How many inspection deficiencies does AUTUMN LAKE HEALTHCARE AT BRIDGEPARK have?

AUTUMN LAKE HEALTHCARE AT BRIDGEPARK has 80 deficiencies from recent inspections. None are at the Immediate Jeopardy level.

What are the staffing levels at AUTUMN LAKE HEALTHCARE AT BRIDGEPARK?

AUTUMN LAKE HEALTHCARE AT BRIDGEPARK has a three-star staffing rating from CMS with 0.90 RN hours per resident per day. This rating is based on registered nurse (RN), licensed practical nurse (LPN), and nurse aide staffing hours.

Where is AUTUMN LAKE HEALTHCARE AT BRIDGEPARK located?

AUTUMN LAKE HEALTHCARE AT BRIDGEPARK is located in BALTIMORE, MD. It is a Medicare and Medicaid certified skilled nursing facility.

How many beds does AUTUMN LAKE HEALTHCARE AT BRIDGEPARK have?

AUTUMN LAKE HEALTHCARE AT BRIDGEPARK has 106 certified beds.

Who owns AUTUMN LAKE HEALTHCARE AT BRIDGEPARK?

AUTUMN LAKE HEALTHCARE AT BRIDGEPARK is a for profit - limited liability company facility and is part of the AUTUMN LAKE HEALTHCARE chain.

AUTUMN LAKE HEALTHCARE AT BRIDGEPARK

Name: AUTUMN LAKE HEALTHCARE AT BRIDGEPARK
Address: 4017 LIBERTY HEIGHTS AVENUE, BALTIMORE, MD, 21207, US
Telephone: (410) 542-5306
Rating: 1.0

4017 LIBERTY HEIGHTS AVENUE, BALTIMORE, MD 21207 · (410) 542-5306

For profit - Limited Liability company 106 Beds AUTUMN LAKE HEALTHCARE Data: November 2025

Trust Grade

35/100

#184 of 219 in MD

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Last Inspection: November 2021

Over 2 years since last inspection. Current conditions may differ from available data.

Overview

Autumn Lake Healthcare at Bridgepark has received a Trust Grade of F, indicating significant concerns regarding the quality of care provided. With a state rank of #184 out of 219 facilities in Maryland, they are in the bottom half, and #24 out of 26 in Baltimore City County, suggesting limited local options for better care. The facility is improving, as the number of issues reported decreased from 30 in 2021 to 15 in 2025. Staffing is rated average, with a turnover rate of 46%, which is close to the state average, but the facility has faced serious concerns, including incidents where staff failed to provide adequate supervision for a resident exhibiting inappropriate behavior and did not ensure proper two-person assistance for another resident, leading to potential harm. Despite having no fines recorded, there are still notable weaknesses, including the failure to administer medications as prescribed for some residents, which raises concerns about the overall competency of the nursing staff.

Trust Score: F
In Maryland: #184/219
Safety Record: Moderate
Inspections: Getting Better
Staff Stability: 46% turnover. Above average. Higher turnover means staff may not know residents' routines.
Penalties: No fines on record. Clean compliance history, better than most Maryland facilities.
Skilled Nurses: Each resident gets 53 minutes of Registered Nurse (RN) attention daily — more than average for Maryland. RNs are trained to catch health problems early.
Violations: 80 deficiencies on record. Higher than average. Multiple issues found across inspections.

★☆☆☆☆

1.0

Overall Rating

★★★☆☆

3.0

Staff Levels

★★★☆☆

3.0

Care Quality

★☆☆☆☆

1.0

Inspection Score

↔

Stable

2021: 30 issues

2025: 15 issues

The Good

Full Sprinkler Coverage · Fire safety systems throughout facility
No fines on record

Facility shows strength in fire safety.

The Bad

1-Star Overall Rating

Below Maryland average (3.0)

Significant quality concerns identified by CMS

Staff Turnover: 46%

Near Maryland avg (46%)

Higher turnover may affect care consistency

Chain: AUTUMN LAKE HEALTHCARE

Part of a multi-facility chain

Ask about local staffing decisions and management

The Ugly 80 deficiencies on record

1 actual harm

Jun 2025 15 deficiencies 1 Harm

SERIOUS (G) 📢 Someone Reported This

A family member, employee, or ombudsman was alarmed enough to file a formal complaint

Actual Harm - a resident was hurt due to facility failures

Accident Prevention (Tag F0689)

A resident was harmed · This affected 1 resident

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record reviews, and interviews, it was determined that facility staff failed to 1.) provide adequate supervision of a resident identified with inappropriate sexual behavior towards residents and staff resulting in actual harm to Resident #11, and 2.) ensure two-person assistance was provided while providing care to a resident in bed, as required by the resident's care plan. This deficient practice was evident for 2 of 5 residents (#11 and #98) reviewed for accidents during the annual survey.The findings include: 1) On 6/4/25, the surveyor reviewed facility incident reports and medical records for Residents #27 and #11. Resident #27 was admitted to the facility on [DATE] with diagnoses including schizophrenia and cognitive impairment. The nursing assessment for Resident #27 dated 6/19/24 documented a Brief Interview of Mental Status (BIMS) score of 6, indicating severe cognitive impairment. A review of the facility reported incident (FRI) MD00193881 revealed that the facility substantiated that Resident #27 inappropriately touched Resident #85 on 6/29/23. The resident’s care plan was revised on 6/30/23, to address sexually inappropriate behaviors toward residents and staff. Interventions included administering psychotropic medications as ordered, monitoring side effects, establishing limits for inappropriate behaviors, and explaining unacceptable behavior to the resident. There was no documentation indicating that the facility revised the care plan to include increased supervision to ensure safety for all residents. Following the incident from 6/29/23, a review of a psychiatric evaluation conducted on 1/30/24 indicated that Resident #27 has a history of inappropriate sexual behavior towards staff. Another psychiatric evaluation was completed on 2/5/24 to assess the resident for Gradual Dose Reduction (GDR) of Zyprexa. It was documented that the resident previously failed a GDR attempt, but a second attempt was made. A progress note from the psychiatrist indicates that Resident #27 continued to display inappropriate behavior. Resident #11 was admitted to the facility on [DATE] with diagnoses including dementia. The nursing assessment for Resident #11 dated 7/22/24 documented a BIMS score of 0 indicating severe cognitive impairment. A review of FRI MD00208357 revealed that Resident #27 inappropriately touched Resident # 11 on 8/2/24. The facility substantiated allegations of sexual abuse based on a witness account provided by Geriatric Nursing Assistant (GNA) #18. According to the investigation, on 8/2/24 at 2:54 PM, GNA #18 reports walking into room [ROOM NUMBER] at 2:54 PM and noticed Resident #27 on his/her knees next to bed A. Resident #27 appeared to be touching Resident #11 in the genital area. The GNA saw that one side of Resident #11 brief was wide open, and she could see his/her genital area exposed. The GNA immediately told Resident #27 to leave the room, and she redressed Resident #11, observing that the non-verbal resident was “tearful and kicking their legs urgently.” The surveyor conducted an interview with GNA #18 regarding FRI MD00208357. The surveyor asked if she recalled the incident involving Resident #11 and Resident #27. GNA #18 stated that she did remember and witnessed tears streaming down Resident #11’s face, explaining that the resident typically does not cry. When asked whether she believed the resident understood what had happened, the GNA stated “yes”. Although the resident is nonverbal, she appears to understand at times. Following the incident on 8/2/24, the facility requested a psychiatric evaluation which was conducted on 8/5/24. A psychiatrist's progress notes documented that the resident was evaluated at the nurse’s station and is now under close supervision by staff. A review of Resident #27s care plan revealed that the care plan was revised on 8/7/24, to address inappropriate touching of others. Previous care plan updates were made on 2/25/24, 2/26/24, 5/29/24 & 8/7/24 including behavioral monitoring, redirecting, and maintaining the resident’s dignity and right to sexual expression. However, the intervention failed to include increased supervision to ensure the safety of other residents. On 6/5/2025 at 7:35 AM, during an interview with the Administrator regarding FRI MD00208357. The surveyor asked whether the incident had been reviewed during the facility’s Quality Assurance and Performance Improvement (QAPI) meeting and if a corrective plan had been developed. The Administrator stated that the incident was reviewed during the facility’s risk management meeting, but no plan was implemented following the incident on 8/2/24. The Administrator confirmed that no additional supervision was initiated for Resident #27 beyond general monitoring and staff rounding. Both the surveyor and the Administrator reviewed Resident #27 care plan and acknowledged that the care plan should have included supervision interventions following the 8/2/24 incident. She also stated that no additional incidents of sexually inappropriate behavior towards another resident occurred between June 2023 and August 2024, she did not believe higher supervision was necessary. On 6/5/25 at 3:49 PM, both the Administrator and Director on Nursing (DON) were informed that the facility’s failure to revise Resident #27 care plan interventions to include more supervision led to the harm that occurred on 8/2/24. Both the Administrator and DON acknowledged that information. Although Resident #11 did not have any documented emotional distress, behaviors, or other negative outcomes from the incident on 8/2/24, the resident was known to be unable to respond normally to situations, to communicate effectively with staff, or to express their feelings clearly. In situations where a resident is unable to express their feelings such as this, the Reasonable Person Concept can be used to approximate how a reasonable person in the resident's situation would have reacted for the purpose of determining the outcome of a deficient practice. Using this concept, it was determined that a reasonable person would have experienced humiliation, anger, shame, and intimidation in response to the actions of Resident #27. Therefore, it was determined that psychosocial harm occurred to Resident #11. 2.) On 06/11/2025 at 11:00 AM, a review of complaint MD#00212331 revealed a concern regarding an incident that occurred in March of 2024 when only one staff member was providing care for Resident #98 which resulted in the resident rolling out of bed and hitting their head on the floor sustaining a cut over their right eye. Review of Resident #98's medical records on 06/12/2025 at 9:14 AM, revealed a baseline care plan for the resident that was completed on 03/12/2024. In this baseline care plan, under section 2B titled, Functional Abilities and Goals- Mobility, Bed Mobility: support provided, the resident was designated as a Two+ persons physical assist.On 06/12/2025 at 11:21, Resident #98's care documentation was reviewed for bed mobility in March of 2024. There were a total of 52 documented tasks performed for bed mobility. Of those 52, there were 30 documented as using a one person physical assist. On March 14, 2024 at 2:00 PM, just prior to the fall, the bed mobility task was documented as using a one person physical assist. Review of a change in condition dated 03/14/2024 revealed that the Resident rolled/fell out of bed during care by the assigned aid at 4:45 PM, thus sustaining a 1.0 cm laceration over the right eyebrow. On 06/12/2025 at 12:49 PM, during an interview with the Director of Nursing (DON), she stated that if a resident is designated as a Two+ persons physical assist for bed mobility then it is expected that the aid or nurse ensures that there are two people present during care.

CONCERN (D) 📢 Someone Reported This

A family member, employee, or ombudsman was alarmed enough to file a formal complaint

Potential for Harm - no one hurt, but risky conditions existed

Deficiency F0558 (Tag F0558)

Could have caused harm · This affected 1 resident

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and staff interview, it was determined that the facility failed to provide reasonable accommodations of preferences by not honoring a resident's request for female only caregivers. This was found to be evident for Resident #105 during investigation of facility reported incident MD00186826. The findings include: On 06/11/2025 at 11:00 AM, facility reported incident MD00186826 was reviewed by surveyor. In the report, Resident #105 alleged that a male caregiver had sexually assaulted them while applying barrier cream during incontinence care on 12/15/2022. The facility initiated an investigation and found the alleged incident to be unsubstantiated. Further record review revealed that Resident #105 was admitted to the facility on [DATE] and transferred to another nursing facility on 2/17/2023. Additional review of facility reported incident MD00186826 on 06/11/2025 revealed that the facility had stated on the Comprehensive & Extended Care Facilities Self-Report Form that the resident, is to receive ADL care from females only going forward. Included in the facility investigation packet was an interview conducted by the Nursing Home Administrator (NHA) with Resident #105 on 12/19/2022, where it was documented that the resident, explained that they did not want any males to work with them. On 06/12/2025 at 10:13 AM, review of Resident #105's electronic health record (EHR) revealed a nurse progress note dated 12/17/2022 that stated, Resident is alert and stable, able to make her needs known. No complaints, cooperated with GNA and RN, due meds and treatment provided as ordered and well tolerated. Supervisor made RN aware that patient cannot have Male care giver. Resident #105's treatment administration record (TAR) for barrier cream application during incontinence care was reviewed on 6/12/2025 at 11:35 AM. It revealed that on dates 1/5/2023, 1/10/2023, 1/15/2023, 1/16/2023, 1/17/2023, 1/24/2023, 1/27/2023, 1/28/2023, 1/29/2023, and 2/7/2023, two presumed male staff members performed the care. Additionally, review of Resident #105's care plan did not show a revision that included their preference for female caregivers. The NHA was interviewed on 06/13/2025 at 9:20 AM and presented a copy of the January and February 2023 TAR. The NHA confirmed that a check mark with initials on the TAR means that staff member performed the care and confirmed that the two presumed male staff members were indeed male. The NHA further stated that the care plan should have been updated to reflect the resident's wishes for only female caregivers and acknowledged surveyor concerns.

CONCERN (D) 📢 Someone Reported This

A family member, employee, or ombudsman was alarmed enough to file a formal complaint

Potential for Harm - no one hurt, but risky conditions existed

Notification of Changes (Tag F0580)

Could have caused harm · This affected 1 resident

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Based on record reviews and interviews it was determined that facility staff failed to notify a resident's representative of a change in the resident's medical condition and failed to inform the resident's representative of the resident's transfer to the hospital. This deficient practice was evident for one (#89) resident reviewed for notification of changes during the annual survey. The term resident representative means the following: An individual chosen by the resident to act on behalf of the resident in order to support the resident in decision-making; access medical, social or other personal information of the resident; manage financial matters; or receive notifications. The findings include: Resident #89 was admitted to the facility August 2023 with medical history that includes aphasia ( language disorder that can affect a person's ability to speak, understand, read or write) among other conditions. A review of complaint intake MD00202589 on 06/10/25 at 7:33 AM reveals that the complainant reported not being notified by the facility about a change in Resident #89's medical condition. The complainant stated that they learned of the resident's hospitalization on 2/10/24; one day after the admission occurred. On 6/11/25 at 6:50 AM, a review of Resident #89's admission record revealed that the complainant is listed as the resident's representative. Further review of the baseline care plan confirmed that the complainant was listed as the resident representative. On 2/9/24, a facility staff documented on a change of condition template that Resident #89 became short of breath. Under Section L1, it was noted that the Certified Registered Nurse Practitioner was notified on 2/9/24 and recommended stat diagnostic testing and medication. Under section M which addresses resident representative notification, staff documented that the resident was their own representative and that the resident was notified on 2/9/24. Resident #89 was transported to the hospital on the same day. There was no documentation indicating that the resident's designated representative was notified of the change in the resident's medical condition or the hospital transfer. On 06/11/25 at 7:33 AM, during an interview with the Director of Nursing (DON) with the Administrator present, the surveyor asked about the facility's expectation for notifying resident representative when a resident is transferred to the hospital. The DON stated that staff are expected to notify the residents' representatives. The surveyor informed the DON of the concerns mentioned in intake MD00202589. The DON stated that if the resident can make their own decisions, staff are not required to notify the representative.

CONCERN (D) 📢 Someone Reported This

A family member, employee, or ombudsman was alarmed enough to file a formal complaint

Potential for Harm - no one hurt, but risky conditions existed

Free from Abuse/Neglect (Tag F0600)

Could have caused harm · This affected 1 resident

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record reviews and staff interviews, it was determined that the facility failed to ensure that a resident remained free of abuse. This deficient practice was evident for one (#11) of five residents reviewed for abuse during the annual survey. The findings include: Review of the facility's investigation file related to the facility reported incident MD00208357 and compliant intake MD00208362 on 6/4/25 at 2:45 PM, revealed that the facility substantiated allegations of sexual abuse based on a witness account provided by Geriatric Nursing Assistant (GNA) #18. GNA #18 reported that while walking into room [ROOM NUMBER] on 8/2/24 as part of her initial shift rounding, GNA #18 witnessed Resident #27 who is cognitively impaired on their knees next to Resident #11's bed and was touching the resident's genital area. The GNA immediately intervened and redirected Resident #27 out of the room. The GNA reported the incident to her floor nurse as they attended to Resident #11. Resident #11 who is cognitively impaired, did not appear to have any injuries but did note that the resident's incontinence brief had been pulled to the side. Review of the investigation file revealed that the incident occurred on 8/2/24, at 2:54 PM. The Director of Nursing (DON) became aware of the incident at 3:15 PM and notified the Administrator at the same time. Further review indicated that the Baltimore City Police Department was notified at 3:57 PM, and the report was submitted to the state agency at 4:57 PM on the same day. On 06/05/25 at 11:39 AM, during an interview, the Administrator stated that she recalled the incident that occurred on 8/2/24. After the incident, Resident #11 was transported to the hospital for further evaluation and returned to the facility with no physical injuries. Upon returning, Resident #11 was placed on a different unit. Resident #27 was evaluated and placed on one-to-one supervision until medication adjustments were effective.

CONCERN (D) 📢 Someone Reported This

A family member, employee, or ombudsman was alarmed enough to file a formal complaint

Potential for Harm - no one hurt, but risky conditions existed

Report Alleged Abuse (Tag F0609)

Could have caused harm · This affected 1 resident

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Based on review of facility reported incident investigation, review of record and interviews, it was determined the facility failed to 1) report an allegation of abuse in a timely manner to the state agency, immediately, but not later than two hours after the allegation was made, and 2) report an injury of an unknown source to the state agency as required. This was evident for 1 resident (Resident #106) of 17 residents reviewed for timely reporting an alleged violation, and 1 resident (#94) of 3 residents reviewed for an injury of unknown origin during an annual survey. The findings include:1) On 06/10/2025 at 8:41 AM, review of the investigation report of Facility Reported Incident (FRI), MD#00190620 revealed that on 03/28/2023 at 09:15 AM, Resident #110 reported to the administrator that Resident #106 might have been choked by Geriatric Nursing Assistant (GNA #21) on 03/27/2023 during the evening shift. On 06/10/2025 at 8:57 AM, further review of the investigation packet showed that on 03/27/2023, Certified Medicine Aide (CMA #32)'s in her statement stated that on that day at around 6:00PM to 6:30 PM, a resident informed her that Resident #106 had been hit and on the same day Resident #106's roommate had given her a note about Resident #106 being hit. On 06/10/2025 at 12:53 PM, in an interview with the Nursing Home Administrator (NHA), when she was asked about the reporting time of an alleged abuse violation, she stated that she typically reports such incidents within two hours or less. When she was informed that the alleged violation was not reported in a timely manner, she responded that she learned about the incident from another resident as she was arriving at the facility and added that this failure to report to the supervisor was a major factor in the termination of CMA #32's employment, noting that CMA #32 was aware of the incident but failed to notify a supervisor who would have informed her(NHA). She was informed that delay in reporting was a concern that would be brought to our office, and she acknowledged understanding of the concern. 2) Review of complaints #MD00210615 and #MD00210588 on 6/4/25 at 10:21 AM, revealed an allegation that Resident #94 sustained an ankle fracture of unknown origin on or about 10/5/24. The Resident's medical record revealed that Resident #94 was non-verbal, and was completely dependent on staff for all care and ADL (Activities of Daily Living) including but not limited to bed mobility, turning and repositioning, toileting, and hygiene; and that s/he had severe contractures (a permanent tightening of the muscles, tendons, skin, and nearby tissues that causes the joints to shorten and become very stiff). A Change in Condition/Concurrent Review dated 10/4/24 12:53 (12:53 PM) noted that the resident's left lower extremity was swollen, and left ankle was red and warm to touch; the Physician was contacted and ordered a STAT (immediate) x-ray to rule out a fracture and an ultrasound to rule out a Deep Vein Thrombosis (blood clot). The X-ray report dated 10/5/24 revealed the resident had fractures of the distal metaphysis of the left tibia and fibula (ankle area) in satisfactory position and alignment. S/he also had severe deformities of the left foot. No documentation was found in Resident #94's record of an accident, incident or trauma associated with the injury.On 06/4/25 at 11:30 AM the Administrator was asked if the facility reported the injury of unknown origin related to Resident #94's fractured ankle to the State Agency. She initially indicated no but then indicated that she would look because there may be something in her office. At 1:10 PM on 06/4/25 the DON (Director of Nursing) and the Administrator confirmed that the facility did not report the resident's injury to the State Agency. The DON provided the surveyor with an investigation that was completed by the facility on 10/7/24 and indicated the injury was not reported because the medical director determined that it was a pathological fracture. The DON confirmed that the medical director's determination was made on 10/7/24, 2 days after the initial injury was identified. She also confirmed that Resident #94 was incapable of moving independently. Cross reference F 628 and F 842.

CONCERN (D) 📢 Someone Reported This

A family member, employee, or ombudsman was alarmed enough to file a formal complaint

Potential for Harm - no one hurt, but risky conditions existed

Investigate Abuse (Tag F0610)

Could have caused harm · This affected 1 resident

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Based on review of a facility reported incident it was determined the facility failed to 1) ensure the thorough investigation of an allegation of abuse, and 2) provide residents with psychological evaluations and physician assessments following a substantiated incident of resident to resident sexual abuse. This was evident for 1 (Resident #106) out of 17 residents reviewed for allegations of abuse, and 1 (MD#00193881) of 17 Facility Reported Incidents (FRI) reviewed during the annual survey.The findings include:1) On 06/10/2025 at 8:41 AM, review of the investigation report of Facility Reported Incident (FRI), MD#00190620 revealed that on 03/28/2023 at 09:15 AM, Resident #110 reported to the administrator that Resident #106 might have been choked by Geriatric Nursing Assistant (GNA #21) on 03/27/2023 during the evening shift. On 06/10/2025 at 11:12 AM, when the surveyor requested copies of employee files/trainings for GNA #21 from the Nursing Home Administrator (NHA), she informed this surveyor that GNA #21 was from a nursing agency and added that the facility did not have his employee file and training. When asked how the facility ensured that nursing agency staff received the required training, she explained that the facility had a contract with the agency stipulating that all staff would be properly trained before being assigned to the facility. On 06/10/2025 at 11:24 AM, She was asked to provide a copy of the contract with the nursing agency.On 06/10/2025 at 1:52 PM, The NHA and Director of Nursing (DON) informed the surveyor that they do not have the contract from the nursing agency do not have any documentation of GNA #21's training. She stated that it seemed the agency did not exist any longer. When they were informed that the inability to maintain an employee training/file record was a concern, the NHA and DON verbalized understanding of it and the DON stated that they should have ensured that GNA #21 had the required training which should have been made available on request. 2) Based on record review and interview with staff, it was determined that the facility failed to provide residents with psychological evaluations and physician assessments following a substantiated incident of resident to resident sexual abuse. On 06/05/2025 at 9:24 AM, the surveyor reviewed an investigation into an incident of resident to resident sexual abuse that took place on 06/29/2023 at 9:23 AM. In the investigation documentation, the facility made several claims that the residents had been seen by psychiatric services and the facility physician for assessment and evaluation following the substantiated incident. On 06/05/2025 at 10:01 AM, a review of Resident #27's medical records failed to reveal that the resident was seen for a psychiatric evaluation following the incident regarding the sexual abuse.On 06/06/2025 at 10:18 AM, a review of Resident #85's medical records failed to reveal that the resident was seen by the facility physician in regards to the sexual abuse. On 06/12/2025 at 2:13 PM, during an interview with the Director Of Nursing (DON), she stated that it was normal practice following any allegation of resident to resident abuse that both residents would be seen by psychiatric services and the physician to be assessed and evaluated. She stated that both residents involved in this incident had not been seen by psych services or the facility physician regarding the sexual abuse. The DON was made aware of the concern on 06/12/2025 and again during the exit conference on 06/13/2025

CONCERN (D) 📢 Someone Reported This

A family member, employee, or ombudsman was alarmed enough to file a formal complaint

Potential for Harm - no one hurt, but risky conditions existed

Deficiency F0628 (Tag F0628)

Could have caused harm · This affected 1 resident

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Based on medical record review and interviews it was determined the facility staff failed to ensure that the required minimum information was provided to the receiving provider upon transfer from the facility. This was evident for 1 (#94) of 3 residents reviewed for an injury of unknown origin. The findings include: A review of Resident #94's medical record on 6/4/25 at 10:21 AM revealed a Change in Condition/Concurrent Review dated 10/4/24 12:53 (12:53 PM) which noted that the resident's left lower extremity was swollen, and left ankle was red and warm to touch. The Physician was contacted and ordered a STAT x-ray to rule out a fracture and an ultrasound to rule out a Deep Vein Thrombosis (blood clot). The Change in Condition form contained a section to document specific information in the event of a hospital transfer. The section was blank. The X-ray report dated 10/5/24 confirmed the resident had fractures of the ankle. A Nursing Note dated 10/6/24 03:13 (3:13 AM) noted that the on-call physician was notified of the results and ordered that the resident be sent to the hospital for evaluation. Another Nurses Note at 03:33 (3:33 AM) on 10/6/24 indicated the resident was sent to the hospital at that time. No documentation was found to indicate that the required information was provided to the receiving provider at the time of the transfer. During an interview on 6/4/25 at 11:30 AM the Administrator was made aware of this finding and indicated the required information should be documented in the Change in Condition form. She reviewed the form and confirmed it did not contain the required information. She indicated that she would check with the DON (Director of Nursing). At 1:10 PM on 6/4/24 the Administrator and DON confirmed that there was no documentation to indicate that the required hospital transfer information was sent to the receiving facility. Cross reference F 609 and F 842.

