Autumn Lake Healthcare At Overlea

Based on observation, clinical record review and interviews, it was determined that the facility failed to apply a hand splint on a resident as ordered by the physician. This was evident in 1 (Resident #43) of 1 resident reviewed for hand splints during the survey.The findings include:Resident #43's diagnoses include Hemiplegia and Hemiparesis following Cerebral Infarction affecting Right Dominant Side and Contracture of Muscle, Right Hand.On 06/29/26 at 8:56 AM during the initial tour, the surveyor observed Resident #43 sitting in a wheelchair watching Television (TV) in their room. The resident's right hand was visibly contracted with the fingers curved towards the palm. The resident was not wearing a hand splint.A review of the resident's clinical record on 06/30/26 at 09:10 AM revealed a physician's order as follows: Patient to wear Resting Hand splint on right hand and wrist at least 8 hours daily: ON: after AM care and OFF: Before PM care. Please notify OT if skin breakdown is observed. Splint cover must be washed and dried when soiled. Order Date: 04/24/26On 07/01/26 at 11:20…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on observation, clinical record review and interviews, it was determined that the facility failed to ensure that dependent residents' grooming needs were met. This was evident in 2 (Resident #11 and #43) of 3 residents reviewed for Activities of Daily Living during the survey.The findings include: On 06/29/26 At 8:50 AM Resident #11 was observed lying in bed. Fingernails were noted to be long and jagged with black material present underneath. At 8:56 AM Resident #43 was observed sitting in a wheelchair. The resident has a known contracture to the right hand. Fingernails on the right hand were observed to be long and curved towards the palm.On 6/29/26 at 12:00PM a review of Resident #11 and Resident #43's clinical record revealed that the residents were dependent on staff for personal hygiene. On 07/01/26 at 11:33 AM the surveyor again observed both Resident #11and #43 with their fingernails in the same condition as observed on 06/29/26.In an interview on 07/01/26 at 11:33 AM the Unit Manager LPN#11 stated that they do not have a schedule for nail care, however the Geriatric…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on observations, staff interviews, and surveyor record reviews, it was determined that the facility staff failed to follow professional standards of practice for oxygen administration and oxygen safety. This finding was found to be evident in 2 (Resident #10 and #99) out of 3 Residents reviewed for respiratory care and services.The findings include:Oxygen concentrator is a medical device that pulls ambient air, removes nitrogen, and delivers concentrated oxygen to individuals with respiratory conditions. The purified oxygen is delivered directly to the user via a nasal cannula.At 8:25 AM on 6/29/2026 the surveyor observed Resident #10 lying in bed, in no distress with oxygen therapy in use. Resident #10 had an oxygen concentrator at the bedside and a portable emergency tank of oxygen (etank) standing on the floor at the head of the bed. The etank was not secured in a cart, stand or bracket. Surveyor notified the Nurse Manager #5 who observed the etank in Resident #10's room that was not secured in a cart or stand and removed the etank from Resident room indicating that the…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on record review and staff interviews, it was determined that the facility staff failed to document the action taken to address medication regimen review irregularity. This deficient practice was evident for 1 (Resident #5) resident reviewed for medication regimen review during the annual survey.The findings include:Medication Regimen Review (MRR) or Drug Regimen Review is a thorough evaluation of the medication regimen of a resident, with the goal of promoting positive outcomes and minimizing adverse consequences and potential risks associated with medication. The MRR includes review of the medical record in order to prevent, identify, report, and resolve medication-related problems, medication errors, or other irregularities. The MRR also involves collaborating with other members of the IDT, including the resident, their family, and/or resident representative.On 07/01/2026, a review of Resident #5's medical records revealed that a monthly MRR was completed in June 2026. The pharmacist's progress note stated, see report for comments and recommendations. At 1:37 PM, the…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on clinical record review and interviews, it was determined that the facility failed to provide adequate side effects monitoring for a resident on anticoagulant therapy. This was evident for 1 (Resident #11) of 6 residents reviewed for monitoring of side effects.The findings include:On 07/02/26 at 8:39 AM a review of Resident #11's clinical record revealed that the resident was receiving anticoagulant medication, Eliquis from 12/03/25. The Physician Order stated as follows:Eliquis Oral Tablet 5 mg (Apixaban) Give 1 tablet via PEG-tube two times a day DVT Prophylaxis Order Date 12/03/25.Further review of the record failed to reveal a process for monitoring side effects associated with anticoagulant therapy.On 07/02/26 at 1:32 PM during an interview Unit Manager LPN#11 (UM #11) stated that it was the practice for the facility to monitor residents for side effects and document the monitoring on the resident's Medication Administration Record or Treatment Administration Record. UM #11 reviewed the clinical record and stated I do not see any monitoring or care plans for…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on interviews, observations, and record reviews, it was determined that facility staff failed to assist a resident in arranging follow up for dental care in a timely manner. This deficient practice was evident for 1 (Resident #5) of 2 residents reviewed for dental