Autumn Lake Healthcare At Arcola

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on resident and staff interviews and record review, it was determined that the facility staff failed to ensure that a dependent resident's personal hygiene needs were adequately met by offering and providing showers as scheduled. This was evident for 1 (Resident #4) of 5 residents reviewed for activities of daily living during the survey process. On 12/9/25 at 12:02 PM, in an interview, Resident #4 stated that s/he does not get showers as often as s/he would like. The Brief Interview for Mental Status (BIMS) revealed a score of 14 indicating adequate cognitive ability. On 12/16/25 at 9:23 AM, a review of Treatment Administration Record (TAR) in the electronic health record: Point, Click, Care (PCC) revealed Resident #4 received only six showers in November. A review of the shower assignment book revealed Resident #4's shower days as Wednesday and Saturday.A review of the Annual Assessment for the Minimal Data Set (MDS) dated [DATE] Section F revealed that it was very important to choose between a bath,…

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 reviews, and interviews, it was determined that the facility failed to provide activities to residents based on their comprehensive assessment to support the physical, mental, and psychosocial well-being. This was evident for 1 (Resident #9) of 3 residents reviewed for activities.The findings include: Resident #3 was a long-term resident of the facility, admitted in late 2015. Current diagnosis includes but not limited to Cerebral infarction.Cerebral infarction, also known as an ischemic stroke, is the death of brain tissue (infarct) from a sudden blockage of a blood vessel supplying the brain, cutting off oxygen and nutrients, making it a medical emergency requiring immediate treatment like clot-busting drugs (tPA) or surgery to restore blood flow and prevent permanent damage, leading to symptoms like weakness, speech problems, and vision issues. On 12/8/235 at 1:01 PM, the resident was observed in bed, lying steady, awake with no activity being provided.A review of Resident #9's medical record on 12/16/25 at 9:42 AM revealed the last annual…

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, observation, and interview, it was determined that the facility failed to provide pain management in accordance with the resident's physician orders and professional standards of practice. This was evidence for 1 (R #2) of 4 residents reviewed for pain management during the recertification survey. The findings include: On 12/18/2025 at 9:27 AM, during a review of R #2's medical record, it was evident that pain medication was being administered to the resident outside of the ordered parameters for that current month of December 2025 and the previous month of November 2025.A review of ordered pain medication and related interventions for R #2 is as follows:Order entry date 08/16/2025 for: Assess resident for Pain Q (every) shift. Document Y/N. Y = Yes; N = No. If yes, medicate as ordered for pain and notify MD (the physician or relevant provider) if pain is not controlled every shift for pain evaluation.Order entry date 08/17/2025 for: OxyCONTIN Oral Tablet ER 12 Hour Abuse-Deterrent 30 MG…

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 interviews, it was determined that the facility failed to 1) implement the physician's order 2) ensure that each resident's drug regimen was free from unnecessary medications, and 3) ensure appropriate medication regimen review, monitoring, and follow-up in accordance with physician orders and professional standards of practice. This was evident for 3 (Resident #3, Resident #2 and Resident #5) of 7 residents reviewed for unnecessary medications during the recertification survey.The findings include: 1) Resident #3 was admitted into the facility in early 2025. The resident's medical record was reviewed on 12/18/25 at 11:11 AM. The review revealed a progress note from the pharmacist indicating that the medication regimen review (MRR) was conducted on 9/20/25 with new recommendations. A separate report pertaining to the pharmacy recommendation was found in Resident #3's hard chart on 12/18/25 at 11:27 AM. The report listed 3 medications that the resident was taking for hyperlipidemia and the result of the resident's lipid panel taken on 8/27/25.…

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 interviews, it was determined that the facility failed to ensure that medications and medical equipment available for resident use were within their expiration dates. This was evident in 3 out of 3 medication storage areas reviewed during the survey.The findings include: On [DATE] at 10:35 AM, an observation of the first-floor medication storage unit was conducted with the Charge Nurse (Staff #17). The Charge Nurse reported that all items in the storage room were available for resident use. Observation revealed a box of [NAME] and Nephew prep wipes that was approximately half full, having an expiration date of [DATE]. Further observation revealed a box of Refresh eye drops prescribed for Resident #115 with an expiration date of 10/2025. The expiration dates were confirmed by Staff #17. Staff #17 removed the expired item from the room.On [DATE] at 10:59 AM, an observation of the second medication storage unit was conducted with the Charge Nurse (Staff #18). Observation of the cabinet…

