Every finding on record at Resorts of Augsburg

Based on record review and interviews, the facility failed to timely implement treatment recommendations for wound management and apply pressure-relieving devices as ordered. This was evident for 3 (Resident #11, #18, and #7) of 3 residents reviewed for wounds during the complaint survey. The findings include:According to the Centers for Disease Control (CDC), pressure ulcers (bed sores, pressure sores, or decubitus ulcers) are wounds from unrelieved pressure on the skin, per the CDC. They are staged by severity: Stage 1 is persistent skin redness; Stage 2 is partial thickness loss (abrasion, blister, shallow crater); Stage 3 is full thickness loss exposing subcutaneous tissue (deep crater); and Stage 4 is full thickness loss exposing muscle or bone. An unstageable ulcer involves full-thickness skin and tissue loss where the extent of damage is obscured by slough or eschar.According to SOM Appendix PP, standard pressure ulcer care requires weekly assessments documenting location, measurement, stage, and characteristics to track healing and treatment effectiveness. Wounds may be colonized (micro-organisms present without signs of infection) or infected (micro-organisms overwhelm tissue defenses, causing symptoms). Signs of infection include increased or changed exudate, decolorization and friability of granulation tissue, undermining, abnormal odor, epithelial bridging at the wound base, or sudden pain. If no progress is evident within 2-4 weeks, the ulcer, complications, and resident's clinical condition must be reassessed to modify or continue interventions. Although clinical complexity can limit treatment responsiveness, clinicians retaining an unchanged regimen despite a lack of healing must document their rationale.1) On 07/21/2026 at approximately 9:05 AM in review of Intake #3030286 noted a concern of wound management and infection.On 07/21/2026 at 12:09 PM, a review of Resident #11's re-admission assessment from the hospital, completed on 02/25/2026 at 6:05 PM, (Section 11-Skin) noted a sacrum pressure ulcer, but no further assessment indicated its measurement, stage, and characteristics.On 07/22/2026 at 8:40 AM, a review of Resident #11's care plan (initiated 03/13/2025, revised 05/22/2026) showed sacral skin breakdown and risk for complications. The infection-free goal (revised 05/21/2026) targeted 06/08/2026. 03/13/2025 interventions included ordered analgesia/treatments, an anti-pressure mattress, a wound vac, turning/repositioning, diet/supplements, and labs. Subsequent interventions added a PT evaluation (05/20/2026) and infection monitoring (03/31/2026). However, the care plan was not updated as it still reflected a wound vac from March 2025.On 07/21/2026 at 12:23 PM, a review of Resident #11's wound evaluation notes revealed the following: -Wound Consult (02/26/2026): Sacrum pressure injury, Stage 4. Measurements note a 1.8 x 1.8 x 3.0 dimension (area: 3.24). Tissue composition consists of 80% granulation and 20% slough, presenting with moderate, serosanguineous exudate. Further documentation included risk factors and comorbidities of morbid obesity, a history of healed stage 3 or 4 pressure injuries, depression, diabetes, sensory neuropathy, atrial fibrillation, and congestive heart failure. Which stated the factors could exacerbate the worsening of the pressure injury and included a goal of prevention of the wound decline.-Wound Consult (03/26/2026) indicated signs of infection (foul odor, pain) and ordered a daily dressing change (collagen, calcium alginate, superabsorbent pad). The sacrum wound description noted moderate serosanguineous exudate, 20% slough, 80% granulation, and increased measurements: L 3.2, W 2.0, Depth 3.0 (Area 6.40). Ciprofloxacin 500 mg PO for 7 days was started on 03/26/2026. However, there was no culture to indicate Ciprofloxacin would be sensitive( the specific bacteria causing your infection can be easily killed or stopped by that antibiotic) to the wound infection. Further review of Resident #11's medical record lacked evidence the Primary care physician was notified of the start of the Ciprofloxacin for wound infection. A review of the March and April 2026 medication and treatment administration records revealed that both the ciprofloxacin and the new wound treatment were delayed by 7 days, not starting until 04/02/2026.-Wound consult (04/02/2026): 7 days post-antibiotic delay and treatment change indicated sacral wound infection with significant foul odor, pain, and inflammation. Description: moderate serosanguineous exudate, moderate odor, and macerated/scarred edges. Tissue: 40% slough, 60% granulation. Size: L 2.8 cm, W 2.0 cm, depth 3.0 cm, and area 5.60 cm^2.-A wound consult (04/09/2026) recommended changing Resident #11's sacrum treatment to daily and as-needed honey on cut-to-fit calcium alginate, covered with bordered gauze. However, the primary nurse practitioner's (NP) progress note from 04/08/2026 indicated continuing Santyl, while the April 2026 TAR showed no treatment change to Santyl on 04/08/2026, the treatment remained in April of honey on cut-to-fit calcium alginate.-Wound consult (04/30/2026) showed increased size and tunneling (3.1 cm at 6 o'clock; L 2.9 cm, W 2.0 cm, depth unable to determine with 4/10 pain). Periwound/Edge: Unstable, macerated, erythematous, calloused. Exudate: Moderate, serous, yellow, serosanguineous. Bed: Full thickness, biofilm, bioburden, 70% slough, 30% granulation.-Wound consult (05/07/2026): 4 weeks after a recommended treatment change, Resident #11's sacrum wound increased to L 3.5 cm, W 3.5 cm, and depth 3.0 (area 12.25, up from 5.80 last week). Exudate is copious, cloudy, and serosanguineous. Tissue composition is 60% slough and 40% granulation. Plan: Apply honey on calcium alginate to the wound bed and bordered gauze daily. However, despite the lack of healing, there was no documented rationale for retaining the current treatment regimen. On 07/21/2026 at 1:00 PM, a review of Resident #11's Attending Nurse Practitioner (NP) progress notes dated 05/07/2026 showed a worsening sacral wound with copious, cloudy drainage on 05/07/2026, alongside an elevated WBC of 12.2. On 07/21/2026 at approximately 1:03 PM, a review of Resident #11's attending nurse practitioner (NP) progress note dated 05/08/2026 showed an increased WBC of 15.4, prompting a 7-day oral doxycycline course for a suspected wound infection and continued Santyl ointment. No wound culture was in the record to confirm antibiotic sensitivity. Additionally, the May 2026 TAR omitted the Santyl treatment, instead specifying daily and as-needed cleansing of a stage 4 sacral pressure ulcer and applying honey on calcium alginate covered by bordered gauze.On 07/21/2026 at approximately 1:10 PM, a review of Resident #11's dietary progress note dated 05/12/2026 revealed a recommendation for vitamin C and zinc for 2 weeks due to increased wound size. However, a review of the May 2026 medication administration record (MAR) showed no implementation of either medication, and there was no documentation indicating the recommendation was communicated to the physician.On 07/21/2026 at approximately 12:35 PM, a review of Resident #11's wound physician note dated 05/21/2026 (6 weeks post-treatment change) documented continued sacrum wound tunneling (3.4 cm at 12 o'clock). The resident reported 4/10 pain, with no odor noted. The wound description remained: Periwound: Erythematous, unstable moisture-associated skin damage. Edge: Erythematous, macerated, undermined pockets; Exudate: Moderate, serous, yellow, serosanguineous; Tissue: 60% slough, 40% granulation. However, despite the lack of healing, there was no documented rationale for retaining the current treatment regimen.On 07/21/2026 at approximately 12:40 PM, a review of Resident #11's nurse practitioner progress note dated 05/26/2026 revealed Resident #11 had nausea and 3 vomiting episodes yesterday; given Zofran x1. Completed a 7-day course of doxycycline 10 days ago for a sacral wound infection. Labs showed worsening leukocytosis with WBC at 31.1, up from 13.6 on 05/22/2026. Resident #11 was sent to the hospital and admitted .On 07/24/2026 at 9:26 AM, during an interview, the facility's current nurse practitioner wound consultant stated that wound infections are identified by drainage, purulent drainage, odor, necrotic tissue, and increased pain. Once identified, she cultures the wound before starting antibiotics to ensure bacterial sensitivity, though broad-spectrum options can be used initially while awaiting results. Delaying antibiotic treatment causes wound deterioration which requires close monitoring, and an ineffective two-month course can lead to sepsis. Regarding comorbidities, she noted that residents with infections can still achieve successful wound healing, though those in late-stage disease progression are less likely to respond.On 07/22/2026 at 11:38 AM, during an interview, the Director of Nursing (DON) stated that a nurse assists twice weekly, conducting wound rounds with the wound physician on Thursdays and completing documentation on Fridays. Wound physician recommendations are documented in progress notes and require approval from the primary care physician. The DON expects any recommended treatment changes or antibiotics from a wound consult to be updated in real time. Additionally, dietician recommendations are expected to be implemented, which the facility reviews daily via progress notes or is discussed at weekly risk meetings. 2a) On 07/23/2026 at 9:22 AM, in review of Resident #18's medical record revealed a physician order dated 06/26/2026 for moon boots while in bed every shift.On 07/23/2026 at 9:20 AM, during an observation Resident #18 was laying flat on his/her back in bed, with moon boots on a windowsill on top of the air conditioner.On 07/23/2026 at 10:03 AM, during an interview with Staff #9 Registered Nurse (RN) explained moon boots are to be on while in bed per the direction of the treatment administration record (TAR). Staff #9 confirmed the boots were not on Resident #18 and applied them in the surveyor's presence.On 07/23/2026 at 2:59 PM, during an interview with the Director of Nursing (DON) stated that if a physician orders moon boots, she would expect the resident to have them on in bed for wound prevention. 2b) On 07/23/2026 at 10:29 AM, during an observation, Resident #7 was lying in bed with an air mattress that appeared non-functional, as its settings indicated no lights were on and Resident #7 appeared sunk in the bed.On 07/23/2026 at 10:36 AM, during an observation/interview, Staff #10, Licensed Practical Nurse (LPN), accompanied the surveyor to Resident #7's room, verifying the air mattress pump was not functioning. Staff #10 noted the air mattress was not plugged into the wall. Staff #10 plugged it in, causing it to inflate, and stated he had been in the room [ROOM NUMBER] minutes prior without noticing it was not functioning.On 07/23/2026 at 11:21 AM, a review of Resident #7's care plan revealed an alteration in skin integrity due to pressure ulcers/wounds on the sacrum, left and right heels, right first toe, left great toe, left lower buttocks, and right buttock excoriation, placing Resident #7 at risk for complications (Initiated: 07/03/2026; Revised: 07/09/2026). The plan included an intervention for an anti-pressure mattress to maintain skin integrity (Initiated: 07/03/2026; Revised: 07/03/2026). However, a further review of the medical record showed no evidence of how the air mattress's functioning would be monitored.On 07/24/2026 at 11:53 AM, during an interview, the Director of Nursing (DON) stated the facility had no documented process for staff to monitor air mattress functionality, though nurses and GNAs are expected to check them during general rounds. On 07/23/2026 at 11:31 AM, a review of Resident #7's wound consults showed that recommendations from 07/09/2026, 07/13/2026, and 07/20/2026 advised changing the right buttock wound treatment to twice-daily cleansing, silver alginate packing (including undermining), and a bordered foam dressing. However, further review of Resident #7's July 2026 treatment administration record (TAR) showed only a 07/03/2026 order for daily cleansing with Vashe, calcium alginate, and a foam dressing-to the right buttocks wound. There was no evidence that treatment recommendations from 07/09/2026, 07/13/2026, and 07/20/2026 had been addressed or implemented. On 07/22/2026 at 11:38 AM, during an interview, the Director of Nursing (DON) stated that a nurse assists twice weekly, conducting wound rounds with the wound physician on Thursdays and completing documentation on Fridays. Wound physician recommendations are documented in progress notes and require approval from the primary care physician. The DON expects any recommended treatment changes from a wound consult to be updated in real time.

