Autumn Lake Healthcare at Glen Burnie

Inspectors wroteBased on review of complaints, 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 4 (Resident #10, #2, #7, #9) of 11 residents reviewed for complaints during a complaint survey.

Inspectors wroteBased on observations and interviews conducted during a complaint survey, it was determined that the facility failed to have an effective process to maintain resident equipment. This issue affected 6 (Resident #17, #16, #18, #19, #20, #14) of 21 residents reviewed during a complaint survey.

Inspectors wroteBased on review of facility reported incidents, documentation review, and interviews, it was determined the facility failed to report an alleged abuse and misappropriation of resident property immediately to the Nursing Home Administrator and within 2 hours to the regulatory agency, the Office of Health Care Quality (OHCQ) for the alleged abuse. This was evident for 2 (Residents #8, #7) of 7 residents reviewed for facility reported incidents during a complaint survey.

Inspectors wroteBased on review of facility reported incident 3094393, medical record review, and interview, it was determined the facility staff failed to conduct a complete and accurate assessment by failing to assess a resident's cognition, mood, and behavior on an annual assessment. This was evident for 1 (Resident #7) of 7 residents reviewed for facility reported incidents during a complaint survey.

Inspectors wroteBased on observation, interview, and medical record review, it was determined that the facility staff failed to provide thorough grooming and personal hygiene services for a resident. This was evident for 1 (Resident #9) of 3 residents reviewed for activities of daily living (ADL) care during a complaint survey.

Inspectors wroteBased on medical record review and interview, it was determined the facility staff failed to administer a resident's medication in a timely manner. This was evident for 1 (Resident #15) of 3 residents reviewed for timely medication administration during a complaint survey.

Inspectors wroteBased on medical record review and staff interview it was determined the facility failed to keep a resident's drug regimen free from unnecessary drugs by failing to follow physician ordered blood pressure parameters for administering blood pressure medications to a resident. This was evident for 1 (Resident #11) of 3 residents reviewed for unnecessary medications during a complaint survey.

Inspectors wroteBased on observation, staff interviews, and documentation review, it was determined that facility staff failed to keep medication carts locked when unattended and discard expired medications/biologicals. This was evident on 2 of 4 nursing units observed during random observations made during a complaint survey.

Inspectors wroteBased on observation and interviews, it was determined the facility staff failed to ensure food was served at a palatable temperature and all the items on a resident's meal ticket were delivered. This was evident for 1 (Resident #15) of 3 observations during a complaint survey.

Inspectors wroteBased on observation, record review, and interviews with staff, it was determined that the facility failed to ensure residents were on time to scheduled dialysis treatment to received their full prescribed time. The facility also failed to ensure an adequate supply, and appropriate maintenance of Dialysis Chairs (Supplied by the [NAME] Lake Healthcare at Glen [NAME], and used for transport to Dialysis). This was found to be evident in 6 (#10, #127, #140, #197, #47, #175) of 17 residents reviewed for dialysis. 1. On 5/7/2026 at approximately 10:00AM, the Surveyor observed the dialysis Registered Nurse (RN #17) send a dialysis chair to the 2nd floor Gateway Unit. Unit Secretary (US #25) retrieved chair and placed it outside Resident #10's room for transport to [dialysis company] on the 1st floor of the building (East Building). [...]

Inspectors wroteBased on observations, staff interviews, and record review, it was determined that the facility failed to:1. Maintain medical records in accordance with accepted professional standards and practices. This was evident for 1 (#186) of 9 residents reviewed for baseline care plans during this annual survey.2(a-c). Accurately document the baseline care plan. This was found to be evident for 8 (#193, #192, #44, #55, #78, #96, #118, #181) of 19 residents reviewed for smoking ,and 1 (#10) of 2 residents' Kardex reviewed.

Inspectors wroteBased on record reviews and staff interviews, it was determined that the facility failed to ensure a resident's right to formulate an Advanced Directive. This was evident for 1 (#55) out of 9 residents reviewed for Advanced Directives during the annual recertification survey.