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, observation and record review, it was determined that the facility failed to provide legible, timely and accurate facility documents as required per the Centers for Medicare and Medicaid Services (CMS) entrance conference worksheet. This was evident at the entrance conference for this survey period. On 12/8/25 at 9:20 AM the surveyor and Acting Director of Nursing DON) commenced the entrance conference. Surveyor provided and reviewed a copy of the CMS entrance conference worksheet and other applicable documents to the DON. The required documentation and timeline for compliance was reviewed. Documents that were due upon entrance and actual date and time received were: On 12/8/25 at 12:23 PM- Census On 12/9/25 at 9:45 AM- Complete matrix for new admissions Documents that were due within 4 hours of entrance and actual date and time received were: On 12/9/25 at 7:23 AM- Complete matrix for all other residents. A record review of this document revealed inaccurate documentation for a hospice resident (Resident #144) and it was illegible. On 12/9/25 at 9:45 AM, in 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.

Based on record reviews and interviews, it was determined that the facility failed to ensure that education was provided to the resident's representative regarding the benefits and potential side effects of the influenza and pneumococcal immunizations. This was evident in 1 (Resident #71) of 5 residents reviewed for immunizations.The findings include: A review of Resident #71's immunization records from the electronic health record (EHR) on 12/11/25 at 3:39 PM, revealed influenza immunizations were refused and education was provided to the resident on 4/1/23, 10/6/23, and 9/23/25. There was no documentation in the EHR to indicate the resident received or declined the influenza immunization for the year 2024.The Infection Preventionist Nurse (Staff #20) was interviewed on 12/15/25 at 10:29 AM. During the interview, she explained the facility's process with vaccinations/immunization, and how they are documented in the resident's medical record. A review of Resident #71's immunization records in the EHR was conducted with Staff #20 on 12/15/25 at 10:53 AM. She confirmed the findings…

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 reviews and interviews, it was determined that the facility failed to ensure that education was provided to the resident's representative regarding the benefits and potential side effects associated with the COVID-19 vaccine. This was evident in 1 (Resident #71) of 5 residents reviewed for immunizations.The findings include: A review of Resident #71's immunization records from the electronic health record (EHR) on 12/11/25 at 3:39 PM, revealed COVID-19 vaccine was refused:a) On 11/13/23 by the resident, education providedb) On 10/17/24 by the resident, no education was providedc) On 10/15/25 by the resident, education providedThe Infection Preventionist Nurse (Staff #20) was interviewed on 12/15/25 at 10:29 AM. During the interview, she explained the facility's process with vaccinations/immunization, and how they are documented in the resident's medical record. A review of Resident #71's immunization records in the EHR was conducted with Staff #20 on 12/15/25 at 10:53 AM. She confirmed the findings listed above and indicated that she would review the resident'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 interviews and medical record review it was determined that the facility failed to: 1) revise a Resident's care plan and 2) provide an invitation and/or invite a resident for a care plan meeting . This was evident in 4 Residents (#65, #36 #143, & #57) and 2 Residents (#63 and #38) out of 10 residents reviewed for care planning. The findings include: 1a) On 6/13/24 at 12:40 PM a review of Resident's #65 medical record revealed that the resident was admitted to the facility on [DATE] with multiple diagnoses which included Dementia, ETOH (alcohol) abuse and Hypertension (high blood pressure). On 4/16/24 Resident #65 sustained a fall and was hospitalized for Hip Fracture. Resident #65 was readmitted to the facility on [DATE]. A review of Resident #65 medical record on 6/14/24 01:06 PM revealed that the resident was administered Lovenox (Enoxaparin) injections for the period 4/22/24 to 5/5/24 for Deep Vein Thrombosis prophylaxis and a care plan was initiated on 4/22/24. The resident's care plan for Lovenox…

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 review, it was determined that the facility failed to ensure sanitary and safe food handling practices were followed to reduce the risk of foodborne illness. This deficient practice has the potential to affect all residents. The findings include: On 6/11/24 at 9:01 AM during an initial tour of the kitchen, the surveyor observed two large white (approximately 4 gallon) containers quarter filled with yellow liquid in Refrigerator #2. The containers were unlabeled and undated. Staff #10 immediately removed the containers and stated that they contained leftover lemonade. On 6/25/24 at 08:08 AM the surveyor observed the following during a follow-up tour of the kitchen: - Six stacks of white saucers (approximately 20 saucers per stack), wet nesting (occurs when wet dishes or pots and pans are stacked together before they are completely dry, which can lead to bacterial growth) with surface up on the countertop next to the dishwasher. Air drying dishes is required to ensure adequate sanitization. Staff #29 stated that she would rewash them and…

