Every finding on record at Autumn Lake Healthcare Post-Acute Care Center

Based on record reviews and staff interviews, it was determined that the facility failed to ensure physician orders and provider recommendations were implemented timely following changes in condition. This was evident for 1 (Resident #6) of 10 residents reviewed for quality of care during the complaint survey.The findings include:On 05/01/2026 at 12:41 PM, review of Resident #6's clinical record showed the resident was admitted on [DATE] with diagnoses including diabetes mellitus, dementia, and chronic kidney disease.Further review of Resident #6's clinical record revealed a change in condition note dated 02/08/2026 showing the resident experienced a ruptured fluid blister to the left heel. Continued review of the note showed provider recommendations to cleanse the left heel with wound cleanser, apply Medihoney daily, and elevate the heel with a pillow.Continued review of Resident #6's February 2026 Treatment Administration Record (TAR) did not reveal evidence that provider-recommended wound treatment to the left heel was provided on 02/09/2026 or 02/10/2026. The wound treatment order appeared on the TAR beginning 02/11/2026.On 05/04/2026 at 1:05 PM, in an interview, the Director of Nursing (DON) stated that physicians are encouraged to enter their own orders into PCC (PointClickCare); however, when nursing staff enter physician orders, the expectation is that orders are entered at the time the order is received and not two days later.The findings were discussed with the Director of Nursing (DON) and Administrator during the exit conference.

Based on reviews of a closed medical record and all pertinent administrative records, and staff interview, it was determined that the facility failed to have a system in place to ensure clinical records were complete and accurately documented. This was found to be evident for 1 (Residents #1) of 3 residents reviewed during a complaint survey.The findings include:Documentation is an integral part of medication administration. Documentation communicates the timing, dosing, and effect of any medications received by a patient. In the setting of skilled nursing care, residents are often prescribed multiple medications for significant medical conditions. They are also often more vulnerable to medication errors and more prone to changes in condition that require review and adjustment of their medication regimen. Inaccurate medication documentation has the potential to place residents at significant risk of medication error, provide incomplete or inaccurate information for providers and care givers to evaluate, and represents a failure of basic medication administration principles.Resident #1 was admitted to the facility on [DATE] after spending a couple days in the hospital being treated for cardiac symptoms. Resident #1 was discharged from the facility on 12/31/25.During a review of complaint 2685115 on 01/20/26 at 12:30 PM, the nurse surveyor requested the Director of Nurses to please ask the medical records to bring for review all of Resident #1's closed paper documents and access to Resident #1's electronic medical record. The facility Director of Medical records presented the nurse surveyor with a folder indicating it held the closed medical records and documents for Resident #1.During the review of Resident #1's closed medical record documents, it was discovered that several of the documents being reviewed were the closed medical records for Resident #3. In an interview with the facility Director of Medical Records (Staff #3) on 01/20/26 at 1:07 PM, Staff #3 stated the documents in Resident #1's closed medical record documents is what s/he received for the staff from the nursing unit and that Resident #1's closed record has not been officially deemed closed because the documents are not in a red folder.

Based on record reviews and staff interviews, it was determined that the facility failed to adhere to professional standards of quality of care based on established clinical practices, physician orders, or facility policies regarding enteral feeding and medication administration. This was evident for 4 residents (Residents #9, #210, #208 and #117) out of 4 residents reviewed for professional standards of quality care during the survey. Findings include:Professional standards of quality relate to the requirement that services provided in a long-term care facility must heavily involve proper medication administration practices. This regulation is part of the Centers for Medicare & Medicaid Services (CMS) guidelines for nursing homes, and citations often occur when facilities fail to adhere to established clinical practices, physician orders, or facility policies regarding medications. Facilities must ensure that all care and services, including medication administration, adhere to accepted standards of clinical practice. This is often interpreted through established guidelines like the six rights of medication administration: right patient; right medication; right dose; right route; right time; and right documentation. 1. During observation rounds on 11/17/25 at 9:00 AM, Resident #9's tube feeding bottle was observed hanging at the bedside. The bottle was unlabeled, with no documented rate of infusion and no time indicating when it had been hung. The feeding was not running, yet the tubing remained connected to the resident's PEG site, posing a risk for contamination. When interviewed, staff #6 were unable to provide the time the feeding was started or the intended rate. Review of the facility's policy titled Care and Treatment of Feeding Tubes requires that feeding tubes be utilized in accordance with current clinical standards of practice, with interventions to prevent complications to the extent possible. Current standards require enteral feeding containers to be labeled with start time, rate, and resident identifiers, and that non-running feedings be disconnected to prevent contamination. These requirements were not followed. 2. On 11/20/2025 at 10:07 AM, the surveyor reviewed complaint #333113. Complaint #333113 indicated that Resident #210's medication was not administered timely. On 11/24/2025 at 3:14 PM, the surveyor reviewed Resident # 210's medical records which revealed that Resident #210's Medication Admin Audit Report indicated that the resident received the following morning medications late on 10/1/25: Hydralazine HCl 100 MG Oral Tablet, for hypertension, was scheduled for 6:00 AM and was administered at 1:21 PM; and Gabapentin 600 MG Oral Tablet, for burning in bilateral lower extremities, was scheduled for 6:00 AM and was administered at 1:21 PM. On 11/24/2025 at 3:34 PM, the surveyor interviewed staff #2. During the interview, the surveyor asked staff #2 what the expectation of staff is when administering medication to residents. Staff #2 stated that the expectation is that staff administer medication to residents either one hour before the medication is scheduled or one hour after medication is scheduled. 3. On November 19, 2025, at 2:45 PM, the surveyor spoke with Resident #208's wife who explained how she was upset with the facility for double-dosing her husband for 14 days. The wife explained how Resident #208 was very drowsy and looked sedated when she came to visit them. The wife was notified by the methadone program at the hospital of their denial to refill the methadone medication too soon after 12/30/24. The wife continued to explain how she had asked the nurses several times why Resident #208 was looking like that (sedated), but received no response. On 11/24/25 at 1 PM, the surveyor spoke with the Director of Nursing (DON) #2 and the Regional DON #17 about what happened with Resident #208 and their methadone dosage. The DON #2 explained that the methadone had come from the program with 2 doses in each bottle, and because the nurses were used to having a single dose in each bottle, the nurses proceeded to give them a whole bottle as their dosage instead of splitting the bottle in half. The DON #2 was asked if any grievance had been filed. The DON #2 stated yes, there was a grievance filed and completed. The surveyor asked for a copy of the grievance. The DON #2 was asked when she was made aware of the error with the medication. The DON #2 explained that she was asking for a refill on the methadone from the Methadone Clinic when the methadone was denied for being too soon for a refill. It was then deduced that a medication error had been made and that the resident had received the wrong dosage of methadone. From 11/21/24 to 12/4/24, the resident was receiving 102 mg of methadone twice a day. When the DON #2 was asked if there were any negative outcomes or adverse reactions identified with this medication error. The DON #2 responded, no. The surveyor then asked for copies of the Medication Error filed, the letter that was sent to the Methadone Clinic, the Medication Administration Records (MAR) for the methadone during November 2024, December 2024, and January 2025, and the Chain of Custody Record for each methadone order. Review of the Grievance Form revealed that on 1/2/25, Resident #208's wife complained that Resident #208 was receiving too much methadone over the last 2 weeks. The grievance was investigated by the DON #2, who concluded that a review of the resident's medication administration record should be completed and that accurate dosing and adherence to physician orders. No negative outcomes or adverse reactions were identified. The resident remained stable, and their medication regimen would continue to be monitored to ensure effectiveness and safety. The facility communicated with the prescribing methadone clinic to ensure medication packaging supports safe administration and reduces the risk of medication errors. Staff education was completed, and the methadone prescription was refilled per the physician's orders to ensure uninterrupted treatment and prevent any lapse in pain management or withdrawal symptoms. Review of the Licensed Nurse Administration Record revealed that the resident started the first dose on 11/20/24 at 10 AM. The initial order was transcribed as Methadone HCL Oral Solution 10 MG/5ML, give 25ml by mouth two times a day for opioid disorder, and should have lasted until 12/16/24. It was discontinued at 11:31 AM on 11/20/24. The next transcribed order stated Methadone HCL Oral Solution 10 MG/5ML, give 10 mL by mouth two times a day for substance abuse. Hold for systolic B/P less than 110 on dialysis days. May give after dialysis and was started on 11/20/24 at 6 PM, and again should have lasted until 12/16/24. It was noted on the Licensed Nurse administration Record that the resident did not miss any doses from 12/16/24 through to 12/30/24; however, the facility only received 14 bottles for use from 11/20 to 12/16/24. Which would have made the methadone last until 12/3/24. The resident would not have had enough to last from 12/4/24 through to 12/16/24, and especially not through to 12/30/24 when the next refill was requested. It was also identified that the perimeters given for the systolic Blood Pressure were not being followed as the order was written. Medication was to be held for any Systolic Blood Pressure less than 110. On the following 8 dates, these instructions were not met: 12/14, 12/19, 12/20, 12/21, 12/25, 12/28/24 and 1/11/25, and 1/20/25. The methadone was not held or any note written that the provider was notified of the low systolic blood pressure. Review of the Chain of Custody Record revealed that the facility had received 28 doses of Methadone to be used from 11/20/24 to 12/16/24. The record also states that there is 102 mg (1st dose split) in each bottle, with 14 bottles received. It was documented on the form that Resident #208 was receiving one dose a day from 11/21/24 to 12/16/24. However, Resident #208 only signed off on 11/20/24 through to 12/2/24 that they received the methadone. From 12/3/24 through 12/16/24, the form was only documented by the nurse giving the methadone with no resident sign-off. The next chain of custody record was not until 12/31/24, with the dosage split into separate bottles for the AM and PM dosage as requested by the DON #2 to the Methadone Program. 4. 11/18/2025 8:15 AM during initial observation and interview with resident #117, a medication cup with approximately 30 mL of light-yellow liquid was observed on the bedside table. When this Surveyor asked the resident what it was, the resident stated oh, this was my medicine I had to take; the resident was unable to state the name or reason of the medication. During this encounter, CMA Staff #15 came to the resident door peering in during our interaction; the Surveyor asked the staff member, while pointing to the medicine cup, what medication was left at the bedside, staff #15 stated that was Lactulose. Staff #15 also stated the resident does not take all of the medications at once; I come back periodically until the resident takes them all. Surveyor then went to the Medication Cart with staff #15, it was in the Dining Hall directly across from Resident #117's room; however, the cart was away from the entrance of the door and out of view of the resident. While at the medication cart with staff #15, the Surveyor observed the medication administration record of Resident #117 with staff #15, it revealed a medication time to be given of 10:00 AM and order for Lactulose Oral Solution 10 GM/15ML (Lactulose) Give 30 ml by mouth one time a day for Hepatic Encephalopathy. This order was not charted as given, despite being left unattended by staff at bedside, prior to the Surveyor's 8:15 AM observation; nearly 2 hours prior to the medication ordered time. On 11/18/2025 at 11:00 AM during interview with Director of Nursing staff #2 and Nursing Home Administrator staff #1, this Surveyor notified them of the observed medication at bedside left unattended by CMA staff #15 and the early administration. When asked if medications were ok to leave at bedside for residents to take on their own and the early timing, both the DON and NHA stated No.

