Autumn Lake Healthcare At Riverview

Based on record review and interview, it was determined that the facility failed to provide necessary services. This was evident for one (Resident #253) out of five residents reviewed for ADLS (activities of daily living).The findings include:During screening on 6/8/26 at 11:53 AM, Resident #253 reported that he/she had only one shower since arriving at the facility on 5/29/26. Resident #253 stated, That was 10 days ago and the only reason I got that shower was I put up a fuss. I cannot shower on my own, especially washing my hair. I need help. I had a stroke. A review of Resident 253's EMR (electronic medical record) revealed that Resident #253 was admitted on Friday, May 29, 2026 with diagnosis including but not limited to, stroke with left-sided hemiplegia (paralysis).During a follow up interview on 6/9/26 at 1:29 PM, Resident #253 stated, I have had only one shower since I came here. I came on Friday, 5/29. I was told my shower day was Wednesday. Wednesday (6/3/26) came and I did not get a shower. On Thursday (6/4/26), when I complained about not getting a shower, GNA (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 and interviews, it was determined that the facility failed to ensure that a resident had a call bell near reach. This was evident for one (Resident #8) out of eight residents reviewed for call bells during the recertification survey.The findings include:On 06/08/2026 at 9:47 AM, during unit round, the surveyor observed Resident #8 without a call bell near reach.On 06/08/2026 at 11:58 AM, an interview with Resident #8 was conducted. Resident reported that since they moved into their room, they've not had a call bell. The surveyor looked around the resident's bed and was unable to locate a call bell. On 06/08/2026 at 12:01 PM, an interview with Staff #4 was conducted in the resident's room. Staff looked under the resident's bed and was unable to retrieve the call bell. On 06/09/2026 at 1:58 PM, an interview with Staff # 6, Unit Manager, was conducted. She reported that it was the facility's expectation that all residents should have a call bell near reach at all times. At this time, the surveyor discussed the call bell concerns with the unit manager. 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.

Based on record review and staff interview, it was determined that the facility failed to implement care plan interventions to report a significant weight loss to the physician and Registered Dietitian. This was evident for one (Resident #2) out of two residents reviewed for nutrition and hydration.The findings include:On 6/8/2026 at 12:46 PM, a review of Resident #2's records was conducted. Resident #2 had a decline of 9.2 lbs (5.7%) from 5/6/2026 (162.2 lbs) to 6/1/2026 (153.0 lbs). This weight was documented by Staff #7. On 6/9/2026 at 10:23 AM, a review of the progress notes revealed that there was no Dietician or Provider notes regarding the weight change. The last Dietician note was on 5/27/2026 and addressed a progressive weight gain over 3 months leading up to the 5/6/2026 documented weight. Dietician documented to monitor for weight changes, labs, and percent of meal intakes. On 6/9/2026 at 10:40 AM, an interview with Staff #7 was conducted. When asked when the nursing staff would notify a Dietician or provider of weight changes, Staff #7 stated the dietician is notified…

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, interview and record review, it was determined that the facility failed to be consistent with professional standards regarding supplemental oxygen requirement. This was found to be evident for two (Resident #15 and #147) out of four residents reviewed for Respiratory Care. The findings include: The facility's Oxygen Administration Policy: Policy Explanation and Compliance Guidelines: 1. Oxygen is administered under orders of a physician, except in the case of an emergency. In such case, oxygen is administered and orders for oxygen are obtained as soon as practicable when the situation is under control. (implemented 1/27/23) 1). Review of Resident #147's EMR (electronic medical record) revealed that the resident was admitted on [DATE]. During screening on 6/8/26 at 10:48 AM, Resident #147 was observed to be utilizing supplemental oxygen at 3 L (liters) of flow via a nasal cannula. On 6/10/26 at 8: 34 AM, Resident #147 was observed utilizing a nasal cannula supplying 3L of supplemental…

