Advanced Rehab At Autumn Lake Healthcare
Inspection history, citations, penalties and survey trends for this long-term care facility in Lutherville, Maryland.
- Location
- 515 Brightfield Road, Lutherville, Maryland 21093
- CMS Provider Number
- 215226
- Inspections on file
- 20
- Latest survey
- December 11, 2025
- Citations (last 12 mo.)
- 19
Citation history
Health deficiencies cited at Advanced Rehab At Autumn Lake Healthcare during CMS and state inspections, most recent first.
The facility did not ensure that comprehensive care plans addressed residents' medical needs, including oxygen therapy and psychiatric medication, nor did it update care plans following significant changes such as hospice admission. Additionally, required quarterly care plan meetings were not conducted for a resident with ongoing sensory concerns, and documentation of these meetings was not available.
Surveyors found that the facility did not consistently ensure narcotic record books were signed by both incoming and outgoing nurses, failed to maintain drug records that accounted for all controlled drugs, and did not administer medications according to physician-ordered parameters. This included cases where a resident's controlled substance was removed from supply without corresponding documentation of administration, and instances where residents received pain and blood pressure medications outside of prescribed parameters, with required non-pharmacological interventions not documented.
The facility failed to conduct thorough investigations and maintain documentation for abuse allegations involving four residents. Investigations lacked interviews, signed statements, and complete reports. The DON and Administrator acknowledged these deficiencies, which were discussed at the exit conference.
The facility failed to follow professional nursing standards in medication administration, resulting in delayed medication for several residents. A resident reported not receiving PRN oxycodone on time, and audits confirmed multiple medications were administered hours late. Further reviews showed a pattern of late documentation and administration for other residents, indicating systemic issues.
The facility failed to report alleged abuse within the required 2-hour timeframe. An incident involving alleged abuse was reported late to the state agency, and a resident's report of verbal abuse by an RN was not immediately reported to the state office or law enforcement. The facility's policy requires immediate reporting of such allegations.
The facility failed to develop and implement comprehensive care plans for two residents. One resident with Type 1 Diabetes Mellitus did not have a diabetes care plan, despite receiving insulin. Another resident with respiratory issues was not included in a care plan meeting and lacked a respiratory care plan, contrary to the facility's Oxygen Administration policy.
The facility failed to follow physician orders for three residents, resulting in deficiencies in care. A resident with lymphedema was not provided with prescribed ACE wraps, another resident received incorrect dosages of pain medication, and a third resident was given an incorrect oxygen flow rate. These issues were due to confusion over orders, lack of EHR access, and lapses in monitoring.
The facility failed to document whether a resident showed signs of abuse following an allegation and did not verify monthly pharmacy reviews for two residents. The medical record for a resident lacked evidence of documentation after an alleged abuse incident, and staff confirmed the absence of necessary documentation. Additionally, staff were unable to locate pharmacy reviews for two residents, indicating a failure to maintain proper documentation.
The facility did not maintain resident dignity by failing to cover foley drainage bags for two residents. One resident's uncovered bag was visible from the hallway, and another resident was observed with an uncovered bag while in a wheelchair. An LPN acknowledged that foley bags should be covered.
A facility failed to include a resident's advance directive in their medical record. A MOLST form was created and signed but was not filed in the electronic or paper chart, leaving it unavailable for nursing staff. The DON confirmed that without the form, the resident would be considered Full Code.
A facility failed to provide a completed bed hold policy notice to a resident before their transfer to a hospital. The notice was incomplete and lacked the resident's name and other details. An LPN stated the resident was drowsy and unable to sign, but this was not documented, and the notice was not given to the resident.
A facility failed to provide a baseline care plan summary to a resident within 48 hours of admission. The resident reported not being invited to a care plan meeting or receiving a baseline care plan summary. Interviews and medical record reviews confirmed the absence of the required documentation, and the staff could not provide evidence of compliance.
A resident reported receiving only two showers in a month, despite a preference for twice-weekly showers. The resident's concerns were communicated to the unit manager and DON, but the preferred schedule was not met. Task documentation showed inconsistencies and missing entries, and the nurse manager had not addressed the issue with the resident. The DON acknowledged the need for GNA reeducation on documentation.
A resident with respiratory conditions was receiving oxygen without a physician order, and the facility staff failed to administer the correct flow rate as prescribed. The resident's care plan did not address their respiratory needs, and staff were unaware of the correct oxygen flow rate, leading to inconsistencies in care. The facility's policy requires a physician order and a care plan for oxygen therapy, which were not in place.
The facility failed to monitor medications properly, resulting in an expired Influenza Vaccine Afluria Quadrivalent 5ml Multi-dose Vial being found in the 1st floor Unit 2 medication room. This was confirmed by a Unit Manager during an observation and interview.
