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 July 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Autumn Lake Healthcare At Arcola during CMS and state inspections, most recent first.
The facility failed to ensure potentially hazardous leftovers were cooled according to acceptable standards. A dietary manager found cooked items such as mac and cheese, turkey, noodles, ground beef, and rice in the refrigerator and initially stated that leftover temperatures were not monitored because the amounts were small. She later said the foods had been prepared and served over the weekend, then dated and stored for possible reuse, but there was no documentation showing the required cooling process was completed.
Laundry staff processed dirty linens while other staff folded clean linens on the opposite side of the laundry room, with vinyl drapes used as the barrier held open about 50% by placing the bottom in a bin. On reinspection, the barrier was still open and was also missing about 6 inches of material, leaving an opening from top to bottom of the doorway.
Advance Directive and MOLST Documentation Failures: Surveyors found that a capable resident who wanted advance directive information did not have documentation showing the information was provided or that an advance directive was completed, and another resident with dementia and cognitive impairment lacked documentation of advance directive discussions and a surrogate decision maker after incapacity was identified. A third resident’s record also lacked evidence that advance directive information was addressed. Staff interviews further showed inconsistent understanding of how to verify code status, the MAR did not display code status, and an LPN located a MOLST order that was for DC rather than MD.
Improper Air Mattress Settings for Residents at Risk for Pressure Injuries. Five residents assessed as at risk for pressure injuries were observed on air mattresses or a low pressure air loss mattress with weight settings that did not match their current weights. The DON and Unit Manager confirmed the settings, and the DON stated nursing staff were responsible for ensuring the mattress weight settings were appropriate to each resident.
Failure to verify delivery of resident financial statements. The facility managed personal funds for several residents, but multiple residents reported not receiving quarterly statements or receiving only one since admission. Staff said the statements were generated and delivered through the activities dept, but no signatures or other documentation confirmed receipt, and the business office did not maintain proof that residents got the statements.
Grievance policy and process were not properly implemented. A resident reported a concern to the unit manager, but the issue was not reflected in the grievance log, and surveyors did not find Grievance Officer contact information, accessible grievance forms, or properly labeled anonymous grievance boxes on multiple units. Staff gave conflicting accounts of where forms were kept and how grievances were initiated, and the NHA acknowledged prior concern forms showed improper implementation of the grievance process.
A facility failed to ensure psychotropic meds were used appropriately for multiple residents. One resident with dementia-related psychosis had a PRN psychotropic order with no 14-day limit and no documentation of why it was given or that nonpharmacologic interventions were tried. Another resident also had a PRN psychotropic order with an indefinite end date. A third resident received Depakote for mood swings and melatonin for insomnia, but the chart lacked documented side effect monitoring, GDR attempts, or clinical justification despite repeated med regimen reviews stating no recommendations.
A facility failed to report a missing resident cell phone as a possible misappropriation to the state agency. The phone was listed as a personal item, staff interviews did not locate it, no police report was on file, and the resident had moderate cognitive impairment and lacked capacity for healthcare decisions. The AIT and Administrator stated the item was not reported because theft was not confirmed, even though the resident later said someone took it.
A resident’s comprehensive assessment was not completed within the required timeframe. The RN responsible for assessments said the work had been done and was awaiting submission, but the printed record showed Section Z was completed 38 days after the ARD, and she later confirmed the assessment was late.
Incomplete and Untimely Care Planning: The facility failed to ensure accurate and timely comprehensive care plans for two residents. One resident's IDT care plan meeting occurred before the MDS was completed, and another resident had multiple rescheduled care plan meetings with no documentation that they were ever held. The SS Director confirmed the meetings were missed because family members could not attend or be reached, even though the meetings still needed to occur.
A dependent resident did not receive showers as scheduled, and staff failed to document any refusals. The resident stated that showers were not provided as often as desired, the TAR showed only six showers in the month, and the shower schedule called for two showers per week. The MDS indicated the resident was dependent, and a GNA reported that refusals should be documented and a bed bath provided, but no refusal documentation was available.