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 failed to ensure a process was in place to address preventative maintenance of hallway handrails, residents' closets, sofas and wheelchairs. This was evident during multiple tours on the Gateway Unit during the recertification survey. The findings include: On 6/21/24 at 9:24 AM during rounds on the Gateway Unit, the surveyor observed the following: -The left side closet door was off its hinges, and propped up in front of the closet. The right side closet door was in place with its handle missing. The first drawer at the bottom of the closet was missing its handle and the second drawer had a loose hanging handle, -The handrail in the short hallway was loose with 3 screws missing, - All handrails on the unit were marred and scratched, - An empty blue manual wheelchair observed on the long hallway with the back support, seat and armrests tattered, exposing padding material underneath, -A large dark brown single seat sofa chair in residents'…

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 failed to provide an accurate mailing address, email address, and telephone number for the State regulatory agency. This was found in 2 of 2 postings located in the facility corridors. The findings include: On 6/17/24 at 6:19 AM, the surveyor observed a sign located on the wall leading to the resident's rooms stating, General Information with the information to contact OHCQ (Office of Health Care Quality) and the number [PHONE NUMBER]. The surveyor next called the number and verified it was not the direct number to OHCQ rather a direct number to a hospital facility surveyor. On 6/18/24 at 8:43 AM, the surveyor conducted an interview with Staff #34. During the interview the surveyor asked Staff #34 where the information and instruction to contact State agencies was located. Staff #34 walked over to the bulletin board just before the entrance to the Potomac floor. At this time the surveyor observed the board where the number listed 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 observation, survey results book review and interview, it was determined that the facility failed to have survey results available for the most recent surveys and reports of the facility readily available for review. The findings include: On 6/11/24 at 8 AM surveyors entered the facility and located a binder labeled CURRENT FACILITY SURVEY, near the receptionist's desk in the front lobby. Review of the survey results binder on 6/11/24 at 8:45 AM revealed the last survey results were from a Complaint survey conducted in February 26, 2019. The surveyor next reviewed the Certification and Survey Provider Enhanced Reporting (CASPER). The review revealed that the facility had additional complaint surveys completed in January of 2021 and January of 2024. No results from either of these surveys were in the binder. On 6/11/24 at 11:45 AM the surveyor interviewed the Director of Nursing (DON) who confirmed that the survey results from the last survey were not in the binder. The DON confirmed that he would update the binder. On 6/14/24 at 11:05 AM, the DON provided the surveyors with…

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 interviews, it was determined that the facility staff failed to obtain advance directives for residents. This was found evident for 3 (Resident #26, #38, and #122) of 8 Residents reviewed for advanced directives during an annual survey. The findings include: 1a) During record review for Resident #26 on 6/12/24 at 11:14 AM, the surveyor did not find documents related to advance directives in the resident electronic record or hard chart. During an interview with Staff #35 on 6/17/24 at 11:16 AM, the surveyor asked about the process of obtaining advance directives for residents upon admission. She stated that a resident's advance directive gets collected at the time of entry, if they have them, then given to the Social Worker for them to follow up with residents within 72 hours. She also stated that advance directives don't necessarily have to be collected during admission and that after admission she does not follow up with residents. During an interview with Staff #15 on 6/17/24 at 1:36 PM, the surveyor asked about whether there was an advance…

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, it was determined that the facility staff failed to provide privacy for resident's protected health information. This was evident for 1 (Resident #239) of 67 residents reviewed during an annual survey. The findings include: During observation on 6/24/24 at 11:41 AM, the surveyor found a medication cart laptop open with Resident #239's medical information visible to anyone in the hallway. It was noted that no residents or facility staff were in the hallway. During an interview with Staff #33 on 6/24/24 at 11:50 AM, the surveyor identified the open laptop and resident record with Staff #33. She stated that she did not recall leaving the laptop open because there was a black screen present. During the interview, it was also revealed that Staff #33 was able to pull up Resident #239's record on the laptop by simply clicking the mouse without entering a secure password. During observation on 6/24/24 at 11:53 AM, the surveyor observed Staff #33 walk away from the laptop with the open browser tab that visibly stated on a white background, THIS SCREEN IS…

