Every finding on record at Autumn Lake Healthcare at Waugh Chapel

Based on record reviews and interviews it was determined that the facility failed to consistently maintain a comfortable homelike environment for the residents. This deficient practice was evidenced in 18 of 29 days during the month of June.The findings are:On 06/29/26 at 10:53 am during observation rounds the surveyor observed a total of twelve portable air conditioning units on the nursing units throughout the building.On 06/29/26 at 10:59 am the surveyor spoke with Resident #5 and asked did they have any issues with the temperature of the building. Resident #5 verbalized it was hot a couple of weeks ago for a few days, but it was cool at that time. On 06/29/06 at 11:01 am the surveyor asked Resident #6 were there days when it was hot in the building. Resident #6 verbalized you bet your life we did, it was 89 degrees in here according to the thermostat. Part of the building was cold and part was hot. The current temp on the thermostat read 74 degrees F. Resident #6 verbalized they couldn't breathe even while on oxygen and they felt like they were going to pass out. Their daughter purchased a fan, but it was just circulating the hot air.On 06/29/26 at 11:12 am the surveyor spoke with Resident #7 stated they were in the building since June 2. The air conditioning went out, and it was 85 F in the room about 6 times. It was not 6 consecutive days. The resident said they felt like they were going to faint. A couple of times the lady from the front office had a key and changed the temperature. It helped some then about 3-4 hours later it went right back to being hot. On 06/30/26 at 2:21 pm the surveyor received a copy of the room temperatures that were recorded from 06/01/26 - 06/29/26. The surveyor asked Maintenance Director #4 are they aware of the range of acceptable temperatures. Maintenance Director #4 verbalized the temperature should be between 71 and 81 degrees Fahrenheit (F).The surveyor reviewed the temperatures and noted there were multiple days that the temperature was above 81 degrees F in resident rooms. Maintenance Director #4 verbalized they randomly checked the temperatures in resident rooms. Abnormal temperatures were documented as follows: On 06/01/26: room [ROOM NUMBER] /84.2 F, room [ROOM NUMBER] / 82.6 F, room [ROOM NUMBER] / 88.2 F, room [ROOM NUMBER] / 82.6 F. On 06/03/26: room [ROOM NUMBER] / 82.9 F, room [ROOM NUMBER] / 82.6 F. On 06/10/26: room [ROOM NUMBER] / 84.7, room [ROOM NUMBER] / 84.4 [NAME] 06/11/26: room [ROOM NUMBER] / 82.2 F, room [ROOM NUMBER] / 85.8 F, room [ROOM NUMBER] / 82.6 F, room [ROOM NUMBER] / 97.4 F. On 06/18/26: room [ROOM NUMBER] / 81.4 F.On 06/22/26 room [ROOM NUMBER] / 84.4 F, room [ROOM NUMBER] / 82.0, room [ROOM NUMBER] / 93.2, room [ROOM NUMBER] / 90.2 F, room [ROOM NUMBER] / 91.4 F. After reviewing the temperature logs the surveyor asked Administrator #1 and Maintenance Director # 4 when the residents' room temperatures were elevated, what intervention were put in place to make the residents comfortable and provide the documentation to verify what interventions were done. The Administrator verbalized the thermostats were reset to ensure the air conditioning was working correctly. Some of the thermostats tripped and they had to be reset. The surveyor was not provided documentation to verify the residents whose room temperatures were elevated were accommodated to be made comfortable.

Based on record review and interview it was determined that the facility staff failed to accurately code a resident's MDS assessment. This deficient practice was evidenced in 1 (#2) of 3 MDS assessments reviewed during the complaint survey.The Minimum Data Set (MDS) is a federally mandated standardized clinical assessment tool used in Medicare and Medicaid-certified nursing homes to evaluate the health, functional capacity, and care needs of residents.The findings include:On 06/30/26 at 12:05 pm a review of Resident #2 medication administration record (MAR) for June 2026 revealed the resident was ordered and receiving Normal Saline 10 ml intravenous (IV) every shift from 06/02/26 until the order was discontinued on 06/15/26. The nursing staff signed off the saline flush was given until 06/13/26 during night shift. A note was written by Licensed Practical Nurse (LPN) dated 06/13/26 at 4:21 pm indicated Resident #2 had a left arm peripherally inserted central catheter (PICC) line was flushed without difficulty.On 06/30/26 at 12:12 pm a review of the resident's MDS that was completed after the resident was transferred to the hospital revealed the MDS Section O Special Treatment, Procedures, and Programs was coded incorrectly. MDS Coordinator #9 denied Resident #2 had an IV line. The assessment review date (ARD) was 06/24/26.On 06/30/26 at 12:37 pm during an interview with MDS Coordinator #9 the surveyor asked what was their process of completing an MDS assessment? MDS Coordinator #9 verbalized they review the chart, documentation, assessments, nursing notes, and assessments that were completed during the look back period; they also speak with the resident when necessary. The surveyor made the MDS Coordinator aware the resident had a PICC line and the assessment was as the resident did not have IV access. MDS Coordinator #9 verbalized they would review the assessment.On 06/30/26 at 12:57 pm MDS Coordinator #9 verbalized they coded the MDS assessment incorrectly and they would make the correction.