Inspectors wroteBased on record reviews and interviews with staff, it was determined that the facility failed to ensure residents' rights to personal privacy. This was found to be evident for 3 (#60, #122, #141) of 4 residents residing together in a room on the Shenandoah Unit.

Inspectors wroteBased on review of Facility Reported Incident (FRI) investigative file and interviews, it was determined that the facility failed to report a misappropriation of resident property to the Office of Health Care Quality (OHCQ) within the required 24 hours after the allegation was made. This was found to be evident for 1 FRI (#3004409) out 7 FRIs reviewed during the annual recertification survey.

Inspectors wroteBased on record reviews and staff interviews, it was determined that the facility failed to provide written notification of transfer and bed hold policy. This was evident in 2 (#6, #19) of 3 resident records reviewed for discharge processes.

Inspectors wroteBased on record review and interview with staff, it was determined that the facility failed to ensure a resident's Minimum Data Set (MDS) assessments were completed and submitted in a timely manner. This was found to be evident for 1(#19) of 8 residents reviewed for accidents during the annual recertification survey.

Inspectors wroteBased on record review, and interviews with residents and staff, it was determined that the facility failed to ensure a Minimum Data Set (MDS) assessment was accurately coded to reflect the resident's status. This was evident for 5 (#12, #51, #55, #85, #139) of 19 residents reviewed for smoking and 1 (#195) of 3 residents reviewed for respiratory care during the annual recertification survey.

Inspectors wroteBased on record review and interview with staff, it was determined that Preadmission Screening and Resident Review (PASARR) was not re-evaluated and updated to reflect a resident's current diagnosis of serious mental illness. This was found to be evident for 1 (#19) of 2 residents reviewed for PASARR during the annual recertification survey.

Inspectors wroteBased on review of complaint #s 2723504 and 2788226, resident records, and staff interviews, it was determined that the facility failed to adhere to professional standards of practice when administering medications to residents. This was found to be evident for 1 (Resident #6) out of 1 resident reviewed for medications during the annual recertification survey.

Inspectors wroteBased on observation, interview and record review it was determined the facility failed to ensure a follow up medical appointment recommendation was followed and timely scheduled. This was evident for 1 (#27) out of 4 Residents reviewed for care planning during the facility's recertification survey.

Inspectors wroteBased on observations, record review, and interview with staff, it was determined that the facility failed to ensure a resident was properly assessed for the safe use of side rails and develop and implement a person-centered care plan. This was found to be evident for 1 (Resident #194) out of 2 resident reviewed for side rails during the annual recertification survey.

Inspectors wroteBased on record review and interview it was determined the facility failed to ensure yearly performance evaluations of geriatric nursing assistants. This was evident for 72 out of 75 geriatric nursing assistants during the surveyor's review of the staffing task during the facility's recertification survey.

Inspectors wroteBased on observation and interview it was determined that the facility failed to ensure daily staffing information was current and displayed in a prominent location. This was evident for 1 out of 1 staffing sheet observed to be present during the surveyor's initial tour of the facility.

Inspectors wroteBased on an interview and record review conducted during the annual survey, it was determined that the facility staff failed to promptly provide or obtain routine dental care and treatment. This was found to be evident for 1 (# 8) out of 8 residents reviewed for dental services during an annual survey.

Inspectors wroteBased on observations, medical record reviews, and interviews, it has been determined that the facility failed to honor resident preferences and provide consistent meal selections. This was evident for 1 (#8) of 8 residents reviewed for food preferences during an annual survey.

Inspectors wroteBased on record review and interviews with a resident and staff, it was determined that the facility failed to ensure a resident had the opportunity to communicate food preferences upon admission. This was evident for 1 (Resident #192) out of 3 residents reviewed for food concerns during the annual recertification survey.

Inspectors wroteBased on interviews and medical record reviews, it was determined that the facility failed to 1) use an interdisciplinary team to revise care plans in order to meet the residents' need and 2) ensure that a resident's representative was offered an opportunity to participate in a quarterly care plan review assessment. This was evident for 5 (#23, #2, #64, #73 and #119) of 34 residents reviewed during the recertification/complaint survey.