Failure to provide activities based on resident assessment and preferences. A resident with severe cognitive impairment and a documented preference to spend time outdoors was listed in the 1:1 activity binder, but the activity records showed only in-room and 1:1 checklists while the facility's outdoor Sunshine Club documentation did not include that resident. The DOR stated that some residents were taken outdoors by family or a sitter without documentation, and could not explain how residents without family or sitters were given the chance to go outside.
Pain Medication Given Outside Ordered Parameters: A resident with chronic pain had orders for scheduled oxycodone ER and PRN acetaminophen for mild pain and hydromorphone for pain rated 6-10/10. MAR review showed multiple PRN hydromorphone administrations when documented pain scores were below the ordered range, with no evidence of physician approval or notification. The unit manager, DON, and medical director gave conflicting accounts regarding awareness of the practice and the resident’s pain documentation.
The facility failed to implement a physician order to discontinue a lipid-lowering medication after a pharmacist’s MRR recommendation, leaving the medication active in the MAR. The facility also documented repeated monthly MRRs with no recommendations despite no documented side-effect monitoring, no GDR attempts, or clinical analysis, and another resident’s psychotropic use lacked documented monitoring, risk-benefit review, or dose-reduction evaluation.
Expired meds and medical supplies were found in 3 of 3 storage areas reviewed. A Charge Nurse confirmed expired prep wipes and eye drops in one med room, while another med room contained expired needles and a suction catheter. In a wall cabinet, open wound dressing packages were not labeled with the date and time opened. In the basement storage room, staff found expired infusion sets, gravity feeding sets, trach care kits, and nebulizer adapters; the Administrator confirmed that meds and medical equipment should be used within their expiration dates.
Illegible and Inaccurate Resident Matrix Provided Late: The facility did not provide required CMS entrance conference documents in a timely manner, and the resident matrix was illegible and inaccurate. A resident identified as being on hospice was incorrectly documented, and the AIT acknowledged the error and the concerns about the matrix's timeliness, legibility, and accuracy.
Immunization documentation was incomplete for a resident whose chart showed refusal of flu vaccine and education entries in the EHR, but no record of the 2024 flu vaccine decision. The hard chart also showed consent and education provided to the resident representative, while the resident had been certified by 2 providers as incapable of making medical decisions, creating a mismatch between who was documented as receiving education and who was authorized to decide.
A facility failed to ensure education was provided to a resident's representative regarding the benefits and potential side effects of the COVID-19 vaccine. EHR review showed one vaccine refusal without documented education, while the hard chart showed declination forms signed by the resident even though two providers had certified the resident as incapable of understanding and making medical decisions.
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.
Failure to Document Cooling of Leftover Foods
Penalty
Summary
The facility failed to ensure potentially hazardous food items were cooled according to acceptable standards. During an initial kitchen tour, cooked food items were observed in the stand-up refrigerator and identified as leftovers, including mac and cheese, turkey, noodles, ground beef, and rice. The dietary manager stated that the items were leftovers and initially reported that the facility did not monitor the temperature for leftovers during the cooling process because they were small amounts. During a later interview, the dietary manager stated that the listed items had been prepared and served over the weekend and then dated and kept in the refrigerator for her to decide whether they could be reused. She also stated that the kitchen staff did go through the cooling process before storing the food, but acknowledged that this was not documented. The report states there was no credible evidence or documentation to indicate the kitchen staff had completed the required cooldown process for the potentially hazardous food items found in the refrigerator.
Laundry Room Clean and Soiled Areas Not Properly Separated
Penalty
Summary
The facility failed to maintain separation between the clean and soiled areas of the laundry room to prevent cross contamination. During an initial tour, a laundry aide demonstrated processing dirty linens while two other laundry aides were folding clean linens on the clean side of the laundry room. The laundry room used vinyl drapes as a barrier between the dirty and clean sides, but the drapes were observed held open at about 50% with the bottom portion placed in a bin so they would not close shut. On a later inspection, the drapes were still set up the same way, and when the barrier was adjusted, it was found to be missing about 6 inches of material, leaving an opening from top to bottom of the doorway.