services during the annual survey.The findings include:On 06/29/2026 at 9:08 AM, during an interview, Resident #5 stated, they were to have their remaining teeth removed but were hospitalized for a month. Since returning to the facility in October 2025, there has been no follow up on the extraction. During the interview, the surveyor observed that the resident had only two small tooth fragments remaining. A review of the resident's medical records on 06/30/26 at 10:03 AM revealed an August 2025 dental consult recommending extraction of remaining root tips. The resident returned from the hospital in October 2025. Records failed to show documented evidence of follow up.On 06/30/26 at 11:16 AM, the Director of Nursing (DON) #2 explained that that after dental appointments, follow up instructions are given to medical…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on observations, staff interviews, and surveyor record review it was determined that the facility failed to install a handrail in the hall on the Ground-TCU Nursing Unit. This finding was found to be evident in review of the physical environment during the annual recertification survey.The findings include:The surveyor observed at 12:25 PM on 7/2/2026 on the Ground-TCU Nursing Unit a gap/space in the handrail on the wall on the right side of the hall. The gap/space was observed to be approximately 30 long, and there were four (4) holes in the wall which appeared to be from a missing piece of the handrail. The gap/space was located between the utility room and medication room and across from Resident room G-9. Residents were observed to be ambulatory, using walkers and wheelchairs. At 12:35 PM on 7/2/2026 the surveyor notified the Nurse Manager #5 of the missing handrail. Nurse Manager #5 observed gap/space in the handrail on the wall with the four (4) holes between the utility room and medication room. Nurse Manager #5 indicated that she would notify Maintenance. Environmental…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations and interview it was determined that the facility staff failed to ensure that the handrails on the third floor were repaired and safe for the residents to use. This deficient practice was widespread on the third floor. The findings include: On 10/22/25 at 10:22 AM while on the third floor of the facility the surveyor observed multiple handrails with screws that were not flush with the handrail. The screws were sticking out with the potential to injure a resident's hand. The handrail near the elevator was separated by a gap. On 10:23 AM the surveyor observed a nail sticking out of the handrail outside of room [ROOM NUMBER]. The surveyor observed a hole in the handrail outside of room [ROOM NUMBER] & the handrail had a yellow screw that was not flush to the surface. The surveyor observed two screws on separate sides of the handrail outside of the MDS Nurse's office that were not flush to the surface. On 10:26 AM the surveyor observed an unflushed screw in the handrail outside of room [ROOM…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on record review and interviews, it was determined that the facility failed to provide treatments to assure proper care for Residents with suprapubic catheters. This was evident in 2 (Resident #5 and #11) of 2 residents reviewed for suprapubic catheter and Urinary Tract Infection (UTI) during the complaint survey. A suprapubic catheter (SPC) is a surgically created connection between the urinary bladder and the skin in the abdomen used to drain urine through a tube from the bladder to a collection bag in individuals with obstruction of normal urinary flow. The findings included: 1a) On 10/21/25 at 9:15 AM, the surveyor reviewed intake # 329288. The intake alleged that Resident #5's suprapubic catheter (SPC) was not cared for properly. On 10/21/25 at 9:32 AM, the surveyor reviewed Resident #5's medical record. The review revealed Resident #5 had a past medical history of benign prostatic hyperplasia without lower track urinary symptoms and urine retention. On further review, a consultation was placed for a urology (provider that specializes in urinary tract system)/pelvic…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on record review, consultation note review and interviews, it was determined that the facility failed to maintain medical records in accordance with acceptable professional standards and practices by keeping complete documentation. This was evident for 2 (Resident #5 & #11) out of 11 residents reviewed during the complaint survey.A suprapubic catheter (SPC) is a surgically created connection between the urinary bladder and the skin in the abdomen used to drain urine through a tube from the bladder to a collection bag in individuals with obstruction of normal urinary flow.The findings included: On 10/21/25 at 9:15 AM, the surveyor reviewed intake # 329288. The intake alleged that the facility was unable to provide medical health information to the hospital emergency room staff upon Resident #5's transfer. On 10/21/25 at 9:32 AM, the surveyor reviewed Resident #5's medical record. The review revealed Resident #5 had a past medical history of benign prostatic hyperplasia without lower track urinary symptoms and urine retention and transferred to the hospital on 5/25/25. Next, the…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on observations and interviews it was determined that the facility staff failed to ensure the shower rooms on the third floor were cleaned for the residents' use. This deficient practice was evidenced in 2 (#A, #B) of 2 shower rooms on the third floor assessed for cleanliness during the complaint survey.The findings include:On 10/21/25 at 8:30 am during observation rounds on the third floor the surveyor observed a large stain on the floor under the sink along with water & stains around the commode in Shower Room B. In Shower Room A the surveyor observed multiple round brown stains on the floor in front of the sink and stains on