Based on observations, interviews with staff and residents' families, and review of Complaints, it was determined that the facility failed to 1.) ensure a safe, functional, sanitary, and comfortable environment for residents, staff, and the public; 2.) provide enough clean linen to all residents; and 3.) ensure repairs were made to a resident door and the hallways hand railings. This was evident for 5 (333137, 333135, 333139, 333141 and 333113) out of 5 complaint intakes; 2 (residents #11 and #140) out of 2 residents; and the hallway railing on the third-floor dementia unit observed for sanitary conditions during the survey. The findings include:1. On 11/20/2025 at 10:07 AM, the surveyor reviewed complaint #333113 which alleged that the facility did not have enough linen for all residents. On 11/24/2025 at 12:40 PM, the surveyor interviewed Staff member #18. During the interview, staff #18 mentioned that the facility does not have enough blankets for all the residents, and that the facility is currently in the process of ordering more blankets for the residents. On 11/24/2025 at 12:45 PM, the surveyor conducted observation rounds. During observation rounds, after the clean linen was distributed to the units, the surveyor observed only 2 blankets on the clean linen cart in the laundry room. 2. On 11/18/25 at 3:00 PM, a resident family member told surveyors that the facility was dirty and nasty and that they needed to do better with cleaning and caring for the residents. On 11/21/2025 at 1:15 PM, review of complaint intakes (#333137, #333135, #333139, and #333141) all stated that the facility was outdated, smelled foul, and was dirty. Observations during initial entrance found the facility was not well-lit, and the walls, baseboards, and railings in the hallways were dirty with old stains and spots. There were areas in the hallways that smelled of urine. The surveyor also observed that there weren't any chairs in some of the residents' rooms for visitors to sit in. On 11/24/25 at 12:32 PM, the surveyor observed that the wall behind Resident #11's bed was stained with a substance that ran down the wall. It appeared to have been there for some time; it was dry-looking. The surveyor interviewed the unit manager, Staff #9, starting with showing her the wall behind Resident #11's bed, and she acknowledged that it was something that Resident #11 had thrown on the wall. Staff #9 stated that she would have it cleaned immediately. Continued observations showed that the whiteboard at the nurse's station had black areas around the base of the whiteboard from where the black markers were being used, and the wall was also dirty with marks all around it. The surveyor notified the unit manager of the appearance of the wall around the whiteboard and the appearance of the residents' room doors with heavy impressions of scratches. 3. On 11/18/2025 at 09:08 AM the surveyor observed areas of linoleum flooring behind the third-floor clinical unit's nursing station with brown rust like stained materials, and several mis-matched linoleum pieces, as well as missing pieces of linoleum near the entrance to sitting area of the nursing station. On 11/20/2025 at 12:20 PM the surveyor observed the hand railings between rooms [ROOM NUMBERS] showed peeling paint. 4. On 11/21/2025 at 10:22 AM the surveyor observed a red biohazard bag inside a carboard box on the floor; dirty linen uncovered with personal resident clothing items. In the clean utility room, the surveyor observed that there were no paper towels in the towel container near the sink and there were O2 tanks both full and empty in holders on the left side of the wall, an old call bell and cord were lying on the floor. On 11/24/2025 at 4:13 PM the surveyor interviewed the housekeeping director, staff #19 regarding the environmental issues found on the third-floor clinical unit. Staff #19 stated that he does not have a schedule for stripping waxing the linoleum floors in the facility. Additionally, staff #19 stated that facility perform deep cleaning of resident rooms monthly but did not provide any documentation to support this statement. Staff #19 stated that facility utilizes the TELS system to document and report environmental issues to the housekeeping and maintenance departments. These deficiencies were discussed with the DON and Administrator prior to and during the exit conference on 11/24/2025.

Based on record reviews and staff interviews, it was determined that the facility failed to review and revise the care plan after each Minimum Data Set (MDS) assessment known as required . This was evident for 1 (Resident #32) out of 2 residents selected for Dialysis review during the survey.Findings include:The Centers for Medicare & Medicaid Services (CMS) defines the Minimum Data Set (MDS) as a standardized, comprehensive assessment of all residents in Medicare or Medicaid-certified nursing homes and swing beds. It is a tool used to gather information on resident strengths and needs, develop individualized care plans, and is used for Medicare/Medicaid reimbursement and quality of care. Section N (High-Risk Drug Classes) of the MDS, is used to document the resident's medication status for injections, high-risk drug classes, and medication-related problems.On 11/20/2025 at 11:40 AM during record review of resident #32, the resident Care Plan (dated 9/11/25) revealed Resident is on Anticoagulant therapy related to cardiac disease process; Date Initiated: 06/06/2023; and Revision on: 09/15/2025. However, further record review revealed no current anticoagulant therapy orders. The resident's last anticoagulant therapy (Heparin) was ordered on 10/15/24 and discontinued 2/4/25; the Care Plan was not updated to reflect this change, despite the MDS properly reflecting the change during 3 cycles of reviews.On 11/20/2025 at 12:08 PM during record review of resident #32, this Surveyor reviewed the Minimum Data Set (MDS), Section N (High-Risk Drug Classes), which is used to document the resident's medication status for injections, high-risk drug classes, and medication-related problems. It revealed an answer of 'Yes' indicating that the resident was receiving Anticoagulant therapy on the 9/13/24: Annual and 12/14/24: Quarterly assessments. Additionally, after the Heparin orders were discontinued on 2/4/25, the MDS, Section N was then answered 'No' during the 3/16/25: Quarterly, 6/16/25: Quarterly, and 9/14/25: Annual assessments for Anticoagulant therapy.On 11/21/2025 at 12:21 PM during an interview with LPN Unit Manager staff # 14 and MDS Coordinator staff #23, when asked who is responsible for discontinuing or updating the resident care plan, MDS Coordinator staff #23 stated the unit manager is responsible for updating the Care Plan with any changes. The Surveyor then asked, how are medication orders and care plan changes monitored; the Unit Manager staff #14 stated orders are ran every 24hrs by the Unit Manager and Care Plan discussions and updates are done weekly on the unit. When asked if this Care Plan accurately reflected the current Anticoagulant therapy, the Unit Manager staff #14, agreed No.

Based on observations, record reviews and staff interviews, it was determined that the facility failed to ensure that respiratory care, including tracheostomy care and tracheal suctioning, was provided consistent with professional standards of practice. This was evident for 4 (Residents #6, #101, #26 and #66) out of 12 residents observed with Tracheostomy tubes during the survey.Findings include:A manual resuscitator, also known as an Ambu bag, is a portable, handheld device used by trained medical professionals to provide positive pressure ventilation to patients who have insufficient or ineffective breathing. The device is essential for emergency situations, such as cardiac arrest, severe asthma attacks, or drug overdoses, to provide oxygen to a patient's lungs until more advanced medical equipment (like a mechanical ventilator) is available. 1. On 11/20/2025 at 7:38 AM, during observation rounds, the surveyor did not observe a manual resuscitator or bag valve mask in Resident #6's room. On 11/20/2025 at 7:42 AM, the surveyor conducted observation rounds Respiratory Therapist staff #5. During observation rounds, the surveyor asked staff #5 to locate the manual resuscitator or bag valve mask in Resident #6's room. Staff #5 searched through Resident #6's room for the manual resuscitator or bag valve mask. Staff #5 stated that the manual resuscitator or bag valve mask was not in Resident #6's room. On 11/20/2025 at 7:45 AM, after surveyor intervention, staff #5 placed a bag valve mask in Resident #6's room. 2. On 11/20/2025 at 7:40 AM, during observation rounds, the surveyor did not observe a manual resuscitator or bag valve mask in Resident #101's room. On 11/20/2025 at 7:44 AM, the surveyor conducted observation rounds Respiratory Therapist staff #5. During observation rounds, the surveyor asked staff #5 to locate the manual resuscitator or bag valve mask in Resident #101's room. Staff #5 searched through Resident #101's room for the manual resuscitator or bag valve mask. Staff #5 stated that the manual resuscitator or bag valve mask was not in Resident #101's room. On 11/20/2025 at 7:47 AM, after surveyor intervention, staff #5 placed a bag valve mask in Resident #101's room. 3. On 11/18/2025 during initial observation of the Terrace Unit at 8:21 AM and follow-up observation at 3:07 PM of resident #26, a resident with a tracheostomy intact with Oxygen in use, this Surveyor was unable to observe or locate a manual resuscitator/Ambu bag at bedside for potential emergent use. 4. On 11/18/2025 during initial observation of the Terrace Unit at 9:00 AM and follow-up observation at 3:17 PM of resident #66, a resident with a tracheostomy intact with Oxygen in use, this Surveyor was unable to observe or locate a manual resuscitator/Ambu bag at bedside for potential emergent use. On 11/19/2025 at 3:23 PM during observation and interview with LPN Unit Manager staff #14, this Surveyor completed a unit walk through with staff #14 and discussed the concerns of no manual resuscitator/Ambu bags available at the bedsides of residents #26 and #66. Staff #14 confirmed no bags were at the bedside. After Surveyor intervention, staff #14 stated the bags would be obtained from the Vent Unit. On 11/20/2025 at 7:44 AM during a follow-up observation, a manual resuscitator/Ambu bag was observed at the bedsides of both residents (#26 and #66).

