Autumn Lake Healthcare At Arcola
Inspection history, citations, penalties and survey trends for this long-term care facility in Silver Spring, Maryland.
- Location
- 901 Arcola Avenue, Silver Spring, Maryland 20902
- CMS Provider Number
- 215014
- Inspections on file
- 16
- Latest survey
- December 19, 2025
- Citations (last 12 mo.)
- 23
Citation history
Health deficiencies cited at Autumn Lake Healthcare At Arcola during CMS and state inspections, most recent first.
Surveyors identified deficient food handling practices, including unlabeled and undated food items, wet nesting of dishes, and improper storage in a facility's kitchen and nourishment room. Observations included unlabeled lemonade, wet saucers, and improperly dated food items, contrary to facility policy. A soiled steam table was also noted, with the DON confirming it was out of service.
The facility failed to maintain preventative maintenance on the Gateway Unit, as observed during a survey. Issues included a closet door off its hinges, a loose handrail with missing screws, marred handrails, a tattered wheelchair, and a sofa chair with torn armrests. The Director of Maintenance was unaware of these issues, indicating a lack of routine maintenance checks.
The facility failed to update care plans for several residents after changes in their medical treatment, such as discontinuation of medications like Lovenox and Seroquel. Additionally, residents were not consistently invited to care plan meetings, with some being excluded despite being capable of participating. These issues highlight deficiencies in communication and documentation within the facility.
A resident in an LTC facility was allegedly abused by a GNA during care. The resident, who was combative, scratched the GNA, leading to the GNA allegedly hitting the resident's hand. The incident was reported late, and inconsistencies were found in the reporting process among staff members.
A facility failed to report an alleged abuse incident immediately to the Administrator and state agency. A resident, needing assistance after a bowel movement, allegedly grabbed a GNA's hand, causing injury. Another GNA claimed the first GNA hit the resident's hand. The incident was reported to a charge nurse but not escalated until weeks later.
The facility failed to provide accurate contact information for the State regulatory agency, OHCQ, on two postings in the corridors. A surveyor found incorrect phone numbers, an outdated office address, and an incorrect website. The Nursing Home Administrator was unaware of these inaccuracies until informed by the surveyor.
The facility did not have the most recent survey results available for review. Surveyors found that the binder labeled 'CURRENT FACILITY SURVEY' only contained results from February 2019, missing results from surveys conducted in January 2021 and January 2024. The DON confirmed the oversight and later updated the binder with the missing results.
The facility failed to obtain advance directives for three residents during an annual survey. Medical records lacked documentation, and staff interviews revealed inconsistencies in the process of obtaining and following up on advance directives. Staff mentioned that directives are collected at entry if available, but there is no consistent follow-up after admission.
A facility staff member failed to protect a resident's health information by leaving a medication cart laptop open in a hallway, allowing access to the resident's medical records without a secure password. The staff member did not recall leaving the laptop open, and the surveyor found that resident information was accessible despite a screen indicating it was hidden.
A facility failed to notify the Ombudsman of a resident's transfer to the hospital, as required. The resident was transferred, but the facility lacked documentation to confirm notification. The DON acknowledged the Social Services Department's responsibility for this task, but attempts to retrieve documentation were unsuccessful. The Ombudsman confirmed no notification was received.
A resident with multiple diagnoses, including Dementia and Hypertension, received Lovenox injections for DVT prophylaxis after a hip fracture. The MDS assessment failed to document the drug classification for these anticoagulant injections, as identified during a surveyor's review and confirmed by the MDS Coordinator.
The facility failed to develop comprehensive care plans for three residents, leading to deficiencies in addressing their specific medical needs. One resident lacked a pain management plan despite having active orders for pain medication. Another resident was on a blood thinner without a corresponding care plan. A third resident, with a history of falls and requiring maximal assistance, did not have a care plan addressing fall risk and safety.
The facility failed to reposition two residents at risk for pressure ulcers according to their care plans and physician orders. One resident reported only being repositioned upon request, and records showed missed repositioning on multiple nights. Staff interviews revealed inconsistencies in following the standard practice of repositioning every two hours or as needed.
A resident with vision impairment did not receive timely eye care due to the facility's failure to arrange an ophthalmologist appointment. Despite the resident's ability to communicate needs and a documented order for consultation, the appointment was delayed for four months, as confirmed by the Unit Manager.
A resident's call light with exposed wires was observed on two occasions, indicating a failure to report and address the hazard. Staff acknowledged the issue, but there was a lapse in the reporting process, as nurses should have identified and logged the faulty call light.
