Average — CMS composite of the measures below.
The next survey window likely opens around May 2027
Estimate from public CMS data, current as of October 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Autumn Lake Healthcare At Ballenger Creek during CMS and state inspections, most recent first.
Failure to provide dignified grooming assistance: A resident with severely impaired cognition and dependence for ADLs was observed with significant facial hair on the chin and upper lip despite expressing a desire to be shaved. The resident’s care plan documented dependence for personal hygiene and grooming, but staff did not ensure the resident was shaved, and the UM stated she expected the facial hair to have been shaved if the resident preferred it.
A resident reported that the room was too cold and that extra blankets were not enough to warm the room. The room had no in-room thermostat or control unit, and the vent cover did not have adjustable louvers. Maintenance staff said room temperature was managed by one thermostat for four rooms and that airflow could be reduced with vent adjustments, but work order entries for the resident’s cold-room complaints were signed as completed without documentation of what was actually done.
Late Completion of Admission MDS Assessments: The facility failed to complete admission MDS assessments within required timeframes for 3 residents. Record review showed that each resident’s assessment was signed after the due date, and an MDS Coordinator confirmed the assessments were completed late.
A resident with dementia and severely impaired cognition had a major decline after a hospital stay for fx repair, with worsened ADLs and significant wt loss documented. The MDS showed increased dependence for eating, oral hygiene, upper-body dressing, and wheelchair mobility, but the facility did not complete a Significant Change in Status MDS within the required timeframe. An RD and MDS nurse confirmed the decline warranted the assessment.
Failure to include resident representative in care plan meeting: A resident with dementia and severely impaired cognition was determined by two providers to lack decision-making capacity, yet the care plan meeting proceeded without the RP present. The record showed the interdisciplinary team and the resident attended, but the RP was only called during the meeting and a voicemail was left, with no evidence the RP had been invited in advance.
False documentation was identified when an LPN signed off that a resident’s low air loss alternating pressure mattress had been checked even though she later stated she had not done so. The resident’s mattress was observed set at 180 lbs with static on, despite an order to set it to the resident’s weight and keep static off unless providing care.
A resident with throat and tongue cancer, dysphagia, Parkinson’s disease, malnutrition, and adult failure to thrive was ordered 1:1 supervision during all meals and oral intake, but surveyors observed the resident eating without staff present, without a spoon, and later eating additional food without supervision; staff documentation also reflected supervision that was not actually provided. Another resident with bilateral BKA and extensive ADL dependence reported not receiving regular showers, and record review showed inconsistent shower documentation and conflicting shower schedules between the paper assignment and the EHR.
Air mattress settings were not kept at the ordered resident weights for two residents receiving pressure ulcer care. One resident’s low air loss mattress was found set far above the documented weight with static mode on, despite a charted task showing it had been checked. Another resident with a reopened heel pressure ulcer had a mattress observed at different settings and the most recent weight in the record was outdated, while the UM could not confirm a recent weight.
Missed Ordered Weights and Incorrect BMI Documentation: Two residents had weight monitoring ordered by the RD, but the chart lacked documentation that weights were obtained on multiple required dates. One resident’s height was initially recorded as 51 inches, which produced an inaccurate BMI, and was later clarified to be 65 inches. Staff interviews and record review showed gaps in weight documentation, including missed weekly and monthly weights and no clear documentation of refusals for most missed entries.
A resident with obstructive sleep apnea and insomnia had a CPAP machine at the bedside, but the record lacked physician orders and a care plan for its use and care. The resident reported that only some staff knew how to use the CPAP correctly, so it was not always used, and the DON confirmed the absence of CPAP-related orders, interventions, and staff tasks in the chart.
Pain management was not provided according to orders for three residents. A resident received PRN opioid and acetaminophen doses for 0/10 pain without documented NPI attempts, another resident had incomplete NPI documentation and received PRN oxycodone for 0/10 and 1/10 pain, and a third resident missed scheduled hydromorphone doses when the supply ran out even though an interim medication supply was available.
A resident with Afib and hypotension received metoprolol and Midodrine even when documented pulse and SBP values met the hold criteria on the MAR. The UM confirmed the metoprolol should have been held when the pulse was below 60, and the DON was made aware that Midodrine was also given when SBP was above the ordered hold parameter.
The facility failed to store refrigerated controlled meds in permanently affixed locked compartments and left an unattended med cart unlocked. A surveyor found removable black lock boxes in two med refrigerators containing controlled meds, while staff acknowledged the boxes were not permanently affixed and that the meds did not fit in the clear locking containers. The surveyor also observed an unlocked med cart left unattended, and separately saw a resident with a pill left in a medicine cup on an overbed table while no nurse was in the room.
Food was not consistently served at safe, appetizing temperatures. Several residents reported that trays were often cold, and service line records were missing required item names and temperatures on multiple occasions. During a tray line observation, a resident's meal included hot items below the facility's 135 F standard and a cold beverage at 70 F, above the 41 F limit in the HACCP plan.
Improper Texture of Pureed Food Served: A resident on a chopped diet with a hx of stroke and dysphagia was served pureed peas that contained significant chunks of pea skin during a tray-line observation. The meal slip called for pureed peas, and staff interviews confirmed that pureed foods should be smooth and not chunky, but the observed food did not match the required texture.