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 medical record review it was determined the facility failed to provide notification to the Ombudsman of the Resident that transferred to the hospital. This was evident in 1 Resident #123 out of 4 Residents reviewed for hospitalization notification. The findings include: On 6/12/2024 at 11:30 AM the surveyor reviewed Resident #123's medical record. The review of the medical record revealed that Resident #123 was transferred to the hospital on 1/30/2024. At 11:15 AM on 6/20/2024 the surveyor requested from the Director of Nursing the documentation of the Ombudsman notification of Resident #123's transfer to the hospital on 1/30/2024. During an interview with the Director of Nursing on 6/21/2024 at 11:00 AM he stated that he requested from the Ombudsman a copy of the email and transfer log that the facility Social Services Department sent to the Ombudsman for January 2024, because the facility was unable to locate documentation of notification to the Ombudsman for Resident #123's transfer on 1/30/2024. The Director of Nursing further stated in the interview 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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based 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 1 (Resident #65) of 67 residents selected for review during the recertification survey. The findings include: Minimum Data Set (MDS) is part of the U.S. federally mandated process for clinical assessment of all residents in Medicare or Medicaid certified nursing homes. This process provides a comprehensive assessment of each resident's functional capabilities and helps nursing home staff identify health problems. MDS assessments are required for residents on admission to the nursing facility and then periodically, within specific guidelines and time frames. On 06/13/24 at 12:40 PM a review of Resident's #65 medical record revealed that the resident was admitted to the facility on [DATE] with multiple diagnoses including Dementia, ETOH (alcohol) abuse and Hypertension (high blood pressure). On 4/16/24 Resident #65 sustained a fall and…

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 staff failed to develop and initiate comprehensive person-centered care plans for residents. This was evident for 3 (Resident #65, #36 and #80) of 10 residents reviewed for comprehensive care plannig. 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. The Minimum Data Set is a standardized assessment tool that measures health status in nursing home residents. MDS assessments are completed every 3 months on all residents of nursing homes. 1a) On 06/13/24 at 12:40 PM a review of Resident's #65 medical record revealed that the resident was admitted to the facility on [DATE] with multiple diagnoses which included Dementia, ETOH (alcohol) abuse and Hypertension (high blood pressure). On 4/16/24 Resident #65 sustained a fall and was hospitalized for hip fracture. The resident was readmitted to the facility 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 medical record review and interviews, it was determined that the facility failed to turn and reposition residents at risk for pressure ulcers. This was evident for 2 (Resident #26 and #158) of 4 residents reviewed for positioning during an annual survey. The findings include: During an interview with Resident #26 on 6/12/24 at 8:49 AM, the surveyor asked if staff repositioned them due to limited range of motion. The resident stated he/she was only repositioned when they asked the staff to do so and not done by a schedule. The resident confirmed that he/she could not reposition himself/herself and would need help. During an interview with Resident #26 on 6/18/24 at 1:08 PM, the surveyor asked if they had been repositioned during the night shift. The resident stated he/she was not repositioned the night before. During record review for Resident #26 on 6/18/24 at 9:46 AM, the records revealed documented care for turn and reposition was not done on 14 days for the night shift during the month of June. The record also revealed the night shift documented the resident as…

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 interview and record review it was determined that the facility staff failed to promptly make appointments for the proper diagnosis and treatment of vision impairment conditions. This was found to be evident for 1 (Resident #38) out of 2 residents reviewed for vision services during an annual survey. The findings include: During a floor rounding, on 6/12/24 at 2:53 PM, Resident #38 stated I only could see vague shadows, my eyesight was getting poor. I had not had an eye appointment since I got here which I was worried about and I feel helpless. Record review, on 6/13/24 at 1:27 PM, of Resident #38's record revealed that he/she was admitted on [DATE] with diagnoses of percutaneous pinning of pelvis on 2/12/24, vision impaired, cardiac arrhythmia and dementia. This resident was able to answer questions appropriately, making his/her own decisions about his/her care and made his/her needs known. Further record review found that the Medical Director Staff #32 had entered the order that the resident may be…