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 and record reviews it was determined that the facility failed to ensure that residents received an annual dental visit. This was evident for two (Resident #13 and #85) out of four residents reviewed for dental services. The findings include: 1)On 6/8/2026 at 9:44 AM, an interview with Resident #13 revealed that he/she had not seen the dentist in a while. On 6/10/2026 at 12:16 PM, record review revealed that the resident was last seen by a dentist on 2/27/2024. 2)On 6/8/2026 at 9:08 AM, an interview with Resident #85 revealed that he/she had not seen the dentist in a while. On 6/10/2026 at 12:09 PM, record review revealed that the resident was last seen by a dentist on 4/2/2024. On 6/12/2026 at 10:40 AM, the concerns were addressed with the Director of Nursing.

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 ensure the accuracy and completeness of the clinical record for one (Resident #119) of five residents reviewed for advance directives during the facility's recertification/complaint survey. The findings include:MOLST stands for Medical Orders for Life-Sustaining Treatment. It is a bright, easy-to-read medical form that turns one's end-of-life care wishes into real doctor's orders. It must be signed by a licensed doctor, nurse practitioner, or physician assistant.On [DATE] at 10:43 AM, review of Resident #119's paper medical record revealed a Medical Orders for Life-Sustaining Treatment (MOLST) form indicating that informed consent had been obtained from the resident's guardian of person as per authority granted by court and other legal authority in accordance with all provisions of the Health Care Decisions Act. Review of the paper medical record and electronic health record (EHR) failed to reveal documentation of a current…

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's designated hospice interdisciplinary team member failed to ensure documentation regarding hospice care was available and communicated with the facility staff. This was evident for one (Resident #147) out of to residents reviewed for hospice. The findings include: A review of Resident #147's electronic medical record (EMR) on 6/10/26 at 10:04 AM revealed Resident #147 was admitted to [Hospice] services on 5/12/26 for metastatic colon cancer. Further review of Resident #147's medical record revealed the record did not have evidence of Resident #147's most recent hospice care plan, the hospice election form, the physician certification, and the names and contact information for the hospice personnel involved in Resident #147's care.During an interview on 6/10/26 at 10:47 AM, RN (registered nurse) #16 (hospice nurse) stated, We have a [hospice] IDT (interdisciplinary team) meeting every Thursday at our [the hospice] office and that is what generates the weekly care plan. I then bring the print out to 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 the facility staff failed to ensure Minimum Data Set (MDS) assessments were accurately coded. This was evident for 6 (Residents #3, #1, #9, #4, #12, #10) of 16 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 4/27/26 at 12:40 PM a review of Resident #3's medical record was conducted and revealed Resident #3 had a history of cerebrovascular disease.Review of Resident #3's MDS assessment with an ARD of 3/2/26, Section J0100A pain management, received scheduled pain medication was coded, yes. Review of Resident #3's March 2026 Medication Administration…

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 complaint, medical record review, and staff interview, it was determined the facility failed to notify a resident's responsible party (RP) when there was a change in condition in a resident's medical status. This was evident for 1 (Resident #11) of 16 residents reviewed during a complaint survey.The findings include: Narcan (naloxone) is a life-saving nasal spray that rapidly reverses opioid overdoses. It is used for emergencies involving heroin, fentanyl, or prescription opioids and is safe to use even if no opioids are present. On 4/27/26 at 9:14 AM a review of complaint 2991540 alleged there was no communication with the RP when the medication Narcan had to be administered to Resident #11 for an alleged overdose. On 4/27/26 at 9:14 AM a review of Resident #11's medical record revealed progress notes that documented Resident #11 was admitted to the facility in March 2026 with diagnoses that included a nondisplaced zone 1 fracture of the sacrum, a nondisplaced fracture of the posterior column of the right acetabulum (the deep, cup-shaped socket on the right side…

