Autumn Lake Healthcare at Summit Park

Inspectors wroteBased on observations, interviews, clinical record reviews, and review of facility policy, the facility failed to ensure care was provided in accordance with the written plan of care for two (2) of 24 sampled residents (Resident #3, and Resident #8). Resident #8 did not receive intravenous (IV) fluids as ordered by the physician, and Resident #3 was not provided wound care in accordance with physician's orders.

Inspectors wroteBased on record review, resident interview, and staff interview, it was determined that the facility failed to maintain an effective pest control program. This was evident in 4 out of 4 units and had the potential to affect all residents.

Inspectors wroteBased on observations and staff interview, it was determined that the facility failed to treat residents with Dignity while dining. This was evident for 8 out 13 residents observed during the dining observation task in recertification survey.

Inspectors wroteNumber of residents sampled: Number of residents cited: Based on observations, record reviews and interviews, it was determined that the facility failed to provide activities to meet the needs and preferences of residents. This was evident to 2 (Resident #88 and Resident #103) out of 3 residents reviewed for activities during the recertification survey.

Inspectors wroteNumber of residents sampled: Number of residents cited: Based on review of Geriatric Nursing Assistant (GNA) personnel files and staff interview, it was determined that the facility staff failed to conduct yearly performance evaluations at least every 12 months for 3 (Staff #13, Staff #14 and Staff #15) of 3 GNAs reviewed for annual performance evaluation.

Inspectors wroteBased on resident interview, observations, and staff interviews, it was determined the facility failed to maintain a homelike environment. This was evident in 2 (Room A21 and Room D18) out of 9 rooms reviewed for environment.

Inspectors wroteBased on medical record review and interview with staff, it was determined that the facility staff failed to ensure a resident's Preadmission Screening and Resident Review (PASARR) form was completed on admission to the facility. This was evident during the review of 1 (Resident #56) of 3 residents reviewed for PASARR screening.

Inspectors wroteNumber of residents sampled: Number of residents cited: Based on record review and interviews, it was determined that the facility failed to ensure that residents were provided with summaries of their baseline care plans including a list of their medications. This was evident for 1 (Resident #15) of 3 residents reviewed for baseline care plans.

Inspectors wroteNumber of residents sampled: Number of residents cited: Based on interviews, record reviews and observations, it was determined that the facility failed to ensure that dependent resident's personal hygiene needs were adequately met by offering and providing showers as scheduled. This was evident for 2 (Resident #103 and #88) out 3 residents reviewed for activities of daily living.

Inspectors wroteNumber of residents sampled: Number of residents cited: Based on observations, record reviews and interviews, it was determined that the facility failed to ensure that residents received treatment and care to promote the highest practicable wellbeing as evidenced by 1) failure to follow physician orders and 2) failure to provide toileting hygiene for residents who were incontinent of bowel and bladder. This was evident for 3 (Resident #88, #126, and #137) out of 5 residents reviewed for quality of care during the recertification survey.

Inspectors wroteNumber of residents sampled: Number of residents cited: Based on record review and staff interview, it was determined that the facility failed provide the necessary treatment and services to promote healing. This was evident for 1 (Resident #131) out of 5 residents reviewed for pressure injuries.

Inspectors wroteBased on record review and staff interview, it was determined that the facility failed to provide the necessary treatment and services to promote healing. This was evident for 1 (Resident #131) out of 5 residents reviewed for pressure injuries.

Inspectors wroteBased on interviews, observations and record reviews, it was determined that the facility failed to provide residents with individualized care based on assessments and physician orders. This was evident for 1 (Resident #88) out of 4 residents reviewed for nursing skills and competency during the recertification survey.

Inspectors wroteBased on resident interview, record review, and staff interview, it was determined that the facility failed to prevent a significant medication error. This was evident for 2 (Resident #105 and #52) out of 6 resident's review for unnecessary medications.