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 interviews, it was determined that the facility staff failed to ensure residents are not exposed to hazards. This was evident for 1 (Resident #26) of 67 residents reviewed during an annual survey. The findings include: During observation on 6/18/24 at 1:12 PM, the surveyor observed Resident #26's call light with wires exposed. During observation on 6/20/24 at 1:50 PM, the surveyor observed Resident #26's call light with wires exposed. Staff #5 was asked to identify if the resident's call light was faulty and who should report and where. She identified the exposed wires, and stated anyone who sees a faulty call bell can report it. She also stated she will put it in the maintenance log book. During an interview with Staff #2 on 6/28/24 at 2:04 PM, he was asked about who should report faulty call lights. He said anyone should be able to identify and the nurses should have seen that and put it in the book.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review and interviews it was determined that the facility staff failed to track the pharmacy's irregularity monthly recommendation, assure the review by the medical staff and have timely action by the medical staff in response to the recommendation. This was found evident of 1 (#26) of 5 residents reviewed for medication regimen review during an annual survey. The findings include: Record Review, on 6/13/24 at 12:05 PM, of Resident #26's record revealed that he/she was admitted on [DATE] with diagnoses of chronic heart failure, arthritis, diabetes, fibromyalgia, hypertension, chronic renal failure, obesity and migraine. Further record review of a Monthly Pharmacy Report, dated on 5/15/24 at 5:42 PM, revealed that the report identified an irregularity that was marked recommendation written for the medical staff to respond. However, there was no record of a medical staff response on 5/15/24. During interview, on 6/13/24 at 12:58 PM, the Director of Nursing (DON) was aware that on 5/15/2024 at 5:42…

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 interview, observation and record review it was determined that the facility staff failed to promptly provide or obtain visit/appointments for routine dental care or treatment for Medicaid Residents. This was found to be evident for 1 (Resident #33) out of 3 residents reviewed for dental services during an annual survey. The findings include: During a floor rounding, on 6/12/24 at 11:50 AM, Resident #33 stated that several months ago he/she had requested the facility staff to arrange a dentist appointment for his/her a few broken teeth. Record review, on 6/12/24 at 1:40 PM, revealed that Resident #33 was admitted on [DATE] to this facility for a short stay then re-admitted on [DATE] as a long-term care resident. This resident had a medical history with diagnoses of hypotension, chronic heart failure and asthma. The resident was able to answer questions appropriately, making his/her own decisions about his/her care and making his/her needs known. Further review record review found that the 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 interviews, and record review, it was determined that the facility failed to maintain medical records in accordance with acceptable professional standards and practices by keeping complete and accurate documentation. This was found evident in 5 (Resident #154, #143 #121 #26 and #158) of 67 residents reviewed during the survey. The findings include: 1a) On 6/12/24 at 10:55 AM, the surveyor reviewed Resident #154's medical record. The review revealed that Resident #154 had a past medical history that included, but was not limited to, below the knee amputation, and osteomyelitis (infection of the bone). On further review Resident #154 had a Peripherally Inserted Central Catheter (PICC) (a catheter inserted into a vein in the upper arm and guided into a large vein above the right side of the heart, used to give intravenous fluid, medications and blood products) on 10/11/22. Orders were also written on the same day for measuring external length of catheter each week, changing dressing every Friday, and measuring arm circumference every Friday. On 6/13/24 at 11:15 AM, 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 observation and interviews it was determined that the facility failed to follow appropriate infection prevention and control practices to prevent the development and transmission of disease and infection. This was found to be evident on 5 random observation during the annual recertification survey. The findings include: 1a) During the initial tour of the laundry department on 6/18/2024 at 9:15 AM the two surveyors observed an employee's purse and personal items in the inside corner of a clean linen bin that was half full of clean folded linens. On tour of the laundry department at 9:30 AM on 6/18/2024 with the facility Nursing Home Administrator (NHA) the two surveyors observed an employee's purse on the clean laundry folding table. Adjacent and connected to the clean area of the laundry room was an open storage area that had four dirty file cabinets (one was empty and three contained unsecured medical records), several cardboard boxes rested directly on the floor filled with clothes, clothes laid 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 a review of a facility reported investigation, clinical record review, and staff interview it was determined that the facility staff failed to prevent abuse of a resident. This was evident for 1 (#155) out of 67 residents in the resident sample. The findings include: An investigation of Facility Reported Incident MD00186212 was started on 6/25/24. On November 11, 2022, during the day shift Resident #155 had a bowel movement and needed assistance from the Geriatric Nursing Assistant (GNA). GNA #21 was assigned to the resident and went into the room to clean and change the resident. GNA #21 entered the room to assist. While changing the incontinence brief the resident grabbed GNA #21's hand and dug their nails into the GNA's skin causing it to bleed. GNA #38 alleged that GNA #21 then hit the resident's hand. GNA #38 then reported the incident to the charge nurse (Staff #39). A review of the facility investigation revealed that Staff #39 no longer works for the facility. The nurse reported the suspected abuse to the Director of Nursing (DON) on 11/29/22 and an investigation…