A facility failed to track and respond to a pharmacy's recommendation for a resident with chronic conditions. The pharmacy suggested a dosage reduction of Diphenhydramine, but the medical staff did not review or act on this until 28 days later, after surveyor intervention. The DON acknowledged the oversight, and a response was documented only after the surveyor's involvement.
A resident with a history of chronic conditions requested a dental appointment for broken teeth, but the facility failed to arrange it despite an active order and MDS assessment indicating the need for prompt treatment. The resident experienced mild pain while eating, and no dental visits were arranged, leading to a deficiency noted during an annual survey.
The facility exhibited multiple infection control deficiencies, including improper storage of personal items in the laundry area, unsecured medical records, and lapses in hand hygiene during medication administration. A resident's room under droplet precautions was found with an overflowing trash can and medical items improperly placed. Additionally, handrails were sticky due to sanitizing solution residue.
The facility failed to maintain accurate and complete medical records for several residents. Discrepancies included incorrect PICC line measurements, incomplete behavior monitoring, missing initials on enteral feeding records, and conflicting bathing documentation. Additionally, a Notification of Change and Bed Hold authorization were incomplete.
Deficient Food Handling Practices Observed
Penalty
Summary
The facility failed to ensure sanitary and safe food handling practices, which could potentially affect all residents. During an initial kitchen tour, surveyors observed unlabeled and undated containers of leftover lemonade in a refrigerator. Additionally, wet nesting of saucers was noted, which can lead to bacterial growth. In the kitchen's ice machine room, a soiled paper towel and a tumbler with an unidentified liquid were found. Sticky floors were observed in a room storing chemicals and kitchen equipment, with no signs indicating which equipment was out of service. Bags of cake mix lacked expiration dates, and ice buildup was found in the walk-in freezer, with no maintenance records verifying recent service. Further observations in the Potomac Unit's nourishment room revealed improperly labeled and dated food items, including an opened cranberry apple juice bottle, a zip lock bag with a withered vegetable, and a container with cooked food dated beyond the facility's policy for food storage. A soiled mobile steam table in the dining room contained various debris and was confirmed by the DON to be out of service. The facility's policy required labeling and dating of food, with daily monitoring for storage duration, but these practices were not consistently followed.
Deficiency in Preventative Maintenance on Gateway Unit
Penalty
Summary
The facility failed to implement a process for preventative maintenance of various items within the Gateway Unit, as observed during a recertification survey. Specifically, the surveyor noted that a closet door was off its hinges and propped up, with another door missing a handle and a drawer with a loose handle. Additionally, a handrail in the short hallway was loose with missing screws, and all handrails on the unit were marred and scratched. An empty manual wheelchair was found with tattered back support, seat, and armrests, exposing the padding material. Furthermore, a large single-seat sofa chair in the residents' dining area had torn armrests, also exposing the padding underneath. The Director of Maintenance was interviewed and stated that he was unaware of these issues but would investigate them. These observations indicate a lack of routine maintenance checks and repairs, leading to the deterioration of essential equipment and furniture used by residents and staff.
Care Plan Deficiencies and Resident Exclusion in Meetings
Penalty
Summary
The facility failed to revise care plans for several residents after changes in their medical treatment. Resident #65 continued to have an active care plan for Lovenox even after the medication was discontinued. Similarly, Resident #36's care plan for Vancomycin remained active despite the medication being stopped. Resident #143's care plan was not updated to reflect the discontinuation of one-on-one monitoring, which was no longer necessary according to psychiatric evaluations. Additionally, Resident #57's care plan included Seroquel, although the medication had been discontinued by the physician. The facility also failed to invite residents to their care plan meetings. Resident #63 reported not receiving invitations to care plan meetings, and there was no documentation of an invitation for a December 2023 meeting. The Social Services Director confirmed the absence of the invitation letter. Resident #38 was not included in care plan meetings, which were conducted telephonically with the surrogate, despite the resident being capable of making decisions about their care. The exclusion was due to the surrogate's limited availability, and the resident was not informed about changes in their discharge plan. These deficiencies highlight a lack of proper communication and documentation regarding care plan updates and resident involvement in care planning. The facility did not ensure that care plans were revised in a timely manner following changes in medication or treatment, nor did it consistently involve residents in discussions about their care, leading to potential gaps in care and resident dissatisfaction.