Advance Directive and MOLST Documentation Failures
Penalty
Summary
The facility failed to provide and document advance directive information for capable residents and failed to identify a responsible party for an incapacitated resident. Resident #67 was admitted without an advance directive in place, was certified by the facility’s medical provider as capable of understanding and making decisions, and stated a desire to receive information to formulate one. The record did not show that an advance directive was completed or that information was provided, and the Social Services Director later stated the resident said children would help with the forms, but there was no documentation of that discussion or any follow-up with the children. Resident #6 had diagnoses including chronic atrial fibrillation, degenerative disc disease, hypertension, hyperlipidemia, dementia, major depressive disorder, and cognitive impairment, and a social service assessment documented the resident as oriented to time, person, place, and situation. Advance directive assessments showed the resident wanted to meet with Social Services to discuss completing an advance directive, and a progress note stated advance directive and resident rights were offered and reviewed. However, the medical record did not contain documentation of advance directive discussions, and after a physician certification of incapacity was found in the paper chart, there was no surrogate decision making form or affidavit of familiarity in the record. The Social Services Director stated the emergency contact verbally declined to make medical decisions, but this discussion was not documented and no follow-up arrangements for representation had occurred. Resident #8’s record also lacked evidence that an advance directive was addressed or established, and there was no documentation that advance directive information was delivered to the resident or family or that follow-up discussions occurred. In addition, surveyors found problems with procedures for determining code status and MOLST orders: staff interviews showed inconsistent understanding of where to verify code status in an emergency, the MAR did not display code status, one LPN could not demonstrate how to locate it in the electronic record, and another LPN found a standing refer-to-MOLST order that was for the District of Columbia rather than Maryland and therefore not an active order for life-sustaining treatment. The DON stated nursing staff can review the order in the electronic record but needs to review the hard chart when determining code status, and the Medical Director acknowledged that scanning and keeping a resident’s MOLST in the electronic record is dangerous.
Improper Air Mattress Settings for Residents at Risk for Pressure Injuries
Penalty
Summary
Failure to provide appropriate pressure ulcer care and prevent new ulcers from developing was identified for 5 of 7 residents reviewed for pressure injuries. During observations, Resident #23, Resident #25, Resident #15, Resident #8, and Resident #2 were each found in beds equipped with air mattresses or a low pressure air loss mattress, and the mattress control boxes were set to weight levels that did not match the residents' current weights. Resident #23 weighed 146.8 lbs. and the mattress was set at 350 lbs.; Resident #25 weighed 178 lbs. and the mattress was set at 280 lbs.; Resident #15 weighed 129 lbs. and the mattress was set at 320 lbs.; Resident #8 weighed 125 lbs. and the mattress was set at 350 lbs.; and Resident #2 weighed 194.5 lbs. and the mattress pump was set at 350 lbs. The residents were all assessed as at risk for developing pressure injuries using the Braden Scale. The DON confirmed the mattress settings observed for Residents #23, #25, #15, and #8, and the Potomac Unit Manager confirmed Resident #2's low air mattress was set at 350 lbs. and did not reflect the resident's current weight. The DON stated that nursing staff were responsible for ensuring air mattress settings were appropriate to the residents, including the weight setting. The report also states that an overinflated air mattress puts a resident at a greater risk for developing pressure injuries.
Failure to Verify Delivery of Resident Financial Statements
Penalty
Summary
The facility failed to provide quarterly financial statements to residents whose personal funds were managed by the nursing home. This deficiency was identified for 4 of 5 residents reviewed for personal funds, including residents who reported that they had not received the statements, had received none since admission, or had received only one statement despite the facility managing their money. The residents involved included a long-term resident admitted in March 2025, a resident admitted in February 2025, and two long-term residents without cognitive decline. Interviews with the business manager and the activities director showed that the facility's financial system automatically generated quarterly statements and that the envelopes were delivered to residents by the activities department. However, staff stated that residents were not required to sign for receipt and that the business office did not receive confirmation of delivery. Quarterly financial statements dated 7/01/2025 through 9/30/2025 were provided for the four residents, but the records did not show resident or resident representative signatures acknowledging receipt. The administrator confirmed that the business office did not maintain documentation verifying that residents received the quarterly financial statements.