Inspectors wroteBased on observations, interviews with facility staff, and review of the facility's documentation, it was determined that the facility failed to accurately provide a meal based on the facility's established menu and respect residents' right to make choices about their diet. This was evident for 10 of 64 residents (Resident #147, #169, #524, #523, #149, #525, #450, #451, #452, #453) reviewed for accuracy of meals during a recertification/complaint survey.

Inspectors wroteBased on observation and interview it was determined the facility failed to: 1.) ensure the plate warming device was in operating condition, 2.) ensure foods were labeled, 3.) ensure accuracy of food discard dates, 4.) ensure food was not adulterated, 5.) ensure stored food was covered/protected, 6.) ensure kitchen surfaces were free from dust/debris, 7.) ensure food preparation surfaces were free from personal belongings, 8.) ensure the ceiling was free from chipping paint, and 9.) ensure kitchen equipment was clean and in good repair. This was evident during the surveyor's initial tour of the facility's kitchens during the facility's recertification/complaint survey.

Inspectors wroteBased on review of facility records and interviews with facility staff, it was determined the facility staff failed to ensure the required committee members consistently attended monthly Quality Assurance (QAPI) meetings.

Inspectors wroteBased on the surveyor's observation, medical record review, and staff interviews, the facility failed to implement an effective infection control program by 1) failed to change oxygen tubing as per the facility protocol. This was evident for one Resident (Resident #38) out of 34 Residents reviewed for infection control, and 2) ensure that they implemented and maintained an effective infection control program related to transmission-based precaution and enhanced barrier precaution protocols: including isolation precaution posted signs on rooms. This was evident by 3 (Resident # 73, # 100 and #119) of 34 residents and 3 residents' rooms reviewed during the recertification/complaint survey.

Inspectors wroteBased on interviews and record review it was determined that the facility failed to ensure that staff received training in effective communication. This was evident for 9 of 9 (Staff #6, #7, #10, #42, #43, #44, #45, #46, and #47) reviewed during the Extended Survey investigation portion of the recertification/complaint survey. The findings Include: On 2/24/25 at 12:53 PM the Director of Human Resources (Staff #41) was interviewed about the employee training records for Staff #6, # 7, #10, #42, #43, #44, #45, #46, and #47. Staff #41 was asked if they have any additional employee training/ in-services other than what is currently in their files. Staff #41 said they would check their old education system called Care fed, and let the surveyor know tomorrow morning. [...]

Inspectors wroteBased on interviews and record review it was determined that the facility failed to ensure that all staff received their annual training for the compliance and ethic program. This was evident for 5 of 9 (Staff #42, #43, #44, #46 and #47) reviewed during the Extended Survey investigation portion of the recertification/complaint survey. The findings Include: On 2/24/25 at 12:53 PM the Director of Human Resources (Staff #41) was interviewed about the employee training records for (Staff #42, #43, #44, #46 and #47). Staff #41 was asked if they have any additional employee training/ in-services other than what is currently in their files. Staff #41 said they would check their old education system and let the surveyor know tomorrow morning. [...]

Inspectors wroteBased on observations, interview with facility staff, and review of the medical record, it was determined that the facility failed to ensure that a resident's documented dining preference was honored. This was evident for 3 of 15 residents (#57, #524 and #525) reviewed for dining preference during the recertification/complaint survey.

Inspectors wroteBased on record review and interviews with facility staff, it was determined that the facility failed to provide residents with information to formulate an advanced directive. This was evident for 1 (Resident #81) of 3 residents reviewed for advanced directives during the recertification/complaint survey.

Inspectors wroteBased on a review of health records and interviews with facility staff, it was determined that the facility failed to notify Resident #449 or appointed family members after a dietary change. This was evident for one resident (Resident #449) out of seven residents reviewed during the complaint investigation.

Inspectors wroteBased on investigating complaints, record review, and interviews, it was determined that the facility failed to follow the grievance process for residents. This was evident for 2 (Resident #9 and #151) of 34 residents reviewed for the grievance process during this recertification/complaint survey.