CONCERN (D) 📢 Someone Reported This

A family member, employee, or ombudsman was alarmed enough to file a formal complaint

Potential for Harm - no one hurt, but risky conditions existed

Comprehensive Care Plan (Tag F0656)

Could have caused harm · This affected 1 resident

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Based on record review and interviews, it was determined the facility failed to ensure comprehensive care plans were developed and implemented. This was evident for 1 resident (Resident#104) out of 17 facility reported investigations, and 2 (Resident #58 and Resident #92) out of 6 residents reviewed for care plans. The findings include:1) A care plan is an outline of nursing care showing all the residents' needs and the ways of meeting the needs. Care plans provide direction for individualized care of the resident. A care plan flows from each resident's unique list of diagnoses and should be organized by the individual's specific needs. It is a dynamic document initiated at admission and subject to continuous reassessment and change by the nursing staff caring for the resident. The care plan typically includes nursing and medical diagnoses, nursing interventions, and outcomes to ensure consistency of care.On 06/11/2025 6:33 AM, the surveyor reviewed the facility's reported incident investigation packet for intake MD#00181243 in which the facility reported an unexpected death of Resident #104 to the state agency.On 06/11/2025 at 8:44 AM, further review of the investigation packet revealed the resident's death certificate which was signed by the certifying physician and dated 07/22/2022 was seen which revealed the following as the cause of deathA)Septic shock with approximate interval between onset and death described as days.B)Necrotizing Fasciitis with approximate interval between onset and death described as weeks.C)History IV drug abuse with approximate interval between onset and death described as years.D)Polysubstance abuse with approximate interval between onset and death described as years.On 06/11/2025 9:04 AM, review of the resident's electronic health record (EHR) showed that Resident #104 had diagnosis of osteomyelitis and history of substance abuse amongst other diagnosis. On 06/12/2025 at 7:31 AM, review of the resident's care plans failed to reveal a plan to address the history of substance abuse and there was no documentation found regarding what intervention would be facilitated by staff to prevent such while the resident was at the facility.On 06/12/2025 at 8:13 AM, in an interview with the Nursing Home Administration (NHA), When asked if there was a care plan in place for Resident #104 which addressed the history of substance abuse, she stated that the facility did not put a care plan in place for history of substance abuse. When asked if there should have been a care plan in place for the history of substance abuse, she stated that there should have been one in place which would have helped to identify that she had the potential for illicit substance use and interventions would have been in place. She also added that she did not know if a post mortem was done or not. 2a) On 06/06/25 at 07:52 AM, a review of Resident #58's medical records was conducted. This review revealed that the resident was dependent on staff for personal hygiene and toileting. Further review of the resident's care plan indicated that Resident #58 needed 2-persons assist during the provision of personal care. On 06/06/25 at 08:00 AM, a review of the resident's Minimum Data Set (MDS) revealed that the resident was coded as dependent on staff. The MDS (Minimum Data Set) is a complete assessment of the resident which provides the facility information necessary to develop a plan of care, provide the appropriate care and services to the resident, and to modify the care plan based on the resident's status. MDS defines dependent as when the caregiver does all of the effort, or, the assistance of 2 or more helpers is required for the resident to complete the activity.On 06/06/25 at 01:50 PM, a review of Resident #58's personal hygiene record for March and April 2025 revealed that the resident received only 1 person assist during various shifts every day in March and April 2025.On 06/06/25 at 02:00 PM, further review of the record revealed a nurse note dated 06/01/2025 that indicated the resident rolled out of the bed and was caught by the aide who assisted the resident to the floor.On 06/06/25 at 02:25 PM, an interview with the Director of Nursing (DON) was conducted. The DON confirmed that according to the facility's provided documentation, Resident #58's care was provided by 1 person instead of 2-persons as care planned. 2b) On 06/11/2025 at 09:06 AM, review of confidential complaints reported to the state agency revealed complaint #MD00206301 which was received on 6/4/2024. This complaint alleged that Resident #92 did not receive tracheostomy care.A tracheostomy is a surgical procedure that creates an opening in the neck, called a stoma, through which a tube is inserted into the trachea (windpipe) to provide an airway and facilitate breathing.On 06/11/2025 at 10:00 AM, further review of Resident #92's medical record was conducted. The review revealed that Resident #92 was admitted into the facility with a tracheostomy on 4/3/24 and was discharged to a hospital on 5/31/24. A review of the resident's care plan did not include tracheostomy care.On 06/11/2025 at 10:30 AM, an interview with the DON was conducted. During the interview, the surveyor and the DON reviewed Resident #92's care plan and the DON confirmed that the resident was never care planned for tracheostomy care.

CONCERN (D) 📢 Someone Reported This

A family member, employee, or ombudsman was alarmed enough to file a formal complaint

Potential for Harm - no one hurt, but risky conditions existed

Deficiency F0657 (Tag F0657)

Could have caused harm · This affected 1 resident

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Based on record review and interviews, it was determined that the facility failed to revise care plans for residents. This was evident for 1 (MD#00207171) out of 17 facility reported investigations, 2 (Resident #100, #27) out of 5 residents reviewed for care plans reviewed during an annual survey.The findings include:1) On 06/09/2025 at 9:48 AM, the surveyor reviewed the facility's reported investigation packet for intake MD#00207171 in which the facility had stated that on 06/28/2024, Resident #64 was seen naked with another resident.On 06/09/2025 at 10:30 AM, further review of the investigative packets showed that the facility stated in the final report sent to the state agency that the corrective action to be taken would be to update Resident #64's care plan to reflect his/her wish for companionship with other residents but that his/her interactions would be supervised by staff, that no sexual interactions would take place due to resident's cognitive deficits and provide assistance with resolution as needed.On 06/09/2025 at 10:51 AM, review of the resident's care plan in the electronic health record dated 07/02/2024 showed inappropriate exposure behaviors with another resident which care-planned underneath behaviors care plan and there was no goal or intervention for the care plan focus. The surveyor did not see a care plan update that addressed Resident #64's desire for companionship with other residents or care plan intervention for staff to supervise him/her so that there would not be sexual interactions.On 06/09/2025 at 12:04 PM, in an interview with the Director of Nursing (DON), when she was asked what measures were put in place after the incident. She stated that she had just started working at the facility 2 days after the incident and that the Nursing Home Administrator would know more about it.On 06/09/2025 at 12:11 PM, in an interview with the Nursing Home Administration (NHA), when asked what measures were put in place after the incident, she stated that the facility had planned to update Resident #64's care plan to reflect the desire for companionship and that he/she would be supervised by staff so that there would be no sexual interaction. When she was asked for the documentation of the care plans, she stated that she would provide it to the surveyor.On 06/09/2025 at 12:16 PM, the NHA informed the surveyor that she had checked the resident's electronic health record but did not find any care plan that addressed Resident #64's desire for companionship with other residents or care plan intervention for staff to supervise him/her so that there would be no sexual interaction. When she was informed that this was a concern that would be taken to the office, she stated that the care plan should have been specific just as it was noted in the final report sent to the state agency. 2) On 06/11/25 at 9:00 AM, a review of Complaint #MD00212923 was conducted. The complaint expressed concerns with how Resident #100 fell and the process after the fall. On 06/12/25 at 9:30 AM, Resident #100's Change of Condition documentation was reviewed. On 12/6/2024, the change of condition documentation stated the resident was found on the floor during rounds.On 06/12/25 at 10:12 AM, a review of Resident #100's care plan and orders was conducted. A care plan of Potential for falls was created on 11/9/24. No revisions made to the care plan's Focus, Goal, or Interventions after the fall on 12/6/24. There was no additional Fall care plan created after the fall on 12/6/24. A review of Resident #100's orders revealed that no orders for interventions were created after fall on 12/6/24.On 06/12/2025 at 12:30 PM, an Interview with the Director of Nursing (DON). The DON noted that there was no Care plan, orders, or interventions created or revised after Resident #100's fall on 12/6/2025. 3.) Monitoring and Modification-Monitoring is the process of evaluating the effectiveness of care plan interventions. Modification is the process of adjusting interventions as needed to make them more effective in addressing hazards and risks.A review of the facility's investigation file related to the facility reported incident MD00208357 and complaint intake MD00208362 on 6/4/25 at 2:45 PM, revealed that the facility substantiated allegations of sexual abuse. The investigation indicates that Resident #27 sexually assaulted Resident #11 on 8/2/24.Further review of the investigation file revealed that the facility's corrective action for the incident included updating Resident #27 care plan to reflect the incident from 8/2/24, monitoring sexually inappropriate behaviors, and assessing the effects of medication changes.On 6/5/25 at 12:26 PM, a review Resident #27 care plan indicates that the facility failed to update care plan interventions to address monitoring and supervision in response to the resident's inappropriate sexual behaviors. 06/05/25 11:39 AM during an interview with the Administrator, the surveyor discussed the facility's investigation file and corrective action plan. The surveyor asked if Resident #27 inappropriate sexual behavior was monitored and supervised, since there was no indication of such on the care plan. The Administrator stated that the resident was receiving psychotropic medication behavioral monitoring, but no additional monitoring or supervision was in place for the inappropriate sexual behavior.

CONCERN (D) 📢 Someone Reported This

A family member, employee, or ombudsman was alarmed enough to file a formal complaint

Potential for Harm - no one hurt, but risky conditions existed

Deficiency F0658 (Tag F0658)

Could have caused harm · This affected 1 resident

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record reviews and interviews, it was determined that facility staff failed to 1.) ensure that a tube feeding container was labeled 2.) follow professional standards when caring for a resident who had a change in condition. This deficient practice was evident for one resident (Resident #53) out of 9 residents reviewed for tube feedings during the annual survey and one (#87) resident reviewed for nursing standards during the annual survey.The findings include: 1.)Gastrostomy tube (G-tube) is a tube that is placed directly into the stomach through an abdominal wall incision for administration of food, fluids, and medications. The most common type is a percutaneous endoscopic gastrostomy (PEG) tube.On 06/04/25 at 07:54 AM, during the initial tour of the facility, Resident #53 was seen sleeping, in bed, with a bottle of enteral feed running at 70 milliliters per hour(mL/hr). The surveyor observed that the enteral feed did not have a name or date on it. The surveyor also observed that the water flush that was up did not have a name or date as well.On 06/04/2025 at 8:12 AM, Registered Nurse #3 was invited for dual observation and confirmed that it was not dated or labeled. When she was asked if the enteral feed and the water flush should have had a name and a date, she stated that it should have been named and dated appropriately. She also added that it would be dated immediately.On 06/04/2025 at 1:15 PM, the surveyor went to observed Resident #53 and discovered that both the enteral feed and the water flush had been labeled.2.) According to the American Nurses Association, nursing documentation must be accurate, timely, and reflect the patient’s condition and care provided. A failure to document an assessment following a change in condition during a nursing shift is inconsistent with these professional standards. A review of complaint intake MD00186830 reveals that a family member reported finding Resident #87 unresponsive during a visit and called 911. The family member reported that staff told them the resident was like that all day. The resident was transported to the hospital for further evaluation. Review of medical records reveals that the resident was admitted to the facility on [DATE]. A baseline care plan was completed and indicated that the resident is alert, cognitively intact, and can make needs and preference know to staff. A review of the nurse’s progress note dated 12/12/22 at 5:31 PM indicated that the resident was alert and responsive to care. Another nurse’s progress note dated 12/13/22 at 12:23 AM also documented that the resident was alert and responsive. Further review of the nursing progress note reveals that the day shift nurse on 12/13/22 failed to document a nursing assessment of the resident. A Physician (MD) #35 progress note dated 12/13/22 at 1:36 PM stated that the resident was seen earlier that day lying on the bed with their feet dangling down and was noted to be confused and disoriented. Laboratory tests were reviewed, and the physician ordered repeat labs in two weeks. A review of the nursing progress note dated 12/13/22 at 3:30 PM indicated that the evening shift nurse entered Resident #87’s room and observed that the resident was unresponsive. The resident’s family who was at the bedside requested that the resident to be transferred to the hospital. The doctor was notified, however, the family member called 911 and the resident was transported to the hospital by paramedics. On 6/11/25 at 9:58 AM, during an interview with MD #35 the surveyor asked about the process for assessing new admission. The MD #35 stated that he reviews the resident's hospital discharge summary and receives a report from the nursing staff. He explained that he completes a physical examination and documents his findings and orders laboratory test and treatment as needed. The surveyor discussed Resident #87 and mentioned that at the time of admission, the resident was documented as alert and cognitively intact. On 06/23/2025 at 5:32 PM, a review of hospital admission notes dated 12/13/22 reveals that at the time of arrival, the resident was noted with altered mental status and was diagnosed with a urinary tract infection and tested positive COVID.

CONCERN (D) 📢 Someone Reported This

A family member, employee, or ombudsman was alarmed enough to file a formal complaint

Potential for Harm - no one hurt, but risky conditions existed

ADL Care (Tag F0677)

Could have caused harm · This affected 1 resident

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Based on record review and interviews, it was determined that the facility staff failed to provide a resident (Resident #92) with oral care. This was evident for 1 (MD#00206301) of 46 intakes reviewed during the recertification survey. The findings include: On 06/10/2025 at 10:00 AM, a review of confidential complaints reported to the state agency revealed complaint #MD00206301. This complaint alleged that Resident #92 did not receive oral care during their stay at the facility. On 06/10/2025 at 10:20 AM, a review of Resident #92's medical record was conducted. The review revealed that Resident #92 was admitted into the facility with a tracheostomy on 4/3/24 and was discharged to a hospital on 5/31/24. A tracheostomy is a surgical procedure that creates an opening in the neck, called a stoma, through which a tube is inserted into the trachea (windpipe) to provide an airway and facilitate breathing. The review of the care plan failed to mention any intervention for tracheostomy care or oral care. On 06/11/2025 at 9:49 AM, an interview with the Director of Respiratory Therapy (Staff #19) was conducted. When asked whose responsibility it was to provide dependent residents with oral care, Staff #19 stated that Respiratory Therapists (RTs) were responsible and that tracheostomy care also included oral care. Additionally, Staff #19 reported that RTs were required to document oral care provided under progress notes. On 06/11/2025 at 10:00 AM, a review of the respiratory therapist progress notes was conducted. The review of these notes revealed that some respiratory therapists had documented oral care provision while others had not. On 06/11/2025 at 10:20 AM, the Director of Nursing (DON) was asked to provide the facility's tracheostomy care policy. On 06/11/2025 at 11:30 AM, the facility's tracheostomy care policy was received. Review of this policy only revealed the care of the tracheostomy and did not include oral care. On 06/11/2025 at 12:00 PM, the DON was notified of the investigation findings and concerns with the lack of oral care provision to a dependent resident.

CONCERN (D) 📢 Someone Reported This

A family member, employee, or ombudsman was alarmed enough to file a formal complaint

Potential for Harm - no one hurt, but risky conditions existed

Deficiency F0679 (Tag F0679)

Could have caused harm · This affected 1 resident

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record reviews, observation, and interviews, it was determined that the facility failed to have documented evidence to support that the facility provided an ongoing program to support residents in their choice of activities. This was evident for 1 (Resident #73) of 3 resident reviewed for activities during the Medicare/Medicaid recertification survey. The findings include: On 06/04/2025 at 10:12 AM, during a family interview with Resident #73's Responsible Party (RP), when she was asked about the resident's activities, she stated that Resident #73 liked listening to music, but the facility was not offering him/her any activity. On 06/04/25 01:59 PM, this surveyor reviewed Resident #73's care plan goal which showed that he/she would accept/participate in one-on-one visits at least 2 times per week and the care plan intervention showed that the facility would provide one-on-one visits 2-3 time a week gospel music, daily bread, television. On 06/05/25 at 07:32 AM, in an interview with the Activities Director (Staff #8), when she was asked about the activity process for the residents, she stated that she would have assessed the residents upon admission to know their interests. She added that she provided activities to all the residents in the facility and that a one-on-one visit was made for residents that cannot go out of their rooms. When asked how activities were carried out, she stated that activity was usually done for residents who do not get out of their room according to the residents' care plans. On the same day at 07:38 AM, when the Activities Director was asked for the type of activities done with Resident #73, she stated that she plays lots of gospel music for him/her. When asked how often the music was played, she stated that it was played about 2 to 3 times a week and the timing depends on how staff were assigned to the residents on the floor and added that each session was about 15 minutes long. On 06/05/25 at 07:46 AM, the surveyor asked Staff #8 to provide an activity assessment and a copy of the residents' activity log. The required documents were provided at 08:40 AM and upon review, it showed that the resident had only logs for May 2025, this surveyor did not see the activity logs from admission on [DATE]. When Staff 19 was asked about the other logs from the time of admission, she stated that her former assistant had spilled drinks on the logs and had trashed them instead of leaving them out to dry. On the same day at 08:49 AM, further review of May 2025 activity log showed that Resident #73 had only 5 visits in May of 2025 (7th, 15th and 27th) and two times in June (3rd and 5th) so far. When she was asked the reason for the inconsistency, she stated that it was due to her not having enough support staff. On 06/06/25 at 01:46 PM, the Nursing Home Administrator (NHA) and the Director of Nursing (DON) were informed of the concerns and the NHA stated that the documents should have been kept even if they were soiled instead of trashing the activity logs.

CONCERN (D) 📢 Someone Reported This

A family member, employee, or ombudsman was alarmed enough to file a formal complaint

Potential for Harm - no one hurt, but risky conditions existed

Deficiency F0825 (Tag F0825)

Could have caused harm · This affected 1 resident

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Based on record review and interviews, it was determined that the facility failed to provide adequate physical therapy services to a resident (Resident #92). This was evident for 1 (MD#00206301) of 46 intakes reviewed during the recertification survey. The findings include: On 06/10/2025 at 10:00 AM, a review of confidential complaints reported to the state agency revealed complaint #MD00206301. On 06/11/2025 at 12:10 PM, the complainant was called. S/He alleged that Resident #92 did not receive physical therapy as ordered and as needed. On 06/11/2025 at 01:00 PM, a review of Resident #92's medical record was conducted. The review revealed that the resident had an order to receive physical therapy services 5 to 7 times a week for the recertification period of 4/4/24 to 5/2/24. On 06/11/2025 at 01:10 PM, the Director of Nursing (DON) was asked to provide physical therapy notes for the month of April 2024. On 06/11/2025 at 02:00 PM, the facility provided physical therapy notes. These documents were reviewed with a physical therapist (Staff #26), and revealed that Resident #92 did not receive adequate physical therapy sessions. The resident received 3 sessions of physical therapy the Week of 4/14/24 to 4/20/24; 4 sessions the week of 4/21/24 to 4/27/24 and only one session the week of 4/28/24 to 5/2/24. On 06/11/2025 at 03:40 PM, the DON was notified of these findings.

CONCERN (D) 📢 Someone Reported This

A family member, employee, or ombudsman was alarmed enough to file a formal complaint

Potential for Harm - no one hurt, but risky conditions existed

Medical Records (Tag F0842)

