Advanced Rehab At Autumn Lake Healthcare

Based on observations, record review, and interviews it was determined that the facility failed to maintain professional standards of practice related to oxygen orders. This was evident for 1 (Resident #5) out of 2 residents reviewed for respiratory care.
The findings include:
On 12/04/2025 at 1:05 PM, an observation of Resident #5 revealed that the resident was on 4 liters (the amount of oxygen) of oxygen.
On 12/05/2025 at 10:55 AM, record review failed to reveal an active order for oxygen.
On 12/05/2025 at 1:21 PM, an interview with the Director of Nursing revealed that the expectation was that if a resident was on oxygen, there should be an order to reflect it. The surveyor reviewed the concern.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, medical record review, and interviews, it was determined that the facility staff failed to ensure residents received respiratory care consistent with professional standards of practice by: 1) failing to ensure respiratory/oxygen equipment was properly labeled and dated, and 2) providing oxygen therapy without a valid physician order and at flow rates inconsistent with prescribed orders. This deficient practice was evident for 2 residents (Residents #1 and #96) out of 3 residents reviewed for respiratory/oxygen therapy during the facility's recertification/complaint survey.The findings include:The findings include:
Oxygen (O2) therapy is a treatment that provides you with extra oxygen to breathe in. It is also called supplemental oxygen. It is only available through a prescription from the health care provider.
Oxygen tubing is a medical-grade hose that connects an oxygen source (like a concentrator or tank) to an oxygen delivery device, such as a nasal cannula or mask. It is designed to be lightweight, flexible, and kink-resistant to ensure a steady and uninterrupted flow of oxygen for therapy.
Liters per minute (LPM) in oxygen therapy is the prescribed flow rate, measuring how much oxygen is delivered to a patient each minute, to increase the oxygen percentage in the air they breathe, helping to improve blood oxygen levels for conditions like respiratory distress.
The MDS (Minimum Data Set) is a federally mandated, standardized assessment tool used in Skilled Nursing Facilities (SNFs) to comprehensively assess a resident's clinical and functional status. The MDS is used to develop individualized care plans, monitor quality of care, and determine Medicare reimbursement.
1) On 12/04/2025 at 10:20 AM, during the initial tour of the facility, the surveyor observed Resident #1 in bed receiving oxygen therapy at 3.5 liters per minute (LPM). The oxygen tubing in use was not dated or labeled.
On 12/04/2025 at 10:24 AM, the Unit Manager, Licensed Practical Nurse (LPN) #4 was called for dual observation. He confirmed that the oxygen tubing was not dated or labeled. When asked about the facility's expectations regarding dating and labeling of oxygen tubing, he stated the tubing should be labeled and dated when initiated and changed weekly per order. When asked when the oxygen therapy for the resident began, he stated the attending provider prescribed oxygen on 12/03/2025 for shortness of breath. When asked what the ordered liter flow rate was, he stated 2 LPM, and confirmed the resident was receiving about 3.5 liters at the time.
On 12/04/2025 at 10:28 AM, during continued observation, the surveyor observed Resident #96 in bed receiving oxygen at 3.5 liters. The humidifier bottle and oxygen tubing were not dated or labeled.
On 12/04/2025 at 10:30 AM, the Unit Manager was brought in for dual observation and confirmed the humidifier and oxygen tubing were not dated or labeled. He stated the overnight nurses should have labeled them. When asked when the equipment was last changed, he stated he did not know and would need to review Resident #96's health record.
On 12/04/2025 at 11:43 PM, the Unit Manager, LPN #4, informed the surveyor that equipment had been labeled for both residents.
On 12/05/2025 at 12:16 PM, during a follow-up observation, the surveyor observed Resident #1 receiving oxygen at 3.5 liters per minute with oxygen tubing that was not labeled. The Director of Nursing (DON) was called for dual observation and confirmed that the tubing was not labeled. When asked about the facility's expectations, she stated the tubing should be labeled and dated to ensure timely changes. She stated she would re-educate unit managers and nursing staff regarding the requirement.
On 12/05/2025 at 12:19 PM, during continued follow-up with Resident #1, the surveyor observed the humidifier had been labeled, but the oxygen tubing remained unlabeled, and oxygen continued to run at 3.5 liters. The surveyor called the DON who was present on the unit at that time for a dual observation and she confirmed again that the tubing was not labeled and reiterated the facility's expectation for proper dating and labeling.
2) On 12/04/2025 at 10:20 AM, during the initial tour of the facility, the surveyor observed Resident #1 in bed receiving oxygen therapy at 3.5 liters per minute (LPM).
On 12/04/2025 at 10:24 AM, LPN #4, the Unit Manager, was called for dual observation. When asked when oxygen therapy was initiated for Resident #1, he stated the attending provider prescribed oxygen on 12/03/2025 for shortness of breath. When asked for the ordered flow liter, he stated the resident was to receive 2 LPM and confirmed the resident was receiving about 3.5 LPM at the time of observation.
On 12/04/2025 at 10:28 AM, during continued observation, the surveyor observed Resident #96 in bed receiving oxygen at 3.5 liters.
On 12/05/2025 at 10:06 AM, review of Resident #1's electronic health record showed that in his/her MDS assessment dated [DATE], Section J coded the resident as having shortness of breath, and Section O reflected that the resident was not receiving oxygen therapy at that time.
On 12/05/2025 at 10:10 AM, during a review of Resident #1's physician orders, the surveyor did not see an order for oxygen therapy. The only order present was for labeling oxygen tubing, which the Unit Manager confirmed he had placed after the surveyor informed him that the oxygen tubing was not dated or labeled.
On 12/05/2025 at 11:52 AM, during a review of Resident #96's electronic health record, the surveyor noted that the resident had an order dated 11/25/2025 stating: OXY Oxygen Inhalation (via nasal cannula at 2 LPM) ATTEMPT TO WEAN. Every shift, check every shift.
On 12/05/2025 at 12:19 PM, when the surveyor requested Resident #1's oxygen therapy order from the Director of Nursing (DON), she stated she would check and provide it.
On 12/05/2025 at 12:21 PM, the DON informed the surveyor that there was no oxygen order for the resident and stated that there should have been one in place. She further stated that she would inquire as to why an order had not been obtained.
On 12/05/2025 at 1:53 PM, the DON informed the surveyor that she had spoken with the physician, who stated that the resident was placed on oxygen at 2 LPM for shortness of breath related to pneumonia. She reported that she had entered the physician's order into Resident #1's electronic record. When informed that the absence of an oxygen order was a concern, she acknowledged the issue and stated that she was implementing measures to audit all residents receiving oxygen to ensure appropriate orders were in place.

Based on observation and interviews, it was determined that the facility failed to ensure a resident's dignified existence was maintained during a meal. This was evident for 1 of several observations made during meal times on the second floor units.
The findings include:
On 12/05/2025 at 12:14 PM, an observation while walking around the second floor units revealed Resident #2 in their room eating their lunch meal. The resident's bed was completely lowered to the floor and the resident was reaching their right hand up above their head onto the bedside table to eat off of their plate. The resident's bedside table which had their meal tray on it was above the resident's eye level.
On 12/05/2025 at 12:16 PM, an interview with the resident revealed that staff informed him/her that their bed had to be in the lowest position. Further interview revealed that he/she was unable to see what he/she was grabbing off of their plate nor how much food was left on the plate as it was above their eye level. The resident further indicated they had to feel the plate to determine how much food was left on it. On 12/05/2025 at 12:26 PM, Geriatric Nursing Assistant (Staff #9) walked into the room where the surveyor was with the resident.
At the same time, an interview with Staff #9 revealed that the expectation was when staff drop off a resident's tray, that they adjust their bed, the resident, and/or the bedside table to ensure the resident can eat properly. She further indicated that although Resident #2's bedside table was above their eye level, it was in the lowest position. She further indicated the staff keep the bed in the lowest position as the resident was a fall risk.
Further interview with Staff #9 revealed that she agreed the bedside table was above the resident's eye level and there should have been some adjustment made with the bed and/or bedside table so that the resident's dignity was maintained while eating.
On 12/05/2025 at 1:29 PM, the surveyor reviewed the finding with the Director of Nursing and she indicated that some adjustment should have been made so that the resident was able to see what was on their plate and not have to reach above their head to grab their food. She further indicated that she understood the concern.

Based on record review and interviews, it was determined that the facility failed to facilitate care plan meetings for residents. This was evident for 2 (Resident #45 and Resident #80) out of 3 residents reviewed for care planning.
Care plan meetings are scheduled discussions where the healthcare team reviews a resident's condition, needs, and progress, using information such as the Minimum Data Set (MDS). The team collaborates to set or update care goals and interventions, address concerts, and ensure care is coordinated and individualized, with input from the resident and/or family when possible.
The findings include:
1) On 12/04/2025 at 11:42 AM, an interview with Resident #45's representative revealed that he/she hadn't been invited to a care plan meeting in 2 years.
On 12/04/2025 at 1:14 PM, an interview with the Social Services Director (Staff #7) revealed that the expectation was that care plans were completed at least quarterly.
Further interview with Staff #7 revealed that residents and family members were invited to the care plan meetings, and the records of who attended were kept in a log book.
On 12/05/2025 at 1:19 PM, the surveyor requested the sign in sheet for Resident #45's care plan meetings within the last year.
On 12/08/2025 at 12:30 PM, an interview with Staff #7 revealed that the last care plan meeting date that she was able to find for Resident #45 was 12/27/2022.
2) On 12/11/2025 at 9:33 AM, an interview with Resident #80 revealed that the resident had not had a care plan meeting in a while.
On 12/11/2025 at 9:55 AM, record review revealed a progress note dated 06/20/2024 that mentioned a care plan meeting had been planned for 07/03/2024. The surveyor was unable to find any further documentation regarding a care plan meeting for the resident since the progress note dated 07/03/2024.
On 12/11/2025 at 10:29 AM, an interview with the Social Services Director (Staff #7) revealed that she was unable to find record of Resident #80's last care meeting date.
On 12/11/2025 at 1:09 PM, the concern was reviewed with the Director of Nursing and she indicated that she understood.

Based on record review, observations, and interviews, it was determined that the facility failed to accommodate a resident's needs based on their condition. This was evident for 1 (Resident #45) out of 1 residents reviewed for accommodation of needs.
The findings include:
On 12/04/2025 at 9:23 AM, record review revealed that Resident #45 was paralyzed on the left side (cannot move the left side of their body).
On 12/04/2025 at 12:45 PM, an observation of Resident #45 revealed that the resident's call bell was hung on the left hand side bed rail.
On 12/05/2025 at 12:11 PM, an observation of the resident revealed that the call bell was still on the resident's left side. At the same time, the resident requested the surveyor to adjust his/her bed. When the surveyor asked if he/she could reach the bed adjustment remote or call bell, he/she reached and further indicated they were unable to.
On 12/05/2025 at 12:16 PM, an interview with Geriatric Nursing Assistant (Staff #9) revealed that the expectation was that the call bell should be within the resident's reach.
On 12/05/2025 at 1:26 PM, the concern was reviewed with the Director of Nursing and she indicated that she understood.