Based on record review and staff interviews, it was determined that the facility failed to provide appropriate pain management that included documentation of non-pharmacological interventions. This was evident for 3 (Resident #7, #9, and #10) out of 3 residents reviewed for pain during the complaint survey. The findings include:Non-pharmacological interventions are methods that manage or reduce pain without the use of pain medication. On 07/21/2026 at approximately 8:00 AM, a review of Intake #3036883, there was a noted concern related to pain management.On 07/21/2026 at approximately 8:15 AM, a review of Intake # 3054032 noted concerns related to an occurrence causing a fracture.1) On 07/23/2026 at 2:11 PM, a review of Resident #7's medication administration record (MAR) for July 2026 revealed that oxycodone 10 MG (ordered 07/03/2026, 1 tablet by mouth every 8 hours as needed for pain) was administered 14 times. A separate order from 07/03/2026 required documenting non-pharmacological interventions before PRN administration using a 1-10 code key (1. Redirection, 2. Distraction, 3. Reposition, 4. Toilet, 5. Give food/beverage, 6. Activity, 7. Deep Breathing, 8. Close Monitoring, 9. Adjust environmental stimuli. 10. Refer to the nurse's note. However, there was no documentation indicating that non-pharmacological interventions were attempted prior to any of the 14 oxycodone administrations.On 07/23/2026 at approximately 2:15 PM, further review of Resident #7's pain care plan showed no evidence of non-pharmacological interventions prior to administering as-needed pain medication.2) On 07/22/2026 at 3:26 PM, a review of Resident #9's medication administration record (MAR) revealed a physician order dated 11/05/2025 for Oxycodone 5 MG (1 tablet via G-tube every 6 hours as needed for moderate to severe pain, score 7-10). A separate order required that non-pharmacological interventions be attempted and documented prior to administering PRN medications, utilizing specific code numbers: 1. Redirection, 2. Distraction, 3. Reposition, 4. Toilet, 5. Give food/beverage. 6. Activity, 7. Deep Breathing, 8. Close Monitoring, 9. Adjust environmental stimuli, and 10. Refer to the nurse's note. However, further review of the MAR showed that oxycodone was administered 17 times in January 2026 and 2 times in February 2026, with no documentation indicating that any non-pharmacological interventions were attempted prior to any of these 19 administrations.On 07/23/2026 at approximately 3:45 PM, continued review of Resident #9's pain care plan showed no evidence of non-pharmacological interventions prior to administering as-needed pain medication. 3) On 07/24/2026 at 9:13 AM, a review of Resident #10's April 2026 medication administration record (MAR) revealed a physician order for Tramadol HCl Oral Tablet 50 MG (1 tablet by mouth every 12 hours as needed for pain management). While the medication was administered 12 times, the resident's medical record contained no documentation indicating that non-pharmacological interventions were attempted prior to any of these administrations.On 07/24/2026 at approximately 9:15 AM, further review of Resident #10's pain care plan showed no evidence of non-pharmacological interventions prior to administering as-needed pain medication.On 07/23/2026 at 3:15 PM, during an interview, the Director of Nursing (DON) explained that if a resident has as-needed pain medication, non-pharmacological interventions are documented on the medication administration record and included in the pain care plan. The concern was shared with the DON at this time.

Based on record review and interviews, it was determined that the facility failed to accurately reflect Resident #8's preferred language. This was evident for one resident (Resident #8) out of three residents reviewed for discharge. The findings include:On 7/23/26 at 1:45 PM while investigating complaint #3093656, the surveyor reviewed Resident #8's medical records. The review revealed that Resident #8 was admitted to the facility on [DATE]th, 2024 and had a past medical history of, but not limited to, systolic heart failure, vascular dementia, diabetes and atrial fibrillation.Further review of Resident #8's medical records revealed that Resident #8 was care planned for difficulty communicating related to lack/limited user/understanding of English. This care plan focus was initiated on 5/20/2024 and interventions documented on the care plan included: . communicate using yes/no questions and responses when able, teach to use communication book/board/electronic device, utilize interpreter for native language as needed, when talking to patient, use gestures and simple sentences. Additionally, in the facility's electronic medical record (EMR), Resident #8's insurance profile that provides demographic information about the resident noted Resident #8's primary language as Korean.On 7/23/26 at 3:10 PM, the surveyor reviewed Resident #8's Minimum Data Set (MDS) assessment. The quarterly assessment completed in May of 2026, in section A (identification information) documented Resident #8 with the preferred language of English (A1110).During an interview on 7/24/26 at 12:30 PM, GNA #16 (Geriatric Nursing Aide) stated, [Resident #8] was in room [number]. No, he/she did not speak English.During an interview on 7/24/26 at 2:20 PM, MDS Coordinator #18 stated, . When doing the MDS assessments regarding language preference, typically we base it off of the Social Work assessment.During an interview on 7/25/26 at 12:25 PM, LPN # 17 (Licensed Practical Nurse) stated, [Resident #8]. he/she did not speak English. not at all.A review of the [hospital] records for the 6/19/2026 hospitalization by the surveyor revealed multiple notes containing the statement, . [AGE] year old Korean- speaking male/female with a diagnosis of dementia.The facility inaccurately documented Resident #8's preferred language in the recent quarterly MDS assessment.

Based on record reviews and interviews, the facility failed to accommodate resident's preference. This was evident for 2 (Resident #21 and #16) of 3 residents reviewed for preferences during the complaint survey. The findings include: 1)While investigating complaints #3026105 and #3091620, a tour of the facility on 7/22/26 at 11:10 AM resulted in an observation of the call light screen in the hallway of the first floor nursing unit with a call light summons that was timed at 13 minutes 23 seconds. Observation of this hallway call light screen lasted until the call light was answered and turned off at 18 minutes 15 seconds. During an interview on 7/22/26 at 11:30 AM, Geriatric Nursing Assistant (GNA #19) stated that he/she was with another resident getting them out of bed with a hoyer lift (a specialized mechanical patient hoist used by caregivers to move individuals with limited mobility between a bed, wheelchair or bathroom) . He/she explained that was the reason for the delay in answering the call light. GNA#19 stated, All six of my residents require hoyer lift transfers, it takes all morning to get them up and out of bed. During an interview on 7/22/26 at 11:35 AM, Resident #21 stated, I rang my light because I want to get out of bed to my wheelchair. It takes a long time for them [the staff] to answer. I often don't get up until lunchtime. I like to get up earlier than that. 2) Activities of Daily Living (ADLs) is a term used collectively to describe fundamental skills required to independently care for oneself, such as eating, bathing, toileting, transferring, and mobility. On 07/21/2026 at approximately 8:00 AM, in review of Intake #3036883, there were noted concerns related to being entirely dependent on staff for mobility and having been left in bed by the geriatric nursing assistant (GNA), causing them to miss a favorite activity. There were other times of being left in common areas from lunchtime until 9:00 p.m. or 10:00 p.m. On 07/21/2026 at approximately 8:05 AM, a review of Intake #3030934 noted a concern related to a resident being dependent on staff for mobility/transfers being left up in a wheelchair for up to 10-12 hours. On 07/23/2026 at 8:56 AM, during an interview with Resident #16, who is dependent and requires a Hoyer lift for transfers, expressed a concern of being left up in the chair for extended periods of time. Resident #16 stated that after staff gets him/her up in the morning, they are often not put back to bed until around 4:00 PM after the next shift arrives. On 07/24/2026 at 8:42 AM, a review of Resident #16's care plan, initiated and revised on 06/18/2026, revealed an ADL deficit from generalized weakness requiring assistance with an intervention that included a Hoyer lift for transfers. However, further review of Resident #16's medical record lacked evidence of the resident's preference regarding the duration of being out of bed in a chair. On 07/23/2026 at 9:07 AM, during an interview, Staff #7 Geriatric Nursing Assistant (GNA) expressed staffing concerns, noting that when staff don't show up, this delays providing care to residents. They noted that short staffing causes delays for residents requiring a Hoyer lift, which demands two staff members. On 07/23/2026 at 1:13 PM, Staff #11 Geriatric Nursing Assistant (GNA) expressed staffing challenges, noting that care is delayed because they are attending to other residents. On 07/24/2026 at 11:49 AM, during an interview with the Director of Nursing (DON), it was stated that a resident's preference regarding their time out of bed would be documented in their care plan. The DON noted it could specify details such as a preference to get up before breakfast but return to bed before or after lunch. At this time the concern was shared with the DON.

Based on facility document review, record review, and interview, it was determined the facility failed to develop a comprehensive plan of care for a resident with known contractures. This was evident for 1 (Resident #9) of 3 residents reviewed for care plans during the complaint survey. The findings include: The Minimum Data Set (MDS) is a comprehensive resident assessment that provides facilities with the information necessary to develop, deliver, and modify care plans based on a resident's status. A care plan serves as a guide to address unique needs, allowing facilities to plan, assess, and evaluate the effectiveness of the resident's care.According to the University of Pittsburgh, a bilateral upper muscle contracture is a permanent, severe tightening and shortening of muscles, tendons, or soft tissues from scarring, fibrosis, or stiffness. This condition reduces range of motion, fixes joint or limb positioning, and may cause chronic pain, locking the arm in a bent position and restricting the ability to straighten the shoulders and elbows normally.On 07/21/2026 at approximately 8:15 AM, a review of Intake # 3054032 noted concerns about a fracture caused by not following an individualized care plan.On 7/22/2026 at 2:16 PM, a review of Resident #9's progress note dated 12/30/2025 at 3:35 PM revealed a pop sound was reported from the right arm during a midline insertion by the Advanced PICC Specialists (APS) nurse. Resident #9 reported 7/10 right arm pain, was medicated for pain, and had a STAT x-ray ordered. On 07/22/2026 at 2:55 PM, a review of the facility's investigation notes dated 12/31/2025 at 1:15 PM revealed that an APS nurse arrived for Resident #9's scheduled midline catheter placement (a soft, 8 to 20 cm long plastic tube inserted into a large vein in the upper arm). While using a vein finder, the APS nurse moved the resident's contracted right arm, and a pop was heard.On 7/24/2026 at 4:00 PM, a review of Resident #9's 12/31/2025 radiology report (exam 11:55 AM, reported 12:14 PM) for right elbow and shoulder x-rays revealed an acute right distal humeral fracture (recent fracture at the lower end of the upper arm bone near the elbow). The right shoulder study was limited due to positioning difficulties, but the distal humerus fracture was noted.On 7/22/2026 at 2:15 PM, a review of Resident #9's diagnosis list included bilateral upper arm muscle contractures. On 07/22/2026 at approximately 2:18 PM, a review of Resident #9's Quarterly MDS (12/22/2025) revealed that under Section GG0115 (Functional Limitation in Range of Motion), 2. Impairments on both sides was selected for Section A, Upper extremity (shoulder, elbow, wrist, and hand).On 07/23/2026 at approximately 3:45 PM, a review of Resident #9's plan of care revealed no evidence of a comprehensive plan of care addressing the interventions, precautions, or care instructions for Resident #9's bilateral upper arm muscle contractures.On 07/29/2026 at 11:00 AM, a review of the occupational Discharge summary dated from 05/05/2025 through 07/30/2025 revealed Resident #9 presented with low tolerance during range in motion (ROM) and stretching tasks and demonstrated 70 degrees of right elbow extension. Further review indicated therapy discharged the resident on 07/30/2026 with staff educated to use a rolled blanket as a mechanical block, however the medical record lacked evidence of implementation.On 07/24/2026 at approximately 3:45 PM, an interview with Staff #15, Certified Occupational Therapy Assistant (COTA), indicated that he was familiar with Resident #9, and therapy was unable to perform minimal stretching on the contracted right arm because Resident #9 could not tolerate it well.On 07/22/2026 at approximately 2:20 PM, a review of Resident #9's progress notes revealed a Nurse Practitioner Note dated 12/31/2025 at 11:15 PM, a follow-up regarding an emergency room (ER) transfer for an urgent orthopedic evaluation of a right distal humeral fracture. Facility imaging on 12/31/2025 showed an acute fracture, prompting the ER transfer, where imaging confirmed an oblique fracture of the distal right humerus with anterior angulation of the distal fragment. Orthopedics evaluated Resident #9 and recommended a posterior splint due to minimal range of motion in the right upper extremity secondary to contractures. However, further review of Resident #9's plan of care lacked evidence of the posterior splint intervention. On 07/24/2026 at 11:33 AM, during an interview with the Director of Nursing (DON), it was confirmed that a resident with a contracture requires a related plan of care. The DON acknowledged the concern related to Resident #9.