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 an investigation into a facility reported incident, clinical record review, and staff interview it was determined that the facility staff failed to ensure an incident of alleged abuse was reported immediately to the Administrator and to the state agency. This was evident for 1 (#155) out of 67 residents that were part of the survey sample. The findings include: An investigation of Facility Reported Incident MD00186212 was started on 6/25/24. On November 11, 2022, during the day shift Resident #155 had a bowel movement and needed assistance from the Geriatric Nursing Assistant (GNA). GNA #21 was assigned to the resident and went into the room to clean and change the resident. GNA #38 entered the room to assist. While changing the incontinence brief the resident grabbed GNA #21's hand and dug their nails into the GNA's skin causing it to bleed. GNA #38 alleged that GNA #21 then hit the resident's hand. GNA #38 then allegedly reported the incident to the charge nurse (Staff #39). There was no evidence that Staff #39 reported the incident to the Administrator nor was there…

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 records review, resident representative interview and staff interview, it was determined that the facility staff failed to notify a resident's responsible party when the resident had a change in status. This finding was evident for 1 of 2 residents reviewed for hospitalization during the survey (#49). The findings include: On 08-22-19, review of resident #49's clinical record revealed a physician's certification of incapacity to make medical decisions was signed on 09-24-18 by the attending psychiatrist and 10-07-18 by the attending physician. However, clinical records dated 11-12-18, 11-23-18, 01-03-19, 02-07-19, 03-12-19, 04-01-19, 04-30-19, 05-03-19, and 07-09-19 revealed that the facility staff discussed medical information pertaining to resident #49 with the resident but not the resident's responsible party. On 08-22-19, clinical record review of resident #49 further revealed that resident #49 had two emergency contact persons listed on his/her clinical record. Clinical record revealed that resident #49's emergency contact#1 was notified of resident #49'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.

Based on surveyor observation and interviews with staff, it was determined that the facility failed to maintain a comfortable temperature between 71 to 81°F. This was evident for 1 of 3 nursing units (Rosemary/Chesapeake) observed during the survey. The findings include: On 07-17-19 at 1 PM, surveyor observation revealed a temperature of 93°F displayed on the Rosemary/Chesapeake thermostat. Further observation revealed no air circulation emitting from the ceiling vents in the hallways and nursing station. There were no residents in the hallways or nursing station at the time of the observation. Rooms 45-70 had individual air conditioner units that were functional and maintained a comfortable temperature in the resident rooms. Potomac unit had a temperature of 75°F and Gateway unit had a temperature of 78°F. On 07-17-19 at 1:57 PM, surveyor observation with the administrator and maintenance assistant on the Rosemary/Chesapeake nursing unit revealed a temperature of 93.4°F on the ceiling and 84°F on the floor, when measured with an infrared thermometer. On 07-17-19 at 2 PM, 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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review, interviews with residents, resident representatives and facility staff, it was determined that the facility failed to ensure that interdisciplinary care plan conferences were conducted timely after each MDS assessment and failed to update resident care plans accurately. This finding was evident for 11 of 33 (#19, 40, 99, 3, 47, 71, 41, 65, 69, 97 and 135) residents selected for review during the survey. The findings include: Minimum Data Set (MDS) is part of the U.S. federally mandated process for clinical assessment of all residents in Medicare or Medicaid certified nursing homes. This process provides a comprehensive assessment of each resident's functional capabilities and helps nursing home staff identify health problems. MDS assessments are required for residents on admission to the nursing facility and then periodically, within specific guidelines and time frames typically done as comprehensive and quarterly review assessments. 1. On 07-19-19, surveyor review of the clinical record…