Inspectors wroteNumber of residents sampled: Number of residents cited: Based on record review, observation and interview, it was determined that the facility failed to use appropriate infection control practice of hand hygiene when performing wound care. This was evident during a wound care and dressing change observation conducted for 1 (Resident #7) of 2 residents who had pressure ulcers.

Inspectors wroteNumber of residents sampled: Number of residents cited: Based on record review and staff interview, it was determined the facility failed to develop an individualized care plan for 1) a resident receiving oxycodone and 2) a resident with an indwelling foley catheter . This was evident for 2 (Resident #12 and Resident #125) out 20 residents reviewed for care planning. 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. 1) On 8/27/2025 at 9:03 AM, a review of Resident #12’s care plans was conducted. No care plan addressing Oxycodone (an opioid used to treat pain) was found. On 8/27/2025 at 9:31 AM, a review of Resident #12’s medication orders were conducted. The resident was ordered 1 Oxycodone 10 mg oral tablet to be given orally every 6 hours as needed for pain. [...]

Inspectors wroteNumber of residents sampled: Number of residents cited: Based on record review and interviews, it was determined that the facility failed to ensure the resident had an identification wrist band on which led to the wrong resident having their blood drawn. This was evident for 1 (Resident #44) of 28 complaints that were reviewed during the annual survey. The Findings Include: On 8/13/25 at 11:39 AM, complaint #330059 was reviewed and it mentioned that the resident had their blood drawn by mistake due to the resident not having an identification wrist band on. On 8/13/25 at 12:15 PM, the complainant was interviewed. They stated that on 12/9/2024, during a visit with the resident, they noticed that there was gauze and tape on the resident's hand. [...]

Inspectors wroteNumber of residents sampled: Number of residents cited: Based on record review and interview, it was determined that the facility failed to obtain laboratory tests as ordered by the physician. This was evident for 1 (Resident #120) of 27 residents reviewed during the investigation portion of the survey. The Findings Include: On 08/18/2025 at 7:27 AM, Resident #120's record review revealed a change in condition stating the resident had a change in mental status with paranoid delusions on 6/17/2025. The physician placed an order to obtain a urine analysis (UA) to rule out a possible urinary tract infection on 6/18/2025. On 08/18/2025 at 7:40 AM, a review of the resident's documented lab results revealed that there were no results for the ordered urine analysis. Further review revealed that there was no documentation of refusal. [...]

Inspectors wroteBased on record review and staff interviews, it was determined that the facility failed to: 1) accurately monitor residents for weight loss and to communicate dialysis residents' accurate condition (body weight loss reported as weight gain) with the dialysis center, which resulted in harm for Resident #78 due to an 8-day hospitalization for low blood volume; 2) report the resident's weight to the dialysis center and physician before Resident #76's blood pressure dropped, and 3) ensure an effective communication system between the dialysis center; 4) report and/or document the dialysis residents' conditions with physicians. This was evident in 2 (Resident #76 and #78) of 2 dialysis residents' records reviewed during the survey.

Inspectors wroteBased on surveyor observation and staff interview it was determined the facility staff failed to keep the building clean, neat, attractive and in good repair. This was evident in the four nursing units on both floors of the facility.

Inspectors wroteBased on interviews of facility staff, it was determined that the facility failed to ensure a full-time clinically qualified nutrition professional for the oversight of food preparation and the daily kitchen operation. All the residents in the facility have the potential to be affected by not having a qualified nutritional professional with the appropriate competencies and skill sets to carry out food and nutrition services.

Inspectors wroteBased on observation, interview, and documentation review it was determined that the person in charge of the kitchen failed to 1) ensure kitchen staff utilized effective hair restraints, 2) ensure the required sanitation levels of the facility's dishwashing machine, 3) keep vents and pipes and conduits clean and in good repair, and 4) ensure sanitary conditions for storage/transfers of ice to reduce the risk of foodborne illness. This practice had the potential to affect all residents that consumed food that was prepared by the kitchen.