Based on record review and interviews, it was determined the facility failed to provide ADL care related to urine incontinence timely to a dependent resident. This was evident for 1 (Resident #16) of 3 residents reviewed for Activities of Daily Living during the complaint survey.The findings include:Activities of Daily Living (ADLs) is a term used collectively to describe fundamental skills required to independently care for oneself, such as eating, bathing, toileting, transferring, and mobility. The Minimum Data Set (MDS) is a required assessment for all residents in Medicare- or Medicaid-certified nursing homes. It evaluates each resident's health and functional status to help staff identify issues and determine resident care decisions. Assessments are conducted at admission, at regular intervals, and at discharge following set guidelines.On 07/21/2026 at approximately 8:00 AM, in review of Intake #3036883, there were noted concerns related to inadequate and delayed incontinence care. On 07/23/2026 at 8:56 AM, during an interview, Resident #16 voiced concerns related to timely incontinence care, waiting up to 4 hours or more to be changed; he/she was changed this morning, but the last time prior was just prior to going to bed the night before.On 07/24/2026 at 8:49 AM, review of the MDS admission dated 06/24/2026 revealed Section GG Self-care for toileting hygiene (maintaining perineal hygiene, adjusting clothes) was marked as 1. Dependent-Helper does ALL of the effort.On 07/24/2026 at 8:42 AM, during a review of Resident #16's care plan, total bowel and bladder incontinence was revealed due to decreased mobility (initiated/revised on 06/18/2026). The care plan specified providing incontinence care on rounds and as needed, thoroughly washing and drying skin, and changing clothes as needed (initiated 06/18/2026).On 07/24/2026 at 8:39 AM, in review of Resident #16's medical record task section for the documented ADL care section for bladder activity, a lapse in care documentation was shown. The last recorded instance of incontinence care was dated 07/22/2026 at 12:35 PM, noting the resident was incontinent of the bladder. This indicated no incontinence care for Resident #16 was provided, exceeding multiple hours of receiving no incontinence care.On 07/23/2026 at 9:07 AM, during an interview, Staff #7 Geriatric Nursing Assistant (GNA) expressed staffing concerns, noting that when staff don't show up, this delays providing care to residents. On 07/23/2026 at 1:13 PM, Staff #11 Geriatric Nursing Assistant (GNA) expressed staffing challenges, noting that care is delayed because they are attending to other residents. On 07/24/2026 at 11:49 AM, during an interview, the Director of Nursing (DON) expressed that residents who are incontinent of bladder should receive incontinence care every two hours and as needed; the care is then documented in the electronic medical record. This concern was shared with the DON during the interview.

Based on record review and interview, it was determined the facility failed to ensure that residents received treatment and care in accordance with professional standards of practice by not documenting the continued monitoring of a resident with chest pain. This was evident for 1 (Resident #10) of 3 residents reviewed for change in condition during the complaint survey. On 07/21/2026 at approximately 8:00 AM, in review of Intake #3036883, there was a noted concern related to pain management and care services. On 07/23/2026 at 8:33 AM, a review of Resident #10's progress notes from 04/27/2026 at 12:30 PM revealed a physician note: Resident #10 was seen for a post-urology follow-up and left-sided rib cage pain, with new complaints of left-sided pleuritic chest pain (a sharp, stabbing discomfort that worsens when you breathe in, cough, or sneeze) under the left breast. Resident #10 denied shortness of breath, nausea, or vomiting, and both a chest X-ray and EKG completed on 04/26/2026 were normal. Despite this, Resident #10 still continued to complain of chest pain. In relation to the intercostal pain (discomfort in the chest wall or rib area), the physician ordered a daily 5% lidocaine topical patch, and nitroglycerin 0.4 mg SL was available as needed for chest pain, and continue to monitor. However, although Resident #10's medical record showed vital signs, there was no evidence of continued monitoring for the specific chest pain or ongoing cardiovascular assessments between 04/27/2026 and 04/29/2026, when Resident #10 was found unresponsive.On 07/23/2026 at 8:40 AM, a review of Resident #10's April 2026 medication administration record (MAR) revealed a nitroglycerin sublingual order (0.4 mg, 1 tablet every 5 minutes as needed for chest pain for one day, up to 3 doses; call MD if no relief) dated 04/26/2026 at 4:30 PM. The MAR listed it as available only on 4/26 and 4/27. Although the physician documented that the medication was available as needed on 04/27/2026, the MAR indicated it was no longer available after that date.On 07/23/2026 at approximately 8:40 AM, continued review of Resident #10's nursing progress notes dated 04/29/2026 at 6:45 AM revealed Resident #10 was short of breath and non-verbally responsive (moaning only). Vital signs were normal except oxygen saturation, which was 87%, rising to 91% on 2L nasal cannula. Following a physician order to transfer to the hospital, 911 was called. Resident #10 had emesis on the stretcher and departed at 06:39 AM.On 07/24/2026 at 10:59 AM, during an interview, Staff #22, Nurse Practitioner (NP), stated that although she was not Resident #10's practitioner, a statement to continue to monitor implies active follow-up. She explained that for a resident with chest pain, she would expect documented monitoring of vital signs, appearance, and any shortness of breath, along with a formal cardiac assessment. She would have personally followed up within 24 hours, noting that nitroglycerin should have remained available, clear monitoring instructions would be communicated to nurses, and despite the patient being under another provider, she would have assessed the patient the next day.On 07/24/2026 at 2:17 PM, during an interview with the Director of Nursing (DON), she stated that if a physician notes they will continue to monitor, she would expect subsequent progress notes to document monitoring and resident assessments. The concern was shared at this time.

Based on medical record review and staff interviews, it was determined that the facility failed to administer medications to treat urinary tract infections as ordered by a physician. This was evident for 2 (Resident #17 and #7) of 4 residents reviewed for infections during the complaint survey. The findings include:According to the Centers for Disease Control and Prevention (CDC), urinary tract infections (UTIs) develop when bacteria from the skin or rectum enter the urethra. On 07/21/2026 at approximately 8:00 AM, in review of Intake #3036883, there was a noted concern related to a urinary tract infection that progressed to sepsis (a life-threatening emergency caused by the body's extreme response to an infection, which most commonly originates in the lung, urinary tract, skin, or gastrointestinal tract).1) On 07/23/2026 at 12:04 PM, a review of Resident #17's medication administration record (MAR) revealed a 7-day physician order (dated 07/18/2026 at 07:13 AM) for Cefuroxime Axetil Oral Tablet 500 mg twice daily for a UTI, set to stop on 07/24/2026. Both doses on 07/18/2026 were marked NA (awaiting delivery, physician notified), delaying the start until 07/19/2026, and the 10:30 PM dose on 07/21/2026 was omitted. Consequently, Resident #17 would receive only 5 1/2 days of the medication. On 07/23/2026 at approximately 12:06 PM, further review of Resident #17's medical record showed no evidence of communication with the physician regarding these missed doses or the shortened prescribed duration. 2) On 07/23/2026 at 2:11 PM, a review of Resident #7's July medication administration record (MAR) revealed a 07/03/2026 order for Macrobid 100 mg, 1 capsule twice daily for a urinary tract infection (UTI) for 5 days (ending 07/07/2026). Both doses on 07/03/2026 were marked NA (awaiting delivery, physician notified), delaying the start until 07/04/2026 and resulting in only 4 days of the medication being administered. On 07/23/2026 at approximately 2:13 PM, further review of Resident #17's medical record showed no evidence of physician communication regarding the missed doses or shortened duration. On 07/23/2026 at 3:15 PM, during an interview, the Director of Nursing (DON) stated that ordered antibiotics should start the same day or the next day. If the medication is in the emergency supply system, a nurse can pull it; if unavailable, they notify the physician and call the pharmacy, documenting the process in a progress note. The DON noted that physicians should be consulted regarding missed doses to extend duration, and administered medication is documented with a checkmark and initials. The concern was shared with the DON at this time.

Based on observation and interview, it was determined that the facility failed to ensure a functioning call light system for all residents. This was evident for 1 (Resident #6) out of 21 resident call lights observed during initial observations. The findings include:1. While investigating complaint #3091620, during an interview with Resident #6 on 7/21/26 at 1:45 PM, the surveyor observed that Resident #6's call light would light up on the call light faceplate in the room turning the button red but the call signal did not appear on the hallway call light monitor screen.During this interview, Resident #6 stated, They [staff] tell me that the call light is working but nobody comes. It is dangerous because I get short of breath and at night my door is closed so they cannot hear that bell [pointing to a desk bell on Resident #6's bedside table]. They have had someone up to fix it several times and they tell me it is working. They gave me that desk bell to ring too if no one answers the call light. The other day when I was short of breath, I used my phone to call my daughter and she sent my grandson here.I don't have the nurses' station phone number.During an interview on 7/21/26 at 1:57 PM, Licensed Practical Nurse (LPN #20) stated, All the call lights are working now. The residents ring their [call] light and it sends a message to the [hallway] screen. I also get a message across my computer screen at the nurses' station. Then I can walkie [walkie talkie] the GNAs (Geriatric Nursing Aide) to check on the resident.During an interview on 7/21/26 at 3:21 PM, the Nursing Home Administrator (NHA) stated, We [facility] got the new system about two weeks ago. The new call system has all new faceplates. It has a push button. There are screens at the nurses' station and in the hallways that alert the staff that a call light was activated. Everyone, the GNAs, nurses, dining staff, maintenance, activities, managers, they all get walkies. So everyone is notified when a resident rings their light. No, I am not aware of any of them [call lights] being broken.During a telephone interview on 7/22/26 at 10:23 AM, Family stated, I was at an event and my mom called me to tell me that she was short of breath and no one was answering her call light. I sent my son up to check on my mom right away. I left my event and went to the [facility] to check on her. I knew my son would get there quicker so I sent him.On 7/22/26 at 8:35 AM, NHA confirmed that Resident #6's call light was not sending an alert to the hallway call light screen the previous day. NHA stated that the facility audited all the call lights yesterday evening and they are all communicating with the hallway screen now.On 7/22/26 at 11:25 AM, the surveyor observed that Resident #6's call light was communicating with the hallway call light screens.2. While investigating complaint #3026105, during a staff interview on 7/21/26 at 10:05 AM, LPN #4 stated, the residents have those hand (desk) call bells related to when the [call light] system was down. I am not sure how long it was down for. The facility got an new system recently.During an interview on 7/21/26 at 3:21 PM, the NHA stated, Since the new [brand name] call light system has gone in the past 2 weeks, we have not had any grievances about call lights.Previously, we were supplementing the existing call light system with bells on the bedside table and frequent rounding.We had one issue with the old system- you rang the call light and it went to a pager. Each GNS had a pager. The pagers started going wonky about April. We were doing more frequent rounds and gave the residents bedside bells. We did not report it to the State agency because we felt we were handling it.

Based on interviews and clinical record review, the facility failed to ensure one (1) of 14 sampled residents was free from a significant medication error when Resident (R) #7 was prescribed and administered a medication that the resident was documented as being allergic to (acetaminophen). The findings include:Review of R#7's clinical record on 3/17/26 at 1:20 PM revealed the resident was admitted into the facility on 8/25/25 with diagnoses that included cerebral infarction, hemiplegia and hemiparesis following cerebral infarction affecting left non-dominant side, conversion disorder with seizures or convulsions, anxiety disorder, borderline personality disorder, and vascular dementia. An admission Minimum Data Set (MDS) assessment was completed on 8/29/25. R#7 was severely cognitively impaired and required total assistance from staff for all activities of daily living (ADLs). Review of the resident's Progress Notes on 3/17/26 at 1:35 PM revealed R#7's allergy to acetaminophen was noted in the progress notes dated 8/25/25, 8/27/25, and 9/8/25. Continued review of the notes revealed a Physician's Progress Note dated 9/9/25 which documented Allergies: acetaminophen and eggs.Other chronic pain. Patient complains of generalized pain and discomfort to forehead. Starting scheduled Tylenol for pain management. Continuing tramadol 50 mg every 12 hours as needed increasing gabapentin from twice daily to every 8 hours for better pain control.On 3/16/26 at 1:38 PM, an in-person interview was held with R#7's daughter. The daughter who was R#7's Medical Power of Attorney (MPOA), said that the facility's Medical Director (MD) 17 prescribed her parent a drug that s/he was allergic to (acetaminophen).An interview on 3/17/26 at 3:25 PM with the Regional Director of Nursing (RD) 3 and the Director of Nursing (DON) 4 revealed that the medication error was brought to the facility's attention in January 2026 when R#7's daughter formally reported the incident from September 2025. When asked what the facility should have done in September 2025 when the resident was prescribed Tylenol in error, RD 3 said the facility should have identified and documented the error/incident. During an interview on 3/19/26 at 10:06 AM, the MD 17 said that it was practice to complete a chart review and obtain/review a resident's history before conducting an assessment. MD 17 said that on 9/9/25, he was not R#7's attending physician but saw the resident in another physician's place. The resident was experiencing discomfort and MD 17 prescribed the resident acetaminophen. MD 17 said, I missed it, I own it. MD 17 continued and stated that nursing staff also missed it and said that the pharmacy didn't pick it up. MD 17 said, I don't know how I missed it, in reference to prescribing R#7 a medication that the resident was documented as being allergic to.