Based on observations and interviews with residents and facility staff it was determined that the facility failed to ensure the resident call bell system was functioning properly. This was found to be evident in 4 Resident's (#68, #125, #106, #74) rooms in 3 of 3 units observed for call light function and response. Findings include: 1. An initial tour of the facility was conducted on 5/3/26 at approximately 10:50 AM on the 100 hallway. During an interview with Resident # 68 the resident stated that s/he wanted to express concerns regarding call response times of staff. The resident stated that it takes up to three hours to get assistance to go to the bathroom. The resident stated that there are times that the call light does not work. At this time the surveyor asked the resident to turn the call light on, and the call light did not light up on the wall unit, the dome located outside of the resident room did not light up and the call light did not light up at the nurse station. At this time the surveyor conducted a dual observation with the unit supervisor (Staff #7) who confirmed each of the findings. The supervisor stated that the facility has been having problems with the call system and stated that she would get the resident a ring bell to alert staff and also notify maintenance about the call light issue. 2. An interview was conducted on 5/3/26 at 11:15AM with Resident #125 and s/he stated that on the weekend, it takes staff greater than one hour to respond to the call light. The resident also stated that the call light was not working on one night last week. The call light was tested and functioned at the time of testing. A meeting was conducted with the Nursing Home Administrator (NHA #1) on the same date at 12:50 PM. The Administrator was made aware that Resident #68's call light was not working and that the supervisor stated that there have been some concerns with the call system. The Administrator confirmed with the survey team that there are concerns regarding the call system and that the facility is currently working on this issue. The NHA provided documentation dated 5/3/26 and 5/4/26 of residents being offered a room change, but the call system repair invoice document was dated 5/1/26. The NHA was unable to provide an explanation as to why the residents were not offered a room change option at the time of the identified concern, and a call ring bell to alert staff when in need of assistance. On 5/6/26 at the time of the exit conference, the NHA stated that the repair team was in the building working on the call system. 3. During an observation tour of clinical unit, 200 on 05/03/2026 at 11:12 AM the surveyor interviewed Resident #106 in room [ROOM NUMBER]. The resident stated that the call bell light had not been working since April 2026. Also, Resident #106 stated that the portable call bell on his/her bedside table did not guarantee that staff would respond. Additionally, the resident stated that often he/she would ambulate to the doorway to find staff to assist him/her. The surveyor tested the call light in room [ROOM NUMBER] and no staff responded to the call light and no staff were observed in the hallway. 4. At 11:20 AM on 05/03/2026 the surveyor interviewed Resident #74 in room [ROOM NUMBER]. Resident #74 stated that his/her call light had not been working for the past month. Also, Resident #74 stated that he/she would sometimes contact their daughter and the daughter would call the facility supervisor in order for the resident to obtain assistance from the clinical unit staff. The surveyor tested the call bell in room [ROOM NUMBER] and the call light was not functional, and no staff members responded to the call light. At 11:30 AM the surveyor interviewed GNA #18 regarding the non -functioning call bells in rooms [ROOM NUMBERS]. GNA #18 stated that the facility had been having issues with call bells not functioning in certain rooms for approximately three weeks. Additionally, GNA #18 stated that rooms most often with non-working call bells were on the 200 and 300 units and that the administration was aware of the problem. GNA #18 walked to the rooms [ROOM NUMBERS] to assess whether the residents had any current needs. On 05/04/2026 at approximately 09:26 AM the surveyor provided the administrator and the DON with the results of the resident interviews and the observations related to non-functional call lights for rooms [ROOM NUMBERS]. The administrator stated that the facility had contracted with a company to repair specific call lights originally but still experienced failures after the work was completed. However, the plan now was to replace 15 call light strips that included rooms 214 through room [ROOM NUMBER]. Additionally, the administrator stated that he could provide the quote for the call light strip replacement.

Based on record review and interview it was determined the facility failed to maintain accurate and complete medical records in accordance with accepted professional standards and practices. This was evident in 3 (#12, #83, #95) of 5 resident medical records reviewed. The findings include: 1. Review of Resident #12's medical record on 05/04/2026 at 09:05 AM revealed a PSYCHIATRIC EVALUATION & CONSULTATION visit note dated 04/10/2026 with no name, address or phone number of the company that provided the service. During an interview on 05/04/2026 at 10:09 AM the Nursing Home Administrator (NHA #1) stated the name of the contracted company that provides psych services to facility residents. The NHA was made aware that the contracted company name, address, and phone number was not on visit note dated 04/10/2026 for Resident #12 and verified that the company that provided the service was in fact the company contracted with the facility. 2. Review of Resident #83's medical record on 05/05/2026 at 08:40 AM revealed a PSYCHIATRIC EVALUATION & CONSULTATION visit note dated 03/06/2026, with no name, address or phone number of the company that provided the service. During an interview on 05/05/2026 at approximately 1:30 PM the Director of Nursing (Staff #2) was made aware that the facility contracted company name, address, and phone number was not on visit note dated 03/06/2026 for Resident #83. 3. On 5/6/26 at 10:05 AM, review of the medical record revealed Resident #95 was admitted to the facility on [DATE] with a Stage II pressure ulcer located on the right buttock/sacral area. Further review of the medical record failed to reveal a corresponding physician treatment order for the identified area. On 5/6/26 at 11:00 AM, an interview was conducted with the Director of Nursing (DON Staff #2). The DON stated the resident's documentation in the medical record was incorrect. The DON stated the resident was admitted with a Stage II pressure ulcer to the left buttock/sacral area; however, when the order was transcribed into the medical record, it was incorrectly documented as the right buttock/sacral area instead of the left. The DON further stated the wound was almost healed and nursing staff had been re-educated regarding the importance of accurate documentation.