Inspectors wroteBased on record review and interviews with residents, families, and staff, it was determined that the facility failed to have sufficient nursing staff to meet the needs of the residents. This was evident for 8 of 21 complaints submitted to the Office of Health Care Quality (OHCQ), the regulatory agency, 11 (#2, #27, #49, #50, #58, #78, #84, #96, #113, #222, #224) interviewable residents, 2 of 3 family interviews conducted, 2 of 10 (#32, #42) staff interviewed, and a review of staffing schedules. This deficient practice had the potential to affect all residents.

Inspectors wrote3. On 12/3/23 at 10:15 AM resident #96 was asked about the food and s/he responded, the food is awful, not much variety it is like low quality food, the meals are cold. 4. On 12/04/23 at 12:57 PM resident #224 indicated that the food is very bland, and the food was cold. On 12/15/23 at 10:38 AM an interview was conducted with the Food Vender Operational Manager of HealthCare Service Group (staff # 27). Upon questioning she indicated that food temperatures are recorded prior to food service and the food is maintained on the serving line. The plates are warmed and placed on a metal plate to keep food warm for an additional 20 minutes. She was asked about the breakdown of why the residents would say they get cold food, and she responded that it would depend on how long it takes to get food passed out. It should take about 20 minutes to get the food passed out. [...]

Inspectors wroteBased on observation, interview, and medical record review, it was determined that the facility staff failed to honor Resident #42's right for self-determination regarding smoking opportunities. This was evident for 1 out of 2 residents reviewed for resident preferences during the survey.

Inspectors wroteBased on clinical record review and staff interviews, it was determined that the facility failed to ensure a resident had a health care agent prior to obtaining an order to withhold CPR (cardiopulmonary resuscitation and 2) ensure the resident offered the opportunity to develop an advance directive for 2 (#67 and #113) of 9 sampled residents for advance directives.

Inspectors wroteBased on medical record review and interview of facility staff it was determined the facility failed to provide written notification to a resident when the facility determined that a resident no longer qualified for Medicare part A skilled services. This was identified for 1(#46) of 1 resident reviewed that remained in the facility after the termination of Medicare part A skilled services.

Inspectors wroteBased on medical record review and interview, the facility staff failed to thoroughly investigate complaints involving resident care. This was evident for 2 (#521 and #368) out of 44 residents reviewed during the survey.

Inspectors wroteBased on medical record review and staff interview, it was determined that the facility failed to orient, prepare, and document a resident's preparation for a transfer to the hospital. This was identified for 1 (#60) of 6 residents reviewed for hospitalization during the recertification survey.

Inspectors wroteBased on record review and interview it was determined that the facility failed to provide a notice of the bed hold policy when a resident was transferred to the hospital. This was evident for 1 (Resident #116) of 6 residents reviewed for hospitalization.

Inspectors wroteBased on observation, medical record review, and interview, it was determined the facility staff failed to ensure Minimum Data Set (MDS) assessments were accurately coded. This was evident for 2 (#58, #11) of 58 residents reviewed during the recertification survey.

Inspectors wrote4). During an interview with Resident #82 on 12/05/23 at 09:05 AM, the resident stated that he/she did not participate in any activity outside the room. Also, the resident reported that no one visited him/her in the room to offer any activities. On 12/21/23 at 8:12 AM, a review of Resident #82's medical record revealed that there was no care plan for Resident #82's activities. During an interview with Staff #11(Director of Activities) on 12/21/23 at 09:38 AM, the surveyor reviewed Resident #82's care plan with her. Staff #11 confirmed that no care plan was developed regarding the resident's activities. During an interview with the Director of Nursing on 12/21/23 at 2:10 PM, the DON was informed of the above concerns and validated the surveyor's concerns. 3). The facility reported incident MD00187009 was reviewed on 12/13/23 at 9:06 AM. [...]

Inspectors wroteBased on observation, record review, and interview, it was determined that the facility staff failed to revise and update a comprehensive care plan for residents and failed to have care plan meetings with a residents and/or resident representatives. This was evident for 3 (Resident #38, #27, #89) of 7 residents reviewed during the recertification survey.