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 the facility staff failed to provide treatment and care in accordance with professional standards of practice for residents. This was evident for 2 (Resident #13 and #11) of 16 residents reviewed during a complaint survey.The findings include: 1) The facility staff failed to administer treatment per the Wound Doctor's orders for Resident #13. Review of Resident #13's medical record on 4/27/26 revealed the Resident was admitted to the facility in February 2026 following a hospitalization with discharge diagnoses to include acute systolic heart failure and peripheral edema. Further review of Resident #13's medical record on 4/28/26 revealed the Resident was first assessed by the Wound Doctor on 3/12/26 for a venous wound of the right shin, left medial foot and left second toe. At the time the Wound Doctor ordered oil emulsion daily for all 3 wounds. Further review of Resident #13's medical record revealed the Wound Doctor reassessed the Resident's wounds on 3/19/26. At the time the Wound Doctor reassessed the right shin,…

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 complaint, observation and staff interview it was determined the facility failed to keep the environment free from accident hazards. This was evident for 1 of 6 nursing units observed during a complaint survey.The findings include:On 4/29/26 at 7:25 AM a review of complaint 2723364 alleged the concern about cleaning supplies not being in a locked area on the dementia unit and the potential for residents to use cleaning wipes for personal use.On 4/30/26 at 8:10 AM observation was made in the dining room of the Seagull Unit, which is the locked dementia unit. Observation was made of disinfectant wipes sitting on a wire shelf. The wording on the containers stated, store in original container in areas inaccessible to children. The back of the contained stated, do not use as a diaper wipe or for personal cleansing. This is not a baby wipe.At the time of the observation Geriatric Nursing Assistant (GNA) #18 was in the dining room with the residents while they were waiting for breakfast. The unit manager, Licensed Practical Nurse (LPN) #13 was with the surveyor 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 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 1 (Resident #11) of 16 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.On 4/27/26 at 9:14 AM a review of Resident #11's medical record revealed the April 2026 Medication Administration Record (MAR) which documented the day, time, and nurse's initials of when medication was administered. At the same time the Controlled Drug Administration Record was reviewed to determine if it matched the April 2026 MAR. The Controlled Drug Administration Record documents when a narcotic such as Hydromorphone is given. Review of both records revealed that Resident #11's April 2026 MAR 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 interview and record review, the facility failed to timely administer medications as ordered. This was evident for 1 (Resident #86) of 85 residents reviewed for medications administration involving 22 medications administered during 6 days in May 2025. The findings include: On 5/27/25 at 11:52 AM, during an interview conducted with Resident #86, the resident expressed the concern that his/her medications are not given on time, especially the medication for his/her liver. On 5/29/2025 at 8:30 AM, a review of Resident #86's MAR for 2025 in the electronic medical record revealed documentation of a check mark for all medications, which indicated that they had been administered. On 6/3/2025 at approximately 1:30PM, the Surveyor requested that the DON provide a copy of Resident #86's MAR for May 2025 and Medication Administration Audit Report from May 17, 2025 through May 31, 2025. The Surveyor confirmed that the Medication Administration Audit Report included the medication, the schedule date, administration time, the documented time, and documented by whom on the report. 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.

Based on observations, interviews, and record reviews, it was determined that the facility failed to promote care in a manner that maintains dignity and respect for residents who required staff assistance with their meals. This was found to be evident during observations of a breakfast and lunch dining experience for 5 (Residents #64, #115, #10, #120, #78) of 85 residents reviewed during the facility's recertification survey. The findings include: 1. On 5/27/25 at 8:15 AM GNA (staff # 19) was observed feeding Resident #64 breakfast in their room. The GNA was standing up above the resident feeding the resident several forkfuls of food from the plate on the resident's overbed table. At this time the surveyor entered the resident room and asked staff # 19 if there was an explanation for not sitting in the chair next to the resident's bed while assisting with feeding? She stated, my sciatica is bothering me, and it is not comfortable when sitting down. The surveyor asked the GNA if she was aware staff are to sit at the level of the resident as to not rush the resident with their dining…