Clean linens were observed exposed in uncovered carts and the clean laundry room door was propped open, while staff acknowledged the door was supposed to stay closed and carts covered. In addition, staff failed to wear gowns during EBP care for a resident with open wounds and during contact precaution care for a resident with MRSA bacteremia, with GNAs and an RN entering rooms wearing gloves only despite posted PPE requirements.
MDS assessments were not accurately coded for several residents. Documentation showed missed entries for high-risk drug classes such as insulin, anticoagulants, antibiotics, antiplatelets, diuretics, and PRN pain meds, and one resident’s MDS also failed to capture a documented fall. The MDS Coordinator confirmed the coding errors during record review.
Facility staff failed to administer ordered meds and wound care for a resident admitted after hospitalization. MAR/TAR review showed missed doses of IV Zosyn for bacteremia, Methocarbamol for muscle spasm, and Iodosorb to the right foot/toes for wound care, and the DON confirmed the findings.
A resident grievance included an allegation that an LPN verbally abused and bullied a resident, but the written outcome focused on unrelated items and did not include a resolution for the abuse complaint. Staff interviews confirmed the grievance did not address the alleged verbal/mental abuse, no abuse report was made, and there was no evidence of staff education related to the allegation.
The facility failed to timely report suspected misappropriation of a resident’s wallet and did not properly report an allegation of staff-to-resident verbal abuse. A cognitively intact resident’s missing wallet was reported to nursing staff, but the Administrator was not notified immediately, and the investigation remained incomplete. In a separate case, a resident with significant medical and cognitive history had a grievance alleging an LPN used racist language and bullied the resident, but the abuse allegation was not addressed in the grievance resolution and was not shown to have been reported as required.
A resident with multiple complex diagnoses and fluctuating cognition was involved in grievances alleging verbal/mental abuse, physical abuse, and medication administration concerns. Surveyors found the abuse allegations were not fully addressed in the grievance resolutions, and the facility had no evidence of staff education related to abuse after the investigations, including one inconclusive abuse investigation and another grievance involving meds left at the bedside despite MAR documentation.
A resident’s medications were found left in a cup in the room even though the MAR had been signed as if they were administered. The resident had multiple chronic conditions, including CHF, DM2, AFib, CKD stage 4, and cognitive impairment. Family and a witness reported that an LPN left the meds in the room without watching the resident take them, while nursing leadership stated meds should be observed until swallowed before signing the MAR. The facility had no documentation of education for the nurse or other nursing staff regarding medication administration.
Surveyors found expired milk, unlabeled veal meat, and improperly labeled cold salad in facility refrigerators, along with a dirty snack fridge described as 'disgusting' by an LPN. Several residents reported receiving cold food, and a review of temperature logs showed missing entries for multiple meals, despite staff being expected to check and reheat food as needed.
The facility did not provide required education or offer the 2024-2025 COVID-19 vaccine to most staff, as shown by missing documentation in five out of six employee files and confirmed by interviews with the Infection Preventionist and the Nursing Home Administrator.
A resident admitted to hospice care did not have a Significant Change in Status MDS assessment completed within the required 14-day period. Medical record review showed that the assessment was finalized after the mandated timeframe, despite the presence of a hospice order, resulting in noncompliance with federal assessment requirements.
Surveyors identified that MDS assessments were inaccurately recorded for four residents, including errors such as documenting restraint use that did not occur, failing to note impaired range of motion after surgery, recording an incorrect discharge destination, and omitting upper extremity impairment despite therapy documentation. Staff interviews confirmed these inaccuracies and attributed some errors to delays in receiving therapy data.
Facility staff did not develop or implement individualized care plans for several residents, resulting in unmet needs related to activity preferences, lack of accessible materials for a visually impaired resident, and inadequate supervision during meals for a resident with severe dysphagia. These deficiencies were identified through interviews, observations, and review of care plans and MDS assessments.
Several residents with varying cognitive abilities did not receive individualized activities aligned with their preferences, as required assessments and care plans were incomplete or not followed. Documentation of activity participation and refusals was lacking, and residents reported limited or no engagement in activities, with some not being offered preferred options such as reading materials or outdoor time. Staff were unable to provide records to support that activities were offered or refused.
A resident with anxiety and on dialysis did not consistently receive Ativan as ordered, with missing documentation for several evening doses and instances where the wrong dosage was administered. Staff documented giving Ativan on the MAR, but drug control sheets did not confirm removal of the medication on multiple dates, and on some occasions, the resident received a higher dose than prescribed due to duplicate orders and incorrect administration.
Staff did not accurately document the administration of a controlled medication for a resident, with missing entries on drug control sheets for several dates. Another resident requiring supervision during meals was observed eating unsupervised in bed, despite documentation stating otherwise and without recording the resident's refusal to get out of bed. Additionally, documentation for personal hygiene and repositioning was incomplete for multiple residents, including one who reported not receiving a shower despite records indicating otherwise and no supporting documentation found.