Failure to Prevent Resident Abuse
Penalty
Summary
The facility staff failed to prevent abuse of a resident, as evidenced by an incident involving a Geriatric Nursing Assistant (GNA) and a resident. During a routine care procedure, the resident, who had a bowel movement, became combative and scratched GNA #21, causing her hand to bleed. In response, GNA #21 allegedly hit the resident's hand. This incident was witnessed by GNA #38, who reported it to the charge nurse, Staff #39. However, the report was delayed, as Staff #39 no longer worked at the facility, and the incident was not reported to the Director of Nursing (DON) until several days later. Interviews conducted during the investigation revealed inconsistencies in the reporting process. GNA #38 reported the incident to multiple staff members, including Staff #27 and Staff #7, but it appears that the information was not effectively communicated to the appropriate authorities in a timely manner. Staff #27 assessed the resident but did not observe any injuries, and GNA #21 denied hitting the resident. The DON confirmed that staff are suspended when there is an allegation of abuse, but there was a lack of communication with the nursing agency regarding the suspension. The resident involved was unable to provide a statement due to cognitive deficits.
Failure to Timely Report Alleged Abuse Incident
Penalty
Summary
The facility staff failed to report an alleged incident of abuse immediately to the Administrator and the state agency. This deficiency was identified during an investigation of a facility-reported incident involving a resident who required assistance from a Geriatric Nursing Assistant (GNA) after a bowel movement. During the incident, the resident grabbed the GNA's hand, causing injury. Another GNA alleged that the first GNA hit the resident's hand in response. The incident was reported to a charge nurse, but there was no evidence that it was further reported to the Administrator or the state agency until several weeks later.
Facility Fails to Provide Accurate State Agency Contact Information
Penalty
Summary
The facility failed to provide accurate contact information for the State regulatory agency, the Office of Health Care Quality (OHCQ), on two postings located in the facility corridors. On June 17, 2024, a surveyor observed a sign with incorrect contact information, including a phone number that directed calls to a hospital facility surveyor instead of OHCQ. The following day, during an interview with a staff member, the surveyor found that the bulletin board near the Potomac floor also displayed outdated contact details, including an old office address and an incorrect website. The Nursing Home Administrator (NHA) was interviewed and was unaware of the inaccuracies in the contact information. The NHA initially directed the surveyor to the same incorrect postings, confirming the facility's failure to update the information. The surveyor pointed out that the mailing address, phone number, and website for OHCQ were all incorrect, and the NHA acknowledged the need to update the board with the correct information.
Failure to Update Survey Results Binder
Penalty
Summary
The facility failed to have the most recent survey results readily available for review, as required. Upon entering the facility, surveyors found a binder labeled 'CURRENT FACILITY SURVEY' near the receptionist's desk. However, upon review, the binder only contained survey results from a complaint survey conducted in February 2019. Further investigation through the Certification and Survey Provider Enhanced Reporting (CASPER) system revealed that additional complaint surveys had been completed in January 2021 and January 2024, but their results were not included in the binder. The Director of Nursing (DON) confirmed the absence of these results and later provided an updated binder with the missing survey results from January 2021 and January 2024.
Failure to Obtain Advance Directives for Residents
Penalty
Summary
The facility staff failed to obtain advance directives for three residents during an annual survey. The surveyor reviewed the medical records of eight residents and found that three of them did not have any documents related to advance directives in their electronic records or hard charts. Interviews with staff members revealed inconsistencies in the process of obtaining advance directives. Staff #35 mentioned that advance directives are collected at the time of entry if available and then given to the Social Worker for follow-up within 72 hours. However, she also stated that advance directives do not necessarily have to be collected during admission, and there is no follow-up after admission. Staff #15 confirmed the absence of advance directives in the records of the three residents and explained that if a resident had an advance directive, it would typically be provided upon entry to the facility. Otherwise, it would be obtained directly from the resident, and they would be offered one if they did not have it. The lack of documentation and follow-up indicates a failure in the facility's process to ensure that residents' advance directives are properly obtained and recorded.
Failure to Protect Resident Health Information
Penalty
Summary
The facility staff failed to maintain the privacy of a resident's protected health information during an annual survey. The surveyor observed a medication cart laptop left open in the hallway with a resident's medical information visible to anyone passing by. At the time of observation, no residents or facility staff were present in the hallway. During an interview, Staff #33 acknowledged the open laptop but claimed not to recall leaving it open, noting that a black screen was present. However, the surveyor demonstrated that the resident's record could be accessed by simply clicking the mouse without needing a secure password. Additionally, the surveyor observed Staff #33 walking away from the laptop with an open browser tab that displayed a message indicating the screen was hidden, yet resident information was still accessible from another open tab.