Could have caused harm · This affected 1 resident

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Based on record review and interviews it was determined the facility staff failed to maintain medical records on each resident that are complete and accurately documented. This was evident for 1) 1 (#94) of 3 residents reviewed for an injury of unknown origin, 2) 1 (Resident #86) out of 2 resident's reviewed for death in the facility, 3) 2 (Resident #33 and #60) of 5 residents reviewed for pressure ulcers, 4) 1 (Resident #30) of 3 residents reviewed for activities, and 5) 1 resident (Resident#104) out of 17 facility reported investigations reviewed during an annual survey.The findings include:1) Review of Resident #94's medical record on 6/4/25 at 10:21 AM revealed that the resident sustained an injury to his/her left ankle on 10/4/24. An x-ray confirmed a fracture, and the resident was sent to the hospital for further evaluation. During an interview on 6/4/25 at 1:10 PM the DON (Director of Nursing) indicated that the Medical Director determined that the fracture was pathological after the hospital confirmed the fracture on 10/7/24. Further review of Resident #94's medical record on 6/4/25 at 1:41 PM failed to reveal physician documentation related to the resident's ankle fracture. The Administrator and DON were made aware at that time and provided the surveyor with the Medical Directors review of the clinical case which concluded that in his medical opinion it appeared to be a pathological fracture secondary due to underlying osteopenia and disuse atrophy in the setting of having contractures. They confirmed that neither the finding nor the report were documented in the resident's medical record. Cross reference F 609 and F 628. 2) On 6/11/25 at 8:29 AM, a review of Complaint #MD00181498 was conducted. A complaint was made regarding the quality of care provided to Resident #86 at the time of their death.On 6/11/25 at 8:40 AM, an interview with the Director of Nursing (DON) was conducted. This surveyor asked the DON to provide a copy of Resident #86's Death Certificate. The DON stated they do not have the Death certificate in the resident's record but will request it from funeral home. On 6/11/25 at 10:03 AM, an interview with DON was conducted. The DON stated they contacted the funeral home to provide Death certificate. This surveyor expressed concern regarding maintaining complete resident records. The DON agreed that the Death certificate should have been maintained in the resident's record. 3a) On 06/06/25 at 12:59 PM, a review of Resident #33's medical record revealed he/she had multiple areas of wounds with active wound care orders that indicated:Left elbow- clean with medication Right elbow- clean with medicationLeft knee- clean with medicationLeft head- clean with medicationBack- clean with medicationLeft ear- clean with medicationLeft buttock- clean with medicationRight buttock- clean with medicationLower back- clean with medicationAt the same time, review of the Treatment Administration Record (TAR) for May 2025 revealed that the areas of wounds with active wound care orders for each day shift, failed to be documented on the following dates:Left elbow- clean with medication: 5/12/25, 5/16/25, 5/23/25, and 5/30/25Right elbow- clean with medication: 5/2/25, 5/5/25, 5/12/25, 5/16/25, 5/23/25, and 5/30/25Left knee- clean with medication: 5/2/25, 5/5/25, 5/12/25, 5/16/25, 5/23/25, and 5/30/25Left head- clean with medication: 5/12/25, 5/16/25, 5/23/25, and 5/30/25Back- clean with medication: 5/2/25, 5/5/25, 5/12/25, 5/16/25, 5/23/25, and 5/30/25Left ear- clean with medication: 5/2/25, 5/5/25, 5/12/25, 5/16/25, and 5/23/25Left buttock- clean with medication: 5/2/25, 5/5/25, 5/16/25, 5/23/25, and 5/30/35Right buttock- clean with medication: 5/2/25, 5/5/25, 5/16/25, 5/23/25, and 5/30/25Lower back- clean with medication: 5/2/25, 5/5/25, 5/16/25 5/23/25, and 5/30/253b) On 06/06/25 at 08:27 AM, review of Resident #30's medical record revealed he/she had a wound on their left heel and an active order that indicated for left heel wound care each day shift.At the same time, review of the Treatment Administration Record (TAR) in May 2025 revealed that the active order for their heel wound care failed to be documented on the following dates: 5/5/25, 5/8/25, 5/16/25, 5/23/25, and 5/30/25On 06/10/25 at 07:28 AM, an interview with the Director of Nursing revealed that the expectation of staff was to document based on orders, whether the care was completed or refused. The surveyor reviewed the concern.4) On 06/05/25 at 11:45 AM, a review of complaint #MD00203753 revealed that the complainant had general concerns regarding the care provided to Resident #30.On 06/05/25 at 11:45 AM, an interview with the complainant revealed she/he had a concern regarding the facility providing activities for the resident.On 06/06/25 at 8:45 AM, an interview with the Activities Director (Staff #8) revealed that when residents are visited by an activities team member or an activity was provided, that the staff would document it. The surveyor requested to see the activity log for Resident #30.On 06/06/25 at 1:34 PM, the surveyor was provided Resident #30's activity log sheet for April-June 2025. Review of the activity log revealed that Activities Assistant (Staff #32) signed off all of the activities provided for the resident between April-June 2025.On 06/06/25 at 1:43 PM, the surveyor requested documentation that would reflect when Staff #32 was in the facility for each date signed off as an activity or visit completed on Resident #30's activity log between April-June 2025.On 06/10/25 at 07:43 AM, review of the documentation provided by the facility that indicated when Staff #32 was in the facility from April-June 2025 revealed 13 days (4/1/25, 4/5/25, 4/6/25, 4/10/25, 4/11/25, 4/16/25, 4/20/25, 4/24/25, 5/2/25, 5/7/25, 5/14/25, 5/21/25, 6/1/25) when an activity was signed off by Staff #32 on the Resident's activity log, but the staff member was not at the facility that day.On 06/10/25 at 08:03 AM, the surveyor reviewed the concern with the Nursing Home Administrator. She acknowledged the concern. 5) PERRLA is an acronym for pupils are equal, round and reactive to light and accommodation. Healthcare providers use the PERRLA eye test to check if the pupils look and function as they should.On 06/11/2025 6:33 AM, the surveyor reviewed the facility's reported incident investigation packet for intake MD#00181243 in which the facility reported an unexpected death of Resident #104 to the state agency.On 06/11/2025 at 9:04 AM, surveyor's review of the resident's electronic health record (EHR) showed a change in condition notes for Resident #104 in which the nurse stated in a brief synopsis of the change that: During routine medication pass, the resident was observed to be extremely lethargic. A neurological assessment revealed the following: PERRLA; speech was intermittently slurred; and the resident responded to their name. When spoken to, Resident #104 briefly opened his/her eyes before closing them again. The attending physician was notified and provided a one-time order for Narcan administration. Hospice was also informed. A 4 mg dose of Narcan was administered. Following administration, Resident #104 made some vocalizations and then returned to sleep. The Responsible Party (RP) was notified and expressed an understanding of the situation.On 06/11/2025 at 09:31 AM, surveyor reviewed the statement in the investigation packets, and it showed a statement from Licensed Practical Nurse LPN #20 dated 07/25/2022 that where she stated that on 07/22/2022, she did not administer 9:00 AM meds due to suspected opioid overdose and Narcan was administered at 1:00 PM. In another statement from the same staff on 07/27/2022, LPN#20 noted that the unit manager had administered Narcan to Resident #104.On 06/12/2025 at 8:04 AM, surveyor received the copies Resident #104's Medication Administration record (MAR). Upon review, it showed that the resident was given one tablet Tegretol extended releasing tablet (a medication that decreases nerve impulses that cause seizures and pain) at 9:00 AM on 07/22/2022 and signed off by LPN #20 as opposed to her statement that she did not administer any medication to the due to suspected opioid use and Narcan 4mg was signed off as given by LPN #20 at 10:19 AM as opposed to her statement of 07/27/2022 in which she stated that the Unit manager administered the medication.On 06/12/2025 at 9:32 AM, in an interview with LPN #20, When asked if she had administered any medication after discovering that Resident #104 could have overdosed, she stated that she did not administer any medication. When she was asked what a checkmark on the medication administration record was for, she stated that it meant the medication was given. When asked why there was documented evidence that she gave Tegretol (extended release).on 07/22/2022 at 9:00 AM, she stated that she had signed it off as given before she discovered that the resident was lethargic and the resident was not given the medication. When asked for the procedure of administering medications and signing them off, she stated that she signed off after popping the medication in a cup. When asked what happened after she had signed off a medication and the resident refused it, she stated that she puts a refusal note in the Electronic Record. When asked who administered the Narcan to the resident on 07/22/2022, she stated that the unit manager did but that she signed off for it.On 06/12/2025 at 10:19 AM, when the Director of Nursing (DON) was informed about the concern with the staff signing off for a medication that was not given and not administered by the nurse, she stated that it was wrong practice for any nurse to document administering a medication before it was given and that it was also wrong for any nurse to sign off medication that was not administered by that staff. She added that the nurse had informed her of the interview with this surveyor and that she had informed the nurse that what she did was not professional.

CONCERN (F) 📢 Someone Reported This

A family member, employee, or ombudsman was alarmed enough to file a formal complaint

Potential for Harm - no one hurt, but risky conditions existed

Deficiency F0726 (Tag F0726)

Could have caused harm · This affected most or all residents

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Based on record review and interviews, it was determined that the facility failed to ensure nursing staff were competent with their skills set. This was evident for 3 (Staff #14, Staff #29, and Staff # 30) of 5 nursing staff evaluated for competency and has the potential to affect all residents. The findings include: 1a) Nursing competence is defined by the American Nurses Association as an expected level of performance that integrates knowledge, skills, abilities, and judgment. On 06/09/25 at 08:08 AM, as part of the sufficient and competent nurse staffing task, the surveyor asked the Director of Nursing (DON) to provide employee files of 5 randomly selected nursing staff. On 06/09/25 at 09:10 AM, the DON provided for Staff #14's employee file, one of the facility's contracted/agency Registered Nurse. On 06/09/25 at 09:15 AM, a review of Staff #14's employee file did not reveal any nursing competencies. The DON reported that she had contacted the staffing agency to request Staff #14 nursing competencies completed. On 06/10/25 at 11:57 AM, an interview with the DON was conducted. The DON reported that the agency could not provide Staff #14 nursing competencies or skill tests. Additionally, the DON acknowledged that she had identified the lack of staff education as a concern. 1b) On 06/10/2025 at 10:00 AM, a review of confidential complaints reported to the state agency revealed complaint #MD00206301. On 06/11/2025 at 12:10 PM, an interview with the complainant was conducted. S/He alleged that nurses who cared for Resident #92 were not skilled in taking care of a tracheostomy. On 06/11/2025 at 2:00 PM, a review of Resident #92's medical record was conducted. The review revealed that Resident #92 became unresponsive and was sent to the hospital on 5/31/24. On 06/11/2025 at 3:00 PM, the facility administrator was asked to provide: (1) the names of the nursing staff that worked on 5/31/24, and (2) their tracheostomy care competencies. On 06/11/2025 at 3:40 PM, the facility provided the names of the nursing staff who worked on 5/31/24, Staff #29 and Staff #30. However, the administrator acknowledged Staff #29 and Staff #30 had no tracheostomy care competencies. On 06/11/2025 at 3:50 PM, the lack of nursing competencies concern was discussed with the facility administrator and the DON.

Nov 2021 30 deficiencies

CONCERN (D)

Potential for Harm - no one hurt, but risky conditions existed

Resident Rights (Tag F0550)

Could have caused harm · This affected 1 resident

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 2. The facility staff failed to have a representative present when a resident signed documents. Review of Resident #285's medical record on 11/4/21 revealed the Resident was admitted to the facility on [DATE] from the hospital with diagnosis to include blindness. Further review of the Resident's medical record revealed the Resident was discharged from the facility on 2/4/20. During interview with Resident #285 on 11/5/21 at 9:22 AM, Resident #285 stated he is blind and the facility staff had him/her sign 2 documents that were not explained to him/her. The Resident stated the 2 documents were for (A) dental insurance and (B) paying the facility money out of his/her check. The Surveyor asked the Resident why he/she would not have asked for someone to be present as a representative and Resident stated at the time he/she trusted the facility staff but later made it a practice to have his/her sister present. A. The facility staff had the Resident sign a document for dental insurance. During interview with Resident #285 on 11/5/21 at 9:22 AM, the Resident stated he/she would have never agreed to paying for dental insurance because he/she had a full set of dentures and did not need any dental services. The Resident stated once he/she realized he/she was paying out of his/her pocket he/she had the payments stopped. Further review of Resident #285's medical record revealed the Resident signed an Application for in-facility prepaid dental policy on 11/19/18. Review of the Resident's Account Statements revealed the Resident was charged and paid for dental care for the amount of 97.20 monthly from January 2019 through July 2019. Further review of Resident #285's medical record revealed on 2/19/19 the Resident was seen by the dentist. The dentist documented, Patient states no oral concerns. Pt has an existing set of complete dentures that he/she doesn't wear. Patient not interested in new dentures. Recommend annual exam. Review of a document provided the facility during the investigation revealed on 7/22/19 the Resident signed a document that stated he/she was totally blind and unable to see the documents that he/she sign and requested that the coverage for dental care be immediately terminated because he/she was unaware what he/she was signing. He/she was never informed that he/she was signing an application for dental coverage. He/she wears dentures so he/she doesn't need dental care. The document was signed by the Resident, the Resident's sister and the former Administrator. B. The facility staff had the Resident sign a document to pay the facility from the Resident's personal funds account. During interview with Resident #285 on 11/5/21 at 9:22 AM, the Resident stated the facility had the Resident sign an agreement to pay the facility from his/her personal funds. The Resident stated he/she was not aware he/she had signed this document and usually has his/her sister present to sign documents. During interview on 11/5/21 at 9:29 AM with the former Administrator of the facility, who has worked at the facility when the Resident lived there, stated the Resident owed the facility money. The former Administrator stated he/she did not have a good relationship with the Resident so the former Administrator sent in Employee #15 to get the Resident to sign. The former Administrator stated there was no other witness to the signing of the document other than Employee #15. Review of document provided to the Surveyor by the facility staff revealed on 9/4/19 the Resident signed a document that stated he/she would pay the facility 81.80 from his/her personal funds divided over the months of September, October and November 2019. Employee #15 signed she witnessed the Resident sign the document. During interview with Employee #15 on 11/5/21 at 9:07 AM, the former Administrator told me I needed to have the Resident sign a document because the Resident owed the facility money. Employee #15 then stated he/she went into the Resident's room, explained to the Resident he/she needed him/her to sign the document that he/she would pay back the facility from his/her check and he/she was okay with this and signed. Employee #15 stated it was only her and the Resident in the room. Employee #15 stated about a week later the Resident told me I stole his/her money. Interview with the Chief Clinical Officer on 11/8/21 at 10:45 AM confirmed the facility staff failed to allow the Resident to have a representative when signing documents. Based on medical record review and interview, it was determined the facility staff failed to 1. ensure Resident #83's responsible party (RP) was provided the opportunity to consent to the flu vaccine for Resident #83 and 2. failed to ensure Resident #285 had a representative when signing documents. This was evident for 2 of 2 residents selected for reviewed for dignity and 2 of 52 residents selected for review during the annual survey. The findings include: 1. The facility staff failed to have a resident's responsible party provide consent. Medical record review for Resident #83 on 11/5/21 at 10:43 AM revealed on 12/13/17 and 1/22/18 the resident was assessed by 2 physicians. At that time, it was determined that Resident #83 is unable to: understand and sign admission documents and other information, unable to understand the nature, extent, or probable consequences of the proposed treatment or course of treatment, unable to make rational evaluation of the burdens, risk and benefits of the treatment and is unable to effectively communicate a decision. Further record review revealed on 10/14/2020 the facility staff approached the resident and documented: resident had been educated on the benefits and risks associated with the flu vaccine and gave the facility permission to administer the flu vaccine. There is no evidence the facility staff contacted the resident's RP (since the resident had been assessed and determined not able to make informed decisions on his/her own) in reference to consent of the flu vaccine. Interview with the Nursing Home Administrator and Chief Clinical Officer on 11/10/21 at 11:30 AM were notified of the facility staff failure to contact the RP for Resident #83 for flu vaccine consent and obtained consent from Resident #83 (assessed not able to make informed decisions).

CONCERN (D)

Potential for Harm - no one hurt, but risky conditions existed

Deficiency F0577 (Tag F0577)

Could have caused harm · This affected 1 resident

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Based on resident interview, staff interview and observation it was determined that the facility staff failed to ensure signage was posted to alert residents and visitors of the location of the survey results. This was evident for 4 out of 4 units. The findings are: This surveyor interviewed members of the resident council (Residents #9, #13, #24, and #40) on 11/4/21 at 11:04 AM. The residents said they were unaware of the survey results or where to find the results. This surveyor toured all 4 floors on 11/5/21 at 1:05 PM and did not see survey book or a sign telling residents where it is located. Staff #18 was interviewed on 11/9/21 at 10:40 AM. The observations were presented to her. Survey book had been pulled to find information regarding a question from the survey team. Signs were not posted prior to the exit conference.

CONCERN (D)

Potential for Harm - no one hurt, but risky conditions existed

Notification of Changes (Tag F0580)

Could have caused harm · This affected 1 resident

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review it was determined the facility staff failed to notify 1. the physician of results of an ammonia level (Resident #75) and 2. the physician and resident's family member of X-ray results (Resident #85). This was evident for 2 of 52 residents selected for review during the annual survey process. The findings include: 1. The facility staff failed to notify the physician of results of an ammonia level. Medical record review for Resident #75 on 11/3/21 at 11:30 AM revealed the facility staff obtained an ammonia level on 9/9/21 with the results of 80, normal level is 19-54. Ammonia is predominantly generated in the gut by intestinal bacteria and enzymes and detoxified primarily in the liver. Elevated ammonia levels can indicate liver disease. Further record review revealed the facility staff failed to notify the physician of the laboratory blood results. Interview with the Nursing Home Administrator and Chief Clinical Officer were notified of the concerns on 11/10/21 11:30 AM at exit. 2. The facility staff failed to notify a resident's physician and family member regarding chest x-ray result that indicated a resident was identified with a pneumonia. Review of Resident #85's closed medical record on 11/05/21 revealed Resident #85 was admitted to the facility on [DATE] with diagnoses that include: nontraumatic intercranial hemorrhage, hemiparesis, hemiplegia, aphasia, tracheostomy, gastrostomy, and hypertension. Resident #85 is totally dependent upon the facility staff for all aspects of his/her care. On 09/26/21 at 1:17 PM, the nursing staff identified Resident #85 with a change in condition that included bilateral lung wheezing with white frothy sputum coming from the tracheostomy. The nurse notified Resident #85's physician and a chest x-ray to rule out pneumonia was ordered. On 09/26/21 at 11:31 PM, the radiology service sent Resident #85's chest x-ray result to the facility that indicated Resident #85 had a moderate pneumonia of the right lung. Further review of Resident #85's closed medical record failed to reveal that Resident #85's physician or family member were notified about the chest x-ray result. In an interview with the facility vice president of clinical services (VPCS) on 11/10/21 at 6:12 AM, the VPCS stated he/she had no further information about staff notifying Resident #85's physician or family member about the 09/26/21 11:31 PM chest x-ray result for Resident #85. The facility nursing staff need to take steps and immediately report positive x-ray results of a pneumonia to the resident's attending physician and family members.

CONCERN (D)

Potential for Harm - no one hurt, but risky conditions existed

Deficiency F0582 (Tag F0582)

Could have caused harm · This affected 1 resident

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Based on a review of the beneficiary notices and staff interview it was determined that the facility staff could not provide sufficient evidence that the residents are provided the proper notice at the time of discharge regarding Medicare coverage (Resident #4, #139 and #140). This was evident for 3 out of the 3 reviewed for the beneficiary notice task. The findings are: The beneficiary notices for Residents #4, #139, and #140 were requested for review on 11/8/21. The beneficiary notices could be either a Notice of Medicare Non-Coverage (NOMNC) or an Advance Beneficiary Notice (ABN). The NOMNC is provided two days before the discontinuation of therapy services. The ABN is provided if the resident wishes to continue therapy even if Medicare might not cover it. The Administrator (#1) was interviewed on 11/8/21 at 12:37 PM. He could not provide copies of either a NOMNC or ABN for any of the three residents.

CONCERN (D)

Potential for Harm - no one hurt, but risky conditions existed

Deficiency F0583 (Tag F0583)

Could have caused harm · This affected 1 resident

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Based on observation it was determined that the facility staff failed to ensure the confidentiality of resident's #39 information. This was evident for 1 out of 52 residents that were part of the Annual survey process. The findings include: This surveyor observed on 11/4/21 at 11:22 AM a medication cart across from Unit three nursing station with the computer screen on and resident's #39 medical information visible. Staff members walked by including the Unit Manager and not one staff member closed the screen. The nurse returned to the cart at 11:30 AM and exit out of the computer. I informed the Unit Manager (staff #12) of my observation.

CONCERN (D)

Potential for Harm - no one hurt, but risky conditions existed

Transfer Notice (Tag F0623)

Could have caused harm · This affected 1 resident

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review and staff interviewed it was determined that the facility failed to ensure the resident, and/or their responsible party, received written notification of a transfer to the hospital, including appeal rights and ombudsman contact information (Residents #21, #22 and #77). This was found to be evident for 3 out of 6 residents reviewed for hospitalization during an annual survey. The findings include: 1. Review of Resident #21's medical record on 11/2/21 revealed the Resident was admitted to the facility on [DATE]. The Resident was discharged from the facility on 10/13/21 to the hospital. Further review of the Resident's medical record failed to reveal any documentation that a notice regarding the transfer had been provided to the resident or the resident's responsible party. Interview with the Acting Director of Nursing on 11/4/21 at 10:45 AM confirmed neither Resident #21 nor their responsible party had been sent a letter that notified them of the transfer to the hospital. 2. Review of Resident #77's medical record on 11/3/21 revealed the Resident was admitted to the facility on [DATE]. The Resident was discharged from the facility on 8/10/21 to the hospital. Further review of the Resident's medical record failed to reveal any documentation that a notice regarding the transfer had been provided to the resident or the resident's responsible party. Interview with the Acting Director of Nursing on 11/5/21 at 1:09 PM confirmed neither Resident #77 nor their responsible party had been sent a letter that notified them of the transfer to the hospital. 3. Review of Resident #22's medical record on 11/05/21 revealed the Resident was admitted to the facility on [DATE]. Further review of the Resident's medical record revealed the Resident was transferred to the hospital on [DATE]. Further review of the Resident's medical record failed to reveal any documentation that a written notice regarding the transfer had been provided to the Resident's responsible party. Interview with the Assistant Director of Nursing (ADON) on 11/09/21 at 8:54 AM, the ADON stated that Resident #22 was sent to the hospital on [DATE] due to an infected G-tube site. The ADON was unable to produce evidence that Resident #22 and Resident #22's responsible parties had been given written notice of the resident's transfer to the hospital.

CONCERN (D)

Potential for Harm - no one hurt, but risky conditions existed

Deficiency F0625 (Tag F0625)

Could have caused harm · This affected 1 resident

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review and staff interview it was determined that the facility staff failed to provide residents and/or their representative (RP) with the proper paper documentation of the facility's bed hold policy (Resident #21, #22 and #77). This was found evident for 3 of 6 residents reviewed for hospitalizations during an annual survey. The findings include: A bed hold policy is written information to the resident or resident representative that specifies the duration that the resident is permitted to return and resume residence in the nursing facility. It is given before a nursing facility transfers a resident to a hospital or the resident goes out on therapeutic leave. 1. Review of Resident #21's medical record on 11/2/21 revealed the Resident had an unplanned transfer to the hospital on [DATE]. Further review of the medical record revealed that a copy of the facility's bed hold policy was not given to Resident #21 or their RP. Interview with the Acting Director of Nursing on 11/4/21 at 10:45 AM confirmed the facility did not send out the bed hold policy to Resident #21 and/or their RP at the time of the Resident's transfer on 10/13/21. 2. Review of Resident #77's medical record on 11/3/21 revealed the Resident had an unplanned transfer to the hospital on 8/10/21. Further review of the medical record revealed that a copy of the facility's bed hold policy was not given to the Resident or their RP. Interview with the Acting Director of Nursing on 11/5/21 at 1:09 PM confirmed the facility did not send out the bed hold policy to Resident #77 and/or their RP at the time of the Resident's transfer on 8/10/21. 3. Review of Resident #22's medical record on 11/05/21 revealed the Resident was admitted to the facility on [DATE]. Further review of the Resident's medical record revealed the Resident was transferred to the hospital on [DATE]. Further review of the Resident's medical record failed to reveal any documentation that the facility bed hold policy was not given to the Resident #22's responsible party on 09/04/21. Interview with the Assistant Director of Nursing (ADON) on 11/09/21 at 8:54 AM, the ADON stated that Resident #22 was sent to the hospital on [DATE] due to an infected G-tube site. The ADON was unable to produce evidence that Resident #22 and Resident #22's responsible parties had been given a copy of the facility bed hold policy on 09/04/21.

CONCERN (D)

Potential for Harm - no one hurt, but risky conditions existed

Assessment Accuracy (Tag F0641)

Could have caused harm · This affected 1 resident

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Based on record review, resident interview, and staff interview it was determined that the facility staff failed to ensure the accuracy of the facility assessments (Resident #60). This was evident for 1 out of the 52 residents reviewed as part of the survey process. The findings are: The Minimum Data Set (MDS) is part of the Resident Assessment Instrument that was Federally mandated in legislation passed in 1986. The MDS is a set of assessment screening items employed as part of a standardized, reproducible, and comprehensive assessment process that ensures each resident's individual needs are identified, that care is planned for based on those individualized needs, and that the care is provided as planned to meet the needs of each resident. Resident #60 was interviewed on 11/3/21 at 9:22 AM. The resident stated he/she does not have a catheter but did have one recently. A review of the resident's clinical record revealed that the resident had a catheter on 7/27/21. Further review revealed there was no evidence that the catheter was continued or removed while in the facility. A review of the clinical record revealed that the discharge - return anticipated MDS of 8/29/21, section H, noted the resident to have a catheter. The 5-day post admission MDS of 9/8/21 and the quarterly MDS of 9/13/21, section H, noted the resident to have a catheter. The Director of Nursing (DON) (Staff #2) was interviewed on 11/5/21 at 10:25 AM. She confirmed that the resident does not have a catheter. Staff #18 was interviewed on 11/9/21 at 11:49 AM. She confirmed that the resident does not have a catheter and may have had one on admission. If there was no order, then it would have been discontinued.