Based on record review and interviews, it was determined that the facility failed to ensure that proper information was provided to the resident and/or resident representative regarding advanced directives. This was evident for 3 (Resident #4, #8, and #10) out of 6 residents reviewed for advance directives during an annual survey.
The findings include:
Advance directives are legal documents that explain a person's wishes for medical care if they are unable to speak for themselves. They may include instructions about treatments a person does or does not want and the designation of a healthcare proxy to make decisions on their behalf. These documents help ensure that medical care aligns with the person's values and preferences.
1) On 12/04/2025 at 1:32 PM, review of Resident #4's medical record failed to reveal an advanced directive.
On 12/05/2025 at 1:08 PM, an interview with the Social Services Director (Staff #7) revealed that the expectation was that advance directives were addressed upon admission and if a resident did not have one that the facility would provide them information to formulate one.
On 12/05/2025 at 1:12 PM, record review of the document titled, social service assessment, dated 11/08/2025, indicated that Resident #4 did not have an advanced directive on file and failed to reveal indication that information was provided to formulate one in result.
On 12/08/2025 at 9:38 AM, an interview with Staff #7 revealed that if information to formulate an advance directive was offered, it would be documented on the social service assessment form. The surveyor requested any further documentation that would indicate that the advance directive was offered.
On 12/08/2025 at 11:17 AM, a follow up interview with Staff #7 revealed that she was unable to find further documentation that the facility provided information to the resident and or representative to formulate an advanced directive.
2) On 12/04/2025 at 12:18 PM, review of Resident #8's medical record failed to reveal an advanced directive.
On 12/08/2025 at 8:38 AM, record review of the document titled, social service assessment, dated 10/21/2025, indicated that Resident #8 did not have an advanced directive on file and failed to reveal indication that information was provided to formulate one in result.
On 12/08/2025 at 1:48 PM, an interview with Staff #7 revealed that she was unable to provide the surveyor with documentation that would indicate information was provided to the resident and/or resident representative to formulate an advanced directive.
3) On 12/04/2025 at 1:45 PM, review of Resident #10's medical record failed to reveal an advanced directive.
On 12/08/2025 at 7:32 AM, record review of the document titled, social service assessment, dated 11/04/2025, indicated that Resident #10 did not have an advanced directive on file and failed to reveal indication that information was provided to formulate one in result.
On 12/08/2025 at 11:17 AM, an interview with Staff #7 revealed that she was unable to provide the surveyor with documentation that would indicate information was provided to the resident and/or resident representative to formulate an advanced directive.
On 12/11/2025 at 12:30 PM, the concerns were reviewed with the Director of Nursing and she indicated that she understood.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record reviews and interviews, it was determined that facility staff failed to ensure that residents and/or resident representative received complete and written notice of transfer and/or bed hold rights. This deficient practice was evident for 2 (Resident #55 and #84) out of 5 residents review for hospitalization/discharge during the annual survey.
The findings include:
1) On 12/09/2025 at 8:11 AM, a review of Resident #55's medical record revealed that the resident was transferred from the nursing facility to the hospital on [DATE] and 10/26/2025. Further review showed a nurse progress note dated 10/13/2025 at 10:49 AM that documented the resident was transferred to the hospital due to altered mental status and the emergency contact was made aware. On 10/26/2025 at 4:32 PM, a nurse progress note documented the resident was pocketing food, appeared lethargic, and was difficult to arose. The resident was ordered to be transferred to the emergency department. The emergency contact was notified and made aware.
During an interview with the Director of Nursing (DON) on 12/09/2025 at 8:17 AM, when asked about the process for resident transfer notices and bed hold notices, she explained that the facility follows multidisciplinary team approach. The nurse responsible for the resident at the time of transfer initiates the transfer notice and bed hold notice process, and the social worker sends the notices to the resident representative and the ombudsman. The surveyor requested to view the transfer notice and bed hold notice for Resident #55 dated 10/13/2025 and 10/26/2025.
During an interview with Registered Nurse (RN) #15 on 12/09/2025 at 8:30 AM, she explained that bed-hold notices and transfer notice forms are completed by nursing staff prior to a resident's transfer to the hospital. The original copy is placed in the resident's paper chart, and a copy is provided to the resident and/or the resident's family. The social worker is responsible for maintaining the transfer notices and bed hold notices forms.
On 12/09/2025 at 10:13 PM, the DON provided the surveyor with Resident #55's transfer notices dated 10/13/2025 and 10/26/2025. Review of the bottom of each form stated that the signature below acknowledges receipt of the transfer notice. The signature section was left blank on both forms.
A review of the bed hold notices dated 10/13/2025 revealed that the form was incomplete. Additionally, the bed hold notice dated 10/26/2025, was entirely blank, except for a section that was checked indicating the resident's emergency contact name was listed under the release of bed hold information.
12/09/2025 9:22 AM During an interview with the Social Services Director (SSD) #7, she explained the facility's transfer and bed hold notice process and stated that the completed notices are placed in a binder. When asked who is responsible for sending the written transfer and bed hold notices to the resident's representative, the SSD #7 stated that she does not mail the transfer or bed hold notices and further explained that she was unsure which staff member is responsible for mailing notices.
On 12/09/2025 at 10:43 AM, the surveyor reviewed the incomplete transfer and bed hold notice forms for Resident #55 dated 10/13/2025 and 10/26/2025. The surveyor informed the Administrator and DON that SSD #7 was unaware she is responsible for providing the resident's representative with written transfer and bed hold notices. Both the Administrator and DON acknowledged this information.
2) On 12/10/2025 at 9:50 AM, record review revealed Resident #84 was hospitalized on [DATE].
Further record review revealed a document titled, Notice of Resident Transfer or Discharge, dated 10/10/2025. Review of the document failed to reveal that a reason for the transfer was completed; the section was left blank. Further review of the document revealed at the bottom of the form it stated that the signature below acknowledges receipt of the transfer notice by the resident and/or resident representative. The signature section was left blank.
On 12/10/2025 at 11:57 AM, the surveyor reviewed the concern with the Director of Nursing and she indicated it should have been filled out by the resident or resident representative. She indicated she had no further documentation to support that a written notice of transfer was provided.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review and staff interviews, it was determined that facility staff failed to accurately code the resident's status on the Minimum Data Set (MDS) assessment. This failure was evident for 1 resident (Resident #77) out of 8 residents reviewed for MDS assessments during the facility's recertification/complaint survey.
The findings include:
The MDS (Minimum Data Set) is a federally mandated, standardized assessment tool used in Skilled Nursing Facilities (SNFs) to comprehensively assess a resident's clinical and functional status. The MDS is used to develop individualized care plans, monitor quality of care, and determine Medicare reimbursement.
On 12/05/2025 at 9:08 AM, review of physician orders dated 10/15/2025 showed an order for a hospice consultation, and physician orders dated 10/16/2025 showed the resident was admitted under [NAME] Hospice services, effective 10/15/2025.
On 12/05/2025 at 9:26 AM, review of Resident #77's most recent Significant Change in Condition (SCSA) MDS, completed on 10/15/2025, revealed that Section O, Item K1 (Hospice Care) was inaccurately coded. The MDS indicated that the resident was not on hospice, with a response of No, despite documentation showing hospice services were initiated effective that same date.
On 12/05/2025 at 10:46 AM, an interview was conducted with the MDS Coordinator (Staff #5). When asked about expectations regarding MDS accuracy, Staff #5 stated that all MDS assessments were expected to be coded accurately. When asked to identify the resident's significant change in condition, Staff #5 stated that the resident's admission to hospice on 10/15/2025 constituted the significant change. When asked how Section O should have been coded regarding hospice services, Staff #5 stated that the response should have been coded Yes instead of No and acknowledged that the incorrect coding was an error. Staff #5 further stated that, going forward, significant changes in condition would be accurately reflected and appropriately coded on the MDS.
On 12/05/2025 at 11:02 AM, the Director of Nursing (DON) was informed of the concern regarding the inaccurate MDS coding for Resident #77. The DON acknowledged the concern.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, record review, and interviews it was determined that the facility failed to ensure 1) a resident's comprehensive care plan included a resident's medical need regarding oxygen and medication, 2) to develop and implement a comprehensive, person-centered care plan to address a resident's significant change in condition related to hospice admission and end-of-life care needs, and 3) to conduct quarterly care plan meetings. This was evident for 1 (Resident #5) out of 2 residents reviewed for respiratory care, 1 (Resident #5) of 5 residents reviewed for medications,1 resident (Resident #77) out of 1 resident reviewed for hospice care, and 1 (Resident #90) out of 5 complaints reviewed during annual survey.
The findings include:
1a) A care plan is a resident-centered document that outlines identified needs, goals and interventions to guide the care provided. It must directly reflect the residents minimum data set (MDS), as the MDS identifies the resident's conditions, risks, and functional status. Any problems, risks, or changes identified on the MDS should be addressed in the care plan with appropriate goals and interventions, and the care plan should be updated to remain consistent with the resident's current assessed needs.
On 12/04/2025 at 1:05 PM, an observation of Resident #5 revealed that the resident was on oxygen.
On 12/05/2025 at 11:15 AM, review of section O of the MDS dated [DATE] revealed that Resident #5 was receiving oxygen at the facility.
Further record review failed to reveal that oxygen was included in Resident #5's comprehensive care plan.
On 12/05/2025 at 1:21 PM, an interview with the Director of Nursing (DON) revealed that the expectation was that oxygen would be in the care plan based on the medical services provided to meet the resident's needs.
On 12/08/2025 at 9:33 AM, the concerns were reviewed with the DON and she indicated that she understood.
1b) On 12/08/2025 at 9:41 AM, review of Resident #5's medical record revealed that he/she was admitted to the facility on [DATE].
At the same time, further record review revealed that the resident was admitted on [DATE] with an active diagnosis of mood disorder (a mental health condition where moods can change quickly), and was ordered risperidone (a medication used to treat mood disorder) upon admission. On 12/08/2025 at 9:52 AM, further record review failed to reveal that the condition nor medication that the resident was actively receiving treatment for was addressed in the comprehensive care plan.
On 12/08/2025 at 11:29 AM, an interview with the Director of Nursing (DON) revealed that the expectation was that resident diagnoses that were actively being treated at the facility should be included in the comprehensive care plan. The surveyor reviewed the concern with the DON and she indicated she understood.
2) The MDS (Minimum Data Set) is a federally mandated, standardized assessment tool used in Skilled Nursing Facilities (SNFs) to comprehensively assess a resident's clinical and functional status. The MDS is used to develop individualized care plans, monitor quality of care, and determine Medicare reimbursement.
Care Area Assessments (CAAs) are a crucial part of the Minimum Data Set (MDS) process in skilled nursing facilities, serving as prompts for detailed reviews of specific resident issues like delirium, nutrition, falls, or mood, forming the basis for personalized care plans by an interdisciplinary team (IDT) to address needs, set goals, and enhance resident well-being. These assessments trigger deeper evaluations beyond basic MDS data, ensuring comprehensive, individualized care plans for residents.
On 12/05/2025 at 9:08 AM, review of physician orders dated 10/15/2025 showed an order for a hospice consultation for Resident #77, and physician orders dated 10/16/2025 showed the resident was admitted under [NAME] Hospice services, effective 10/15/2025.
On 12/05/2025 at 9:26 AM, a review of the resident's most current comprehensive and most recent quarterly Minimum Data Set (MDS) and Care Area Assessments (CAAs) related to the resident's significant change in condition on 10/15/2025 was conducted for areas pertinent to the resident's end-of-life care, services, and needs.
On 12/05/2025 at 9:31 AM, review of pertinent documentation revealed that the resident began receiving hospice services effective 10/15/2025; however, no care plan addressing hospice or end-of-life care needs was present in the medical record.
On 12/05/2025 at 9:37 AM, review of the resident's care plan showed that the care plan was not initiated until 12/04/2025, the date the survey team arrived at the facility.
On 12/05/2025 at 10:01 AM, an interview was conducted with the Unit Manager, Licensed Practical Nurse (LPN) #4, when asked about expectations regarding care plans, he stated that a baseline care plan was completed upon admission and reviewed and updated as needed. When asked about care plan updates following a change in condition, he stated that care plans were updated after a change in condition. When asked when the resident was admitted to hospice, he stated that the resident was admitted in October and added that the care plan should have been initiated on the day of hospice admission or the following day.
On 12/05/2025 at 10:36 AM, an interview was conducted with the Director of Nursing (DON). When asked about expectations for care plan initiation, the DON stated that a resident should have a baseline care plan within 24 hours of admission and a comprehensive care plan completed within 14 days. The DON further stated that care plans should be initiated or updated following a change in condition, particularly when the change was significant. When asked when the care plan for this resident was completed, the DON stated that it was completed on 12/04/2024. When asked when the care plan should have been initiated, the DON stated that the care plan should have been initiated following the resident's change in condition on 10/15/2025, and not on 12/04/2025.
On 12/05/2025 at 10:43 AM, when the DON was informed that the failure to initiate and update the care plan following the resident's significant change in condition was a concern, she acknowledged the concern and stated that audits would be conducted, and education would be provided to nursing staff regarding timely care plan initiation and updates.
3) On 12/09/2025 at 1:39 PM, a review of complaint intake #2624519 revealed concerns related to Resident #90s hearing and vision, which had been reported to facility staff on multiple occasions.
A review of Resident #90s medical records revealed the resident was admitted to the facility on [DATE], for skilled rehabilitation services. Further review revealed that an initial interdisciplinary care conference was conducted on 04/16/2025, with the resident, two family members, Social Services Director, and Director of Physical Therapy were in attendance.
Further review of the medical records revealed that the resident was discharged from physical and occupational therapy services on 06/30/2025 and remained in the facility under long term care services until September 2025. Records review failed to show evidence of a care plan meeting nor conference following 04/16/2025.
On 12/10/2025 at 1:45 PM, the surveyor requested care plan meeting notes and attendance records after 04/16/2025 from the Director of Nursing (DON).
At 2:10 PM, the Social Services Director informed the surveyor that she was unable to provide the requested information, as no additional care plan meetings were conducted following 04/16/2025.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record reviews and interviews, it was determined that facility staff failed to ensure a geriatric nursing assistant (GNA) maintained an active certification. This deficient practice was evident for 1 (GNA #2) out of 4 GNA employee files reviewed during the annual survey.
The findings include:
On [DATE] at 7:30 AM, the surveyor reviewed the employee file for GNA #2, which failed to show evidence of an active GNA license. Further review of the filed revealed that the employee annual performance review was conducted on [DATE].
On [DATE], a GNA license search was conducted using Maryland Board of Nursing license lookup which revealed a license expiration date of [DATE] with a status of not renewed. The surveyor informed the Director of Nursing of the expired license and requested evidence of an active license and documentation of shifts worked since [DATE].
On [DATE] at 10:04 AM, during an interview with Human Resources (HR) the surveyor inquired about the process for ensuring nursing employee files are up to date. The HR explained that monthly employee file audits are conducted and a tracking system was used to identify employee who are due for license renewal and annual performance review. The surveyor informed HR of GNA #21 expired license and requested evidence of active license.
On [DATE] at 1:26 PM, the DON and HR provided the surveyor with GNA #21's work schedule. Review of the schedule revealed that GNA #21 worked every weekend from [DATE] until [DATE] with an expired license.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, review of records, review of complaints and staff interviews, it was determined that the facility failed to 1) ensure narcotic record books were consistently signed by both incoming and outgoing nurses, 2) ensure that drug records were maintained in a manner that accounted for all controlled drugs and allowed for reconciliation of dispensed and administered medication, and 3) ensure that medication was administered in accordance with physician ordered parameters. This was evident for 8 of 8 medication carts observed during the medication storage task, 2 (Complaint #2646715, #2613978 ) of 5 complaints reviewed, and 1 (Resident #71) of 2 residents reviewed for pharmacy services during the annual survey.
The findings include:
The MDS (Minimum Data Set) is a federally mandated, standardized assessment tool used in Skilled Nursing Facilities (SNFs) to comprehensively assess a resident's clinical and functional status. The MDS is used to develop individualized care plans, monitor quality of care, and determine Medicare reimbursement.
Brief Interview for Mental Status (BIMS) is a quick cognitive screening tool used in healthcare (especially long-term care) to check for memory, orientation, and recall (like remembering three words) in patients, scoring 0-15 to flag potential impairment.
1) On 12/09/2025 at 8:50 AM, during a medication cart observation on unit 2, the surveyor reviewed the narcotic record book and observed multiple missing signatures.
During an interview with Registered Nurse (RN) #15 who confirmed the missing signatures, when asked whether narcotics were counted at shift change that morning, RN #15 stated, Yes. When asked about expectations for signing the narcotic record book, she stated that the book should be signed by the incoming nurse and the outgoing nurse.
On 12/09/2025 at 9:28 AM, during a medication administration observation of Licensed Practical Nurse (LPN) #17 on unit 3, the surveyor reviewed the narcotic record book and observed that it had not been signed that morning by the incoming nurse. LPN #17 confirmed that she was the incoming nurse and stated that the lack of signature was an oversight. The surveyor also observed multiple missing signatures in the narcotic record book. When asked about expectations regarding signing the narcotic record book, LPN #17 stated that the outgoing nurse and incoming nurse were expected to sign the narcotic record book every shift after counting the controlled medications together.
On 12/09/2025 at 9:49 AM, during an observation of medication cart on unit 4, the surveyor reviewed the narcotic record book and observed that it had not been signed that morning. LPN #13 stated that it had been a busy morning and that she had counted the narcotics with the outgoing nurse but forgot to sign the record. The surveyor also observed multiple missing signatures in the narcotic record book. When asked about expectations for signing the narcotic record book, LPN #13 stated that both the outgoing nurse and incoming nurse were required to sign the narcotic record book across all shifts after completing the count together.
On 12/09/2025 at 11:32 AM, during an interview with the Director of Nursing (DON), the surveyor asked about expectations regarding signing narcotic record sheets. The DON stated that incoming and outgoing nurses were expected to count and account for all narcotics at shift change and that both nurses were required to sign the narcotic record sheet. The surveyor discussed the concerns identified during medication observations with the DON, who stated that she would provide education for all staff involved.
2) On 12/10/2025 at 12:47 PM, review of Complaint #2646715 revealed that on 10/17/2025, a complaint was filed with the State Agency alleging that on 10/04/2025 and/or 10/05/2025, the facility's narcotic record sheet reflected that a controlled substance had been administered to the complainant's loved one; however, the resident reported that he had not received the medication. The complainant further stated that review of the resident's chart did not show documentation that the medication was administered during that period.
On 12/10/2025 at 12:52 PM, review of Resident #91's clinical record revealed that the resident had a Brief Interview for Mental Status (BIMS) score of 12 out of 15 on the Minimum Data Set (MDS) assessment dated [DATE], indicating that the resident was cognitively intact at the time of the alleged incident.
On 12/11/2025 at 7:15 AM, review of Resident #91's physician orders in the electronic health record revealed an active order dated 09/29/2025 for Oxycodone HCl 5 mg oral tablet, to be administered 5 mg by mouth every six (6) hours as needed for pain rated 5–10.
On 12/11/2025 at 7:28 AM, review of the controlled drug administration record provided by the pharmacy revealed that Oxycodone HCl 5 mg was removed from the narcotic supply on the following dates and times:
10/04/2025 (no time documented)
10/05/2025 at 8:15 AM
10/05/2025 at 1:56 PM
10/05/2025 at 9:00 PM
10/12/2025 at 9:50 AM
On 12/11/2025 at 7:39 AM, review of the resident's Medication Administration Record (MAR) for October 2025 failed to show documentation that Oxycodone HCl 5 mg was administered to the resident on the above-listed dates, despite the medication being removed from the controlled drug supply.
On 12/11/2025 at 9:49 AM, during an interview with the Director of Nursing (DON), the surveyor asked about expectations regarding the administration and documentation of controlled substances. The DON stated that the nurse administering a controlled medication was expected to sign the pharmacy-provided controlled drug record to indicate removal of the medication from the narcotic supply and document the remaining count and then sign the MAR to indicate that the medication was administered to the resident. When informed of the discrepancy between the controlled drug removal record and the lack of documentation on the MAR, the DON stated that such practice was not acceptable. The DON further stated that all licensed nursing staff would be educated on proper documentation of controlled substances and that random audits would be conducted to prevent recurrence.
3a) On 12/10/2025 at 8:50 AM, review of Complaint #2613978 revealed that on 09/10/2025, a complaint was filed with the State Agency alleging that Resident #87 reported experiencing increased pain due to missed pain medication on multiple occasions, which reportedly interfered with the resident's ability to participate in therapy services.
On 12/10/2025 at 8:57 AM, review of Resident #87's clinical record revealed a MDS discharge assessment dated [DATE], which documented a Brief Interview for Mental Status (BIMS) score of 15 out of 15, indicating that the resident was cognitively intact at the time of the complaint.
On 12/10/2025 at 9:34 AM, review of Resident #87's physician orders revealed an order dated 08/18/2025 for Oxycodone HCl 5 mg oral tablet as follows:
Give three (3) tablets by mouth every four (4) hours as needed for pain rated 7 to 10, and
Give two (2) tablets by mouth every four (4) hours as needed for pain rated 4 to 6.
On 12/10/2025 at 9:59 AM, review of the Medication Administration Record (MAR) revealed that Oxycodone HCl 5 mg, two (2) tablets, prescribed for pain rated 4 to 6, was administered on the following dates and times when the documented pain level did not meet the ordered parameters:
08/28/2025 at 5:07 AM with pain level of 0
08/29/2025 at 7:33 PM with pain level of 0
08/30/2025 at 5:50 AM with pain level of 0
09/04/2025 at 7:31 PM with pain level of 8
09/05/2025 at 6:36 AM with pain level of 10
09/09/2025 at 6:02 AM with pain level of 8
09/12/2025 at 10:22 AM with pain level of 0
09/15/2025 at 5:35 PM with pain level of 7
Further review of the MAR revealed that Oxycodone HCl 5 mg, three (3) tablets, prescribed for pain rated 7 to 10, were administered on the following dates and times when the documented pain level did not meet the ordered parameters:
08/28/2025 at 00:04 AM with pain level of 0
08/31/2025 at 6:34 AM with pain level of 0
08/31/2025 at 10:00 PM with pain level of 5
09/05/2025 at 11:45 AM with pain level of 5
04/06/2025 at 8:16 PM with pain level of 6
09/09/2025 at 1:31 PM with pain level of 6
09/10/2025 at 6:00 PM with pain level of 5
09/11/2025 at 8:34 PM with pain level of 6
09/12/2025 at 00:37 AM with pain level of 6
09/18/2025 at 6:33 PM with pain level of 0
09/19/2025 at 6:49 AM with pain level of 5
On 12/10/2025 at 12:16 PM, during an interview with the Director of Nursing (DON), the surveyor asked about expectations regarding administration of pain medications. The DON stated that pain medications were to be administered strictly in accordance with physician orders and the prescribed pain scale parameters. When informed of the findings related to both under-medication and over-medication of Resident #87, as well as administration of pain medication when not clinically indicated, the DON acknowledged the concern and stated that the staff involved would be reeducated. The DON further stated that all nursing staff on the unit would receive reeducation regarding adherence to physician orders and proper pain assessment and medication administration.
3b) On 12/09/2025 at 12:57 PM, a review of Resident #71's Medication Administration Record (MAR) for November and December 2025 revealed that the following medications were administered outside of the physician ordered parameters:
Doxazosin Mesylate 4mg was ordered to be held for systolic blood pressure (SBP) less than 110mmHg, however, the medication was administered on the following dates:
11/08/25 SBP of 104/73
11/11/25 SBP of 99/58.
12/08/25 SBP of 101/56
Losartan Potassium-Hydrochlorothiazide 100-25mg was ordered to be held for SBP less than 110mmHg, however, the medication was administered on the following dates:
11/09/25 SBP of 104/57
11/11/25 SBP of 99/58.
Nifedipine 60mg was ordered to be held for SBP less than 110mmHg, however, the medication was administered on the following dates:
11/10/25 SBP of 102/60
11/20/25 SBP of 83/56
12/05/25 SBP of 106/59
Carvedilol 25mg, was ordered to be held for SBP less than 110mmHg, however, the medication was administered on the following dates:
11/10/25 SBP of 102/60
11/14/25 SBP of 92/57
12/05/25 SBP of 106/59
Clonidine 0.1mg, was ordered to be held for SBP less than 110mmHg, however, the medication was administered on the following dates:
11/05/25 SBP of 106/72
11/09/25 SBP of 104/57
11/10/25 SBP of 102/60
11/20/25 SBP of 97/48
12/05/25 SBP of 106/59
Oxycodone 5mg was ordered on 10/27/25, for staff to administer three tablets as needed (PRN) for severe pain rated 7-10 and was discontinued on 11/07/25. The medication was administered on the following dates:
11/03/25 pain score of 5- medication administered.
11/04/25 pain score of 6-medication administered.
11/05/25 pain score of 5-medication administered.
11/06/25 pain score of 5-medication administered
11/07/25 at 12:33 AM, pains score of 5-medication administered.
11/07/25 at 06:31 AM, pain score of 5-medication administered.
Oxycodone 5mg was ordered on 11/07/25, for staff to administer three tablets PRN for severe pain rated 7-10 and was discontinued on 11/19/25. The medication was administered on the following dates:
11/10/25 pain score of 4-medication administered.
11/14/25 pain score of 4-medication administered.
11/17/25 pain score of 1-medication administered.
Oxycodone 5mg was ordered on 11/19/25 for staff to administer three tablets PRN for severe pain of 8-10 and was discontinued on 11/28/2025. The medication was administered on the following dates:
11/22/25 at 6:30 PM, pain score of 0-medication administered.
11/22/25 at 9:30 PM, pain score of 0-medication administered.
11/23/25 pain score of 0-medication administered.
11/24/25 pain score of 2-medication administered.
11/27/25 pain score of5-medication administered.
Oxycodone 5mg was ordered on 11/28/2025 for staff to administer two tablets PRN for pain rated 5-10. The medication was administered on the following dates:
12/04/25 at 3:03 AM, pain score of 1-medication administered.
12/04/25 at 6:08 AM, pain score of 0-medication administered.
12/04/25 at 1:11 PM, pain score of 3-medication administered.
12/06/25 pain score of 0-medication administered.
The November 2025 MAR included an order to offer non-pharmacological interventions including repositioning, food or drink, and back rubs prior to administering PRN medication and to document interventions. A review of records from 11/01/2025-11/30/2025 showed these services were not documented as offered prior to medication administration.
On 12/09/2025 at 1:26 PM, during an interview, the Director of Nursing (DON) explained that staff are expected to administer medications as ordered by the physician's parameters and document when medications are held if the order parameters are not met. The surveyor review Resident #71's MAR for November and December 2025 with the DON which showed medications were administered outside of the physician's parameters. The DON acknowledged the findings and stated staff education would be provided.