Inspectors wroteBased on interview and record review it was determined the facility failed to implement their policy for abuse, neglect and exploitation and their policy for employment background investigations. This was evident for one facility employee (Geriatric Nursing Assistant #64) during the surveyor's review of the following facility reported incidents and complaints: MD#00210602, MD#00210823, MD#00211759, and MD#00210884 during the recertification/complaint survey.

Inspectors wroteBased on interview and record review it was determined the facility failed to ensure timely reporting of abuse allegations. This was evident for 1 out of 1 resident (Resident #151) reviewed for allegations of abuse during the surveyor's review of the following facility reported incidents and complaints: MD#00210602, MD#00210823, MD#00211759, and MD#00210884 during the recertification/complaint survey.

Inspectors wroteBased on review of a facility reported incident it was determined the facility failed to ensure the thorough investigation of an allegation of abuse. This was evident for 1 out of 1 resident (Resident #151) reviewed for allegations of abuse during the surveyor's review of the following facility reported incidents and complaints: MD#00210823, MD#00210602, MD#00211759, and MD#00210884 during the recertification/complaint survey.

Inspectors wroteBased on medical record review and staff interviews, it was determined that the facility failed to notify the Resident/Resident representative in writing about the bed hold policy when the Resident was transferred/discharged from the facility to an acute care facility. This was evident for one (Resident #64) of two residents reviewed who were transferred to an acute care facility during the recertification/complaint survey.

Inspectors wroteBased on the surveyor's observation, medical record review, and staff interviews, it was determined that the facility failed to have an accurate MDS (minimum data set) assessment regarding the status of dental issues for 1 (Resident # 38) of 80 Residents reviewed during the recertification/complaint survey.

Inspectors wroteBased on medical record review and staff interviews, it was determined that the facility failed to ensure that the Level II Preadmission screening and Resident review (PASARR) screen was completed by Adult Evaluation and Review Services (AERS) before the resident's admission. This was evident for 1 (Resident #82 ) of 60 residents reviewed for PASARR compliance.

Inspectors wroteBased on interviews with residents, review of medical records, and interview with facility staff, it was determined that the facility failed to ensure that residents and/or residents' representatives were provided with summaries of their baseline care plans including a list of their medications and failed to timely complete a baseline care plan. This was evident for 3 (#5, #57, and #145) of 34 residents reviewed for baseline care plans during the recertification/complaint survey.

Inspectors wroteBased on observations, record review, and interviews of the residents and facility staff, it was determined that the facility failed to initiate and develop a comprehensive person-centered care plan that includes measurable objectives, interventions, and timeframes to meet a resident's medical, nursing, mental, and psychosocial needs. This was evident for 3 (Resident #38, #57, and #145) of 34 residents reviewed during the facility's recertification/complaint survey.

Inspectors wroteBased on medical record review and resident and staff interviews it was determined the facility staff failed to ensure that dependent resident's personal hygiene needs were adequately met by offering and providing showers as scheduled. This was evident for 1 (#4) of 2 residents reviewed for Activities of Daily Living (ADL) care during a recertification/complaint survey.

Inspectors wroteBased on record reviews, observation, and interviews, it was determined that the facility failed to have documented evidence to support that the facility provided an ongoing program to support residents in their choice of activities. This is evident for 1(Resident #119) of 3 residents reviewed for activities services during the recertification/complaint survey. Findings Include: On 2/18/25 at 2:20 PM, in an interview with Resident #119's healthcare representatives, they revealed concerns that the facility failed to provide any activities to the resident. The healthcare representative stated that the resident was bedbound, alert but non-verbal and the facility never tried to get the resident out of bed to engage in any activities. On 2/25/25 at 10:44 AM, an observation revealed the resident resting in bed, awake, alert, but non-verbal, the TV on was on in the resident's room; [...]

Inspectors wroteBased on a review of the resident medical records and interviews with facility staff, it was determined that the facility failed to 1) ensure that a resident followed up with a GI (gastrointestinal) specialist and 2) ensure that a physician's order for an anticoagulant lab draw was carried out. This was evident for 2 (Resident #11, and # 437) of 71 residents medical records reviewed during this recertification/complaint survey process.