A resident reported missing bottom dentures and difficulty eating without them. The facility failed to document the dentures upon admission and did not schedule a dental appointment or arrange transportation, despite agreeing to do so after a grievance was filed by the resident's family.
Failure to Develop and Implement Comprehensive Care Plans for Residents
Penalty
Summary
The facility failed to ensure that comprehensive, person-centered care plans were developed and implemented to address residents' specific medical needs and significant changes in condition. One resident receiving oxygen therapy did not have this intervention included in their care plan, despite documentation in the Minimum Data Set (MDS) and direct observation of oxygen use. Additionally, the same resident had an active diagnosis of mood disorder and was prescribed risperidone, but neither the diagnosis nor the medication was addressed in the care plan. Another resident was admitted to hospice services following a significant change in condition, as indicated by physician orders and MDS documentation. However, there was no care plan addressing hospice or end-of-life care needs until several weeks after hospice admission, and only after the survey team arrived at the facility. Staff interviews confirmed that care plans should be updated promptly following significant changes in condition, but this did not occur in this case. A third resident, admitted for skilled rehabilitation and later transitioned to long-term care, did not have quarterly care plan meetings conducted as required. After the initial interdisciplinary care conference, there was no evidence of subsequent care plan meetings or documentation, despite ongoing concerns related to the resident's hearing and vision. The facility was unable to provide records of any additional care plan meetings after the initial conference.
Failure to Ensure Proper Medication Management and Documentation
Penalty
Summary
The facility failed to ensure proper management and documentation of controlled substances and medication administration according to physician orders. Surveyors observed that narcotic record books on multiple medication carts were missing required signatures from both incoming and outgoing nurses at shift changes. Several nurses confirmed that although narcotics were counted together, signatures were often omitted due to oversight or busy shifts. The Director of Nursing (DON) confirmed that both nurses are expected to sign the narcotic record book after each count, but this was not consistently done. A review of complaints and resident records revealed discrepancies in the documentation and administration of controlled substances. In one case, a resident's controlled drug administration record showed that oxycodone was removed from the narcotic supply on several occasions, but the Medication Administration Record (MAR) did not reflect that the medication was administered, despite the resident being cognitively intact at the time. Another complaint involved a resident who reported increased pain due to missed pain medication, and record review showed that pain medications were administered outside of the physician-ordered pain scale parameters, including both under- and over-medication, as well as administration when not clinically indicated. Further review of another resident's MAR showed that multiple medications, including antihypertensives and pain medications, were administered outside of the physician-ordered parameters, such as giving medications when blood pressure was below the specified threshold or administering pain medication for pain scores lower than required. Additionally, non-pharmacological interventions ordered to be offered prior to PRN medication administration were not documented as provided. These findings were confirmed through interviews with the DON and review of clinical records.
Incomplete Abuse Investigations and Documentation
Penalty
Summary
The facility failed to conduct thorough investigations and maintain proper documentation regarding allegations of resident abuse for four residents. In the case of Resident #424, the investigation lacked interviews with residents or staff and did not include signed statements. The Director of Nursing (DON) confirmed the absence of these documents and acknowledged the need for staff education. Similarly, for Resident #101, the investigation was incomplete as it did not include statements from the Geriatric Nursing Assistant (GNA) who reported the abuse or from the resident themselves. The Administrator noted that the incident occurred before the facility's change of ownership, and no additional documentation was available. For Resident #120, the facility could not provide a complete report of the incident involving an RN allegedly not stopping an enema when requested by the resident. The regional nurse indicated that older reports might be in storage, but the complete report was not retrieved by the survey's conclusion. Additionally, the investigation for Resident #99's physical abuse allegation was incomplete, lacking staff interviews, written statements, and a 5-day investigation result. The Administrator and Regional Nurse admitted the absence of a complete investigation file. These deficiencies were discussed with the administrative team at the exit conference.
Medication Administration Delays and Documentation Issues
Penalty
Summary
The facility failed to adhere to professional standards of nursing practice in administering medications to residents, as evidenced by multiple instances of delayed medication administration. Resident #60 reported not receiving medications on time, including PRN oxycodone, which was delayed until the next shift. The medication administration audit report confirmed that several medications scheduled for specific times were administered hours later than prescribed. Further investigation revealed that Resident #15's medication administration audit record showed multiple instances of late documentation, with some medications documented up to seven hours after administration. This practice violates the standard of nursing practice, which requires immediate documentation post-administration to ensure accurate records and prevent medication errors. Additional reviews of medication administration audit records for Residents #502, #509, and #102 demonstrated a pattern of late documentation and administration. For Resident #102, multiple doses of Tylenol were administered several hours after the scheduled time. These findings were discussed with the facility's administration team, highlighting a systemic issue with medication administration timing and documentation.