Based on observation and interview it was determined the facility failed to use appropriate infection control practice for resident urinary catheter care. This was evident for 1 (#35) out of 1 residents observed with a urinary catheter during the survey.The findings include:During observation rounds on 05/03/2026 at approximately 10:47 AM, Resident #35 was found sitting in a geriatric chair in the facility dining room with a urinary catheter in place. The catheter drainage bag was observed resting directly on the floor. This practice increases the risk of contamination and is a potential source of infection for the resident. During an observation and interview on 05/03/2026 at approximately 10:50 AM with Geriatric Nursing Assistant Staff #5 stated, the bag should not be on the floor and should be attached to the chair. I will take care of it.

Based on observations and interviews with residents and facility staff, it was determined the facility failed to provide a safe, functional, sanitary, and comfortable environment for residents, staff and the public. This was found to be evident for 2 (#76, #15) of 100 residents reviewed during observational rounds, and 2 (dirty and clean) of 2 laundry areas observed. Findings include:1.During observation rounds conducted on 5/3/26 at approximately 11:00AM, an interview was conducted with Resident #76 and the resident stated that s/he had a difficult time sleeping. The resident went on to say that the air system in his/her room abruptly came on at approximately 1:45 PM on 5/2/26 and was very loud. The resident went on to say that the air system did not turn off until approximately 7:45 AM on 5/3/26, the next day. The resident stated that s/he got very little sleep due to the noise level.A meeting was conducted with the Nursing Home Administrator (NHA #1) on 5/4/26 at approximately 9:35 AM and he was made aware of the resident's concern. The Administrator went on to explain that with the current system there is one (1) thermostat per four (4) resident rooms and if the vent is shut, the air is shifted to another room, and this contributes to the loud uncomfortable sound. He was made aware of the resident's concern about not getting sleep due to this and stated that he would address it.2. An observation was made of Resident #15's room on 5/3/26 at approximately 11:10AM. There were three (3) long and deep marks located on the wall at the head of the resident's bed. 3.A tour was conducted by two surveyors on 5/5/26 at approximately 10:50AM of the laundry area located in the lower basement area. Immediately upon stepping off the elevator there was a pungent odor of rotten eggs along the hallway. The Nursing Home Administrator (NHA #1) was notified at this time and came to assess. The Environmental Services District Manager (#13) and the Maintenance Director (#11) were also present. The NHA explained that the smell is related to a sewer issue and when it is warm, the odor appears. He went on to explain that the facility receives maintenance services such as hydro jetting (high pressure plumbing tool that shoots water to clear sewer lines) to ensure that there is no blockage present. He went on to say that when the hydro jetting maintenance is done, it does not alleviate the smell. He stated that the facility is looking into other options because they are not eliminating a possible leakage.4.A tour of the laundry room identified the following concerns:In the separate clean area where the dryers are located, there were storage cabinets along the wall with missing top fronts and exposed nails. In the separate area, where the washing maschines are located and dirty laundry is brought to be cleaned, the cabinet baseboards were torn away and dragging on the floor.All concerns (1-4) were discussed with the Administration team at the exit conference on 5/6/26.

Based on observation and interview, it was determined that the facility failed to maintain resident dignity by leaving a resident's urinary catheter tubing uncovered and in public view. This was evident for 1 (resident # 35) out of 1 resident observed with a urinary catheter during the survey.The findings include:During observation rounds on 05/03/2026 at approximately 10:47 AM, Surveyor observed Resident #35 sitting in a geriatric chair in the facility dining room with a urinary catheter in place. The catheter tubing was uncovered and exposed in public view. Further observation revealed the resident was not fully clothed and lacked a blanket or sheet to cover the catheter tubing while in the common dining area.During an observation and interview conducted on 05/03/2026 at approximately 10:50 AM, Geriatric Nursing Assistant (GNA) Staff #5 observed the resident and agreed with the findings, stating, I will take care of it.

Based on random observations and interviews it was determined that the facility failed to provide services in the facility with reasonable accommodation of resident needs and preferences (dependent resident preference for linen changes and to be out of bed at least daily). This was evident for 1 (Resident #94) of 20 residents interviewed and investigated for reasonable accommodations needs / preferences. The findings include:On 05/05/2026 at 11:17 AM the surveyor was informed by GNA# 18 that Resident #94 wanted to speak with a surveyor. The surveyor entered Resident 94's room and observed that the resident's over the bed table had a small portable call bell in place. The resident stated that the GNAs on 3PM-11PM and 11PM to 7AM shift were slow to respond to call bells on the dates of 05/02 and 05/03, 2026. Additionally, the resident stated that the GNAs did not ensure the resident was out of bed on Saturday or Sunday, 05/02 and 05/03, 2026. Also, the resident stated that he/she requested to have his/her linen changed because he/she frequently feels wet, but the GNA staff would not believe him/her and refused to change his/her linens. Resident #94 stated that in past he/she has called the nursing supervisor or the Ombudsman, and / or 911 in the recent past if his/her clinical requests were not met.On 05/06/2026 at 9:35 AM the surveyor interviewed GNA #19 who stated that he/she worked 7AM-11PM on both Saturday and Sunday this past weekend, May 2nd and May 3rd, 2026 and was assigned to Resident #94. GNA #19 stated that she did tell the resident that he/she was not wet and /or that the resident's bed linens were not wet and did not change the resident's bed linen two times. The GNA #19 stated that the day and evening shifts were very busy and that there may have been delays answering the call bells as well.On 05/06/2026 at 09:41 AM the surveyor spoke with the unit manager, ADON 1 Staff #16 and she was unaware of the resident's concern on the 3-11PM and 11PM to 7AM shifts this past Saturday and Sunday, May 2nd and 3rd, 2026. The ADON was advised that there was one GNA who verified that the resident's bed on 3-11 PM shift this past weekend was not changed when the resident made the request and that there had been delays in responding to the call bells because the unit GNAs were busy with other residents. The ADON stated that she would talk to the GNA and the resident regarding the events over the weekend. The ADON stated that she was not aware of Resident 94's concerns.On 05/06/2026 at approximately 10:30AM the surveyor spoke with the DON Staff #2, and shared the information that Resident #94 had provided the surveyor. The surveyor requested the schedule for both May 2nd and 3rd, 2026 that included GNA # 18 and GNA # 19. The surveyor reviewed the schedules and verified that GNA #19 had worked 7AM to 11 PM on May 2nd and May 3rd, 2026.