Surveyors identified multiple infection control deficiencies, including staff failing to perform hand hygiene between glove changes, improper handling of clean gloves, and not wearing required gowns during high-contact care for a resident on Enhanced Barrier Precautions. Additionally, soiled linen bins in the laundry area were found uncovered and unlabeled, with clean laundry bins brought into the soiled area, contrary to infection prevention protocols.
The facility did not conduct thorough investigations into multiple abuse allegations, including incidents where residents reported being struck, pushed, inappropriately touched, or roughly handled by staff. Investigation files were incomplete, lacked proper documentation, and failed to identify alleged perpetrators or include necessary follow-up, resulting in insufficient responses to serious resident concerns.
Multiple dependent residents did not consistently receive required ADL care, including incontinence care, bathing, and feeding. Some residents were left in soiled linens or went extended periods without showers or grooming, despite being fully dependent on staff. Documentation was often incomplete or inaccurate, with care sometimes recorded as provided when residents denied receiving it, and required supporting records were missing. Staff interviews confirmed delays and omissions in care delivery.
A deficiency occurred when a Hoyer lift, essential for resident mobility assistance, was found to be inoperable due to dead batteries. A grievance was filed and validated by both staff and the county ombudsman, with facility leadership aware of the issue. No harm resulted to the resident involved.
A resident who had difficulty chewing facility food relied on family to bring in outside food, which was later found missing from the unit refrigerator. Staff interviews revealed inconsistent application of the facility's food labeling policy, with dietary staff discarding items lacking an expiration date, while nursing staff only required the date of placement. This inconsistency led to the resident's food being discarded and unavailable.
A resident was observed on two occasions seated in a wheelchair at bedside with the call bell tied to the opposite bed rail, making it inaccessible. Staff confirmed the call bell was out of reach and only repositioned it after being prompted by surveyors. Inaccessible lighting controls were also noted in all rooms observed.
A resident with decision-making capacity did not have a health care advance directive on file, despite documentation indicating otherwise. Staff had recorded the presence of an advance directive during admission and in a social service assessment, but only a non-health care-related power of attorney document was found. The Social Service Designee confirmed the absence of the correct document and that the family was not informed about the issue.
Two residents experienced deficiencies in environmental cleanliness and personal care. One resident's room remained dirty for an extended period, with debris and dried fluids on the floor, despite daily cleaning protocols. Another resident, fully dependent on staff, had visibly soiled and unchanged bed linens for several days, including a urine-soaked incontinence pad, contrary to the facility's stated linen change schedule.
A resident reported that the leg rests from their personal wheelchair were missing for about a month. Although the physical therapist and a nurse were aware and attempted to locate the items, the facility did not document the concern or initiate the required grievance process, as confirmed by the Director of Rehabilitation.
A resident's admission MDS assessment was completed four days past the required regulatory deadline. The assessment, which should have been finalized within 14 days of admission, was instead completed on day 18, as confirmed by the MDS Coordinator. This delay resulted in the facility failing to maintain timely and accurate assessment records for care planning.
A resident who had both quarterly and significant change MDS assessments did not have documented interdisciplinary care plan meetings following these assessments. Review of medical records and staff interviews confirmed that no care plan meetings were held for this resident during the relevant period.
The facility did not ensure that care plan interventions to prevent accidents were consistently implemented or documented. Two residents with fall risk did not have required floor mats in place despite staff documentation stating otherwise, and another resident at risk for elopement had no documentation of required wander guard functionality checks after a change in orders. These deficiencies were confirmed through observation and staff interviews.
Two residents did not receive pain management services as ordered: one was left without access to PRN oxycodone due to lack of medication supply, and another received PRN pain medication without documented pain assessments or attempts at non-pharmacological interventions as required by provider orders.
A resident with anxiety, insomnia, and moderate depression did not receive consistent behavioral health services or proper documentation of prescribed Ativan administration. Despite recommendations for ongoing therapy and medication, there was no evidence of follow-up behavioral health visits or confirmation that all ordered doses of Ativan were given, resulting in a deficiency in behavioral health care.
A pharmacist did not identify significant medication errors for a resident prescribed Ativan, including missed doses and extra doses, due to incomplete review of the medical record. The errors were linked to duplicate active orders and discrepancies between the Medication Administration Record and drug control sheets, which the pharmacist did not fully reconcile during the monthly drug regimen review.
A resident with severe cognitive impairment was the subject of an abuse allegation reported by a family member to a nurse, who documented the concern. There was a two-day delay before the DON submitted the initial report to authorities, despite the DON stating the concern was addressed immediately.
A resident with a diabetic foot wound and recent amputation did not receive consistent Negative Pressure Therapy (VAC) as ordered, with multiple days lacking documentation or assessment of the device's functioning. Nursing staff failed to monitor and document the VAC therapy, and the wound specialist and DON confirmed that care and documentation were substandard, resulting in deterioration of the surgical site.