Inspectors wroteBased on a review of the medical record, policy and procedures, and interview with staff, it was determined that the facility failed to meet professional standards of practice by failing to ensure physician orders for administration of narcotics as evidenced by nursing staff documented on the Medication Administration Record (MAR) and Controlled Drug Administration Record (known as control sheet). This was evident for 4 (#13, #84, #99, and #105) of 5 residents who were reviewed Controlled drug administration records and unnecessary drugs during the survey.

Inspectors wroteBased on observation, medical record review and interview, it was determined that the facility staff failed to maintain Resident #42's hygiene and appearance. This was evident for 1 out of 6 residents reviewed Activities of Daily Living (ADLs) during the survey.

Inspectors wroteBased on observation, medical record review and interview it was determined the facility failed to ensure effective oversight for the assessment and care of a resident's wound. This was evident for 1 out of 1 (Resident #19) resident reviewed for non-pressure skin conditions.

Inspectors wroteBased on observation, medical record review, and interview, it was determined the facility failed to: 1) properly date label oxygen tubing when changed, 2) have physician's orders for the administration of oxygen, and 3) develop and implement a person-centered comprehensive care plan with resident centered goals for respiratory care to include oxygen therapy. This was evident for 3 (#84, #59, #78) out of 5 residents reviewed for respiratory care during the recertification survey.

Inspectors wrote2. On 12/14/23 at 12:34 PM during an interview with the Director of Nursing (DoN), the Surveyor requested copies of Physician #25's visit notes on Resident #13 in the last 6 months for review and the DoN found only 2 visit notes. The DoN stated the resident was seen twice during the past 6 months: on 8/24/23 and 11/14/23. Additionally, the DoN confirmed that both visit notes were still not uploaded to the electronic medical record system. On 12/19/23 at 11:00 AM during an additional medical record audit using Resident #13's physical floor paper chart, only one Physician #25 visit note dated 8/24/23 was located. Based on medical record review and staff interview it was determined facility failed to provide timely visit notes in the electronic record or physical chart after each visit. This was evident for 2 (#13, #14) of 58 residents reviewed during the survey.

Inspectors wroteBased on a review of the medical record, policy and procedures, and interview with staff, it was determined that the facility staff failed to ensure narcotics removed from the resident's supply were administered to the resident, as evidenced by staff documenting the removal of narcotics without documentation of the need for the narcotic or documentation that the narcotic was administered to the resident. This was evident for 4 (#13, #84, #99, and #105) of 4 residents reviewed of 4 Controlled drug administration records and medication administration records reviewed during the survey.

Inspectors wroteBased on medical record review and staff interview it was determined that the facility failed ensure that accepted physician's responses to the consultant pharmacist recommendations were implemented. This was identified for 1 (resident #14) of 5 residents reviewed for unnecessary medications.

Inspectors wroteBased on medical record review and interview, it was determined the facility staff failed to follow physician orders by administering as needed (PRN) pain medication outside the prescribed parameters. By failing to follow the prescribed parameters for the medication administration, the resident was given an unnecessary medication. This was identified for 2 (#84, #105) of 5 residents reviewed during a recertification survey.

Inspectors wroteBased on observation and staff interview, it was determined that the facility failed to ensure that all expired drugs and biologicals used in the facility were removed from storage. This was evident on 2 of 3 medication carts and 2 of 4 medication storage rooms. Also, the facility failed to store drugs and biologicals in locked compartments. This was evident in 1 of 2 medication carts on unit A during an the survey.

Inspectors wroteBased on observation, medical record review, and interview it was determined the facility failed to ensure a resident timely received a dental provider consult for acute dental issues. This was evident for 1 out of 4 (Resident #11) residents reviewed for dental during the facility's recertification survey.

Inspectors wroteBased on observation, medical record review and interview, it was determined that the facility staff failed to ensure resident's religious preferences were honored and to provide a consistent Kosher diet. This was evident for 1 (Resident #91) out of 7 residents reviewed for food preferences.