the floor in the shower stall & in the area where the commode is located.On 10/22/25 at 10:12 am the surveyor observed the same round brown spots on the floor in front of the sink in Shower Room A, the same spots from the previous day. The surveyor wet a paper towel with water and was able to remove one of the brown spots on the floor.On 10/22/25 at 10:14 am during an interview with Geriatric Nursing Assistant (GNA) #7 the surveyor asked how often the…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on record review and interview it was determined that the facility staff failed to ensure residents whose funds were managed by the facility had access to their money anytime. This deficient practice was evidenced in 94 of 94 resident accounts being managed by the facility staff. The findings include: On 04/28/25 at 11:28 AM during an interview with Business Office Manager # 31 the surveyor asked a series of questions related to the residents' ability to access their finances. Business Officer Manager #31 verbalized the normal business hours at the facility was 8:30 AM-5:00 PM Monday-Friday and he/she is available on Friday if any of the residents need money for the weekend. Prior to the Coronavirus Disease 2019 (COVID-19) pandemic the Receptionist would give the residents money. If they worked on Saturday or Sunday he/she would be available to give them money. When asked can residents access their funds on the weekend? Business Office Manager #31 verbalized nobody can access the funds during the weekend. When asked how many residents funds are being managed, Business Office…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, record review and interviews it was determined that the facility staff failed to ensure the high temperature dishwasher's final rinse was at the temperature to sanitize the dishes and utensils at the required 180F-Fahrenheit degree temperature,and 2) failed to ensure that the foods are stored, prepared, distributed, and served in accordance with professional standards for food service safety procedures. This was evident for 11 of 11 food service and kitchen equipment in the kitchen areas noted during survey activities. The findings include: 1) On 04/23/25 at 10:15 AM, an initial tour of the kitchen area was conducted with the District Manager and the Dietary Manager. A record review of the mechanical dishwasher log revealed that the final rinse temperatures did not reach the required final rinse temperature of 180F on 04/23/2025 at 10:17 AM as indicated on the data plate by the unit manufacturer specifications. A follow up observation of the dishwasher was conducted on 04/23/2025 at 10:22…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on observations and interviews it was determined that the facility staff: 1) failed to label residents basins and urinals to prevent cross contamination of bodily fluids in shared bathrooms located on the second floor and 2) failed to ensure that the clean linens were kept separate from the contaminated linen by the use of separate rooms, closets, or other designated spaces with a closing door to provide secure methods for reducing the risk of accidental contamination within the laundry rooms. This was observed during an annual survey. The findings include: 1) During observation rounds on 04/24/25 at 8:26 AM the surveyor observed two round and 1 square unlabeled basin in the shared bathroom between Rooms 205-207 located on the second floor. There was an unlabeled urinal in the bathroom as well. The surveyor asked Geriatric Nursing Assistant # 27 how the staff deciphers which basin belongs to each resident. GNA #27 verbalized they usually write the room numbers on the basin so they could know which resident's they belong to. At 8:34 AM the surveyor observed a used urinal in a…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on observations and interviews it was determined that the facility staff failed to ensure residents had their call bells in reach to notify the staff when assistance was needed. This deficient practice was evidenced in 5 (#5, #30, #47, #94, #97) resident observed without their call bells during the recertification survey. The findings include: During observation rounds on 04/23/25 at 8:25 AM the surveyor observed Resident #47 call bell on the floor and Resident # 30 call bell was on the other side of the room which was not in reach. Geriatric Nursing Assistant (GNA) # 27 confirmed the residents did not have their call bells. At 8:43 AM the surveyor observed Resident # 94's call bell on the floor near the left side of the bed. At 9:08 AM the surveyor observed Resident #97's call bell on the floor near the right side of the bed. At 9:10 AM the surveyor observed Resident #5's call bell on the floor on the left side of the bed. On 04/29/25 at 9:53 AM during an interview with the Assistant Director of Nursing (ADON) #1 the surveyor asked, does the management team expect the staff…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on review of Geriatric Nursing Assistant personnel files and staff interview, it was determined that the facility staff failed to conduct yearly performance reviews at least every 12 months on 3 out of 5 personnel files reviewed. The findings included: On 4/29/25 at 8:03 AM, the surveyor reviewed 5 Nursing Assistant employees' files. The review revealed that the employee files for Staff # 20, 21, and 22 (all three staff had been employed over a year) did not contain a yearly performance reviews. On 4/29/2025 at 9:21 AM, the surveyor conducted an interview with the Assistant Director of Nursing (ADON) who was also in charge of staff development. During the interview the surveyor asked if GNAs had yearly performance reviews. The ADON stated he had just started in October of last year and would follow-up. On 4/30/25 at 8:22 AM, the surveyor conducted an interview with the Nursing Home Administrator (NHA). During the interview the NHA confirmed that annual evaluations of GNA were not being completed.

