Above average — CMS composite of the measures below.
The next survey window likely opens around November 2026
Estimate from public CMS data, current as of August 2026. Survey timing is at the state agency's discretion.
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.
Resident ate lunch with the bed fully lowered and the bedside table positioned above eye level, requiring the resident to reach up above the head to eat and feel the plate to tell how much food remained. The GNA and DON both acknowledged the tray setup should have been adjusted so the resident could eat properly and maintain dignity.
Failure to facilitate resident care plan meetings affected two residents reviewed for care planning. One resident’s representative said they had not been invited to a care plan meeting in years, and the Social Services Director could only locate an old meeting date in the log book. Another resident stated they had not had a care plan meeting in a while, and record review found only a note that a meeting had been planned, with no further documentation available; the Social Services Director could not find the last care meeting date.
A resident with left-side paralysis had a call bell hung on the left side bed rail and it remained there on a later observation. When asked, the resident indicated they could not reach the bed adjustment remote or call bell. A GNA stated the call bell was expected to be within the resident's reach, and the DON acknowledged the concern.
Failure to Document Advance Directive Information Provided: The facility did not ensure that proper information was provided to residents and/or resident representatives regarding advance directives for 3 residents reviewed. Each resident's record and social service assessment showed no advance directive on file and no documentation that information was offered to help formulate one, and the SS Director was unable to produce supporting documentation.
Incomplete transfer and bed-hold notices were found for two residents after hospital transfers. Nursing notes documented acute changes such as altered mental status, lethargy, and difficulty arousing, but the transfer forms and bed-hold forms were left incomplete or blank, including missing reasons for transfer and missing signatures acknowledging receipt of the notices. The DON stated there was no further documentation showing that written transfer notice was provided.
Facility staff inaccurately coded a resident’s MDS by marking hospice care as No even though physician orders showed hospice services had begun and the resident’s significant change in condition was the hospice admission. The MDS Coordinator acknowledged the error and stated the item should have been coded Yes; the DON was informed of the concern.
Missing Oxygen Order: A resident was observed receiving oxygen at 4 liters, but record review did not reveal an active oxygen order. The DON stated that if a resident is on oxygen, there should be an order reflecting it.
Unlabeled oxygen equipment and oxygen therapy without valid orders. Two residents were observed receiving oxygen with tubing and humidifier equipment that was not dated or labeled. An LPN confirmed one resident was receiving oxygen at a higher flow than the stated order, and a record review found no oxygen order in place for that resident, while the other resident had an order for 2 LPM but was observed receiving 3.5 LPM.
Facility staff failed to ensure that a GNA maintained an active certification. Survey review found one GNA file without evidence of an active license, and a state license lookup showed the certification had expired and was not renewed. HR stated that monthly file audits and a tracking system were used for renewals, but the surveyor later reviewed a schedule showing the GNA worked every weekend with an expired license.
A resident’s SNFABN was not completed in full, as the section asking which Medicare billing option the resident chose was left blank. During record review, an LPN/staff member confirmed that no option had been marked, and the DON was informed of the issue.
Failure to Establish Infection Control Interventions: Surveyors observed that EBP signage was not posted and PPE was not available outside the rooms of three residents with wounds, a foley catheter, PICC line care, or other dressing-change needs. Record review found no EBP orders for these residents until the DON entered them later, and one resident who was ordered Vancomycin for C. difficile had no documented transmission-based precautions. The DON stated EBP were required for residents with tube feedings, foley catheters, and wounds requiring dressing changes, but could not explain the missing orders or why precautions were not started for the resident with C. difficile.
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.
Resident Ate Meal With Tray Positioned Above Eye Level
Penalty
Summary
The facility failed to ensure a resident’s dignified existence was maintained during a meal. During an observation on the second floor units, Resident #2 was found in the room eating lunch with the bed completely lowered to the floor and the bedside table positioned above the resident’s eye level. The resident was reaching up above the head to eat from the plate on the tray, which was placed on the bedside table. During interview, the resident stated staff told him/her the bed had to remain in the lowest position and reported being unable to see what was being taken from the plate or how much food remained because the tray was above eye level. The resident said he/she had to feel the plate to determine how much food was left. A GNA stated the expectation was for staff to adjust the bed, resident, and/or bedside table so the resident could eat properly, and agreed the table was above eye level and should have been adjusted. The DON also stated some adjustment should have been made so the resident could see the plate and not have to reach above the head to get food.