Inspectors wroteBased on observation, interview, and record review, it was determined that the facility staff failed to provide appealing options to residents who choose not to eat the menu scheduled food items. This was evident for 1 (Resident # 91) out of 7 residents reviewed for substitute food during the survey.

Inspectors wroteBased on record review and interview it was determined that the facility failed to provide accurate and comprehensive clinical information to the survey team during the initial phase of the recertification survey. This was evidenced by the inaccurate resident matrix provided by the Director of Nursing (DON). This impeded the survey team's ability to determine all care areas that should be investigated.

Inspectors wroteBased on medical record review and interview of facility staff it was determined the facility failed to retain resident records for the required time period (Resident #528), ensure accuracy of medical order documentation and identify duplicate orders for the care of a resident's feeding tube (Resident #55) and document care that was provided (Resident #111 and #116). This was evident for 4 of out of 58 residents reviewed during the survey. one out of five residents reviewed for tube feedings during the facility's recertification survey.

Inspectors wroteBased on record review and interviews, it was determined that the facility failed to communicate with hospice representatives regarding the provision of care for the terminal illness, related conditions, and other conditions, to ensure quality of care for the patient and family. This was evident for 1 (Resident #23) of 1 residents reviewed for hospice services during the survey.

Inspectors wroteBased on observation and interview it was determined that the facility failed to ensure standard infection control precautions were maintained for residents. This was evident during several observations made throughout the facility.

Inspectors wroteBased on observation, interview, and record review it was determined the facility failed to ensure the most recent survey results were posted and readily accessible. This was evident during the facility's recertification survey.

Inspectors wroteBased on review of resident medical records and interview with facility staff, it was determined that the facility failed to provide notice to a resident and a resident's representative when the facility made the determination to involuntarily discharge the resident during an acute hospitalization. This was evident for 1 (Resident #1) of 1 resident reviewed for involuntary discharge.

Inspectors wroteBased on review of resident medical records and interview with facility staff, it was determined that the facility failed to comply with discharge requirements prior to denying readmission to a resident with documented aggression after the resident was cleared for discharge from an acute hospitalization. This was evident for 1 (Resident #1) of 1 resident reviewed for involuntary discharge.

Inspectors wroteBased on observation, staff interviews, and review of medical records and other pertinent documentation, on March 15, 2019, it was determined that the facility failed to maintain a safe environment for a resident with documented high-risk elopement behavior (Resident #10), in addition to providing proper supervision to residents identified at risk for wandering, elopement and potentially unsafe smoking. This was evident for 3 (Resident #10, #3, #75) of 8 (Resident #10, #28, # 91, #25, #89, #2, #3 and #75) residents reviewed for accidents. The facility's failures in this case led to the determination that immediate jeopardy existed, and the facility was notified of this determination on March 15, 2019 at 1:40 PM. The immediate jeopardy was removed on March 21, 2019 at 5:45 PM prior to survey exit. [...]

Inspectors wroteBased on observation and interview with residents and staff it was determined that facility staff failed to treat residents with respect and dignity by failing to knock prior to entering residents' rooms, asking permission before providing services or care and failed to keep private information about activity of daily living (ADL) information in an area that was not viewable by the public as evidenced by posting information on the staffing board. This was found to be evident for 3 rooms on multiple days. This has the potential to affect all the residents. Residents #50 and #20 had personal information posted on the staffing board in the hallway.

Inspectors wroteBased on medical record review and interview it was determined that the facility failed to ensure the a resident and family were fully informed of the risks versus the benefits of the use of an antipsychotic medication. This was found to be evident for 1 out of 6 residents (Resident #62) reviewed for unnecessary medications.

Inspectors wroteBased on observations and interview the facility failed to accommodate the residents need to have his/her bed positioned properly as desired thus prohibiting his/her view of the television. This was observed for 1 of 1 residents (Resident #7) selected for accommodation of needs.