Based on observation, interview, and record review, the facility failed to ensure medications were administered and documented in accordance with physician orders, accepted standards of nursing practice, and the facility's established medication administration time parameters for 2 (#98, #18) of 5 residents observed during medication administration observations.Findings include:This deficient practice had the potential to affect the effectiveness of medications intended to manage hypertension, pain, constipation, anxiety, and provide prophylactic and supplemental treatment.During a medication administration observation conducted on 5/3/26 beginning at 10:15 AM with Licensed Practical Nurse (LPN) Staff #4, review of the Medication Administration Record (MAR) for Resident #98 revealed physician-ordered medications scheduled for administration at 9:00 AM had not been administered within the facility's established medication administration timeframe. Observation revealed the medications were administered at approximately 10:29 AM. The medications included:-Aspirin 81 mg by mouth for deep vein thrombosis prophylaxis-Multivitamin one tablet by mouth for supplement-Vitamin B3 by mouth for supplementDuring an interview conducted at the time of observation, LPN Staff #4 stated he got a late start.During a medication administration observation conducted on 5/3/26 beginning at 10:35 AM with LPN Staff #5, Resident #18 was observed receiving medications at approximately 10:45 AM despite physician-ordered administration times of 8:00 AM or 9:00 AM according to the MAR. The medications included:-Hydralazine 20 mg by mouth for hypertension, scheduled for 8:00 AM-Calcium-Vitamin D 500 mg-125 mg one tablet by mouth for supplement, scheduled for 9:00 AM-Colace 100 mg by mouth for constipation, scheduled for 9:00 AM-Amlodipine Besylate 5 mg by mouth for hypertension, scheduled for 9:00 AM-Sertraline HCL 100 mg by mouth for anxiety, scheduled for 9:00 AM-PreserVision AREDS 2 tablets by mouth for vision support, scheduled for 9:00 AM-Tylenol Extra Strength 500 mg one tablet by mouth for pain, scheduled for 9:00 AMFurther review of the medication administration audit record and medication reconciliation conducted on 5/4/26 at 2:00 PM revealed the medications administered on 5/3/26 were not documented on the MAR as administered until 5:21 PM on 5/3/26.During an interview conducted on 5/4/26 at approximately 2:15 PM, the Director of Nursing acknowledged medications are expected to be administered within the facility's established acceptable medication administration timeframe and documented promptly following administration in accordance with professional standards of nursing practice and facility policy.

Based on observation and interview, it was determined the facility failed to post the required nurse staffing data and post it in a prominent place readily accessible to visitors and residents. This was evident on 1 out of 2 nursing stations observed during the survey. The findings included:During observational rounds on 05/03/2026 at 10:50 AM of the facility Long-Term Care Unit, this surveyor was unable to locate the daily data requirements for the current nurse staffing information for units 4 and 5. During interview and observation on 05/03/2026 at 10:55 AM with manager on duty Staff #7, a Daily Assignment Sheet Nursing form was found in a hard plastic sign holder located on a counter behind the nursing station which was not in a prominent place or accessible for residents and visitors in wheelchairs. The manager on duty stated, This is the wrong sheet and not the nurse staffing information. I will get the correct one. The manager further agreed that the sign holder was not located in a prominent place, was not assessable for residents and visitors in wheelchairs, and would be the sign holder where required daily staffing information would be placed.