Failure to Facilitate Resident Care Plan Meetings
Penalty
Summary
The facility failed to facilitate care plan meetings for residents, affecting 2 of 3 residents reviewed for care planning. For one resident, the resident’s representative stated that he or she had not been invited to a care plan meeting in 2 years. The Social Services Director stated that care plans were expected to be completed at least quarterly and that residents and family members were invited to meetings, with attendance documented in a log book. However, when the surveyor requested the sign-in sheet for the resident’s care plan meetings within the last year, the last care plan meeting date the director could locate was 12/27/2022. For another resident, the resident stated that he or she had not had a care plan meeting in a while. Record review showed a progress note on 06/20/2024 stating that a care plan meeting had been planned for 07/03/2024, but the surveyor could not find any further documentation of a care plan meeting after that note. The Social Services Director was unable to find the resident’s last care meeting date, and the concern was reviewed with the DON, who indicated understanding.
Call Bell Not Within Reach of Resident With Left-Side Paralysis
Penalty
Summary
The facility failed to reasonably accommodate a resident's needs based on their condition. Resident #45 was documented as paralyzed on the left side and unable to move the left side of the body. Despite this condition, the resident's call bell was observed hung on the left hand side bed rail on 12/04/2025 and was still on the resident's left side on 12/05/2025. During the later observation, the resident requested assistance to adjust the bed and, when asked, reached toward the bed adjustment remote and call bell but indicated they were unable to reach them. A GNA stated that the expectation was for the call bell to be within the resident's reach, and the DON acknowledged the concern when it was reviewed with her.
Failure to Document Advance Directive Information Provided
Penalty
Summary
The facility failed to ensure that proper information was provided to residents and/or resident representatives regarding advance directives for 3 of 6 residents reviewed for advance directives during the annual survey. Resident #4's medical record did not reveal an advance directive, and the social service assessment dated 11/08/2025 indicated that the resident did not have an advance directive on file but did not show that information was provided to help formulate one. The Social Services Director stated that advance directives were expected to be addressed upon admission and that if a resident did not have one, the facility would provide information to formulate one. Resident #8's medical record also did not reveal an advance directive, and the social service assessment dated 10/21/2025 did not show that information was provided to formulate one. Resident #10's medical record likewise failed to reveal an advance directive, and the social service assessment dated 11/04/2025 did not indicate that information was provided to the resident and/or resident representative to formulate one. In each case, Staff #7 was unable to provide documentation showing that advance directive information had been offered, and the DON later indicated that she understood the concerns.
Incomplete Transfer and Bed-Hold Notices
Penalty
Summary
Facility staff failed to ensure that residents and/or resident representatives received complete written notice of transfer and bed-hold rights for two residents reviewed for hospitalization/discharge. For one resident, the medical record showed transfers to the hospital on two occasions, with nursing notes documenting altered mental status on one transfer and pocketing food, lethargy, and difficulty arousing on the other. The DON stated the nurse responsible for the resident at the time of transfer initiates the transfer notice and bed-hold notice process, and the social worker sends the notices to the resident representative and ombudsman, but the surveyor requested the transfer and bed-hold notices and found the signature sections blank on both transfer notices. The bed-hold notice dated for one transfer was incomplete, and the bed-hold notice for the other transfer was entirely blank except for a checked section indicating the emergency contact name was listed under release of bed-hold information. For another resident, record review showed hospitalization and a Notice of Resident Transfer or Discharge dated 10/10/2025. The form did not include a completed reason for transfer, and the signature section acknowledging receipt of the transfer notice by the resident and/or resident representative was blank. When the surveyor reviewed this concern with the DON, she stated the form should have been filled out by the resident or resident representative and that she had no further documentation to support that a written notice of transfer was provided.
Inaccurate MDS Coding for Hospice Status
Penalty
Summary
Facility staff failed to accurately code Resident #77’s status on the Minimum Data Set (MDS) assessment. Review of physician orders showed a hospice consultation order dated 10/15/2025 and an order dated 10/16/2025 indicating the resident was admitted under hospice services effective 10/15/2025. However, the resident’s most recent Significant Change in Condition MDS, completed on 10/15/2025, coded Section O, Item K1 (Hospice Care) as No, despite documentation showing hospice services had been initiated effective that same date. During interview, the MDS Coordinator stated that all MDS assessments were expected to be coded accurately and identified the resident’s admission to hospice as the significant change in condition. The MDS Coordinator acknowledged that Section O should have been coded Yes instead of No and stated the incorrect coding was an error. The DON was informed of the concern and acknowledged it.
Missing Oxygen Order
Penalty
Summary
The facility failed to maintain professional standards of practice related to oxygen orders for Resident #5. On 12/04/2025 at 1:05 PM, the resident was observed receiving oxygen at 4 liters. On 12/05/2025 at 10:55 AM, record review did not reveal an active order for oxygen. During an interview on 12/05/2025 at 1:21 PM, the DON stated that if a resident was on oxygen, there should be an order reflecting it.