CONCERN (D)

Potential for Harm - no one hurt, but risky conditions existed

Deficiency F0657 (Tag F0657)

Could have caused harm · This affected 1 resident

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 4. The facility failed to have care planning documentation that supported interdisciplinary review or oversight of the critical planning process. Failure to ensure the required interdisciplinary input increased the risk for poor or inadequate planning determinations related to insufficient expertise of the team. Review of Resident #47's medical record on [DATE] at 10:15 AM revealed on [DATE], [DATE] and [DATE] care conference note which documented that the resident and social services were the only ones that attended the resident's care plan meeting. On [DATE] at 11:30 AM an interview with the Social Service Director revealed that she/he did not have the interdisciplinary team care plan meeting signature pages documented and could not recall who were the other members of the IDT (Interdisciplinary team) that attended the care plan meeting. On [DATE] at 1:30 PM the Nursing Home Administrator and the Director of Nursing were informed of the concerns. 3. The facility failed to have quarterly care plan meetings with resident's responsible party. Review of Resident #21's medical record on [DATE] revealed the Resident was admitted to the facility on [DATE] from the hospital with a diagnosis to include vascular dementia. Vascular dementia is a decline in thinking skills caused by conditions that block or reduce blood flow to various regions of the brain, depriving them of oxygen and. nutrients. During an interview with Resident #21's responsible party (RP) on [DATE] at 8:45 AM, the RP stated the facility used to have care plan meetings every 3 months but they have not had one for the Resident in a long time. Review of the Resident's record on [DATE] confirmed no evidence of care plan meetings with the Resident's RP since [DATE]. The facility failed to hold a quarterly care plan meeting in April, July and [DATE]. Interview with the Social Worker on [DATE] at 1:40 PM revealed the facility is to hold care plan meetings every 3 months and the last care plan meeting for Resident #21 with the Resident's RP was [DATE]. Interview with the Acting Director of Nursing on [DATE] at 1:09 PM confirmed the facility staff failed to hold quarterly care plan meetings with Resident #21 and/or his/her RP. Based on medical record review and observation it was determined the facility staff failed to 1. review and revise care plans for residents to reflect current and accurate interventions (Resident #81 and #78), 2. ensure care plan meetings were held within the required timeframe (Resident #21), and 3. have documented evidence of an interdisciplinary care planning process as evidenced by only social services and resident attendance at care plan meetings (Resident #47). This was evident for 4 of 52 residents reviewed during the annual survey process. The findings include: The Long Term Care Minimum Data Set (MDS) is a standardized, primary screening and assessment tool of health status which forms the foundation of the comprehensive assessment for all residents of long-term care facilities certified to participate in Medicare or Medicaid. The MDS contains items that measure physical, psychological and psycho-social functioning. Some sections and assessments of the MDS include: Hearing, Speech and Vision, Cognitive Patterns, Mood, Behavior, Preferences for Customary Routine and Activities, Functional Status, Bladder and Bowel, Health Conditions, Swallowing/Nutritional Status, Oral/Dental Status, Skin Conditions, Medications, Special Treatments, Procedures and Programs and Restraints. A care plan is a formal process that correctly identifies existing needs and recognizes potential needs or risks. Care plans provide communication among nurses, their patients, and other healthcare providers to achieve health care outcomes. Once the facility staff assesses the resident and documents on the MDS, care plans are originally initiated. Once the resident is in the facility for a period of time, the care plans are to be reviewed and revised after a MDS is completed to reflect current and accurate interventions. 1 A. The facility staff failed to review and revise the care plan for Resident #81 to reflect current and accurate interventions. Medical record review for Resident #81 on [DATE] at 11:50 AM revealed on [DATE] the facility staff initiated and care plan related to activity. An intervention on that care plan was: When resident chooses not to participate in organized activities, turn on TV, music in room to provide sensory stimulation. Surveyor observation of the resident and room on [DATE] at 12:30 PM, [DATE] at 8:45 AM, [DATE] at 1:00 PM and [DATE] at 9:00 AM revealed the resident in bed. Further observation of the resident's room failed to reveal any TV or any provision of music in the room. Further review of the record revealed the facility staff assessed and documented the completion of the MDS on: [DATE], [DATE], [DATE], [DATE], [DATE] and [DATE]; however, failed to review and revise the activity care plan to reflect current and accurate documentation. 1 B. The facility staff failed to review and revise the care plan for Resident #81 to reflect current and accurate interventions. Medical record review for Resident #81 on [DATE] at 11:50 AM revealed on [DATE] the facility staff initiated a care plan to address end of life wishes- Advance Directive: with an intervention of: Obtain physician order related to resident's decision for: Full code. Full code is the directive that all and any means of life support will be initiated in the event of death. Further record review revealed on [DATE] the resident's surrogate in collaboration with the physician ordered that the resident would be: No CPR, Option B, Palliative and supportive care- No CPR and death would be allowed to occur naturally. Further of the record revealed the facility staff assessed and documented the completion of the MDS on: [DATE], [DATE], [DATE], [DATE], [DATE] and [DATE]; however, failed to review and revise the end of life- Advance Directive care plan to reflect current and accurate documentation. 2. The facility staff failed to review and revise the care plan related to falls for Resident #78. Medical record review for Resident #78 on [DATE] at 12:00 PM revealed [DATE] the facility staff initiated a care plan related to falls and updated on [DATE]; however, the facility staff failed to address fall mats for the resident on the care plan. Further record review revealed on [DATE] the physician ordered: bilateral fall matt while in bed. Review of MDS revealed the facility staff documented assessment of Resident #78 on [DATE], [DATE], [DATE], 5/4 21 and [DATE]; however, failed to address the order for the fall mats on the care plan. Interview with the Nursing Home Administrator and Chief Clinical Officer on [DATE] at 11:00 AM were notified of the concerns related to the facility staff failure to review and revise care plans for Residents #78 and #81 to reflect current and accurate interventions.

CONCERN (D)

Potential for Harm - no one hurt, but risky conditions existed

Deficiency F0658 (Tag F0658)

Could have caused harm · This affected 1 resident

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Based on observation and record review, it was determined that the facility failed to administer medications within 1-hour time frame in accordance with professional standards for Resident #79. This was evident for 1 of 52 residents reviewed during the annual survey. The findings include: On 11/2/21 at 8:45 AM, an interview conducted with Resident #79, revealed Resident #79 had been alert and oriented to person, place, and time. Resident #79 expressed concern that he/she had been receiving his/her medications late. On 11/3/21 at 11:10 AM, observation on Unit 3 revealed Resident #79 standing at the nursing station requesting his/her 9 AM medications. The medications which had been schedule for 9 AM was administered at the nursing station at 11:10 AM. On 11/4/21 at 1:30 PM a record review of Resident #79's medication administration audit for September and October 2021, revealed Resident #79 had been receiving his/her medications late on a regular basis. In 9/2021, the following medications had been administered outside the 1-hour time frame: On 9/6/21 -Keppra 500 mg 3 tablets by mouth two times a day, which it has been schedule for 9 AM, however, was not administered until 11:44 AM. This medication was administered outside the 1-hour time frame on 9/8 administered at 10:54 AM, 9/13 administered at 10:54 AM, 9/22 administered at 10:48 AM, 9/23 administered at 10:38 AM, 9/24 administered at 2:49 PM, 9/25 administered at 11:09 AM, and 9/30 administered at 10:45 AM on day shift. All Resident #79's medications that was prescribed by the physician at 9 AM were administered outside the 1-hour time frame on those days. In 10/2021, the following medications had been administered outside the 1-hour time frame: On 10/1/21 -Keppra 500 mg 3 tablets by mouth two times a day, which it has been schedule for 9 AM, however, was not administered until 10:58 AM. This medication was administered outside the 1-hour time frame on 10/3 administered at 11:59 AM, 10/5 at administered at 12:46 PM, 10/6 administered at 11:01 AM, 10/7 administered at 12:01 PM, 10/9 administered at 10:49 AM, 10/10 administered at 12:45 PM, 10/13 administered at 10:10 AM, 10/14 administered at 12:02 PM, 10/30/21 administered at 3:16 PM on day shift. All Resident #79's medications that was prescribed by the physician at 9 AM were administered outside the 1-hour time frame on those days. The Administrator, Director of Nursing, and Regional Nurse were made aware of concern at time of exit on 11/5/21 at 1:30 PM.

CONCERN (D)

Potential for Harm - no one hurt, but risky conditions existed

Deficiency F0679 (Tag F0679)

Could have caused harm · This affected 1 resident

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Based on complaint, reviews of medical record review and staff interview, it was determined that the facility failed to implement an ongoing resident centered activities program for 1 (Resident #37) of 52 residents reviewed for activities during an annual recertification survey. The findings include: During 2020 and 2021 the facility has had to take mitigating actions to prevent the spread of the COVID19 virus. At times, residents have had to stay in their rooms and were not allowed to attend group activities. To help prevent residents from suffering isolation, an implementation of a resident centered activities care plan may help prevent this isolation from occurring. The facility activities programs can help residents during these times. In an interview with Resident #37 on 11/08/21 at 11:51 AM, Resident #37 complained that the facility does not allow residents to have access tot the Internet nor does the facility have the local news paper delivered to the facility. The resident complained that he/she does have anything to do while residing in the facility. Review of the activities care plan for Resident #37 revealed interventions that included: to have resident attend activities of interest/choice and engage in self-initiated leisure activities, resident will initiate leisure activities 1-2 x/day such as visiting with family/friends, resident will participate in 2-3, in or out of room activities a week x 90 days, inform resident of newspaper and daily chronicle availability in activity room, provide activity calendar in resident's room, respect wishes to decline invitations when rest/leisure-type activities are preferred. An interview was conducted with the Activities Director (AD) on 11/09/21 at 9:46 AM. The AD stated and confirmed that Resident #37 does not currently have a way to access the Internet. The AD stated that Resident #37 can read but has never requested to access the Internet. The AD stated that Resident #37 can use one of six tablets that are assigned to the activities department but has never asked. The AD stated that the facility does not have the local newspaper delivered to the facility, but the activities staff do read the daily editorials to the residents. Review of Resident #37's medical record failed to reveal any resident centered activities for Resident #37 except smoking and reading the bible.

CONCERN (D)

Potential for Harm - no one hurt, but risky conditions existed

Pressure Ulcer Prevention (Tag F0686)

Could have caused harm · This affected 1 resident

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review and interview, the facility staff failed to provide treatment/services to prevent/heal pressures ulcers and arterial wounds (Resident #10 and #21). This is evident for 2 of 52 residents reviewed during an annual survey. A pressure ulcer also known as pressure sore or decubitus ulcer is any lesion caused by unrelieved pressure that results in damage to the underlying tissue. Pressure ulcers are staged according the their severity from Stage I (area of persistent redness), Stage II ( superficial loss of skin such as an abrasion, blister or shallow crater), Stage III ( full thickness skin loss involving damage to subcutaneous tissue presenting as a deep crater), Stage IV (full thickness skin loss with extensive damage to muscle, bone or tendon) or Unstageable Pressure Ulcer (full thickness tissue loss in which the base of the ulcer is covered by slough and / or eschar in the wound bed). The findings include: 1. Review of Resident #10's medical record on 11/5/21 revealed the Resident was admitted to the facility on [DATE] from the hospital. Further review of the Resident's medical record revealed the Resident had multiple pressure ulcers including: right heel, right leg, left foot and sacrum. Review of the Resident's Treatment Administration Records for September and October 2021 reveal the following dates where staff failed to administer the treatments as ordered to the Resident's pressure ulcers: a. Right heel-9/17, 9/28, 9/29, 10/5, 10/7, 10/8, 10/11, 10/12, 10/17, 10/18, 10/19, 10/25, 10/26, 10/28, 10/30 and 10/31/2021 b. Right leg-9/17, 9/28, 9/29, 10/5. 10/7 and 10/8/21 c. Left foot-9/17, 9/21, 9/28, 9/29, 10/5, 10/7 and 10/8/2021 d. Sacrum-9/17, 9/28, 9/29, 10/5, 10/7 and 10/8/2021 Interview with the Chief Clinical Officer on 11/8/21 at 8:10 AM confirmed the facility staff failed to provide treatment as ordered for pressure ulcers for Resident #10. 2. Review of Resident #21's medical record on 11/3/21 revealed the Resident was admitted to the facility on [DATE] from the hospital with a diagnosis to include dependence on ventilator. A ventilator is a machine that provides mechanical ventilation by moving breathable air into and out of the lungs, to deliver breaths to a patient who is physically unable to breathe, or breathing insufficiently. Further review of Resident #21's medical record on 11/3/21 revealed the Resident was seen by the Wound Care specialist on 9/1/21 and 9/8/21. At that time the Wound Care specialist assessed the Resident to have a Stage 3 pressure ulcer to the neck/tracheostomy site. The Wound Care specialist recommended the site to be cleansed with normal saline and to apply a Medihoney and Calcium Alginate dressing to the wound daily. Review of Resident #21's Treatment Administration Record for September 2021 revealed the facility staff failed to administer the wound treatments as recommended by the Wound Care specialist until 9/13/21. Interview with the Acting Director of Nursing on 11/4/21 at 9:17 AM confirmed the facility staff failed to administer treatments as recommended by the Wound Care specialist in a timely manner.

CONCERN (D)

Potential for Harm - no one hurt, but risky conditions existed

Deficiency F0687 (Tag F0687)

Could have caused harm · This affected 1 resident

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on complaint, reviews of a medical record, and staff interview, it was determined that facility staff failed to obtain podiatry consultation for Resident #37 as ordered by the physician. This was evident for 1 of 52 residents selected for review during an annual survey. The findings include: In an interview with Resident #37 on 11/08/21 at 11:51 AM, Resident #37 came into the conference and approached the nurse surveyor with a complaint that he/she has not been seen by a Podiatrist since being admitted to the facility. Medical record review for Resident #37 on 11/08/21 at 1:30 PM revealed Resident #37 was originally admitted to the facility on [DATE] and most recently readmitted to the facility on [DATE]. On 11/04/2020, Resident #37's physician wrote an order instruction the nursing staff to obtain a podiatry consult as needed. Further review revealed an endocrinology consult, dated 09/30/21, requesting the facility staff to please arrange for a podiatry appointment. As of 11/09/21, no podiatry appointment was requested by the facility staff for Resident #37. Podiatry is a branch of medicine devoted to the study, diagnosis, and medical and surgical treatment of disorders of the foot, ankle, and lower extremity. Further reviews of Resident #37's medical failed to reveal that Resident #37 had seen a Podiatrist since admission. In an interview with the vice president for clinical services (VPCS) on 11/10/21 at 7:15 AM, the VPCS was made aware of the failure of the facility staff to obtain a podiatry consultation as ordered by the physician for Resident #37. All concerns were discussed with the Nursing Home Administrator at the time of exit on 11/10/21 at 11:47 AM.

CONCERN (D)

Potential for Harm - no one hurt, but risky conditions existed

Deficiency F0688 (Tag F0688)

Could have caused harm · This affected 1 resident

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Based on record review it was determined the facility staff failed to ensure Resident #83 received restorative nursing program (RNP) as ordered by the physical therapist and speech language pathologist in conjunction with the physician. This was evident for 1 of 5 residents selected for review of range of motion and 1 of 52 residents selected for review during the annual survey. The findings include: Restorative nursing is person-centered nursing care designed to improve or maintain the functional ability of residents, so they can achieve their highest level of well-being possible. It is a different way of looking at the care that is regularly given. A restorative nursing program has nursing interventions that promote the resident ' s ability to adapt and adjust to living as independently and safely as possible. Restorative nursing program together with therapy (physical, occupational or speech) because restorative programs build from the base of progress made in therapy. 1 A. The facility staff failed to provide restorative nursing program for Resident #83. Medical record review for Resident #83 on 11/3/21 at 7:30 AM revealed on 1/13/21 the physician in collaboration with the therapy department ordered: Patient will be provided with RNP for self feeding and transfers, 6 x a week for 15 minutes daily. Further record review revealed no evidence the facility staff provided the RNP as ordered by the physician . 1 B. The facility staff failed to provide restorative nursing program for Resident #83. Medical record review for Resident #83 on 11/3/21 at 7:30 AM revealed on 2/3/21 the physician in collaboration with the therapy department ordered: Restorative nursing program, frequency=6 times/week X 15 mins Modalities ROM (range of motion): AAROM BUE (bilateral upper extremities) and BLE (bilateral lower extremities) X 10 reps X 1 set transfers : moderate - Maximum assist , get OOB (out of bed) daily sit in chair. Further record review revealed no evidence the facility staff provided the RNP as ordered by the physician . Interview with the Nursing Home Administrator and Chief Clinical Officer on 11/10/21 at 11:30 AM were notified of the concerns of the facility staff failure to provide RNP to Resident #83.

CONCERN (D)

Potential for Harm - no one hurt, but risky conditions existed

Accident Prevention (Tag F0689)

Could have caused harm · This affected 1 resident

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Based on medical record review and observations, it was determined the facility staff failed to provide fall mats next to the bed of Residents #75, 78 and #81. This was evident for 3 of 52 residents selected for review during the annual survey process. The findings include: Fall mats are made from high-impact foam and are designed to help prevent injury from potential falls and are usually placed next to the bed where most falls occur. 1. The facility staff failed to provide fall mats next to the bed of Resident #75 as ordered by the physician. Medical record review for Resident #75 on 11/3/21 at 10:45 AM revealed on 9/2/15 the physician ordered: fall mat, both side of the bed, when in bed. Surveyor observation of the Resident #75 on 11/2/21 at 9:00 AM, 11/3/21 at 8:45 AM, 11/4/21 at 8:30 AM and 11/5/21 at 8:00 AM revealed the resident in bed; however, the facility staff failed to apply fall mat on either side of the as ordered by the physician. 2. The facility staff failed to place fall mats next to the bed of Resident #78 as ordered by the physician. Medical record review for Resident #78 on 11/2/21 at 9:00 AM revealed on 10/14/21 the physician ordered: bilateral fall matt while in bed. Surveyor observation of the resident on 10/2 at 10:15 AM, 10/3 at 11:45 AM, 11/4 at 8:45 AM and 11/5 at 8:00 AM and 11:43 AM revealed the resident in bed; however, the facility staff failed to apply the bilateral fall mats as ordered. 3. The facility staff failed to apply fall mats to the sides of the bed of Resident #81 is indicated on the care plan. Medical record review for Resident #81 on 11/2/21 at 12:00 PM revealed on 11/7/17 the facility staff initiated a fall care plan for Resident #81. An intervention on the care plan was: fall mats on the floor while in bed. Surveyor observation of the resident on 11/2/21 at 12:30 PM, 11/3/21 at 8:45 AM, 11/4/21 at 1:00 PM and 11/5/21 at 9:00 AM revealed the resident in bed; however, the facility staff failed to apply fall mats on the floor next to the bed as indicated in the care plan. ( A nursing care plan is a formal process that correctly identifies existing needs and recognizes potential needs or risks. Care plans provide communication among nurses, their patients, and other healthcare providers to achieve health care outcomes). Interview with the Nursing Home Administrator and Chief Clinical Officer on 11/10/21 at 11:00 AM were notified of the concerns of the facility staff failure to place fall mats next to the bed of Residents #75, #78 and #81.

CONCERN (D)

Potential for Harm - no one hurt, but risky conditions existed

Deficiency F0697 (Tag F0697)

Could have caused harm · This affected 1 resident

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2. The facility staff failed to thoroughly assess the need for pain medication and medicate Resident (#57). Pain is often regarded as the fifth vital sign regarding healthcare because it is accepted now in healthcare that pain, like other vital signs, is an objective sensation rather than subjective. As a result, nurses are trained and expected to assess pain. A component of pain assessment-focusing on words to describe pain, intensity, location, duration, and aggravating or alleviating factors. It is the expectation the facility staff assess pain prior to and after the administration of pain medication to determine the need of the medication and the effectiveness of the medication. Medical record review for Resident #57 revealed the physician ordered: 1. On 7/7/20 Tylenol 500 milligrams by mouth every 8 hours as needed for pain. Tylenol is used to reduce fever and relieve minor pain caused by headache, muscle aches, arthritis, and fevers. 2. On 9/20/21 Tramadol 50 mg 2 tablets by mouth every 6 hours as needed for pain. Tramadol is used to relieve moderate to moderately severe pain. Tramadol extended-release tablets and capsules are only used by people who are expected to need medication to relieve pain around-the-clock. Tramadol is in a class of medications called opiate (narcotic) analgesics. It works by changing the way the brain and nervous system respond to pain. 3. On 10/15/20 ibuprofen tablet 800 mg give 1 tablet by mouth every 8 hours as needed for pain. Ibuprofen is in a class of medications called NSAIDs. It works by stopping the body's production of a substance that causes pain, fever, and inflammation. Review of the Medication Administration Record (MAR) revealed the facility staff assessed the resident's pain on 10/1 and 10/4 and documented the resident's pain level as a 3 out of 10 and administrated the Tylenol. The staff documented that the Tylenol was effective. Further MAR reviewed revealed the facility staff asses the resident's pain on 10/1 and documented the resident's pain level as a 3 out of 10 and administrated the Tramadol. Facility staff documented the administration of the Tramadol on 10/3 pain level as a 3 out of 10, 10/4 pain level as a 3 out of 10, 10/11 pain level as a 4 out of 10, 10/12 pain level as a 2 out of 10, and 10/13 pain level as a 3 out of 10. Further record review revealed the facility staff failed to thoroughly determine with collaboration with the resident and the physician at what pain level would the Tylenol, ibuprofen and Tramadol be administered. On 11/5/2021 at 1:30 PM the Nursing Home Administrator and the Director of Nursing were informed of the concerns. Based on medical record review and interview, it was determined the facility staff failed to ensure Residents #9 and #57 were provided pain medication when requested. This was evident for 2 of 2 residents reviewed for pain and 2 of 52 residents selected for review during the annual survey process. The findings include: 1. The facility staff failed to ensure pain medication was available and administered to Resident #9 when requested. Medical record review for Resident #9 on 11/3/21 at 9:30 AM revealed on 7/21/21 the physician ordered: Tramadol 50 milligrams by mouth, 2 tablets every 6 hours as needed for severe pain, 7-10. Tramadol is used to help relieve moderate to moderately severe pain. Interview with Resident #9 on 10/4/ 21 at 10:00 AM revealed the resident stated that he/she requested the Tramadol early in the morning. The resident stated he/she was informed by the facility staff that there was no medication available. Interview with the staff #17 at that time revealed that the sticker should have been pulled and sent to the pharmacy for a refill. The medications are supplied from the pharmacy with a label on the top of the blister pack. The label contains the: name of the drug, resident's name, room number, and the physician's order for administration of the medication. It is the responsibility of the nursing staff to pull the label and ensure the label is faxed to the pharmacy as an indication that a renewal of the medication is needed. It is the expectation to refill the prescription while the resident still has a 5 to 7 day supply left. Interview with the resident on 11/5/21 at 8:45 AM revealed the resident stating that he/she was not administered the Tramadol on 11/4/21 at all. Review of the Medication Administration Record revealed the facility staff failed to administer the Tramadol to Resident #9 on 11/4/21. (Of note, the resident stated that Tylenol was administered on 11/4/21. The resident did not verbalize to the surveyor any complaints of unbearable pain due to not having the Tramadol. Surveyor observation of the resident on 11/5/21 revealed the resident resting in bed with no apparent overt signs of pain). Interview with the Nursing Home Administrator and Chief Clinical Officer on 11/10/21 at 11:00 AM were notified the failure of the facility staff to administer pain medication to Resident #9 when requested.

CONCERN (D)

Potential for Harm - no one hurt, but risky conditions existed

Deficiency F0698 (Tag F0698)

Could have caused harm · This affected 1 resident

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Based on medical record review and interview, it was determined that the facility staff failed to complete the Dialysis record communication sheet and obtain post dialysis weights and vital signs for Resident #47. This is evident for 1 of 1 resident reviewed for dialysis during the annual survey. The findings include: Review of Resident #47's medical record on 11/3/21 at 7:20 AM revealed the resident receives dialysis treatments three times a week on Tuesdays, Thursdays and Saturdays. Dialysis is a treatment that filters and purifies the blood using a machine. This helps keep your fluids and electrolytes in balance when the kidneys can't do their job. On 11/4/21 at 11:30 AM interview with the United manager (staff #12) revealed that dialysis residents are sent to an outside facility for dialysis treatment and that the outside facility does not have access to the residents' electronic medical record. Resident information is communicated to the dialysis center by completing the Dialysis Communication Form which is sent with the Residents to dialysis. Further review of Resident #47's medical record revealed the facility staff failed to obtain completed Communication Form from the dialysis center that included post treatment vital signs, weights, dates, medications given, or labs obtained during the dialysis treatment and the facility staff failed to include post and pre dialysis vital signs and weights for Resident # 47. 1. Review of the Dialysis Communication form dated 9/2/21, was without pre and post dialysis weights and post vital signs. The dialysis center staff failed to complete the dialysis report such as treatments, Kilograms removed, access of ports/shunt/fistula, medications given and if labs were obtained. 2. Review of the Dialysis Communication form dated 9/4/21, was without pre and post dialysis weights and post vital signs. The dialysis center staff failed to complete the dialysis report such as treatments, Kilograms removed, access of ports/shunt/fistula, medications given and if labs were obtained. 3. Review of the Dialysis Communication form dated 9/28/21, was without post vital signs and weight to be completed by facility staff and no weight was recorded in the Resident's Electronic Medical Record. 4. Review of the Dialysis Communication form dated 9/30/21, was without post vital signs to be completed by facility staff. The dialysis center staff failed to complete the dialysis report such as treatments, Kilograms removed, access of ports/shunt/fistula, medications given and if labs were obtained. 5. Review of the Dialysis Communication form dated 10/9/21, The dialysis center staff failed to complete the dialysis report such as treatments, Kilograms removed, access of ports/shunt/fistula, medications given and if labs were obtained. 6. Review of the Dialysis Communication form dated 10/12/21, was without pre and post dialysis weights and post vital signs. 7. Review of the Dialysis Communication form dated 10/15/21, was without pre and post dialysis weights and post vital signs. The dialysis center staff failed to complete the dialysis report such as treatments, Kilograms removed, access of ports/shunt/fistula, medications given and if labs were obtained. 8. Review of the Dialysis Communication form dated 10/19/21, was without pre and post dialysis weights and post vital signs. The dialysis center staff failed to complete the dialysis report such as treatments, Kilograms removed, access of ports/shunt/fistula, medications given and if labs were obtained. 9. Review of the Dialysis Communication form dated 10/21/21, was without pre and post dialysis weights and post vital signs. The dialysis center staff failed to complete the dialysis report such as treatments, Kilograms removed, access of ports/shunt/fistula, medications given and if labs were obtained. On 11/5/2021 at 1:30 PM the Nursing Home Administrator and the Director of Nursing were informed of the concerns.