Failure to Provide Dignified Grooming Assistance
Penalty
Summary
The facility failed to ensure that Resident #34, who required staff assistance with self-care, was groomed in a manner that preserved dignity. On 6/24/26, the resident was observed seated in a wheelchair by the bedside with a significant amount of facial hair on the chin and upper lip, and the resident expressed a desire to have it shaved. A follow-up observation on 6/25/26 showed the facial hair was still present. Record review showed Resident #34 had severely impaired cognition and required staff assistance with self-care, including personal hygiene. The care plan documented that the resident was dependent for ADL care, including bathing, grooming, personal hygiene, dressing, eating, bed mobility, transfer, locomotion, and toileting, but did not indicate a preference to wear facial hair. During interview, a nursing assistant stated the resident required staff help with personal hygiene, including shaving, and the unit manager stated she expected the resident’s facial hair to have been shaved if the resident preferred it.
Resident Room Temperature Not Maintained to Comfort Preference
Penalty
Summary
The facility failed to ensure a resident room temperature was maintained according to the resident’s comfort level and preference. A newly admitted resident reported that the room was too cold and stated that nobody knew what to do. The resident said a thick blanket brought in by a friend was not enough and was still using it on top of the facility-provided blanket because the room remained cold. The resident’s room had an air vent cover with fixed louvers and no thermostat or control unit in the room for the resident to adjust the temperature. The maintenance director stated that room temperatures were controlled by a thermostat, with one thermostat serving four rooms, and explained that staff tried to find a median setting for the four rooms. He also stated that if one room still needed adjustment, vent covers with adjustable louvers could be used to lessen airflow and extra blankets could be offered. When the resident’s room was observed with the maintenance director, he confirmed the vent cover did not have adjustable louvers and said he would find a replacement. The maintenance binder contained a work order entry stating the resident reported the room was really cold and asked about adjusting the vent blades, but the completed section only had a signature with no documentation of what was done. A staff member later stated the thermostat was adjusted and an internal damper was closed, but there was no documentation of those actions. A later work order for the same room stated the vent was blowing cold air and wanted covered, but it was also signed as completed without documentation of any action taken.
Late Completion of Admission MDS Assessments
Penalty
Summary
The facility failed to complete comprehensive MDS assessments within the required regulatory timeframes for 3 residents reviewed for resident assessment. The report states that the admission MDS is a federally mandated assessment tool used to gather information about each resident’s strengths and needs, and that it must be completed by the end of day 14 after admission, with the admission date counted as day 1. Record review showed that Resident #24’s admission MDS was due by 6/21/26 but was signed complete on 6/23/26, 16 days after admission and 2 days late. Staff #4, an MDS Coordinator, confirmed during interview that the assessment was completed late. A similar delay was identified for Resident #37, whose admission MDS had an ARD of 6/14/26 and was due by 6/21/26, but was signed complete on 6/24/26, 17 days after admission and 3 days late. Resident #34’s admission MDS was also late; the assessment was due on 6/14/26 but was signed complete on 6/16/26, 16 days after admission and 2 days late. During follow-up interviews, Staff #4 confirmed that Resident #37’s and Resident #34’s admission MDS assessments were completed late.
Failure to Complete Significant Change in Status MDS After Decline in ADLs and Weight Loss
Penalty
Summary
The facility failed to complete a Significant Change in Status MDS assessment within 14 days for a resident who experienced a major decline in health status affecting more than one area of health. Resident #3 had a diagnosis of dementia with severely impaired cognition and, before the decline, required setup or cleanup assistance with eating, partial/moderate assistance with oral hygiene and upper-body dressing, and assistance wheeling in a wheelchair for 50 feet. After hospitalization in March 2026 for repair of a left thigh fracture, the resident returned to the facility and an MDS with an ARD of 3/23/26 documented a decline to partial/moderate assistance with eating and full dependence for oral hygiene, upper-body dressing, and wheeling self for 50 feet. A nutrition evaluation note dated 3/24/26 also recorded significant weight loss over 1, 3, and 6 months. The record did not show that a Significant Change in Status MDS was completed to reflect the decline in ADLs and significant weight loss. A registered dietitian confirmed the resident had significant weight loss after returning from the hospital, and an MDS nurse reviewed the record and agreed the decline would warrant a Significant Change in Status MDS, but the interview did not show that the corporate MDS person was notified of the resident’s decline.
Failure to Include Resident Representative in Care Plan Meeting
Penalty
Summary
The facility failed to ensure that a resident's representative participated in the care plan process for one resident who had impaired decision-making capacity. The resident was admitted in June 2026, had been evaluated by two attending providers and determined to lack adequate decision-making capacity due to dementia, and the admission MDS documented severely impaired cognition. A baseline care plan dated 6/1/26 identified the resident's son as the resident representative. Care plan meeting notes dated 6/9/26 showed that the rehab manager, unit manager, dietitian, social services, activities director, and the resident were present, but the resident's representative was not present. The notes indicated that a message was left for the representative during the meeting, and the record lacked evidence that the facility had attempted to involve the representative before the meeting. The notes also stated that advance directive information was offered and the resident declined, even though the resident had already been determined incapable of making health care decisions due to dementia.