Failure to Timely Report Alleged Abuse
Penalty
Summary
The facility staff failed to notify the state agency of an alleged case of abuse within the required 2-hour timeframe. This deficiency was identified during a survey when it was found that an incident involving alleged abuse occurred on 09/25/22 during the 3 pm to 11 pm shift, but was not reported to the state agency until 09/26/22 at 1 pm. The facility's policy mandates that all alleged violations involving abuse must be reported immediately, but no later than 2 hours after the allegation is made. The Administrator acknowledged the delay in reporting during an interview. Additionally, a resident reported verbal abuse by an agency RN to the DON, but the allegations were not reported to the state office or law enforcement within the required timeframe. The resident expressed feeling unsafe receiving medications from the nurse involved. The DON confirmed that the abuse allegations were not reported immediately as required, and the survey team was later provided with a copy of the initial report. These findings were discussed with the administration team at the time of the survey exit.
Failure to Develop and Implement Comprehensive Care Plans
Penalty
Summary
The facility failed to ensure comprehensive care plans were developed and implemented for two residents, leading to deficiencies identified during a survey. Resident #112, who was admitted with Type 1 Diabetes Mellitus, did not have a diabetes care plan in place. Despite receiving insulin, there was no documented care plan addressing the resident's diabetes management, which is crucial for monitoring and adjusting treatment as needed. This oversight was noted during a review of the resident's medical record and was acknowledged by the Director of Nursing (DON) and Regional DON during an interview. Additionally, Resident #85, who had multiple diagnoses affecting respiratory function, including chronic obstructive pulmonary disease and emphysema, was not included in a care plan meeting and lacked a respiratory care plan. The absence of a care plan meant there were no documented goals or interventions to address the resident's respiratory needs, such as oxygen therapy. The facility's Oxygen Administration policy requires that care plans identify interventions for oxygen therapy, but this was not done for Resident #85, as revealed during a review of the resident's medical record and the facility's policy.
Failure to Follow Physician Orders for Residents
Penalty
Summary
The facility failed to adhere to physician orders for three residents, leading to deficiencies in care. Resident #40, who has multiple diagnoses including lymphedema and chronic kidney disease, was observed multiple times without the prescribed ACE wraps on their legs. Despite having clear physician orders to apply the wraps daily, the staff did not follow through, partly due to confusion over duplicate orders in the electronic health record (EHR) and a lack of access to the EHR by new staff. Resident #15 experienced issues with pain management due to the facility's failure to administer pain medication according to the physician's specified parameters. The medical record indicated that the resident was given incorrect dosages of Morphine Sulfate and Ibuprofen, which did not align with the pain scores documented. This discrepancy was noted over several instances, leading to the resident experiencing unmanaged pain. Resident #37 was observed receiving an incorrect oxygen flow rate, set at 3 liters per minute instead of the ordered 2 liters. This error was identified during a surveyor's observation and confirmed by the resident's assigned nurse. The nurse was unaware of the discrepancy until it was pointed out, indicating a lapse in monitoring and adherence to the physician's orders for oxygen therapy.
Failure to Document Abuse Allegation and Pharmacy Reviews
Penalty
Summary
The facility failed to document whether a resident exhibited signs and symptoms of abuse immediately following an allegation of abuse. This deficiency was identified during a review of Resident #508's medical record, which lacked evidence of documentation regarding the resident's condition after the alleged abuse. The Assistant Director of Nursing (ADON) confirmed the absence of a progress note or documentation that the physician was notified, although an x-ray was ordered two days after the alleged incident. The facility's policy requires thorough documentation of any changes in a resident's condition, but no such documentation was found for Resident #508. Additionally, the facility did not provide documentation to verify that monthly pharmacy reviews were completed for two residents, #11 and #21. During interviews, staff members, including an LPN Unit Manager and the Director of Nursing (DON), were unable to locate the pharmacy reviews for these residents. The DON mentioned that pharmacy reviews are printed and reviewed by the Medical Director, with copies kept in a binder in their office. However, no evidence of the pharmacy reviews for the specified residents was found, indicating a failure to maintain proper documentation as required.
Failure to Cover Foley Drainage Bags
Penalty
Summary
The facility failed to uphold the dignity of residents by not ensuring that foley drainage bags were covered. This deficiency was observed in two residents. During observation rounds, one resident was found with an uncovered foley catheter bag attached to their bed, visible from the hallway due to the open door. The bag contained amber-colored liquid. A Unit Manager LPN confirmed that foley bags should be covered. Another resident was seen in a wheelchair with an uncovered foley bag, also containing amber-colored liquid, while ambulating in the hallway.
Failure to Include Advance Directive in Resident's Medical Record
Penalty
Summary
The facility failed to ensure that a current copy of a resident's advance directive was included in the resident's medical record. This deficiency was identified during a record review and staff interviews, where it was found that a Medical Orders for Life-Sustaining Treatment (MOLST) form for a resident was not present in either the electronic or paper chart. The resident had been admitted to the facility, and the MOLST form was created and signed by a doctor but was left on the doctor's desk instead of being properly filed. As a result, the MOLST form was unavailable for nursing staff to reference from the time it was created until it was discovered missing during the survey. The Director of Nursing confirmed that without a MOLST or advance directive, the resident would be considered Full Code.