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 and an interview with a resident, it was determined that the facility failed to maintain a clean homelike environment. This was evident for 1 room out of 18 rooms observed during the initial tour of two second floor nursing units. The findings include: On 5/27/2025 at 8:52 AM, a tour of Resident #86's room revealed two curtains, one on each side of the resident's bed, with multiple dry reddish-brown stains on each curtain. During an interview with Resident #86, the Surveyor was informed that the resident uses the curtains to wipe blood off his/her finger after a finger stick. On 5/27/2025 at approximately 10:20 AM, the Surveyor made the Nursing Home Administrator (NHA) aware of the findings in Resident #86's room. The NHA stated maintenance will replace the curtains.

2. MD00204713 was reviewed on 5/30/25 at 1:15 PM for allegations of abuse to Resident #232. According to the investigation and a statement provided by staff, Environmental Staff (EVS) #18, who indicated that she overheard the resident say to GNA (#17), you are hurting me and the GNA went on to use [explicative] at the resident. Further review of the investigation revealed that the allegation could not be verified or refuted based on the timeline of events, interviews with the resident and other residents and no one else reported hearing cursing from the resident room. There was a possibility that Staff # 18 voiced the concern as retaliation towards Staff #17 due to the staff making a complaint about Staff #18 the previous day. An interview was conducted with the DON on 5/30/25 at 2:00 PM and she stated that according to the investigation, Staff # 18 allegedly overheard staff verbal abuse and did not report it until the next day. The DON stated that Staff #18 received a written warning for failure to report in a timely manner and that education was provided to staff. 3. MD00204531…

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 staff, it was determined that the facility failed to provide written notification of transfer to the resident and resident representative or provide written notification of bedhold, and failed to ensure the local ombudsman was notified of transfer to the hospital. This was evident for 1 (Resident #9) out of 3 residents reviewed for hospitalizations. The findings include: On 6/2/2025 at 12:13 PM, during a review of Resident #9 medical record, the Surveyor discovered that Resident #9 was transferred to the hospital on [DATE], 10/17/2024, and 3/30/2025. An additional review failed to reveal documentation to verify that Resident #9 received a copy of the facility's bed hold form upon discharge to the hospital on [DATE], 10/17/2024, and 3/30/2025. Bed Hold is holding or reserving a resident's bed while the resident is absent from the facility for therapeutic leave or hospitalization. On 6/3/2025 at 2:00 PM, during an interview conducted with Unit Manager #34, the Surveyor 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.

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 develop and implement a baseline care plan within 48 hours of admission. This was evident for 1 (Resident #84) of 4 residents reviewed for care planning during survey. The findings include: A care plan is a guide that addresses the unique needs of each resident. It is used to plan, assess, and evaluate the effectiveness of the resident's care. During a record review on 05/29/25 at 12:32 PM it was revealed that Resident #84 was admitted to the facility on [DATE]. The baseline care plan for Resident #84 was dated 10/31/23, six days after the resident's admission. An interview was conducted with Staff #4 on 05/30/25 at 11:31 AM. Staff #4 stated that the facility's expectation is for the baseline care plan to be developed within 48 hours of a resident's admission. On 05/30/25 at 12:23 PM, Staff #4 provided documentation indicating that a care plan meeting took place on 10/27/23, which was within the 48-hour requirement;…

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, record review and interviews with staff, it was determined that the facility failed to have a comprehensive person-centered care plan for 2 Residents (#73,# 471) out of 85 residents reviewed during survey. The findings include: 1) Record review on 6/3/2025 revealed Resident #471 had a past medical history of a right-sided stroke with residual of left-sided hemiparalysis, and was discharged from the hospital with a diagnosis of encephalopathy pyelonephritis. Encephalopathy, specifically mild encephalopathy with a reversible splenial lesion (MERS), can occur as a complication of pyelonephritis, an infection of the kidneys. While pyelonephritis is primarily known for its kidney-related symptoms like fever and flank pain, in rare cases, it can lead to neurological symptoms like headache, vision changes, or altered mental status. A urinary tract infection (UTI) is an infection that occurs in any part of the urinary system, which includes the kidneys, bladder, ureters, and urethra. They are typically caused by bacteria entering the urinary tract through the urethra…