Based on staff interviews, interviews with the family, and record review, it was determined that the facility failed to ensure that each resident's drug regimen was free from unnecessary drugs, such as those in excessive dosage or given for an excessive duration. This was evident for 1 (Resident #208) out of 1 resident reviewed for unnecessary drugs.The findings include:On November 19, 2025, at 2:45 PM, the surveyor spoke with Resident #208's wife regarding the complaint intake. Resident #208's wife explained how she was upset with the facility for double-dosing her husband for 14 days. The wife explained how Resident #208 was very drowsy and looked sedated when she came to visit them. The wife was notified by the methadone program at the hospital of their denial to refill the methadone too soon after 12/30/24. The wife continued to explain how she had asked the nurses several times why Resident #208 was looking like that (sedated), but received no response. On 11/24/25 at 1 PM, the surveyor spoke with the Director of Nursing (DON) #2 and the Regional DON #17 about what happened with Resident #208 and their methadone dosage. The DON #2 explained that the methadone had come from the program with 2 doses in each bottle, and because the nurses were used to having a single dose in each bottle, the nurses proceeded to give them a whole bottle as their dosage instead of splitting the bottle in half. The DON #2 was asked if any grievance had been filed. The DON #2 stated yes, there was a grievance filed and completed. The surveyor asked for a copy of the grievance. The DON #2 was asked when she was made aware of the error with the medication. The DON #2 explained that she was asking for a refill on the methadone from the Methadone Clinic when the methadone was denied for being too soon for a refill. It was then deduced that a medication error had been made and that the resident had received the wrong dosage of methadone. From 11/21/24 to 12/4/24, the resident was receiving 102 mg of methadone twice a day.When the DON #2 was asked if there were any negative outcomes or adverse reactions identified with this medication error. The DON #2 responded, no. The surveyor then asked why Resident #208 had been found on the floor in their room on 11/21/24 and 11/23/24. The DON #2 explained that Resident #208 stated that they had lost their balance and slid down to the floor in front of their bed. The DON #2 was asked if the resident might have fallen because he/she was drowsy from the double-dosing of methadone. The DON #2 was unsure and stated, no. The surveyor then asked for copies of the Medication Error filed, the letter that was sent to the Methadone Clinic, the Medication Administration Records for the methadone during November 2024, December 2024, and January 2025, and the Chain of Custody Record for each methadone order. On 11/24/25 at 12:30 PM, revealed that in the progress notes, it was noted that Resident #208 had a fall on 11/21/24 and then again on 11/23/24. The progress noted did not explain in detail the condition of the resident or why they had fallen on those 2 days. Review of the Grievance Form revealed that on 1/2/25, Resident #208's wife complained that Resident #208 was receiving too much methadone over the last 2 weeks. The grievance was investigated by the DON #2, who concluded that a review of the resident's medication administration record should be completed and that accurate dosing and adherence to physician orders. No negative outcomes or adverse reactions were identified. The resident remained stable, and their medication regimen would continue to be monitored to ensure effectiveness and safety. The facility communicated with the prescribing methadone clinic to ensure medication packaging supports safe administration and reduces the risk of medication errors. Staff education was completed, and the methadone prescription was refilled per the physician's orders to ensure uninterrupted treatment and prevent any lapse in pain management or withdrawal symptoms.Review of the Licensed Nurse Administration Record revealed that the resident started the first dose on 11/20/24 at 10 AM. The initial order was transcribed as Methadone HCL Oral Solution 10 MG/5ML, give 25ml by mouth two times a day for opioid disorder, and should have lasted until 12/16/24. It was discontinued at 11:31 AM on 11/20/24. The next transcribed order stated Methadone HCL Oral Solution 10 MG/5ML, give 10 mL by mouth two times a day for substance abuse. Hold for systolic B/P less than 110 on dialysis days. May give after dialysis and was started on 11/20/24 at 6 PM, and again should have lasted until 12/16/24. It was noted on the Licensed Nurse administration Record that the resident did not miss any doses from 12/16/24 through to 12/30/24; however, the facility only received 14 bottles for use from 11/20 to 12/16/24, which would have made the methadone last until 12/3/24. The resident would not have had enough to last from 12/4/24 through to 12/16/24, and especially not through to 12/30/24 when the next refill was requested.Review of the Chain of Custody Record revealed that the facility had received 28 doses to be used from 11/20/24 to 12/16/24. The record also stated that there was 102 mg (1st dose split) in each bottle, with 14 bottles received. It was documented on the form that Resident #208 was receiving one dose a day from 11/21/24 through to 12/16/24. However, Resident #208 only signed off on 11/20/24 through to 12/2/24 that they received the methadone. From 12/3/24 through 12/16/24, the form was only documented by the nurse giving the methadone with no resident sign-off. The next chain of custody record was not until 12/31/24, with the dosage split into separate bottles for the AM and PM dosage as requested by the DON #2 to the Methadone Program.

Based on staff interviews, interviews with the family, and record review, it was determined that the facility failed to ensure that residents were free of any significant medication errors. This was evident for 1 (Resident #208) out of 1 resident reviewed for medication errors.The findings include:On November 19, 2025, at 2:45 PM, the surveyor spoke with Resident #208's wife regarding the complaint intake. Resident #208's wife explained how she was upset with the facility for double-dosing her husband for 14 days. The wife explained how Resident #208 was very drowsy and looked sedated when she came to visit them. The wife was notified by the methadone program at [NAME] of their denial to refill their methadone too soon after 12/30/24. The wife continued to explain how she had asked the nurses several times why Resident #208 was looking like that (sedated), but received no response.On 11/24/25 at 1 PM, the surveyor spoke with the Director of Nursing (DON) #2 and the Regional DON #17 about what happened with Resident #208 and their methadone dosage. The DON #2 explained that the methadone had come from the program with 2 doses in each bottle, and because the nurses were used to having a single dose in each bottle, the nurses proceeded to give them a whole bottle as their dosage instead of splitting the bottle in half. The DON #2 was asked if any grievance had been filed. The DON #2 stated yes, there was a grievance filed and completed. The surveyor asked for a copy of the grievance. The DON #2 was asked when she was made aware of the error with the medication. The DON #2 explained that she was asking for a refill on the methadone from the Methadone Clinic when the methadone was denied for being too soon for a refill. It was then deduced that a medication error had been made and that the resident had received the wrong dosage of methadone. From 11/21/24 to 12/4/24, the resident was receiving 102 mg of methadone twice a day.When the DON #2 was asked if there were any negative outcomes or adverse reactions identified with this medication error. The DON #2 responded, no. Review of the Grievance Form revealed that on 1/2/25, Resident #208's wife complained that Resident #208 was receiving too much methadone over the last 2 weeks. The grievance was investigated by the DON #2, who concluded that a review of the resident's medication administration record should be completed and that accurate dosing and adherence to physician orders. No negative outcomes or adverse reactions were identified. The resident remains stable, and their medication regimen will continue to be monitored to ensure effectiveness and safety. The facility communicated with the prescribing methadone clinic to ensure medication packaging supports safe administration and reduces the risk of medication errors. Staff education was completed, and the methadone prescription was refilled per the physician's orders to ensure uninterrupted treatment and prevent any lapse in pain management or withdrawal symptoms.Review of the Licensed Nurse Administration Record revealed that the resident started his first dose on 11/20/24 at 10 AM. The initial order was transcribed as Methadone HCL Oral Solution 10 MG/5ML, give 25ml by mouth two times a day for opioid disorder, and should have lasted until 12/16/24. It was discontinued at 11:31 AM on 11/20/24. The next transcribed order stated Methadone HCL Oral Solution 10 MG/5ML, give 10 mL by mouth two times a day for substance abuse. Hold for systolic B/P less than 110 on dialysis days. May give after dialysis] and was started on 11/20/24 at 6 PM, and again should have lasted until 12/16/24. It was noted on the Licensed Nurse administration Record that the resident did not miss any doses from 12/16/24 through to 12/30/24; however, the facility only received 14 bottles for use from 11/20 - 12/16/24. Which would have made the methadone last until 12/3/24. The resident would not have had enough to last from 12/4/24 through to 12/16/24, and especially not through to 12/30/24 when the next refill was requested.Review of the Chain of Custody Record revealed that the facility had received 28 doses to be used from 11/20/24 to 12/16/24. The record also states that there is 102 mg (1st dose split) in each bottle, with 14 bottles received. It was documented on the form that Resident #208 was receiving one dose a day from 11/21/24 through to 12/16/24. The next chain of custody record was not until 12/31/24, with the dosage split into separate bottles for the AM and PM dosage as requested by the DON #2 to the Methadone Program.

Based on observation and interview, the facility failed to ensure the kitchen was maintained in a sanitary manner to prevent the potential for food contamination. This deficient practice had the potential to affect any resident who consumes food prepared in the kitchen.Findings Include:During an observation on 11/18/25 at 9:00 AM, the following were noted in the kitchen food-service area:1. A large pile of dark black substance was observed on the floor under a shelf inside the walk-in freezer.2. The lid holder tray contained dried food residue.3. Chipping paint was observed on a post within the kitchen.4. Standing water was present on the floor near the dishwasher.5. Ten (10) ice cubes were observed spaced out across the kitchen floor.During follow-up observations on 11/19/25 at 10:00 AM and 11/20/25 at 11:00 AM, the above unsanitary conditions remained unaddressed.During an interview on 11/19/25 at 11:00 AM, the Certified Dietary Manager (CDM) (Staff #3) stated that the area should be cleaned each day. She acknowledged that the conditions observed should not have been present.After surveyor intervention on 11/21/25 at 10:00 AM, the above unsanitary conditions were addressed.