Grievance Policy and Process Not Properly Implemented
Penalty
Summary
The facility failed to ensure that its grievance policy and process were properly implemented. During the annual survey, the surveyor found that on the Potomac Unit a resident reported a recent incident to the unit manager, but the resident stated that nothing came of the concern. The surveyor also observed that the Potomac Unit did not have the Grievance Officer’s name and contact information posted, accessible grievance forms, or an anonymous grievance box. On the Gateway and Chesapeake Units, a second surveyor likewise did not observe Grievance Officer notices, accessible grievance forms, or labeled and locked anonymous grievance boxes. Interviews showed conflicting information about how grievances were handled. The AIT said any staff member receiving a grievance was expected to report it to the unit manager or charge nurse, and the unit manager would complete a concern form; however, the Potomac Unit Manager stated concern forms were not at the nurses’ station but in her office, and that she completed the form and placed it in a folder for agency and in-house nurses. The Social Service Director identified herself as the Grievance Officer and said staff initiated a concern form and sent it to her, after which departments investigated and returned it to her for the grievance log. A review of the grievance log did not show any concern related to the resident’s report. The NHA stated concern forms were at each unit’s nurses’ station and that the Abuse Coordinator sign on the bulletin board was the Grievance Officer information, while also stating that abuse and grievance were the same. The facility’s grievance policy dated 12/23/22 stated that grievance notices with Grievance Officer information would be posted in prominent locations, written decisions would be provided, and anonymous filing would be allowed; however, the surveyor and NHA reviewed prior concern forms and the NHA acknowledged improper implementation of the grievance policy and process.
Unnecessary Psychotropic Medication Use and Inadequate PRN Limits
Penalty
Summary
The facility failed to ensure residents were free from unnecessary psychotropic medication use and failed to ensure PRN orders for psychotropic medications were limited to 14 days. For Resident #144, who had diagnoses including dementia with psychotic disturbance, the record showed a PRN psychotropic medication order with an indefinite end date. The medication was administered once, but there was no documentation showing why it was given or that non-pharmacological interventions were attempted before administration. The facility policy stated that non-pharmacological approaches must be attempted unless clinically contraindicated and that PRN psychotropic orders are limited to 14 days. For Resident #15, who had been in the facility since mid-2009, the record also showed a PRN psychotropic medication order with an indefinite end date. The facility policy again required PRN psychotropic orders to be limited to 14 days. During the survey, the concern was discussed with the AIT, who stated he would review the record, but no further documentation was provided before survey exit. For Resident #5, the record showed Depakote delayed release 125 mg twice daily for mood swings and melatonin 6 mg at bedtime for insomnia. The chart included monitoring orders for psychotropic medication use and side effect monitoring, but the MAR did not show that side effect monitoring was documented as ordered for psychotropic medication use. Monthly medication regimen reviews were completed and each stated, 'No recommendations,' yet there was no documented evidence of side effect monitoring, no gradual dose reduction attempts, and no documented contraindication. Staff stated the resident was receiving Depakote for mood disorder and sundowning, but no risk-benefit analysis or clinical justification was documented in the record.
Failure to Report Missing Resident Cell Phone as Possible Misappropriation
Penalty
Summary
The facility failed to report an allegation of misappropriation of resident property to the appropriate state agency for one resident. The resident’s cell phone was listed as a personal item on the original inventory sheet, and the grievance record showed that the phone was not recovered. The facility documented that it planned to reimburse the resident for the cost of the phone, but the missing phone was not reported as a possible misappropriation because the Administrator-in-Training stated the resident representative did not say the phone was stolen and the resident said it may have been misplaced. The investigation file showed that ten staff members were interviewed and each denied coming across the resident’s cell phone. The resident was interviewed by a nurse and documented as saying, “Yes, I think I misplaced the phone after using it today.” The phone was reported missing the day after it was discovered, and no police report was found in the record. The resident had moderate cognitive impairment on the Brief Interview for Mental Status and lacked capacity to make healthcare decisions, and later told the surveyor, “Someone took it,” when asked what happened to the iPhone. The Administrator confirmed that the facility only reported missing items when theft was confirmed.