Failure to Provide Completed Bed Hold Policy Notice
Penalty
Summary
The facility failed to provide a completed bed hold policy notice to a resident prior to their transfer to a hospital. The deficiency was identified during a review of the medical records and staff interviews, which revealed that the resident was transferred to the hospital without receiving a copy of the bed hold policy. The notice was found in the resident's paper chart, but it was incomplete, lacking the resident's name and other necessary details. It was noted that the resident was their own representative, yet the notice indicated that the resident's son approved the bed hold policy via phone. An LPN involved in the process stated that the resident was drowsy and unable to sign the notice at the time of transfer, but this was not documented in the resident's chart. Additionally, the LPN admitted to not providing a copy of the notice to the resident before discharge.
Failure to Provide Baseline Care Plan Summary
Penalty
Summary
The facility failed to provide a baseline care plan summary to a resident within 48 hours of admission, as required. This deficiency was identified during a survey where it was found that a resident had not been invited to a care plan meeting nor received a baseline care plan summary. Interviews with the resident and the Director of Social Services confirmed the absence of a baseline care plan. Additionally, a review of the medical record did not reveal any documentation indicating that the resident was given a baseline care plan or summary. The nurses were unable to provide any progress notes or additional documentation to support that the baseline care plan was provided.
Failure to Provide Showers According to Resident Preference
Penalty
Summary
The facility failed to provide activities of daily living (ADLs), specifically showers, according to a resident's preference. The resident, who had recently moved from the first floor to the second floor, reported receiving only two showers in the past month, despite a preference for twice-weekly showers. The resident had communicated this concern to the unit manager and the Director of Nursing (DON) but did not receive the preferred frequency of showers. The resident also required a shower chair for assistance, which was not consistently provided. The surveyor's review of the electronic task documentation revealed inconsistencies and missing entries regarding the resident's shower schedule. The task form showed that the resident received showers on only three occasions during the month, with several dates left blank. The nurse manager had not recently spoken with the resident to address these concerns, and the DON acknowledged the need for reeducation of the geriatric nursing assistants (GNAs) on accurate documentation. This deficiency was discussed with the unit manager and the DON before the exit conference.
Failure to Provide Appropriate Respiratory Care
Penalty
Summary
The facility staff failed to provide appropriate respiratory care for a resident, as evidenced by the lack of a physician order for oxygen administration and the absence of a care plan addressing the resident's respiratory needs. The resident, who had diagnoses including chronic obstructive pulmonary disease, emphysema, atrial fibrillation, and atherosclerotic heart disease, was observed receiving oxygen at a flow rate of 2.5 liters per minute without a corresponding physician order in the electronic health record or paper chart. During the survey, it was noted that the resident continued to receive oxygen without a documented order, and the staff was unaware of the correct flow rate prescribed. An LPN initially stated the resident was on 3 liters of oxygen, but upon checking, realized the flow rate was 2.5 liters, which did not match any documented order. The LPN confirmed the absence of an oxygen order and notified the Unit Manager, who also acknowledged the lack of a physician order and was unsure of the reason for the oxygen administration. The Director of Nursing was informed of the findings and confirmed that a physician order should be in place for residents receiving oxygen. The facility's policy on oxygen administration requires a physician's order and a care plan outlining the interventions for oxygen therapy. Despite these requirements, the resident's care plan did not address their respiratory needs, and the staff failed to administer oxygen as prescribed, leading to inconsistencies in the oxygen flow rate provided to the resident.
Expired Vaccine Found in Medication Room
Penalty
Summary
The facility failed to properly monitor medications, as evidenced by the presence of an expired Influenza Vaccine Afluria Quadrivalent 5ml Multi-dose Vial in the 1st floor Unit 2 medication room. This deficiency was identified during observation rounds conducted at 03:05 PM, where surveyors found the expired vaccine. During a subsequent interview and observation with the Unit Manager, staff #6, at 03:15 PM, the staff member confirmed the presence of the expired vaccine, acknowledging the oversight in monitoring the medication's expiration date.
Failure to Arrange Dental Services and Transportation
Penalty
Summary
The facility staff failed to schedule a dental appointment and arrange transportation for a resident who reported missing bottom dentures. The resident could not recall the exact time or staff member to whom the incident was reported. Upon review, there was no documentation of the resident having dentures upon admission, and the resident expressed difficulty eating without them. The Director of Nursing (DON) confirmed that all residents' belongings are logged at admission, discharge, and readmissions, and a grievance form is completed for missing items. However, the resident's dentures were not listed on the personal inventory form. A grievance was filed by the resident's family member, who reported the missing dentures and was informed by the Director of Guest Services that the dentures were not documented upon admission. The family member planned to contact the insurance company for a replacement, and the facility agreed to schedule a dental appointment and cover transportation costs. Despite this agreement, the DON and Regional Nurse were unable to confirm that the dental appointment and transportation arrangements had been made, and there was no documentation to verify these actions were completed.