Based on observations and interviews with facility staff it was determined the facility failed to adhere to infection control practices and guidelines to prevent the spread of germs and cross contamination of microorganisms in the facility. This was found to be evident for 5 occurrences 1.) Resident #31 during the initial tour and screening of residents; 2.) Resident #73 during a lunch dining observation; 3.) An observation made during a tour of the laundry area; 4.) An observation of a Clean Linen bin placed within a resident-use bathroom; and 5.) The urinary catheter bag of resident #26 observed on the floor.Findings include: 1. An initial tour of the building was conducted on 11/18/25 at 8:00AM by the survey team and while screening residents and making observations of the resident rooms, the following concerns were identified: Resident # 31's room was observed at approximately 9:00AM and was noted to have an odor present. There was a very large brown dried area noted on the floor underneath the resident bed and to the side. The resident was present in the room and was asked if s/he needed assistance from staff with care. The resident stated that s/he received medication to help to go to the bathroom but was unable to feel or know if the medication worked. At that time the surveyor went outside the resident room and met the nurse, Staff # 21 who was giving out medications. The nurse was asked to come into the resident room to observe the area on the floor. The nurse went into the resident room with the surveyor and confirmed that there was a very large dried brown area present on the floor. The surveyor asked the nurse to pull the resident covers back and upon doing so, the resident pad had a large brown area noted and the edges were brown and dried. The nurse stated that he would get someone to assist him with changing the resident. During a follow-up observation on the same date at approximately 9:45 AM of Resident # 31's room, there was a blanket covering the large dried brown area on the floor. The surveyor once again asked the nurse, staff # 21, to accompany the surveyor to the resident room and he confirmed the area was covered with a blanket. At that time, he asked Environmental (EVS) staff to go in to clean the resident room. Resident # 31 was in the hallway sitting in a wheelchair at that time and dressed and clean. On 11/20/25 at 9:00AM the NHA and the DON were made aware of the observation and this being a concern. The DON stated that the resident room should have been cleaned immediately. They were also made aware that multiple complaints were submitted regarding the building having problems with maintaining sanitary environment. They stated that re-education would be provided for staff. 2. During a lunch dining observation conducted on 11/21/25 at approximately 12:05 PM the following concern was identified: GNA # 11 was observed sitting at a table feeding Resident #73 who was sitting at a table with another Resident #82, whose family was feeding the resident. The family had a wig/ hair unit lying on top of the table next to Resident #73's food. Staff # 11 continued to feed the resident while the wig/hair unit was next to the resident plate of food. The surveyor alerted the nurse; Staff # 22 and he immediately went over to the family and spoke with them. The family then removed the hair item from the table. The DON was made aware of the concerns on the same date. 3. A tour and observation was conducted in the laundry area on 11/24/25 at 12:45 PM with two surveyors, and the following concerns were identified: The entrance door into the washroom needed repair. The door was slightly ajar, appearing to not be able to close. The clean linen area that was next to the washroom was opened upon observation and the linen carts were not covered. There were multiple carts located in the linen room that had covers that were rolled up leaving the linen exposed. Further observation of the linen covers found each of the covers worn, and with exposing open areas. One cart had a large open area noted to the top of the cart. During an interview with the laundry staff # 18 on 11/24/25 at 12:45 PM she stated that the covers were old and needed to be replaced. She confirmed that the covers did not safely cover the linen during transport due to the obvious wear and tear noted. The NHA was made aware of the identified concerns on the same date at 1:30 PM. 4. On 11/18/2025 at 8:23 AM during initial observation and interviews, the urinary catheter bag of Resident #26 was observed in a dignity bag, however the bag was lying on the floor to the right side of the bed. The Nurse Supervisor staff #30 was notified immediately and was asked what the expectation was; stating the urinary bag should not be on the floor. On 11/24/2025 at 12:50 PM record reviews and interviews were completed. The Policy & Procedures for Catheter Care, Appropriate Use of Indwelling Catheter, and Infection Prevention and Control Program failed to indicate to maintain proper infection control and keep catheter bag off the floor. During interview DON staff #2, also the Infection Prevention Nurse stated, despite the Policy & Procedure specifically stating this, the expectation is to keep the bag off the floor. When asked how staff are educated; staff #2 stated they are educated to keep bag below hip level and a hook is provided to hang the bag on the bed and it is the standard of practice to maintain infection control by keeping the bag off the floor. 5. On 11/20/2025 at 9:05 AM during observations on Terrace Unit, this Surveyor observed a Clean Linen bin inside the resident room bathroom with the door closed. The LPN Unit Manager staff #14 was immediately notified while on the unit. This Surveyor then observed staff #14 remove the linen bin from the resident bathroom and place the bin in the room marked 'Clean Utility' room for further staff use on the unit; this was despite there being a room marked 'Soiled Utility' directly next door for the linens to return to Laundry to be cleaned. On 11/20/2025 at 9:10 AM during an interview with DON staff #2 & NHA staff #1, findings were shared regarding the linen bin.

Based on observations and interviews with facility staff, it was determined that the facility failed to ensure that residents' rights to a dignified existence during meals and incontinence care for residents. This was evident for 4 residents (#4, #188, #31 and #58) of 7 residents observed for dignity during the survey. 1. On 11/20/2025 at 11:00 AM the surveyor reviewed the Dietary Meal Serving form provided by the facility. The third-floor lunch meal delivery time was listed as 11:55 AM and 12:05PM for the residents listed as needing assistance with the meal. On 11/20/2025 at 12:08 PM the surveyor interviewed the GNA #24 regarding how the residents were monitored and/or fed in the dining room during meals. GNA #24 stated that she had been employed by the facility for the past three years. GNA #24 stated that clinical staff members are assigned to take turns feeding and monitoring residents in dining room throughout the shift. Also, GNA # 24 stated that a hospitality aide usually assist with distributing water and other fluids to the residents throughout the shift, however the hospitality aide was not working today. GNA #24 stated that the three food carts are unloaded at the same time because some residents will try to take food from other resident's trays if the staff are not present to monitor the residents. On 11/20/2025 at 12:12 PM the surveyor interviewed the unit manager for the third floor, dementia unit. The unit manager stated the current census on the unit was 48 residents. The unit manager stated that the white board located across from the nurses station indicated the number of residents who required assistance with meals and which staff members were assigned to each of these residents. On 11/20/2025 at 12 noon the surveyor performed an observation round of the third-floor clinical unit and well as a dining room observation. The surveyor observed the clinical staff escorting residents to seats in the dining room. [NAME] protective aprons were in place on most of the residents in the dining room located directly across from the nursing station. On 11/20/2025 at 12:08 PM the surveyor observed the documentation on the census white board across from the nurses station that indicated which residents were identified as requiring assistance with meals as well as the number of staff members assigned to the unit. On 11/20/2025 from 12:26 PM to 12:32 PM three food carts arrived on the third-floor dementia unit and were placed outside the dining room across from the nurses station. On 11/20/2025 at 12:34 PM the surveyor spoke with the unit manager #25 and GNA #24 regarding the surveyor's observation of GNA #24 feeding resident #4 in the dining room while the GNA was standing up. The unit manager #25 stated that an in-service would be provided to the clinical staff advising them to sit in a chair while feeding residents during mealtimes. On 11/24/2025 at 12:45 PM the surveyor observed GNA #27 standing on the left side of the resident # 188 while spooning food into the resident's mouth. The surveyor observed that there was no empty chair available to staff #27 to sit on while feeding the resident. On 11/24/25 at 12:47 PM the surveyor spoke with the unit manager #25 and GNA # 27 regarding the surveyor's observation of GNA #27 standing while spoon feeding food into a resident #188's mouth. The GNA#27 stated that he was aware that staff are to be seated when feeding residents. The unit manager #25 stated that she would re-educate clinical staff members again regarding the correct practice of sitting while feeding residents. These resident dignity concerns were reviewed with the DON and administrator prior to the exit conference on 11/24/2025. 2. An initial tour of the building was conducted on 11/18/25 at 8:00AM by the survey team. During initial screening and observations of residents and their rooms, the following concerns were identified: Resident # 31's room was observed at approximately 9:00AM and was noted to have an odor present. There was a very large brown dried area noted on the floor underneath the resident bed and to the side. The resident was present in the room and was asked if s/he needed assistance from staff with care. The resident stated that s/he received medication to help to go to the bathroom but was unable to feel or know if the medication worked. At that time the surveyor went outside the resident room and met the nurse, Staff # 21 who was giving out medications. The nurse was asked to come into the resident room to observe the area on the floor. The nurse went into the resident room with the surveyor and confirmed that there was a very large dried brown area present on the floor. The surveyor asked the nurse to pull the resident covers back and upon doing so, the resident pad had a large brown area noted and the edges were brown and dried. The nurse stated that he would get someone to assist him with changing the resident. During a follow-up observation on the same date at approximately 9:45 AM of resident #31's room, there was a blanket covering the large dried brown area on the floor. The surveyor once again asked the nurse, staff # 21, to accompany the surveyor to the resident room and he confirmed the area was covered with a blanket. At that time, he asked Environmental (EVS) staff to go in to clean the resident room. Resident # 31 was in the hallway sitting in a wheelchair at that time and dressed and clean. On 11/20/25 at 9:00AM the NHA and the DON were made aware of the observations and this being a concern. The DON stated that the resident room should have been cleaned immediately. They were also made aware that multiple complaints were submitted regarding the building having problems with maintaining sanitary environment. They stated that re-education would be provided for staff. 3. A lunch dining observation was conducted at the facility on 11/21/25 at approximately 12:05 PM of residents awaiting lunch tray arrivals in the dining room located on second floor and the following concerns were identified: At approximately 12:15 PM a food tray was delivered by dietary staff to resident # 58. The staff placed the plate of food in front of the resident and continued serving food to other residents in the dining room. Resident # 58 was observed with their body bent over and his/her face very close to the plate using his/her mouth to retrieve food from the plate. The surveyor alerted the nurse (Staff # 22) who came into the dining room at the time of the observation and the nurse then alerted Geriatric Nurse Assistant (GNA)# 11 a who was at the next table feeding another resident. GNA # 11 immediately retrieved utensils and placed them into the resident hand. Resident # 58 began eating with the utensils after setup with utensils and cuing by the GNA. All concerns were discussed with the NHA and DON at the time of observation and at the exit conference on 11/24/25.