Based on observation and interview with facility staff, it was determined that the facility failed to maintain an effective infection control program. Specifically, the facility failed to: 1) follow infection control practices consistent with accepted standards of practice, 2) prevent oxygen tubing from resting on the floor, 3) review and revise infection control policies and procedures annually, and 4) provide required follow-up care for a resident with a major infection. This was evident for 1 out of 4 nursing units reviewed, one of three residents reviewed for oxygen therapy (Resident #6), five of five facility policies reviewed, and one of one resident (Resident #89) reviewed for Transmission-Based Precautions during the facility's recertification survey. The findings include:According to the Centers for Disease Control (CDC), dirt and germs can live under fingernails and contribute to the spread of some infections, such as pinworms. 1) On 12/2/25 at 11:43AM Geriatric Nursing Assistant (GNA #6) was observed in the dining room on the Sudbrook unit cutting his fingernails. At that time, residents were sitting in the dining area, engaged in activities. The observation lasted approximately 5 minutes upon which GNA #6 noticed the surveyor, stopped, stood up, and walked out of the dining room. The surveyor then approached GNA #6 and in an interview, when asked if he was on a break, he stated, Yes, I took my 15 minutes. The surveyor shared the concern that he was clipping his fingernails which were falling all over the floor in a dining room where residents eat and were occupying at that moment. GNA #6 acknowledged understanding. On 12/2/25 at 12:28 PM in an interview with the Regional Nursing Home Administrator (RNHA #5) and the facility's Nursing Home Administrator (NHA), when asked the expectation regarding staff grooming and personal hygiene tasks, RNHA #5 stated, If they have to attend to a personal item. I would expect them to get off the floor and address it. During the interview when asked if they should be taking care of personal hygiene tasks in a public space such as the facility's dining room, he stated, It is not the expectation for staff to be taking care of personal hygiene in a public space. The surveyor shared the concern with RNHA #5 and the Nursing Home Administrator, that GNA #6 was clipping his fingernails in the dining room on the 2nd floor Sudbrook unit while residents were in the area participating in activities, who both acknowledged and confirmed understanding of the concern. 2) On 12/01/25 at 2:26 PM, the surveyor observed Resident #6 receiving 1.5L of oxygen via nasal cannula; however, a portion of the tubing was touching the floor. A second observation on 12/05/25 at 9:56 AM revealed the oxygen tubing was again lying on the floor while connected to the oxygen tank. During an interview on 12/05/25 at 10:00 AM, Staff #45 (LPN) verified that oxygen tubing must not touch the floor to maintain proper infection control. The Director of Nursing (DON) validated these findings during an interview later that afternoon. 3) On 12/07/25, the surveyor requested infection control policies and procedures. On 12/08/25 at 9:42 AM, the surveyor reviewed policies titled: Infection Control, Isolation Precautions, Antibiotic Stewardship, Pneumococcal Vaccine, and Influenza Vaccine. None of these policies contained a review or revision date. During an interview on 12/08/25 at 10:08 AM, the DON (who also serves as the Infection Preventionist) stated he had not reviewed or revised the policies since starting his role in December 2024. He validated the surveyor's concern. 4) The surveyor received the completed facility matrix on 12/01/25, which identified Resident #89 as the only resident under Transmission-Based Precautions. A medical record review on 12/05/25 revealed that Resident #89 was diagnosed with Methicillin-Resistant Staphylococcus Aureus (MRSA) via bone biopsy upon re-admission on [DATE]. While the facility-initiated contact isolation on 11/12/25, there was no documentation of follow-up assessments or care regarding the MRSA. On 12/09/25, the DON stated that the resident's precautions were related to a sacral wound and claimed the facility did not conduct follow-up because there were no hospital recommendations. However, a review of the 11/11/25 hospital discharge summary explicitly stated: Bone biopsy grew MRSA . follow up with infectious disease doctor within 1 week. On 12/10/25, the attending Nurse Practitioner (Staff #50) reviewed the discharge summary with the surveyor and stated that a bone biopsy positive for MRSA should have been followed up with a CT scan. A review of Resident #89's progress notes, imaging results, and consultation logs showed no record of an Infectious Disease consultation, CT scan, or follow-up evaluation by the attending physician. The DON and Nursing Home Administrator (NHA) validated these findings on 12/10/25.

Based on interviews with residents and outside agency staff, surveyor observation, review of pertinent documentation, and interview with facility staff, it was determined that the facility failed to maintain an effective pest control program. This was found to be evident during the facility's recertification survey.The findings include:On the initial tour of the facility on 12/1/25 at 9:50 AM, in an interview with Resident #83, he/she stated that mice were a big problem in the facility. During the interview, he/she started to look under the radiator. The surveyor observed sticky mice traps. He/she said even the man who laid the traps said there was a hole in that wall. Additionally, he stated, I've seen up to 5 mice at a time running across the floor where you're standing. Some come out at and have the insulation from the walls on them. I can hear them in the walls. On 12/1/25 at 11:43 AM in an interview with Outside Agency Staff ([NAME] #48), he/she shared concerns about a mice infestation in the facility and that there are mice traps all over the facility. During the interview, he/she shared that these concerns were continuous and ongoing for over 2-3 years. An interview was conducted with Maintenance Technician (MT #29) and the Regional Nursing Home Administrator (RNHA #5) on 12/8/25 at 1:30 PM. During the interview, when asked if the facility had an insect/pest control program, MT #29 stated, Yes. When asked who the servicer was and how often they came, he stated, Allstate. Twice a week. an issue with insects or rodents, MT #29 stated, Yes, we may have, but they get addressed immediately. Staff are instructed to put it in the log binder, and it's addressed the next visit. There's a binder at each nurse's station and at the reception area and kitchen. On 12/8/25 at 2:50 PM RNHA #5 provided Pest Management Logs from the facility and Allstate Service Inspection Reports dated: 9/2/25, 9/9/25, 9/16/25, 9/21/25, 9/30/25, 10/5/25, 10/12/25, 10/21/25, 10/28/25, 11/4/25, 11/11/25, 11/18/25, and 11/25/25.On 12/8/25 at 2:51 PM review of the Allstate Service Inspection Reports conducted by Allstate technicians revealed the following:- 9/2/25: All logbooks are missing from each nurse's station and logbook is missing at the front desk.Inspected and treated basement dry storage for prior mice activity.- 9/9/25 (1 week later): Checked logbooks. Inspected and treated room [ROOM NUMBER] for reported mice activity. Inspected and treated wood dining room for reported mice activity. - 9/21/25 (12 days later): Inspected and treated dry storage room for prior mice activity.- 9/30/25 (9 days later)- 10/5/25 (5 days later, 2 times this week): One time move from 10/7. - 10/12/25 (1 week later): One time move from 10/14. Inspected and treated room [ROOM NUMBER] for reported mice activity. - 10/21/25 (9 days later): Inspected and treated movie theater room for prior roach activity. - 10/28/25 (1 week later): Inspected and treated men's and women's locker room for prior roach activity. - 11/4/25 (1 week later)- 11/11/25 (1 week later)- 11/18/25 (1 week later)- 11/25/25 (1 week later): Inspected and treated dry storage room for prior mice activity.On 12/8/25 at 4:21 PM review of the Allstate Pest Management logs revealed the following staff observations:- 5/3/25, Staff Observations: Mice, Location: 138, Location of Application: Running around in room- 5/5/25, Staff Observations: Mice, Location: Storage Room, Location of Application: Storage- 5/8/25, Staff Observations: Mouse nest beside and under heater, Location of Application: 244- 7/2/25, Staff Observations: Mice using insulation under heater, Location: Watersedge, Location of Application: Under heater- 7/11/25, Staff Observations: Mice dining/Rm 242, Location: Watersedge, Location of Application: 242- 7/16/25, Staff Observations: Mouse nesting under every heater, Location of Application: under each heater- 8/2/25, Staff Observations: Mice, Location: room [ROOM NUMBER]-A, Location of Application: 124- 8/6/25, Staff Observations: Mice, Location: room [ROOM NUMBER]-B, Location of Application: 128-B- 9/2/25, Staff Observations: Mice, Location: Meadowood, Location of Application: Nurse's Station- 9/3/25, Staff Observations: Mice, Location: Meadowood, Location of Application: room [ROOM NUMBER]- 9/4/25, Staff Observations: Mice, Location: Meadowood, Location of Application: Common Area- 9/5/25, Staff Observations: Mice, Location: Meadowood, Location of Application: Nurse's Station- 10/7/25, Staff Observations: Mice in both room, Location: Powdermill, Location of Application: 137 and 138- 11/15/25, Staff Observations: Mouse, Location: 218, Location of Application: RM [ROOM NUMBER]On 12/9/25 at 12:43 PM in an interview with the Nursing Home Administrator (NHA) when asked if he was aware that mice were an issue in the building, he stated, I am not aware. When asked what interventions had been put in place to address the issue, he stated, Allstate comes twice a week. When asked what additional interventions had been put in place to address the issue since, based on the Allstate Pest Management logs and Allstate Service Inspection Reports (which were shared and shown with the NHA), it was still an issue. The NHA stated, It's not my documents, it's for Allstate and they handle it. The surveyor shared this was a concern and the NHA acknowledged understanding.