Based on observation, interview, and record review, the facility failed to ensure medications were administered in accordance with physician orders and within the facility's established medication administration time parameters for 2 (#98, #18) of 5 residents observed during medication administration observations. The facility also failed to ensure prompt documentation of medication administration following administration.Findings include:During a medication administration observation conducted on 5/3/26 beginning at 10:15 AM with Licensed Practical Nurse (LPN) Staff #4, review of the Medication Administration Record (MAR) for Resident #98 revealed physician-ordered medications scheduled for administration at 9:00 AM had not been administered within the facility's established medication administration timeframe. Observation revealed the medications were administered at approximately 10:29 AM. The medications included:-Aspirin 81 mg by mouth for deep vein thrombosis prophylaxis-Multivitamin one tablet by mouth for supplement-Vitamin B3 by mouth for supplementDuring an interview conducted at the time of observation, LPN Staff #4 stated he got a late start.During a medication administration observation conducted on 5/3/26 beginning at 10:35 AM with LPN Staff #5, Resident #18 was observed receiving medications at approximately 10:45 AM despite physician-ordered administration times of 8:00 AM or 9:00 AM according to the MAR. The medications included:-Hydralazine 20 mg by mouth for hypertension, scheduled for 8:00 AM-Calcium-Vitamin D 500 mg-125 mg one tablet by mouth for supplement, scheduled for 9:00 AM-Colace 100 mg by mouth for constipation, scheduled for 9:00 AM-Amlodipine Besylate 5 mg by mouth for hypertension, scheduled for 9:00 AM-Sertraline HCL 100 mg by mouth for anxiety, scheduled for 9:00 AM-PreserVision AREDS 2 tablets by mouth for vision support, scheduled for 9:00 AM-Tylenol Extra Strength 500 mg one tablet by mouth for pain, scheduled for 9:00 AMFurther review of the medication administration audit record and medication reconciliation conducted on 5/4/26 at 2:00 PM revealed the medications administered on 5/3/26 were not documented on the MAR as administered until 5:21 PM on 5/3/26.During an interview conducted on 5/4/26 at approximately 2:15 PM, the Director of Nursing acknowledged medications are expected to be administered within the facility's established acceptable medication administration timeframe and documented promptly following administration in accordance with professional standards of nursing practice and facility policy.

Based on complaint, reviews of a closed medical record, and staff interview, it was determined that the nursing staff failed to follow a physician's orders for withholding an antihypertensive medication when the resident's blood pressure reading was less than 110 mm/Hg. This was evident for 1 of 2 residents (Resident #1) reviewed during the complaint survey.The findings include:Review of Complaint 2605041 on 11/19/25 at 12 noon revealed an allegation Resident #1 was not receiving quality of care at the facility.Resident #1 was admitted to the facility on [DATE] with diagnoses that include but are not limited to post vascular surgery, arthritis, and hypertension. Resident #1 requires assistance from the nursing staff for some aspects of his/her care.Review of Resident #1's closed medical record on 11/19/25 at 12 noon revealed a physician order, dated 08/09/25, instructing the nursing staff to administer the blood pressure lowering medication, Amlodipine Besylate oral tablet, 2.5 mg, by mouth, one time a day, and hold for a systolic blood pressure reading less than 110 mm/Hg.A review of Resident #1's August and September 2025 Medication Administration Records (MAR) revealed the nursing staff were administering a dose of Amlodipine Besylate at 9 AM when Resident #1 blood pressure readings were less than 110 mm/Hg on the following days:08/11/2025 - 109/74.08/12/2025 - 109/74.08/14/2025 - 106/70.08/25/2025 - 106/70.08/28/2025 - 109/70.09/04/2025 - 100/60.In an interview with Staff Nurse #1 on 11/19/2025 at 3:40 PM, after reviewing Resident #1's August and September MAR's, Staff Nurse #1 stated that s/he should have withheld administering the dose of Amlodipine Besylate, 2.5 mg orally, to Resident #1 on 08/11/25, 08/14/25, 08/25/25, 08/28/25, and 09/04/25 due to Resident #1's blood pressure reading was less than 110 mm/Hg.

Based on observation and interview with facility staff, it was determined that the facility failed to maintain the safety of the food items to prevent foodborne illness. This was evident for two nourishment room refrigerators out of two nourishment room refrigerators audited during the recertification/complaint survey. The findings include: During the surveyor's tour of the facility on 03/13/25 at 12:10 PM, the surveyor observed a large zip-lock bag with cooked food items dated 03/08/25 and an uncooked cauliflower, brown to black in color in a plastic bag dated 03/08 in the refrigerator, located in the nourishment room, close to the 400-unit Nurses' station. Licensed Practical Nurse (LPN) staff # 29 validated the findings and removed the resident's food from the refrigerator. The surveyor's further observation on 03/13/25 at 12:20 PM noted apple sauce dated 03/08/25 in the refrigerator, located near the 200-unit Nurses station. Unit secretary staff #37 witnessed and validated the findings and removed the apple sauce from the refrigerator. On 03/13/25 at 12:10 PM, an interview with LPN staff # 29 revealed that the food brought from outside the facility for the residents was dated and saved in the refrigerator for three days, and the resident's food should have been out of the fridge, as it was past three days. On 03/13/25 at 1 PM, Reviewed with the Infection Preventionist (Staff #1), and Staff # 1 validated the concerns.