Based on staff interviews, interviews with the family, and record review, it was determined that the facility failed to ensure that medical records and forms were complete and accurately documented. This was evident for 3 (Resident #208, Residents #213, and Resident #214) out of 3 resident reviewed for medical records.The findings include:1. On November 19, 2025, at 2:45 PM, the surveyor spoke with Resident #208's wife regarding the complaint intake. Resident #208's wife explained how she was upset with the facility for double-dosing her husband for 14 days. The wife explained how Resident #208 was very drowsy and looked sedated when she came to visit them. The wife was notified by the methadone program at [NAME] of their denial to refill their methadone too soon after 12/30/24. The wife continued to explain how she had asked the nurses several times why Resident #208 was looking like that (sedated), but received no response. On 11/24/25 at 1 PM, the surveyor spoke with the Director of Nursing (DON) #2 and the Regional DON #17 about what happened with Resident #208 and their methadone dosage. The DON #2 explained that the methadone had come from the program with 2 doses in each bottle, and because the nurses were used to having a single dose in each bottle, the nurses proceeded to give them a whole bottle as their dosage instead of splitting the bottle in half. The DON #2 was asked if any grievance had been filed. The DON #2 stated yes, there was a grievance filed and completed. The surveyor asked for a copy of the grievance. The DON #2 was asked when she was made aware of the error with the medication. The DON #2 explained that she was asking for a refill on the methadone from the Methadone Clinic when the methadone was denied for being too soon for a refill. It was then deduced that a medication error had been made and that the resident had received the wrong dosage of methadone. From 11/21/24 to 12/4/24, the resident was receiving 102 mg of methadone twice a day. Review of the Licensed Nurse Administration Record revealed that the resident started the first dose on 11/20/24 at 10 AM. The initial order was transcribed as Methadone HCL Oral Solution 10 MG/5ML, give 25ml by mouth two times a day for opioid disorder, and should have lasted until 12/16/24. It was discontinued at 11:31 AM on 11/20/24. The next transcribed order stated Methadone HCL Oral Solution 10 MG/5ML, give 10 mL by mouth two times a day for substance abuse. Hold for systolic B/P less than 110 on dialysis days. May give after dialysis and was started on 11/20/24 at 6 PM, and again should have lasted until 12/16/24. It was noted on the Licensed Nurse administration Record that the resident did not miss any doses from 12/16/24 through to 12/30/24; however, the facility only received 14 bottles for use from 11/20 - 12/16/24. Which would have made the methadone last until 12/3/24. The resident would not have had enough to last from 12/4/24 through to 12/16/24, and especially not through to 12/30/24 when the next refill was requested. Review of the Chain of Custody Record revealed that the facility had received 28 doses to be used from 11/20/24 to 12/16/24. The record also states that there is 102 mg (1st dose split) in each bottle, with 14 bottles received. It was documented on the form that Resident #208 was receiving one dose a day from 11/21/24 through to 12/16/24. However, Resident #208 only signed off on 11/20/24 through to 12/2/24 that they received the methadone. From 12/3/24 through 12/16/24, the form was only documented by the nurse giving the methadone with no resident sign-off. The next chain of custody record was not until 12/31/24, with the dosage split into separate bottles for the AM and PM dosage as requested by the DON #2 to the Methadone Program. 2. The Skilled Nursing Facility Advanced Beneficiary Notice of Non-coverage form (CMS-10055) provides information to residents/beneficiaries that services may no longer be covered by Medicare and addresses the resident's liability for payment should they wish to continue receiving the skilled services.The Notice of Medicare Non-coverage form (CMS-10123) informs the beneficiary of his/her right to file an appeal of the decision and the right to an expedited review of Medicare non-coverage of services. On 11/18/2025 at 11:00 AM, the Entrance Conference worksheet: Beneficiary Notice – Residents discharged Within the Last Six Months form was provided to the facility. The facility completed the form and indicated that the following residents were discharged to home, residents #213 on 8/7/25 and resident #214 on 9/17/25. On 11/24/2025 at 11:00 AM, a review of the SNF Beneficiary Protection Notification Review form (CMS-20052) completed by the facility for resident #213 revealed: Medicare Part A Skilled Services Episode Start Date: 6/24/25; Last covered day of Part A service: 8/7/25; and How was the Medicare Part A Service Termination/Discharge determined?: Other (explain): Resident discharged to hospital 8/7/25. On 11/24/2025 at 2:00 PM during record review of resident #213 it revealed two discharge to home notes. A Social Service Note (dated 8/7/25 at 13:18), noted Discharge summary: [resident] is discharging home this date into [their spouse's] care. [The resident] is to receive home health services from [name of home care agency] to include pt(physical therapy), ot(occupational therapy) and skilled nursing. [The resident] has all recommended equipment at home including oxygen. [The resident] is to return to [name of medical provider] on a M, W, F 2nd shift 10:00 a.m. schedule. [The resident] should follow up with [their] primary care physician within 2 weeks of discharge. The Nurse Note (dated 8/7/24 at 14:49), noted 'Resident discharged home today with spouse at 2:43 PM. Discharge paper and prescriptions given to spouse. Resident had no pain or discomfort upon leaving.' 3. On 11/24/2025 at 11:05 AM, a review of the SNF Beneficiary Protection Notification Review form (CMS-20052) completed by the facility for resident #214 revealed: Medicare Part A Skilled Services Episode Start Date: 6/27/25; Last covered day of Part A service: 9/17/25; and How was the Medicare Part A Service Termination/Discharge determined?: Other (explain): Resident discharged to hospital 9/17/25. On 11/24/2025 at 2:05 PM during record review of resident #214 it revealed two discharge to home notes. The Discharge Summary note (dated 9/17/25 at 16:02), revealed 'Patient discharged to home at 330pm. Daughter picked patient up on w/c. All scripts and discharge instructions given to daughter. Patient left facility in stable condition'. The Social Service Note (dated 9/17/25 at 16:18), revealed Discharge summary: [The resident] discharged home this date in the care of [their] daughter who transported [them] home. [The resident] will be living with [their] son who will be provided 24/7 supervised assistance. Home health services will be provided by [name of home care agency]. [The resident] received a wheelchair from [medical equipment provider name]. [The resident] should follow up with PCP within 2 weeks of discharge. On 11/24/2025 at 2:35 PM, during interview with the Nursing Home Administrator (NHA) staff #1, the Surveyor informed NHA staff #1 that the SNF Beneficiary Protection Notification Review (CMS-20052) forms for residents #213 and #214 indicated the residents were discharged to the hospital despite the record review for both residents and conference worksheet: Beneficiary Notice – Residents discharged Within the Last Six Months form indicating the residents were discharged home. In response the NHA staff #1 stated 'my MDS Coordinator completed the form and likely put the wrong discharge information, the residents were discharged to hospital, let me look into it'. On 11/24/2025 at 4:05 PM during a follow-up interview with NHA staff #1, the Surveyor asked for further information regarding the discharge. The NHA staff #1 stated there is no other information, the residents were discharged home.

Based on observations and interviews the facility failed to ensure the residents were provided with a homelike environment related to their rooms. This was determined to be true for three resident rooms, # 312, # 309, and #316 on one unit during surveyor observation tours at the facility.These findings include:On 11/18/2025 at 08:45 AM the surveyor performed walking observation rounds of the third floor nursing unit. rooms [ROOM NUMBERS] were observed with dirty built up wax on the linoleum floors. On 11/20/2025 at 12:20 PM the surveyor observed room [ROOM NUMBER] had a deep gouge of missing wood on the door. The linoleum flooring in room # 312 was dirty with built up wax, in the bathroom there was a rusty bolt on the toilet, and black marks/stains within the toilet. The linoleum in the bedroom in room [ROOM NUMBER] had built -up wax and was dirty. room [ROOM NUMBER] had a broken bedside cabinet drawer with a broken handle.On 11/24/2025 at 4:13 PM the surveyor interviewed the housekeeping director, staff #19 regarding the environmental issues found on the third-floor clinical unit. Staff #19 stated that he does not have a schedule for stripping waxing the linoleum floors in the facility. Additionally, staff #19 stated that facility performs deep cleaning of resident rooms monthly but did not provide any documentation to support this statement. Staff #19 stated that facility utilizes the TELS system to document and report environmental issues to the housekeeping and maintenance departments. Prior to the exit conference staff #19 did not provide documentation of any repairs and/or cleaning of resident rooms related to the third floor rooms. These deficiencies were discussed with the DON and Administrator prior to and during the exit conference on 11/24/2025.

Based on observations, interviews, and record reviews, it was determined that the facility failed to ensure safe enteral feeding practices by failing to: 1) ensure a resident's tube feeding was properly labeled with the rate of infusion; and 2.) ensure the time the feeding was hung and an inactive feeding setup was disconnected from the resident's PEG site to prevent potential complications of enteral feeding and to maintain dignity. This was evident for 3 (residents #9, #66 and #87) of 7 residents observed on tube feeding on during the survey. Findings include:A PEG tube, or Percutaneous Endoscopic Gastrostomy tube, is a feeding tube that is inserted through the abdominal wall directly into the stomach. It is used to deliver nutrition, fluids, and medications to individuals who cannot eat or swallow by mouth due to medical conditions. The Centers for Medicare and Medicaid Services (CMS) recommend that staff practices for handling, hang-time, and changing tube feeding bags are consistent with accepted standards of practice for infection control and manufacturer instructions. Professional standards of quality, according to the National Library of Science, Chapter 17 Enteral Tube Management-Managing Tube Clogging states, to prevent enteral tubes from clogging, it is important to follow these guidelines: flush feeding tubes at a minimum of once a shift; and flush feeding tubes immediately before and after intermittent feedings. During continuous feedings, flush at standardized, scheduled intervals. 1. During observation rounds on 11/17/25 at 9:00 AM, Resident# 9's tube feeding bottle was observed hanging at the bedside. The bottle was unlabeled, with no documented rate of infusion and no time indicating when it had been hung. The feeding was not running, yet the tubing remained connected to the resident's PEG site, posing a risk for contamination. When interviewed, staff #6 was unable to provide the time the feeding was started or the intended rate. Review of the facility's policy titled Care and Treatment of Feeding Tubes requires that the facility to utilize feeding tubes in accordance with current clinical standards of practice, with interventions to prevent complications to the extent possible. The current standard of practice requires enteral feeding containers be labeled with start time, rate, and resident identifiers, and that non-running feedings be disconnected to prevent contamination which were requirements that were not followed. This deficient practice placed the resident at risk for receiving unsafe enteral nutrition, contamination of feeding equipment, and potential clinical complications. 2. On 11/18/2025 at 8:22 AM during initial observation of Resident #66, the Surveyor observed NEPRO with CARBSTEADY Tube Feed bottle hanging at bedside. The label read: 'hung at 2a on 11/18/25'. The Kangaroo OMNI Infusion Pump was in progress and the screen read: FEEDING; Intermittent Rate: 50mL/hr; Time Left: 179 mins; Feed Left 149mL; and Total Fed: 9025mL. However, at the time of the observation, the concern was the fluid level remaining in the bottle and the Time Left to be infused on the pump. The fluid remaining was approximately at 900mL level, despite the label reading that the bottle was hung at 2a for an infusion rate of 50mL; which should have infused approximately 300mL over the 6 hours, by the time of the observation. On 11/18/2025 at 2:37 PM during a follow-up observation on Day 1, the fluid level left in the same bottle observed during the initial observation now read at 800mL, again with the label stating hung at 2a on 11/18/25 and pump read FEEDING; infusing at 50mL/hr; Time Left: 1125 mins; Feed Left: 938ml, and Total Fed: 9161mL. On 11/19/2025 at 3:05 PM during follow-up observations, it revealed the fluid level left in bottle approximately 900mL, labeled 'hung at 6a on 11/19/25. The Kangaroo OMNI feeding pump read FEEDING; infusing at 50mL; Time Left: 1093mins; Feed Left: 911mL; and Total Feed: 10096mL. On 11/19/2025 at 3:23 PM during walk-through observations and interview with LPN Unit Manager staff #14, this Surveyor shared concerns of enteral feeding (Tube Feed) labeling, remaining fluid levels in the bottle, and the management of the feeding pumps. Staff #14 stated all Tube Feeds are held at 9a-1p. On 11/20/2025 11:00 AM a record review revealed the following enteral feeding orders: Enteral Feed every shift Nepro (or novasource renal if unavailable) via G-TUBE at 50 mls/hour x 20 hours/day to = 1000mls total infused. Up at 1pm; Down at 9AM or when total volume infused. AND every shift Administer H2O via g-tube/PEG at 75ml/hr times 20 hours for hydration for a total of 1500mls/day. Down when Water and Enteral feeding are infused. Enteral Feed Active10/23/2025 at 15:00. 3. On 11/24/2025 at 8:45 AM during follow-up observation of resident #87 and interview with RN Supervisor of Terrace Vent Room staff #6, this Surveyor observed the resident was connected to the enteral feed tubing and a bottle of Jevity 1.5 Cal with approximately 350mL left in bottle, labeled 'hung date: 11/23 and start time blank. At this time the Assistant DON staff #7 arrived on unit and were present during an interview with staff #6; when asked when the resident feed was completed, staff #6 stated about 8:20 AM. The Surveyor asked about the resident orders for the disconnect/down time for this resident; staff #6 stated down or when infused amount is reached. The Surveyor then asked why resident #87 was still connected to the turned off machine and concerns for resident dignity; Staff #6 stated I have not given my meds yet, I disconnect then. When asked, was this the typical policy; staff #6 stated, that's what is done, disconnect when meds is given, I do it all at the same time. The Surveyor then asked what time meds are due for this resident; staff #6 stated 10a or 9a. The Surveyor then asked will the resident remain connected to the line despite being complete; staff #6 stated, usually until meds are given. The Surveyor asked staff #6 if the Kangaroo OMNI pump was turned back on would it reveal tube feed completion information and infused amount; staff #6 stated, yes. This Surveyor, staff #6 and ADON staff #7 proceeded to Resident #87 bedside to review the last message on the pump, staff #6 turned the pump back on and it immediately revealed: 'FEED INCOMPLETE, Pump did not complete the specified feed; Feed Left: 530 mL; and Feed Volume: 1500mL. On 11/24/2025 at 9:07 AM during record review for Resident #87 it revealed the following orders: Enteral Feed every shift Jevity 1.5 (or IsoSource 1.5 is Jevity is unavaliable) via PEG at 75mL/hr x20hrs/day to = 1500mL total infused. UP @ 1PM, DOWN @ 9am or until TV is administered. Enteral Feed Active 8/13/2024 15:00. On 11/24/2025 at 10:59 AM during interview Nursing Home Administrator staff #1, Assistant DON staff #7 and DON staff #2, this Surveyor shared dignity and tube feed management concerns regarding Resident #87, resident remaining connected despite tube feed being off and feeding not fully administered based on last message of pump. This Surveyor asked if the expectation for residents to remain connected to feeding tube once the infusion is complete or during the downtime; they stated No.