Inspectors wroteBased on interview with residents during a resident council meeting and observation, it was determined that the facility failed to have the facility survey results in a location accessible and frequented by the majority of said residents.

Inspectors wroteBased on Beneficiary Protection Notification Review and interview with the facility staff, it was determined that the facility failed to provide an Advance Beneficiary Notice (ABN) and failed to ensure that the beneficiary(resident) or representative signed and dated the Notice of Medicare Non-Coverage (NOMNC). This was evident for 1 out of 3 residents(Resident #304) reviewed regarding liability notices.

Inspectors wroteBased on observation, review of Maintenance Request Log and interview it was determined that the facility failed to ensure a clean, comfortable and homelike environment as evidenced by ceiling tiles in multiple resident rooms with stains and black splotches. This was found to be evident on 1 of the 4 units in the facility.

Inspectors wroteBased on review of the facility reported incident MD00123567, investigative information, medical records and interview with staff it was determined that the facility failed to keep a resident free from abuse. This was evident for 1 out of 6 residents (Resident #255) reviewed for abuse

Inspectors wroteBased on medical record review and interview with facility staff, it was determined that the facility administered a chemical restraint to a resident (Resident #10) on 2 occasions.

Inspectors wroteBased on review of facility policy and interview with residents and facility staff, it was determined that the facility failed to initiate an investigation into a potential allegation of abuse. This was evident during a resident council meeting. This has the potential to affect all residents.

Inspectors wroteBased on medical record review and interview with staff it was determined that the facility failed to have an effective system in place to ensure residents and responsible parties were provided written notice of hospital transfers. This was found to be evident for 2 of 5 residents (Resident #82 and #103) reviewed for hospital transfers during the investigative stage of the survey.

Inspectors wroteBased on medical record review and interviews with staff it was determined that the facility failed to ensure the resident, or the resident's representative, was notified in writing of the bed-hold policy at the time of a hospital transfer. This was found to be evident for 1 out of 5 residents (Resident #82) reviewed for hospitalization during the survey.

Inspectors wroteBased on medical record review and interview it was determined that the facility failed to ensure the Minimum Data Set (MDS) assessments accurately reflected the resident's status as evidenced by failure to: 1. assess the use of antipsychotic medication (Resident #62), 2. assess that a resident was receiving restorative nursing services (Resident #61), 3. code a resident use of a diuretic correctly (Resident #24), 4. assess the resident's Activities of Daily Living (ADL) (Resident #20) and 5. code medication usage accurately (Resident #82). This was found to be evident for 5 out of 13 residents (Resident #62, #61, #24, #20, #82) reviewed during the investigative stage of the survey.

Inspectors wroteBased on medical record review and interviews of facility staff it was determined that the facility failed to 1. develop a care plan to address the initiation and continued use of an antipsychotic medication for the treatment of agitation and aggression related to dementia and 2. failed to develop a care plan for a resident who was diagnosed with Vitamin D Deficiency (low levels can result in soft brittle bones). This was found to be evident for 1 out of 6 residents (Resident #62) reviewed for medications and 1 of 5 self reports (Resident # 96) reviewed during the facility's annual Medicare/Medicaid survey.

Inspectors wroteBased on observation, medical record review and interview with staff it was determined that the facility failed to: 1. update and revise care plans that accurately reflect the resident's current assessment regarding Activities of Daily Living (ADL) and 2. update a resident care plan to include two residents being in a romantic relationship. This was evident for 3 out of 8 residents (Resident #42, Resident #19 and Resident #78) reviewed during the investigation stage of the long-term care survey.

Inspectors wroteBased on observation, interview and review of medical record it was determined that the facility failed to provide activity services as indicated in the resident's care plan. This was found to be evident for 3 out of 5 residents (Resident #47, Resident #97 and Resident #7) reviewed for activities during the survey.