Based on a review of facility investigative material and interviews with facility staff, it was determined that the facility failed to ensure that a resident remained free of physical abuse. This was evident for 1 (Resident #92) out of 2 residents reviewed for abuse during the Medicare/Medicaid recertification/complaint survey. The findings include: The Minimum Data Set (MDS) is a standardized and comprehensive assessment screening tool used to identify resident's individual needs and areas of concern. BIMS stands for Brief Interview for Mental Status. It is a screening tool used to assist with identifying a resident's current cognition and to help determine if any interventions need to occur. On 03/11/2025 at 12:09 PM, review of resident's record revealed that on 03/06/2023, Resident #92's BIMS assessments score was 13.0 out of 15.0 which indicated that the resident was cognitively intact around the time of the incident. On 03/11/2025 at 12:29 PM, during review of facility reported incident MD00190653 dated 03/29/2023, Resident #92 told Licensed Practical Nurse (LPN) #32 and Medical Doctor (MD) #33 that Geriatric Nursing Assistant (GNA) #7 slapped the back of his/her hand during care when he/she(resident) reached his/her hand toward perineal while asking GNA #7 question about his/her Foley catheter. On 03/11/2025 at 12:38 PM, upon further review of the investigation packet, the facility determined that statements were obtained from Resident #92, Geriatric Nursing Assistant (GNA) #7, Licensed Practical Nurse (LPN) #32, and Registered Nurse (RN) #34. Based on the statement provided by Resident #92, the facility noted that the resident mentioned GNA #7 repeatedly entered his/her room to apologize, and the behavior suggested that GNA #7 might have been aware of an error and was attempting to make amends with the resident. As a result of the investigation, the facility deemed that Resident #92's complaint was credible and validated while GNA #7's story had conflicting information & was not credible on interview. On 03/11/2025 at 3:35 PM, in a phone interview with the Director of Nursing, she was asked to clarify the reason for the termination of GNA #7. The DON stated that the facility had gathered sufficient evidence to substantiate that the GNA #7 had slapped a resident's hand with enough force for the resident to perceive it as a violation. Regarding whether the allegation of abuse had been substantiated, the DON confirmed that it had, which ultimately led to GNA #7's termination. On 03/17/2025 at 9:31 AM, in an interview with Human Resource Director #23, when asked to describe the process following an allegation of resident abuse, she stated that regarding the process followed in cases of resident abuse, she explained that the staff member involved is suspended during the investigation. Once the investigation was completed, the findings of the investigation were discussed with the staff and if the allegation was not substantiated the staff member was reinstated. She also noted that it served as an opportunity to provide additional training, depending on the outcome of the investigation. However, if the allegation was substantiated, the employee was informed that their employment would be terminated based on the investigation's findings. She added that disciplinary documentation indicating termination was issued immediately, and a formal termination letter was mailed to the employee.

Based on observations, interviews and record reviews it was determined that the facility failed to maintain a resident's dignity by not covering the urinary drainage bag when the resident was being transported to and from rehabilitation activities. This was evident for 1 (Resident #73) of 2 residents reviewed for urinary catheter during a recertification/complaint survey. The findings include: On 3/10/25 at 7:55 AM during the initial tour of the facility, Resident #73 was observed with a Foley catheter, a device that drains urine from the bladder. The catheter was observed attached to a urinary drainage bag 1/3 filled with urine hanging under the bed. The Resident was asleep in bed at the time. 03/10/25 at 11:19 AM the surveyor returned to check on the resident and observed Staff #31, a Certified Occupational Therapy Assistant (COTA) as she wheeled the resident back to their room in a wheelchair. The urinary bag was not covered in a dignity bag, it was hanging on the wheelchair. In an interview with staff #31 she stated that part of her job description was to transport residents to and from therapy. She was asked the process for covering the urinary bag with a dignity bag during transport. Staff #31 stated that residents with foley catheters would have a dignity bag covering the urinary drainage bag during transport and if the resident did not have a bag, she would contact nursing to provide one for the resident. Staff #31 was asked about the process for applying the dignity bag and stated that nurses were responsible for applying it and that she gets instructions from them to conceal the urinary bags prior to taking the residents out of their rooms. She acknowledged that the resident did not have the covering on when she took them to therapy, but should have. On 3/11/25 at 7:45 AM an interview with Staff #1 the acting Director of Nursing (DON), she was asked about the process for concealing the urinary bags during transport. Staff #1 stated that the facility provides each resident with a foley catheter, a leaf bag used to conceal the urinary bags during transport. Residents with foley catheter are offered leg bags as alternates during transport and leaf bags are provided if they decline to use the leg bags to ensure dignity. She was asked if residents with urinary drainage bags should be transported out of their rooms without the leaf bag covering and she said no. She was made aware of the concern and said she would go and check it out.

Based on staff Interviews and medical record reviews, it was determined that the facility failed to review and revise the Resident's comprehensive care plan by an interdisciplinary team (IDT). This was evident for 2 Residents (Residents #13 and #35) out of forty-four Residents reviewed for care plan revisions during the recertification/ Complaint survey. A care plan is used to assess, plan, and evaluate the effectiveness of the resident's care, and it flows from each Resident's unique list of diagnoses. It should be organized according to the Resident's specific needs. The care plan is a means of communicating and organizing the actions and assuring the Resident's needs are attended to. The care plan is to be reviewed and revised at each assessment time of the Resident to ensure the interventions on the care plans are accurate and appropriate for the Resident. The findings include: 1) Resident # 13 was admitted to the facility on [DATE] and received long-term care, with a diagnosis of hemiplegia and hemiparesis following cerebral infarction affecting the left side. On 03/10/25 at 10:55 AM, the surveyor observed Resident #13 with left arm contracture without having the bolster in place. On 03/14/25 at 11 AM medical record review revealed that Resident #13 had an order for a soft bolster for LEFT arm positioning r/t contracture. Gently place bolster between elbow and ribs for abduction and between forearm and bicep to allow the antecubital space to allow airflow every shift, dated 09/13/2023. (As per the National Institutes of Health (NIH), Bolsters are cushions that elevate a part of the body) On 03/14/25 at 11:10 AM, in an Interview with the unit manager, staff # 3 confirmed that Resident #13 had an order for a bolster. The care plan did not reflect the intervention of Bolster usage. The care plan was last revised on 08/21/23. On 03/14/25 at 11:30 AM, Infection Preventionist Staff # 1 validated that the care plan for Resident #13 did not reflect the intervention for contracture management. 2) Resident # 35 was admitted to the facility on [DATE], receiving long term care. On 03/12/25 at 09:42 AM, a medical record review of the Medication administration record (MAR) for January and February 2025 revealed that resident #35 had an order dated 12/22/23 for Non-pharmacological interventions were attempted prior to administering any PRN pain med. as needed. Document the number corresponding to the NonPharmacological Interventions attempted: 1. Warm beverage offered 2. Repositioned 3. Soft music played 4. Lights dimmed 5. Other (document in a progress note) 6. The resident refused. On 03/14/25 at 11:30 AM, Infection Preventionist Staff # 1 validated that the care plan was revised on 08/21/23 and the revised care plan does not reflect the intervention of nonpharmacological interventions prior to administering the pain medication.