Based on record review and interview, it was revealed that the facility failed to ensure the Skilled Nursing Facility Advance Beneficiary Notice of Non-coverage (SNFABN) form was completed entirely. This was evident for 1 (Resident #26) out of 3 residents reviewed for beneficiary notification.
The findings include:
In a nursing home, beneficiary notifications are required notices given to residents or their representatives to inform them of changes in Medicare or Medicaid coverage, services or financial responsibility. These notices explain when covered services are ending, when services may not be covered, any potential costs to the resident, and the resident's right to appeal. Providing timely beneficiary notifications helps protect resident rights and ensures regulatory compliance.
On 12/11/2025 at 10:12 AM, record review of the SNFABN document revealed that Resident #26's SNFABN form was incomplete. The section which asked the resident which option they would like regarding the billing of Medicare was left blank.
On 12/11/2025 at 10:12 AM, an interview with Staff #7 revealed that the expectation was that the form should be completely filled out. During the interview, the surveyor reviewed the document noted above with Staff #7, she indicated she was unable to indicate which option the resident chose as none were checked off. She further indicated it should have been filled out entirely including an option marked.
On 12/11/2025 at 10:30 AM, the concern was addressed with the Director of Nursing and she indicated that she understood.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, record reviews, and interviews, it was determined that facility staff failed to establish infection control interventions to prevent the transmission of infection to residents. This deficient practice was evident for 3 (Resident #55, #3, and #95) of 5 residents reviewed for the infection control task during the annual survey.
The findings include:
On 12/04/2025, observations were made of Resident #3 at 9:07 AM, Resident #95 at 11:10 AM, and Resident #55 at 11:43 AM in their assigned rooms. During the observations, the surveyor noted that enhanced barrier precautions (EBP) signage was not posted on the residents' doors, and personal protective equipment (PPE) was not available outside of the residents' rooms.
A review of Resident #3 medical record revealed an admission to the facility on [DATE], with multiple diagnosis, including orthopedic aftercare. The medical record included an order for daily wound dressing changes, however, further review failed to show an order for EBP.
A review Resident #95 medical record revealed an admission to the facility on [DATE], with a left femur fracture. The medical records included an order for left lower extremity dressing changes, however, further review failed to show an order for EBP.
A review of Resident #55's medical record revealed the resident was admitted to the facility on [DATE]. In October 2025, the resident had physician orders for PICC line dressing change, daily wound dressing change, and foley catheter care. Further review of the medical records failed to show an order for EBP. Additionally, on 10/20/2025 the resident was ordered Vancomycin four times daily for Clostridioides Difficile infection; however, the medical records failed to show evidence that transmission-based precautions were ordered.
On 12/08/2025 at 7:30AM, a review of the medical records for Resident #3, Resident #95, and Resident #55, revealed that the Director of Nursing (DON) entered an order on 12/07/2025, for EBP.
During an interview on 12/08/2025 at 9:30 AM, the DON stated that EBP are required for residents with tube feedings, foley catheters, and wounds requiring dressing changes. The DON stated that the admitting nurse or unit manager were responsible for ensuring EBP orders were entered. When asked about the lack of EBP orders prior to 12/07/2025 for Resident # 3, Resident #95, and Resident #55, the DON was unable to provide an explanation. Additionally, the DON could not explain why transmission-based precautions were not initiated in October 2025 for Resident #55.