Latest citations in Maryland
The facility did not ensure that its Infection Preventionist (IP) met required qualifications for managing the Infection Prevention and Control Program. The DON reported serving as the IP but acknowledged lacking the specialized infection control training required for the role, and confirmed that no other staff member was currently qualified. Records showed that the previously qualified IP left several months earlier, and the Administrator and DON confirmed they were still seeking a replacement, leaving the infection control program without a properly trained leader.
Staff failed to consistently secure medications and medical supplies across three units, including an oxygen tank left on the floor behind a resident’s bed without a supporting device, a treatment cart with Collagenase Santyl cream left on top while two residents in power wheelchairs passed by, an unattended and unlocked treatment cart at a nursing station, and another treatment cart with Diclofenac gel and dressings left on top, indicating repeated lapses in maintaining locked and secure storage for drugs, biologicals, and related supplies.
The facility failed to provide sufficient dietitian coverage and timely nutritional assessments for several residents with significant dietary needs. A resident admitted for diabetic management with a high A1C was placed on a regular diet instead of the recommended carb-controlled diet and had only one weight taken in the first two weeks, with no dietitian review of the record. Another resident with prior significant weight loss had no documented dietitian follow-up despite continued weight loss, and a resident admitted with severe protein-calorie malnutrition experienced further significant weight loss without any dietitian assessment. The dietitian reported working limited hours and prioritizing certain high-risk cases, resulting in delayed or missed evaluations for new admissions and residents with ongoing nutritional concerns.
The facility failed to maintain adequate linen and incontinence supplies and did not keep resident care areas in good repair, resulting in delays and alterations in incontinence care and substandard environmental conditions. Staff reported that towels and washcloths were used instead of wipes and then discarded due to heavy soiling, and that linen deliveries to units were late, leaving residents waiting for care. Observations showed very limited numbers of clean washcloths and other linens on units and in the laundry, with no stock of disposable wipes or backup washcloth supply despite repeated reports to housekeeping. Additional observations revealed recliner chairs blocking a dining-area handwashing sink and kitchenette, multiple resident and shared bathrooms with unfinished spackle, chipped paint, musty odors, black substances near showers, missing threshold molding, exposed cracks and nails, and eroded, rusted baseboard heaters. Hallway handrails on both units were worn, chipped, and splintered, and a shower room contained fecal odors, dried brown stains on the toilet, and deteriorated fixtures, all contributing to a failure to provide a safe, clean, and homelike environment.
Facility staff did not thoroughly investigate two separate abuse allegations involving a resident and an injury of unknown origin involving another resident. In both cases, investigations focused on the directly affected resident and included staff interviews, but there were no interviews of other residents on the unit or documented assessments of those residents for signs of abuse or injuries of unknown origin, including residents unable to communicate due to cognitive status.
Two residents who were dependent on staff for oral care, including one with a tracheostomy, were observed with thick, white or milky substances coating their mouths and teeth, indicating inadequate oral hygiene. One resident communicated that staff did not brush their teeth and that staff "need to." In another case, despite oral care supplies being present in the room, the resident’s mouth and teeth remained unclean on multiple observations, with a thick milky substance caking the teeth and stringing between them when the resident tried to open their mouth. These findings showed that staff did not consistently provide oral care to residents who relied on them for this ADL.
Staff failed to maintain complete and accurate medical records for multiple residents, including missing and inconsistent documentation of wound care, delayed pain assessment after discovery of an injury of unknown origin in a cognitively impaired resident, and inaccurate recording of a PPD test result that was documented as negative despite no evidence the injection was administered and no supporting nurse’s note. Residents reported not receiving certain treatments, while MAR entries either lacked signatures for completion or contained conflicting information about whether care was provided.
Surveyors found that the facility failed to consistently implement and communicate correct transmission-based precautions and PPE use. One resident with a Foley catheter related to wounds had no precaution signage posted, while another resident in a double room had a contact precautions sign at the door, yet the NP entered without PPE and the GNA provided high-contact care wearing only gloves. Staff in that room stated the resident was not on contact precautions and later reversed the sign to show no PPE requirement. Therapy staff reported they rely solely on posted signs to determine PPE, and surveyors identified broader issues with inaccurate signage and staff awareness of which residents required contact precautions.
Surveyors found that MDS assessments were inaccurately coded for two residents. In one case, a resident sustained a femoral neck fracture after a fall, but the subsequent significant change MDS did not code the fall as a major injury and failed to capture prn Tylenol use documented on the MAR within the look-back period. In the other case, a quarterly MDS indicated opioid use for a resident, but the MAR for the same period showed no prescribed opioid, indicating incorrect coding of high-risk drug classes.