Failure to Notify Ombudsman of Resident Hospital Transfer
Penalty
Summary
The facility failed to provide timely notification to the Ombudsman regarding the transfer of a resident to the hospital. This deficiency was identified during a review of the medical records and interviews conducted by the surveyor. The resident in question was transferred to the hospital on January 30, 2024, but the facility did not have documentation to confirm that the Ombudsman was notified of this transfer. The Director of Nursing acknowledged the absence of such documentation and indicated that the responsibility for notifying the Ombudsman lay with the Social Services Department. During the investigation, the Director of Nursing attempted to retrieve the necessary documentation from the Ombudsman and the Social Services Department but was unsuccessful. The Ombudsman confirmed that they had not received any notification from the facility regarding the resident's transfer in January 2024. This lack of communication and documentation highlights a failure in the facility's process for notifying the Ombudsman about resident transfers, as required by regulations.
Inaccurate MDS Coding for Anticoagulant Injections
Penalty
Summary
The facility staff failed to ensure that Minimum Data Set (MDS) assessments were accurately coded for a resident during the recertification survey. The resident, who was admitted with multiple diagnoses including Dementia, alcohol abuse, and Hypertension, sustained a fall resulting in a hip fracture and was hospitalized. Upon readmission, the resident received Lovenox injections for Deep Vein Thrombosis prophylaxis. However, the MDS assessment did not document the drug classification for the anticoagulant injections received during the assessment period. This omission was identified during a review of the resident's medical record and confirmed through an interview with the MDS Coordinator.
Deficiencies in Comprehensive Care Planning
Penalty
Summary
The facility staff failed to develop and initiate comprehensive person-centered care plans for three residents, leading to deficiencies in addressing their specific medical needs. Resident #65, who was admitted with multiple diagnoses including dementia and hypertension, sustained a fall resulting in a hip fracture. Despite having active physician's orders for pain management with Tramadol and Tylenol Extra Strength, there was no active care plan for pain management in the resident's medical record. Similarly, Resident #36, admitted with conditions such as hypertension and atrial fibrillation, was receiving Xarelto, a blood thinner, without a corresponding care plan to address the use of this medication. Additionally, Resident #80, who had a history of falls and required maximal assistance for daily living activities, did not have a care plan addressing fall risk and safety. This resident had previously fallen while attempting to use the bathroom independently, yet no care plan was developed to mitigate future fall risks. The lack of comprehensive care plans for these residents highlights a significant oversight in ensuring that their individual medical and safety needs were adequately addressed.
Failure to Reposition Residents at Risk for Pressure Ulcers
Penalty
Summary
The facility failed to adequately turn and reposition residents at risk for pressure ulcers, as evidenced by the cases of two residents during an annual survey. Resident #26 reported that they were only repositioned upon request and not according to a schedule, despite being unable to reposition themselves. A review of Resident #26's records revealed that the care for turning and repositioning was not documented on 14 nights in June, with the resident being noted as requiring substantial or maximal assistance on several occasions. Interviews with staff indicated a lack of clarity and consistency in following the standard practice of repositioning residents every two hours or as needed. Similarly, Resident #158 was not turned and repositioned according to physician orders and the care plan. Staff interviews confirmed the task was not completed on the night shift, and there was insufficient documentation to support that the required care was provided. The deficiency highlights a failure in adhering to the care plans and physician orders, as well as a lack of proper documentation and execution of care tasks by the facility staff.
Delayed Vision Care for Resident
Penalty
Summary
The facility staff failed to promptly arrange for an eye appointment for a resident with vision impairment, leading to a deficiency identified during an annual survey. The resident, who was admitted with diagnoses including vision impairment, expressed concerns about worsening eyesight and the lack of an eye appointment since admission. The resident was capable of making decisions about their care and had communicated their needs, yet no action was taken to address the vision impairment in a timely manner. The Medical Director had ordered a consultation with an ophthalmologist shortly after the resident's admission, and the resident's Minimum Data Set assessment documented significant vision impairment. Despite these indicators, the facility staff did not secure an eye appointment until four months later. The Unit Manager confirmed the delay in scheduling the eye examination, acknowledging that the referral process had only recently been completed, leaving the resident without necessary vision care for an extended period.