Based on the interview of the facility staff and review of the medical records, it was determined that the facility failed to provide needed care and services that are resident-centered, in accordance with the resident's goals for care and professional standards of practice that will meet each resident's physical needs. This was evident for one Resident (Resident #13) out of 44 residents reviewed for quality of care during the recertification/complaint survey. The findings include: Resident # 13 was admitted to the facility on [DATE] and received long-term care, with a diagnosis of hemiplegia and hemiparesis following cerebral infarction affecting the left side. On 03/10/25 at 10:55 AM, the surveyor observed Resident #13 with left arm contracture without any pillow or device in place to treat the contracture. On 03/14/25 at 11 AM medical record review revealed that Resident #13 had an order for a soft bolster for LEFT arm positioning r/t contracture. Gently place bolster between elbow and ribs for abduction and between forearm and bicep to allow the antecubital space to allow airflow every shift, dated 09/13/2023. (As per the National Institutes of Health (NIH), Bolsters are cushions that elevate a part of the body) On 03/14/25 at 11 AM, an Interview with Licensed Practical Nurse (LPN) staff #29 revealed that he/she did not see a bolster or pillow being used during the medication administration earlier that morning. He/she stated that the staff used a folded pillow sometimes in place of a bolster. On 03/14/25 at 11:10 AM, in an Interview with the unit manager, staff # 3 confirmed that Resident #13 had an order for a bolster, but the staff used a folded pillow. On 03/14/25 at 11:11 AM , in an interview, the Infection Preventionist Staff # 1 validated that Resident #13 used the bolster for contracture management, and the bolster was found in the resident's closet.

Based on resident interview, staff interviews and medical record review, the facility failed to ensure that pain management is provided to residents who require such services, consistent with professional standards of practice, the comprehensive person-centered care plan, recognition and management of Pain. This was evident for one resident (Resident # 35) out of two residents reviewed for pain management, during the recertification/Complaint survey. The findings include: On 03/12/25 at 09:42 AM, a medical record review of the Medication administration record (MAR) for January and February 2025 for Resident #35 revealed that Pain medication was administered without attempting to offer any nonpharmacological interventions. Further review of physician's orders revealed: - Acetaminophen Tablet 325 MG, Give 2 tablets by mouth every 8 hours as needed for Mild Pain 1-4, Order Dated 06/20/2024. - Non-pharmacological interventions were attempted prior to administering any PRN pain med. as needed. Document the number corresponding to the NonPharmacological Interventions attempted: 1. Warm beverage offered 2. Repositioned 3. Soft music played 4. Lights dimmed 5. Other (document in a progress note) 6. Resident refused, Order dated 12/22/23. Resident # 35 received Acetaminophen Tablet 325 MG 2 tablet for mild pain On 01/11/25 at 9:17 PM from License Practical Nurse (LPN) staff # 36, on 02/06/25 at 4: 39 PM from LPN, Staff # 28, and on 02/07/25 at 4:03 PM from LPN staff #28. There was no documentation that the resident # 35 was offered any non pharmacological interventions, before administering the medication for pain. Further review of medical records revealed a medication order for OxyCODONE HCl Tablet 10 MG Give 1 tablet by mouth every 4 hours as needed for moderate to severe pain, order dated 01/02/2025. Resident # 35 received Oxycodone 10mg, on 01/18/25 at 5:57 PM by LPN staff #28, on 01/19/25 at 08:01 PM from LPN staff # 28, on 02/08/25 at 11:30 AM from LPN staff # 29, and on 02/23/25 at 9:12 PM from LPN staff # 28. There was no documentation that the resident # 35 was offered any non pharmacological interventions, before administering the medication for pain. On 03/12/25 at 03:00 PM, an interview with License Practical Nurse (LPN) staff # 29 revealed that he/she administered pain medication after assessing the pain but was unable to confirm if any nonpharmacological interventions were offered to the Resident before administering the pain medication. On 03/14/25 at 11:01 AM, Reviewed with Infection Preventionist Staff # 1 and validated that PRN Acetaminophen and Oxycodone were administered without offering nonpharmacological interventions.

Based on record review and interviews with facility staff, it was determined that the facility failed to initiate and develop a comprehensive person-centered care plan for Residents who had frequent urinary tract infections (UTI). This was evident for one Resident (Resident #35), out of one Resident reviewed for urinary tract infections during the recertification/complaint survey. The findings include: On 03/11/25 at 10:15 AM medical record review revealed that Resident #35 had UTIs and used antibiotic therapy on 01/19/24: Keflex, on 05/22/24: Cipro, on 06/05/24: Cipro and on 12/30/24: Bactrim. The care plan was not initiated for risks and prevention of UTI. On 03/11/25 at 9:57 AM, an Interview with Social Services staff # 4 revealed that the Care plans are conducted regularly. The social worker documents the overview of the care plan meeting notes, and individual departments initiate and revise their care plans. On 03/12/25 at 03:59 PM, Reviewed with Infection Preventionist Staff # 1 and validated that Resident #35 ' s care plan did not include the risks and prevention for getting frequent urinary tract infections.