Based on observations, review of medical records, and interview with facility staff, it was determined that the facility failed to follow physician orders as evidenced by: 1) ensuring ordered ACE wraps were in place, 2) administering medication as ordered by the physician, and 3) a resident not receiving the ordered amount of oxygen. This was evident for 3 (Residents #40, #15, #37) of 9 residents reviewed during the survey.
The findings include:
1) On 6/13/24 during initial tours of the facility and multiple surveyor observations of Resident #40 with the last observation of the day made at 2:12 PM, Resident #40 was observed without any ACE wraps in place anywhere on the resident.
Medical record review for Resident #40 on 6/14/24 at 10:20 AM revealed multiple diagnosis including lymphedema, essential (primary) hypertension, pulmonary embolism, personal history of transient ischemic attack, atherosclerotic heart disease of native coronary artery, and chronic kidney disease, stage 4 (severe). Furthermore, Resident #40's physician orders were reviewed and noted the following, ACE wraps toes to knees on in am, off in pm, one time a day for edema, with a facility time code noted as QD 9a (every day at 9:00 AM). The order was created by Physician #31 on 6/12/24 at 5:33 PM.
Resident #40 was observed again on 6/14/24 at 10:30 AM. The resident was lying in bed and at that time no ACE wraps were observed on the resident.
Surveyor observed on 6/18/24 at 9:21 AM, the resident was lying in bed with no ACE wraps observed on their legs.
On 6/18/24 at 10:01 AM, in an interview with Licensed Practical Nurse (LPN) #54, when asked about Resident #40's ACE wraps for his/her legs, she stated this is my first day ever working in this building. When asked if LPN #54 had reviewed Resident #40's orders, she indicated she had not logged on to the system yet as she had a log in, but it had to get reset.
On 6/18/24 at 10:09 AM in an interview with Unit Manager (UM) #6, when asked the process for when staff do not have access to the electronic health record (EHR), she stated they can come to one of us [clarified us as the UM, Director of Nursing (DON), or Assistant Director of Nursing (ADON)] and we can email IT (information technology for the EHR). They can also call the IT number. The response time is sometimes quick and sometimes not. During the interview, when asked why Resident #40 was ordered ACE wraps she stated, he/she has lymphedema. When asked when they are to be applied, UM #6 stated, in the morning and removed at night. When asked about the application and removal time on the order, she looked in the EHR and stated, it seems the doctor came in after [me] and also created an order. UM #6 stated, I will update and get rid of one of these orders.
The second order stated, Apply ace wraps to BLEs (bilateral lower extremities) on in the morning and remove at bedtime every evening and night shift for lymphedema with a facility time code of 3-11/11-7 (ace wraps removed for the 3PM-11PM and 11PM-7AM shift). Therefore, per this order, starting at 7:01AM, the ACE wraps should have been applied to both of the resident's lower legs. When asked why the ACE wraps were not currently on Resident #40's legs, UM #6 stated, Clarification of the orders since there are two ACE wrap orders. However, either order a staff member read in the EHR, the ACE wraps should have been applied to the resident's legs [per the physician orders] at all the above times the resident was observed without ACE wraps.
2) On 6/13/24 10:24 AM in an interview with Resident #15, they stated there are times when they are in pain because their pain medicine has run out and they have to wait for it.
Medical record review for Resident #15 on 6/17/24 at 10:33 AM revealed on 4/22/24 the physician ordered:
Ibuprofen Oral Tablet 400 MG (Ibuprofen), Give 2 tablet by mouth every 6 hours as needed for pain 1-3,
Morphine Sulfate Oral Tablet 15 MG (Morphine Sulfate) *Controlled Drug*, Give 1 tablet by mouth every 4 hours as needed for Pain scale 4-5,
Morphine Sulfate Oral Tablet 15 MG (Morphine Sulfate) *Controlled Drug*, Give 2 tablet by mouth every 4 hours as needed for pain scale 6-10.
On 6/21/24 at 12:57 PM review of the Medication Administration Record (MAR) revealed the facility staff documented on:
5/27/24 at 5:00 PM a pain score of 5 and administered 2, 15mg tablet of Morphine Sulfate Tablet,
5/29/24 at 9:01 AM a pain score of 5 and administered 2, 15mg tablet of Morphine Sulfate Tablet,
5/31/24 at 5:53 PM a pain score of 8 and administered 1, 15mg tablet of Morphine Sulfate Oral Tablet,
5/31/24 at 10:03 PM a pain score of 8 and administered 1, 15mg tablet of Morphine Sulfate Oral Tablet,
6/1/24 at 3:00 AM a pain score of 5 and administered 2, 15mg tablet of Morphine Sulfate Tablet,
6/1/24 at 9:19 AM a pain score of 6 and administered 1, 15mg tablet of Morphine Sulfate Oral Tablet,
6/1/24 at 2:02: PM a pain score of 8 and administered 1, 15mg tablet of Morphine Sulfate Oral Tablet,
6/1/24 at 5:55 PM a pain score of 5 and administered 2, 400mg tablet of Ibuprofen Oral Tablet,
6/2/24 at 6:13 AM a pain score of 6 and administered 1, 15mg tablet of Morphine Sulfate Oral Tablet,
6/4/24 at 12:30 AM a pain score of 5 and administered 2, 15mg tablet of Morphine Sulfate Tablet,
6/4/24 at 4:00 PM a pain score of 4 and administered 2, 15mg tablet of Morphine Sulfate Tablet,
6/11/24 at 12:30 AM a pain score of 0 and administered 2, 15mg tablet of Morphine Sulfate Tablet; however, the documented pain scale and pain medications administered were outside the parameters as indicated by the physician.
Interview with the DON and ADON on 6/21/24 at 1:27 PM were notified of the concerns related to administration of pain medication outside of the physician ordered parameters for Resident #15.
3) On 06/13/24 at 09:49 am the surveyor observed Resident #37 resting in bed with oxygen tubing in their nose and the oxygen concentrator was set to humidified 3 liters(L) of oxygen (02) via nasal cannula (NC).
On 06/13/24 at 1:43 pm A review of the medical record revealed an order dated 05/02/24, at 6:39 pm for Resident #37 to receive 2 liters of oxygen via nasal cannula continuously. It also specified that after every shift post treatment the resident's heart rate, respiratory rate, pulse oximetry, skin color, and breath sounds should be evaluated.
On 06/17/24 at 11:54 am, Resident #37 was observed resting in bed with humified oxygen set at 3L via NC.
On 06/17/24 at 11:55 am during an interview with the resident's assigned nurse LPN #14, the surveyor asked how many liters of 02 Resident #37 was ordered. LPN #14 stated it was set to 2 liters. LPN #14 and the surveyor entered Resident #37 room and confirmed that the oxygen concentrator was set at 3 liters. LPN #14 reported they would contact the resident's doctor for a new oxygen order.