Based on observations, staff interviews, and records review, it was determined that the facility failed to adhere to the professional standards of practice regarding medication storage. This was found to be evident in 2 (Ground, and 2nd floor) out of 2 medicine drawers and 1 (2nd floor) out of 2 medication storage rooms reviewed for medicine storage. The findings include: On 04/25/25 at 8:00 AM, the surveyors reviewed the medicine room with LPN # 3 on the 2nd floor. The surveyors observed a blister pack labelled Famotidine 20 mg tablet that expired on 10/26/ 2024.The surveyor verified with LPN # 3 that the medication expired. LPN # 3 stated that the drugs would be removed and returned to the pharmacy. On 4/28/25 at 08:57 AM the surveyors observed the 3rd floor medication cart with RN # 13 and found 11 loose pills. The surveyors asked where the pills came from. RN # 13 stated the pills might have fallen out of the packets and she would turn them in to Unit Manager # 4. On 04/28/25 at 11:00 AM, the surveyors observed 4 loose pills in the ground floor medication cart. LPN # 11 stated…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations and interviews it was determined that the facility staff failed to consistently provide a clean, comfortable and home-like environment. This deficient practice was discovered during the recertification survey. The findings include: During observation rounds on 04/23/25 at 8:16 AM the clothing armoire door was hanging off in room [ROOM NUMBER]. At 8:32 AM the surveyor observed an empty bottle of Pepsi, a folded piece of paper, two small blue packs of a snack, and tissues under Resident #25's bed. At 8:41 AM the surveyor observed the toilet paper dispenser was broken and the middle light bulb was out in the shared bathroom between Rooms 213 & 215. Geriatric Nursing Assistant (GNA) #28 confirmed the surveyor's findings. At 8:47 AM the surveyor observed room [ROOM NUMBER]-B did not have a privacy curtain. At 8:50 AM the surveyor observed room [ROOM NUMBER]-B did not have a privacy curtain. At 8:53 AM the surveyor noticed the faucet was loose and the surveyor was unable to turn the water off in…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on observations and staff interviews, it was determined that the facility failed to provide a clean, comfortable and homelike environment. This was found to be evident in 2 (G10 and G11) out of 11 ground floor rooms reviewed during the annual survey. The findings include: On 04/29/25 at 10:33 AM, the surveyors observed the environment of the resident's room. The room was dirty, sticky on the floor when stepped on, and the bathroom wall had brown stains smeared on the wall. On further observation, the surveyors saw that the window blinds were broken, the ceiling tiles were coming apart, the toilet pipe wasn't fixed in the wall and the wall was cracked around the pipe. The floor was cracked and broken at the joint at the entry to the bathroom. On 04/29/25 at 11:42 AM, interviews and observations were conducted with the Administrator, Maintenance Director, and Account Manager of the Healthcare Services Group (AMHSG) were conducted to review the concerns. The Maintenance Director said the facility performed some repairs and contracted out other repair work when necessary. The…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on medical record review and interview it was determined that the facility staff failed to implement a patient centered care plans for dental care and integumentary care. This deficient practice was evidenced in 3 (#25, #37, #112) of five resident records reviewed for dental and integumentary care during the recertification survey. The findings include: On 04/25/25 at 1:41 PM a review of Resident #37 electronic medical record revealed the resident did not have a care plan for dental care. On 04/28/25 at 9:21 AM a review of Resident #25 electronic medical record (EMR) revealed the resident did not have a care plan for dental care. On 04/30/25 at 11:39 AM a review of Resident #112 EMR revealed a care plan for integumentary care was not initiated although the resident is ordered to receive a skin treatment twice a day for his/her skin condition. On 04/30/25 at 11:56 AM during an interview with the Director of Nursing (DON) the surveyor asked, should Resident's #25 & #37 have a care plan for poor dentition and should Resident #112 have an integumentary care plan? The DON…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on medical record review and resident's family and staff interviews it was determined the facility staff failed to ensure that dependent resident's personal hygiene needs were adequately met by offering and providing showers as scheduled. This was evident for 1 of 1 (101) residents reviewed during the survey process. The findings include: In an interview with Resident #101's son on 4/24/2025 at 12:00 PM, revealed that Resident #101 stated they don't give showers I get a bed bath every day. I would like a shower. The son stated that the resident had asked their spouse to take them to the shower, but the spouse was physically unable to do so and instead gave the resident a sponge bath. The Resident's son reported that both the water and the