Based on record review and interviews, it was determined the facility staff failed to report an allegation of abuse within 2 hours of the allegation to the regulatory agency, the Office of Health Care Quality (OHCQ). This was evident for 1 (Resident #29) of 3 residents reviewed for abuse during a recertification/complaint survey. The findings include: On 3/11/2025 at 8:38 AM, a review of the investigation report of Facility Reported Incident (FRI) #MD00202441, revealed that on 2/10/2024 Resident #29's daughter notified facility staff that the resident reported that on the previous evening care, the GNA (Geriatric Nursing Assistant) hit her/him on the buttock after s/he by self-admission punched the GNA. A review of the timeline of events revealed that the Director of Nursing (DON) was made aware of the allegation of abuse on 2/10/2024 at 3:00 PM and the Nursing Home Administrator (NHA) on 2/10/2024 at 4:50 PM. However, further review of the investigation report of the FRI revealed documentation that the initial self-report of the allegation of abuse was submitted to the State Survey Agency (OHCQ) on 2/10/2024 at 5:30 PM, more than 2 hours past the time the facility staff were made aware of the allegation. However, the investigation report packet did not include any confirmation receipt for when the initial self-report of the allegation of abuse was submitted to OHCQ. On 03/11/2025 at 10:37 AM, during an interview with a surveyor, the Nursing Home Administrator (NHA) was asked about the facility's procedure for reporting allegations of abuse. He stated that any allegation of abuse must be reported to the State Agency within two hours of its occurrence and that substantiation was not required before reporting to the State Agency. On 3/12/2025 at 7:35 AM, surveyor requested and received from the NHA the email confirmation receipt for when the initial self-report of the FRI was submitted to OHCQ. On 3/12/2025 at 8:10 AM, A review of the email confirmation receipt revealed the initial self-report of the allegation of abuse was submitted to OHCQ on 2/10/2024 at 6:13 PM, more than 3 hours from when facility staff were made aware of the allegation of physical abuse. Thus, failing to meet the 2-hours reporting requirement for any allegation of abuse. On 3/12/2025 at 8:48 AM, An interview was conducted with the Nursing Home Administrator (NHA). Surveyor shared concerns regarding the investigation report of the FRI with date and time the initial self-report was submitted to OHCQ noted as 2/10/2024 at 5:30 PM and the email confirmation receipt of the initial self-report with date and time report was sent to OHCQ noted as 2/10/2024 at 6:13 PM: NHA verified and affirmed that the date and time on both documents were more than 2 hours from when the facility staff were made aware of the allegation of abuse. Thus, the facility failed to report an allegation of abuse to the State Agency within the 2 hours required by regulation. On 3/17/2025 at 1:10 PM during the exit conference, the Director of Nursing (DON) confirmed that the initial self-report of the above allegation of abuse was submitted to the State survey Agency (OHCQ) later than the 2- hour time frame required for such submissions. DON stated that she was made aware of the allegation on a Saturday and she had to rush home to submit the report. She added that when she got home and submitted the initial self-report, she realized that it was late (past the 2-hour window). Thus, admitting the facility's failure to timely report an allegation of abuse.

Based on observation and staff interview, it was determined that the facility failed to safely install lighting in a shower room which could potentialy cause significant injury to residents and staff. The findings include: At 12:30 PM on 1/23/12, while on environmental tour with the maintenance director, the surveyor observed a one inch gap between the lenses of the lights and the ceiling in resident shower stalls two and three. Interview of the maintenance director revealed that he could not confirm whether the fixtures were approved for wet area use. The maintenance director and surveyor checked to see if the light switch and outlet in the room were protected by Ground Fault Interrupters, (GFI), devices that would turn off the power in case of accidental shock. The maintenance director verified that there was no protective device installed for the lights or electrical outlet. The gap between the light fixtures allowed them to be exposed to moisture and the possibility that the light fixture and bulb could be inadvertently sprayed by the hand held shower nozzle. Accidental spray of the fixture could present a shock hazard, or the risk that the bulb could shatter and expose residents and staff to broken glass. It was determined that these lights presented an immediate jeopardy to health and safety of residents and staff using the shower. The Administrator and Maintenance Director were notified at 1:00 PM on January 23, 2012. The Administrator immediately began, along with the Maintenance Director, to correct the deficiency. The showers were put out of service and the shower nozzles were removed to prevent use of the showers. The written plan of correction was accepted at 2:15 PM on January 23, 2012. During a general environmental tour, between 10:00 AM and noon, equipment was observed stored in the hallway exit corridor. This equipment included a Hoyer lift, scale and four wheelchairs in the 200 wing. Hoyer lifts were stored in the hallway by rooms 3A and 10A. Items not currently in use must not be stored in exit corridors to ensure that the halls are not blocked in case of fire or other emergency evacuation. On January 30, 2012, the surveyor made a site visit to the facility and verified through interview of the maintenance director that the repairs were partially complete and that the showers were not being used. The surveyor verified by inspection that the shower hoses were removed and the showers were taped off and labeled "Do Not Use".