Based on surveyor observations, review of the medical record, and interview with facility staff, it was determined the facility staff failed to provide residents with respiratory care consistent with professional standards by failing to ensure there was a physician order for oxygen administration/indication, failing to administer oxygen as prescribed, and failing to develop plans of care to address the resident's respiratory needs. This was evident for 1 (#85) of 3 residents reviewed for respiratory care during the investigation phase of the survey.
The findings include:
Oxygen flow meters are a relatively simple device that consist of a tube through which gas passes and a small, free-moving indicator such as a ball. When valves are open, the gas moves through the flow meter and causes the ball to float. A numbered scale on the tube along with the indicator allows the healthcare provider to determine the flow rate of oxygen. To ensure the most accurate reading of the flow rate, read the flow meter from a close distance, straight in front of the meter, and at eye level with the indicator.
On 6/13/24 at 11:32 AM Resident #85 was observed receiving oxygen via nasal cannula at a flow rate of 2.5 Liters per minute (L/min). A nasal cannula is a device that delivers oxygen directly to a person's nostrils via a flexible plastic tube.
On 6/14/24 at 1:19 PM during review of Resident #85's medical record, no physician order for oxygen could be found in the electronic health record (HER) or paper chart. Further review revealed Resident #85's diagnoses included chronic obstructive pulmonary disease, emphysema, atrial fibrillation, and atherosclerotic heart disease, all of which can affect a person's breathing and respiratory care and services needed. However, there was no respiratory care plan that identified a focus, goal, or intervention to address the resident's respiratory care or services.
During a second observation that took place on 6/17/24 at 11:31 AM, Resident #85 was noted to still be receiving oxygen at a flow rate of 2.5 L/min.
On 6/17/24 at 11:34 AM, in an interview with Licensed Practical Nurse (LPN) #19, when asked how many liters of oxygen Resident #85 was currently receiving, she stated they are on 3L. Upon surveyor intervention, LPN #19 bent down to eye level and stated, Oh, they are on 2.5 L, but they are supposed to be on 3 L. When asked how many liters the order stated the resident is supposed to be receiving, LPN #19 looked in the EHR and stated, it is not on their treatment administration record (TAR), and not under their physician orders. When asked if there should be a physician order for a resident to be on oxygen, LPN #19 stated, yes. LPN confirmed there was no oxygen order for Resident #85 in the EHR.
On 6/17/24 at 12:15 PM in an interview with LPN #19, she stated I could not find an oxygen order for the resident in the paper chart. She also stated, I notified the Unit Manager (UM) #10 and he is going to follow up with the doctor(Staff #31.)
On 6/17/24 at 12:19 PM in an interview with UM #10, when asked about an oxygen order for Resident #85, he stated, I did not see there was one. I am trying to figure out what they were on it for. I think it was just for comfort in the hospital. When asked if there should be a physician order for residents receiving oxygen he stated, Yeah, there should be an order for a resident to be on oxygen.
On 6/17/24 at 1:03 PM, the Director of Nursing (DON) was made aware of the findings. During the interview, she confirmed there should be an oxygen order for residents receiving oxygen.
On 6/17/24 at 2:42 PM in an interview with the DON she stated, I just talked to the medical director and will bring a copy of the oxygen order.
On 6/17/24 at 3:36 PM, review of the facility's Oxygen Administration policy stated, Oxygen is administered to residents who need it, consistent with professional standards of practice, the comprehensive person-centered care plans, and the resident's goals and preferences. Further review revealed Policy Explanation and Compliance Guidelines:
1.Oxygen is administered under orders of a physician, except in the case of emergency. In such case, oxygen is administered and orders for oxygen are obtained as soon as practicable when the situation is under control.
3. The resident's care plan shall identify the interventions for oxygen therapy, based upon the resident's assessment and orders, such as, but not limited to:
a. The type of oxygen delivery system
b. When to administer, such as continuous or intermittent and/or when to discontinue.
c. Equipment settings for the prescribed flow rates.
d. Monitoring of SpO2 (oxygen saturation) levels and/or vital signs, as ordered.
e. Monitoring for complications associated with the use of oxygen.
On 6/17/24 at 3:46 PM, the DON provided a copy of an oxygen order for Resident #85 that stated, oxygen 2 liters via nasal cannula every shift for COPD, with an order date of 6/17/24 at 3:44 PM.
A third observation of Resident #85's oxygen rate was made on 6/18/24 at 10:47 AM. The oxygen rate at that time was noted to be 2.5 L/min.
On 6/18/24 at 10:57 AM in an interview with LPN #28, she stated the only one [resident] who has oxygen on my assignment is Resident #85 and they are receiving 2L.
On 6/18/24 at 11:16 AM, LPN #28 entered Resident #85's room and reported the resident was receiving 3L and she did not even realize they were supposed to be on 3L of oxygen [surveyor observed resident on 2.5L]. When asked about the resident's oxygen order, LPN #28 pulled up the resident's orders in the EHR and stated the resident is ordered 2L NC. LPN #28 re-entered the resident's room at 11:19 AM and adjusted the knob on the oxygen flow meter stating the resident was now on the 2L of oxygen [surveyor observed resident on 1.5L]. Upon surveyor intervention, LPN #28 adjusted the knob on the oxygen flow meter to read 2L as per the physician order.
On 6/18/24 12:30 PM Regional DON and DON made aware of the above findings.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations and interviews the facility failed to properly monitor medications. This was evident in 1 out of 4 medication storage rooms and carts during the survey.
The findings include:
During observation rounds on [DATE] at 03:05 PM the following was found in the 1st floor Unit 2 medication room:
1 expired Influenza Vaccine Afluria Quadrivalent 5ml Multi-dose Vial with an expiration date of [DATE].
During an interview and observation round of the 1st floor Unit 2 medication room with Unit Manager staff #6 on [DATE] at 03:15 PM, staff #6 stated and confirmed that there was 1 expired Influenza Vaccine Afluria Quadrivalent 5ml Multi-dose Vial.

Based on interviews and medical record reviews it was determined that the facility staff failed to schedule a dental appointment and arrange transportation to and from the dental appointment. This deficient practice was evident for 1 (#37) of 1 resident record reviewed for dental care during the survey.
The findings include:
On 06/13/24 at 9:28 am, during an interview with Resident #37, he/she reported that his/her bottom dentures were lost. He/she could not recall which staff member he/she reported the incident to, or the exact month it occurred. Review of the resident's personal belongs log in Point Click Care (PCC) revealed there was no documentation of the resident having dentures upon admission to the facility. The resident reported difficulty eating without having bottom dentures.
During an interview with Director of Nursing (DON) #17 on 06/17/24 at 12:23 pm, the DON reported all resident's belongings are logged into PCC under the evaluation tabs at the time of admission, discharge, and readmissions. DON #17 explained that a grievance form would be completed for all reported missing or misplaced personal items. Residents are encouraged to report missing items to the Nurse Supervisor, Unit Manager, or Guest Services.
On 06/17/24 at 12:23 pm the surveyor and DON #17 reviewed Resident #37's personal belongings log in PCC at the time of admission, which revealed the staff documented that Resident #37 had eyeglasses and an eyeglass case upon admission.
On 06/17/24 at 1:10 pm, a review of the grievance form received from the DON#17 and completed by Director of Guest Services (DGS) #22 revealed that Resident #37's family member reported his/her lower dentures missing on 12/28/23 at 1:30 pm. DGS #22 spoke with Resident #37's family member and explained that the dentures were not listed on the personal inventory form. Resident #37's family member stated they would contact the resident's insurance company for a replacement. The grievance form noted that the facility staff would schedule a dental appointment for Resident #37 and the facility agreed to cover transportation costs.
On 06/17/24 at 01:57 pm during an interview with DON #17 and Regional Nurse #9 regarding a resident's grievance, the surveyor inquired if the dental appointment and transportation had been arranged. DON #17 and Regional Nurse #9 were unable to confirm transportation arrangements were made.
On 06/20/24 at 10:16 am a follow up with Regional Nurse #9 regarding the dental appointment and transportation arrangements. Regional Nurse #9 reported that there was no documentation to verify the dental appointment was scheduled or transportation arrangement were made.

Based on record review and interview with facility staff, it was determined the facility failed to provide documentation whether a resident had signs and symptoms of abuse immediately following an allegation of abuse and failed to provide documentation to verify monthly pharmacy review was completed in 2024. This was evident for 3 (#508, #11, #21) of 15 residents reviewed during the survey.
The findings include:
1) Review of the facility's Abuse, Neglect and Exploitation Policy on 6/25/24 at 3:01 PM revealed in the Investigation of Alleged Abuse, Neglect and Exploitation section, Written procedures for investigations include: Focusing the investigation on determining if abuse, neglect, exploitation and/or mistreatment has occurred, the extent, and cause; and Providing complete and thorough documentation of the investigation. Further review of the policy in the Protection of Resident section, Examining the alleged victim for any sign of injury, including a physical examination or psychosocial assessment if needed .
Resident #508's medical record was reviewed on 6/26/24 at 11:22 AM. During the review, there was no evidence of documentation whether the resident had signs and symptoms of abuse promptly following an allegation of abuse.
On 6/26/24 at 12:17 PM in an interview with the Assistant Director of Nursing (ADON), when asked for documentation the physician was notified, she stated I did not see a progress note or documentation that the physician was notified, but I did bring a copy of the x-ray ordered by the physician.
Review of the Radiology Results Report on 6/26/24 at 12:44 PM revealed, Findings: There is shoulder arthritis .There is no acute fracture. However, the alleged abuse occurred on the 5/29/23 11PM-7AM shift and the x-ray order date and time was 5/31/23 at 10:18 AM.
On 6/26/24 at 12:51PM in an interview with the ADON, when asked the expectation if a resident alleges abuse, she stated the expectation is that nurses complete a change in condition or risk management.
On 6/26/24 at 2:00 PM, review of the facility's policy, Charting and Documentation revealed, All services provided to the resident, or any changes in the resident's medical or mental condition, shall be documented in the resident's medical record. Furthermore, it stated, All incidents, accidents, or changes in the resident's condition must be recorded.
On ADON 6/26/24 at 2:18PM in an interview with the ADON she stated, I do not see a change in condition or risk management in the medical record for Resident #508.
On 6/27/24 at 12:25PM in an interview with the DON, when asked after Resident #508 reported an allegation of abuse if a nurse assessed the resident, she stated the expectation was to complete a head to toe assessment and document a progress note or a change in condition. During the interview, she reported there was no progress note or change in condition from a nurse that is documented in the resident's medical record.
2) On 06/17/24 at 11:30 am A review of Resident #11 and Resident #21, paper charts and electronic medical records, revealed there were no files or documentation to verify the monthly pharmacy reviews were completed.
On 06/17/24 at 11:40 am During an interview with License Practical Nurse (LPN) Unit Manager (UM) #11 verbalized uncertainty about where to locate the pharmacy reviews. They mentioned that they would contact the pharmacy to obtain this information. The surveyor waited, but LPN UM #11 was unable to confirm the pharmacy reviews for Resident #11 and Resident #21 were completed.
On 06/17/24 at 11:43 am During an interview with LPN #34, they checked Resident #11 and #21 charts for the pharmacy reviews and reported they did not see a pharmacy reviews for either resident. LPN #34 explained that when pharmacy reviews are received, the doctor reviews them, and decides the next course of action. However, LPN #34 was not sure about the process of how the pharmacy review is received.
On 06/17/24 at 12:02 pm, during an interview with Director of Nursing (DON) #17, they explained that they print the pharmacy reviews, and the Medical Director reviews them. They also report that they keep copies of the reviews in a binder in their office. The surveyor accompanied the DON #17 to their office to review the requested pharmacy reviews for Resident #11 and Resident #21. DON#17 was unable to locate any pharmacy reviews for both residents.
On 6/28/24 prior to existing the facility, the DON was not able to provide evidence of monthly pharmacy review for Resident #11 nor Resident #21.