Late Completion of Comprehensive Assessment
Penalty
Summary
The facility failed to complete a comprehensive assessment within the required timeframe for Resident #8, who was admitted in early 2025. On 12/11/25, review of the medical record showed the resident’s most current comprehensive assessment with an ARD of 10/21/25 was still in progress. The RN responsible for comprehensive assessments explained that she completed each section and that two corporate nurses reviewed the work and signed Section Z to show completion. When the assessment was reviewed again with the RN, she stated it had been completed but remained in progress because it had not yet been submitted. A printed copy of the assessment showed Section Z was completed on 11/28/25, which was 38 days after the ARD. After reviewing the record with the corporate nurses, the RN stated, “we are late.”
Incomplete and Untimely Care Planning
Penalty
Summary
The facility failed to ensure that comprehensive care plans were accurate and completed within 7 days of the comprehensive assessment for 2 residents reviewed. For Resident #2, the annual MDS showed an ARD of 10/17/25 and a completed date of 11/5/25, while a progress note documented that a care plan meeting with the IDT occurred on 10/17/25, before the MDS was completed and signed. The Social Service Director confirmed that the resident's last care plan meeting occurred before the MDS completion and acknowledged she was unaware that the regulation required the comprehensive care plan to be completed within 7 days of the comprehensive assessment. For Resident #23, the medical record showed that the last 3 scheduled care plan meetings, dated 5/2/25, 8/19/25, and 11/4/25, were rescheduled, but there was no documentation that any of those meetings were later held. The Social Services Director confirmed that the meetings did not take place because family members were not able to attend in person or answer the phone for teleconference, and she stated that the 11/4/25 meeting had not yet been rescheduled. The NHA and AIT were informed that the meetings still needed to occur even if family members or residents could not or would not attend, and they acknowledged the concern.
Inadequate Shower Assistance and Documentation
Penalty
Summary
Facility staff failed to ensure that a dependent resident's personal hygiene needs were adequately met by offering and providing showers as scheduled. Resident #4 stated during interview that s/he did not get showers as often as desired, and the BIMS score of 14 indicated adequate cognitive ability. Review of the TAR in the electronic health record showed that Resident #4 received only six showers in November, even though the shower assignment book listed shower days as Wednesday and Saturday. The annual MDS assessment showed that it was very important for the resident to choose between a bath, shower, bed bath, or sponge bath, and Section GG indicated the resident was dependent. The TAR did not document that the resident refused showers, and a GNA stated that residents were scheduled for showers two days per week and that if a resident refused, staff should document the refusal and provide a bed bath. The GNA was unable to provide documentation that Resident #4 refused showers.
Failure to Provide Activities Based on Resident Preferences
Penalty
Summary
The facility failed to provide activities to residents based on their comprehensive assessment to support physical, mental, and psychosocial well-being. Resident #9 had a last annual comprehensive assessment with an assessment reference date of 12/22/24 showing severely impaired cognitive skills for daily decision making, was rarely/never understood, had no family or significant other available to interview for daily and activity preferences, and had a staff assessment indicating a preference to spend time outdoors. During review, the Director of Activities explained that residents who are rarely/never understood are provided in-room and 1:1 activities, and a binder was presented showing checklist documentation for 24 residents, including Resident #9, for in-room and 1:1 activities. The Director of Activities also provided a group activity binder for outdoor activities and identified a Sunshine Club activity as the facility's outdoor activity when weather permits. She stated that some residents in the 1:1 binder were taken outdoors by family members or a sitter, but that such outings were not documented in the medical record. When asked about residents who do not have family members or sitters, she did not provide an answer. Surveyors discussed concern that residents who are fully dependent on staff and rarely/never understood, and who do not have family members or sitters, were not given the opportunity to spend time outdoors. The Nursing Home Administrator and Administrator in Training acknowledged the concern.