A resident who had recently been admitted and experienced a fall received multiple doses of the narcotic analgesic Tramadol, but the facility failed to accurately document all administered doses on the Medication Administration Record (MAR). Review showed only one Tramadol dose recorded on the MAR, while the Controlled Drug Receipt/Record/Disposition Form on the med cart reflected three doses given over two days. In interview, the DON stated staff are expected to document narcotic administration on the MAR and confirmed that two administered doses were not recorded there, resulting in an incomplete and inaccurate medical record.
Unqualified Infection Preventionist Overseeing Infection Control Program
Penalty
Summary
The facility failed to ensure that its designated Infection Preventionist (IP) met the mandatory qualifications for overseeing the Infection Prevention and Control Program. During an interview on 3/24/26 at 10:00 AM, the DON confirmed that she/he was serving as the facility’s IP but had not completed the specialized training in infection control required for the position. The DON further stated that no other staff member currently met the qualifications to serve as IP. Record review showed that the previously qualified IP left the facility in October 2025, and as of the survey date, the position remained unfilled by a qualified individual. At 1:30 PM on the same day, the Administrator and DON confirmed they were still in the process of finding a qualified IP for the facility, leaving the Infection Prevention and Control Program without a properly trained and qualified leader. No specific residents, medical histories, or clinical conditions were described in relation to this deficiency.
Unsecured Medications, Treatment Carts, and Oxygen Equipment
Penalty
Summary
Facility staff failed to ensure that drugs, biologicals, and related medical supplies were securely stored and properly maintained on multiple units. On one unit, an oxygen tank assigned to a resident was observed sitting on the floor behind the resident’s bed without any supporting device. On another unit, a treatment cart was observed with a tube of Collagenase Santyl cream labeled for a specific resident left on top of the cart, while residents in power wheelchairs passed by and staff were present at the nursing station. These observations showed that medications and oxygen equipment were not consistently secured as required. Further observations on additional units revealed an unattended and unlocked treatment cart at a nursing station, and on a separate occasion, a treatment cart with Diclofenac gel labeled for a resident left on top along with multiple packs of dressings. These incidents occurred across three units and on more than one date, demonstrating repeated failures to keep medications and treatment supplies in locked compartments or otherwise secured from unauthorized access.
Insufficient Dietitian Coverage and Delayed Nutritional Assessments
Penalty
Summary
The deficiency involves the facility’s failure to employ sufficient food and nutrition staff, including adequate dietitian coverage, to ensure timely assessment and appropriate diets for residents with significant nutritional and diabetic needs. A resident admitted over two weeks earlier with multiple comorbidities and an A1C of 11.5% had a hospital discharge recommendation for a carbohydrate-controlled diet, but was placed on a regular diet at admission with no acknowledgment of the recommended diet until one week later, when the resident requested larger portions. As of the survey date, the dietitian had not yet seen or reviewed this resident’s medical record, and the resident reported not having seen a dietitian and being very frustrated with the meals. During the first two weeks after admission, only one weight was obtained for this resident, despite physician notes stating the resident’s weight was “stable.” Further review of other residents showed additional failures in timely dietitian assessment and follow-up. One resident, readmitted in January and previously seen by the dietitian in September for a 6.4 lb weight loss over 30 days, had no documented follow-up despite continued weight loss totaling 22 lbs since the last dietitian review. Another resident admitted at the end of February with severe protein-calorie malnutrition had not been seen by the dietitian after about a month in the facility, despite a documented 14 lb (7%) weight loss over two weeks. The dietitian reported working only 12 hours per week at the facility and stated that she must prioritize which residents to see, focusing first on residents with tube feedings and those identified in risk meetings, resulting in delayed or absent assessments for new admissions and residents with ongoing weight loss and malnutrition diagnoses.