Based on administrative record review and interviews with facility staff, it was determined the facility failed to complete a thorough investigation and maintain documents regarding allegations of resident abuse. This was found to be evident for 4 (Resident #424, Resident #101, Resident #120, and Resident # 99) of 25 residents reviewed for abuse during the facility's survey.
Findings include,
1. MD00190231 was reviewed on 6/17/24 at 12:30PM for allegations of abuse. The survey team requested a copy of the facility's investigation for the incident that occurred on 2/27/23 with Resident #424. On the same date at 1:30PM the Regional Nurse (Staff # 9) provided the survey team with a copy of the investigation and upon review, it included the following documents: a list of the resident's diagnosis, an initial 5-day report and a summary page. There were no interviews with residents or staff and no signed statements.
The DON was interviewed on the same date at 1:45 PM and she was asked if the facility had any additional documentation of resident and staff interviews as part of their investigation and she stated, no. She further stated that the facility obtained new ownership in May 2023. The DON went on to say that part of completing a thorough investigation is interviews of staff and residents to determine if or not abuse occurred. The DON stated that education would be provided to the staff.
On 6/17/24 at 1:45PM the DON provided the survey team a typed statement from the Director of Guest Services (# 22). In the statement, staff # 22 indicated that at the time of the incident residents were interviewed and a handwritten copy of the interviews were provided to the DON. This document was not included in the facility's investigation. The DON again confirmed that they are unable to produce documentation of residents and staff interviews.
2. On 06/18/24 at 9:20 AM, a review of the facility reported incident MD00183880 revealed Resident #101 reported verbal abuse from a Registered Nurse (RN) #50. Further review of the investigation revealed a Geriatric Nursing Assistant (GNA) notified RN#50 of the alleged verbal abuse, but a statement from the GNA was not included in the investigation. The resident was interviewed by Unit Manager #51, but there was not a statement for the surveyor to review. Also, a statement from Resident #101 was not included in the investigation.
On 06/21/24 at 10:29 am during an interview with Administrator #3 the surveyor verbalized different parts of the investigation were missing. Administrator #3 verbalized the case happened prior to the change of ownership of the building and that was all that was in the record.
3. The surveyor reviewed MD00165055 on 06.18.24 at 10:30 AM related to a facility reported incident (FRI) dated 03.14.2021. The facility reported that Resident #120 accused RN staff #27 did not stop pushing while administering an enema as requested by the resident.
On 06.18.24 at 09:15 AM the surveyor interviewed the regional nurse, staff # 9. Staff # 9 stated that the facility incident reports prior to the year 2023 may be in storage and would take a couple of days to retrieve.
During an interview with staff #9 on 06.18.24 at 10:38 AM stated that she was not able to find the complete facility report for Resident #120. However, she would look within the system to try to retrieve additional information.
The surveyor requested the hard copy of Resident #120's closed record and FRI for the second time on 06.21.24 at 11:40 AM.
The facility failed to provide the complete facility report by the close of the exit conference on 06.28.24 at 3:00 PM. The facility reported incident documents provided did not include any documentation related to post event educational training of facility staff related to resident rights, abuse training, or documentation or the suspension of the alleged perpetrator, RN #27 immediately after the incident was reported by Resident #120.
4. On 6/17/24 at 12:36 pm, the surveyor received a copy of the facility's self-report investigation MD00166760 for Resident #99. The report revealed physical abuse allegation from Geriatric Nursing Assistant (GNA) #51. Further review of investigation revealed no staff interviews or staff written statements, and there was not a copy of the 5-day investigation results.
During an interview on 6/21/24 at 10:31am, Administrator #3 and Regional Nurse #9 regarding the process for reporting abuse allegations, the Administrator #3 explained that all grievances reported by staff should be reported to either the Administrator or Director of Nursing. The alleged staff member would be suspended pending an investigation and written statements are gathered from alleged staff members.
On 06/21/24 at 11:29 am during an interview with Administrator #3 and Regional Nurse #9, who verbalized that the facility did not have a complete investigation file for MD00166760.
All concerns were discussed with the administrative team at the time of exit on 6/28/24 at 3:00PM.

Based on record review and staff interviews, it was determined that the facility failed to provide to the resident a copy of the completed bed hold policy prior to transfer. This was evident for 1 (Resident #1) of 4 residents reviewed for transfer and discharge.
The findings include:
On 6/17/24 at 9:21 AM, a review of the medical records revealed the resident was sent to the hospital on 6/14/2024. A bed hold notice was identified in the resident's paper chart. The bed hold notice had not been completed and notes [resident's son] approved Bed hold policy via phone initialed KC on the side of the form. The resident's name was not on the bed hold notice nor any of the other fields completed on the form. According to the medical record, the resident was his/her own representative.
On 6/17/24 at 2:05 pm, an interview was conducted with Licensed Practical Nurse (LPN) #23. LPN #23 was asked what is expected when notice of transfer is presented to a resident? LPN #23 responded, The resident or representative will sign the notice if they are capable. When asked if Resident #1 could sign the notices prior to discharge, LPN #23 stated, that day he/she was drowsy, and I didn't think he/she was able to sign. When asked if LPN #23 documented this in the resident's chart, the LPN stated, No, I did not. When asked if LPN #23 gave a copy of the notice to the resident prior to discharge, the LPN stated, No I did not.

Based on interview with the resident, review of medical records, and interview with facility staff, it was determined that the facility failed to provide a baseline care plan summary to residents. This was evident for 1 (#85) of 5 residents reviewed for baseline care plan summaries during the survey.
The Findings Include:
On 6/13/24 at 11:30AM, in an interview with Resident #85, they stated they have not been invited to a care plan meeting nor received a baseline care plan summary or baseline care plan.
On 6/14/24 at 1:15 PM, review of the medical record did not reveal any evidence that Resident #85 was given a baseline care plan summary or a copy of a baseline care plan.
On 6/21/24 at 10:37 AM, in an interview with the Director of Social Services (DSS) #2 she stated she did not have a baseline care plan for Resident #85. During the interview, she further stated that the nurses could not find a progress note or provide any additional documentation to show as evidence that Resident #85 was given a baseline care plan or baseline care plan summary.

Based on interview and medical record review, it was determined the facility failed to ensure comprehensive care plans were developed and implemented. This was found to be evident for 2 (Resident #112 and Resident #85) of 18 residents reviewed for care plans during the facility's survey.
Findings include:
1. A care plan is a guide that addresses the unique needs of each resident. It is used to plan, assess, and evaluate the effectiveness of the resident's care they receive in a facility. It should describe the resident's goals and desired outcomes, the care/services that will be furnished, the resident's discharge plans, and refusals of care and action taken by facility staff to educate the resident.
Review of Resident #112's medical record revealed the resident was admitted with the following but not limited diagnosis: Type 1 Diabetes Mellitus (a lifelong condition where the pancreas makes little or no insulin, which leads to high blood sugar levels).
MD00203565 was reviewed on 6/25/24 at 4:00 PM for allegations of neglect in which Resident #112 reported not receiving insulin medication when at the facility. The allegation was unsubstantiated. Further record review on the same date revealed resident #112 receives insulin (a hormone that lowers the level of glucose in the blood), however there was no Diabetes care plan in place.
An interview was conducted with the DON (# 17) and Regional DON (# 9) on 6/26/24 at 9:45 AM and she was made aware that resident #112 did not have a diabetes care plan. The DON went on to explain that a care plan should have been developed for the resident, specifically to address the resident care concerns related to Diabetes and that education would be provided to her staff.
.
All concerns were discussed with the administrative team at the time of exit on 6/28/24 at 3:00 PM.
2. On 6/13/24 at 11:31 AM in an interview with Resident #85 they stated they had not been invited or participated in a care plan meeting.
Resident #85's medical record was reviewed on 6/14/24 at 1:15PM and revealed the resident's diagnoses included chronic obstructive pulmonary disease, emphysema, atrial fibrillation, and atherosclerotic heart disease, all of which can affect a person's breathing and respiratory care and services needed. However, there was no respiratory care plan that identified a focus, goal, or intervention to address the resident's respiratory care or services.
On 6/17/24 at 3:36 PM, review of the facility's Oxygen Administration policy revealed, Oxygen is administered to residents who need it, consistent with professional standards of practice, the comprehensive person-centered care plans, and the resident's goals and preferences. Further review revealed Policy Explanation and Compliance Guidelines section: The resident's care plan shall identify the interventions for oxygen therapy, based upon the resident's assessment and orders, such as, but not limited to:
a. The type of oxygen delivery system
b. When to administer, such as continuous or intermittent and/or when to discontinue.
c. Equipment settings for the prescribed flow rates.
d. Monitoring of SpO2 (oxygen saturation) levels and/or vital signs, as ordered.
e. Monitoring for complications associated with the use of oxygen.

Based on interviews with the resident and facility staff and record reviews, it was determined the facility failed to follow professional standards of nursing practice when administering medications to residents. This was found to be evident for 5 (Resident #60, #15, #502, and #509, #102) of 76 residents reviewed during the survey.
The findings include:
1.) Resident # 60 was admitted with the following but not limited diagnosis: Chronic Pain
An interview was conducted with Resident # 60 on 6/13/24 at 11:15 AM and the resident stated that s/he cannot get medications on time. The resident went on to say that s/he puts the call light on at 2:00 PM to receive PRN (as needed) oxycodone (a controlled medication used to treat moderate to severe pain) and the medication is not given until 4:00 PM, after the next shift comes on duty. The resident also stated that his/her scheduled medications are given late as well.
The DON was made aware of the resident concerns on 6/13/24 at 1:45 PM and a request was made by the survey team for access via point click care electronic computer system to review the medication administration audit reports. The facility later provided a copy of the medication administration audit report for Resident # 60.
Upon review of resident # 60 medication administration audit report on 6/21/24 at 10:00 AM for the dates: 6/12/24 -6/13/24, it revealed the following:
1. HCL 5 mg (1) tablet every 4 hours for pain was documented on 6/12/24 as administered at 16:11 PM (4:11 PM).
2.Voltaren Gel 1% Apply to back three times a day for pain scheduled for 6/12/24 at 14:00 PM (2 PM) and the documented administration time is 6/12/24 at 16:11 PM (4:11 PM).
3.Cephalexin Oral 500 mg 1 tablet every 12 hours for urinary tract infection (UTI) until 6/16/24 scheduled for 6/13/24 at 9:00 AM and the documented administrated time is 6/13/24 12:53 PM.
4.Apixaban 5 mg 1 tablet two times a day for Atrial Fibrillation (irregular heartbeat) scheduled for 6/13/24 at 9:00 AM and the documented administration time is 12:53 PM.
5.Lamotrigine 200 mg 1 tablet two times a day for Schizoaffective Disorder (Mental Health Disorder) scheduled for 6/13/24 at 9:00 AM and the documented administration time is 12:53 PM.
6.Lidocaine External Patch 4% apply topically 1 time a day for pain scheduled for 6/13/24 at 9:00 AM and the documented administration time is 12:53 PM.
7.Amiodarone HCL 200 mg 1 tablet two times a day for Atrial Fibrillation scheduled for 6/13/24 at 9:00 AM and the documented administration time is 12:53 PM.
8.Gabapentin Capsule 400 mg 2 tablets two times a day for neuro pain scheduled for 6/13/24 at 9:00 AM and the documented administration time is 12:53 PM.
9.Metformin 500 mg 1 tablet two times a day for Diabetes Mellitus scheduled for 6/13/24 at 9:00 AM and the documented administration time is 12:54 PM.
10.Sennosides-Docusate Sodium 8.6-50 mg 2 tablets two times a day for constipation with parameters scheduled on 6/13/24 at 9:00 AM and the documented administration time is 12:54 PM.
11.Lisinopril 10 mg 1 tablet one time a day for Hypertension (HTN) with parameters scheduled on 6/13/24 at 9:00 AM and the documented administration time is 12:54 PM.
12.Risperidone 3 mg 1 tablet two times a day for schizoaffective disorder scheduled on 6/13/24 at 9:00 AM and the documented administration time is 12:54 PM.
13. Multivitamin 1 tablet one time a day for supplement scheduled on 6/13/24 at 9:00 AM and the documented administration time is 12:54 PM.
14.Lactulose 20 gm/30 ml give 30 ml two times a day for constipation with parameters scheduled on 6/13/24 at 9:00 AM and the documented administration time is 12:54 PM.
An interview was conducted with the DON on 6/21/24 and she stated that the facility has identified this as a concern and is currently educating staff regarding giving medications within the time frame of one hour before or after the scheduled time and PRN pain medication when requested.
2.) It is a standard of nursing practice to document administered medications immediately after administration. Failing to do this results in an inaccurate record where it cannot be determined when a medication was actually given and has the potential to result in medication errors (such as a resident receiving a dose twice, or two doses of a medication being given too close in time).
Resident #15's medication administration audit record (MAAR) was reviewed on 6/20/24 at 2:05 PM for the period of 5/1/24 to 6/20/24. The review revealed multiple staff documenting medication late with some medication documented up to 7 hours late.
In an interview with the DON, on 6/21/24 at 1:39 PM, made aware of the above concerns and when asked about the expectation regarding medication administration times, she stated the expectation is to administer 1 hour before or 1 hour after the ordered time and to document the medication after it is administered.
3.) Resident MAARs were reviewed for the following residents:
Resident #502 on 6/25/24 at 11:29 AM for the period of 12/7/2022 to 1/14/2023
Resident #509 on 6/24/24 at 3:01 PM for the period of 2/1/23 to 2/25/23
Review of these MAARs demonstrated a pattern of multiple staff documenting medications late with some medications documented several hours late.
All concerns were discussed with the Administration team at the time of exit on 6/28/24 at 3:00 PM.
4.) On 06/20/24 at 1:29 pm A review of the medication administration audit for Resident # 102 revealed that it was documented multiple doses of Tylenol 500 mg 2 tablets were not given as ordered.
Tylenol Extra 500 mg (two tablets) was scheduled to be administered on 05/17/24 at 2:00 pm. However, the medication was given at 7:40 pm.
Tylenol Extra 500 mg (2 tablets) was scheduled on 05/14/24 2:00 pm and given at 05/14/24 at 7:03 pm.
Tylenol Extra 500mg (2 tablets) was scheduled on 05/04/24 2:00 pm and given at 05/04/24 at 4:07 pm.
Tylenol Extra 500mg (2 tablets) was scheduled on 05/01/24 2:00 pm and given at 05/28/24 at 3:58 pm.
Tylenol Extra 500mg (2 tablets) was scheduled on 04/15/24 2:00 pm and given at 04/15/24 at 4:37 pm.
On 06/21/24 at 1:32 pm during an interview with Director of Nursing (DON) #17 regarding the expectation of medication administration, the DON #17 reported that scheduled medications can be administered up to one hour before or one hour after the due time. DON #17 also mentioned that medication administration audits are overseen by nursing leadership which includes DON#17, Assistant Director of Nursing #8, and the Unit Managers. DON #17 was made aware of the multiple doses of documented late medication administration for Resident #102.