CONCERN (D)

Potential for Harm - no one hurt, but risky conditions existed

Deficiency F0757 (Tag F0757)

Could have caused harm · This affected 1 resident

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2. The facility staff failed to ensure Resident #9 was free from unnecessary medications. Medical record review for Resident #9 on 11/2/21 at 11:30 AM revealed on 8/9/21 the physician ordered: Nifedipine ER 30 milligrams by mouth, hold for SBP less than 110, heart rate 60. Nifedipine is in a group of drugs called calcium channel blockers. It works by relaxing the muscles of the heart and blood vessels. Nifedipine is used to treat hypertension (high blood pressure). Review of the Medication Administration Record revealed the facility staff documented the resident's blood pressure on 10/16/21 at 9:00 AM as 105/72; however, documented administration of the medication. Interview with the Nursing Home Administrator and Chief Clinical Officer on 11/10/21 at 11:00 AM were notified that the facility staff failed to ensure Resident #9 was free from unnecessary medications. Based on clinical record review and staff interview it was determined that the facility staff failed to ensure medications were administered within ordered parameters. This was evident for 2 (#5 and #9) out of 7 residents reviewed for medications. This was evident for 2 of 5 residents selected for review of unnecessary medications and 2 of 52 residents selected for review during the annual survey process. The findings are: 1. A review of resident #5's clinical record revealed the resident was ordered Clonidine 0.1 mg by mouth two times a day for hypertension hold if systolic [top number of blood pressure] is less than 100 or pulse is less than 60. A review of the November Medication Administration Record (MAR) revealed the resident had a blood pressure of 96/56 on 11/8/21 at 5:00 PM and was administered the medication instead of it being held per the physician's order. Staff #18 was interviewed on 11/9/21 at 10:40 PM. She was informed of the medication being administered outside of parameters.

CONCERN (D)

Potential for Harm - no one hurt, but risky conditions existed

Unnecessary Medications (Tag F0759)

Could have caused harm · This affected 1 resident

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Based on record review and observation of medication administration, it was determined the facility staff failed to maintain an error rate below 5%. Observation of medication administration resulted in an error rate of 10.26%. This was evident for 2 of 4 (#33 and #13) residents observed and 4 of 39 opportunities for error. The findings include: Error 1: The facility staff failed to administer a medication as ordered by the physician. Medical record review for Resident #33 on 11/4/21 at 12:30 PM revealed on 5/5/20 the physician ordered: Cholecalciferol 2000 UT, 1 tablet by mouth 1 time a day as a supplement. Cholecalciferol is vitamin D3. Vitamin D helps the body absorb calcium. Cholecalciferol is used as a dietary supplement in people who do not get enough vitamin D in their diets to maintain adequate health. Observation of medication pass on 11/4/21 at 8:45 AM revealed staff #16 failed to administer the medication as ordered by the physician. Error 2: The facility staff failed to administer a medication as ordered by the physician. Medical record review for Resident #33 on 11/4/21 at 12:30 PM revealed on 2/3/21 the physician ordered: Lasix 40 milligrams by mouth, 1 time a day for high blood pressure. Lasix is a loop diuretic (water pill) that prevents the body from absorbing too much salt. This allows the salt to instead be passed in the urine. Observation of medication pass on 11/4/21 at 8:45 AM revealed staff #16 failed to administer the medication as ordered by the physician. Error 3 and 4: The facility staff failed to administer a medication as ordered by the physician. Medical record review for Resident #13 on 11/4/21 at 1:00 PM revealed on 10/16/18 the physician ordered: Senna 2 tablets by mouth 2 times a day for constipation. Senna is an herb. It is used to treat constipation. Observation of medication pass on 11/4/21 at 9:20 AM revealed staff #16 failed to administer the Senna. Staff #16 administered Senna Plus, 2 tablets. Senna Plus is used to treat constipation; however, it contains 2 medications: sennosides and docusate. Interview with the Director of Nursing on 11/5/21 at 1:00 PM and the Nursing Home Administrator and Chief Clinical Officer on 11/10/21 at 11:30 AM were notified of the concerns related to observation of medication pass on 11/4/21.

CONCERN (D)

Potential for Harm - no one hurt, but risky conditions existed

Deficiency F0761 (Tag F0761)

Could have caused harm · This affected 1 resident

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Based on observation, it was determined that the facility staff failed to properly store medications in a locked compartment that were only accessible to authorized staff. This was observed on two different nursing units during an annual recertification survey. The findings include: 1) During an observation of the facility on 11/10/21 at 5:40 AM, the nurse surveyor observed an unlocked an unattended medication cart, on the fourth floor, in the vicinity of the nurse's station. A medication cart houses Resident's medications that can be wheeled to each resident's room. A medication cart may have, but is not limit to, containing injectable medications, oral medications, and scheduled II (or pain) medications 2) During an additional observation of the facility on 11/10/21 at 5:43 AM, the nurse surveyor observed an unlocked an unattended treatment cart located in the vicinity of the third-floor elevator. A treatment cart contains medications, lotions and supplies that the nursing staff may use when assisting a physician with or providing wound care to residents.

CONCERN (D)

Potential for Harm - no one hurt, but risky conditions existed

Laboratory Services (Tag F0770)

Could have caused harm · This affected 1 resident

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review it was determined the facility staff failed to obtain laboratory specimens as ordered by the physician for Residents #66, #75, #83 and #85. This was evident for 4 of 52 residents selected for review during the annual survey process. The findings include: 1. The facility staff failed to obtain laboratory blood test for Resident #66 as ordered by the physician. Medical record review for Resident #66 on 10/18/21 at 11:45 AM the resident had an ammonia level obtained with the result of 62, normal 19-54. Ammonia is a nitrogen waste compound that is normally excreted in the urine. An elevated blood ammonia level is an excessive accumulation of ammonia in the blood. An elevated blood ammonia level occurs when the kidneys or liver are not working properly, allowing waste to remain in the bloodstream. Further record review revealed the resident was to have another ammonia level obtained on 10/25/21; however, the facility staff failed to obtain the ammonia level as ordered by the physician. 2 A. The facility staff failed to obtain laboratory blood test as ordered by by the physician. Medical record review for Resident #75 on 11/3/21 at 10:50 AM revealed on 10/25/21 the physician ordered: CBC. The complete blood count (CBC) is a group of tests that evaluate the cells that circulate in blood, including red blood cells, white blood cells, and platelets. Further record review revealed the facility staff failed to obtain the laboratory blood test as ordered. 2 B. The facility staff failed to obtain laboratory blood test as ordered by by the physician. Medical record review for Resident #75 on 11/9/21 at 10:50 AM revealed on 10/25/21 the physician ordered: CBC and BMP weekly. The complete blood count (CBC) is a group of tests that evaluate the cells that circulate in blood, including red blood cells, white blood cells, and platelets. Further record review revealed the facility staff failed to obtain the laboratory blood test as ordered. A basic metabolic panel (BMP) is a test that measures eight different substances in the blood (glucose, calcium, sodium, potassium, chloride, carbon dioxide, blood urea nitrogen and creatinine). It provides important information about the body's chemical balance and metabolism. Further record review revealed the facility staff failed to obtain the CBC and BMP on 11/1/21 and 11/8/21 as ordered. 3. The facility staff failed to obtain a urine specimen as ordered by the physician for Resident #83. Medical record review for Resident #83 on 11/9/21 at 8:00 AM revealed on 10/7/21 the physician ordered: urine toxin. The urine toxin profile is a complete assessment of urine metal excretion and assesses any suspected of toxic metal exposure as well as mineral imbalances. Further review of the medical record revealed the facility staff failed to obtain the urine toxin as ordered by the physician. Interview with the Nursing Home Administrator and Chief Clinical Officer on 11/10/21 at 11:30 AM were notified of the failure of the facility staff to obtain laboratory specimens as ordered by the physician for Residents #66, #75 and #83. 4. The facility staff failed to obtain laboratory blood test as ordered by by the physician. Resident #85 was admitted to the facility on [DATE] with diagnoses that include congestive stroke, respiratory failure, seizure, tracheostomy, gastrostomy and hypertension. Resident #85 is totally dependant upon the facility staff for all of his/her care. Review of Resident #85's closed medical record on 11/08/21 revealed a physicians order, dated 09/22/21, instructing the nursing staff to obtain a urine sample to test for Legionella. (Legionnaires disease) Legionnaires' disease is a type of pneumonia caused by Legionella bacteria. Further review of Resident #85's closed medical record revealed a nursing progress note, dated 09/23/21 at 12:12 PM, that indicated the facility laboratory had called and informed the nurse that the urine sample for Legionella was rejected due to the sample that was collected did not have a label. The facility nursing staff must take steps to correctly label all laboratory specimens.

CONCERN (D)

Potential for Harm - no one hurt, but risky conditions existed

Dental Services (Tag F0791)

Could have caused harm · This affected 1 resident

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Based on complaint, reviews of a medical record, and staff interview, the facility failed to provide dental services for a resident (Resident #22). This was evident for 1 out of 52 residents selected for review during the annual survey process. The findings include: In an interview with Resident #22's responsible party on 11/03/21 at 10:29 AM, Resident #22's family member stated that he/she was unable to look into Resident #22's mouth and did not recall the last time Resident #22 was seen by a dentist. Review of Resident #22's medical record revealed a physician order, date 09/08/21, that instructed the nursing staff to obtain a dental consult annually and as needed. Interview with the Assistant Director of the Nursing (ADON) on 11/08/21 at 08:54 AM, the ADON stated and confirmed that Resident #22 has not been seen by the facility dentist since being admitted in 2016. The ADON also stated that the 09/08/21 order to see a dentist was just written after Resident #22 was readmitted from the hospital in September 2021.

CONCERN (D)

Potential for Harm - no one hurt, but risky conditions existed

Medical Records (Tag F0842)

Could have caused harm · This affected 1 resident

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Based on medical record review and interview, it was determined the facility staff failed to maintain the medical record for Residents #81 and #184 in the most accurate and complete form. This was evident for 2 of 52 residents selected for review during an annual survey. The findings include: 1. The facility staff failed to maintain the medical record for Resident #81 in the most complete and accurate form. The medical record forms a permanent account of the care a resident has received. The clarity and accuracy of the medical record is paramount for effective communication between healthcare professionals and residents. The maintenance of good medical records ensures that a resident's assessed needs are met comprehensively. Medical record review for Resident #81 on 11/4/21 at 11:48 AM revealed that the physician completed a MOLST on 10/19/21. At that time, the MOLST revealed- Part A- Certifications for the basis of these orders and the physician documented: the resident's surrogate as per the authority granted by the Health Care Decisions Act. It was also revealed on the MOLST that: the orders are based on: other legal authority in accordance with all provisions of the Health Care Decisions Act. All supporting documentation must be contained in the resident's medical record. MOLST stands for Medical Orders for Life-Sustaining Treatment. The MOLST form includes the most common widely recognized life-sustaining treatment options such as: Do Not Resuscitate, Full Code, Artificial Ventilation, Blood Transfusions, Hospital Transfer, any medical workups, use of antibiotics, use of artificially administered fluids and nutrition and use of hemo-dialysis. Maryland MOLST is a portable and enduring medical order form. If there is no advance directive in which an agent has been appointed, a surrogate decision maker as defined in the law can make decisions according to the duty the law gives the surrogate. The surrogate must follow the wishes of the resident, considering: the current diagnosis and prognosis with and without treatment. A surrogate is to make a decision that is consistent with the resident's wishes or, if those wishes are known or unclear, that is in the resident's best interests. The Act includes factors for the surrogate to consider in determining the patient' s wishes. Further record review revealed the facility staff failed to maintain the documentation supporting the legal authority of the surrogate decision making in reference to the MOLST and end of life wishes for Resident #81. The facility staff was not able to provide the surveyor with any evidence the Health Care Decision Act or the means by which the surrogate was appointed. Interview with the Nursing Home Administrator and Chief Clinical Officer on 11/10/21 at 11:00 AM revealed the facility staff failed to maintain the medical record for Resident #81 in the most accurate and complete from by failure to maintain the Health Care Decisions Act. 2. The facility staff failed to maintain an accurate medical record by not removing all former resident documents from the new resident's paper medical record. Reviews of Resident #184's medical record on 11/03/21 at 11:24 AM revealed insurance and other medical documents from former Resident #72's closed medical record in Resident #184's current paper medical record. Staff member #9 was made aware of the concern and removed Resident #72's documents from Resident #184's paper medical record.

CONCERN (D)

Potential for Harm - no one hurt, but risky conditions existed

Room Equipment (Tag F0908)

Could have caused harm · This affected 1 resident

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Based on observation, staff interview it was determined that the facility failed to maintain kitchen equipment in safe operating condition. This deficient practice has the potential to affect all residents. The findings include: 1. On 11/5/21 at 10:10 AM observation of the facility's kitchen with the Dietary Manger revealed a non-operational hot water faucet handle. The hand sink is located on the kitchen's tray line. This was the closest hand sink available to the 3 staff working on the tray line at the time of observation. 2. The 2 compartments sink; hot water faucet had a steady drip and would not turn off completely to stop the flow of hot water. 3. The wall by the exit door had peeling paint. 4. The floor outside the utility closet had an area of missing tile. These concerns were discussed with the Director of Nursing and Administrator during the exit conference on 11/5/21.

CONCERN (E)

Potential for Harm - no one hurt, but risky conditions existed

Quality of Care (Tag F0684)

Could have caused harm · This affected multiple residents

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Based on medical record review and interview it was determined the facility staff failed to provide needed care to Residents (#9, #78, #75, #83 and #66) to provide the highest practical well-being. The facility staff failed to administer medications to Resident #9 as ordered by the physician, failed to float heels for Resident #78, failed to obtain a neurology consultation for Resident #75, failed to obtain a neurology consultation for Resident #83 and failed to obtain a Heptalogy and GI consultation for Resident #66. This was evident for 5 of 52 residents selected for review during the annual survey process. The findings include: 1 A. The facility staff failed to administer medication to Resident #9 as ordered by the physician. Medical record review for Resident #9 on 11/2/21 at 1:30 PM revealed on 7/21/21 the physician ordered: Glatopa 40 mgs SQ in the mornings on MWF for MS. Glatopa is a prescription medicine used to treat relapsing forms of multiple sclerosis (MS). Interview with the resident on 11/2/21 at 11:45 AM revealed the resident stating that she/he does not always get all of his/her medications. Further review of the Medication Administration Record (MAR) revealed on 9/10/21, 9/13/21, 9/22/21, 9/24/21, 9/29/21, 10/1/21, 10/11/21 and 10/13/21 at 9:00 AM the facility staff failed to administer the medication as ordered. 1 B. The facility staff failed to administer pain medication as ordered by the physician. Medical record review for Resident #9 on 11/2/21 at 1:30 PM revealed on 2/21/21 the physician ordered: Tramadol 50 mgs, 2 tablets by mouth every 6 hours as needed for severe pain between 7-10. Tramadol is used to relieve moderate to moderately severe pain. Review of the MAR revealed on 8/20/21 at 8:00 PM the facility staff documented the resident's pain as 4; however administered the Tramadol. Further review of the MAR revealed on 9/7/21 at 9:20 PM the facility staff documented the resident's pain as 2 and administered the Tramadol; on 9/27/21 at 10:28 PM documented the resident's pain as 0; however, documented the administration of the Tramadol. On 10/5/21 at 6:28 PM the facility staff documented the resident's pain as 2; on 10/6/21 at 5:02 AM the pain level was documented as 3, on 10/8/21 at 6:35 PM the pain level documented as 5, on 10/10/21 at 7:00 AM documented the resident's pain as 0 and on 10/22/21 at 6:06 PM the pain level was documented by the facility staff as 0; however, documented the administration of the Tramadol. 2. The facility staff failed to float heels for Resident #78. Medical record review for Resident #78 on 11/2/21 at 9:30 AM revealed on 12/19/19 the physician ordered: float heels at all times while in bed. Float the heels means that a resident's heel should be positioned in such a way as to remove all contact between the heel and the bed. Surveyor observation of Resident #78 on 11/2/21 at 12:45 PM, 11/3/21 at 8:50 AM and 1:45 PM, 11/4/21 at 11:30 AM, 11/5/21 at 11:43 AM revealed the resident in bed; however, the facility staff failed to float the heels as ordered. 3. The facility staff failed to obtain a neurology consultation as ordered for Resident #75. Medical record review for Resident #75 on 11/8/21 at 10:50 AM revealed on 9/9/21 and 10/21/21 the physician ordered: neurology consultation for seizures. Neurology is the branch of medicine concerned with the study and treatment of disorders of the nervous system. Neurology assesses and treats disorders that affect the brain, spinal cord, and nerves. Further record review revealed the facility staff failed to obtain the neurology consultations as ordered by the physician. 4. The facility staff failed to obtain a neurology consultation as ordered for Resident #83. Medical record review for Resident #83 on 11/5/21 at 10:50 AM revealed on 10/7/21 the physician ordered: neurology consultation for seizures. Neurology is the branch of medicine concerned with the study and treatment of disorders of the nervous system. Neurology assesses and treats disorders that affect the brain, spinal cord, and nerves. Further record review revealed the facility staff failed to obtain the neurology consultations as ordered by the physician. 5 A. The facility staff failed to obtain a Hepatology consultation for Resident #66 as ordered by the physician. Medical record review for Resident #66 on 11/9/21 at 9:50 AM revealed on 9/15/21 and 10/1/21 the physician ordered: Heptalogy consultation for elevated ammonia. Hepatology is a branch of medicine concerned with the study, prevention, diagnosis, and management of diseases that affect the liver. An elevated ammonia level can indicate some damage or liver conditions. Further record review revealed the facility staff failed to obtain the Hepatology consultation as ordered by the physician. 5 B. The facility staff failed to obtain a GI consultation as ordered by the physician for Resident #66. Medical record review for Resident #66 on 11/9/21 at 9:50 AM revealed on 9/9/21 and 9/28/21 the physician ordered: GI consultation for history of Chrons disease. Gastroenterology is the branch of medicine focused on the digestive system and its disorders. Diseases affecting the gastrointestinal tract, which include the organs from mouth into anus, along the alimentary canal, are the focus. Crohn's disease is a type of inflammatory bowel disease (IBD). It causes inflammation of the digestive tract, which can lead to abdominal pain, severe diarrhea, fatigue, weight loss and malnutrition. Further record review revealed the facility staff failed to obtain the GI consultation as ordered by the physician. Interview with the Nursing Home Administrator and Chief Clinical Officer on 11/10/21 at 11:30 AM were notified of the concerns related to Residents #9, #78, #75, #88 and #66.

CONCERN (E)

Potential for Harm - no one hurt, but risky conditions existed

Deficiency F0692 (Tag F0692)

Could have caused harm · This affected multiple residents

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 4. The facility staff failed to thoroughly monitor and add interventions timely when the facility staff documented a significant weight loss for Resident #77. Review of Resident #77's medical record on 11/5/21 revealed the Resident was admitted to the facility on [DATE] with a diagnosis to include esophageal obstruction. Further review of the Resident's medical record revealed the Resident returned from the hospital on 8/16/21 and on 8/18/21 the facility staff obtained a weight of 122.4 pounds. The Resident was not reweighed until 10/14/21 and the facility staff documented the Resident's weight to be 112.2. This indicated a weight loss of 10.2 pounds in 3 months or 8.3%. Further review of the Resident's medical record revealed the Resident was not seen by the Regional dietitian until 11/2/21, 19 days after the documented weight loss. At that time no further interventions were put in place including reweights. Interview with the Regional dietitian on 11/8/21 at 8:56 AM revealed the Resident should have been reweighed. After surveyor intervention the Resident was reweighed on 11/8/21 and the facility documented the Resident weight as 125.8 indicating the Resident had not lost weight since readmission on [DATE]. Interview with the Chief Clinical Officer on 11/8/21 at 12:38 PM confirmed the facility staff failed to reweigh Resident #77 after a documented weight loss. Based on medical record review, observation and interview, it was determined the facility staff failed to provide Resident #9 with the prescribed diet as ordered by the physician; failed to obtain weights on Resident # 75 for 5 months, failed to withhold straw for Resident #83 and facility staff failed to thoroughly monitor and add interventions timely when the facility staff documented a significant weight loss for a resident (Resident #77). This was evident for 4 of 7 residents selected for review for nutrition and 4 of 52 residents selected for review during the annual survey. The findings include: 1. The facility staff failed to provide Resident #9 with the prescribed diet as ordered by the physician. Surveyor interview and observation with Resident #9 on 11/4/21 at 8:40 AM revealed the resident not eating breakfast. When questioned, the resident stated that ham was being served and he/she does not eat pork. Observation of the resident's breakfast at that time revealed the resident was served a slice of ham. Observation of the resident's meal ticket that accompanies the resident's tray from the kitchen to the room revealed diet of: low potassium, no tomatoes and NO PORK and NO POTATOES. Potassium is an essential mineral keeps the muscles healthy and the heartbeat and blood pressure steady. If the resident has a heart or kidney condition, though, the doctor may recommend a low-potassium diet. The facility staff was notified at that time that the resident received ham and was not to have pork. Observation of the resident's breakfast on 11/5/21 at 8:45 revealed the resident being served a western omelet which contained tomatoes. Observation of the resident's lunch on 11/5/21 revealed the resident was served potatoes au gratin. The Chief Clinical Officer was notified of the dietary concerns related to Resident #9 on 11/5/21 at 1:00 PM. 2. The facility staff failed to weigh Resident #75 for 5 months. Medical record review for Resident #75 on 11/4/21 at 11:45 AM revealed the resident was weighed on 5/13/21 with a documented weight of 175.6. Further record review revealed the facility staff failed to weigh the resident for 5 months. It was revealed the resident was not weighed until 10/21/21 with a documented weight of 164.6, an 11 pound weight loss and there is no evidence the facility obtained a re-weight to determine accuracy. Interview with staff #21 on 11/4/21 at 10:30 AM revealed the resident should have been weighed monthly. 3. The facility staff failed to withhold a straw from Resident # 83. Medical record review for Resident #83 on 11/3/21 at 9:50 AM revealed on 8/14/19 the physician ordered: No chewy meats/ no straws, Patient is blind, requests finger foods but soft textured foods. Surveyor observation of the resident on 11/4/21 at 12:30 PM revealed the resident with water and a straw and on and 11/5/21 at 12:31 PM revealed the resident with coffee and a straw. The Chief Clinical Officer was notified of the observations of Resident #83 with straws. Interview with the Nursing Home Administrator and Chief Clinical Officer on 11/10/21 at 11:00 AM were notified of the nutritional concerns for Residents #9, #75 and #83.

CONCERN (E)

Potential for Harm - no one hurt, but risky conditions existed

Drug Regimen Review (Tag F0756)

Could have caused harm · This affected multiple residents

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Based on medical record review, it was determined the facility staff failed to 1. address Consultant Pharmacy Drug Regimen Review in a timely manner for Residents (#9 and #22) and 2. document a monthly Consultant Pharmacy Drug Regimen Review in the resident's chart. This was evident for 2 of 5 residents reviewed for unnecessary medication and 2 of 52 residents selected for review during the annual survey sample The findings include: 1. Medical record review for Resident #9 on 11/3/21 at 8:45 AM revealed on 7/21/21 the physician ordered: Lidocaine patch 4%, apply to left knee topically in the morning for pain and on 7/21/21 ordered: Lidocaine patch 4%, apply to left shoulder topically in the morning for pain. Lidocaine 4% patch can be used for: it is used to stop pain and it is used to treat painful nerve diseases. It is also used to ease long-term pain problems. The recommendation that each patch should be worn for no longer than 12 hours is made because the patch may cause localized skin reactions if used beyond this duration. Lidocaine: Basics, Side Effects & Reviews - GoodRxhttps://www.goodrx.com > lidocaine. Further review of the medical record revealed the Consultant Pharmacist assessed the medications on 8/17/21 and 10/15/21 with the recommendation that the Lidocaine patch be administered 12 hours on and 12 hours off; however, the facility staff failed to address that recommendation. Interview with the Nursing Home Administrator and Chief Clinical Officer on 11/10/21 at 11:00 AM were notified of the facility staff failure to act upon the Consultant Pharmacist recommendation for Resident #9 in a timely manner. 2. The facility failed to ensure that monthly medication regimen reviews were conducted by a consultant pharmacist to identify any irregularities in the resident medication regimen for Resident #22. Review of Resident #22's medical record on 11/05/21 failed to reveal any consultant pharmacy reviews for the year 2021. The last documented consultant pharmacy review located in Resident #22's medical record was dated 12/01/20. In an interview with the consultant pharmacist on 11/05/21 at 4:08 PM, the consultant pharmacist stated that he/she was instructed by the facility staff not to enter any of the consultant pharmacy reviews in the resident's record. The consultant pharmacist also stated that he/she was recently contacted by the facility's Director of Nursing to request that I send the last 6 months of pharmacy reviews. All concerns were discussed with the Nursing Home Administrator at the time of exit on 11/10/21 at 11:47 AM.