False Documentation of Air Mattress Check
Penalty
Summary
The facility failed to ensure that staff only documented tasks that were actually completed for one resident receiving pressure ulcer care. Resident #117 had an order in effect since 6/5/26 for a low air loss alternating pressure mattress to be checked every shift, set to the resident’s weight, with the static button off unless providing care. The resident’s weight was documented as 81.8 lbs on 6/23/26, and on 6/24/26 at 2:13 PM the resident was observed seated in the room with the bed equipped with an air mattress set at 180 lbs and the static function set to on. Review of the June 2026 TAR showed no documentation at 3:08 PM to indicate the day shift check had been completed, but later at 3:59 PM the TAR showed Nurse #23 had signed off that the mattress check was completed during the day shift on 6/24/26. When asked at 4:16 PM, Nurse #23 stated she had not checked the resident’s air mattress that day. She then reviewed the record with the surveyor, confirmed her initials on the documentation indicating the mattress had been checked and the static button was off, and then entered the resident’s room where the mattress was still set at 180 lbs with static on. The concern was later reviewed with the Unit Nurse Manager and the Director of Nursing.
Failure to Provide Ordered Supervision for Meals and Scheduled Showers
Penalty
Summary
The facility failed to ensure that residents who required assistance with ADLs received the ordered supervision with oral intake and showers. For one resident with squamous cell carcinoma, malignant neoplasm of the tongue and pharynx, dysphagia, Parkinson’s disease, malnutrition, and adult failure to thrive, the record showed orders and care plan instructions for 1:1 supervision during all meals and oral intake, along with assistance with eating. During survey observations, the resident was seen eating without staff present, without a spoon, and later eating additional food items without supervision. The resident stated that staff only set up the tray and left, and the roommate reported that staff did not stay to help the resident eat. The resident’s record also included a speech therapy evaluation stating the resident was at high risk for aspiration and required close 1:1 supervision during all meals and all PO intake, with upright positioning, small bites and sips, and a slow rate. Despite this, staff documentation indicated the resident had been supervised while eating even when the surveyor observed otherwise. The unit nurse manager stated the resident was only thought to need cueing and was not aware of the physician’s order for 1:1 supervision during meals. The director of nursing confirmed the resident was required to receive supervision while eating all meals. For another resident who had bilateral below-the-knee amputations and relied on staff for most self-care, the surveyor observed white, flaky particles in the resident’s facial hair and clothing and the resident stated that regular showers were not being received. The care plan listed a Saturday shower preference, but the shower documentation from January through June showed inconsistent completion, including multiple no-shows, blanks, and refusals, and did not show that the resident was consistently offered a shower every Saturday morning. The unit manager reported that staff used both the paper shower schedule and the electronic record, but the two sources conflicted, with the paper schedule listing bed baths while the electronic record listed showers.
Air Mattress Settings Not Kept at Ordered Resident Weights
Penalty
Summary
The facility failed to ensure air mattresses were kept at the appropriate settings for two residents receiving pressure ulcer care. One resident had a low air loss alternating pressure mattress ordered with instructions to check function every shift, set it to the resident’s weight, and keep static mode off unless providing care. On observation, the mattress was set at 180 lbs. with static mode on, even though the resident’s documented weight was 81.8 lbs. Although the treatment administration record showed the task had been signed off as completed, the nurse later stated she had not checked the mattress and did not know the resident’s current weight. A second resident had a history of a deep tissue injury to the heel that had resolved, but later had a stage one pressure ulcer on the heel that had reopened. The resident also had an order for a low air loss alternating pressure mattress to be checked every shift and set to the resident’s weight with static mode off unless providing care. On observation, the mattress was set at 320 lbs. and later observed at just above 280 lbs. The resident’s most recent documented weights in the record were 328.8 lbs. and 288.4 lbs., and no later weight was found in the vital sign section despite an order for monthly weights. The unit nurse manager stated staff were supposed to check the resident’s weight, but could not confirm a recent weight when questioned.
Missed Ordered Weights and Incorrect BMI Documentation
Penalty
Summary
The facility failed to ensure that weights were obtained as ordered and failed to ensure an accurate BMI assessment for two residents. For one resident with diagnoses including adult failure to thrive and dysphagia, a Nutrition Evaluation documented a weight of 89 lbs., a height of 51 inches, and a BMI of 23 or greater. The resident’s MDS also listed the height as 51 inches. During survey, the RD stated nursing staff normally obtained the height, but later clarified the resident’s height was 65 inches, which changed the BMI to 13.6. The surveyor also observed that the resident did not appear to be as short as 51 inches, and the RD stated she did not know where the 51-inch measurement came from. The same resident had orders to be weighed weekly for 4 weeks and monthly starting on the 1st for 3 days, with spaces on the MAR to document weights on multiple dates. No weight values were found for several ordered dates, and the record showed only a few weights in the vital signs section. The RD documented a significant 7.8 lb weight loss and changed supplement orders, but the chart did not show weights obtained when due on multiple ordered dates. The UM stated she could not explain why the weights were not obtained and suggested the resident may have refused, but the record only showed refusal documentation for one date and no documentation for the other missed weights. For another resident, the record showed a series of weight changes and an order to weigh weekly for 2 weeks, followed by an order to weigh every day shift for 3 days each month. The MAR contained spaces for the ordered weights, but the vital signs section did not show a weight after the weekly monitoring period, and one of the monthly weight dates was left blank. The RD note stated the resident was being monitored weekly, but the record did not contain a weight when one was due. The UM stated GNAs obtained weights and reported them to nurses, and staff confirmed GNAs could not enter weights into the EHR, but the record still lacked documentation that the ordered weights were obtained on the required dates.