Inspectors wroteBased on record review and interview with facility staff, it was determined that the facility failed to monitor a resident's weight who was assessed as underweight and at risk of malnutrition. This was evident for 1 resident (Resident #29) of 5 residents reviewed for nutrition during the recertification/complaint survey.

Inspectors wroteBased on surveyor observations, review of the medical record, and interview with facility staff, it was determined the facility staff failed to provide residents with respiratory care consistent with professional standards by failing to 1) administer oxygen as prescribed, 2) label oxygen administration equipment, and 3) develop and implement a care plan that includes appropriate interventions for respiratory/tracheostomy care. This was evident for 2 (#57, and #115) of 4 residents reviewed for respiratory care during a recertification/complaint survey.

Inspectors wroteBased on medical record reviews, resident, a complaint review #MD00208110 and interviews, it was determined the facility staff failed to 1) ensure that a resident was given pain medication consistent with professional standards of practice and 2) assess the resident's pain level. This was evident for 3 (#38, #115, #431) of residents reviewed for pain management during a recertification/ complaint survey process.

Inspectors wroteBased on record review, observation, and resident and staff interviews, it was determined the facility failed to provide culturally competent, trauma-informed care to eliminate or mitigate triggers that may cause re-traumatization for a resident with Post-Traumatic Stress Disorder (PTSD). This was evident for 1 (#145) of 2 residents reviewed for Behavioral-Emotional care during the recertification/complaint survey.

Inspectors wroteBased on observation, medical record review, and interview with staff, it was determined that the facility failed to promptly ensure that the Resident received the recommended dental services. This was evident for one Resident # 38 out of five Residents reviewed for dental services during the recertification/complaint survey.

Inspectors wroteBased on observation, interviews, and medical record review, it was determined that the facility failed to ensure that residents who require dental services on a routine or emergent basis receive necessary or recommended dental services in a timely manner. This was evident for 2 (#11, #23) of 5 residents reviewed for dental services during the recertification/complaint survey. 1) On 02/18/25 at 11:35 AM, Resident #11 stated that she/he could not get a dental appointment for his/her top and bottom teeth. The surveyor observed missing teeth and side teeth with visual cavities. On 02/19/2025 at 1:52 PM, a record review revealed that Resident #11's MDS, dated [DATE] and 2/22/25 under Dental/Oral Evaluation, indicated that the resident has obvious or likely cavities or broken natural teeth. [...]

Inspectors wroteBased on review of the medical record and staff interview, it was determined that the facility failed to ensure accurately documented resident's health condition. This was found to be evident for 1 (Resident #73) out of 3 residents reviewed for pressure ulcers during this annual survey.

Inspectors wroteBased on interviews and an administrative record review, it was determined that the facility failed to have a full-time qualified social worker for the number of licensed beds exceeded 120 in the facility. This facility was licensed for 190 certified beds. This was evident during the recertification/complaint survey and had the potential to affect all residents, as a result an extended survey was conducted. Findings Includes: On 02/19/25 at 12:15 PM, in an interview with the Nursing Home Administrator (NHA) and the Director of Nursing (DON) it was revealed that the facility's licensed social worker comes in once a month. The NHA stated that they have 3 licensed social workers who work on a part-time/as needed basis, and there was full-time social services designee who did not have a qualifying bachelor's degree. [...]

Inspectors wroteBased on observation and interview it was determined the facility failed to 1) ensure the maintenance of the facility's exterior environment and 2) ensure that repairs were made, as needed, in resident areas as identified in 3 resident rooms/bathrooms. This was evident for 2 out of 2 facility buildings observed during the recertification/complaint survey process.

Inspectors wroteBased on interviews and record review it was determined that the facility failed to complete the annual nurse aide in-service training. This was evident for 1 of 3 (Staff #6 GNA) reviewed during the recertification/complaint survey. The findings Include: On 2/24/25 at 12:53 PM the Director of Human Resources (Staff #41) was interviewed about the employee training records for Staff #6, GNA. Staff #41 was asked if they have any additional employee training/ in-services other than what is currently in Staff #6, GNA employee file. Staff #41 said they would check and let the surveyor know tomorrow morning. On 02/24/25 at 2:20 PM the Director of Nursing (DON) was interviewed about employee files missing various training courses and that some staff had no name and no supervisor signature to verify the training. [...]