Linen Shortages and Poor Environmental Maintenance Compromise Resident Care and Comfort
Penalty
Summary
The deficiency involves the facility’s failure to maintain an adequate supply of clean linens and appropriate incontinence wipes, resulting in delays and alterations in residents’ incontinence care, as well as the use of towels and washcloths in place of disposable wipes. During the initial tour, the surveyor observed that the linen supply on one nursing unit hallway was low. Complaint reviews included concerns about delays in incontinence care and bed linens not being changed regularly, with residents left without clean bedding. A complainant reported that there was not enough clean linen available for residents. Staff interviews confirmed that towels, sheets, and washcloths were being used to wipe residents for incontinence care due to the absence of wipes, and that many of these linens were being thrown away when soiled. Staff also reported a shortage of linen, that linen deliveries to the units were late, and that residents who preferred to get up before breakfast had to wait for care when linen was delayed. Further observations showed that the clean supply room contained no disposable wipes or cloths for incontinence care, and a resident reported that staff did not use wipes, that the resident had to purchase their own, and that heavily soiled towels or washcloths were discarded. A tour of all nursing unit linen carts and closets revealed only six clean washcloths and limited supplies of towels, gowns, and bed linens. In the laundry room, only three washcloths were present, and the laundry assistant stated that there were only three washcloths available for each nursing unit that morning, that the facility was short on linen supply, and that these concerns had been repeatedly reported to the Director of Housekeeping over the preceding month and again that morning. The laundry assistant confirmed there was no additional laundry in process. The DON stated that wipe squares should be used for incontinence care, but no such wipes were found in the clean medical supply room, and no backup supply of washcloths was present in the emergency linen supply. The Director of Housekeeping confirmed there was no backup supply of washcloths. The deficiency also includes environmental and maintenance issues affecting resident bathrooms, handrails, and common areas. In the main dining area, a recliner chair was observed positioned directly in front of the handwashing sink, and two recliner chairs were stored in front of the nutrition area kitchenette. Multiple resident bathrooms and shared bathrooms were repeatedly observed over several days with unfinished spackle on walls that needed resurfacing and painting, chipped paint around sinks, uneven boards nailed to walls under sinks that appeared to partially cover holes, musty odors, black substances between shower bases and walls, missing threshold transition molding exposing cracks, missing tiles, and a nail, as well as eroded and chipped paint on baseboard heaters with exposed dark brown metal and rust-like material. Hallway handrails on both nursing units were observed to be worn, with chips, splintering, holes, and areas where the wood finish had worn off. A shower room was observed with a foul fecal odor, dried brown stains on the back of the toilet seat and in the toilet bowl, and a baseboard heater with eroded, chipped paint and rust-like material, along with chipped paint on the handrail. These conditions were acknowledged by the Director of Maintenance and other leadership, and some areas were noted to be in the process of renovation, but the observed deficiencies remained present during the survey period. Overall, the facility did not maintain a safe, clean, comfortable, and homelike environment in good repair across both nursing units and the dining area. The lack of adequate linen and incontinence supplies, combined with the poor condition of resident bathrooms, handrails, and certain common areas, constituted the basis for the cited deficiency. The observations and staff and resident reports consistently described shortages of essential hygiene supplies, delayed care related to linen availability, and multiple unresolved environmental and maintenance issues in resident care areas and shared spaces.
Failure to Thoroughly Investigate Abuse Allegations and Injuries of Unknown Origin
Penalty
Summary
Facility staff failed to thoroughly investigate allegations of potential abuse involving one resident and an injury of unknown origin involving another resident. For one resident, there were two separate allegations of abuse occurring on different days in early February. The facility’s investigation packets included interviews with staff who cared for or were scheduled to work with this resident on the days of the alleged incidents, and the investigations focused solely on this resident. However, there were no interviews conducted with other residents on the unit to inquire about abusive or neglectful treatment by the staff who were working during the times of the allegations. The surveyors noted that, although the allegations were not validated, there was no documentation that other residents were interviewed, if able, or assessed for signs or symptoms of injury. In a separate incident, another resident was identified on March 4 with a new bruise on the right eye, documented as a change in condition at 4:09 AM. This resident had a BIMS score of 99, indicating the resident was unable to complete an interview and therefore could not report how the injury occurred. The facility’s investigation identified a potential cause of the injury but did not reach a definitive resolution. Additionally, there were no interviews of other residents on the unit regarding possible abuse, nor were there documented assessments of other residents for injuries of unknown origin, particularly for those unable to speak for themselves, as in this resident’s case.
Failure to Provide Oral Care to Dependent Residents
Penalty
Summary
The deficiency involves the facility’s failure to provide oral care to residents who were dependent on staff for activities of daily living, specifically oral hygiene. One resident with a tracheostomy was observed with a thick, sticky white substance in the mouth and was noted to intermittently chew on nearby bedding. This resident made good eye contact and, when asked if staff brushed their teeth, shook their head no and mouthed that staff “need to.” According to the resident’s Minimum Data Set (MDS) dated 2/11/26, the resident was dependent on staff for oral care. Another resident, also dependent on staff for oral care per the 3/11/26 MDS, was observed sitting propped up in bed and able to respond with smiles. During the initial observation, the inside of this resident’s lips and upper and lower teeth had a thick, clear, white milky substance visible when the resident tried to open their mouth to smile. Oral care supplies were present in the nightstand, but the resident’s mouth and teeth were not clean. On a subsequent observation with the DON, NHA, and Corporate VP of clinical services, the same resident again had a thick, clear, milky substance between the lips and caking the teeth, which would string between the teeth when the resident attempted to open their mouth, demonstrating a lack of consistent oral care for residents dependent on staff for this ADL.