Pain Medication Given Outside Ordered Pain Parameters
Penalty
Summary
The facility failed to provide pain management in accordance with the resident’s physician orders and professional standards of practice for one resident reviewed for pain management. The resident had orders for scheduled OxyCONTIN 30 mg every 12 hours, acetaminophen 1,000 mg every 8 hours as needed for pain rated 1-5/10, and hydromorphone 6 mg every 4 hours as needed for pain rated 6-10/10. The resident also had an order to assess for pain every shift, document yes or no, medicate as ordered, and notify the physician if pain was not controlled. Review of the MAR showed multiple administrations of PRN hydromorphone outside the ordered pain parameters. In December 2025, seven documented administrations were identified where hydromorphone was given when the recorded pain scores were below 6/10, including scores of 2, 4, 3, 2, 5, 5, and 3. The surveyor concluded there was no supporting evidence that the ordering physician approved these administrations at the corresponding pain scores. The review was expanded and identified 12 similar administrations in November 2025 and 5 in October 2025, also below the ordered 6-10 pain range, with no supporting evidence that the physician was notified or issued an order. During interview, the unit manager stated residents are typically reassessed 30 minutes to 1 hour after pain medication administration, and acknowledged that the resident was well known to be in chronic pain, but also stated the documentation did not reflect the need for the medication when pain scores were below 6-10. The DON stated the medical director was aware of PRN pain medication being administered outside the parameters and described the resident as insisting on receiving the medication, but the record contained no evidence of that pattern during the review period. The medical director later stated he was not aware of the practice, did not authorize it, and that PRN pain medication should be administered according to the pain scale as written.
Failure to Implement Pharmacy Recommendations and Monitor Medication Regimens
Penalty
Summary
The facility failed to implement a physician order and failed to ensure that a resident’s drug regimen was free from unnecessary medications. For one resident, the pharmacist completed a medication regimen review and recommended that the physician review whether medications for hyperlipidemia could be reduced or discontinued based on lipid panel results. The physician agreed and ordered ezetimibe discontinued, but the resident’s active medication orders still showed ezetimibe as an active order with no change since the original order date. The Nurse Unit Manager confirmed that the physician’s response was to discontinue the medication and acknowledged that the order had not been changed in the chart, while the DON stated that Unit Managers were expected to ensure physician orders were implemented. The facility also failed to ensure appropriate medication regimen review, monitoring, and follow-up for other residents. For one resident, the pharmacist documented repeated monthly medication regimen reviews with “No recommendations,” despite no documented side-effect monitoring, no evidence of gradual dose reduction attempts, and no documented contraindications to dose reduction; the pharmacist acknowledged that the chart was being reviewed without documenting clinical analysis for the no-recommendation decision. For another resident, psychotropic medication use was not supported by documented clinical monitoring, risk-benefit analysis, or evaluation for dose reduction, and the facility failed to ensure the drug regimen was free from unnecessary drugs.
Expired Medications and Medical Supplies Found in Storage Areas
Penalty
Summary
The facility failed to ensure that medications and medical equipment available for resident use were within their expiration dates in 3 of 3 medication storage areas reviewed. During an observation of the first-floor medication storage unit with the Charge Nurse, a box of [NAME] and Nephew prep wipes was found approximately half full with an expiration date of [DATE], and a box of Refresh eye drops prescribed for Resident #115 had an expiration date of 10/2025. The Charge Nurse confirmed the expiration dates and removed the expired item from the room. In the second medication storage unit, a package of Safe Step needle 20 Gauge x 0.75 inch and a suction catheter were observed with expiration dates of [DATE]. In the second-floor wall cabinet outside the medication storage room, seven boxes of Tender Gentle Calcium Alginate wound dressings were observed, and four boxes were open with at least one individual dressing package opened and part of a dressing removed; the opened packages were not labeled with the date and time opened. In the basement medication and medical equipment storage room, expired Angiocath Shielded Catheter Infusion Sets, Entra Flo 1000 ml gravity feeding sets, tracheostomy clean and care kits, and nebulizer adapters were observed, with all expiration dates confirmed by staff. The Administrator later confirmed that medications and medical equipment should be used within their expiration dates.