CONCERN (E)

Potential for Harm - no one hurt, but risky conditions existed

Infection Control (Tag F0880)

Could have caused harm · This affected multiple residents

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 2. The facility staff failed to store/ handle dirty linens in a manner that would limit the spread of infections as much as possible and in accordance with the accepted national standard to decrease the spread of any infections. Surveyor observation of room [ROOM NUMBER] on 11/4/21 at 11:30 AM revealed the facility staff placed a pile of dirty, wet linen: diaper, gown, towels and sheets on the floor next to the door. It was also noted gnats flying around the linen. The Director of Nursing was notified at that time of the dirty linen noted on the floor. Subsequent observations of the room did not reveal any further incidents of dirty linen on the floor. Interview with the Nursing Home Administrator and Chief Clinical Officer on 11/10/21 at 11:00 AM were notified of the observation of the dirty linen observed on the floor in room [ROOM NUMBER] on 11/4/21. Based on observation and staff interview, it had been determined that the facility had not implemented infection control practices to prevent the spread of COVID 19 as evidenced by 1. facility staff failing to wear a face mask while working in the facility and providing during patient care (This was observed 3 times during an annual recertification survey) and 2. the facility staff failed to store/ handle dirty linens in a manner that would limit the spread of infections as much as possible and in accordance with the accepted national standard to decrease the spread of any infections (This was observed 1 time during an annual recertification survey). The findings include: 1. The facility staff failing to wear a face mask while working in the facility and providing during patient care. Consistent with the 4/2/2020 CMS guidance, on 4/27/2021, the Centers for Disease Control and Prevention (CDC) published updated guidance which stated, In general, fully vaccinated HCP (health care provider) should continue to wear source control while at work. However, fully vaccinated HCP could dine and socialize together in break rooms and conduct in-person meetings without source control or physical distancing. On 5/4/2021 The Maryland Department of Health (MDH) Secretary issued an amended Directive and Order Regarding Nursing Home Matters. The 5/4/21 Directive and Order, finding it necessary for the prevention and control of 2019 Novel Coronavirus (SARS-CoV-2 or 2019-NCoV or COVID-19), and for the protection of the health and safety of patients, staff, and other individuals in Maryland, hereby authorize and order the following actions for the prevention and control of this infectious and contagious disease under the Governor's Declaration of Catastrophic Health Emergency. This Amended Directive and Order replaces and supersedes the Directives and Orders Regarding Nursing Home Matters, dated February 8, 2021, November 17, October 1, July 24, June 19, April 29, April 24, April 9, and April 5, 2020. 1C. documented, All staff, volunteers, vendors, visitors, and residents, shall follow CDC and CMS guidance on face covering usage when in the facility. Due to the COVID19 pandemic, facility staff are required to wear personal protective equipment (PPE) which include the use of face masks, gloves, face shields, gowns. Staff are also required to perform preventative measures like hand washing before and after resident care. The following are observations of facility staff members failing to wear a face mask. This was observed on different units at different times during the annual recertification process. A) During an observational tour of the 200 hall on 11/08/21 at 10:26 AM with the facility Assistant Director of Nurses (ADON), the surveyor observed housekeeper, staff member #36, standing at the doorway of room [ROOM NUMBER] with his/her mask pulled under his/her chin and not covering his/her mouth and nose. The facility 200 hall houses resident who are ventilator dependent and totally dependent upon the nursing and respiratory staff for all of their care. The ADON was aware of the observation. B) During an observation of the facility on 11/10/21 at 5:30 AM, the nurse surveyor observed a facility porter, staff member #31, washing the lower-level floor and speaking to the director of maintenance. Staff member #31 was observed not wearing any mask at this time. C) During an observation of the third floor on 11/10/21 at 5:43 AM, the nurse surveyor observed staff member #32 exiting resident room [ROOM NUMBER] with his/her face mask pulled under his/her chin not covering the staff members mouth and nose.

MINOR (B)

Minor Issue - procedural, no safety impact

Staffing Information (Tag F0732)

Minor procedural issue · This affected multiple residents

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Based on observation and staff interview it was determined that the facility staff failed to post a staffing assignment that was complete. This was evident for 1 out of the 4 nursing units. The findings include: The survey team observed on 11/5/21 at 9:00 AM and on 11/8/21 at 1:15 PM that the fourth-floor nursing unit did not have required information on the staff assignment board. The assignments for the nurses and the Geriatric Nursing Assistants (GNA) were not posted. Residents would not know which nurse and which GNA would be assigned to them. Staff #18 was interviewed on 11/9/21 at 11:20. She stated she understood the findings.

MINOR (C)

Minor Issue - procedural, no safety impact

Deficiency F0838 (Tag F0838)

Minor procedural issue · This affected most or all residents

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Based on review of facility records and an interview with staff, it was determined the facility failed to provide revise and document an accurate up-to-date facility-wide assessment annually. This was identified during an annual recertification survey. This has the potential to affect all residents within the facility. The findings include: A facility-wide assessment is conducted to determine what resources are necessary to care for its residents competently during both day-to-day operations and emergencies. The assessment is to include the care required by the resident population considering the types of diseases, conditions, physical and cognitive disabilities, overall acuity, and other pertinent facts that are present within that population. A copy of the Facility Assessment was requested during the survey on 11/05/21. Review of the Facility assessment on 11/05/21, revealed the facility assessment was reviewed was on 06/14/21. The facility director of nurses provided a sign-in sheet that indicated the facility assessment was reviewed and approved by the facility quality assurance committee on 06/21/21. The surveyor requested the front door screen. An interview was conducted with the facility vice president of clinical services (VPCS) on 11/10/21 at 6:10 AM, the VPCS stated that the quality assurance committee sign in sheet for 06/21/21 was incorrect. The VPCS stated that 2 of the staff members, staff member #34 and staff member #35, have not worked in the facility since 2020 and could not have reviewed and approved the facility assessment in June 2021 during the quality assurance committee meeting. In an follow-up interview with the facility administrator on 11/10/21 at 7:52 AM provided documentation that staff member #34 last worked in the facility in November 2020 and staff member #35 worked in the facility in June 2020. The facility staff must take steps to review and update the facility assessment yearly.

Nov 2018 18 deficiencies

CONCERN (D)

Potential for Harm - no one hurt, but risky conditions existed

Deficiency F0561 (Tag F0561)

Could have caused harm · This affected 1 resident

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Based on medical record review and staff interview, it was determined that the facility failed to follow a resident's wishes to obtain a laboratory test. This was evident for 1 (Resident #82) of 4 residents reviewed for choices during an annual recertification survey. The findings include: Review of Resident #82's MOLST form on 11/19/18, revealed that Resident #82's health care agent wanted Resident #82 to be a full code and also wanted all aspects of life sustaining treatment to be performed including any medical testing indicated to diagnose and/or treat a medical condition. On 10/17/18, Resident #82 was admitted to the facility hospice provider. Further review of Resident #82's medical record revealed a pharmacy consultant request, dated 10/30/18, requesting Resident #82's physician to order a Vitamin D level to check Resident #82's Vitamin D replacement therapy. Resident #82 was receiving Vitamin D as a supplement. On 11/01/18, Resident #82's physician disagreed with the facility pharmacy consultant and indicated the reason for not obtaining a Vitamin D level for Resident #82 was because Resident #82 was on hospice. In an interview with Employee #4 on 11/21/18 at 10 AM, Employee #4 stated s/he was not aware of the issue with Resident #82's wishes regarding laboratory samples.

CONCERN (D)

Potential for Harm - no one hurt, but risky conditions existed

Deficiency F0568 (Tag F0568)

Could have caused harm · This affected 1 resident

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Based on resident complaint, reviews of administrative records including a resident's personal funds records, individual resident account statements, transaction reports, transaction receipts, and staff interview, it was determined that the facility staff failed to maintain a system that ensures a full and complete accounting of a resident's personal monies entrusted to this facility. This was evident for 1 (Resident #55) of 1 resident reviewed for personal property during an annual recertification survey. The findings include: In an interview with Resident #55 on 11/19/18 at 8:10 AM, Resident #55 stated that s/he does not get enough money. In an interview with the facility director of nursing (DON) on 11/27/18 at 02:29 PM, the DON stated that the facility does not have a business office manager. In an interview with Employee #21 on 11/28/18 at 08:04 AM, Employee #21 stated that resident money and resident balance sheets come from the corporate offices in New York. A review of Resident #55's cash withdrawal receipts from 07/01/18 thru 09/19/18 revealed Resident #55 had a -$51.98 amount in his/her account at the end of this period. Reviews of the facility quarterly statement revealed several days the facility staff failed to document Resident #55 had received money from his/her resident fund account.

CONCERN (D)

Potential for Harm - no one hurt, but risky conditions existed

Report Alleged Abuse (Tag F0609)

Could have caused harm · This affected 1 resident

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Based on review of facility administrative records and staff interview, it was determined that the facility staff failed to immediately report an allegation of abuse to the facility administrator. This was evident for 1 (Resident #195) of 4 residents reviewed for abuse during an annual recertification survey. The findings include: A review of the facility reported incident MD00126351, revealed documentation of an allegation of staff to resident abuse involving Resident #195 that occurred on 05/05/18. The facility documentation indicated the facility initiated an investigation into the alleged staff to resident abuse on 05/07/18. In an interview with Employee #19 on 11/21/18 at 7 AM, Employee #19 stated s/he witnessed the 05/05/18 incident and stated that the local police had been notified and came to the facility to investigate the incident. Employee #19 stated that he documented the incident on the daily security form but also stated that this form is not provided to the facility administrative staff. Employee #19 also stated that s/he did not speak to anyone about the incident until 05/07/18. Further review of the facility investigation indicated the facility was unable to substantiate an allegation of abuse related to facility reported incident MD00126351.

CONCERN (D)

Potential for Harm - no one hurt, but risky conditions existed

Comprehensive Care Plan (Tag F0656)

Could have caused harm · This affected 1 resident

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Based on observation, reviews of a medical record, and staff interview, it was determined that the facility staff failed to implement a care plan for a resident who smokes. This was evident for 1 (Resident #89) of 2 residents reviewed for smoking during an annual re-certification survey. The findings include: During an observation of the smoking area on 11/26/18 at 09:05 AM, Resident #89 was observed outside smoking. A review of Resident #89's medical record failed to reveal an updated safe smoking assessment and a care plan for safe smoking. Resident #89's medical record did have an admission smoking assessment completed on 10/27/18 but Resident #89 was receiving a medicated smoking cessation patch at that time. Resident #89 medicated smoking cessation patch was discontinued in early November 2018. Resident #89's 10/27/18 smoking assessment indicated that he/she was not allowed to smoke. A review of the facility smoking policy manual, which is kept in close proximity to the smoking area, revealed a list of all smokers in the facility but failed to list Resident #89 as an identified smoker. In an interview with Employee #13 and Employee #18 on 11/26/18 10:14 AM, both employees indicated Resident #89 does utilize the smoking area to smoke and that Resident #89 tries to go out for every smoke break the facility allows.

CONCERN (D)

Potential for Harm - no one hurt, but risky conditions existed

Quality of Care (Tag F0684)

Could have caused harm · This affected 1 resident

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Based on observation during a medication pass, it was determined the nurse failed to follow standards of practice regarding medication preparation and poured an excess of dispensed medication back into the medication container. This was observed one time during a medication pass observation. The findings include. During the observation of the medication administration on 11/21/18 at 10:00 AM Employee #10 was observed measuring Resident #67's Keppra (seizure medication) into a medication cup and then pouring the excess back into the original bottle twice until the desired amount was obtained. The Director of Nursing was informed of the findings on 11/21/18. No evidence to dispute this finding was presented to the team prior to exit.

CONCERN (D)

Potential for Harm - no one hurt, but risky conditions existed

Deficiency F0685 (Tag F0685)

Could have caused harm · This affected 1 resident

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Based on resident interview, reviews of a medical record, and staff interview, it was determined that the facility staff failed to obtain an eye consultation. This was evident for 1 (Resident #89) of 1 resident reviewed for communication difficulty and/or sensory problems during an annual recertification survey. The findings include: In an interview with Resident #8 on 11/19/18 at 12:10 PM, Resident #89 stated that he/she needed to see an eye doctor for poor vision. Review of Resident #89's medical record revealed a physician order, dated November 2018, instructing the nursing staff to obtain an Optometry consult as needed. Further review of Resident #89's medical record revealed a social service note indicating a care plan conference had been held on 11/08/18 and Resident #89's family member had requested the facility staff to obtain an vision consult for Resident #89. In an interview with the facility social worker on 11/27/18 at 10 AM, the facility social worker stated that Resident #89 had not been seen by an eye doctor and that an appointment had not been scheduled.

CONCERN (D)

Potential for Harm - no one hurt, but risky conditions existed

Deficiency F0757 (Tag F0757)

Could have caused harm · This affected 1 resident

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review and staff interviews, it was determined that the facility staff failed to ensure that a resident's medication regimen was free from unnecessary medication by failing to ensure that a psychotropic medication had an adequate indication for use. This was evident for 1 (Resident #89) of 5 residents reviewed for unnecessary medications during an annual recertification survey. The findings include: Review of Resident #89's medical record revealed a physician order, dated October 2018, instructing the facility nursing staff to obtain a psychiatric assessment as needed and to administer an antipsychotic medication every evening for the indication of mood disorder. A review of Resident #89's physician assessment dated [DATE] indicated Resident #89 to be calm, cooperative, with an appropriate mood, and able to follow commands. Resident #89's physician assessment dated [DATE] indicated that psychiatry was onboard assessing Resident #89. Further review of physician assessments, dated 11/19/18 and 11/23/18, revealed Resident #89 had no agitation or distress and indicated psychiatric services had assessed Resident #89. A review of the facility pharmacy consultant October 2018 assessment of Resident #89's medication indicated the pharmacist requested an updated diagnosis for the antipsychotic medication Resident #89 was receiving. In an interview with Employee #7 on 11/27/18 09:47 AM, Employee #7 stated that Resident #89 had not been assessed by the facility psychiatrist since being admitted to the facility.

CONCERN (D)

Potential for Harm - no one hurt, but risky conditions existed

Medication Errors (Tag F0758)

Could have caused harm · This affected 1 resident

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2) A review of Resident #43's medication orders revealed a physician's order for Sertraline and Olanzapine. Sertraline is a medication used to treat Depression and Olanzapine is used to treat psychosis. Medical record review for Resident #43 revealed on 4/13/17 the physician ordered: Document behavior note under progress note every day on 3 PM-11 PM shift. The resident's chart was absent of behavior monitor documentation that would indicate if the medication regimen was effective. Further Reviews of Resident #43's medical record on 11/29/18 revealed that the facility psychiatrist assessed Resident #43 on 10/22/18 and recommended reducing Resident #43's antipsychotic medication, Olanzapine, from 7.5 milligrams (mg) to 5 mg orally every evening. The facility psychiatrist recommended a gradual dose reduction (GDR) for Resident #43's at this time. Review of Resident #43's November 2018 medication administration record revealed that Resident #43 was not currently receiving his/her antipsychotic medication Olanzapine. The Director of Nursing (DON) was made aware of these concerns on 11/29/2017 at 10:00 AM. The DON confirmed that no antipsychotic medication was given to the resident since October 23, 2018. Based on staff interview and clinical record review it was determined that the facility staff failed to 1) ensure the residents' behaviors were monitored and recorded routinely, and 2) to conduct behavior monitoring for a resident receiving an psychotropic medication. This was evident for 2 (Resident #87 and #43) out of the 5 residents selected for a review for unnecessary medications during an annual recertification survey. The findings are: 1) A review of Resident #87's clinical records revealed that the resident was being administered Remeron 45 mg (an anti-depressant), Depakote delayed release 125 mg to treat a behavioral issue, and Seroquel (an antipsychotic medication) 50 mg twice a day. A form or log to monitor the specific behaviors these medications were prescribed for was not in the chart. A review of the care plans revealed that the care plan for depression included an intervention to Monitor/document/report to Nurse/MD s/sx [signs and symptoms] of depression, including: hopelessness, anxiety, sadness, insomnia, anorexia, verbalizing, negative statements, repetitive anxious or health-related complaints, tearfulness. How often these behaviors occur was not recorded and monitoring was left to the assumption that any and all occurrences would be recorded in the progress notes. It was not clear if this was a list of all the behaviors that are manifested by the resident while in a depressed state or if it is a generic list of the signs and symptoms that a depressed person could exhibit. The Administrator and Director of Nursing (DON) were interviewed on 11/29/18 at 9:18 AM. The DON informed the surveyor that the staff only complete monitoring sheets for prn (as needed) medications. Medications that a resident receives every day are only monitored for side effects.

CONCERN (D)

Potential for Harm - no one hurt, but risky conditions existed

Deficiency F0761 (Tag F0761)

Could have caused harm · This affected 1 resident

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 2. During an observation of the 400's-nursing hall on 11/29/18 at 10:30 AM, the surveyor observed a medication cart unlocked outside room [ROOM NUMBER]. There were no staff. One resident (#43) was sitting in a wheelchair near the unlocked medication cart. Employee #15 was in the lobby area with his back to the medication cart, looking out the window and talking on a cell phone. The surveyor observed the medication cart and Employee #15 for 7 minutes. At 10:37 AM on 11/29/18, surveyor made Employee #15 aware that the medication cart was unlocked. Employee #15 acknowledged that the cart was unlocked. The facility assistant director of nursing was made aware of the observations at this time. Based on observation and staff interview it was determined that the facility staff failed to ensure the treatment and medication carts were locked and secured. This was true for 2 out of 4 nursing units. The findings are: 1. Surveyor observed an unlocked treatment cart on 11/21/18 at 9:10 AM in front of room [ROOM NUMBER]. Inside the treatment cart were several creams and ointments. The items included were Lanolin (skin protectant), Metaphen (anti-infective ointment), Santyl (a debriding enzyme), and Nitro Bid ointment (nitroglycerin). Two nurses and the unit manager were informed on 11/21/18 at 9:15 AM. The treatment cart was then locked.

CONCERN (D)

Potential for Harm - no one hurt, but risky conditions existed

Dental Services (Tag F0791)

Could have caused harm · This affected 1 resident

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, reviews of a medical record, and staff interview, it was determined that the facility staff failed to obtain dental services for a resident. This was evident for 1 (Resident #55) of 1 resident reviewed for dental services during an annual recertification survey. The findings include: A review of Resident #55's medical record revealed a physician order, dated 10/26/17, instructing the nursing staff to obtain a dental consult as needed. Further review of Resident #55's medical record failed to reveal any documentation a dental consult had been offered or obtained since Resident #55 was admitted to the facility. A review of Resident #55's annual Minimum Data Set (MDS) dated [DATE] indicated Resident #55 had all of his/her teeth. During an observation of Resident #55 on 11/19/18 at 8:07 AM, Resident #55 was observed with some missing teeth to his/her right upper ridge with several discolored teeth. In an interview with Employee #7 on 11/27/18 at 10:34 AM, Employee #7 confirmed Resident #55 had never been referred to a dentist since being admitted and that Resident #55 had not complained about any dental concerns.

CONCERN (D)

Potential for Harm - no one hurt, but risky conditions existed

Deficiency F0825 (Tag F0825)

Could have caused harm · This affected 1 resident

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Based on resident complaint, medical record review and staff interview, it was determined that the facility therapy staff failed to evaluate and take steps to reassess a resident's wheelchair. This was evident for 1 (Resident #6) of 1 resident reviewed for rehabilitation and restorative nursing services during an annual recertification survey. The findings include: In an interview with Resident #6 on 11/29/18 12:25 PM, Resident #6 stated that s/he was currently having problems with his/her wheelchair when ambulating throughout the facility. Resident #6 stated that his/her arms were hitting the backrest poles when trying to wheel himself/herself around the facility. Resident #6 stated that s/he received the wheelchair approximately two years ago and that his/her weight had increased several pounds since being originally fitted for the wheelchair. Resident #6 stated that s/he had difficulty sitting in an upright position in his/her wheelchair due to a previous injury and surgical condition. Review of Resident #6's medical record failed to reveal that a follow-up wheelchair sitting assessment had been conducted by the facility therapy staff since Resident #6 originally received his/her wheelchair. In an interview with Employee #16 on 11/19/18 at 12:25 PM, Employee #16 stated that s/he had observed Resident #6 to be sitting low in the wheelchair and that is why Resident #6's arms were hitting the backrest poles when ambulating. Employee #16 also stated it appeared that if Resident #6 could sit higher in the wheelchair that Resident #6's arms would not hit the wheelchair back rest poles when ambulating. In an interview with Employee #17 on 11/29/18 at 12:37 PM, Employee #17 stated that one of the staff occupational therapist performed the initial measurements for Resident #6's wheelchair 1.5 years ago. Employee #17 stated that Resident #6 had not had a follow up wheelchair sitting assessment since that time.

CONCERN (D)

Potential for Harm - no one hurt, but risky conditions existed

Medical Records (Tag F0842)

Could have caused harm · This affected 1 resident

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Based on reviews of a medical record and staff interview, it was determined that the facility staff failed to maintain an accurate medical record by not including documentation from the facility hospice service provider in the medical record. This was evident for 1 (Resident #82) of 2 residents reviewed for hospice services during an annual recertification survey. The findings include: Review of Resident #82's medical record on 11/21/18 revealed Resident #82 was admitted to the facility hospice services provider on 10/17/18. Further review of Resident #82's medical record failed to reveal any hospice documentation of care in Resident #82 medical record. In an interview with the facility social worker on 11/21/18 at 10:00 AM, the facility social worker stated that s/he was unable to find any of the hospice documentation in Resident #82's medical record.

CONCERN (D)

Potential for Harm - no one hurt, but risky conditions existed

Infection Control (Tag F0880)

Could have caused harm · This affected 1 resident

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Based on administrative record review and staff interview, the facility staff failed to track and monitor a resident with an infection upon admission. This was evident for 1 (Resident #193) of 2 residents reviewed for infections during an annual recertification survey. The findings include: During an interview with the corporate infection control practitioner on 11/29/18 at 10:52 AM, the corporate infection control practitioner stated that all residents admitted with an infection and receiving antibiotics from the hospital are placed on a surveillance list that monitors each residents progress. Reviews of Resident #193 medical record revealed Resident #193 was admitted in October from the hospital with an infection and was receiving intravenous antibiotics through a large bore central line. The corporate infection control practitioner reviewed each of the facility nursing unit documents to see if Resident #193 was on the list that the staff were monitoring for infections. The corporate infection control practitioner indicated there were no records Resident #193 had been monitored since admission as a resident identified with an infection and receiving intravenous antibiotics through a large bore central line.

CONCERN (D)

Potential for Harm - no one hurt, but risky conditions existed

Smoking Policies (Tag F0926)

Could have caused harm · This affected 1 resident

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Based on observation, reviews of a medical record, and staff interview, it was determined that the facility staff failed to identify a resident as a smoker, assess the resident to be a safe smoker, implement a care plan for smoking, and update the facility list of smokers. This was evident for 1 (Resident #89) of 2 residents reviewed for smoking during an annual recertification survey. The findings include: During an observation of the smoking area on 11/26/18 at 09:05 AM, Resident #89 was observed outside smoking. A review of Resident #89's medical record failed to reveal an updated safe smoking assessment and a care plan for safe smoking. Resident #89's medical record did have an admission smoking assessment in October 2018 but Resident #89 was receiving a medicated smoking cessation patch at that time. Resident #89's medicated smoking cessation patch was discontinued in early November 2018. A review of the facility smoking policy manual, which is kept in close proximity to the smoking area, revealed a list of all smokers in the facility but failed to list Resident #89 as an identified smoker. In an interview with Employee #13 and Employee #18 on 11/26/18 10:14 AM, both employees indicated Resident #89 does utilize the smoking area to smoke and that Resident #89 tries to go out for every smoke break the facility allows.

