12/03/24 was requested. Review of the undated recipe for Buttered Corn provided by the facility revealed neither cinnamon nor brown sugar were ingredients that were supposed to be added to the recipe. The Regional Certified Dietary Manager (CDM) who was present on the tray line stated the recipe did not call for cinnamon sugar and the cook should have followed the recipe. 3. During an observation and interview on 12/05/24 at 5:37 PM, a test tray of a pureed diet was evaluated on the first floor with the Regional CDM after the last resident was served his/her meal from the food cart. The Regional CDM stated her goal for temperatures when residents received their trays was for the hot foods to be at least 140 degrees Fahrenheit (F) and the cold foods to be 34 degrees F or colder. The food temperatures were 113 degrees F for mashed potatoes with gravy which was lukewarm to the palate. The pureed soup was 118 degrees F, of a pasty consistency with a bland flavor confirmed by the Regional CDM. The pureed vegetable was 127 degrees F and was bland in flavor confirmed by the Regional CDM. The pureed meat was 127 degrees. The milk was 47 degrees F and was cool but not cold to the palate. During an observation on 12/05/24 at 6:05 PM a test tray to the secured unit of a regular diet was evaluated with the Regional CDM after the last resident was served his/her meal from the food cart. The food temperatures were 113 degrees F for kielbasa sausage which was lukewarm to the palate, vegetables were 107 degrees F which were bland (confirmed by the Regional CDM) and cool to the palate, and the soup was 132 degrees F and acceptable in temperature but bland in flavor confirmed by the Regional CDM. The milk was 49 degrees F and was cool but not cold. 3. Review of Resident Council Minutes from December 2023 to October 2024 provided by the facility showed ongoing concerns with food palatability as follows: a. Review of the Resident Council Minutes dated 12/14/23 revealed, Dietary: Food salty, food cold served in rooms . b. Review of the Resident Council Minutes dated 01/25/24 revealed, Food served in rooms especially first floor is cold. c. Review of the Resident Council Minutes dated 03/14/24 revealed, food is served cold. d. Review of the Resident Council Minutes dated 04/18/24 revealed, Food is not always hot. e. Review of the Resident Council Minutes dated 09/17/24 revealed, Quality of food . condiments not always on tray . Requesting either Dietitian or someone to meet with them 1:1 to get requests . Requests made if Food Committee no follow up. f. Review of the Resident Council Minutes dated 10/17/24 revealed, some bread offered is hard .Turkey sausage is hard and tasteless . 4. During an interview on 12/05/24 at 4:18 PM the Regional CDM stated she was aware of the residents' complaints that the food was not hot from resident council meetings. The Regional CDM stated she had been working with the Food Service Director (FSD) to improve the food quality. During an interview on 12/06/24 at 2:30 PM, the Administrator stated she had been aware of the residents' complaints about the food from the start of her employment and had been working to correct the problem by having the Regional CDM come more often, addressing performance issues of dietary staff, being present in the dining room regularly, and instituting a dining program for lunch.