Based on review of employee files and interviews with facility staff, it was determined that the facility staff failed to conduct required performance reviews of Geriatric Nursing Assistants (GNAs) at least once every 12 months. This was found to be evident for 8 (GNA #36, GNA #40, GNA #41, GNA #33, GNA #42, GNA #34, GNA #37, GNA #38) out of 10 GNA employee files reviewed during the Sufficient and Competent Nurse Staffing facility task for the facility's recertification survey. The findings include:Performance reviews are to be completed for each GNA at least every 12 months to identify specific, in-service education based on the outcome of those individual performance reviews. On 12/5/25 at 9:57 AM the surveyor requested the complete employee files (including, but not limited to, health records, training, evaluations, et cetera) for GNA #18 and GNA #20. On 12/5/25 at 11:47 AM the Nursing Home Administrator (NHA) provided the employee files to the survey team. At that time, the surveyor asked if these were the complete employee files (including, but not limited to, health records, training, reviews/evaluations, et cetera) for GNA #18 and GNA #20. The NHA stated, This is everything.On 12/8/25 at 12:56 PM review of GNA #18's employee file revealed he/she was hired on 12/3/24; however, further review failed to reveal a performance review for 2025. On 12/8/25 at 1:11 PM review of GNA #20's employee file revealed he/she was hired on 1/1/24; however, further review failed to reveal a performance review for 2025. On 12/8/25 at 1:41 PM in an interview with the Director of Nursing (DON) when asked if performance reviews were conducted for the GNAs he stated, I have not personally done one, but I saw one. When asked where the performance review was observed, he clarified, That was at other facilities. When asked how often they are to be conducted, he stated annually. When asked if he knew of any staff who had completed a performance review for a GNA in this building, he stated, I'm not sure I have to check on that. On 12/9/25 at 11:43 AM in an interview with the Director of Nursing (DON), the surveyor shared that the complete employee files were requested for GNA #18 and GNA #20 and provided by the facility. Additionally, when the NHA provided the employee files, he verified and confirmed that they were the complete employee files including, but not limited to, health records, reviews/evaluations, trainings, et cetera; however, after looking through the files in their entirety there were no annual performance reviews for 2025 for GNA #18 and GNA #20. When asked if he could provide a copy of their performance reviews he stated, I don't have those today. When asked the required amount of in service education GNAs needed per year he stated, Around 15 hours. At that time, the surveyor requested a copy of the 2025 performance reviews for GNA #18 and GNA #20. On 12/9/25 at 2:41 PM the surveyor made a second request for a copy of the 2025 performance reviews for GNA #18 and GNA #20. On 12/10/25 at 8:33 AM the surveyor made a third request to the DON for a copy of the 2025 performance reviews for GNA #18 and GNA #20 and any and all policies and procedures related to GNA Performance Reviews. On 12/10/25 at 9:13 AM the DON provided the surveyor with a copy of a performance review for GNA #18 and GNA #20. In an interview with the DON, the surveyor shared the concern that they were not in the employees' files and when asked where they were found, the DON stated in the Human Resource Director's office. On 12/10/2025 at 9:25 AM in an interview with the Human Resource Director (HRD #8) when asked where she found the performance reviews for GNA # 18 and GNA #20 she stated, Typically they would be in the employee file, but we have a new DON, so he's trying to sort through the stuff on the previous Director of Nursing's desk. They were in the previous DON's office, so that's why they weren't in their personnel file. During the interview when asked the facility's expectation of where performance reviews for GNAs were stored, the HRD stated, The expectation of the facility is that performance reviews are stored in the employee's file. When asked if there was any other place they might be stored, she stated, There may be some in the previous DON's office, but there is no other place they would be stored. When asked if as the Human Resources Director, she kept any GNA performance reviews in her office or any other location in a file cabinet, binder, manilla file, et cetera, she stated, No, I do not have a binder, file cabinet, or file of performance reviews. I do have a small pile of papers in my office I have not organized and put away, but no, there are no GNA performance evaluations in that pile. On 12/10/2025 at 9:36 AM in an interview with the DON and HRD #8, the surveyor shared the concern that the DON stated the performance reviews for GNA #18 and GNA #20 were found in the Human Resource Director's office, but HRD #8 stated they were found in the previous DON's office. The DON then turned to face HRD #8 and stated, Didn't you bring these.weren't these in your office? HRD #8 stated, Not that I am aware of. Then, the DON stated, I found them in the HR office.in the inner room. There are files in there. I was looking through the pile of paper there. I searched through there. When asked the facility's expectation of where GNA reviews were stored, the DON stated, Performance reviews should be in the file for that staff but when we looked through the file it was not there. The surveyor asked aside from the employee file was there another location GNA performance reviews would be stored and he stated, No. When asked if there would be any performance reviews in the previous DON's office, he stated, No. On 12/10/2025 at 9:45 AM surveyor, HR, DON walked up to HR office to obtain copies of 8 GNAs' performance reviews. On 12/10/2025 at 9:47 AM HRD #8 reviewed GNA #36's entire employee file and stated there were performance reviews from the years 2008-2018; however, when asked if there was a performance review from 2025, she stated no. On 12/10/2025 at 9:48 AM review of GNA #40's entire employee file revealed performance reviews from 1999-2019; however, failed to reveal a performance review from 2025.On 12/10/2025 at 9:53 AM HRD #8 reviewed GNA #41's entire employee file and stated there were performance reviews from the years 2003-2020; however, when asked if there was a performance review from 2025, she stated no. On 12/10/2025 at 9:55 AM the DON reviewed GNA #33's entire employee file and stated there were performance reviews from the years 2014-2019; however, when asked if there was a performance review from 2025, he stated no. On 12/10/2025 at 9:56 AM HRD #8 reviewed GNA #42's entire employee file and stated there were performance reviews from the years 2005-2018; however, when asked if there was a performance review from 2025, she stated no. On 12/10/2025 at 9:59 AM the DON reviewed GNA #34's entire employee file and when asked if there was a performance review from 2025, the DON stated, I do not see any in there.On 12/10/2025 at 10:00 AM HRD #8 reviewed GNA #37's entire employee file and stated there were performance reviews from the years 2002-2020; however, when asked if there was a performance review from 2025, she stated no. On 12/10/2025 at 10:00 AM the DON reviewed GNA #38's entire employee file and when asked if there was a performance review from 2025, the DON stated, I don't see any.On 12/10/2025 at 10:12 AM in an interview with Staff #43 when asked if he/she had a performance evaluation since the facility changed ownership on 1/1/24 he/she stated, No.On 12/10/2025 at 10:16 AM in an interview with Staff #44 when asked if he/she had a performance evaluation since the facility changed ownership on 1/1/24 he/she stated, No.On 12/10/25 at 1:52 PM in an interview with the DON, when asked who conducted performance reviews for the GNAs, he stated, Clinical Leadership. During the interview when asked to clarify Clinical Leadership he stated, the UMs, the ADON, DON, and the nurses can also do it because they directly supervise the GNAs. At that moment, the Regional Administrator (RA #5) who was in the room approached the DON and surveyor and asked what was going on. The surveyor shared that the DON had just stated that the UMs, ADON, DON and nurses can conduct annual performance reviews for the GNAs, and the RA #5 shook his head and stated, No, it is just nursing administration. When asked what the requirements for the annual in service training/competencies for GNAs were, the DON stated, What it needs to include is to make sure they can do what's included in the packet successfully. The RA #5 stated, 12 hours. At this time, the surveyor shared the concern with RA #5 and the DON that there were no performance reviews for any of the 8 GNAs reviewed in HRD #8's office. When asked how the facility can provide regular in-service education/competencies/training to GNAs that was based on the outcome of their performance review if performance reviews were not being conducted, RA #5 stated, They were conducted, we cannot find them. I have housekeeping and dietary; we cannot find the clinical staff. The surveyor shared this was a concern and he acknowledged understanding.

Based on medical record reviews and staff interviews, it was determined that the facility failed to ensure key essential personnel were present during monthly Quality Assurance (QA) meetings. This was evident in 6 out of 11 monthly QA meeting attendance sheets reviewed during this recertification/complaint survey.The findings include:On 12/10/25 at 10:00 AM, surveyors requested the January through November 2025 QA monthly meeting sign-in sheets. The review revealed the following:The Medical Director's signature was missing for January, April, June, July, and August 2025.The Infection Preventionist's signature was missing for May 2025.During an interview with the Director of Nursing (DON) on 12/10/25 at 11:22 AM, he stated that the facility administrator and himself are the individuals responsible for Quality Assurance and Performance Improvement (QAPI). The DON also explained that monthly QAPI meetings should be held with the Medical Director, Administrator, DON, Infection Preventionist, Social Worker, Therapy team, Activity Director, Dietitian, and Nursing Aides.In a follow-up interview with the Nursing Home Administrator (NHA), DON, and Staff #5 (Regional Administrator) on 12/10/25 at 2:23 PM, the surveyor reviewed the facility's QAPI attendance sheets with the DON and NHA. They verified that the Medical Director's signature was missing for January, April, June, July, and August 2025. Additionally, they confirmed the Infection Preventionist's signature was missing for May 2025. The surveyor shared the above concerns, and the NHA validated the findings.

Based on observation and interview with facility staff, it was determined that the facility failed to ensure the labeling, dating, and expiration of nourishment items and that expired food items were discarded. This was observed in the facility's kitchen during the recertification/complaint survey.The findings include:On 12/1/25 at 7:35 AM, the surveyor conducted an initial tour of the facility's kitchen.On 12/1/25 at 7:39 AM the surveyor observed the following:- Turkey with a use by date of 11/20/25- Jelly with a use by date of 11/24- Woeber's Salad Style Mustard labeled 4/18- Orange cheese with no use by date- Chef's Wonder Instant Soup labeled 11/20/25- Cross Valley Farms [NAME] Caseras with a use by date of 11/12/25- Loose potatoes in a white plastic container with a use by date of 11/30/25- Loose lettuce in a white plastic container which had no labeling or dates present to indicate preparation or expiration dates- Loose green bell peppers in a white plastic container which had no labeling or dates present to indicate preparation or expiration dates- Loose cabbage in a white plastic container which had no labeling or dates present to indicate preparation or expiration dates- A plastic container with a clear flip lid labeled Breadcrumbs Nov.1, 2025 to Nov. 30, 2025- A plastic container with a clear flip lid labeled Flour Nov.1, 2025 to Nov. 30, 2025On 12/1/25 at 8:01 AM in an interview with Dietary Manager (DM #2) the surveyor shared the abovementioned concerns and DM #2 acknowledged and confirmed understanding of the concerns. When asked whose responsibility it was to properly label the nourishment items, he stated, It's everybody's responsibility to date items when they open them. I expect them to have the right thing labeled on each product. The expectation is to have an open date and an expiration date. When asked if all kitchen staff had been trained on how to properly label items, he stated, No I can't say everybody. When asked if the lack of training could have contributed to items not having any date, only having the month and date and no year, having a date without labeling on if it is the open date or the expiration date, he stated, I see what you're saying.