CONCERN (E)

Potential for Harm - no one hurt, but risky conditions existed

Transfer Notice (Tag F0623)

Could have caused harm · This affected multiple residents

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 4. Review of the medical record for Resident #64 on 11/21/2018 at 1:34 PM revealed that on 7/21/18- 8/8/18, 8/27/18- 9/20/18 and on 9/21/18- 9/28/18 Resident #64 was sent to the hospital for evaluation and treatment. Further medical record review failed to reveal that the facility staff informed Resident #64's representative and the State Ombudsman in writing of the transfer to the hospital. In an interview with the Director of Nursing on 11/26/18 at 8:40 AM she confirmed that the facility staff failed to inform Resident #64's representative and the State Ombudsman in writing of the transfer to the hospital. Based on medical record review and interview with staff it was determined that the facility staff failed to 1) provide a written notice for emergency transfers to the resident and/or the resident representative, and 2) ensure the local ombudsman was notified of a facility initiated resident discharge or transfer. This was found to be evident for 6 out of 46 (Residents #36, #39, #18, #64, #26, #70) residents reviewed for a facility-initiated transfer during an annual re-certification survey. The findings include: 1. A medical record review for Resident #36 was conducted on 11/27/18. Review of the physician order written on 4/1/2018, revealed that Resident #36 had a change in their medical condition that required an immediate transfer to an acute care hospital for further evaluation. Review of the medical record failed to reveal a written notice for emergency transfers to the resident, resident representative and the ombudsman. 2. A medical record review for Resident #39 was conducted on 11/27/18. Review of the physician order written on 8/22/2018 , revealed that Resident #39 had a change in their medical condition that required an immediate transfer to an acute care hospital for further evaluation. Review of the medical record failed to reveal a written notice for emergency transfers to the resident, resident representative and the ombudsman. 3. A medical record review for Resident #18 was conducted on 11/27/18. Review of the physician order written on 5/13/2018, revealed that Resident #18 had a change in their medical condition that required an immediate transfer to an acute care hospital for further evaluation. Review of the medical record failed to reveal a written notice for emergency transfers to the resident, resident representative and the ombudsman. 5. A review of Resident #26's clinical record revealed that the resident was admitted to the hospital on [DATE] for evaluation after a fall. A record of the ombudsman being notified of this transfer could not be found in the clinical record. 6. A review of Resident #70's clinical record revealed that the resident was sent to the hospital on 9/25/18, 10/2/18, 10/19/18, and 10/29/18. A record of the ombudsman being notified of any of the hospitalizations could not be located. The Director of Nursing was interviewed on 11/26/18 at 9:28 AM. She stated that the sister facilities have a system in place that alerts the respective ombudsman of resident transfers. She confirmed that this facility does not currently notify the ombudsman.

CONCERN (E)

Potential for Harm - no one hurt, but risky conditions existed

Deficiency F0688 (Tag F0688)

Could have caused harm · This affected multiple residents

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Based on medical record review, observation, and staff interview, it was determined that the facility staff failed to provide Residents #18, #36 and Resident #39 with services to maintain/attain the highest level of mobility. The facility staff failed to apply splints as ordered by the physician. This was evident for 3 of 46 residents selected for review during the annual re-certification survey. The findings include: 1. Medical record review for Resident #18 revealed on 10/19/18 the physician ordered: Bilateral leg braces on for 24 hours daily; Skin check every 2 hours; If any skin tissue, stop the braces and resume when area is healed; Remove for ADL's; Every shift for contracture management. A splint/boot or brace are devices used for holding a part of the body stable to decrease pain and prevent further injury. Splints support and protect injured soft tissue and can also reduce pain, swelling, and muscle spasm. Surveyor observation of Resident #18 on 11/19/18 at 8:30 AM, 11/27/18 at 10:30 AM, and 11/28/18 at 1:30 PM, revealed Resident #18 was in his/her room in bed, however, the facility staff failed to apply the splint as ordered by the physician. On 11/28/18, Employee #14 confirmed that the facility staff failed to apply the splint as ordered by the physician. After surveyor's intervention Employee #14 applied the splints as ordered by the physician. 2. Medical record review for Resident #36 revealed that on 10/19/18 the physician ordered: Wear knee braces bilaterally for 24 hours with skin check every 2 hours; Removed for ADL's. Surveyor observation of Resident #36 on 11/19/18 at 9:50 AM and 11/28/18 at 11:53 AM revealed Resident #36 was in his/her room in bed, however, the facility staff failed to apply the splint as ordered by the physician. On 11/28/18 at 11:54 AM, interview with Employee #8 revealed that he/she was unaware that Resident #36 had a physician order for knee braces. 3. Medical record review for Resident #39 revealed that on 09/15/18 the physician ordered: Right foot multipodus boot to address right ankle tightness/contracture. Boot to be worn for 24 hours. Removed for ADL's. Surveyor observation of Resident #39 on 11/19/18 at 9:50 AM and 11/28/18 at 1:30 PM revealed Resident #39 was in his/her room in bed, however, the facility staff failed to apply the splint as ordered by the physician. On 11/28/18, Employee #14 confirmed that the facility staff failed to apply the boot as ordered by the physician. After surveyor's intervention Employee #14 applied the boot as ordered by the physician. The Director of Nursing was made aware of the findings on 11/27/18.

CONCERN (E)

Potential for Harm - no one hurt, but risky conditions existed

Food Safety (Tag F0812)

Could have caused harm · This affected multiple residents

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Based on observation during the initial tour of the main kitchen it was determined the facility staff failed to 1. discard expired food, date and label food stored in the walk-in refrigerator, 2. properly label and store open containers in dry storage and throughout the kitchen, and 3. maintain a clean environment. The findings include: Observation was made during the initial tour of the kitchen on 11/19/18 at 7:35 AM of the walk-in refrigerator with the following concerns identified: 1) A portable rack with 2 large containers of Iced tea and fruit punch covered with plastic not labeled or dated with the date prepared. 2) On a storage shelf there was a tray containing pudding in dishes that were not labeled or dated as to when prepared or to be used by. 3) A container of opened mandarin oranges with no date indicating when opened. 4) A whipped topping container and a bottle of syrup with no expiration dates. 5) 2 boxes of juice cups with no expiration dates on the juice containers. 6) A carton of 6 eggs with no expiration date. 7) A box with 10 Cantaloupe dated 10/25/18 which were dark, soft and leaking juice on to the floor. 8) 13 containers of Lactaid Milk with a use by date of 9/9/18. In dry storage and throughout the rest of the kitchen the following concerns were identified: 9) A dented can of chunk light tuna. 10) 2 8 oz. Boxes of cornstarch opened and not dated when opened. 11) A box of sprinkles opened and not dated when opened. 12) A large box of Thick and Easy Corn Starch in an opened bag not dated when opened or transferred to a covered storage container. 13) A Bread Cart with the following: Expired rolls 3 bags of Italian rolls 2 dated 11/13/18; 1 bag with mold on rolls; 1 dated 11/14/18; 1/2 bag of hamburger rolls expiration date 11/15/18; 1/2 loaf of wheat bread with the expiration date ripped off; 2 loaves of white bread 1 dated 11/7/18 and the other with no date. Additional concerns identified in the kitchen include: 14) A Juice cart with 3 large boxes of juice concentrate apple, orange and cranberry opened with no date; Dirty equipment/hoses which were left on cart; on the bottom shelf there was a box of 6x 5 plastic sheets that appeared to have had juice spilled on it as well as other miscellaneous equipment which was sticky and covered in dust. 15) A popcorn machine which was used for a weekend activity had been left on a portable cart and appeared dirty with oil/butter and un-popped corn kernels. 16) The floor in the main kitchen and the dry storage room was sticky and there was food and debris throughout. 17) In addition, surveyor observed a dirty trash can sitting next to and touching a tray filled with clean bowls. The Food services Director was with the surveyor at the time of observation. The Administrator was made aware of these concerns on 11/20/18 at 10:40 AM

CONCERN (E)

Potential for Harm - no one hurt, but risky conditions existed

Room Equipment (Tag F0908)

Could have caused harm · This affected multiple residents

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Based on observation and staff interview it was determined the facility staff failed to keep the air intake unit in the main kitchen in a clean and safe operating condition. This was evident during the initial tour of the kitchen. The findings include: Observation was made on 11/19/18 at 7:35 AM of the air intake unit in the main kitchen. The front of the unit appeared dirty with dust, paper and other debris that was stuck to the grate and appeared to be occluding several of the holes in the grate. There was very little force to the air coming through the vents. In an interview with the Maintenance Director on 11/20/18 at 8:25 AM surveyor requested the cleaning schedule for the air intake unit. The Maintenance Director stated that it is done monthly. When asked for a schedule or record of the monthly cleaning he stated there is no book he just does it monthly and in fact it was on the schedule for that day. In a follow-up visit to the kitchen on 11/20/18 at 9:10 AM the Maintenance Director was observed cleaning and changing the filters in the unit. Following the cleaning there was a significant difference in the volume of air flowing from the vents. The Nursing Home Administrator was advised of the concern on 11/20/18 10:40 AM.

Aug 2017 17 deficiencies

CONCERN (D)

Potential for Harm - no one hurt, but risky conditions existed

Deficiency F0225 (Tag F0225)

Could have caused harm · This affected 1 resident

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review and staff interview it was determined the facility staff failed to report an Unusual Occurrence to the Office of Health Care Quality for Resident (# 97). This was evident for 1 of 44 residents selected for review during the stage 2 survey sample. The findings include: Medical record review for Resident # 97 revealed on [DATE] at 2:30 PM the facility staff nurse documented: Resident was found on the floor. Further record review and interviews revealed the facility staff assessed the resident and notified the physician of changes in the resident's condition. On [DATE] at 5:00 AM, the facility staff documented Resident # 97 became unresponsive and noted with no heartbeat. The facility staff began CPR and called 911. Cardiopulmonary resuscitation (CPR) is an emergency procedure that combines chest compressions often with artificial ventilation in an effort to manually preserve intact brain function until further measures are taken to restore spontaneous blood circulation and breathing in a person who is in cardiac arrest. Upon arrival to the facility, 911 continued with CPR and Resident was pronounced deceased at 5:29 AM (approximately 15 hours after falling out of bed); however, the facility staff failed to report the incident as an Unusual Occurrence and failed to report the incident to the Office of Health Care Quality. Interview with the Director of Nursing, Nursing Home Administrator and Corporate Nurse on [DATE] at 4:30 PM and [DATE] at 2:30 PM confirmed the facility staff failed to report the above incident as an Unusual Occurrence and failed to report the incident to the Office of Health Care Quality. Refer to F 385 for complete tag related to the incident.

CONCERN (D)

Potential for Harm - no one hurt, but risky conditions existed

Deficiency F0241 (Tag F0241)

Could have caused harm · This affected 1 resident

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2. During an interview with Resident #128 on 07/31/17 at 12:40 PM when asked if s/he was treated with dignity and respect Resident #128 pulled his/her shorts down slightly showing the surveyor the disposable underwear provided by the facility (undergarments for people with urinary or fecal incontinence) and replied No, they make you wear these diapers whether you need them or not. Resident #128 stated that s/he is able to use the bathroom independently but they still make you wear diapers. This surveyor observed Resident #128 ambulating in his/her room independently at the time of this interview. Resident #128 was observed on several occasions throughout the survey ambulating independently throughout the unit without any assistive devices and without difficulty. In addition s/he was observed walking to the restroom around the corner from the nurse's station on 08/01/17 at 1:43 PM and again on 08/02/17 at 9:10 AM. In an interview with LPN Staff #2 on 08/01/17 at 1:45 PM it was revealed that Resident #128 has been wearing the disposable underwear since she began working on this unit in June 2017. When asked if Resident #128 needs them for incontinence she said she wasn't sure but would check. Within a few minutes she returned and said she would ask the Unit manager about getting Resident #128 some regular underwear. In an interview on 08/02/17 at 8:45 AM The Director of Nursing (DON) was made aware of the concern that resident #128 felt s/he was being forced to wear disposable underwear though s/he was independent with toileting. The DON said she would investigate immediately and stated that the facility will provide Resident #128 with underwear. Based on observation of dining and staff interview, it was determined that the facility staff failed to provide Resident # 22 lunch in a timely manner and to treat resident with dignity and respect (# 128). This was evident for 1 out of 18 residents observed for lunch and 1 out of the 44 residents reviewed in Stage 2. The findings include: 1. Surveyor observation of fine dining lunch on 7/31/17 at 12:30 PM revealed Resident # 22 entered the dining room at 12:30 PM and sat at a table. The facility staff (1 volunteer, activities director and 1 geriatric nursing assistant) proceeded to serve the residents in the dining room with their lunches. During that time Resident # 22 made note he/she had not been provided with lunch on several occasions. The facility staff responded 3 times that the lunch tray for Resident # 22 was on the unit; however, the facility staff failed to get the lunch tray for Resident # 22 at that time or failed to have a new lunch made from the kitchen. Resident # 22 was provided with lunch at 1:20 PM (50 minutes after arriving to fine dining lunch). Interview with the Director of Nursing on 7/31/17 at 2:00 PM confirmed Resident # 22 was not served lunch in a timely manner during fine dining.

CONCERN (D)

Potential for Harm - no one hurt, but risky conditions existed

Deficiency F0246 (Tag F0246)

Could have caused harm · This affected 1 resident

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Based on record review and resident interviews, it was determined that the facility staff failed to provide showers to residents as ordered and per facility policy (# 41, # 63 and # 115). This was evident for 3 of 44 residents selected for review in the stage 2 survey sample. The finding include: 1. The facility staff failed to provide Resident # 41 with showers. Interview with Resident # 41 on 8/2/17 at 11:38 AM revealed the resident stated that showers are not always provided and she/he would like showers. Review of the medical record revealed Resident # 41 was scheduled showers on the 3-11 shift on Wednesday and Saturday. Further review revealed the facility staff documented the resident received showers on 7/5/17 and 7/12/17; however, the facility staff failed to provide a shower to the resident on: 7/8/17, 7/15/15, 7/19/17, 7/22/17, 7/26/17 and 7/29/17 (of note, there is no documentation the resident refusing showers on the scheduled shower days). 2. The facility staff failed to provide Resident # 63 with showers. Interview with Resident # 63 on 8/1/17 at 8:30 AM revealed the resident stated that showers are not provided and she/he would like a shower. Review of the medical record revealed Resident # 63 was scheduled showers on the 3-11 shift on Monday and Thursday 3-11 shift and no documented shower for 7/6/17, 7/10/17, 7/13/17, 7/17/17, 7/20/17, 7/24/17, 7/27/17 and 7/31/17. 3. The facility staff failed to provide Resident # 115 with showers. Interview with Resident # 115 on 7/31/17 at 12:00 PM revealed the resident stated that showers are not always provided and she/he would like a shower. Review of the medical record revealed Resident # 115 was scheduled for showers on Wednesday and Saturday 3-11 shift. Further record review revealed the facility staff failed to administer showers to the resident on: 7/5/17; 7/8/17; 7/12/17; 7/15/17; 7/22/17; 7/26/17. (The facility staff documented the resident received a shower on 7/19/17 and refused on 7/29/17). Interview with the Director of Nursing on 8/4/17 at 4:00 PM confirmed Residents # 41, # 63 and # 115 were not provided showers as ordered.

CONCERN (D)

Potential for Harm - no one hurt, but risky conditions existed

Deficiency F0253 (Tag F0253)

Could have caused harm · This affected 1 resident

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation it was determined that facility staff failed to provide housekeeping and maintenance services necessary to maintain a sanitary, orderly and comfortable interior. This was evident on 1 of 4 nursing units observed. The findings include: On 07/31/17 during an initial tour and during Resident interviews on 07/31/17 and 08/01/17 the surveyor observed multiple areas of disrepair as well as walls in need of repair and paint in the following residents' rooms and bathrooms: room [ROOM NUMBER] B- 2 Areas approximately 3x4 were observed on the wall at the head of the bed with paint and the top layer of dry wall scraped off. In addition there were 2 walls in the bathroom with paint and the top layer of drywall scraped off. room [ROOM NUMBER] A- On the wall to the right when entering the bathroom an area measuring approximately 8 x 14 of deeply gouged drywall was observed. In the bathroom shared by a total of 4 residents from 416 and the adjoining room [ROOM NUMBER] the toilet was observed pulled out approximately 6 from the wall on the right side (when facing the wall) and not securely anchored. room [ROOM NUMBER]- In the bathroom which is shared by 4 residents in 418 and 2 residents in room [ROOM NUMBER] an observation was made of a stained bathroom ceiling tile measuring approximately 10 x 8. In addition an area measuring approximately 10 x 10 to the right of this sink was observed with spackle which had not been sanded or painted. room [ROOM NUMBER]- The wall to the left of the door when entering the room has a deep gouged area measuring approximately 18x 18 with paint and a thick layer of drywall missing. Additionally there are areas on the wall at the head of both beds that have deep scratches with paint and the top layer of drywall missing. On 7/31/17 at 9:30 AM the maintenance director was made aware of the loose and dislodged toilet. This surveyor was made aware that there is only one maintenance person to take care of the entire facility. On 08/02/17 the Administrator was made aware of the damaged walls and additional environmental concerns.

CONCERN (D)

Potential for Harm - no one hurt, but risky conditions existed

Deficiency F0278 (Tag F0278)

Could have caused harm · This affected 1 resident

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review and staff interview it was determined that the facility staff failed to document accurate assessment for Resident (# 41) on the MDS. This was evident for 1 of 44 residents selected for review in the stage 2 survey sample. The MDS is a federally-mandated assessment tool that helps nursing home staff gathers information on each resident's strengths and needs. Information collected drives resident care planning decisions. MDS assessments need to be accurate to ensure each resident receives the care they need. Medical record review for Resident # 41 revealed the resident was originally admitted to the facility 8/2/16 and re-admitted [DATE] and attended hemodialysis 3 days a week. The principle of hemodialysis involves the use of solutions and a machine to filter the poisons out of the body that the healthy kidneys perform. The resident on hemodialysis usually is in end stage renal disease in that the kidneys can no longer filter the blood and remove the waste products, allowing poisons to build up. The hemodialysis care team (the facility staff and the dialysis staff) monitors the treatment to make sure the resident is getting the right amount of hemodialysis to remove enough wastes from the blood. Review of the MDS- Section O-Special Treatment and Programs: J-Dialysis-revealed the facility staff assessed and documented on 5/29/17 and 6/3/17 that Resident # 41 was not receiving Dialysis and in actuality the resident was a Dialysis resident. Interview with the Director of Nursing on 8/4/17 at 4:00 PM confirmed the MDS documented on 5/29/17 and 6/3/17 for Resident # 41 and Special Treatments and Programs were an error.

CONCERN (D)

Potential for Harm - no one hurt, but risky conditions existed

Deficiency F0312 (Tag F0312)

Could have caused harm · This affected 1 resident

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Based on medical record review, observation and interview, it was determined the facility staff failed to thoroughly provide daily care by not shaving Resident (# 115). This was evident for 1 of 44 residents selected for review in the stage 2 sample. The findings include: Surveyor observation of Resident # 115 on 7/31/17 at 12:00 PM revealed the resident out of bed in the wheelchair. The resident was noted to have a substantial amount of facial hair. The resident verbalized at that time, the facility staff had not provided any facial care-shaving the resident and is not able to provide that self-care and would like it done. Further record review revealed the facility staff assessed the resident on 7/6/17 and determined the resident was an extensive assist for personal hygiene which included shaving. (Of note, the resident was noted to be clean shaven when observed on 8/1/17 at 9:30 AM). Interview with the Director of Nursing on 8/1/17 at 1:30 PM and 8/4/17 at 4:00 PM confirmed the facility staff failed to provide basic daily care for Resident # 115.

CONCERN (D)

Potential for Harm - no one hurt, but risky conditions existed

Deficiency F0315 (Tag F0315)

Could have caused harm · This affected 1 resident

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Based on medical record review and staff interview it was determined that the facility staff failed to provide appropriate treatment and services to restore as much normal bladder function as possible for (Residents # 115). This was evident for 1 of 44 residents reviewed in the Stage 2 survey sample. The findings include: Urinary incontinence is not normal. Although aging affects the urinary tract and increases the potential for urinary incontinence, urinary incontinence is not a normal part of aging. Because urinary incontinence is a symptom of a condition and may be reversible, it is important to understand the cause and to address incontinence to the extent possible. If the underlying condition is not reversible, it is important to treat or manage the incontinence to try to reduce complications such as pressure ulcers and infection. Whether the resident is incontinent of urine on admission or develops incontinence after admission, the steps of assessment, monitoring, reviewing, and revising approaches to care, as needed, are essential to managing urinary incontinence and to restoring as much bladder function as possible. The Minimum Data Set (MDS) is a multidisciplinary assessment of the resident. At the end of the MDS assessment the interdisciplinary team develops the plan of care for the resident to obtain the optimal care for the resident. Medical record review for Resident # 115 revealed on 10/21/16 and 1/19/17 the facility staff assessed the resident and documented on the MDS- Section H- Bowel and Bladder- the resident was (1)-occasionally incontinent of urine-less than 7 episodes of incontinent voiding. On 4/21/17, the facility staff assessed the resident and documented that the resident had declined to (2)-frequently incontinent of urine-7 or more episodes of urinary incontinence, but at least 1 episode of continent voiding. 4/21/17 at 4:40 PM The team held a care plan meeting with resident and daughter was conference via phone, she had some concerns about him/her wearing pull ups she says this is the reason she stopped getting him/her overnight, she said he/she was going to the bathroom fine until he/she started wearing the pull ups and she feels this is enabling him/her from using the bathroom. He/she will go on restorative program for toileting; however, Interview with the Director of Nursing on 8/3/17 at 12:30 PM revealed there was no restorative program for toileting at that time. Further record review revealed the facility staff conducted a 3 day Bladder Dairy; however, the facility staff failed to initiate that diary until 5/22/17 (1 month after the initial decline in urinary continence was noted). Interview with the Director of Nursing on 8/3/17 at 12:30 PM revealed that once the Bladder Diary was concluded, the facility staff failed to initiate any interventions to restore bladder function for Resident # 115. On 7/6/17, the facility staff assessed the resident again and documented the resident had again declined to (3)-always-incontinent-no episodes of continent voiding; however, failed to again conduct a Bladder Diary or add interventions to restore as much bladder function as possible. Interview with the Director of Nursing on 8/4/17 at 4:00 PM confirmed the facility staff failed to initiate interventions to restore as much Urinary continence as possible for Resident # 115.

CONCERN (D)

Potential for Harm - no one hurt, but risky conditions existed

Deficiency F0323 (Tag F0323)

Could have caused harm · This affected 1 resident

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation and staff interview it was determined that the facility failed to keep a resident's environment free from accident hazards as evidence by a dislodged and unsecured toilet in a residents bathroom. This was evident for 1 of 35 (#56) resident's rooms observed during Stage 1 of the Quality Indicator survey. The findings include: Observation was made by this surveyor on 08/01/17 at 8:43 AM of Resident #56's bathroom. In the bathroom shared by a total of 4 residents from room [ROOM NUMBER] and the adjoining room [ROOM NUMBER] the toilet was observed pulled out approximately 6 from the wall on the right side (when facing the wall) and not securely anchored to the floor. The seat of the toilet was sitting at an angle and approximately 4 from the wall to the left. At 9:10 Am the Maintenance director was made aware and stated Oh that resident is always banging into the toilet with her wheelchair and knocking it out. I'll take care of it. On 08/02/17 at 11:15 AM this surveyor met the Maintenance Director in the first floor hallway and he stated that the toilet had been taken care of. On 08/04/17 at 9:17 AM the toilet in the bathroom of room [ROOM NUMBER] was again observed in the same position as noted on 08/01/17. On 08/04/17 at 11:43 AM the Administrator was made aware of the concern with the dislodged and unsecured toilet.