Inspectors wroteBased on observation, medical record review and interview it was determined that the facility failed to ensure interventions included in a resident's care plan were implemented as evidenced by failure to ensure a roam guard was in place as ordered. This was found to be evident for 1 out of 3 residents (Resident #91) reviewed for elopement risk.

Inspectors wroteBased on medical record review and interview it was determined that the facility failed to have an effective system in place to ensure ophthalmology consults were obtained as ordered. This was found to be evident for the 1 out of 1 resident (Resident #63) reviewed for vision services during the survey.

Inspectors wroteBased on medical record review and interview with staff it was determined that the facility failed to provide necessary care to prevent the development of new pressure ulcers and to prevent infections of pre-existing pressure ulcers. This was found to be evident for 2 out of 8 residents (Resident #82 and #47) reviewed for pressure ulcers during the survey.

Inspectors wroteBased on medical record review of employee files and other pertinent documentation and interview with facility staff, it was determined that the facility failed to ensure staff was trained in tracheostomy care. This was evident in the review of 1 of 1 residents (Resident #55) reviewed for having a tracheostomy.

Inspectors wroteBased on review of the facility assessment, employee files and interviews, it was determined that the facility failed to ensure that geriatric nursing assistants (GNA) demonstrated skills competency prior to being allowed to work independently with residents and annually after hire. This was found to be evident for 1 of 6 recently hired GNAs (#11)

Inspectors wroteBased on review of the medical record and interview with facility staff it was determined that the physician failed to address an irregularity identified by the clinical pharmacist and the clinical pharmacist failed to identify discrepancies in the residents' drug regimens. This was evident for 2 of 3 residents (Resident #70 and #16) reviewed for chemical restraints.

Inspectors wroteBased on review of the medical record and interview with facility staff it was determined that the facility staff failed to ensure PRN (as needed) psychotropic drugs were limited to 14 days. This was evident for 2 of 3 residents (Resident #70 and #16) reviewed for chemical restraints.

Inspectors wroteBased on observation, interview and medical record review it was determined that the facility failed to ensure the medication error rate was less than 5% as evidenced by 5 observed errors out of 31 opportunities for error. The errors observed included failure to measure the dose of a pain relief gel on two separate occasions, failure to administer a pain relief gel, failure to administer the correct dosage of a medication to treat high blood pressure, and failure to assess the resident's blood pressure prior to the administration of a medication with orders to hold the medication if the blood pressure was below a certain level. This practice was found to be evident for 3 out of the 4 residents (Resident #92, #86, and #17) observed during medication administration observation.

Inspectors wroteBased on observations and interviews it was determined the facility failed to: 1. store medications appropriately by removing expired medications from medication carts and 2. failed to ensure that medications were kept secure as evidenced by the observation of a container of vitamin D drops being left unattended on top of a medication cart located in a hallway while the nurse responsible for the cart was in the resident's room administering medication. This was found to be evident for 2 of 4 medication carts observed and 1 of 4 medication observations (Resident #7) completed during the facility's annual Medicare/Medicaid survey.

Inspectors wroteBased on medical records review and interview with staff it was determined that the facility failed to obtain a radiology test in a timely manner causing a potential delay in treatment. This was evident for 1 out of 8 residents (Resident #42) reviewed during the investigative stage of the survey.

Inspectors wroteBased on medical record review and interview with staff it was determined that the facility failed to ensure physician progress notes were written in a manner that they were readily accessible to staff as evidenced by two staff being unable to easily read a physician's progress notes. This was found to be evident for 1 out of the 9 residents reviewed during the survey but had the potential to affect any of the residents seen by this physician (Staff #31).

Inspectors wroteBased on pertinent record review and interview with facility staff, it was determined that the facility failed to have an effective quality assurance plan (QAPI) in place to prevent the repetition of deficiencies and identified concerns that have effects on residents. This was evident in the review of the facility QAPI plan and CASPER (Certification and Survey Provider Enhanced) report.

Inspectors wroteBased on medical record review, observation and interview it was determined that the facility failed to ensure staff completed hand sanitation after handling soiled dressings.