Missing CPAP Orders and Care Plan for Resident with Sleep Apnea
Penalty
Summary
The facility failed to ensure that a resident with obstructive sleep apnea and insomnia had physician orders and a care plan for the use and care of a CPAP device. During an initial screening, the resident reported using a CPAP at times but stated that only some staff knew how to use it correctly, so the resident did not always get to use it. The resident also reported trouble sleeping and wanting to use the CPAP, and a CPAP machine was observed on the bedside table. A subsequent medical record review found no physician orders or care plan addressing the CPAP, including directions for use, settings, cleaning and maintenance, or related nursing interventions. The DON confirmed that the resident had begun using the CPAP after a sleep study, but the record still lacked orders, care plan interventions, and nursing assistant or nursing staff tasks related to the device at the time of the surveyor's review.
Pain medications given outside ordered parameters and scheduled opioid doses missed
Penalty
Summary
The facility failed to provide pain management according to physician orders and professional standards of practice for three residents reviewed for pain management. For one newly admitted resident, orders were in place for acetaminophen as needed for mild pain, hydromorphone as needed for severe pain, and non-pharmacological interventions (NPI) to be attempted before any as-needed pain medication. The medication administration record showed hydromorphone was given for a pain score of 0/10 and acetaminophen was given when pain was documented as 0/10, with no documentation that NPI had been attempted before the as-needed medications were administered. For another newly admitted resident with constant pain, orders were in place for acetaminophen as needed for pain rated 1-4, oxycodone as needed for pain rated 5-10, and NPI to be attempted before any as-needed pain medication. The resident stated that staff were giving oxycodone and Tylenol for pain. Review of the administration record showed only 39 documented NPI entries for 53 documented administrations of as-needed pain medication. The record also showed oxycodone was administered for pain scores of 0/10, 1/10, and 0/10 on separate occasions. For a third resident with osteoarthritis and chronic pain syndrome, the care plan addressed comfort and included administering pain medications as ordered. The resident had a standing order for hydromorphone 4 mg every 6 hours, but two scheduled doses were not administered on one day. Documentation did not explain why the medication was not given when due, and the record showed the resident’s supply had reached zero before the pharmacy delivery arrived later. The facility had an interim medication supply available, but the record did not show that the backup supply was accessed when the resident’s hydromorphone ran out.
Unnecessary Medication Administration Despite Hold Parameters
Penalty
Summary
The facility failed to ensure that a resident’s drug regimen was free from unnecessary drugs when medications were administered despite documented hold parameters. For one resident reviewed, the medical record showed an order for metoprolol succinate 25 mg in the evening for atrial fibrillation with instructions to hold if the pulse was 60 or less. The June 2026 MAR showed that on June 2, June 3, and June 17, 2026, the resident’s pulse was documented as less than 60, yet the metoprolol was still given. The Unit Nurse Manager confirmed that the medication should have been held when the pulse was below 60 and stated that the administration on those dates was an issue. The same resident also had an order for Midodrine 10 mg every 8 hours for hypotension, initially with instructions to hold if SBP was 140 or greater. A note from the primary care NP on June 24, 2026 documented a plan to continue Midodrine and add a hold parameter if SBP was 95 or greater, and a new order was written that day with instructions to hold if SBP was 95 or greater. The June MAR showed that on June 24 at 10 PM, June 25 at 2 PM and 10 PM, and June 26 at 6 AM, the recorded SBP was above 95 and the Midodrine was still administered. The DON was informed of the concern and acknowledged awareness of the metoprolol issue and the Midodrine administration issue.
Medication Storage and Supervision Failures
Penalty
Summary
The facility failed to ensure that refrigerated controlled medications were stored in a separately locked, permanently affixed compartment. During observation, a surveyor found black lock boxes inside medication refrigerators in the 400s and 500s hall medication storage rooms that were not permanently affixed to the refrigerators. Nurse #15 stated the black box in the 400s hallway refrigerator was where refrigerated controlled medications were kept and said she thought it used to be nailed down. Nurse #16 then opened the black carry-away lock box in the 500s hallway refrigerator and showed the surveyor two boxes of Lorazepam, confirming that the box was not permanently affixed. The facility’s medication storage policy stated that narcotics and controlled substances are to be stored within a separately locked, permanently affixed compartment. In contrast, the surveyor observed that the 100, 200, and 300 hall medication refrigerator contained a narcotics lock box that was permanently affixed, while the other two refrigerators contained removable lock boxes. The DON stated that controlled medications are to be double locked and secured to the refrigerator, and the ADON stated that nurses had begun using the black lock boxes because the medications would not fit inside the clear locking containers. The ADON also stated that the clear locking box had been removed from the 500s hallway refrigerator and that the 400s hallway refrigerator did not have one. The facility also failed to keep a medication cart locked when unattended. While walking through the 500s hallway, the surveyor observed an unattended medication cart that was unlocked and was able to open the medication drawers. Nurse #16 later acknowledged that the cart should never be left unlocked and unattended and confirmed it should have been locked. In a separate observation, the surveyor saw Resident #117 sitting in a chair with a medicine cup containing one pill on an overbed table, with no nurse in the room. Nurse #23 later identified the pill as famotidine and stated she had given it to the resident but had been called away urgently and asked Nurse #21 to watch.