CONCERN (D)

Potential for Harm - no one hurt, but risky conditions existed

Deficiency F0325 (Tag F0325)

Could have caused harm · This affected 1 resident

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Based on record review, observation and interview, it was determined the facility staff failed to provide a resident with a frozen nutritional treat in a timely manner (Resident # 110) and failed to provide a resident with fortified food and ensure maximum intake for meals was provided for (Resident # 115). This was evident for 2 of 44 residents selected for review in the stage 2 survey sample. The findings include: 1. The facility staff failed to provide a resident with a frozen nutritional treat in a timely manner. Medical record review for Resident # 110 revealed on 6/9/17 the physician ordered: frozen nutritional treat 3 times a day, document amount consumed. A frozen nutritional supplement is a 4 oz. frozen cup that provides 290 calories and 9 grams of protein in four great flavors. It is a nutritional supplement that can be eaten as a pudding or frozen as an ice cream. It can be eaten with meals or in between meals as a snack. Surveyor observation of the 4th floor nurses' station on 8/1/17 at 10:00 AM revealed a frozen nutritional treat for Resident # 110. Further observation revealed the frozen nutritional treat was date 7/30/17 at 10:00 AM (the expected date of delivery to the resident). Further surveyor observation of the 4th floor nurses' station revealed at 11:30 AM, the facility staff still had not delivered the frozen nutritional treat to the resident. Interview with the Director of Nursing on 8/4/17 at 4:00 PM confirmed the facility staff failed to provide Resident # 110 with a frozen nutritional treat in a timely manner. 2. The facility staff failed to provide 1:1 supervision to ensure Resident # 115 received maximum intake and failed to provide Resident # 115 with fortified mashed potatoes. Medical record review for Resident # 115 revealed on 2/14/17 the physician ordered: 1:1 supervision with assistance with all meals to ensure maximum intake for meals. Review of Resident # 115's meal ticket revealed the resident is to have: fortified mashed potatoes with lunch. Food fortification or enrichment is the process of adding micronutrients (essential trace elements and vitamins) to food. It may be a purely commercial choice to provide extra nutrients in a food, while other times it is a public health policy which aims to reduce the number of people with dietary deficiencies within a population the nutrients regularly used in grain fortification prevent diseases, strengthen immune systems, and improve productivity and cognitive development. Surveyor observation of dining on 7/31/17 at 12:30 PM revealed Resident # 115 in the dining room. Further observation revealed the resident was served his/her lunch tray at 12:52 PM which consisted of: grilled cheese sandwich, fortified mashed potatoes. The resident consumed his/her lunch. At 1:20 PM the facility staff volunteer removed the resident's plate and disposed of it. Surveyor observation revealed no facility staff observing the plate to determine the amount the resident ate per physician's order to ensure Resident # 115 attained maximum intake for meals. On 8/1/17 at 12:35 PM Resident # 115 was noted in the dining room. Review of the resident's menu ticket revealed the resident was to receive: grilled cheese sandwich, tossed salad with dressing (1 cup); fresh fruit and fortified mashed potatoes (1/2 cup). Surveyor observation of the lunch tray at that time revealed the facility staff failed to provide the resident with the salad and the fortified mashed potatoes. Interview with the resident at that time revealed the resident stating he/she needed the mashed potatoes. The facility staff was made aware of the same and sent the resident a plate of French fries (no fortified mashed potatoes). Further observation revealed the facility volunteer removed the plate at 12:50 PM; removed the plate to the hall and placed the plate in a pan of soapy water. Interview with the Director of Nursing on 8/4/17 at 4:00 PM confirmed the facility staff failed to provide 1:1 supervision for Resident # 115 to ensure maximum intake and failed to provide Resident # 115 with fortified mashed potatoes for lunch on 8/1/17.

CONCERN (D)

Potential for Harm - no one hurt, but risky conditions existed

Deficiency F0371 (Tag F0371)

Could have caused harm · This affected 1 resident

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Based on observations, it was determined the facility staff failed to date label food items stored in the main kitchen refrigerator and freezer. This was evident during an initial tour of the facility's main kitchen. The findings include: An initial tour was conducted on 07/31/17 at 8:30 AM with the food service director (FSD) present and the following concerns were identified of prepared food being stored that were not covered, labeled or dated as to when prepared. Frozen chicken not covered or dated, 12 prepared sandwiches covered with no date, a package of Churro not covered or dated, and 3 frozen cakes covered with no date. The Food services supervisor was with the surveyor at the time of observation and discarded identified items immediately.

CONCERN (D)

Potential for Harm - no one hurt, but risky conditions existed

Deficiency F0385 (Tag F0385)

Could have caused harm · This affected 1 resident

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Based on medical record review and interviews, it was determined the physician failed to send Resident # 97 out to the hospital for further evaluation when changes in the resident's condition was noted. This was evident for 1 of 44 residents selected for review in the stage 2 survey sample. The findings include: Medical record review for Resident # 97 revealed on 3/26/17 at 2:30 PM the facility staff nurse documented: Resident was heard yelling for help, when this writer went to do a visual check resident was found on the floor in his/her room beside the bed. He/she was assessed by writer and noted to have an abrasion to the left lateral side of the head measuring 3 cm x 2 cm. Bleeding was observed at the site, pressure was applied. Dr. notified of resident falling and injury. No order was given to send the resident to ER for assessment due to the doctor being en route to the facility. Dr. stated that he will assess the resident when he comes to the facility to determine if the resident should be sent out. Resident is alert and verbally responsive. Record review and interviews with Nurses #1, #2, and # 3 revealed the resident was alert and oriented to time, place and person. Record review revealed on 3/26/17 at 4:40 PM the following nurses' note: MD present at the facility to assess the patient from the fall, the writer went into the room with the attending physician to tell him what my observation was since I arrived on duty, that resident was confused and falling out of consciousness, MD assessed the resident and ordered x-ray of scalp and CT of head in the AM, x-ray called and will be done today. A CAT (computed tomography) scan of the head (also called a head CT) is a painless test that uses a special X-ray machine to take pictures of a patient's brain, skull, and sinuses, as well as blood vessels in the head. On 3/26/17 at 6:10 PM the following nurses' note: Resident remain alert and disoriented (the disorientation noted at this time was a change from previous assessments of the resident), O2 sat (oxygen saturation) checked read 84%, O2 initiated at 2 liter via nasal cannula, O2 sat observed rising to 94% and temp is 98.4, routine medication administered including pain medication. MD notified again of the SOB (shortness of breath) and elevated blood pressure. MD order to keep O2 at 2 liter via n/c as needed and added chest x-ray to previous order to rule out pneumonia- x-ray called to Mobilex. Record review revealed on 3/26/17 11:23 PM the following nurses' note: Resident condition remain the same, x-rays result received, MD made aware of the recommendation to follow up with CT SCAN, MD stated he already order CT Scan and that should be follow as ordered. Review of the skull x-ray revealed the following: Cannot exclude right parietal bone fracture. CT recommended. The parietal lobe is either of the paired lobes of the brain at the top of the head, including areas concerned with the reception and correlation of sensory information. Despite the physician being aware of the following events: 1. The resident being admitted to the facility on a blood thinning medication, 2. The resident having a fall out of bed, hitting his/her head to the point of receiving a laceration (cut) 3 cm X 2 cm, 3. A change in resident's pulse oximetry (the need to apply oxygen) and 4. The results of the skull x-ray indicating that a skull fracture could not be ruled out; the physician failed to thoroughly intervene and act upon those changes. The physician failed to send the resident to the emergency room for a thorough assessment and interventions. Interview with the Medical Director on 8/4/17 at 2:00 PM confirmed that physician should have sent the resident to the hospital for further assessment and intervention. Interview with the Director of Nursing, Nursing Home Administrator and Corporate Nurse on 8/4/17 at 4:30 PM and 8/14/17 at 2:30 PM confirmed the physician failed to act as a prudent physician by failing to send Resident # 97 to the hospital when the above documented changes in condition were noted which resulted in harm to Resident # 97.

CONCERN (D)

Potential for Harm - no one hurt, but risky conditions existed

Deficiency F0441 (Tag F0441)

Could have caused harm · This affected 1 resident

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Based on review of employee files of new hires over the last 6 months, observation and interview with staff it was determined that the facility staff failed to maintain an effective infection control program. A complete screening for infectious disease and immunizations was not completed for 1 of 5 new hires reviewed. Findings include: During a review of the employee records on 08/03/17 at 2:25 PM the surveyor observed that the record for LPN Staff #1 who was hired on 04/19/17 failed to show documentation that he/she received a twostep tuberculosis skin test. Tuberculosis (TB) screening tests are used to screen people who are at high risk for TB exposure, such as healthcare workers and others whose occupations bring them in close contact with those who may have active TB. During an interview with the Director of Nursing (DON) who is also identified as the Infection Control Nurse On 08/04/17 at 9:48 AM the DON was made aware of the concern of this missing information. No additional documentation was provided.

CONCERN (D)

Potential for Harm - no one hurt, but risky conditions existed

Deficiency F0492 (Tag F0492)

Could have caused harm · This affected 1 resident

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 2. A review of facility documentation revealed the presence of a Notice of Medicare Non Coverage for Resident # 62 and Resident #103. Each notice states that services will end on [DATE]. Resident # 62 and Resident #103 signed their respective notices on [DATE]. On [DATE] at 12:00 PM an interview was conducted with MDS Coordinator 1. MDS Coordinator 1 stated that Resident # 62 did not want to sign the Notice of Medicare Non Coverage until the day of discharge, which was [DATE]. MDS Coordinator 1 also stated that Resident # 103 was unable to be found and therefore unable to sign the Notice of Medicare Coverage until [DATE]. MDS Coordinator 1 confirmed that there was no documentation in the medical record of Resident # 62 and Resident # 103 to support these assertions. The findings were shared with the Director of Nursing on [DATE] at 2:30 PM. It was confirmed that Resident #62 and Resident # 103 signed their Notice of Medicare Care Non -Coverage on the date that services were terminated and that no earlier attempts to notify Resident # 63 and Resident #103 were documented in the medical record. Based on record review and interview, it was determined the facility staff failed to report to the Medical Examiner the sudden and potential un-expected death of Resident # 97 and to notify residents in a timely manner of non-coverage by Medicare (# 61 and # 103). This was evident for 3 of 44 residents selected for review during the stage 2 survey sample. The findings include: Medical record review for Resident # 97 revealed on [DATE] at 2:30 PM the facility staff nurse documented: Resident was found on the floor. Further record review and interviews revealed the facility staff assessed the resident and notified the physician of changes in the resident's condition. On [DATE] at 5:00 AM, the facility staff documented Resident # 97 became unresponsive and noted with no heartbeat. The facility staff began CPR and called 911. Cardiopulmonary resuscitation (CPR) is an emergency procedure that combines chest compressions often with artificial ventilation in an effort to manually preserve intact brain function until further measures are taken to restore spontaneous blood circulation and breathing in a person who is in cardiac arrest. Upon arrival to the facility, 911 continued with CPR and Resident was pronounced deceased 5:29 AM (approximately 15 hours after falling out of bed); however, the facility staff failed to report the incident to the Medical Examiner as a potential case to determine the actual cause of death. The Medical Examiner is a medically qualified public officer whose duty is to investigate deaths occurring under unusual or suspicious circumstances, to perform postmortems, and to initiate inquests. Interview with the Director of Nursing, Nursing Home Administrator and Corporate Nurse on [DATE] at 4:30 PM and [DATE] at 2:30 PM confirmed the facility staff failed to report the above incident to the Medical Examiner. Refer to F 385 for complete tag related to the incident.

CONCERN (D)

Potential for Harm - no one hurt, but risky conditions existed

Deficiency F0502 (Tag F0502)

Could have caused harm · This affected 1 resident

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Based on record review and staff interview, it was determined that the facility staff failed to obtain laboratory blood test as ordered by the physician for Residents (# 41 and # 110). This was evident for 2 of 44 residents selected for review in the stage 2 survey sample. The findings include: 1 A. The facility staff failed to obtain laboratory blood test as ordered by the physician. Medical record review for Resident # 41 revealed on 4/21/17 the physician ordered: CBC, BMP, NH3 and HgbA1C. The Complete Blood Count (CBC) is a very common test that can help assess for any infection, inflammation or bleeding. The Basic Metabolic Panel (BMP) can be used to evaluate kidney function, blood acid/base balance, and levels of blood sugar, and electrolytes. The Ammonia (NH3) test measures the amount of ammonia in the blood. Most ammonia in the body forms when protein is broken down by bacteria in the intestines. The liver normally converts ammonia into urea, which is then eliminated in urine. Ammonia levels in the blood rise when the liver is not able to convert ammonia to urea. The Hgb A1C measures glycated hemoglobin and is currently one of the best ways to check diabetes is under control. Further record review revealed the facility staff failed to obtain the laboratory blood test as ordered by the physician. 1 B. The facility staff failed to obtain laboratory blood test as ordered by the physician. Medical record review for Resident # 41 revealed on 2/11/16 the physician ordered: CBC, CMP, lipid profile, TSH and HgbAIc every year in July. Complete Blood Count (CBC) is a very common test that can help assess for any infection, inflammation or bleeding. The comprehensive metabolic panel (CMP) is a blood test that measures the sugar (glucose) level, electrolyte and fluid balance, kidney function, and liver function. Glucose is a type of sugar the body uses for energy. Electrolytes keep the body's fluids in balance. The lipid profile is a panel of blood tests that serves as an initial broad medical screening tool for abnormalities in lipids, such as cholesterol and triglycerides or to evaluate the effectiveness of medication use. A thyroid-stimulating hormone (TSH) blood test is used to check for thyroid gland problems. The Hgb A1C measures glycated hemoglobin and is currently one of the best ways to check diabetes is under control; however, the facility staff failed to obtain the laboratory blood test as ordered by the physician. Interview with the Director of Nursing on 8/4/17 at 4:00 PM confirmed the facility staff failed to obtain laboratory blood test for Resident # 41 as ordered by the physician. 2 A. The facility staff failed to obtain laboratory blood test as ordered by the physician. Medical record review for Resident # 110 revealed on 6/12/17 the physician ordered: Uric acid level with next blood draw. Uric acid is produced from the natural breakdown of your body's cells and from the foods you eat. Most of the uric acid is filtered out by the kidneys and passes out of the body in urine. But if too much uric acid is being produced or if the kidneys are not able to remove it from the blood normally, the level of uric acid in the blood increases. High levels of uric acid in the blood can cause solid crystals to form within joints. This causes a painful condition called gout. Further record review revealed the facility staff failed to obtain the laboratory blood specimen as ordered. It was also noted laboratory blood draws were obtained on: 6/22/17, 6/26/17, 6/28/17, 7/3/17, 7/6/17, 7/10/17, 7/20/17, 7/21/17, 7/24/17, 7/27/17 and 7/31/17; however, failed to obtain the uric acid level as ordered by the physician. 2 B. The facility staff failed to obtain an INR as ordered by the physician. Record review for Resident # 110 revealed on 6/22/17 the physician ordered: Coumadin 5 milligrams by mouth in the evening for DVT. Deep vein thrombosis (DVT) occurs when a blood clot (thrombus) forms in one or more of the deep veins in the body, usually in the leg. Blood clots occur when blood thickens and clumps together. DVT treatments focus on keeping the clot from growing. In addition, treatment will attempt to prevent a pulmonary embolism (a clot from the leg breaking off and moving to the lungs) and lower the risk of having more clots. The standard treatment for DVT is the administration of a blood thinner medication. Coumadin is an anticoagulant (blood thinner) and reduces the formation of blood clots. The physician determines the amount of Coumadin to be administered based on the results of the INR. The International Normalized Ratio (INR) measures the clotting tendency of blood. On 6/28/17 the physician ordered: repeat INR on Friday 6/30/17. Review of the laboratory blood slip revealed the facility staff obtained an INR on 6/28/17 with the results of 3.43 (normal range for resident receiving oral anticoagulants .80-3.00); however, the facility staff failed to obtain the INR as ordered by the physician. Interview with the Director of Nursing on 8/4/17 at 4:00 PM confirmed the facility staff failed to obtain laboratory blood test for Resident # 110 as ordered by the physician.

CONCERN (D)

Potential for Harm - no one hurt, but risky conditions existed

Deficiency F0503 (Tag F0503)

Could have caused harm · This affected 1 resident

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Based upon medical record review and staff interview it was determined that facility staff failed to perform laboratory testing as ordered by a physician. This was evident for 1 of 29 residents (Resident #22) reviewed during Stage 2 of the Quality Indicator Survey. The findings include: Review of Resident #22's medical record revealed the presence of the following physician's laboratory order, entered into the medical record on 2/24/2017 : CBC ( complete blood count), CMP ( Comprehensive Metabolic Panel), Lipids, TSH ( Thyroid Stimulating Hormone), HgbA1c ( Hemoglobin A1c), Vitamin D, PSA ( Prostate Specific Antigen) and CEA (carcinoembryonic antigen) levels to be drawn 2/24/207 in the AM. There are no correlating lab results or evidence of collection documented in the medical record. Further review of Resident #22's medical record reveals the following physician's order, entered into the medical record on 2/27/2017 : CBC, CMP, Lipids, TSH, HgbA1c, Vit D, PSA, CEA levels to be drawn 2/28/17. There are no correlating lab results or evidence of collection documented in the medical record. The findings were shared with the Director of Nursing on August 2, 2017 at 2:30 PM. It was confirmed that CMP, CBC and CEA labs were not collected until 3/24/2017 and that the remainder of the bloodwork was not collected as ordered.

CONCERN (D)

Potential for Harm - no one hurt, but risky conditions existed

Deficiency F0514 (Tag F0514)

Could have caused harm · This affected 1 resident

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2. Facility staff failed to correctly transcribe a physician's order. Review of Resident #154's medical record reveals the presence of the following physician's order, entered into the record on 7/27/2017: Sacrum: Cleanse with NSS (Normal Saline Solution), apply silver alginate and dry dressing BID (twice a day) every evening shift for wound healing. Further review of Resident # 154's July and August 2017 Medication Administration Record and Treatment Administration Record reveals that Resident #154's dressing changes were performed once a day and not twice a day as indicated by the physician's order from July 27- August 1, 2017. The findings were shared with the Director of Nursing (DON) on 8/02/2017 at 11:50 AM. The DON stated that there was an error in the order's transcription and that the dressing change was to be performed once a day, not twice a day as written. Based on medical record review and interview, it was determined the facility staff failed to maintain the medical record in the most accurate form as possible for Resident (# 115) and to correctly transcribe a physician's order (# 154). This was evident for 2 out of 44 residents selected for review in the stage 2 survey sample. The findings include: 1. A medical record is the official documentation for a healthcare organization. As such, it must be maintained in a manner that follows applicable regulations, accreditation standards, professional practice standards, and legal standards. All entries to the record should be legible and accurate. Medical record review for Resident # 115 on 8/2/17 at 10:00 AM revealed the following: physician certifications related to medical condition- comprehend information and make decisions for Resident # 46 and Physicians' Orders for Residents # 55, # 22 and # 3 in the medical record for Resident # 115. Interview with the Director of Nursing on 8/4/17 at 4:00 PM confirmed the facility staff failed to maintain the medical record for Resident # 115 in the most accurate form by containing information for Resident's # 46, # 55, # 22, and # 3.

CONCERN (D)

Potential for Harm - no one hurt, but risky conditions existed

Deficiency F0520 (Tag F0520)

Could have caused harm · This affected 1 resident

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Based on medical record review and interview with staff it was determined that the facility's Quality Assurance Committee failed to develop and implement an appropriate plan of action to correct the issue of the facility's failure to provide adequate physician supervision of care. Cross reference with F 385 The findings include: On 8/4/17, the issue of the repeat deficiencies from the previous annual surveys was brought to the attention of the Administrator and the Director of Nursing. Review of the facility's survey history for the past three years revealed that F- 385(Resident's Care Supervised by a Physician) had been cited during the past two annual surveys and on this current survey.

Understanding Severity Codes (click to expand)

Life-Threatening (Immediate Jeopardy)

J - Isolated K - Pattern L - Widespread

Actual Harm

G - Isolated H - Pattern I - Widespread

Potential for Harm

D - Isolated E - Pattern F - Widespread

No Harm (Minor)

A - Isolated B - Pattern C - Widespread

Questions to Ask on Your Visit

"Can I speak with families of current residents?"
"What's your RN coverage like on weekends and overnight?"

Our Honest Assessment

Strengths

• No fines on record. Clean compliance history, better than most Maryland facilities.

Concerns

• 80 deficiencies on record, including 1 serious (caused harm) violation. Ask about corrective actions taken.
• Grade F (35/100). Below average facility with significant concerns.

Bottom line: Trust Score of 35/100 indicates significant concerns. Thoroughly evaluate alternatives.

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About This Facility

What is Autumn Lake Healthcare At Bridgepark's CMS Rating?

CMS assigns AUTUMN LAKE HEALTHCARE AT BRIDGEPARK an overall rating of 1 out of 5 stars, which is considered much below average nationally. Within Maryland, this rating places the facility higher than 0% of the state's 100 nursing homes. A rating at this level reflects concerns identified through health inspections, staffing assessments, or quality measures that families should carefully consider.

How is Autumn Lake Healthcare At Bridgepark Staffed?

CMS rates AUTUMN LAKE HEALTHCARE AT BRIDGEPARK's staffing level at 3 out of 5 stars, which is average compared to other nursing homes. Staff turnover is 46%, compared to the Maryland average of 46%.

What Have Inspectors Found at Autumn Lake Healthcare At Bridgepark?

State health inspectors documented 80 deficiencies at AUTUMN LAKE HEALTHCARE AT BRIDGEPARK during 2017 to 2025. These included: 1 that caused actual resident harm, 77 with potential for harm, and 2 minor or isolated issues. Deficiencies causing actual harm indicate documented cases where residents experienced negative health consequences.

Who Owns and Operates Autumn Lake Healthcare At Bridgepark?

AUTUMN LAKE HEALTHCARE AT BRIDGEPARK is owned by a for-profit company. For-profit facilities operate as businesses with obligations to shareholders or private owners. The facility is operated by AUTUMN LAKE HEALTHCARE, a chain that manages multiple nursing homes. With 106 certified beds and approximately 85 residents (about 80% occupancy), it is a mid-sized facility located in BALTIMORE, Maryland.

How Does Autumn Lake Healthcare At Bridgepark Compare to Other Maryland Nursing Homes?

Compared to the 100 nursing homes in Maryland, AUTUMN LAKE HEALTHCARE AT BRIDGEPARK's overall rating (1 stars) is below the state average of 3.0, staff turnover (46%) is near the state average of 46%, and health inspection rating (1 stars) is much below the national benchmark.

What Should Families Ask When Visiting Autumn Lake Healthcare At Bridgepark?

Based on this facility's data, families visiting should ask: "Can I visit during a mealtime to observe dining assistance and food quality?" "How do you handle medical emergencies, and what is your hospital transfer rate?" "Can I speak with family members of current residents about their experience?"

Is Autumn Lake Healthcare At Bridgepark Safe?

Based on CMS inspection data, AUTUMN LAKE HEALTHCARE AT BRIDGEPARK has a clean safety record: no substantiated abuse findings (meaning no confirmed cases of resident harm), no Immediate Jeopardy citations (the most serious violation level indicating risk of serious injury or death), and is not on the Special Focus Facility watch list (a federal program monitoring the lowest-performing 1% of nursing homes). The facility has a 1-star overall rating and ranks #100 of 100 nursing homes in Maryland. While no facility is perfect, families should still ask about staff-to-resident ratios and recent inspection results during their visit.

Do Nurses at Autumn Lake Healthcare At Bridgepark Stick Around?

AUTUMN LAKE HEALTHCARE AT BRIDGEPARK has a staff turnover rate of 46%, which is about average for Maryland nursing homes (state average: 46%). Moderate turnover is common in nursing homes, but families should still ask about staff tenure and how the facility maintains care continuity when employees leave.

Was Autumn Lake Healthcare At Bridgepark Ever Fined?

AUTUMN LAKE HEALTHCARE AT BRIDGEPARK has no federal fines on record. CMS issues fines when nursing homes fail to meet care standards or don't correct problems found during inspections. The absence of fines suggests the facility has either maintained compliance or corrected any issues before penalties were assessed. This is a positive indicator, though families should still review recent inspection reports for the full picture.

Is Autumn Lake Healthcare At Bridgepark on Any Federal Watch List?

AUTUMN LAKE HEALTHCARE AT BRIDGEPARK is not on any federal watch list. The most significant is the Special Focus Facility (SFF) program, which identifies the bottom 1% of nursing homes nationally based on persistent, serious quality problems. Not being on this list means the facility has avoided the pattern of deficiencies that triggers enhanced federal oversight. This is a positive indicator, though families should still review the facility's inspection history directly.

Facility Details

Beds: 106
Avg. Residents: 85
Occupancy: 80.6%
Ownership: For profit - Limited Liability company
Chain: AUTUMN LAKE HEALTHCARE
Medicare: Yes
Medicaid: Yes
Sprinklers: Yes

Trust Score Breakdown

Base Score: 50
1-Star Rating: +0
1 Actual Harm citation: -5
80 Deficiencies: -10
Final Score: 35/100

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Data: CMS Medicare Care Compare

Updated: November 2025

Facility ID: 215195