Unlabeled oxygen equipment and oxygen therapy without valid orders
Penalty
Summary
Respiratory care was deficient for two residents receiving oxygen therapy. During observation, Resident #1 was seen in bed receiving oxygen at 3.5 LPM, and the oxygen tubing in use was not dated or labeled. The Unit Manager confirmed the tubing was not dated or labeled and stated the tubing should be labeled and dated when initiated and changed weekly per order. Resident #96 was also observed in bed receiving oxygen at 3.5 LPM, and the humidifier bottle and oxygen tubing were not dated or labeled; the Unit Manager confirmed this during dual observation and stated the overnight nurses should have labeled them. Resident #1’s oxygen flow was inconsistent with the stated order. The Unit Manager stated the attending provider had prescribed oxygen on 12/03/2025 for shortness of breath and that the ordered flow rate was 2 LPM, while the resident was observed receiving about 3.5 LPM. A later review of Resident #1’s record showed shortness of breath documented in the MDS, but Section O reflected that the resident was not receiving oxygen therapy at that time. Review of the physician orders did not show an oxygen order for Resident #1 at the time of the surveyor’s review. Resident #96 had a physician order dated 11/25/2025 for oxygen inhalation via nasal cannula at 2 LPM with an attempt to wean and checks every shift. Despite that order, the resident was observed receiving oxygen at 3.5 LPM. The survey findings documented that the oxygen equipment for both residents was not properly labeled and dated, and that Resident #1 was receiving oxygen without a valid order in place during the survey review.
Expired GNA Certification in Employee File
Penalty
Summary
Facility staff failed to ensure that a geriatric nursing assistant (GNA #2) maintained an active certification. During record review, the surveyor found that GNA #2’s employee file did not contain evidence of an active GNA license, although the annual performance review had been completed. A Maryland Board of Nursing license lookup showed that the GNA license had expired and was listed as not renewed. The surveyor notified the DON and requested evidence of an active license and documentation of shifts worked since the expiration date. In an interview, HR stated that monthly employee file audits were conducted and that a tracking system was used to identify employees due for license renewal and annual performance review. Despite this process, the surveyor was later provided a work schedule showing that GNA #21 worked every weekend from one date until another date with an expired license.
Incomplete SNFABN Form
Penalty
Summary
The facility failed to ensure that the Skilled Nursing Facility Advance Beneficiary Notice of Non-coverage (SNFABN) form was completed entirely for Resident #26. During record review, the SNFABN document showed that the section asking the resident which Medicare billing option they wanted was left blank. During interview, Staff #7 stated that the form was expected to be fully completed and confirmed that no option had been checked, so the resident’s choice could not be identified. The concern was then discussed with the DON, who indicated understanding.
Failure to Establish Infection Control Interventions
Penalty
Summary
Facility staff failed to establish infection control interventions to prevent the transmission of infection for 3 of 5 residents reviewed for the infection control task during the annual survey. On 12/04/2025, surveyors observed Resident #3, Resident #95, and Resident #55 in their assigned rooms and noted that enhanced barrier precautions (EBP) signage was not posted on their doors and PPE was not available outside their rooms. Record review showed Resident #3 had an admission with multiple diagnoses, including orthopedic aftercare, and an order for daily wound dressing changes, but no order for EBP was found. Resident #95 had been admitted with a left femur fracture and had an order for left lower extremity dressing changes, but no EBP order was documented. Resident #55 had been admitted to the facility and, in October 2025, had physician orders for PICC line dressing change, daily wound dressing change, and foley catheter care, but no EBP order was found. The record also showed that on 10/20/2025 Resident #55 was ordered Vancomycin four times daily for Clostridioides Difficile infection, but there was no evidence that transmission-based precautions were ordered. On 12/08/2025, review of the records for all three residents showed the DON entered an EBP order on 12/07/2025. During interview, the DON stated EBP were required for residents with tube feedings, foley catheters, and wounds requiring dressing changes, and stated the admitting nurse or unit manager were responsible for ensuring EBP orders were entered, but could not explain the missing EBP orders or why transmission-based precautions were not initiated for Resident #55 in October 2025.
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.
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Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
Walk-in cooler logs missing for 12 days; expired supplements in the medication room fridge.
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Nursing homes near Lutherville
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Autumn Lake Healthcare At Ruxton | 1.8 mi | ★★★★★ | 43 | 0 |
| Greater Baltimore Medical Center Sub Acute Unit | 2.2 mi | — | 0 | 0 |
| Chestnut Grn Hlth Ctr Blakehur | 2.3 mi | ★★★★★ | 13 | 0 |
| Pickersgill Retirement Community | 2.3 mi | ★★★★★ | 6 | 0 |
| Orchard Hill Rehabilitation And Healthcare Center | 2.9 mi | ★★★★★ | 42 | 0 |
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Trusted data, never guesswork. Every citation, penalty, rating and Plan of Correction on this page is sourced from public CMS records (latest release August 2026) and official state health department websites.