Based on record reviews and interviews the facility failed to provide ADL's (activities of daily living) such as showers according to the resident's preference. This was determined to be true for 1 (Resident # 44) out of 6 residents reviewed for ADL care during the survey.
The findings include:
At 2:50 PM on 06.18.24 the surveyor spoke with Resident #44 in his/her room. Resident was observed sitting in a wheelchair dressed in clean civilian clothes. The resident stated that s/he had recently moved from the first floor to the second floor within the last week. Resident #44 stated that he/she had received a shower only twice within the last month. This resident stated that her preference was to receive a shower twice per week. Additionally, the resident stated that he/she had discussed this concern with the unit manager and DON within the last month.
On 06/20/24 at 01:56 PM Resident #44 stated that he/she was promised to receive a shower on Wednesday and Saturdays. Also, the Resident stated that he/she must be placed in a shower chair for the Geriatric Nursing Assistant (GNA) to provide the shower in the shower room.
On 06.20.24 at 2:10 PM the surveyor reviewed the electronic task documentation form that was completed by the geriatric nursing assistants (GNA)'s assigned to Resident #44 which documented that the resident had refused a shower on 06.14.24 and 06.19.24.
On 06/20/24 02:15 PM the surveyor spoke with the nurse manager, LPN # 10. The surveyor asked if he/she had spoken with the resident recently. The nurse manager, LPN #10's response was, no and stated that he had planned to meet with the resident this afternoon to discuss some areas of concern related preferred days to shower.
On 06/20/24 at 3:15 PM the DON provided the surveyor with a hard copy of the Task form for the month of June 2024. The surveyor reviewed the task form with the DON and ask why there were blank spaces for some dates related to the Resident #44 either receiving or not receiving a bath or shower. The DON stated that the GNA staff would be reeducated regarding the responsibility to accurately document on the task form.
On 06.28.24 at 11:30 AM the surveyor received a hard copy of the task form for the month of June 2024. The June task form indicated that on 06.2: no shower was provided, 06.05: there was no data entry for a shower or bath, on 06.08: resident received a shower, for the following dates: the data entry slots were left blank for the following regarding showers: 06.09, 06.15, 6.18, 6.19, 6.21, 6.22, 6.25. The task form document for 17th and 23rd of June showed the resident received assistance with bathing. In summary, the task form record showed the resident was documented as receiving three showers in the month of June 2024 which were on the 8th , the 14th and the 26th.
The deficient practice was reviewed with the unit manager, LPN # 10 and the DON prior to the exit conference on 06.28.24.

Based on observations and staff interview, it was determined that the facility failed to treat each resident with dignity by not ensuring that residents' foley drainage bags were covered. This was evident for 2 (Resident #1 and Resident #504) of 5 residents reviewed for dignity.
The findings include:
A foley drainage bag, or urinary drainage bag, is a medical device used to collect urine from a catheterized patient. The drainage bag is usually worn on the leg or attached to a bed.
During observation rounds on 6/12/24 at 7:50 am, Resident #1 was noted to have a foley catheter bag attached to their bed. The foley drainage bag was uncovered and had amber colored liquid. The bag was attached to the door side of the bed. Resident #1's door was open, and the foley drainage bag was visible from the hallway.
On 6/12/24 at 7:54 am, the surveyor interviewed Unit Manager Licensed Practical Nurse (LPN) #6. When asked if residents with foley bags should have covers on the bags, LPN #6 stated foley bags should be covered and that she would ensure that the foley bags were covered.
On 6/24/24 at 2:01 PM, Resident #504 was observed ambulating in a wheelchair in the hallway of Unit 3. Attached to the wheelchair was a foley bag with amber colored liquid visible in the bag. There was no covering on the foley bag.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and staff interviews, it was determined that the facility failed to ensure that a current copy of a resident's advance directive was in the resident's medical record. This was evident for 1 (Resident #512) of 5 residents reviewed for advanced directives.
The findings include:
During Record review on 6/13/24 at 1:45 PM, there was no record of an advance directive in Resident #512's electronic chart or paper chart. Based on medical records, the resident was admitted on [DATE].
On 6/13/24 at 2:15 PM, in an interview with the Director of Nursing (DON #17), DON #17 stated that the resident did have a Medical Orders for Life-Sustaining Treatment (MOLST) form created on 5/31/2024. DON #17 provided a copy of resident's MOLST form, which was signed by Doctor #31 on 5/31/2024. DON #17 stated the Doctor had completed the form and left the MOLST form on their desk instead of placing it in the paper chart or uploading it in the electronic chart. The MOLST form was not in Resident #512's chart for nursing staff to use from 5/30/2024 until 6/13/2024. DON #17 stated that if a resident does not have a MOLST or advanced directive then the resident would be considered Full Code.
On 6/17/24 at 10:33 AM, the surveyor reviewed the paper chart after surveyor intervention, and a copy of MOLST form was placed in the chart.
On 06/17/24 at 1:00 PM during a follow up interview with DON #17, the DON states Medical Director, Doctor #32, addressed Doctor #31 regarding the MOLST form issue.

2. During a screening of residents during the facility's annual survey, resident # 83 was interviewed by two surveyors and the resident stated that an agency Registered Nurse (RN) (# 53) was very disrespectful when s/he asked the nurse for a shower. The resident further stated that s/he was called out of their name and the nurse (# 53) was verbally abusive. The resident went on to say that s/he does not feel safe receiving medications from the nurse and that s/he spoke to the Director of Nursing (DON) (# 17) about this incident.
On the same date at 9:15 AM an interview was conducted with the DON and the Administrator (# 3), and they were made aware of resident # 83's concerns. The DON stated that she spoke with the resident on 6/11/24 regarding the resident concerns.
During a subsequent interview with the DON on 6/12/24 at 1:30 PM, she was asked if the facility reported the abuse allegations to the state office and she responded, no. The DON was asked if law enforcement was notified and she responded, no. She acknowledged that all allegations of abuse are to be reported immediately within the two (2) hour required time frame.
On 6/13/24 at 2:00 PM, the DON informed the survey team that the abuse allegations were reported to the Office of Health Care Quality and provided a copy of the initial report to the survey team.
All concerns were discussed with the Administration team at the time of exit on 6/28/24 at 3:00 PM.
Based on record review and interview it was determined that the facility staff failed to notify the state agency of an alleged case of abuse within the 2-hour allotted timeframe and failed to report allegations of abuse to the state health department and to law enforcement. This was found to be evident for 2 (Resident # 83 and Resident #101) of 15 residents reviewed for abuse during the facility's survey.
The findings include:
1. On 06/18/24 at 9:20 am surveyor received a copy of the facility's investigation of the facility reported incident MD00183880. Review of the self-report form revealed the alleged incident occurred on 09/25/22 during 3 pm to 11 pm shift. The alleged incident was reported to the state agency on 09/26/22 at 1 pm which was outside of the 2-hour allotted timeframe for reporting alleged abuse case.
On 06/20/24 at 10:34 am a review of the facility's Abuse, Neglect, and Exhibition policy revealed under Section VII Reporting Abuse Reporting of all alleged violations to the Administrator, state agency, Adult Protective Services and to all other required agencies immediately but no later than 2 hours after the allegation is made, if the events that cause the allegation involve abuse.
On 06/21/24 at 10:29 am during an interview with Administrator #3 who verbalized any concern is followed up with them and the Director of Nursing. They discuss the issue and determine if it is reportable. For alleged abuse cases they are reported within 2 hours. Interviews are done with staff, residents, and witnesses. The police are notified; the alleged employee is suspended. Other residents are interviewed to see if there are any concerns. Administrator #3 was made aware the facility reported incident was reported outside of the allotted 2-hour window, verbalized understanding.

Based on observation, medical record review and interview with facility staff, it was revealed the facility failed to administer medications as ordered by the physician. This was evident for 1 of 1 (Resident #1) reviewed during the complaint survey.
The findings include:
Medical record review on 1/10/24 at 9am revealed that Resident #1's diagnoses included but were not limited to Dementia, Anxiety, high blood pressure, Depression and Multiple Sclerosis. According to the hospital discharge Resident #1 was admitted in October of 2022 for Physical and Occupational Therapy Rehabilitation.
Review of resident #1's medical record on 1/10/24 at 2pm revealed the following:
1. On 10/3/2022 a physician ordered resident #1 to receive Amlodipine 10 mg(milligrams) at 10am every day by mouth for high blood pressure.
2. On 5/17/23 a physician ordered resident #1 to receive Seroquel 25mg at 10am every day by mouth for depression.
3. On 9/8/2023 a physician ordered resident #1 to receive Meloxicam 15mg everyday at 12noon by mouth for joint pain.
Review of the MAR (Medication Administration Record) for January 2024 revealed on 1/4/24 the medications were signed off as not available from pharmacy.
During an audit of Resident #1's medications on 1/11/24 at 10am, the medication Amlodipine 10 mg, Seroquel 25mg and Meloxicam 15mg were missing from the medication cart. During the interview with the LPN (Licensed Practical Nurse)#15, who was administering medications at that time verified the medications were not available in the cart.
During an interview with pharmacy (staff #6) on 1/11/24 at 11:30am, revealed the Amlodipine 10 mg was last refilled at the pharmacy on 11/14/23, the Seroquel 25mg was last refilled at the pharmacy on 12/2/23 and the Meloxicam 15mg was refilled on 1/8/24; however, prior to 1/8/24 the medication was last refilled on 11/17/23. Staff #6 also verified the medications were not being taken from the interim box. She stated when medications are removed a slip must be filled to replace the medications and there was no record of the Amlodipine, Seroquel or the Meloxicam being removed from the interim box.
The Amlodipine 10 mg was last refilled at the pharmacy on 11/14/23; however, the medication was signed off for the entire month of December 2023 as being administered and signed off for 7 days in January 2024 as being administered.
The Seroquel 25mg was last refilled at the pharmacy on 12/2/23; however, the medication had been signed off for 7 days in January 2024 as being administered.
The Meloxicam 15mg was refilled on 1/8/24, however prior to 1/8/24 the medication was last refilled on 11/17/23; yet the medication was signed off as being administered for the entire month of December 2023 and 5 days in January 2024.
During an interview with DON on 1/11/24 at 1pm, she was made aware of the findings. She stated that she had spoken with the pharmacy and has started to in-service staff on reordering medications.