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 resident and staff interviews, and review of the medical record it was determined that the facility failed to 1) ensure residents were offered the opportunity to participate in their care planning process by holding timely quarterly care plan meetings for 1 (Resident # 21) of 2 residents reviewed for care planning, and 2) develop and revise a comprehensive, person-centered care plans with measurable objectives and timetables to address the resident needs for 1 (Resident #130) of 2 residents reviewed for pressure injuries during the survey. The findings include: A care plan is used to summarize a person's health conditions, specific care needs, and current treatments and outlines what needs to be done to plan, assess, and manage care. Care plans are developed, reviewed, and/or revised by the Interdisciplinary Team (IDT) after the completion of a comprehensive Minimum Data Set (MDS) assessment (Admission, Annual, Quarterly, Significant Change) to help to evaluate the effectiveness of the resident's care…

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 a review of administrative records and interviews with facility staff it was determined the facility staff failed to properly turn and position a resident while providing care. This was found to be evident for 1 (Resident # 232) of 18 residents reviewed for abuse allegations during the survey. Findings include: MD00204713 was reviewed on 5/30/25 at 1:15 PM for allegations of abuse. According to the facility's investigation, on 4/14/24 GNA #17 was rough while turning and repositioning Resident #232 during ADL care. The resident was interviewed and stated that s/he was fine and was not afraid but does not desire to have the GNA provide further care. An interview was conducted with the DON on 5/30/25 at 1:45 PM and she stated that she worked at the facility for a long period of time and that she can recall this incident. She went on to explain that the GNA did not use proper turning techniques when turning and repositioning the resident. She further explained that the GNA was terminated for not providing good customer service during care. Abuse was unsubstantiated. All…

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 staff interview, it was determined that the facility failed to implement timely, appropriate, and individualized interventions to prevent and treat a pressure injury. This is evident for 1 (Resident #130) of 2 residents reviewed with pressure wounds. The findings include: The Braden Scale is a clinical tool used to assess a person's risk of developing pressure injuries by evaluating factors like mobility, moisture, activity level, nutrition, sensory perception, and friction/shear. A score of 12 or below is considered high risk for developing pressure injuries. During review of Resident #130's electronic medical record on 5/29/25 at 9:59 AM, it was revealed the resident was admitted on [DATE] with a Braden Scale score of 12 (high risk). From that date through 4/23/25, multiple Braden assessments reflected a continued high risk for skin breakdown, with scores ranging from 11 to 13. A nursing note dated 10/14/24 at 11:49 PM indicated a physical therapist reported an open area on 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.

2. Food temperatures above 41 degrees Fahrenheit (for cold foods) and below 135 degrees Farhenheit (for hot foods) allow the rapid growth of pathogenic microorganisms that can cause foodborne illness. On 06.01.25 at 12:30 PM the surveyor observed the kitchenette/galley serving station in the Seagull activity room/dining room. There was no dietary aide present in the galley preparation area. The surveyor observed a bin of small containers/cups of apricots and applesauce that were not refrigerated on the second shelf next to the hot water/steam serving table. The outside of the containers were warm to touch. The surveyor observed the 40 residents in the Seagull dining room waiting to be served their lunch meal. Six geriatric nursing assistants (GNAs) were present in the dining room. On 06.01.25 at 1:07 PM the surveyor observed the dietary staff # 11 enter the galley area and unloaded the food items to the steam table. The surveyor during the interview informed dietary staff #11 of the presence of the cups of apricots and applesauce that were unrefrigerated. Staff #11 stated that…

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.