Food Served at Improper Temperatures
Penalty
Summary
The facility failed to ensure that residents received meals at a palatable temperature. During an initial tour, several residents reported that the facility's food was usually cold by the time they received their trays. A review of the service line checklist records for June 1-24, 2026 found missing item names and temperatures for breakfast and dinner on 6/3/26; for breakfast on 6/13/26 and 6/18/26; and for breakfast and lunch on 6/23/26, despite a notation that item names and temperatures for all hot and cold foods should be taken prior to service and recorded. During an observation of tray line service for dinner, a test tray prepared for a resident on a regular diet included roast turkey, poultry gravy, creamed spinach, bread dressing, a dinner roll, margarine, a chocolate chip cookie, and cranberry juice. Before the surveyor tasted the food, the dietary manager recorded temperatures of 122.3 F for the roast turkey, 126.9 F for the creamed spinach, and 70 F for the cranberry juice. The facility's HACCP plan stated that hot foods were to be held at 135 F or higher and cold foods and drinks at 41 F or lower, but the observed tray contained hot foods below 135 F and a cold drink above 41 F.
Improper Texture of Pureed Food Served
Penalty
Summary
The facility failed to ensure that food was prepared in a form suitable for residents with altered ability to chew and swallow. During a tray-line observation, a test tray prepared for a resident on a regular chopped diet included pureed buttered green peas, but tasting of the food showed the peas contained significant chunks of pea skin rather than a smooth, pudding-like consistency. The meal slip for the resident specified chopped Parmesan-crusted fish fillet, white sauce, pureed buttered green peas, mashed potatoes, hot tea, sugar, salt, pepper, and chopped marble cake with white frosting. Record review showed the resident had a care plan initiated and revised for nutritional risk related to a therapeutic and mechanically altered diet due to a previous stroke and difficulty swallowing. Interviews with dietary and therapy staff confirmed that pureed foods for a resident on a chopped diet should be smooth and not chunky, and that items such as peas needed to be pureed for the resident's safety. Despite this, the observed pureed peas served on the tray contained pea skin chunks.
Infection Control Failures With Laundry Handling and PPE Use
Penalty
Summary
The facility failed to maintain infection control practices in the laundry area when clean linens were observed exposed and the clean laundry room door was propped open. On 6/26/26, two linen carts containing clean folded linens were seen in the hallway with their covers pulled back, and inside the clean laundry room two of four linen carts also had covers pulled back while clean laundry was being folded on a table. The door to the clean side of the laundry room was held open with a container, and staff stated the door was kept open because the room was hot and humid. Staff also confirmed that linen carts were supposed to remain covered, while the Environmental Services Manager and Infection Preventionist acknowledged the expectations for the clean laundry room and carts. The facility also failed to ensure appropriate PPE use for a resident on Enhanced Barrier Precautions. Resident #11 had physician-ordered EBP because of open wounds, with signage posted directing staff to wear gloves and gowns during high-contact care activities, including transfers. During an observed transfer, two GNAs assisted the resident while wearing gloves only and no gowns. One GNA later stated he thought a gown was not needed because he was only helping with the transfer, then acknowledged he should have worn one. The second GNA also stated she should have been wearing a gown and put one on after the observation, while still wearing the same gloves used during the transfer. The facility further failed to follow contact precaution PPE requirements for a resident with MRSA bacteremia. Resident #130 had a diagnosis of bacteremia and was on IV antibiotics for MRSA, with a contact precaution order in place. A nurse entered the resident’s room and took a blood sugar reading while wearing gloves but no gown, then stated she believed gowns were only needed when dealing with wounds. The DON acknowledged the concern when it was discussed, and the record confirmed the resident was on contact precautions related to MRSA.
MDS Assessments Not Accurately Coded for High-Risk Drugs and Falls
Penalty
Summary
The facility failed to ensure Minimum Data Set (MDS) assessments were accurately coded for high-risk drug classes and, in one case, falls and PRN pain medication use. During review of Resident #16’s records, the November 2025 MDS did not capture documented use of Clindamycin and Gabapentin, the February 2026 MDS did not capture insulin injections, Maxitrol ophthalmic solution, or PRN Tylenol, and the May 2026 MDS did not capture Torsemide or Neomycin eye drops. The MDS Coordinator reviewed these assessments and confirmed the findings. For Resident #4, the annual MDS with an ARD of 11/21/25 coded anticoagulant use even though the November 2025 MAR showed Eliquis had been stopped on 11/11/25 and was not given within the look-back period. The February 2026 MDS for the same resident also failed to capture insulin use documented on the MAR. The MDS Coordinator confirmed these findings during review. For Resident #10, the admission MDS with an ARD of 1/21/26 coded no falls since admission even though a change in condition note and care plan progress note documented the resident was observed kneeling against the bed with the upper body on the bed and legs between the wheelchair on 1/20/26. The same assessment also coded no PRN pain medication use despite PRN Tylenol being administered, and it failed to capture diabetes medications including glipizide, metformin, and Lispro. The February 2026 MDS also failed to capture hypoglycemic medications. Additional record reviews showed Resident #5’s March 2026 MDS failed to capture insulin and Apixaban, and Resident #3’s January 2026 MDS failed to capture aspirin and insulin while the April 2026 MDS failed to capture Mupirocin ointment. The MDS Coordinator confirmed these findings.