Based on review of medical records and interview with facility staff, it was determined that the facility failed to 1) develop policies and procedures that address the time frames for the steps in the MRR process and the steps the pharmacist must take when he or she identifies an irregularity that requires urgent action to protect the resident 2) ensure a pharmacist conducted a complete MRR, at least monthly 3) ensure monthly Medication Regimen Reviews were completed by the facility's providers, 4) respond to recommendations made by consulting pharmacists in a timely manner, and 5) identify instances where the medication indication was inaccurately documented. This was evident for 2 (Resident #7and #8) out of 5 residents reviewed for unnecessary medications during the facility's recertification survey. The findings include: The Medication Regimen Review (MRR) is a review of the medication regimen (plan) of each resident with the goal of promoting positive outcomes and minimizing adverse (negative) consequences and potential risks associated with medications. The MRR must be completed at least once a month by a licensed pharmacist and includes a review of the residents' medical record to identify, report, and resolve medication-related problems, errors, and/or other irregularities. 1)In an interview with the Director of Nursing (DON) on 12/4/25 at 12:11 PM when asked what happens during the monthly pharmacy MRR, he stated the pharmacist sends the recommendations via email to the attending physician, Nurse Practitioner (NP), DON, and Assistant Director of Nursing (ADON). The physician reviews them and they are filed in a binder by the DON. At the end of the interview, the surveyor requested the MRR's from January 2025 to present for Resident #7 for the months that there was a recommendation from the pharmacist. On 12/4/25 at 1:58 PM the Nursing Home Administrator (NHA) brought the MRR documentation for Resident #7 which only included a Note to Nursing from 11/5/25 Atorvastatin Calcium Oral Tablet 10 MG Give 1 tablet by mouth at bedtime for Hyperlipemia. Could not locate lipid panel within the last 12 months. Recommend lipid panel to assess statin dose. Handwritten was agreed with an illegible signature and date of 11/20/25. In an interview with the NHA, when asked if this was the only pharmacist recommendation for Resident #7, he stated he would have to check. On 12/5/25 at 8:58 AM in an interview with the DON and Regional DON, the Regional DON stated that she had seen progress notes written documenting if the resident did or did not have a recommendation and that as soon as we get it the time expectation is that it would be completed before the next monthly review. The surveyor made a second request for all monthly pharmacy recommendations for Resident #7 expanding the request to: from July 2024 to present. On 12/5/25 at 11:45 AM the DON and Regional DON provided documentation for Resident #7, Note to Attending Physician/Prescriber, dated 8/10/25 and another document titled, Order Summary Report. The recommendation form was completed by the provider and addressed by the facility. On 12/5/25 at 12:18 PM in an interview with the NHA, the surveyor requested the policies and procedures for MRR's. On 12/5/25 at 12:36 PM the DON provided the Pharmacy Consultant Report and verified it was the facility's policies and procedures for the monthly MRR. Review of the document failed to reveal that the time frames for the steps in the MRR process were addressed or the steps a pharmacist must follow when he or she identified an irregularity that required immediate action to protect the resident and prevent an adverse drug event. On 12/5/25 at 1:00 PM in an interview with the DON, when asked to share the facility's process during the monthly MRR, he stated the DON or ADON prints the recommendations from the pharmacist, physically hands them to the UMs, and then the UMs physically hand the recommendations to the doctors. When asked about the process for the physician to respond to the recommendations, the DON stated the physician must respond to the recommendations before the next monthly MRR. Furthermore, he stated that the facility's expectation was for the physician to check one of the three boxes (agree, disagree, or other, write a rationale if he/she disagreed, and to sign and date the form. When asked who was responsible for putting in new orders and/or discontinuing orders, he stated, Doctors put in the new orders and the nurses confirm the orders. When asked who was responsible for following through to ensure that it had been completed, he stated, The DON and ADON. During the interview, a dual observation was conducted of the facility's policies and procedures for the monthly MRR. When asked what whether the MRR's policies and procedures addressed the time frames for the steps in the MRR process, the DON stated, Not technically. There are 6 steps. No, there is no time frame for each step. Additionally, when asked whether the policies and procedures addressed the steps a pharmacist must follow when he or she identified an irregularity that required immediate action to protect a resident and prevent the occurrence of an adverse drug event, he stated, Yes. It may not be specified here but if they notice someone is, for example, on multiple blood pressure medications and they review the resident's vital signs, they might say do this and this and this. The surveyor shared the concern that the facility's policies and procedures did not include the time frames for the steps in the MRR process or the steps a pharmacist must follow when an irregularity was identified that required immediate action. The DON confirmed that the facility's policies and procedures did not include either and acknowledged and validated the surveyor's concern. On 12/7/25 at 10:26 AM the surveyor reviewed the medical record for Resident #7 which revealed progress notes titled, Consultant Pharmacist Note/Medication Regimen Review and documented the following: 11/4/2025 11:50 Note Text: Medication regimen review completed. Recommendation to Nursing. 8/10/2025 13:11 Note Text: Pharmacist MRR completed. See pharmacy report for recommendations. 6/4/2025 14:48 Note Text: Pharmacist medication review completed. See pharmacy report for recommendations noted. 12/2/2024 09:16 Note Text: Pharmacist medication review completed. See pharmacy report for recommendations noted. 8/5/2024 13:53 Note Text: Pharmacist medication review completed. See pharmacy report for recommendations noted. Further review of the medical record revealed that the 11/4/25 and 8/10/25 MRRs had been completed by the provider and addressed by the facility (copies of these two MRRs were provided to the survey team; however, the MRRs from 6/4/25, 12/2/24, and 8/5/24 were not provided by the facility. On 12/7/25 at 2:07 PM in an interview with the DON, he stated, The additional MRR (8/10/25) I gave you is all that I found. I'm still looking, but that's all I found. The surveyor shared it was a concern that out of the abovementioned 5 MRR's, only 11/4/25 and 8/10/25 had been provided. The DON acknowledged and confirmed understanding of the concern. The surveyor requested a third time for a copy of the completed MRRs from 6/4/25, 12/2/24, and 8/5/24. On 12/8/25 at 8:12 AM in an interview with the 2nd floor, Unit Manager (UM #12), she stated the MRR documentation was not in the residents' paper chart. When asked where it would be found she stated in PCC or with the DON. When asked if she as the UM played a role in the MRR process she stated no, the UM was not involved in the MRR process. When asked to share the process she stated, The DON prints them, gives to the providers who complete them, and give back to the DON. On 12/8/25 at 8:20 AM in an interview with the 1st floor Unit Manager (UM #31), when asked where the MRRs are stored she stated in PCC and they are also emailed. When asked to share the MRR process, she stated, The DON prints them and give them to the providers, they complete them, and the provider either gives it back to the DON, the UM or the nurse, but it's usually the DON who gets them back and he faxes them to the pharmacist. If the provider gives it to me, I fax it to the pharmacist. If the provider gives it to the resident's nurse, they will give it to the DON or UM, whoever they see first, and that person faxes it to the pharmacist. Additionally, she stated the exception to this process was NP #17 who completed and addressed her own recommendations. When asked where the paper copy is stored, she stated in the DON's office. When asked if they were ever stored in the paper chart, she stated no. On 12/8/25 at 8:29AM the surveyor requested any MRR binders or other forms of storage for the MRRs from the DON. On 12/8/25 at 8:55 AM review of the MRR documentation revealed a 3-ring binder labeled Jan-[DATE] and included the following: - September 2025 MRRs, but none of the recommendations were completed by a provider. The boxes were not checked and had no signature or date. - August 2025 MRRs: 29 recommendations that were not completed. - July 2025 documentation: 42 recommendations that were not completed. - June 2025 documentation: 5 recommendations that were not completed. - May 2025 documentation: 12 recommendations completed by NP #17 and 4 MRRs that were not completed. - April 2025 documentation: 6 recommendations completed by NP #17 and 6 MRRs that were not completed. - March 2025 documentation: 6 recommendations completed by NP #17 and 2 MRRs that were not completed. - [DATE] documentation: 10 recommendations completed by NP #17 and 2 MRRs that were not completed. - January 2025 documentation: 23 recommendations completed by NP #17. - December 2024 documentation: 2 MRRs that were not completed. There were no MRRs for Resident #7 in the documentation provided. On 12/8/25 at 9:18 AM in an interview with the DON when asked if Note to Attending Physician/Prescriber and Note to Nursing were different recommendations from the pharmacist, he stated, I believe so, but ultimately it's going to be under the physician's guidance. When asked what staff addressed the monthly recommendations, the DON stated, The physician has to look at the recommendation and address it, but if, for example, someone is on a routine stool softener and the recommendation is to hold the medication for loose stools, the provider does not need to see that recommendation because the nurse can just hold it. When asked for clarification that the provider does not need to be aware of that recommendation to hold the stool softener, the DON stated, It's just a given that if the resident has loose stools to hold it; that doesn't need a doctor's approval for that. When asked where the completed MRRs, that the provider has documented their written response on of agree, disagree, or other and signed and dated, the DON stated, They're stored in the binders in my office. The surveyor shared the concern that the documentation he provided of the binders from his office, it only included 1 month of 2024 (December). The DON acknowledged understanding of the concern. During the interview when asked how often the MRR needed to be conducted by a licensed pharmacist, he stated, Monthly. When asked if for example, a MRR was conducted on 6/4/25, when would the next one need to be completed by, he stated, July 4, 2025. When asked if a MRR was conducted on 8/10/25, when would the next one need to be completed by, he stated, September 25, 2025. In a dual observation of Resident #7's progress notes, it was observed that a MRR was conducted on 6/4/25; however, the next MRR was conducted on 7/17/25. When asked if that was conducted monthly, the DON stated, It looks like it's not. Additionally, it was dually observed that a MRR was conducted on 8/10/25; however, the next MRR was conducted on 9/28/25. When asked if that was conducted monthly, the DON stated, It was not within a month. The surveyor shared that it was a concern and the DON verbalized understanding. On 12/8/25 at 9:59 AM in an interview with the DON the surveyor shared the discrepancies in the facility's MRR process as described by the two UM's and himself as, for example, the 2nd floor UM stated UM's did not even have a role in the monthly MRR process. The DON stated, [NP #17's name] was the NP covering for Attending Physician (AP #24) and AP #25. In other words, NP #17 covered the residents for all the physicians. She came every day, Monday-Friday. When the pharmacist sent the MRR, NP #17 looked at them, signed them, and sent them back. Now NP #17 doesn't come here every day anymore, she only comes on Fridays. So now she doesn't look at them all anymore. So now the UMs give them to the 2 physicians and around September 2025, we got a new NP, [NP #47's name]. On 12/8/2025 at 1:26PM in an interview with the DON, when asked about the requested MRRs from 6/4/25, 12/2/24, and 8/5/24, he stated, I am still looking. The surveyor made a fourth request for the completed MRRs. On 12/9/25 at 9:01 AM the DON provided a manilla folder with some 2024 MRR's; however, none were the requested ones for Resident #7. On 12/9/25 at 10:41 AM the surveyor made a fifth request for the completed MRRs from 6/4/25, 12/2/24, and 8/5/24 along with evidence they were addressed by the facility. On 12/10/25 at 8:26 AM in an interview with the DON, he stated, I sent an email to pharmacy to clarify their progress notes. I looked at these dates you shared, and I don't see we have a recommendation for those dates. The surveyor shared this was a concern. The DON stated, It's concerning to me too. On 12/10/25 at 2:10 PM the DON provided a copy of Resident #7's 8/5/24 MRR. Review of the document titled, Consultant Pharmacist Recommendation to the Physician, revealed Resident has been receiving levothyroxine 112mcg (micrograms) daily. The last TSH noted is from 6/2023. Consider checking a TSH with the next labs. Further review revealed the provider checked the box, Agree and signed and dated it on 8/14/24. In an interview with the DON, the surveyor requested evidence that the TSH lab was obtained after the facility's provider signed and dated the recommendation on 8/14/24 and before the next monthly MRR on 9/5/24. At this time the surveyor provided an additional opportunity for any and all further documentation to be provided by the facility for surveyor review. No additional information was provided by the facility at the time of survey exit. 2)In a review of Resident #8's medical records on 12/04/25 at 10:20 AM, it was revealed that the facility's contracted pharmacist sent a monthly Medication Regimen Review (MRR). The MRR report dated 5/23/25 contained the note: Review resident's medical history to ensure this is an appropriate dx (diagnosis) for Seroquel. It has previously been listed for Bipolar. The attending physician accepted the recommendation and provided a signature on the same day. Consequently, the order indication was revised on 5/23/25 from Schizophrenia to Bipolar. However, further review of Resident #8's medical records on 12/05/25 around 1:00 PM noted that the Seroquel was again incorrectly indicated for Schizophrenia from 7/08/25 to 9/23/25. The MRR reports documented on 7/18/25 and 8/08/25 failed to identify this inaccurate indication of Seroquel. In an interview with the Director of Nursing (DON) on 12/05/25 at 1:43 PM, he confirmed that Resident #8's Seroquel has been used for Bipolar Disorder. The surveyor reviewed the resident's medical records with the DON and shared the concern regarding the pharmacist's failure to identify the inaccurate Seroquel indication. The DON validated the concern.

Based on observation and interview with facility staff, it was determined that the facility failed to 1) ensure medications were secured as evidenced by observations of medications left at the bedside and on the floor, and 2) store and label medication in accordance with currently accepted professional principles. This was evident for 2 (Resident #35 and #9) out of 36 residents reviewed, 2 of 3 medication cart observed, and 2 of 2 nursing supply rooms observed during the recertification/complaint survey.The findings include 1) On [DATE] at 2:49 PM the surveyor observed from the hallway one white tablet on Resident #9's floor. At that time, Registered Nurse (RN #9) walked by and the surveyor requested an interview. During the interview when asked if she stayed with residents until they finished taking all medications she stated yes. She stated Resident #35, takes all day to take his/her medication, so she said to herself that she would come back and check on him/her. Additionally, she stated that she had administered 4 capsules around 9:00 AM and then the cardiologist called and the facility's provider, Attending Physician (AP #25), was calling for her to talk to the cardiologist. She stated, It's not the policy that you leave medications at the bedside. The policy is when you give a medication, you wait until they take it. My goal was to come back. I said, let me go and see what the doctor needs from me, but when I came back, rehab had taken him/her. RN #9 went into Resident #35's room, retrieved a small, white medicine cup from the bedside table, and came back into the hallway. The surveyor observed 1 capsule inside the medicine cup. Resident #35 was not observed in the room. The surveyor was inquiring about a medication observed on Resident #9's floor; however, RN #9's interview and observation referenced another unsecured medication from the room across the hall, belonging to Resident #35. The surveyor shared this was a concern and RN #9 verbalized understanding of the concern. The surveyor and RN #9 entered Resident #9's room on [DATE] at 3:04 PM and the surveyor pointed out the white tablet on the floor. In an interview with Resident #9 and RN #9, Resident #9 stated that when he/she was given the medication, as he/she was taking the medication, he/she dropped one and had tried to call for RN #9 but did not get a response. The surveyor shared the two medications left unsecured were a concern. RN #9 acknowledged and confirmed understanding of the concern. A few moments later in the hallway, RN #9 approached the surveyor and stated, I'm just being honest. I've been a nurse for a long time, and I know it's not the right thing to do, but the doctor called me. I do apologize. I messed up. It's not something that's supposed to happen, but it did. 2) On [DATE] at 2:25 PM, the surveyor began conducting a check of the facility's medication storage and labeling of; the medication carts, treatment carts and nursing supply rooms (which stores commonly used items for resident care). On the Sudbrook Unit Medication Cart 1-590, the surveyor, in the presence of Staff #49 (LPN), observed a large open bottle of Sennoside 8.6 mg tablets and a large open bottle of Acetaminophen 500 mg tablets. Both bottles of this floor stock medication, or non-resident specific medication, lacked an open date. On [DATE] at approximately 2:42 PM, in the Sudbrook Unit Nursing Supply Room the surveyor observed: (2) one-liter bags of 5% Dextrose Intravenous Fluid that expired in [DATE]; A one-liter bag of Lactated Ringer's Intravenous Fluid that expired in [DATE]; and a single 24-gauge needle with a yellow-colored cap, stored among other needles, was no longer in its original packaging. On [DATE] at 2:51 PM, in the Meadowood Unit Nursing Supply Room, the surveyor observed a box of various needles that included an orange-capped needle stored without its original packaging. On [DATE] at 2:51 PM on Meadowood Unit Medication Cart 1-590, the surveyor found a container of Vitamin D 10 mcg pills that was unlabeled and a bottle of liquid Multivitamin Iron Supplement (220 mg/5 ml) was marked with the date 6/12, but the year the medication was opened was unknown, and the expiration date was illegible. On [DATE] at 3:16 PM, the Director of Nursing (DON) was present throughout the medication storage and labeling facility task. At the conclusion of this task, the surveyor made the DON aware of the concerns, which the DON acknowledged.