Illegible and Inaccurate Resident Matrix Provided Late
Penalty
Summary
The facility failed to provide legible, timely, and accurate documents during the CMS entrance conference process. On 12/8/25 at 9:20 AM, the surveyor and Acting DON began the entrance conference and reviewed the CMS entrance conference worksheet and required documentation timeline. The census was not received until 12/8/25 at 12:23 PM, the complete matrix for new admissions was not received until 12/9/25 at 9:45 AM, and the complete matrix for all other residents was not received until 12/9/25 at 7:23 AM. Review of the resident matrix showed inaccurate documentation for Resident #144, who was identified as a hospice resident, and the matrix was illegible. During an interview on 12/9/25 at 9:45 AM, the Administrator in Training acknowledged that the matrix was illegible and that the error involved Resident #144's hospice status. An updated matrix provided on 12/9/25 at 1:15 PM still inaccurately reflected Resident #144's hospice status, and the AIT was made aware of the concerns regarding timeliness, illegibility, and accuracy of the matrix.
Immunization Education and Consent Documentation Deficiency
Penalty
Summary
The facility failed to ensure that education was provided to the resident's representative regarding the benefits and potential side effects of the influenza and pneumococcal immunizations for one resident reviewed for immunizations. Review of the resident's EHR showed influenza immunizations were refused and education was documented as provided to the resident on 4/1/23, 10/6/23, and 9/23/25, but there was no documentation that the resident received or declined the influenza immunization for 2024. A review of the resident's hard chart showed a consent form for the influenza immunization signed and education provided to the resident representative on 9/12/24. The chart also showed the resident had been certified as incapable of understanding and making medical decisions by 2 providers on 5/8/23. During interview, the Infection Preventionist Nurse confirmed the EHR findings, and the Administrator in Training acknowledged the concern that the resident was documented as making refusal decisions and receiving education despite being certified as unable to understand and make decisions for self.
COVID-19 Vaccine Education and Consent Documentation Deficiency
Penalty
Summary
The facility failed to ensure that education was provided to the resident's representative regarding the benefits and potential side effects associated with the COVID-19 vaccine for one resident reviewed for immunizations. Review of the resident's electronic health record showed that the COVID-19 vaccine was refused on multiple occasions, with education documented on some refusals but not on one refusal. During interview, the Infection Preventionist Nurse confirmed the immunization documentation and stated she would review the record further. Review of the resident's hard chart showed consent forms for the COVID-19 vaccines indicating the resident declined, signed, and had been educated on the listed dates. The chart also showed that the resident had been certified as incapable of understanding and making medical decisions by two providers. The findings were discussed with the AIT, who confirmed the concern that the resident had signed the declination forms despite being certified as lacking capacity to make medical decisions.
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.
What surveyors are citing around you — mapped
All 10 risk areas, ranked with evidence
Repeat citations, what's rising near you, and quality measures — ranked so department heads know exactly where to look first.
Illustrative
What surveyors actually found near you
We read the 1,656 citations issued within 25 miles in the last 12 months — including the 13 immediate-jeopardy cases — and tell you exactly what happened, in plain English, matched to your record.
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.
Illustrative
A prioritized, do-first checklist
Every risk area becomes concrete audit steps drawn from real citations at facilities like yours — run them this week, before your window opens.
Illustrative
Risk indicators are statistical estimates from public CMS data — not predictions, findings, or compliance advice.
Nursing homes near Silver Spring
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Montcare At Wheaton | 1.7 mi | ★★★★★ | 0 | 0 |
| Turtle Creek Rehabilitation And Wellness Center | 1.9 mi | ★★★★★ | 9 | 1 |
| Autumn Lake Healthcare At Oakview | 1.9 mi | ★★★★★ | 12 | 0 |
| Complete Care At Springbrook | 2.2 mi | ★★★★★ | 14 | 0 |
| Regency Care Of Silver Spring, Llc | 2.3 mi | ★★★★★ | 7 | 0 |
Every risk area ranked, a do-first checklist, and your local survey patterns
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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 July 2026) and official state health department websites.