Based on a review of the facility investigation, resident medical records, and other pertinent documentation, interviews, and observations it was determined that the facility failed to provide immediate action, ongoing supervision, and/or a plan of care interventions to address a resident who was known to have exit seeking/elopement behaviors. This was evident for 1 (Resident #1) of 4 residents reviewed for elopement during the complaint survey. This failure resulted in an Immediate Jeopardy for Resident #1.
The facility implemented effective and thorough corrective measures following this incident. The facility's plan and action were verified during this survey, therefore this deficiency will be cited as past noncompliance. The date of correction was 1/8/24.
The findings include:
Medical record review on 1/10/24 at 9am revealed that Resident #1's diagnoses included but were not limited to Severe Dementia, Anxiety, Depression, and Multiple Sclerosis. According to the hospital discharge Resident #1 was admitted in October 2022 for Physical and Occupational Therapy Rehabilitation. The resident was independent in ambulation. The resident has 2 certifications in his/her medical record dated 3/3/23 and 4/26/23 stating the resident was incapable of making his/her medical decisions. According to the medical record, the resident's cognitive status varied with short-term memory loss severely impaired. Further review of the medical record revealed a physician order dated 4/28/23 to apply an alert bracelet (wander guard) to the right lower extremity due to exit seeking/elopement risk - (resident packing belongings and exit seeking.) An elopement risk evaluation dated 10/9/23 resulted in a score of (12) which revealed the resident was at high risk for elopement. Review of the TAR (Treatment Administration Record) on 1/10/24 at 9:30am, revealed the 11pm-7am nurse signed that Resident #1's wander guard was functioning.
During the review of the facility reported incident MD00201210 and review of the facility investigation on 1/10/24 at 10:00 am, revealed that on 1/4/24 between 4pm and 5pm GNA #1 (Geriatric Nursing Assistant) delivered resident #1's dinner tray to his/her room, and found the residents' lunch tray undisturbed. Resident #1 was not located in his/her room. The Supervisor from 3-11pm (staff #18) was notified by GNA #1. When the resident's room was checked by the GNA (staff #1) and the Supervisor (staff 18), the resident's belongings were bagged, two cell phones and a tablet were still in the room, but his/her coat was gone. The facility called an Elopement Alarm and an internal and external search began. At approximately 5pm the local police department was notified. At 5:30pm the local police aided with the search of the facility and surrounding areas and a silver alert was called. The family was made aware on 1/4/24 at 6:45pm.
During observation rounds on 1/10/24 at 11am with the maintenance director staff #9; all doors with mag locks and keypads were secure. The wander guard system was tested and was in working order the alarm sounded and the second-floor elevator was disabled when the wander guard encountered the elevator. The maintenance director stated all keypads were changed from hand swipes to keypad on 1/4/24 after the resident eloped for added safety.
During an interview with the Administrator and the DON (Director of Nurses) on 1/10/24 at 1pm revealed the following:
After review of the facility cameras several times on 1/4/24 and 1/5/24 the resident was seen exiting the building through the front door the wander guard s/he was wearing did not disable the elevator on the 2nd floor, so the resident was able to reach the first floor, where there were no wander guard sensors. Resident #1 walked through the parking lot to Brightfield Road and onto Falls Road, where the resident hitched a ride with a female motorist. The DON stated the resident went to his/her previous apartment building, his/her family's home, and then to a friend's home. The police were contacted on 1/5/24 at around 5:30pm by a family friend and the resident was returned to the facility. On 1/5/24 at around 6:30pm the resident was transferred to the hospital for an evaluation. The resident returned at around 4:30am on 1/6/24 with no injuries and no new orders were noted.
During the interview with Activity Staff #13 on 1/10/24 at 3pm she stated that while she was helping another resident, she saw Resident #1 on 1/4/24 at around 12 noon on the second floor, walking down the hallway from unit 3 towards the elevator. She stated Resident #1 was wearing a purple Raven hoodie and a black hat. Staff #13 stated to the resident where are you going? Resident #1 responded, I will see you later. Staff #13 stated she finished helping the other resident and wheeled them to the elevator to transport him/her to the hair salon. When Staff #13 arrived at the elevator from unit 4, the doors were closed, and Resident #1 was no longer in the hallway. Staff #13 left the resident that she was taking to the hair salon at the elevator area and went to unit 3 and told the Nurse or GNA, sitting at the desk, that Resident #1 went down the elevator. The Nurse or GNA stated ok, I'll handle it. When asked if she knew the Nurse or GNA name, she stated no but she was wearing purple scrubs. When asked if she saw the resident get onto the elevator she stated no, but I saw him/her walking towards the elevator. I did not see the elevator door open or hear the alarm sound.
During an interview with Registered Nurse (RN)#18 on 1/10/24 at 4pm she stated on 1/4/24 after 5pm that 2 GNA's (GNA #1 and GNA #10) reported to her that Resident #1 was missing. She stated she asked both GNA's if they saw the resident at the beginning of the shift. Both GNA's stated no. RN #18 then paged overhead for all staff to search for the resident. The DON and ADON (Assistant Director of Nursing) were made aware of the incident, 911 was called, the resident RP and physician were also called. The maintenance director was called to pull the video footage to see if and how the resident left the facility. RN #18 stated the facility staff was sent to the resident's prior residence and a photo was left at the desk of the apartment building in case s/he returned there. She stated she continued to contact hospital emergency rooms and family members until the end of her shift with no luck.
During an interview with GNA #2 on 1/10/24 at 4:30pm she stated she was working on unit 3; but was not assigned to Resident #1. She stated she saw the resident around 1:30-2pm walking up the hall wearing a black jacket and slippers. She stated the resident roamed up and down the hallways but was unable to leave the unit without his/her alarm going off.
During the interview with Licensed Practical Nurse (LPN) (agency staff #5) via phone on 1/11/24 at 10am, she stated she worked two shifts on 1/4/24 on unit 2 (7am-3pm) and (3pm-11pm). I laid my eyes on the resident at approximately 8am when I went to do my morning rounds/medication pass. The resident was stable at that time. At 12:45pm, I went to his/her room to give afternoon medications and s/he was not there. I do not recall seeing her after 8am that morning. When asked, if Staff #5 knew the resident was an elopement risk, she replied yes but Staff #5 indicated Resident #1 had a wander guard and could not get off this unit.
During an interview with GNA #1 on 1/11/24 at 10:30am she stated she was not assigned to the resident on 1/4/24 but did take his/her vital signs at around 8am. She stated at that time the resident was in unit 3, near the shower door looking down at the hallway.
During an interview with GNA #10 on 1/11/24 at 11am she stated she was not assigned to the resident on 1/4/23 from 3-11pm, but she was passing out trays and noticed the resident lunch tray was not touched. She stated she knew something was wrong, as the resident usually ate all his/her food. GNA #10 stated the supervisor was made aware that the resident was missing.
During an interview with LPN (agency staff #4) on 1/11/24 at 12:30pm she stated she reported to work at around 4pm, received report and I was handling an emergency and then [GNA #10] informed me that [Resident #1] was missing. After checking for the resident, the supervisor [RN #18] was notified. I was assigned to the resident for the 3-11pm shift on 1/4/24 but had not made rounds yet.
In an interview with the DON on 1/10/24 at 2:30pm she stated the following Immediate actions were taken by the facility between 1/4/24 and 1/8/24:
(1.) The facility verified the wander guard alarms and would disable the elevator.
(2.) The physician, family and the police were contacted.
(3.) Several local businesses were canvassed. The video footage from the facility was reviewed.
(4.) A head count was done for every resident in the facility.
(5.) All staff were re-educated on the facility Elopement procedures, the agency staff and any part-time or PRN staff would not be able to work until they receive the education on elopements. (education was on-going).
(6.) All the internal mag locks codes required to open the stairwell doors were checked, and additional sensors for the wander guard were ordered and/or added to the 1st floor and ground hallways from the elevator, along with the hallway leading to the lobby.
(7.) The elopement binder was up to date and pictures of residents who were an elopement risk were posted at the reception desk and the nursing units.
(8.) Resident #1 wander guard was replaced and verified it alarmed and disabled the elevator on 1/5/24.
(9.) Resident #1 was placed on one-to-one after returning to the facility on 1/5/24 from the elopement and 1/6/24 after returning from the hospital.
(10.) The facility will continue to pursue alternate placement, and the resident has been counseled to request an LOA if he/she wants to leave the building.
(11.) Maintenance will continue to monitor wander guards' effectiveness through random checks of the elevator's sensors.
The Director of Nursing (DON) was interviewed on 1/11/24 at 1pm. During the interview, the DON demonstrated Quality Assurance (QA) material that she did a facility wide audit to determine if there were other residents with exit-seeking behaviors located on the first or second floor. From this audit 2 additional residents were added to the elopement list, which brought the facility total to 4 residents for elopement/exiting seeking behaviors.
A record review of (Residents #1, #2, #3, and #4) was performed by this surveyor on 1/11/24 at 1:30pm for elopements/wandering behaviors. The review revealed that the residents' care plans had been updated and/or initiated.
Based on the above actions taken by the facility and verified by the surveyor on-site, it was determined that the facility had corrected the deficient practice by 1/8/2024, prior to the start of the survey.

Based on reviews of administrative records and staff interview, it was determined that the nursing administrative staff failed to conduct a yearly performance review on 2 of 6 geriatric nursing assistants for the prior 12 months. The findings include:
On 08/28/19, a review of 6 random geriatric nursing assistant (GNA) for yearly performance appraisal revealed that 2 of the 6 GNA's had not had a yearly appraisal in the previous 12 months. Review of GNA #3's records revealed GNA #3's last performance appraisal was conducted on 08/14/2010. Review of GNA #1's records revealed that GNA #1's last performance appraisal was 08/20/2013.
In an interview with the Director of Nursing (DON) on 08/29/19 at 12:25 PM, the facility DON confirmed that GNA #1 and GNA #3 were not given a performance appraisal for the past 12 months.

Based on observation of medication pass and interview, it was determined the facility staff failed to obtain a medication error rate less than 5% (Resident #286). This includes 1 out of 3 residents observed for medication pass, 2 errors out of 25 opportunities with a medication error rate of 8%.
The findings include:
The facility uses an Electronic Medical Record (EMR) for the administration and documentation of medications for administration to the residents. The physician's orders for the medications are entered in the EMR with the times of medication administration.
The Five Rights of Medication Administration. One of the recommendations to reduce medication errors and harm is to use the five rights: the right patient, the right drug, the right dose, the right route, and the right time.
1. The facility staff #21 failed to administer medication to Resident # 286 as ordered by the physician. Medical record review for Resident #286 revealed the physician ordered: Prednisone 1 mg tablets, give 2 tablets po every day. Prednisone is used as an anti-inflammatory or an immunosuppressant medication. Observation of medication pass on 8/29/19 at 8:30 AM revealed facility staff nurse #21 failed to administer the Prednisone as ordered by the physician and was observed giving a total of 3 Prednisone tablets.
2. The facility staff #21 failed to administer medication to Resident # 286 as ordered by the physician. Medical record review for Resident #286 revealed the physician ordered: Breo Ellipta 1 puff and rinse mouth after use. Breo Ellipta is a steroid inhaler, prescription medicine used to treat chronic obstructive pulmonary disease (COPD) and asthma in adults. Breo Ellipta can cause serious side effects, including fungal infection in your mouth or throat (thrush). Rinsing your mouth with water without swallowing after using helps reduce your chance of getting thrush.
Observation of medication pass on 8/29/19 at 8:30 AM revealed facility staff nurse #21 failed to administer the Breo Ellipta as ordered by the physician and was observed giving the resident the inhaler to use with out instructing or giving the resident the necessary supplies to rinse the mouth after medication use.
Interview with the Director of Nursing on 8/29/19 at 9:30 AM confirmed the facility staff failed to administer medications according to The Five Rights of Medication Administration and as ordered by the physician.

Based on observation and interview, it was determined the facility staff failed to ensure medications were thoroughly labeled with residents' name and dated when the medication were open. This was evident for 2 of 4 medication carts observed during the annual survey process.
The findings include:
Observation of the medication cart on 08/30/19 at 8:16 AM revealed the following observation:
1. The medication cart 1 on Unit 1 had the following: insulin medications with no open dates, Humalog, Novolog and two Basaglar pens.
2. The medication cart on Unit 2 had the following: brimonidine eye drops with no open date, Plavix with no name and Ipratropium nasal spray with no open date.
Interview with the Director of Nursing on 08/30/19 8:30 AM confirmed the facility staff failed to ensure medications were thoroughly labeled with residents' name and dated when open.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations and interviews with staff it was determined that the facility failed to ensure residents had a means of directly contacting staff. This was evident for 3 pull chords in 2 resident spa rooms.
The findings include:
On 8/28/2019 at 8:09 AM the spa room across from room [ROOM NUMBER] was observed to have the call light in the shower suspended between the wall unit and the escutcheon plate for the shower's grab bar. This caused the pull chord to be suspended approximately 30 from the ground and not easily accessible to a resident should they fall. The toilet room within this spa room was observed with the call light chord wrapped around the grab bar preventing the alarm from activating when the chord was pulled. At 8:25 AM observation of the spa room across from room [ROOM NUMBER] revealed the pull chord in the first shower on the left was also wrapped around the grab bar preventing it from functioning properly.
These findings were reported immediately to GNA #8. The Administrator and Director of Nursing were made aware of these findings on 8/30/2019 during the exit conference.