3. Review of Resident #192's MAR on 6/3/25 at 1:30 PM revealed an order for Rexulti 3 mg(milligrams) one tablet by mouth one time a day; however, there was no indication for the use of this medication for the resident. Rexulti is a medication used to treat several mental conditions. On 6/3/25 at 1:00 PM, the surveyor shared the above concerns with the Director of Nursing (DON). The DON stated all medications should have reason documented as to why the resident is prescribed it. 4. Resident #163's medical record was reviewed on 6/2/25 at 12:05 PM for pressure ulcers. During a review of the residents' Change Of Condition (COC) form dated 11/24/24 it indicated the resident was noted to have a new open area to right heel. Further review of the medical record revealed a care plan for risk for alteration in skin integrity that was initiated 11/11/24. There was no care plan for actual open area. An interview was conducted with the DON on 6/2/15 at 1:00 PM and she was asked to provide a copy of the resident care plan for the identified open area to the resident heel. The DON stated 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.

3. On 6/2/25 at 1:25 PM the surveyor observed the Licensed Practical Nurse (LPN) #40 in the dining room on Seagull Unit take a white napkin from her uniform pocket, wipe her nose and then put the napkin back into her uniform pocket. Staff #40 then proceeded to pick up a resident's tray in the dining room and began to cut up the items on the tray without sanitizing and washing her hands. After surveyor intervention the LPN #40 discarded the tray, and another tray was prepared for the resident. LPN #40 stated she knows she should have washed and or sanitized her hands prior to picking up the resident's tray. Based on observations and interviews with facility staff it was determined the facility failed to adhere to infection control practices and policies by ensuring that dirty dishes are removed from a resident's room (Resident #59) and a process was in place for cleaning after use and ensuring that staff sanitized their hands in between residents during medication administration. This was found to be evident for 1 out of 85 residents observed and 2 staff observed 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 observations and staff interviews, it was determined that the facility failed to maintain a clean and sanitary environment by ensuring that dirty trash was emptied and removed, clothes bins containing dirty clothes were emptied and the utility room and Dining Room floors were cleaned. This was evident when observations were made on the Seagull Unit during the facility's survey. The findings include: On 5/27/25 at 8 am during observation rounds at Seagull Unit storage room the following was observed: 1. The dirty utility room on seagull located next to the nursing unit was observed with 13 bags of dirty trash noted on the floor. There were 2 large yellow trash cans noted in the room which were full and trash bags hanging them over. 2. Three large clothing bins which were filled to the top with dirty clothing. 3. The room smelled of urine and feces which could be smelled through the closed door to the storage room. The LPN staff #40 accompanied the surveyor to the room and verified the findings. The laundry/housekeeping supervisor staff #41 was contacted and the storage 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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY AL Riverview F574 Based on observations and interviews, the facility failed to post contact information for the Ombudsman and provide the correct contact information to file a complaint with the Office of Healthcare Quality. The findings include: The Long-Term Care (LTC) Ombudsman advocates for residents of nursing homes by protecting their rights and promoting the well-being of residents of Long-Term Care facilities. They work to resolve problems of individual residents and to bring about changes at the local, state, and national levels that will improve residents' care and quality of life. The Office of Health Care Quality (OHCQ) is the agency within the Maryland Department of Health charged with monitoring the quality of care in Maryland ' s health care facilities and community-based programs. On 10/21/21 at 11:33 am during the Resident Council meeting the residents denied knowing how to file a complaint with the state and how to reach the LTC Ombudsman ' s office about concerns. 10/21/21 at 11:52 am Next to…

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.