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 clinical records review, resident representative interview and staff interview, it was determined that the facility staff failed to to provide effective discharge planning for resident #49. This finding was evident for 1 of 2 residents reviewed for discharge during the survey. The findings include: On 08-22-19 clinical record review revealed that resident #49 had a physician's certification of incapacity to make medical decisions signed on 09-24-18 by the attending psychiatrist and 10-07-18 by the attending physician. Further clinical record review revealed that the facility social services staff discussed transferring resident #49 to another skilled nursing facility in November 2018 and February 2019 although he/she had been deemed incapacitated by two physicians. In addition, there was no evidence that the facility staff attempted to involve resident #49's responsible party in discharge planning after he/she was deemed incapacitated. On 07-12-19 resident #49 was transferred to the hospital for 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 surveyor review of the clinical record and staff interview, it was determined that the facility staff failed to provide appropriate assistance in establishing a clearly defined authorized decision maker for a resident deemed to be incapacitated. (#49) This finding was evident in the investigation of complaint #MD00142746 which was valid. The finding includes: Review of the clinical record for resident #49 on 08-22-19 revealed a diagnosis of schizophrenia/schizoaffective disorder as the basis for a certification of incapacity signed by the psychiatrist on 09-24-18 and by the attending physician on 10-07-18. This certification deemed the resident unable to make medical decisions. There was no evidence in the clinical record that the facility staff notified the responsible party and/or emergency contacts to inform them of the physicians ' determination of resident #49 ' s incapacity, or the need to establish a clear authorized decision maker as a result of the incapacity certification. (Refer to F-550)…

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 surveyor review of clinical records, and staff interview, it was determined that facility administrative staff failed to recognize the rights of an incapacitated resident, failed to permit the resident to return to the facility after an emergency room visit, and failed to involve the authorized decision maker in the discharge planning process. (#49) This finding was evident during the investigation of complaint MD00142746 which was valid. The findings include: On 08-22-19, review of the clinical record for resident #49 revealed a diagnosis of schizophrenia/schizoaffective disorder as the basis for a certification of incapacity signed by the psychiatrist on 09-24-18 and by the attending physician on 10-07-18. This certification deemed the resident unable to make medical decisions. There was no evidence in the clinical record that the facility staff notified the responsible party and/or emergency contacts to inform them of the physicians ' determination of resident #49 ' s incapacity, or the need 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 surveyor review of the clinical record and staff interviews, it was determined that facility staff failed to provide evidence that the Quality Assurance Committee had made good faith attempts to address deficient practice identified by the committee as it related to social services. On 08-22-19 at 5:30 PM, interview with the director of nursing revealed that it was social services responsibility to ensure that the correct information was in the clinical record on who had guardianship, or who was the authorized decision maker. The director of nursing also added, nursing is not responsible for that, social services is. We would not have known the information on the face sheet was incorrect. On 08-28-19 at 10:00 AM, an additional interview with the director of nursing revealed the facility had been addressing concerns related to social services as part of their Quality Assurance Committee meetings. The director of nursing stated that social services collected and analyzed trends and facility data and findings that were discussed in the meeting. The director of nursing also…

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 facility administrative and clinical record review and staff interviews, it was determined that the facility staff failed to protect resident #403's right to personal privacy. This finding was evident for 1 of 18 residents reviewed during the revisit survey. The findings include: On 11-04-19, clinical record review of resident #403 revealed a diagnosis of dementia with significant cognitive impairment resulting in the need for a surrogate decision maker. On 11-05-19 at 4:18 PM, telephone interview with GNA staff #5, who had been accused of abusing resident #403, revealed that the Director of Nursing (DON) informed GNA staff #5 via telephone of an abuse allegation related to his care of resident #403. GNA staff #5 alleged that, on 10-22-19 at approximately 10 PM, the DON forwarded a photograph of resident #403 as a text message via his cellular phone to GNA staff #5. Upon interview on 11-05-19 at 4:35 PM, the DON stated he did not know anything about facility staff having taken a photograph of resident #403. He stated he did not have any photographs of the resident with him…

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 clinical record review, surveyor observation, and interviews with staff and local law enforcement authorities, it was determined that the facility staff failed to recognize a resident's right to be free from neglect. This finding was evident for 1 of 3 residents reviewed for abuse/neglect care area (#403). The findings include: On 11-04-19 at 4:13 PM, surveyor observed resident #403 sitting in a wheelchair outside the dining area. On 11-05-19 at 4:18 PM interview with the GNA staff #5 revealed that resident #403 often become combative and agitated during ADL (activities of daily living) care. Resident #403 had a diagnosis of dementia and was assessed to be a high fall risk due to restlessness. According to staff #5, nursing staff put the resident in a wheelchair in the dining area (next to nurse's station) most of the time, so that staff could keep a close eye on him/her. GNA staff #5 further stated that, on 10-22-19, he/she was accused of abuse of resident #403 by resident #401 (roommate of resident…