Based on observations and interviews of facility staff it was determined the facility failed to ensure that a resident received appropriate supervision during care. This was found to be evident for 1 (Resident # 80) of 2 residents reviewed for accidents during the survey conducted at the facility.Findings include,Resident # 80 was admitted to the facility with the following but not limited diagnosis: Marfan Syndrome (Genetic Disorder that affects the body's connective tissue, which supports bones, muscles, blood vessels and other organs), and Anoxic Brain Damage.A medical record review was conducted on 11/21/25 at 11:03 AM and it revealed the resident had a fall on 8/22/25. Review of the facility's fall investigation revealed that the resident's assigned GNA stated that the resident rolled out of bed while she was cleaning the resident. Resident was assessed and did not have any injuries.On the same date the resident fall care plan was reviewed, and it revealed the resident had an actual fall and was at high risk for falls related to paralysis, immobility with spontaneous autonomic movement. Date initiated 5/25/20. Interventions include the following: Two person assist with transfer, repositioning per MDS/Care plan.An interview was conducted with the DON on 11/21/25 at 12:05 PM and she was asked to explain how the resident fell out of bed. The DON explained that the GNA pulled the resident towards her to reposition the resident to wipe the resident's back. The GNA then went to the other side and when she pulled the resident towards her the resident rolled onto the floor. The DON stated that the resident was known to have spontaneous movements. The surveyor asked the DON did the resident require the assistance of one or two staff and the DON stated that only one staff member was required at the time. The DON confirmed that the GNA provided care alone. The DON was made aware that of the resident fall care plan, and that the resident was a fall risk due to spontaneous movements and required 2-person assistance for bed transfers and repositioning, initiated 5/25/20. The DON stated that re-education will be provided for staff.All concerns were discussed with Administration during the exit conference on 11/24/25.

Based on observations and interviews, it was determined the facility failed to 1.) maintain up-to-date activity calendars in the residents' rooms; 2.) ensure the residents received activities that addressed the specific preferences and/or stimulation requested by family members of a dependent resident; and 3.) demonstrate that consistent activity services were provided and documented. This was evident for 3 (Residents #6, #101, and #1) residents out of 17 residents reviewed for Activities during the survey.The findings include:1. On 11/18/2025 at 8:21 AM, during the tour of the facility, the surveyor observed an outdated activities calendar in Resident #6's room. The calendar was from September 2025. On 11/19/2025 at 9:45 AM, during observation rounds, the surveyor observed an outdated activities calendar in Resident #6's room. The calendar was from September 2025. On 11/20/2025 at 8:41 AM, during observation rounds, the surveyor observed an outdated activities calendar in Resident #6's room. The calendar was from September 2025. On 11/20/2025 at 9:57 AM, the surveyor interviewed the Activities Director staff #4. During the interview, the surveyor made staff #4 aware that Resident #6's activity calendar was outdated. Staff #4 stated that she would update the resident's activity calendar. 2. On 11/18/2025 at 8:21 AM, during the tour of the facility, the surveyor observed an outdated activities calendar in Resident #101's room. The calendar was from October 2025. On 11/19/2025 at 9:48 AM, during observation rounds, the surveyor observed an outdated activities calendar in Resident #101's room. The calendar was from October 2025. On 11/20/2025 at 8:43 AM, during observation rounds, the surveyor observed an outdated activities calendar in Resident #101's room. The calendar was from October 2025. On 11/20/2025 at 9:57 AM, the surveyor interviewed the Activities Director staff #4. During the interview, the surveyor made staff #4 aware that Resident #101's activity calendar was outdated. Staff #4 stated that she would update the resident's activity calendar. 3. On 11/18/2025 08:29 AM the surveyor observed resident #1 in bed on the vent unit. The resident's Brief Interview for Mental Status assessment score was 15, which indicates intact cognition and was able to nod his/her head yes or no for simple questions. The surveyor observed an outdated activity calendar (October 2025) posted in the resident's room. On 11/19/2025 at 09:30 AM and 11/20/25 at 9:45 AM observations revealed the facility failed to display an up-to-date activities calendar on the resident's wall. On 11/21/2025 at 11:30 AM the facility provided an up-to-date activities calendar on the wall in the resident's room. The administrator provided copies of the once per week musical encounters 1 to 1 session during visits with the vent residents. The documentation regarding musical encounters did not specify which specific resident received the musical experience on a specific date and time or the response of the resident to musical activity. The concerns for activities were reviewed during the prior to and during the exit conference.

Based on medical record review and interview, the facility staff failed to thoroughly investigate a complaint of a neglect (Resident #35). This was evident for 1 out of 39 residents reviewed during a complaint survey. Findings include: Review of Resident #35's facility reported incident (MD 00190514) on 10/8/23 at 11:00 am revealed the resident's family made an allegation of neglect after the resident fell on the unit on 3/14/23 and sustained a fracture leg. The surveyor reviewed the facility investigation on 10/8/24 at 11:30am revealed that the facility failed to thoroughly investigate the events surrounding the allegation of neglect. The investigation contained information about the fall incident on 3/14/24. The facility investigation did not contain other resident interviews disproving widespread negligence from staff. Interview with the Director of Nursing on 10/8/24 at 2:00pm confirmed the facility investigation of Resident #35's did not contain resident interviews disproving widespread negligence from staff.