AL Riverview F577 Based on observation and interviews, the facility staff failed to have the survey results book readily accessible for review by residents, family members, and legal representatives of residents in areas of the facility that are prominent and accessible to the public. This was found to be evident during observations made during the facility's annual Medicare/Medicaid survey. The findings include: On 10/21/21 at 11:33 am during the resident council meeting the residents verbalized they were not aware the facility had a copy of the survey results nor where to find the survey book. On 10/21/21 at 12:00 pm, two surveyors went to the front lobby to assess whether the survey book was readily accessible. Observation of the area confirmed the facility ' s survey book was not was not visible. The surveyors asked the receptionist for the facility ' s survey book. On 10/25/21 at 8:48 am during an interview with the Director of Nursing (DON) (Staff #3). The DON stated the facility ' s lobby has changed since COVID, and the survey book was on a table in the front lobby between…

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 AL Riverview F584 Based on observations and interviews the facility failed to ensure the environment was maintained in a manner that was safe, comfortable, and homelike. This was evidenced for 4 of 46 resident rooms and in 1of 2 communal dining areas observed during the survey. The findings include: On 10/13/21 at 7:47 am during the initial tour, the communal dining room located on the 2nd floor had two chairs that were broken. There was a white substance in an electrical outlet on the wall near the emergency cart, and a metal hook on the wall about 12 inches from the electrical outlet. On 10/14/21 at 11:20 am the air conditioner near the window in room [ROOM NUMBER] had a black substance on the exterior grate. On 10/15/21 at 12:02 pm the hand sanitizer dispenser in room [ROOM NUMBER] did not work and it was not tightly secured to the wall. On 10/26/21 at 10:08 am during a walk-through of [NAME] with Maintenance Director #30 the commode in room [ROOM NUMBER] was stopped up. On 10/26/21 at 10:26 am during 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 observation of medication administration, interview with facility staff, and review of facility policy, it was determined that the facility failed to ensure that nursing staff followed professional standards of medication administration when Certified Medical Assistant (CMA) #6 failed to document all medications that were administered to Resident #24 at the time that they were administered. This was evident for 5 of 26 medications observed during the medication administration observation. The findings include: The surveyor observed CMA #6 administer medication to Resident #24 on 10/20/21 at 7:45 AM. During the observation, CMA #6 administered nine different medications to Resident #24: lisinopril, colace, a multivitamin, metoprolol, glipizide, low-dose aspirin, vitamin D3, Januvia, and gabapentin. The resident took and ingested all medication. The surveyor reviewed Resident #24's Medication Administration Record (MAR) on 10/20/21 at 8:50 AM, 9:20 AM, and 9:55 AM. On all three checks, the MAR showed that only four medications had been administered by CMA #6: lisinopril,…

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, interview with facility staff, and review of facility policies, it was determined that the facility failed to have a medication error rate of less than 5% during the medication observation facility task. This was evident for 4 of 26 medications administered during the observation. The findings include: During a medication administration observation that took place on 10/20/21 at 7:36 AM, the surveyor observed Certified Medical Assistant (CMA) #6 administer medications to Resident #80. The medications included a tablet of Lexapro 10mg (miligrams). Later at 7:45 AM, the surveyor observed CMA #6 administer medications to Resident #24 including Januvia and Gabapentin. During a second medication administration observation that took place on 10/20/21 at 8:01 AM, the surveyor observed Registered Nurse (RN) #7 administer medications to Resident #3. During the administration, RN #7 gave Resident #3 a dose of Wixela inhaler. The RN administered the medication by placing the mouthpiece of the inhaler in Resident #3's mouth and depressing the plunger. RN #7 failed to…

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 and interview with facility staff, it was determined that the facility failed to ensure that medications requiring refrigeration were stored at the correct temperature, that medication was not kept in storage beyond its expiration date, and that narcotic lock boxes in medication refrigerators were secured to the inside of the refrigerator and could not be removed. This was evident for 1 of 3 medication refrigerators and 3 of 3 medication rooms reviewed during the survey. The findings include: During a tour of the 600 unit medication room that took place on 10/25/21 at 9:16 AM, the surveyor found that the lock box in the refrigerator was not permanently affixed to the inside of the refrigerator. It contained three unopened 30 mL vials of Lorazepam, 2mg per mL. A pack of 19 Humanlog Kwikpen insulin pens were reviewed and 1 of the 19 had expired, with an expiration date of January, 2021. Review of the temperature logs showed that temperatures were not recorded 10/9/21, 10/19/21, 10/21/21, 10/23/21, and 10/25/21. The surveyor spoke with Licensed Practical Nurse…