washcloth that had been used were black with dirt. The complainant also reported that the Resident had stated that they were itchy from lack of washing. Review of Resident #101's most recent MDS revealed that s/he is totally dependent for bathing requiring extensive assistance for all Activities of Daily Living (ADL). The Minimum Data Set…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on observations, medical record reviews, and interviews it was determined that the facility staff: 1) failed to clarify a physician's order, failed to monitor a resident for extrapyramidal side effects who was prescribed psychotropic medication, failed to ensure a resident received their therapeutic treatment for a skin condition, and 2) failed to follow through on laboratory monitoring recommendations. This was found evident of 3 (Resident #72, #112, and #126) out of 6 Residents reviewed for medication regimen review. The findings include: 1) During observation rounds on 04/24/24 at 11:03 AM the surveyor observed Resident #112 skin was extremely dry and scaly. A review of the resident's electronic medical record revealed the resident was diagnosed with Atopic Dermatitis. On 04/29/25 at 9:42 AM a review of Resident #112 treatment administration record (TAR) revealed the resident was ordered to receive a dermatologic cream to their skin twice a day. Further review of the order revealed the physician failed to indicate where the cream should be applied. At 1:40 PM the surveyor…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on medication record review and interviews it was determined that the facility staff failed to act upon a pharmacy recommendation to add a dosage to a supplement prescribed to a resident. The deficient practice was evidenced in 1 (#127) of 2 pharmacy recommendations reviewed during the recertification survey. The findings include: On 04/28/25 at 10:38 AM a review of the pharmacist recommendations revealed there was a recommendation dated 02/19/25 in which the nursing staff failed to act upon. During an interview with the Director of Nursing (DON) at 12:25 PM the surveyor asked what the process is for addressing pharmacy recommendations. The DON verbalized the recommendations are received via email and the unit managers print the reviews and give them to the physicians. After they review the recommendations, the management team checks to see if there is a new order to be carried out. The form is signed and given to Medical Records to file. On 04/30/25 at 9:36 AM review of the pharmacy review dated 02/19/25 revealed Cyanocobalamin did not have strength. There are multiple doses…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on review of facility reported incidents and staff interview, it was determined the facility failed to provide documentation that allegations of abuse were thoroughly investigated. This was evident for 4 (#31, #7, #26, #33) residents of 19 facility reported incidents reviewed during a complaint survey. The findings include: 1) On 2/13/25 at 2:00 PM facility reported incident MD00182916 was reviewed and revealed that Resident #31 was discharged to the hospital on 7/25/22 due to abnormal blood work. On 8/26/22 the facility was made aware by a hospital social worker that Resident #31 alleged verbal abuse by nurses at the facility and physical abuse by the geriatric nursing assistants at the facility. According to the facility's documentation an investigation was initiated. Review of the investigative packet that was given to the surveyor by the Nursing Home Administrator (NHA) revealed an initial and 5 day email confirmation that an investigation was done, however there was no investigation included in the paperwork. On 2/13/25 at 2:23 PM an interview was conducted with the NHA.…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on medical record review and interview, it was determined the facility failed to maintain complete and accurate medical records in accordance with accepted professional standards. This was evident for 4 (#12, #23, #7, #21) of 42 residents reviewed during a complaint survey. The findings include. A medical record is the official documentation of 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. 1.Review of Resident #12's medical record on 2/13/25 revealed the Resident was admitted to the facility on [DATE] with a diagnosis to include cerebral infarction. Cerebral infarction, also known as an ischemic stroke, is a condition where blood flow to the brain is interrupted, causing brain cells to die. Further review of Resident #12's medical record revealed a nurse's note on 7/3/24 at 10:15 AM that stated, Resident left…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on record review and interview it was determined that the facility staff failed to immediately inform the resident representative of the residents' transfer to the hospital. This was evident for 1 (#16) of 42 residents reviewed during the complaint survey. The findings include: Resident #16's medical record was reviewed on 2/18/25 at 9:33 AM. A change in Condition progress note dated 1/21/24 at 00:15 (12:15 AM) indicated that Resident #16 was found lying on the floor. Upon assessment the resident had no apparent injuries