Inspectors wroteBased on interviews and record review it was determined that the facility failed to ensure that all staff received behavioral health training. This was evident for 3 of 9 (Staff #10 #43, and #46) reviewed during the Extended Survey investigation portion of the recertification/complaint survey. The findings Include: On 2/24/25 at 12:53 PM the Director of Human Resources (Staff #41) was interviewed about the employee training records for (Staff #10, #43, and #46). Staff #41 was asked if you have any additional employee training/ in-services other than what is currently in their files. Staff #41 said they would check their old education system and let the surveyor know tomorrow morning. On 02/24/25 at 2:20 PM the Director of Nursing (DON) was interviewed about employee files missing various training courses and that some staff had no name and no supervisor signature to verify the training. [...]

Inspectors wroteBased on record reviews and interviews, it was determined that the facility failed to accurately assess and update the Facility Assessment as required. This deficient practice has the potential to affect all residents in the facility. Findings Include: The Facility Assessment evaluates its resident population and identifies the resources needed to provide the necessary care and services that the residents require. On 02/26/25 at 02:59 PM, a review of the facility assessment revealed that the assessment failed to accurately identify all available resources within the facility. The following resources were inaccurately assessed and documented on the Facility Assessment form: 1) a special care unit within the facility, 2) the social worker and 3) the infection preventionist (IP). 1) On 02/27/25 at 11: [...]

Inspectors wroteBased on complaint, medical record review, resident and staff interview, it was determined the facility staff failed to: 1) honor a resident's choices to be seen by an outpatient physician consultant (Resident #77) and 2) provide showers as ordered to residents (Resident #16 and #101). This was evident for 3 out of 3 residents selected for review of choices and 3 out of 63 residents reviewed during the annual recertification survey.

Inspectors wroteBased on surveyor observation it was determined the facility failed to provide a safe, clean, comfortable and homelike environment. This deficiency has the potential to affect multiple residents.

Inspectors wroteBased on clinical record review, resident review, and staff interview it was determined the facility staff failed to: 1) ensure residents were receiving ordered medications (Resident#35); 2) provide incontinence briefs that fit (Resident #63) and 3) obtain weekly weights as ordered for a resident (Resident #77). This was evident for 3 out of 63 residents sampled for the survey.

Inspectors wroteBased on record review and staff interview it was determined the facility failed to ensure that residents who require dialysis received services consistent with professional standards of practice. This was evident for 4 of 63 residents (Resident #13, #39, #382, and #383) reviewed during the annual survey process.

Inspectors wroteBased on medical record review and staff interview, it was determined the consultant pharmacist failed to conduct a thorough medical record review to identify and bring to the facility staff's attention that Resident #22 received medications that had been discontinued. This was evident for 1 of 63 residents selected for review during the annual survey process.

Inspectors wroteBased on observation and interviews of facility staff, it was determined that food service employees failed to ensure that sanitary practices were followed and equipment was maintained to reduce the risk of foodborne illness. This deficient practice has the potential to affect all residents.

Inspectors wroteBased on observation, resident and staff interview it was determined that the facility failed to maintain resident equipment in safe operating condition. This was evident for 1 resident of 63 residents (Resident #115) reviewed during the investigative portion of the survey.

Inspectors wroteBased on observation and interview, it was determined the facility staff failed to provide a resident with the most dignified existence related to meals. This was evident for 1 of 1 resident (Resident #23) reviewed for dignity during the survey process and 1 of 63 residents selected for review during the annual survey.

Inspectors wroteBased upon staff interview and medical record review it was determined the facility staff failed to take immediate steps to have documentation in place to carry out the family's wishes for a Maryland Order of Life Sustaining Treatment (MOLST), that Resident #332 was to have an order for Do Not Resuscitate (DNR) and failed to get a translator for the spouse who was the surrogate decision maker. This was evident for 1 of 63 residents (Resident #332) reviewed during a complaint survey.