Incomplete and Inaccurate Medical Record Documentation for Treatments and Assessments
Penalty
Summary
Facility staff failed to maintain complete and accurate medical records and documentation for multiple residents. For one resident with wound care needs, review of the MAR showed that wound care and related treatments were signed as completed on the dates initially reported, despite the resident’s ongoing complaints that wound dressings were not being changed. When additional dates were reviewed, there were missing staff signatures for wound care on two specific dates, as well as three instances where application of A&D ointment to the resident’s feet was not signed off out of 24 days reviewed. Another resident with severe cognitive impairment, as evidenced by a BIMS score of 00, was found to have an injury of unknown origin (a bruise on the left hand). Documentation showed that a change in condition was initiated late in the morning, but a formal pain evaluation was not initiated and completed until that night, and the resident was unable to explain how the injury occurred or verbalize pain using a standard pain scale. For a third resident, documentation related to the admission PPD test was inconsistent and incomplete. The MAR contained an entry indicating “9” for the administration date, meaning “see nurse’s note,” but there was no corresponding nurse’s note. Despite the absence of a signed administration of the PPD injection, staff documented the PPD result as “negative” on the scheduled read date. The resident reported never receiving the PPD injection, and the DON confirmed that the facility had been out of PPD solution at the time, so the test would not have been administered. These findings demonstrate failures in accurate documentation of treatments and assessments, including wound care, pain assessment, and TB screening, as well as missing or incomplete supporting notes in the medical record.
Failure to Implement and Communicate Correct Transmission-Based Precautions
Penalty
Summary
Surveyors identified a deficiency in the facility’s infection prevention and control program related to inconsistent and incorrect implementation of transmission-based precautions and PPE use. During a complaint investigation focused on residents on transmission-based precautions, one resident with a visible Foley catheter was observed in the room with physical therapy, but there were no signs posted indicating any need for PPE, despite the resident being a new admission with a Foley catheter placed related to wounds. In another double-occupancy room, a contact precautions sign was posted at the doorway, but the nurse practitioner was in the room on a personal phone with no PPE, and the assigned GNA was repositioning the resident in bed while wearing only gloves. When questioned, the NP, RN, and GNA all stated that the resident in the room was not on contact precautions, and the GNA reported that signs were hanging at all doors and that this particular resident’s sign was “just wrong.” The surveyor observed the GNA later return to the room and turn the sign around to indicate no PPE requirement. Subsequent interviews revealed that therapy staff relied on posted signage to determine PPE use and that if the sign was wrong, the PPE used would be wrong. Overall, surveyors found problems with signage accuracy and staff awareness of which residents required contact precautions, as well as observed failures to follow appropriate PPE use for residents who should have been on contact precautions.
Inaccurate MDS Coding for Falls, Pain Management, and High-Risk Medications
Penalty
Summary
Facility staff failed to ensure Minimum Data Set (MDS) assessments were accurately coded for two residents reviewed during a complaint survey. For one resident, a facility-reported incident showed that the resident was found seated on the floor beside the bed and was diagnosed with a non-displaced femoral neck impaction fracture of the left hip following an x-ray. Despite this fall with a major injury, the subsequent significant change MDS dated 11/4/25 did not code the fall with major injury in Section J1900C. Review of the resident’s Medication Administration Records for October and November 2025 showed administration of Tylenol on 10/31/25 at 9:30 PM, which fell within the 5-day look-back period for the MDS, but Section J0100 (prn pain) of the same significant change MDS did not capture the use of Tylenol. For another resident, review of a quarterly MDS with an assessment reference date of 10/15/25 showed that Section N0415 (High-Risk Drug Classes) documented the use of an opioid medication. However, review of the resident’s October 2025 Medication Administration Record did not show that the resident had been prescribed an opioid during that period. In both cases, MDS staff later confirmed that these were errors in MDS coding, demonstrating that the assessments did not accurately reflect the residents’ clinical status and medication use as documented in their medical records.
Incomplete Documentation of Narcotic Administration on MAR
Penalty
Summary
The facility failed to maintain complete and accurate medical records in accordance with accepted professional standards for one resident receiving narcotic medication. The resident, admitted in March 2026, had a fall on 3/6/26 and was sent to the hospital on 3/9/26. Review of the March 2026 Medication Administration Record (MAR) showed documentation of a single 25 mg dose of Tramadol administered on 3/8/26 at 9:23 AM. However, review of the resident’s Controlled Drug Receipt/Record/Disposition Form, kept on the nurse’s medication cart and not in the medical record, showed that Tramadol 25 mg was administered three times between 3/8/26 and 3/9/26: at 11:00 AM and 9:00 PM on 3/8/26, and at 9:00 AM on 3/9/26. In interview, the DON stated that staff are expected to document narcotic administration on the MAR and confirmed that only one of the three Tramadol doses reflected on the controlled drug record was documented on the resident’s MAR. This discrepancy between the controlled substance record and the MAR, with missing documentation of two administered doses of Tramadol on the official medical record, constituted the failure to maintain a complete and accurate medical record for the resident.
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