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 with facility staff and review of a facility investigation involving an alleged employee to resident case of abuse, it was determined that the facility failed to thoroughly investigate an alleged employee to resident abuse incident. This finding was evident for 1 of 2 residents reviewed for abuse during the survey. The findings include: On 07-19-19, surveyor review of a facility reported incident investigation revealed that an alleged employee to resident abuse was reported on 07-10-19. The facility investigation report revealed that the abuse could not be substantiated. The investigation included interviews with facility staff, the alleged perpetrator, the involved resident, and one additional resident. There was no evidence that other residents that were assigned to the alleged perpetrator were interviewed or assessed for possible abuse. Furthermore, a skin assessment was conducted by facility staff on resident #39 on 07-10-19, which revealed pre-existing skin discolorations to resident #39's left big toe and left forehead. The facility investigation report…

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 clinical record review, facility staff interview, and hospital social staff interview, it was determined that the facility failed to provide a safe and effective transition of care during a facility-initiated transfer. In addition, the facility failed to ensure that a facility-initiated discharge was necessary to meet the needs of resident #49. This was evident for 1 of 2 (#49) records reviewed for hospitalization during the survey and is related to MD00142746. The findings include: On 07-17-19 record review of resident #49's medical record revealed that on 07-12-19 the resident requested the facility to call 911 for a complaint of right leg pain. Also, staff documented that the resident was making suicidal statements and gestures. The resident was transferred to the emergency room (ER) at 10:50 AM. On 7-17-19 at 11:00 AM, interview with the social worker from the hospital revealed that, on 07-12-19, resident #49 was evaluated for medical and psychiatric complaints and was cleared medically by the ER…

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 clinical record review, resident representative interview and staff interview, it was determined that the facility staff failed to notify a resident's representative before transferring a resident out of the facility. In addition, the facility failed to provide a notice of discharge 30 days prior to the discharge. This finding was evident for 1 of 2 residents reviewed for hospitalization during the survey. (#49) The findings include: On 08-22-19, resident #49 was transferred to the hospital on [DATE] for a medical evaluation and a notice of discharge was given to the resident the same day. Review of resident #49's clinical record also revealed a physician's certification of incapacity to make medical decisions was signed on 09-24-18 by the attending psychiatrist and 10-07-18 by the attending physician. However, the facility staff had resident #49 sign and acknowledge the notice of transfer on 07-12-19 although two physicians had previously deemed the resident unable to make medical decisions. 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 surveyor review of the clinical record, it was determined that the facility staff failed to follow a physician's order to hold a medication based on established parameters. This finding was evident in 1 of 3 records selected for review of the discharge care area during the revisit survey. (#71) The findings include: On 11-04-19, review of the clinical record for resident #71 revealed a physician's order for Metoprolol (beta blocker which slows the heart rate) 25mg twice daily. The order also included instructions for facility staff to hold (not administer) the medication if the heart rate was less than 60. On 10-25-19 at 4:30 PM, resident #71 received the Metoprolol with a documented heart rate of 51. On 10-28-19, the resident received the medication at 8:30 AM with a heart rate of 55, and a second dose at 4:30 PM with a heart rate of 51. On 10-29-19, the resident received the Metoprolol at 4:30 PM with a heart rate of 51. There was no documentation in the clinical record to support why the medication was administered outside the parameters established by the physician.…

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 with facility staff, it was determined that the facility failed to document the rationale or duration of an as needed (PRN) psychotropic medication in a resident's medical record. This finding was evident for 1 of 9 (#80) residents selected for review of unnecessary medications during the survey. The findings include: On 07-15-19, review of resident #80's clinical record revealed a physician's order, written on 04-01-19, for an as needed psychotropic medication. The order did not contain a duration limit for the medication. Further review revealed that resident #80 was examined by the psychiatrist on 04-01-19 and the psychiatric nurse practitioner on 04-05-19, 05-01-19, 06-12-19, and 07-03-19. There was no documented evidence in the psychiatrist's or psychiatric nurse practitioner's progress notes, that resident #80 was prescribed the as needed psychotropic medication. In addition, there was no documented evidence that a rationale was provided for the use of the as needed psychotropic medication or that a duration for the order was specified. 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.