Based on medical record review, administrative record review, and staff interviews, it was determined that the facility failed to protect a cognitively impaired resident (Resident #362) from physical abuse from a facility staff member on 5/15/22. This was evident for 1 of 29 residents (Resident #362) reviewed for abuse during an annual recertification survey. Resident #362 sustained a fall during a physically abusive incident and suffered a fractured hip. Thereafter, Resident #362 never regained his/her ability to walk independently. This failure to protect residents from physical abuse by facility staff members resulted in an Immediate Jeopardy. However, the facility developed, initiated, and completed an acceptable plan of correction to prevent further abuse which met all elements of past noncompliance. The period of noncompliance began on 5/15/22 and ended on 6/22/22. The Findings Include: Minimum Data Set (MDS) is a comprehensive assessment of a resident completed by facility staff. The MDS is a multi-disciplinary tool that allows many facets of the resident's care (cognition, behavior, mobility, activities of daily living, accidents, activities, weight, pain, and medications to name a few) to be addressed. The MDS assessment is part of the broader Resident Assessment Instrument (RAI) process. The RAI process ties the assessment and care plan to the delivery of care to meet the needs of the resident. A care plan is a guide that addresses the unique needs of each resident. It is used to plan, assess, and evaluate the effectiveness of the resident's care. Brief Interview for Mental Status (BIMS) is an assessment that assists staff in evaluating a resident's cognitive status. A score of 13-15 implies cognitively intact status, 08-12 implies moderately impaired status, and 00-07 implies severe impairment status. A score of 99 indicates the facility attempted the assessment but the resident was unable to answer a sufficient number of questions to complete the assessment. Medical record review on 3/2/23 at 9:30 AM revealed Resident #362 was a long-term care resident admitted to the facility on [DATE] with significant comorbidities including a dementia related diagnosis. The resident was alert and oriented to self with a BIMS score of 99 documented in the quarterly MDS assessment dated [DATE]. Resident #362 was cognitively impaired and received extensive assistance with care. Medical record review and review of facility-reported incidents MD00178528 and MD00178603 and complaint MD00177160 on 3/2/23 at 10:00 AM revealed a hospital discharge report dated 5/31/22 which indicated Resident #362 was sent to the hospital on 5/16/22 and stayed until 5/31/22. Resident #362 went to the hospital for an X-ray to determine if the resident sustained a fracture from the fall on 5/15/22. The X-ray revealed the resident sustained a left hip fracture. Resident #362 underwent hip pinning surgery on 5/18/22 and required a 14-day hospital stay to treat after-surgery pain and be provided physical therapy. Resident #362 was unable to walk after sustaining the fall on 5/15/22. Additional medical record review on 3/6/23 at 8:30 AM revealed the MDS quarterly assessment dated [DATE] assessed Resident #362 as requiring supervision while ambulating on the unit or in his/her room. After the surgery to Resident #362's left hip, the MDS quarterly report dated 6/24/22 assessed the resident as being unable to walk on the unit and required a wheelchair to ambulate. On 3/7/23 at 12:59 PM, in an interview with the Director of Nursing (DON) and the Administrator regarding the abuse allegations against GNA #38, a contracted staff member, the DON revealed the facility substantiated abuse after viewing video surveillance of a 5/15/22 abuse incident involving Resident #362. The DON and the Administrator displayed the video surveillance of the 5/15/22 abuse incident for the survey team. Review of video surveillance revealed that on 5/15/22, GNA #38 walked toward Resident #362 in view of several other cognitively impaired residents and attempted to take plastic gloves from Resident #362's hands. Resident #362 moved away from GNA #38 as GNA#38 attempted to remove the plastic gloves from Resident #362's hands. GNA #38 then moved aggressively toward Resident #362, pushing and striking him/her repeatedly. Resident #362 tried to avoid GNA#38's punches by backing up toward a wall resulting in Resident #362 hitting a wall and falling on his/her left side. While Resident #362 fell on his/her left side, the jacket the resident was wearing fell from his/her shoulders. GNA#38 then continued to repeatedly strike Resident #362 while the resident fell . GNA #38 then picked up Resident #362's jacket, threw it at him/her, and then walked away from the incident location. None of the nursing staff were present in the hallway before, during or after the incident. In an interview after viewing the 5/15/22 abuse incident, the DON stated none of the unit's nursing staff witnessed the 5/15/22 abuse incident because they were providing resident care at the time of the incident. The DON also advised that the nursing unit was comprised of cognitively impaired residents and the residents did not remember the 5/15/22 abuse incident when facility staff members attempted to interview them. The DON also revealed the facility did not know the incident was an allegation of abuse until the video surveillance was retrieved on the morning of 5/16/22. The DON also stated the video quality was poor when the facility initially attempted to view the 5/15/22 abuse incident initially so the facility contacted the video vendor to provide a better quality of the video. The DON stated the facility was able to view the video surveillance, for the first time, on 5/17/22. The DON officially terminated GNA #38 from his/her contract on 5/17/22. The DON also stated GNA#38 last worked for the facility on 5/15/22, the date of the abuse incident. The DON stated that she received the information about the resident's left hip fracture on 5/18/22. The DON then called law enforcement to report the employee abuse and issued a complaint to the Maryland Board of Nursing on 5/19/22. The DON stated the resident was unable to walk independently after the 5/15/22 abuse incident. On 3/8/22 at 9:50 AM, in an interview with the DON and the Assistant Director of Nursing (ADON) regarding abuse training protocols before and after the 5/15/22 abuse incident, the DON stated the facility now requires agencies to provide proof of background checks, abuse training, and valid nursing license prior to the contracted nursing staff's first shift. The DON stated the facility changed their onboarding procedures for contracted nursing staff after the 5/15/22 incident. The facility also now requires new agency nursing staff to complete an orientation prior to their first shift. The orientation is performed by the DON, ADON or supervisor prior to the contracted employee's first shift. The DON also stated she performed an audit on the training received by current agency nursing staff and the abuse training provided by the agencies. The DON stated two agencies were unable to provide their abuse training materials for facility approval. The DON was able to approve two other agencies for facility use. These two agencies provided the facility with their training materials including abuse prohibition training. The DON reviewed the submitted training and approved the agencies' abuse training as adequate for potential future contracted staff. The DON also stated the facility no longer employs agency nursing staff for the cognitively impaired/memory care unit, which was the location of the 5/15/22 abuse incident. On 3/8/23 at 12:30 PM, in interview with the DON and the ADON regarding the orientation packet given to all agency nursing staff after the 5/15/22 abuse incident, the DON stated that all agency nursing staff are given the packet prior to their first shift at the facility. The DON was asked if the training materials contained abuse education and the DON stated that the training packet contained an abuse education review because all staff from facility contracted agencies had their abuse training reviewed and approved prior to the facility accepting the agency contract. The DON also stated after completion of the orientation, the contracted nursing staff member signs an acknowledgment form which the facility keeps for their records. The survey team reviewed and verified the abuse in-service training dated 5/15/22 through 5/19/22 for all staff including abuse training certificates for permanent staff dated throughout the month of February 2023 and acknowledgment forms for agency staff orientation from June 2022 to the present and new permanent staff abuse training certificates from July 2022 to February 2023. On 3/10/22 at 11:00 AM, the surveyor interviewed the DON and the Administrator regarding the training cycle for abuse prohibition. The DON stated permanent staff members have yearly training by March of each year. If there is an allegation of abuse, the facility provides in-service training for all staff including contracted staff members. New permanent staff members are required to complete abuse training prior to finishing their probation period and all new agency staff members have a review of abuse training prior to their first shift. On 3/17/22 at 7:30 PM, the survey team verified that after the resident abuse incident on 5/15/22, in-service education for abuse and neglect training for all staff members was completed by 5/19/22. By 5/19/22, the facility also completed an audit sweep of all residents which included skin assessments by nursing staff to assess for signs and symptoms of abuse including possible bruising, and resident interviews by social service staff to assess for any resident concerns related to possible abuse. In addition, the facility implemented a new process to validate that contracted nursing staff received education on abuse and neglect and instituted a policy to not allow contract nursing staff to work their first shift in the facility without verification of the abuse and neglect training. On 6/22/22, the facility gained access of abuse and neglect education verification from the last of the nursing agencies the facility utilized for contract staffing. However, the facility continued to staff from this agency after 5/19/22 and prior to obtaining the verification access on 6/22/22. The facility implemented a monitoring plan beginning 5/19/22 that included random checks by social services staff and nursing. These random checks were conducted at least weekly for four weeks and then continued monthly. The monthly checks were still in place at the open of the survey, and the facility DON was accountable for the monitoring portion of the facility correction plan. With a corrective action plan including monitoring fully in place prior to the survey open, the elements of past noncompliance were met. The past noncompliance for the immediate jeopardy began with an substantiated abuse incident that occurred on 5/15/22, and ended on 6/22/22 when the facility fully implemented the new policy to not allow contract staff to work on facility units without verification of abuse and neglect training.