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 and interview with facility staff, it was determined that the facility failed to ensure that food was prepared and stored in accordance with professional standards for food service safety. This had the potential to affect all residents in the facility. The findings include: The surveyor conducted an initial brief tour of the kitchen on 10/13/2021 at 7:44 AM with the Kitchen Supervisor/ [NAME] (staff #13). During the tour, the surveyor observed 1) a tray with one pork tenderloin thawing in the refrigerator on bottom shelf without a date the thawing began, 2) paper trash in the ice cream freezer which was contained a small cardboard box on top of frozen goods, 3) wet nesting of clean white dessert bowls, wet-nesting occurs when wet dishes or pots and pans are stacked, preventing them from drying, and creating conditions that are ripe for microorganisms to grow, 4) alfredo sauce in a metal container laid on top of several loaves of bread in the freezer 5) ice on the ceiling of the walk in freezer with evidence of droplets of condensation with multiple small ice…

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 surveyor observations and interview with facility staff and residents, the facility staff failed to protect and value resident's private space (residents #22, #45, #72 & #110). This was evident for 4 out of 75 residents reviewed during a recertification survey. The findings include: On 10/13/21 at 11:30 AM, during the initial tour of the Swan and Egret units, the Surveyor observed several incidents of facility nursing staff failing to protect and value residents' private space by not knocking on resident doors and requesting permission before entering residents' rooms. The Surveyor observed facility staff failing to knock on resident doors and request permission before entering resident's rooms for residents #22, #45, #72 & #110. Interview with resident #110 on 10/14/21 at 10:45 AM revealed that it was normal for facility staff to enter resident #110's room without knocking on the door or asking permission. The surveyor observed facility staff failing to knock on resident #110's room door and request permission before entering on 10/15/21 at 9:15 AM, 10/19/21 at 10:15 AM…

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 the facility's investigative report, record review, observation, and staff interview it was determined that the facility staff failed to thoroughly investigate an allegation of resident abuse nor notify law enforcement when a resident reported sexual and physical abuse. This was evident for 2 of 13 residents (Resident #133, #125) reviewed for abuse during this recertification/complaint survey. The findings include: On 10/20/2021, Surveyor review of the facility reported incident #MD00138808 revealed that on 4/1/2019 Resident #133 complained to the nurse manager that on Saturday 11-7 shift, resident's Geriatric Nursing Assistant (GNA # 81) threw a small piece of a diaper tab in their face while receiving incontinence care. Further review of the facility investigation revealed the facility was not able to substantiate the abuse, however the facility failed to do a thorough investigation. The facility failed to interview other staff members or residents during the investigation. Surveyor found written interviews from the resident, the nurse, and GNA #81. GNA #81's…

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 review of narcotic change of shift counts, it was determined that the facility failed to ensure that narcotic medications were consistently reconciled by two nurses at change of shift. This was evident for 1 (Egret, 400's unit) of 3 nursing units reviewed for accuracy and completeness of controlled medication storage and documentation. The findings include: Narcotic (controlled) medication, due to its potential for abuse and addiction, is required to be thoroughly tracked and accounted for by the facility. This includes but is not limited to an accounting of all narcotics in storage whenever a change of shift among nursing staff occurs. This medication count must be performed by two nursing staff at the same time to verify the counts being conducted. Any discrepancy in the count from what is expected to be found must be addressed immediately. In the course of performing the medication storage facility task, the surveyor reviewed the narcotic count logs for October, 2021, for the Egret unit at [DATE] at…

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.