Based on record review and interview with facility staff, it was determined the facility failed to 1) ensure the monitoring of a psychotropic medication for a resident and 2) ensure a resident's medication regimen was free from unnecessary medications. Specifically, the facility prescribed as needed (PRN) psychotropic medication without documentation of a supporting evaluation This was evident for 2 (Resident #7 and #13) out of 5 residents reviewed for unnecessary medications during the facility's recertification/complaint survey.The findings include: The Centers for Medicare & Medicaid Services (CMS) defines a psychotropic medication in the regulations at 483.45(c)(3), as any drug that affects brain activities associated with mental processes and behavior (CMS, 2023). These drugs include, but are not limited to, drugs in the following categories: anti-psychotic, anti-depressant, anti-anxiety, and hypnotic medications. These medications can have serious potential risks, including side effects, drug interactions, and the possibility of neuroleptic malignant syndrome (a rare but potentially life-threatening condition) or tardive dyskinesia (a movement disorder that can develop if you take an antipsychotic medication) therefore requiring careful consideration and monitoring. 1) On 12/2/2025 1:10 PM review of Resident #7's medical record revealed an order for Duloxetine HCl (hydrochloride) Oral Capsule Delayed Release Particles 20 mg (milligrams). Give 20 mg by mouth two times a day for depression. Further review failed to reveal a behavior monitoring order. On 12/4/25 at 12:22 PM in an interview with the Director of Nursing (DON) when asked if there were certain medications that required behavior monitoring, he stated Yes, the psych medications. During the interview when asked if there would be an order and where it would be documented, he stated, There's an order called behavior monitoring and so you will see it in the TAR (treatment administration record). On 12/8/25 at 9:38 AM in an interview with the DON when asked why residents ordered psychotropic medications have their behaviors monitored, he stated, To see if the medication is working or not or if or it is having any adverse effects. If someone is on anti-anxiety med, you want to check their behavior to see if they are showing signs of anxiety. During the interview, a dual observation of Resident #7's orders was conducted. The surveyor pointed out that Resident #7 was ordered Duloxetine for depression and when asked if the resident had a behavior monitoring order, the DON stated, I do not see a behavior monitoring order. When asked why he/she was ordered a psychotropic medication and did not have a behavior monitoring order, he stated, Well, he/she has this order, Monitor and report tremors, dizziness and other side effects every 12 hours for drug side effects monitoring. The surveyor pointed out that the order was written for drug side effects monitoring and that Resident #7 was ordered a psychotropic medication and did not have a behavior monitoring order was stated was the expectation in the previous interview. The DON acknowledged and confirmed understanding of the concern. 2) A review of Resident #13's medical records on 12/04/25 at 11:05 AM revealed that the resident was diagnosed with anxiety upon admission. Since admission, the resident was administered scheduled Lorazepam (a benzodiazepine used to treat anxiety and related sleep disturbances) twice daily. In addition to the scheduled dose, Resident #13 had the following PRN Lorazepam orders: 10/06/25 to 10/17/25: One tablet PRN every 24 hours.10/17/25 to 10/31/25: One tablet PRN every 24 hours.11/03/25 to 11/05/25: One tablet PRN every 12 hours.11/05/25 to 11/19/25: One tablet PRN every 12 hours. A further review of Resident #13's medical records on 12/08/25 at 2:22 PM revealed no documentation of an evaluation by the attending physician or psychiatry services prior to the PRN orders placed on 10/17/25 and 11/05/25. While the attending physician wrote a progress note on 11/03/25 detailing an increase in the routine Lorazepam dose (from 1 mg twice daily to three times daily per family request), there was no documented assessment or evaluation regarding the PRN dosage. During an interview with the Director of Nursing (DON) on 12/09/25 at 11:23 AM, the DON stated that the facility has a Psychiatric Nurse Practitioner (NP) who visits at least once a week to assess residents. The DON explained that PRN psychotropic medication orders are limited to a maximum of 14 days and stated that a re-evaluation is required to renew the order. The surveyor reviewed Resident #13's Lorazepam order history with DON. The DON claimed that because the PRN order on 10/17/25 was written by an attending NP, it was assumed the NP had evaluated the resident. However, the PRN order starting 11/05/25 was entered by a nurse and was not verified by a provider until 11/10/25. In an interview on 12/10/25 at 2:08 PM, Staff #50 (Nurse Practitioner) stated that while nurses are permitted to enter verbal or telephone orders into the electronic medical record, these must be verified by a physician within 48 hours. Staff #50 further emphasized that any resident taking PRN psychotropic medication must be evaluated by a provider. During a follow-up interview with the DON on 12/10/25 at approximately 3:00 PM, the surveyor presented the concerns. The DON validated the findings.

Based on medical record review and staff interview, it was determined that the facility failed to ensure that advance directives were discussed with residents and/or responsible representatives and failed to ensure that residents were evaluated by two physicians for a decision-making capacity. This was found to be evident for 1 (Resident #6) out of 5 residents reviewed for advance directives during this recertification/complaint survey.The findings include:A physician's certification for decision-making capacity confirms if a patient can understand their medical situation, appreciate the consequences, use reasoning, and communicate a choice for treatment, often requiring formal documentation by one or two doctors based on specific legal standards, like Maryland's law requiring two physicians (one being the attending) for incapacity certification, ensuring the process is documented, consistent, and follows patient rights. During the screening process on 12/02/25 at 11:18 AM, the surveyor attempted to interview Resident #6. Since the resident was mumbling, the surveyor could not determine the resident's current cognitive status.On 12/03/25 at 1:49 PM, the surveyor reviewed Resident #6's medical records including Medical Orders for Life-Sustaining Treatment (MOLST) form. The review revealed that MOLST was completed by him/herself as full code upon his/her admission. However, there was no Advance Directive or Physician's Certificate of Incapacity documented in Resident #6's medical records.In an interview with the Social Worker (Staff #10) on 12/03/25 at 1:30 PM, he explained that facility staff assess all residents' advance directive status upon admission: they ask residents to bring any existing documents or assist residents in completing one. He also confirmed that regardless of a resident's cognitive level, the facility should evaluate their capacity using two physicians.During a subsequent interview with Staff #10 on 12/04/25 at 2:56 PM, the surveyor shared the concerns that Resident #6 lacked an Advance Directive and an incapacity evaluation in his/her medical records. Staff #10 verified that the facility did not have Resident #6's Advance Directive or incapacity evaluations.

Based on review of pertinent documentation and interview with facility staff, it was determined that the facility failed to follow the grievance process and communicate the resolution to the resident. This was evident for 1 (Resident #9) out of 2 residents reviewed for grievances during the recertification/complaint survey.The findings include:On 12/4/25 at 8:47 AM in an interview with the Nursing Home Administrator (NHA) and the Regional Nursing Home Administrator (RNHA) when asked who the grievance official for the facility was, they stated the Social Services Director (SSD). On 12/4/25 at 12:01 PM in an interview with the SSD when asked about the grievance process, he stated, We have a grievance form posted all around the building that anyone can complete and then it is forwarded to me. I address the issue with whatever department is involved and then share the findings. On 12/4/25 at 9:00 AM the facility provided the survey team with copies of grievance forms including a grievance form for Resident #9 dated11/15/24. Review of the Resorts at Augsburg Resident/Guest Grievance Form for Resident #9 revealed the bottom of the form was not completed. There were three lines that were blank: Resolution communicated to, Copy Offered, and Response to Investigation. On 12/4/25 at 1:40 PM review of the facility's grievance policies and procedures revealed, Once the resolution is completed the responsible party/resident will be notified. On 12/8/25 at 10:36 AM in an interview with the SSD, a dual observation of the Resorts at Augsburg Resident/Guest Grievance Form for Resident #9 was conducted. When asked if the SSD saw evidence that the resolution was communicated to the resident he stated, It was communicated to her because I communicated it to her. When asked where in the form it included that the resolution was communicated to the resident he stated, It was communicated to him/her, but I see what you are saying. The surveyor shared this was a concern and the SSD acknowledged understanding.

Based on medical record review, other pertinent documentation, and staff interviews, it was determined that the facility failed to provide pain medication to Resident #17 who complained of pain and had a suspected fracture. Failure of the facility to administer pain medication resulted in harm to Resident #17 who remained in prolonged pain. This was evident for 1 out of 3 residents reviewed for pain during the survey The findings include: Review of Resident #17's medical record on 04/10/2024 at 2:00 PM revealed that Resident #17 was admitted to the facility in July 2021 with a diagnosis that included Dementia. According to the Minimum Data Set assessment with a reference date of 09/15/2022, Resident #17 was totally dependent on staff for care and had a Brief Interview for Mental Status (BIMS) assessment score of 00 indicating severe cognitive impairment. Review of the medical record on 04/15/2024 at 1:00 PM revealed a Situation Background Appearance Review Communication Form (SBARF) that was completed on 10/03/2022 at 11:40 AM and which LPN (#63) documented that the Physician was made aware that Resident #17 was guarding his/her left extremity and the left leg appeared to be dangling. The pain evaluation section of the SBARF revealed that Resident #17 was exhibiting non-verbal signs and symptoms of pain that included occasional labored breathing, short periods of hyperventilation, occasional moaning and groans, low level of speech with a negative or disapproving quality, facial grimacing, tense, fidgeting, resident was unable to console, distract or reassure. The Physician ordered Resident #17 to have a stat x-ray of the left hip, knee, and ankle. Further review of Resident #17's medical record on 04/15/2024 at 2:00 PM revealed that the physician x-ray order was not put into the system to be completed until 12:02 PM on 10/03/2022 by LPN (#63). On 10/03/2022 at approximately 12:56 PM an x-ray was completed in the facility and Resident #17 was found to have a left acute fracture of the proximal fibula with displacement and an acute spiral fracture of the mid to distal tibia. On 04/15/2024 at 3:30 PM Resident #17's Medication Administration Record for October 2022 was reviewed and revealed Resident #17 did not receive any medication for pain management although the resident had a PRN (as needed) order for Tylenol 2 tabs (650mg) by mouth every 8 hours for pain. Review of the Emergency Management Services (EMS) report on 04/15/2024 at 3:10 PM revealed that on 10/03/2022 at 1:16 PM EMS was called and arrived at Resident #17 bedside at 1:35 PM. According to the pain assessment completed by EMS, Resident #17 had a chief complaint of left lower leg pain, rated as a 4, dull and radiation. EMS and Resident #17 left the facility at 1:58 PM and Resident #17 was taken to the hospital for further evaluation and treatment. During an interview on 04/15/2024 at approximately 3:50 PM, Director of Nursing (#2) and Regional Director of Nursing (#8) both stated that pain medication should have been given to Resident #17, however, they both stated they were not in the facility at that time of the incident. During an interview on 04/17/2024 at approximately 11:00 AM, the Regional Administrator #9 stated that he was in contact with LPN (#63) supervisor, and she was able to obtain a statement from LPN (#63) in reference to the pain medication. Review of LPN (#63) statement on 04/17/2024 at approximately 11:30 AM revealed she documented the following: I do not remember this incident however it is my practice to not give medications by mouth when a patient is being transferred to the hospital in preparation for further evaluation, up to and including surgery.