Exposed Call Light Wires Not Reported
Penalty
Summary
The facility staff failed to ensure that residents were not exposed to hazards, as evidenced by the condition of a call light with exposed wires for one resident. During observations on two separate occasions, the surveyor noted that the call light for Resident #26 had exposed wires. Staff #5 acknowledged the issue and stated that anyone who notices a faulty call bell can report it, and she would log it in the maintenance book. However, during an interview, Staff #2 indicated that nurses should have identified the faulty call light and reported it in the maintenance log, suggesting a lapse in the reporting process.
Failure to Track and Respond to Pharmacy Recommendations
Penalty
Summary
The facility staff failed to adequately track and respond to a pharmacy's monthly drug regimen review recommendation for a resident with multiple chronic conditions, including chronic heart failure, arthritis, diabetes, fibromyalgia, hypertension, chronic renal failure, obesity, and migraine. The pharmacy report, dated 5/15/24, identified an irregularity and recommended a dosage reduction of Diphenhydramine, which was not acted upon by the medical staff. The Director of Nursing (DON) acknowledged the lack of a hard copy of the recommendation and the absence of a timely response from the medical staff. The deficiency was highlighted during an annual survey when it was discovered that the medical staff had not reviewed or acted upon the pharmacy's recommendation until 28 days later, following the surveyor's intervention. The DON later presented a response from a Nurse Practitioner, agreeing with the recommendations, but this was only documented after the surveyor's involvement. This delay in addressing the pharmacy's recommendation indicates a failure in the facility's process for tracking and responding to medication regimen reviews.
Failure to Provide Prompt Dental Services
Penalty
Summary
The facility staff failed to promptly provide or obtain dental services for a resident, leading to a deficiency identified during an annual survey. The resident, who had a medical history of hypotension, chronic heart failure, and asthma, had requested a dental appointment for broken teeth several months prior. Despite being able to make decisions about their care, the resident's request was not fulfilled. An active order for dental treatment was entered by the Medical Director on 3/3/24, and the resident's Minimum Data Set (MDS) assessment on 3/12/24 identified the need for prompt dental treatment due to broken teeth. Observations during the survey revealed that the resident experienced mild pain while eating due to the broken tooth, and by 6/14/24, no dental visits had been arranged. The Unit Manager confirmed that the resident had not received any dental care since admission on 3/3/24, despite the MDS assessment highlighting the need for treatment. This inaction by the facility staff resulted in the deficiency noted in the survey report.
Infection Control Deficiencies in Facility
Penalty
Summary
The facility failed to adhere to proper infection prevention and control practices, as evidenced by several observations during the annual recertification survey. In the laundry department, surveyors observed personal items, such as an employee's purse, placed in a clean linen bin and on a clean laundry folding table. Additionally, an adjacent storage area connected to the clean laundry area contained unsecured medical records, clothes on the floor, and stacked mattresses, all of which were acknowledged by the Nursing Home Administrator as inappropriate infection control practices. Further deficiencies were noted in resident care areas. A room under droplet precautions for a resident with sepsis, hypertension, and acute respiratory failure was found with an overflowing trash can, a pressure-relieving boot on the floor, and a syringe on the window sill. Hand hygiene lapses were observed during medication administration, where staff entered rooms under Enhanced Barrier Precautions without sanitizing their hands. Additionally, handrails in the Gateway Unit were found to be sticky and grimy, attributed to residual sanitizing solutions, although they were later reported to be cleaned.
Inaccurate and Incomplete Medical Record Documentation
Penalty
Summary
The facility failed to maintain medical records in accordance with professional standards, as evidenced by incomplete and inaccurate documentation for several residents. For one resident with a PICC line, there was a significant discrepancy in the recorded arm circumference measurements, with the facility's documentation differing by 22 cm from the placement company's records. This discrepancy was acknowledged by the Director of Nursing (DON) as an error in documentation. Another resident's behavior monitoring records were incomplete, with several shifts lacking documentation of observed behaviors. The DON confirmed the missing documentation and stated that it was expected for both GNAs and nurses to monitor and document behaviors. Additionally, there were missing initials on the enteral orders for a resident receiving tube feedings, with no documentation in the progress notes explaining the absence of administration on specific dates. Further issues included inaccurate documentation of bathing preferences for a resident, where records conflicted between a shower and a bath. Additionally, a Notification of Change and Bed Hold authorization for another resident were incomplete, missing critical information such as hospital details and required signatures.
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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