however his/her oxygen saturation (SpO2) was 75% (Normal SpO2 is between 95%-100%). A respiratory assessment revealed diminished lung sounds and grunting-like breathing. The physician was notified and ordered oxygen administration and if there was no improvement, send to the emergency room (ER) for further evaluation. The note indicated that the resident's representative was made aware. It did not identify the time of the notification. Another progress note at 1:00 AM on 1/21/24 indicated that the resident's oxygen saturation improved to 85%, and 911 was…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on review of facility reported incidents and staff interview, it was determined the facility failed to provide documentation that allegations of abuse were reported timely to the appropriate agencies. This was evident for 2 (#26, #27) residents of 42 residents reviewed during a complaint survey. The findings include: 1) On 2/20/25 at 11:49 AM a review of facility reported incident MD00186485 alleged that on 12/6/22 Resident #26 alleged that a geriatric nursing assistant (GNA) had abused the resident during care early on 12/6/22. Review of the facility reported incident was blurred as to the actual time, with it either being at 3:00 AM or 8:00 AM, which was confirmed by the NHA. Review of the email confirmation that was submitted to OHCQ documented that the initial report was not filed until 12/6/22 at 5:25 PM, which was not within 2 hours of suspected abuse. There was no email confirmation as to when the final report was submitted to the Office of Healthcare Quality (OHCQ). On 2/20/25 at 12:05 PM an interview was conducted with the NHA. The NHA confirmed the report was not…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on medical record review and staff interview, it was determined the facility staff failed to ensure Minimum Data Set (MDS) assessments were accurately coded. This was evident for 2 (#10, #14) of 42 residents reviewed during a complaint survey. The findings include: The 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 based on those individualized needs, and that the care is provided as planned to meet the needs of each resident. 1) On 2/14/25 at 12:25 PM Resident #10's medical record was reviewed and revealed Resident #10 was admitted to Hospice services on 11/9/24. Review of the quarterly MDS with an assessment reference date of 2/10/25, Section O, failed to capture that the resident received Hospice services. On 2/20/25 at 12:55 PM an interview was conducted with the MDS coordinator who confirmed the…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on record review, observation and staff interview, it was determined the facility staff failed to revise a resident's care plan. This was evident for 1 (#10) of 42 residents reviewed during a complaint survey. The findings include: On 2/14/25 at 12:25 PM facility reported incident MD00209375 was reviewed and revealed Resident #10 alleged that on 9/1/24 GNA #23 hurt Resident #10's arm. Review of the facility investigation documented that Resident #10 had a history of banging his/her arm on the side rail. The investigation documented that padding had been placed on the side rail to prevent further injury and that the issue had been care planned. On 2/19/25 at 11:30 AM observation was made of Resident #10 lying in bed having a dressing change by hospice staff. There was a quarter bed rail up on the right side of the bed with a yellow foam noodle on the top of the bed rail. Review of the care plan, has potential for skin tear, failed to have the intervention of padding the side rail. Review of the care plan, has skin tears to right lower arm and has a behavior problem r/t banging…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review and interview with facility staff, it was determined that the facility failed to ensure that a recapitulation of the resident's stay was completed following a resident's discharge from the facility. This was evident for 1 (Resident #23) of 42 residents reviewed during a complaint survey. The findings include: On 2/14/25 at 10:42 AM a record review was conducted for Resident #23. Resident #23 was admitted to the facility in July 2017 for physical and occupational therapy following an amputation of the right leg above the knee. On 1/20/23 a care plan note documented, Family and patient in agreement that they desire the matter of social work addressing alternative nursing home locations. Patient will look to pursue further the Alf [assisted living facility] after that patient is located within another nursing home facility. On 4/28/23 social services documented a Maryland Discharge Instructs for Resident #23 for a discharge of 5/1/23 to an assisted living facility. It was completed by the…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on medical record review and interview, it was determined the facility staff failed to provide showers twice weekly to a resident (Resident #17). This was evident for 1 of 42 residents reviewed during a complaint survey. The findings include: Review of Resident #17's medical record on 2/14/25 for a concern related not receiving showers from October 2023 until January 2024 revealed the Resident was admitted to the facility on [DATE] with a diagnosis to include dementia. Dementia is a general term for a decline in mental abilities that impacts a person's daily life. It's caused by brain damage that destroys nerve cells. Further review of Resident #17's medical record revealed the facility staff assessed the Resident on 11/7/23 to need supervision and/or touching assistance for showering and bathing. Review of Resident #17's care plans revealed a care plan entitled: Resident has an ADL (Activities of Daily Living) Self Care Performance Deficit related to dementia initiated on 10/26/23 that included an…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