Inspectors wroteBased on complaint, reviews of a medical records, and interview with staff it was determined the facility failed to provide a resident and the resident's responsible party with a written notice and reason for the room change before the resident was actually moved. This was evident for 2 of 63 residents (Residents #17 and #231) observed during the annual recertification survey.

Inspectors wroteBased on medical record review and staff interview, it was determined that the facility staff failed to void an older Medical Orders for Life-Sustaining Treatment (MOLST) form located in a resident's active medical record for Resident (#129) and the facility staff failed to ensure the criteria of a resident's advance directive was met prior to changing the code status of Resident (#131). This was evident for 2 of 6 residents reviewed for Advance Directives during the annual recertification survey.

Inspectors wroteBased on observation and staff interview it was determined the facility staff failed to ensure resident's medical records were maintained securely. This was evident for 1 out of 63 residents (Resident #26) reviewed as part of the survey.

Inspectors wroteBased on a resident complaint, reviews of administrative documents and staff interview, it was determined the facility failed to notify local law enforcement of an allegation of alleged physical abuse. This was evident for 1 of 5 residents (Resident #77) reviewed for abuse during the annual recertification survey.

Inspectors wroteBased on record review and staff interview it was determined the facility staff failed to report an allegation of abuse of a resident to the Office of Health Care Quality(OHCQ) in a timely manner for Residents (#282). This was evident for 1 of 5 residents selected for review of abuse during the annual survey and 1 of 63 residents selected for review during the annual survey process.

Inspectors wroteBased on clinical record review and staff interview it was determined the facility staff failed to ensure the Ombudsman was notified when a resident was sent to the hospital. This was evident for 1 out of 25 residents (Resident #67) sent to the hospital.

Inspectors wroteBased on clinical record review and staff interview it was determined that the facility staff failed to ensure the full interdisciplinary team including residents and/or their responsible parties were invited to the quarterly care plan meetings. This was true for 1 out of 63 residents (Resident #76) reviewed during the survey process.

Inspectors wroteBased on clinical record review, resident interview, and staff interview it was determined the facility staff failed to: 1) ensure a resident had an audiology appointment (Resident #128) and 2) ensure residents had a vision appointment (Resident #128 and #131). This was evident for 2 out 5 residents selected for review for vision and 2 out of 63 residents in the survey sample. The evidence is as follows: 1. Interview of Resident #128 on 12/2/19 at 10:01 AM revealed that the resident had not been seen for either an audiology exam or a vision exam since admission. A review of Resident #128's clinical record on 12/2/19 at 1:30 PM revealed that neither an audiological nor a vision exam had been done for the resident since admission in December 2015. The Director of Nursing (DON) was interviewed on 12/6/19 at 9:55 AM and the resident's wishes were shared with her. [...]

Inspectors wroteBased on observation, medical record review and interview, the facility staff failed to provide treatment/services to prevent pressure ulcer to (Resident #101). This is evident for 1 of 7 residents selected for review of pressure ulcers during the annual survey process and 1 of 63 residents selected for review during the annual survey.

Inspectors wroteBased on medical record review, observation and interview, it was determined the facility staff failed to apply a palm guard as ordered for a resident. This was evident for 1 of 2 residents (Resident #16) selected for review of range of motion during the annual survey process and 1 of 63 residents selected for review during the annual survey.

Inspectors wroteBased on medical record review and staff interview it was determined the facility staff failed to document the percentage of intake for Resident #14 as ordered and failed to obtain a dietary consultation for Resident #14. This was evident for 1 of 8 residents reviewed for nutrition during the annual survey. 1A. Medical record review on 12/4/19 at 10:00 AM for Resident #14 revealed on 10/3/19 the dietician in collaboration with the physician ordered: 4 oz med pass 3 times a day at 10:00 AM, 2:00 PM and at hour of sleep and document percentage consumed. Med Pass Fortified Nutritional Shakes provides a convenient way to supplement calories and protein. Designed to be used as a medication pass drink, Med Pass products deliver more nutrition than water, juice or milk. This additional intake can mean weight maintenance or weight gain. [...]