Based on observations, staff interviews, record reviews, and review of facility documents, the facility failed to ensure: 1) appropriate transmission based precautions were ordered and implemented (immediate isolation from asymptomatic roommates) for suspected COVID-19 residents (Resident (R) 1, 3, 5, 7 and 9), 2) staff properly used personal protective equipment (PPE) when caring for COVID-19 positive or COVID-19 suspected residents, 3) implementation of hand washing practices consistent with CDC (Centers for Disease Control and Prevention) guidelines to reduce the spread of respiratory germs, infections and prevent cross-contamination during the COVID-19 pandemic, and 4) posting of contact/droplet precaution signage throughout the facility to promote easy and correct use of PPE that describe the type of precautions needed and required PPE. These failures in proper infection control practices had the potential to affect all residents in the facility through the development and transmission of COVID-19 and other communicable diseases. It was determined the provider's non-compliance with one or more requirements of participation has caused, or was likely to cause, serious injury, harm impairment or death to residents. The Immediate Jeopardy (IJ) was related to §480.80 Infection Control. The Director of Nursing (DON) and the facility interim Administrator were made aware the IJ existed for the 114 residents in the facility on [DATE] at 2:00 PM. The sample size was 15 residents. An acceptable action plan was received on [DATE] at 6:45 PM. The Immediate Jeopardy was removed on [DATE] at 11:00 AM, after onsite verification on [DATE]. The findings included: A review of the facility policy titled Coronavirus revealed the following: A resident with known or suspected COVID-19, immediate infection prevention and control measures will be put in place. Resident will be transferred to Airborne Infection Isolation Room and if movement or transport is necessary, the resident is to wear a facemask. It is the policy of this facility to minimize exposures to respiratory pathogens and promptly identify residents with Clinical Features and Epidemiologic risk for the COVID-19 and to adhere to standard, contact and airborne precautions, including the use of eye protection. In the event of a facility outbreak, institute outbreak management protocols. Place residents in private rooms on contact precautions. Residents that have a confirmed case of COVID-19 can cohort with other residents who have a confirmed COVID-19. Cohort residents identified with same symptoms. Limit only essential personnel to enter room with Gloves, Gown, N95 respiratory protection and eye protection. Facility will keep a log of all persons who enter the room. Signs will be posted at the entrances, elevators and breakrooms to provide residents and staff if an outbreak is identified, instructions on hand and respiratory hygiene. Employees who have uprotected exposure to a resident with COVID-19 should report to the Infection Preventionist. Exclude from work for 14 days after last exposure. The policy was dated ,[DATE] A review of the facility's policy titled Isolation- Notices of Transmission- Based Precautions revealed the following: A. When transmission-based precautions are implemented, the Infection Preventionist (or designee) determines the appropriate notification to be placed on the room entrance door and on the front of the resident's chart so that personnel and visitors are aware of the need for and type of precautions. B. Signs and notifications comply with the resident's right to confidentiality or privacy. The following may be used to indicate: 1. Airborne Precautions: a. A notice at the doorway instructing visitors to report to the nurses' station before entering the room. b. A sign indicating Airborne Precautions on the door to the resident's room. c. A precautions sticker on the front of the resident's chart. 2. Contact Precautions: a. A notice at the doorway instructing visitors to report to the nurses' station before entering the room. b. A sign indicating Contact Precautions on the door to the resident's room. c. A precautions sticker on the front of the resident's chart. 3. Droplet Precautions: a. A notice at the doorway instructing visitors to report to the nurses' station before entering the room. b. A sign indicating Droplet Precautions on the door to the resident's room. c. A precautions sticker on the front of the resident's chart. The policy was dated ,[DATE]. Review of the facility document dated [DATE] entitled, Covid-19 Pandemic Plan revealed: Good judgement must be used since each potential pandemic is different. The focus is to assume the worst case scenario and try to put the systems in place to continue operations. The WHO has declared COVID-19 a pandemic. Communication will be extremely important to allay fear, keep everyone calm and follow the pandemic plan. With regard to cohorting residents with respiratory infection, the HCC will utilize the rehab unit for suspected or confirmed cases. According to CDC guidelines for COVID-19 infections at cdc.gov, Covid-19 is a coronavirus and based on what is currently known about COVID-19, spread is thought to occur mostly from person-to-person via respiratory droplets among close contacts. Recent studies indicate that people who are infected but do not have symptoms likely also play a role in the spread of COVID-19. Healthcare personnel caring for patients with confirmed or possible COVID-19 should adhere to CDC recommendations for infection prevention and control (IPC): oAssess and triage these patients with acute respiratory symptoms and risk factors for COVID-19 to minimize chances of exposure, including placing a facemask on the patient and placing them in an examination room with the door closed. oUse Standard and Transmission-Based Precautions when caring for patients with confirmed or possible COVID-19. oPerform hand hygiene with alcohol-based hand rub before and after all patient contact, contact with potentially infectious material, and before putting on and upon removal of PPE, including gloves. Use soap and water if hands are visibly soiled. oPractice how to properly don, use, and doff PPE in a manner to prevent self-contamination. 1) Resident Care and Appropriate Transmission Based Precautions The Director of Nursing (DON) provided a copy of the Covid-19 surveillance report. This report showed Resident (R) 1, 3, 5, 7 and 9 were suspected positive for Covid-19. On [DATE] at 10:15 AM, an observation of room assignment for the West Unit room [ROOM NUMBER] revealed that 2 residents were roomed together. R6 was not suspected of having covid, and R5 was suspected of having covid. There was no sign or visual alert posted outside of resident room indicating the type of precautions needed. No PPE supply cart was available outside the room for easy access. The review of the medical record on [DATE] for R6 revealed she did not have any signs/symptoms of Covid-19 and was not suspected of having Covid-19. R6 was admitted on [DATE] with a [DIAGNOSES REDACTED]. The nurse documented on [DATE] Resident alert, no coughing, sob, or c/o pain; afebrile. Interview with Employee (E) 1 on [DATE] at 10:20 AM, revealed that she did not know which residents were on transmission based precautions (TBP). E1 stated, We don't know. They didn't tell us nothing. We don't know who has the infection or Covid-19. They just gave us gowns today when you came. She additionally said, I'm concerned about the lack of communication. As you can see there are no signs posted for any precaution. R5 has symptoms of Covid-19. She has a cough and her roommate does not have symptoms. She did confirm that R5 was awaiting Covid-19 test results and was placed in the same room with R6 who was not suspected of having Covid-19. R5 was being tested since the resident was symptomatic. On [DATE] at 11:10 AM, an observation of Unit 2 North (West) revealed 8 residents (including R1, R3 and R9 suspected positive COVID-19) was located in the dining area, were not [MEDICATION NAME] social distancing measures of consistently staying six feet apart from one another. Only the staff members were wearing masks. No residents were seen wearing masks while they were in close proximity to each other. Further observation of the suspected covid19 resident rooms revealed there was no signage posted for isolation precautions. The required Personal Protective Equipment (PPE) carts were not present. Interview with E2 on [DATE] at 11:15 AM revealed that she did not know which residents were on transmission based precautions (TBP). E2 stated The DON did not communicate this to me. They don't communicate it. Our infection control nurse is not here today. When asked about how residents room assignment were done regarding suspected Covid-19, she responded, They get tested for covid because they are showing symptoms, while waiting for results, these residents were kept in the same room with the other residents who are not tested or showing symptoms. E2 also stated, They are not moved until they are positive for Covid-19. E2 informed surveyor that R1, R3, R7 and R9 were still waiting for covid 19 test results. When asked where each of the residents were located, while they were waiting for test results, she explained R1, R3, R7 and R9 are being roomed with residents who are not suspected of having covid. She further informed surveyor that a resident (R11) had died of covid last weekend and this resident was the roommate of one of the resident being currently tested (R9). E2 further stated that R10 was moved to the same room with R9. When asked if R10 was suspected of having covid, she stated No. She also explained that another resident (R8) had tested positive for covid and was then moved to the covid unit a few days ago. The roommate (R7) remained in the room and she has a nonproductive cough. She also informed surveyor that 2 other symptomatic residents (R1 and R3) were being roomed with residents that were not suspected of having covid (R2 and R4). Further review and observation of the room assignments on the surveillance/report, on [DATE] at 11:20 AM, revealed Residents (R1, 3, 5, 7 and 9) suspected positive for Covid-19 were housed in the same room with residents not suspected of Covid-19. All five residents suspected of covid (Resident (R) 1, 3, 5, 7 and 9) were not placed in a private room for isolation to contain [MEDICAL CONDITION]. The facility failed to ensure that the residents suspected of Covid-19 (R -1, 3, 5, 7 and 9) were immediately isolated from asymptomatic roommates (R-2, 4, 6 and 10) and failed to follow CDC guidelines to reduce the spread of respiratory germs (i.e. handwashing and spatial separation). As a result 3 of 4 asymptomatic roommates (R-2, 4 and 6) tested positive for Covid-19, a few days later. Only R10 tested negative for Covid-19. These findings were from the covid report reviewed on [DATE]. 2) PPE Usage An observation was made on [DATE] at 9:40 AM of E5, in room [ROOM NUMBER]. She was donning personal protective equipment (PPE, gowns and gloves). The door to the room had no signage posted for isolation precautions. E5 stated, I think I am only required to wear gown and gloves. I am not sure what precautions is required. They did not communicate it. An observation was made on [DATE] at 09:45 AM of E4, in room [ROOM NUMBER]. E4 was wearing full personal protective equipment (PPE, face shield, gown, gloves and two surgical mask). The two surgical mask were worn on the lower part of her face, one on top of the other. The door of the room she entered had no signage posted for isolation precautions. R15 in room [ROOM NUMBER] was not suspected of having an infection or Covid-19 per the surveillance report. An interview was conducted on [DATE] at 09:50 AM with E4 regarding her use of PPE for this room which had no indications of it being an isolation precaution room. E4 was asked why she was wearing PPE for this room. She stated, I need to protect myself because I don't know who has [MEDICAL CONDITION]. This is the first time we got these gowns. People are coughing. They don't tell me who has covid. An observation was made on [DATE] at 10:50 AM of E6, in room [ROOM NUMBER] talking with R14 (Covid-19 positive per the surveillance report). E6 was not wearing personal protective equipment eye protection goggles or shield. This room had no isolation precaution signage at the entrance. E6 was asked why she was not wearing eye protection for this room. She stated, Should I be wearing eye protection. I did not know that. I will get one. Thank you. A review of the facility's Covid-19 surveillance/report the DON provided dated [DATE] revealed eight total Covid-19 positive residents and seven Covid-19 positive staff. Interview with the nurse (E7) on [DATE] at 10:55 AM revealed that all residents on this unit were on isolation precautions for Covid-19. When asked about the type of precautions needed for residents in the isolation unit, E7 stated We just know. There is no signage. This is the covid unit. We wear full PPE. 3) Hand Washing Practices An observation was made on [DATE] at 11:25 AM of E3, in room [ROOM NUMBER] with R12. No isolation precaution signage was present at the entrance of the room. E3 was not wearing the necessary personal protective equipment (PPE, gowns and gloves). The door to the room had a PPE supply cart which contained PPE. E3 was then observed as she exited room [ROOM NUMBER]. E3 did not use hand sanitizer or wash her hands with soap and water at the resident sink before exiting the room. The next room [ROOM NUMBER] also had PPE cart present at the entrance. E3 was observed entering the room [ROOM NUMBER] without performing hand hygiene. E3 assisted in moving the side tables and resident towels in room [ROOM NUMBER]. When E3 was done in resident room [ROOM NUMBER], she did not washed her hands upon leaving. E3 then went to another room to attend to another resident in room [ROOM NUMBER] which also did not have a PPE cart present at the entrance. She again did not perform hand hygiene. Upon interview with E3 on [DATE] at 11:35 AM, when asked about why handwashing was not performed, she responded, I did not perform resident care, so I did not have to wash my hands when I left the room. When asked about why the PPE carts were present, she responded, I don't know if the resident is on isolation precaution. An interview with the DON, on [DATE] at 12:30 PM, DON was asked about the isolation signage not being present, and she confirmed that the isolation signage was not posted. She stated that, I took them down because of HIPAA (Privacy Rule) resident rights. Surveyor made DON aware that staff had informed surveyor that they do not know who is on isolation precautions or transmission based precautions since there were no signs. She stated I will put them up. Surveyor made DON aware that the room assignments for R1, R3, R5, R7 and R9 were observed to have a suspected covid resident rooming with a resident not suspected of Covid-19. It was also brought to her attention that the residents were not [MEDICATION NAME] social distancing within the dining hall where they were observed. An emphasis was placed on the increased risk of transmission in the way the residents were roomed together. DON was in agreement with these findings. Onsite verification of the removal plan was completed on [DATE], at 11:00 AM. The surveyor verified that the plan of removal & corrective actions taken by the facility had been fully implemented to prevent the serious adverse outcome from occurring or recurring. The decision was based on observations, staff interviews, review of education, in-services, and training provided by the facility to the staff and monitoring logs to verify the immediate corrective actions were in place.