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 for a resident (Resident #1). This is evident for 1 of 3 residents reviewed for pressure ulcers during a complaint survey. The findings included: 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). Review of Resident #1's medical record on 2/14/25 revealed the…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on medical record review and interview, the facility failed to ensure a resident's drug regimen was free from an unnecessary drug (Resident #6 and #15). This was evident for 2 of 42 residents reviewed during a complaint survey. The findings include: 1. Review of Resident #15's medical record on 2/14/25 revealed the Resident was admitted to the facility on [DATE] with a diagnosis to include hypertension. Hypertension, also known as high blood pressure, is a condition where the blood pressure in the arteries is consistently elevated above normal levels. Review of Resident #15's physician orders revealed on 4/1/24 the Resident was ordered Metoprolol 25 mg one time a day for high blood pressure, hold if blood pressure is less than 110 or heart rate less than 60. Review of Resident #15 April 2024 Medication Administration Record revealed from 4/1 through 4/14/24 the Resident was administered Metoprolol 2 times outside of the parameters: a) on 4/8/24 at 6:00 PM when the Resident's heart rate was 59 and b) on…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on medical record review and interview, the facility staff failed to schedule a follow up appointment with a consultant for a resident (Resident #15). This was evident for 1 of 42 residents reviewed during a complaint survey. The findings include: Review of Resident #15's medical record on 2/14/25 revealed the Resident was admitted to the facility on [DATE] with a diagnosis to include hydronephrosis. Hydronephrosis is a condition where urine backs up into the kidney, causing it to swell. Review of a nurse's note on 3/31/24 at 11:37 PM stated the Resident had a Foley in place. A Foley catheter is a thin, flexible tube inserted into the bladder to drain urine. Review of the Resident's hospital Discharge summary dated [DATE] revealed the Resident's plan: 1. Will need outpatient urology follow up for moderate right hydronephrosis, referral for urology appointment has been made. 2. Foley catheter currently in place, will need voiding trial. Further review of Resident #15's medical record revealed a nurse's note…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on record review and staff interview, it was determined that facility staff failed to properly maintain the mandatory testing frequency for staff to help prevent the spread of COVID-19. This was found to be true for all employees tested during the week of November 17, 2020. This deficient practice has the potential to affect all residents, staff, and visitors in the facility. The findings include: A review of intake # MD00160661 conducted on August 3, 2021 at 8:30 a.m. revealed a concern about the facility failing to maintain the mandatory COVID-19 testing frequency outlined in the Amended Directive and Order Regarding Nursing Home Matters document (MDH 2020-11-17-02) effective November 17, 2020. MDH 2020-11-17-02 which stated to increase mandatory COVID-19 testing to twice a week for nursing home employees and once a week for nursing home residents. A review of facility COVID-19 testing records for facility staff and residents for the month of November 2020 conducted on August 3, 2021 at 10:30 am revealed facility staff were not tested twice a week as ordered by MDH…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation it was determined that the facility failed to maintain an effective pest control program as evidenced by the presence of insects. This was evident for the ground floor conference room and the back staircase. The findings include: On 7/29/2021 at 8:18 AM room [ROOM NUMBER] was observed with live gnats flying in the room. On 8/3/2021 at 10:43 AM, a live gnat was observed in the ground floor conference room that the survey team was working from. At 10:45 AM observation of the employee entrance/ground floor exit/outdoor smoking section revealed the presence of multiple gnats just outside the facility door. A nonfunctional Ecolab bug trap was observed inside the door to the stairwell among 3 live gnats. On 8/4/2021 at 10:25 AM a house fly and a gnat were observed inside the ground floor conference room. The Administrator and Director of Nursing were made aware of these findings on 8/4/2021 during the exit conference.