Inspectors wroteBased on medical record review and interview, it was determined the Certified Registered Nurse Practitioner (CRNP) failed to ensure the criteria of a resident's advance directive was met prior to changing the code status of Resident #131. This was evident 1 of 5 residents selected for review of advance directives and 1 of 63 residents selected for review during the annual survey process.

Inspectors wroteBased on medical record review, observation and interview, it was determining the facility staff failed to: 1.) ensure the pharmacy provided the facility with the accurate dose of medication for administration for Resident #117. This was evident for 2 out of 26 opportunities for error and 1 out of 4 residents observed for medication pass and 2.) ensure the accurate completion of the Controlled Drugs Count Records for residents. This was evident for 2 of 5 Controlled Drug Count records reviewed during the survey process.

Inspectors wroteBased on medical record review and staff interview, it was determined the facility staff failed to ensure Resident #22 was free from unnecessary medication. This was evident for 1 of 6 residents selected for review of unnecessary medication and 1 of 63 residents selected for review during the annual survey process.

Inspectors wroteBased on medical record review, observation and interview, it was determined that the facility staff failed to obtain a medication error rate less than 5% for residents. This was evident for 2 out of 26 opportunities for error and 2 out of 4 residents (Resident #12 and #117) observed for medication pass.

Inspectors wroteBased on observations and staff interview it was determined that the facility staff failed to: 1.) ensure proper temperature storage of medications to preserve medication integrity, 2.) properly label multi-dose medications and 3). properly secure controlled substance medications. This was true for 1 of 3 medication storage rooms and 3 of 5 medication carts reviewed during the annual survey.

Inspectors wroteBased on medical record review and interview, it was determined the facility staff failed to obtain laboratory blood specimens on Resident #281 as ordered by the physician. This was evident for 1 of 1 resident selected for review of infection and 1 of 63 resident selected for review during the annual survey process.

Inspectors wroteBased on clinical record review, resident interview, and staff interview it was determined that the facility staff failed to obtain a dental consult for the residents. This was evident for 2 out 5 residents (Resident #128 and #131) selected for review of dental services and 2 of 63 residents in the survey sample.

Inspectors wroteBased on clinical record review, resident interview, and staff interview it was determined the facility staff failed to ensure residents received sufficient food amounts and respected resident choice. This was evident for 1 out 7 residents (Resident #35) selected for investigation of food quality.

Inspectors wroteBased on interview and observation it was determined the facility failed to provide food at a safe and appetizing temperature. This deficient practice has the potential to affect all residents.

Inspectors wroteBased on medical record review, observation and interview, it was determined the facility staff failed to assure the food is prepared and appropriate to meet resident's needs and according to their assessment. This was evident for 1 of 8 residents (Resident #28) selected for review of nutrition and 1 of 63 residents selected for review during the survey process.

Inspectors wroteBased on medical record review and interview, it was determined that facility staff failed to maintain a medical record in the most accurate form for Resident #115. This was evident for 1 of 63 residents reviewed during the survey.

Inspectors wroteBased on medical record review and interview, it was determined the facility staff failed to 1.) read the purified protein derivative (PPD) skin test of Resident #281 per standard of practice. This was evident for 2 of 63 residents selected for review of infection control during the annual survey process and 2.) provide a safe, sanitary environment to prevent the development and transmission of disease and infection (Resident #331). This was evident during the initial tour on 12/02/19 of the nursing units.

Inspectors wroteBased on surveyor observation and interview with staff, it was determined that the facility failed to provide a sanitary environment for a resident by failing to clean and prevent lingering odors in the resident's room. This was evident for 1 of 63 residents (Resident #79) reviewed during an annual recertification survey.

Inspectors wroteBased on surveyor observation and interview with staff it was determined that the facility failed to post the total number and the actual hours worked for Registered Nurses, Licensed Practical Nurses and Certified Nurse Aides. This was evident throughout the nursing units.