Based on observation, medical record review, and interview with staff it was determined that the facility failed to ensure residents received treatment and care in accordance with professional standards of practice as evidenced by 1.) failure to follow physician orders for 1 of 8 (Resident #155) residents reviewed for pressure ulcers, and 2 of 10 (Resident #40 and #19) residents reviewed for physician orders; 2.) failure of the GNA to notify the nurse after a resident had a fall for 1 of 5 (Resident # 609) residents reviewed for falls; 3.) failure of the facility to ensure that a resident received treatment for a possible wound infection for Resident #359, and 4.) failure to administer a pain medication for Resident #87 as ordered by the physician. This was found to be evident during the facility's annual Medicare/medicaid survey. The findings include: 1. Failure to follow physician orders regarding pressure ulcer dressing change On 3/14/23 at 2:30 PM surveyor observed Registered Nurse (RN) #76 doing a dressing change to Resident #155's pressure ulcer. The RN explained to the surveyor that he was cleaning the wound with wound cleaner and then he applied Medi honey, a brand name wound and burn gel made from 100% Leptospermum (Manuka) honey. Manuka honey is unique in that it has antibacterial and bacterial resistant properties. Review of the physician orders dated 2/23/23 active order reveal the following: Cleanse posterior head wound with wound cleanser, apply hydrogel (a gel in which the liquid component is water) and dry dressing change daily. Further review of the medication administration record (MAR) was the order to cleanse posterior head wound with wound cleanser apply hydrogel and dry dressing, change daily one time a day. The treatment was signed off as being completed. On 3/14/23 at 2:40 pm RN 76 was interviewed about the current treatment order for hydrogel and not Medi honey, he replied I thought the order was for Medi honey, I'll remove it. During an interview with the Director of Nursing (DON) on 3/14/23 at 3:00 PM the surveyor informed her of the dressing change observation and what was used versus the physician order. The DON informed the surveyor that the resident was seen early this morning by the wound team and that the order would be changed tonight. The surveyor asked what the current dressing change order was and she replied the nurse should have applied hydrogel and not Medi honey since that was the current order. The DON, ADON and Corporate staff were made aware at that time of the staff failure to follow the physician order while doing a treatment. 45795 2. Failure of staff to follow physician orders to meet the resident needs. On 02/23/23 at 02:52 pm a tour of the Dementia Unit floor was conducted. An observation of Resident #40's room revealed Resident #40 sitting up in their bed. Surveyors noted on top of a bedside table a capped disposable Styrofoam cup, handwritten with 02/22/2023 and 11-7 am shift. Also noted was an uncapped straw inserted inside the cup. Further observation revealed two handwritten signs that indicated No Straws posted on the wall next and above the resident's headboard. When asked, Resident #40 indicated that it was their cup and that they had drank from it using the straw. The resident gestured to surveyors to come closer. When surveyor approached the opposite side of the bed, it was noted that a floormat laid between the resident's bedside table and the bed. The resident was asked if they could reach their cup and the resident shook their head and said No. A review of Resident #40's medical record was conducted on 02/24/23 at 08:30 am. The resident had diagnoses which included Dementia, Dysphagia, (difficulty in swallowing), and muscle weakness. Review of Resident #40's order summary sheet showed an order dated 2/17/20 that read; Liberalized Diabetic diet, Ground texture, thin liquids. Further review of the medical record revealed the February 2023 quarterly care plan assessment stated the resident was able to eat and drink with supervision and required physical assistant support from one person. Further review of the medical record found no documentation to support that the resident was required to have floor mats placed at bedside or was not to have the use of straws. On 2/24/2023 at 09:30 an observation of Resident #40 s room revealed that the handwritten signs were replaced with two typed signs that stated, NO STRAWS. Further observation found a capped disposable insulated cup with no straw with the handwritten date of 2/24/23. There was no floor mat noted. However, the bedside table holding the beverage cup was towards the head of the bed and the cup stood closer to the far end of the resident's nightstand table. Surveyor asked Resident #40 if s/he could reach their beverage, the resident looked back over their right shoulder and stated No. The resident stated that they were thirsty. One of the unit's nurses walking by in the hallway was alerted to the resident's need and they instructed staff to assist Resident #40 with their beverage. A review of Resident's 40's physician order sheet noted that the 02/17/2020 order was updated on 2/23/2023 to Liberal Diabetic diet, ground texture, thin liquid consistency, NO STRAWS. Further review found no documentation in the medication or treatment administration records that indicated the added instructions regarding the straws. During an interview conducted on 2/24/2023 at 2:30 pm, the DON was made aware of the observations conducted and asked what was their expectation of staff in providing individualized care to residents. The DON replied that it is expected that all personnel should read, review, and follow every resident care plan and assessment. A record review conducted on 02/27/2023 at 10:12 am revealed a Skilled Chart note dated 2/25/2023 that showed Resident #40 required extensive assistance with 1 person to provide physical support for eating and drinking. 42782 3. Failure to clarify a physician order for a resident receiving Ensure On 03/06/23 at 2:30 pm, A review of Resident #19's electronic medical record (EMR) revealed an order dated 02/28/23 at 4:12 pm was written for Ensure Plus three times a day. On 03/06/23 at 2:29 PM during an interview with LPN #19, he/she stated the resident receives nightly tube feeding and water flushes; the resident also eats by mouth. The Ensure supplement comes from dietary with Resident #19's meals. LPN #19 has cared for Resident #19 multiple times since he/she has been in that unit. After reviewing the order, LPN #19 confirmed the route in which the resident is supposed to receive the Ensure is missing and the staff review orders every 24 hours. On 03/06/23 at 2:56 pm during an interview with Unit Manager#13, she reported the shift nurses are supposed to check the chart and see if any new orders were taken off. The 11 pm - 7 am shift runs a 24-hour report. She does an order recap every morning Monday through Friday and on the weekend the supervisor does the order recap. Unit Manager #13 was shown the incomplete order written for Resident #19 Ensure. 30440 4. Failure of the GNA to notify the nurse after a resident had a fall Intake MD00184621 was reviewed on 3/15/23 at 10:00 AM for multiple concerns. One of the concerns was an allegation of abuse in which the family reported Resident #609 was pushed from the wheelchair by a staff member. Further review of the facility's investigation of the fall on 3/15/23 at 12:00 PM revealed the resident had a fall on 10/12/22 while being transported by the GNA #89. The resident abruptly stood up while being pushed in the wheelchair and the resident foot was caught, causing the resident to fall forward. The resident sustained a hematoma to the forehead. The resident was assisted into bed by GNA #89 and a housekeeper staff. According to the facility investigation, the nurse was not notified after the resident fell . An interview was conducted with the Director of Nursing (DON) on 3/15/23 at 1:20 PM and she stated that the GNA #89 was suspended and then subsequently terminated for not notifying the nurse after the resident fell which delayed the resident assessment by the nurse. The DON went on to say that the GNA was terminated for putting the resident into bed after a fall and not reporting the fall to the nurse. She stated that GNA #89 did not follow the facility policy. All concerns were discussed with the Administration team at the time of exit on 3/21/23 at 7:45 PM. 42886 5. Failure to ensure that a resident received treatment for a possible wound infection On 03/17/23 at 09:48 AM, the surveyor reviewed a complaint MD00168833 which alleged the facility delayed sending the resident out for emergency treatment for pressure ulcers. Review of medical record at 3/17/23 at 10:00 AM revealed the resident was admitted to the facility on [DATE] for care after a stroke (muscle weakness to one side of the body). Review of labs from June 2021 revealed the facility conducted lab blood tests 6/3/21, 6/5/21, 6/8/21, and 6/10/21 which revealed Resident #359 had increased white blood cells (WBC) levels. Review of skin notes from 6/2/21, 6/9/21, and 6/16/21 revealed no mention of infections. Review of wound notes from 6/2/21, 6/9/21, and 6/16/21 revealed Resident #359 was being treated for several pressure wounds, including a left foot wound, and none of the notes revealed any mention of wound infection. Additional review of medical records at 3/17/23 at 11:00 AM revealed a discharge summary dated 6/27/21 which revealed Resident #359 was admitted to the hospital from 6/18/21 to 6/28/21 for difficulty in breathing. The hospital diagnosed Resident #359 with an overall systemic infection (sepsis) due to the infection of a left foot wound. Emergency treatment was required including IV antibiotics to treat the overall systemic infection. On 3/20/23 at 11:00 AM, the surveyor expressed concerns to the Assistant Director of Nursing (ADON). 21859 6. Failure to administer a pain medication for a resident as ordered by the physician. Review of the medical record revealed Resident #87 was a resident whose diagnoses included falls with multiple fractures. The resident was cognitively impaired and was totally dependent on staff for care. On 02/21/23 at 8:25 AM Resident #87 was observed with two white pills sitting in a medication cup on his/her bed side table. The Nurse Manager #49 verified the findings before removing the pills. During follow-up interview with Nurse Manager #49 on 2/21/23 at 10 am she stated, the medication was Acetaminophen (Tylenol), and the resident was scheduled to receive it at 6 am on 2/21/23. Review of Resident # 87 MAR (Medication Administration record) for 2/21/23 at 11 am revealed the Acetaminophen (Tylenol) was signed off as being administered at 6 am.

Based on observation, record review, and staff interview it was determined that the facility staff failed to store, prepare, and serve food and beverages using proper sanitary practices. This deficient practice has the potential to affect all residents in the facility. Findings include: An initial tour of the facility's kitchen was conducted on [DATE] at 08:15 am with the Dietary Manager (DM) #27 present. After surveyors sanitized hands and donned hairnets. Dietary Aid (DA) #34 entered the kitchen, passed surveyors and DM #27, opened, and entered a storage refrigerator without sanitizing their hands. The DM #27 was alerted to the observation and asked what was the expectation of staff entering into the kitchen. The DM #27 replied that it was expected that all personnel sanitize their hands before entering any area of the kitchen, including the refrigerator. Observation of the storage refrigerator found and undated, opened partially exposed package of shelved cheese. Observation of the food preparation area revealed several storage racks with opened spices, seasonings food [NAME], and condiments with inconsistent and undated label and shelving dates. Four items were labeled with expired dates from 2022. Two items were labeled expired [DATE]. The DM #27 stated that upon arrival to the facility, all food items are dated as received. The items are dated when opened and placed on shelves for use in the kitchen. S/he added that all items were listed with specific used by dates but when asked to show us for review, the DM #27 stated they were not readily available for reference. Observation of the kitchen equipment storage area noted a meat slicer covered with a white clear wrap. When the cover was lifted, surveyor observed multiple dried pieces of residual meat on the blade, handle, slicer, and tabletop. When asked, the DM #27 stated the slicer was not in use that morning. At the beverage dispenser area, surveyor observed the dispensing tubing laying on the floor, with dried white, red, and orange tanned residue on and around them. The floor that surrounded the dispensing area was noted with multiple-colored dark stains, debris, and crumbs. Two of the juice base boxes failed to be dated with an opened or expiration date. Observation of the dry storage area surveyors found on the floor in the far left-hand corner several racks of bagged, sliced bread and hot dog buns. Further observation of the first three shelves surveyors observed on various portions of the bread loaves and hot dog buns a green, white, furry mold were visible through the wrappers. Observation of all bread loaves revealed none were labeled with an expiration date. The DM #27 stated that some of the shelved breads was previously frozen and bought to this area for thawing. Observation of the right front side of the storage area revealed three storage bins sitting directly on the floor. Two bins one labeled flour the other corn, were noted with cracked, warped, and poor fitted lids. All three containers were noted with dark scratches and stains. At 08:33 am surveyors observed the facility residents' breakfast service line. During the observation, surveyors noted multiple reusable cups with contents later identified by DM #27 of cranberry, orange and apple juices sat on a multiple tiered railed cart in the absence of ice. Observation of a beverage chest on the opposite side of the service tray line that contained several milk and supplement drink cartons remained opened during the service. Surveyors watched as the service line staff pulled the juice cups, milk, and supplement cartons to place on resident's trays for distribution to the units. The DM #27 was alerted to observation and a temperature of selected containers and reusable cups was taken and recorded. The temperature of the milk in cartons were found to be 42.8 degrees Fahrenheit. The temperature of the orange juice, was 62.6 Fahrenheit , and a cranberry juice was noted at 60.7 Fahrenheit. At 08:43 am, surveyors observed as staff #34 retrieved the remaining juice containers and cups from the service area and placed them into the storage refrigerator. An observation of the kitchen staff's food line tray service and distribution was conducted on [DATE] at 12:30 pm accompanied by the facility's DM#27. At 12:33 pm, Staff #34 walked into kitchen, to the food distribution area, retrieved a pushcart with a food tray and attempted to head to the facility's ventilator unit to deliver the tray to a resident without washing their hands. During an observation of the tray service line at 12:42 pm. Surveyor observed staff #35 retrieve a plate of food from staff #36 observed with the top of their face mask worn on their upper lip. Staff #35 placed the plate on the tray, readjusted their mask on their face with their hand, placed a cup of juice on the tray, pushed it down towards the next person on tray line, grabbed an empty tray and retrieved another resident's plate of food from staff #36. The DM #27 standing next to them was immediately alerted to the observation. Surveyors watched as staff #36 continued to have their mask fall off their nose, without any self-correction or acknowledgement from the kitchen staff. At 12:50 pm, surveyor observed Cook #37 prepare mashed potatoes to replenish the food service line. Without any measuring utensils, the cook #37 poured powdered potatoes into a bowl, shook an unmeasured amount of salt, and another seasoning container, poured liquid out of a pot on the stove, which was later identified as melted butter, was mixed and presented to the tray line for service to the residents. Cook #37 was interviewed and when asked if she followed a recipe, the cook replied that they held many years of experience and knew how the residents liked their food prepared. The DM #27 approached, informed of the observations, and asked to submit the recipe for the mashed potatoes for review. On [DATE] at 9:45 am, an interview and record review of the submitted mashed potatoes recipe by the DM #27 was conducted with surveyor team. A review of the submitted recipe for the mashed potatoes failed to show that salt, seasoning, or butter was included in the recipe. During the interview, the DM #27 responded that s/he allowed additions/changes to recipe to please the residents.