Based on surveyor observation and interview with staff it was determined the facility staff failed to ensure that residents call bells were within reach. This was evident for 2 (#27 and #74) of 60 residents observed during the initial resident sample observations. The findings include: On 7/22/2021 at 10:18 A.M. Resident #74 and Resident #27's call bells were observed on the floor where the residents could not reach them. Staff #5 was made aware of the call bell issues at this time. The Administrator and Director of Nursing were made aware of these findings on 8/4/2021 during the survey exit conference.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on surveyor observation and resident interview it was determined that the facility failed to provide a safe, clean, comfortable and homelike environment. This deficiency has the potential to affect multiple residents. The findings include: On 7/22/2021 at 10:34 AM during an initial tour of the facility, Resident #31's bathroom was observed with no soap or paper towels. On 7/27/2021 at 1:10 PM room [ROOM NUMBER]'s window was observed with 4 missing pieces of the vertical blinds. Resident #89 stated that they had to hang a blanket over the broken blinds to prevent the sun from waking them up in the morning. On 8/3/2021 at 9:33 AM the facility's rear elevator, registration # BC4264, was observed with dust buildup on the ceiling vent. At 9:43 AM the air intake vent on the side of the building facing the main parking lot was observed in disrepair and protruding from the wall allowing for possible pest entry. The Administrator and Director of Nursing were made aware of these findings on 8/4/2021 during the…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on clinical record review, observation, staff interview and review of an abuse investigation it was determined that nursing staff failed to ensure that residents were free of abuse. This was evident for 1 (#59) out of 3 residents reviewed for abuse. The findings are: A review of the facility investigation into a reported incident of staff to resident abuse revealed that Resident #59 was being assisted in bed by Nurse #14 on 1/1/21 at 7:30 PM. GNA #15 was assisting Resident #59's roommate and had the privacy curtain closed. She heard Nurse #14 talking loudly and very mean to Resident #59 because the resident got out of bed again. GNA #15 wrote that she continued with the task. When Nurse #14 became louder and started cursing she looked around the curtain. Nurse #14 was struggling to get the resident into the bed. Nurse #14 asked for her assistance, and she helped the resident back into bed. GNA #15 wrote that she called the (now former) Director of Nursing (DON) (Staff #16) to report the incident. A follow up interview with GNA #15 revealed that Nurse #14 was saying Get the…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on medical record review and staff interview, it was determined that facility staff failed to update a resident's care plan after a change in status. This was evident in 1 (resident #31) of 60 residents reviewed during a survey. The findings include: Review of Resident #31's medical records on July 29, 2021 at 7:01A.M. revealed that on February 25, 2021, the resident attempted to escape from their assigned floor several times during the day. Resident #31's escape attempts caused the facility to complete a risk assessment on February 25, 2021 at 3:48 P.M. which assessed the resident as being at risk of attempting to escape from the facility in the future. Further review of Resident #31's medical records on July 29, 2021 at 9:20 A.M. revealed that a medical order for a Wanderguard was issued on February 25, 2021. A Wanderguard is a device used to monitor the location of a resident who was assessed as being at risk of escaping from the facility. A Wanderguard will make an alarm sound if the resident is close to elevators, steps, or doors that lead from the floor or unit to which…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on clinical record review and staff interview it was determined that the facility staff failed to ensure that resident clinical records were maintained in a complete and accurate manner. This was evident for 2 (#34 and #55) out of 60 resident clinical records reviewed. The findings are: 1) A review of Resident #34's clinical record revealed that the resident had a Preadmission Screening and Resident Review (PASRR) completed on 2/26/19. The resident's PASRR was to be reviewed by the state agency for determination of additional services and care related to mental illness. Further review revealed that the state agency reviewed the resident's PASRR for Intellectual Disability (ID) and determined that the PASRR would not be the subject of review because the resident did not have a diagnosis of ID. The facility social worker failed to thoroughly review this inaccurate determination and resubmit it for a corrected review. 2) A review of Resident #55's clinical record revealed that a PASRR was completed on 6/7/17. The state agency determined that additional services and/or a directed…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation and staff interview it was determined that the facility staff failed to ensure hand rails were secured firmly to the wall. This was evident for 1 resident floor observed during the survey. This deficient practice has the potential to affect all residents, staff, and visitors on the unit. The findings include: On 8/4/2021 at 09:21 AM during a tour of the facility, the handrail outside room [ROOM NUMBER] was observed to be loose and not securely affixed to the walls. It was also observed at this time that the handrail end caps were missing on the handrails outside of room [ROOM NUMBER] and the Spa/shower room. The Administrator and Director of Nursing were made aware of these findings during the exit conference on 8/4/2021.