Missed Ordered Medications and Wound Treatment
Penalty
Summary
Facility staff failed to administer medications and treatments as ordered for one resident who was admitted in September 2025 following a hospitalization. Review of the resident’s February, March, and April 2026 Medication and Treatment Administration Records showed missed doses of Zosyn 3.375 grams IV every 8 hours for bacteremia on 2/1, 2/2, and 2/6/26 at 6 AM, missed doses of Methocarbamol 500 mg four times daily for muscle spasm on 2/1, 2/2, 3/7, 3/19, 4/11, and 4/16/26 at 6 AM, and missed Iodosorb application to the right medial toes/right lateral foot daily for wound care on 3/9 and 3/10/26. The DON confirmed the surveyor’s findings during interview.
Grievance investigation lacked written outcome for alleged abuse complaint
Penalty
Summary
The facility failed to provide the resident or representative with an outcome and/or resolution after completing a grievance investigation for one sampled resident. The grievance policy required the Grievance Official or designee to keep the resident informed of progress and to issue a written decision at the conclusion of the investigation, including the date received, steps taken, findings, whether the grievance was confirmed, corrective action, and the date issued. Resident 5 was admitted on 3/19/24 and had a history that included cerebral infarction, aphasia, heart failure, atherosclerotic heart disease, type 2 diabetes mellitus, cardiomyopathy, protein-calorie malnutrition, hypothyroidism, depression, atrial fibrillation, chronic kidney disease stage 4, cognitive communication deficit, traumatic brain injury, and recent pleural effusion. An annual MDS with an ARD of 2/12/25 showed a BIMS score of 15/15, indicating the resident was cognitively intact, while a later quarterly MDS showed a BIMS score of 3/15 after a recent hospital stay. A grievance dated 9/5/25 addressed three topics, including an allegation of verbal/mental abuse reported to have occurred on 9/4/25 and described by the complainant as an LPN calling the resident a racist, banging on the bed, and bullying the resident. The grievance outcome focused mainly on paper bowls and containers, stating they were replaced and the resident and family were satisfied, but it did not include a resolution for the abuse allegation. Staff interviews confirmed the grievance did not appear to address the alleged verbal/mental abuse, there was no evidence of education provided to staff regarding abuse, and no report was made of the alleged verbal abuse. The Administrator stated the complaint was not considered verbal abuse and said the resolution was documented, but could not identify the statement or resolution when asked.
Failure to timely report suspected misappropriation and alleged verbal abuse
Penalty
Summary
The facility failed to ensure that suspected misappropriation of a resident’s property was reported immediately, and no later than 24 hours, to the Administrator and other required officials. Resident 6 was admitted with diagnoses including anemia, coronary artery disease, and hypertension, and had a BIMS score of 15/15, indicating cognitive intactness. The resident’s admission inventory listed dentures and eyeglasses, but not a wallet. During the investigation, the resident’s family reported that the wallet had been in the room the day before and was missing when the family came to retrieve the resident’s belongings after the resident went to the hospital. The missing wallet was reported to nursing staff at approximately 4:30 p.m., and the missing items form was started at that time. Guest Services and the ADON were notified and began an investigation, but the Administrator was not notified until two days later, after the family member confirmed the wallet was not at the hospital. The facility investigation remained incomplete, the missing items form was not fully completed, no alleged perpetrator was identified, and the facility had no surveillance cameras. Staff interviews confirmed that missing items should be reported immediately to the Administrator, but that did not occur when the item was first reported. The facility also failed to implement its abuse policy for immediately reporting an allegation of staff-to-resident verbal abuse to the State Agency, local law enforcement, and Adult Protective Services within the required time frame. Resident 5 had multiple diagnoses including cerebral infarction, aphasia, heart failure, diabetes, cardiomyopathy, malnutrition, hypothyroidism, depression, atrial fibrillation, chronic kidney disease stage 4, cognitive communication deficit, traumatic brain injury, and recent pleural effusion. The resident’s MDS showed a BIMS score of 15/15 on one assessment, while a later quarterly assessment showed a BIMS score of 3/15 after a recent hospital stay. A grievance reported that an LPN allegedly called the resident a racist, banged on the bed, and bullied the resident, but the grievance resolution did not address the abuse allegation, and there was no evidence that the allegation was reported as required or that staff education was provided related to the abuse complaint.
Failure to Document Abuse Grievance Outcomes and Staff Education
Penalty
Summary
The facility failed to take appropriate corrective action after investigating allegations of abuse by not providing evidence of staff education related to abuse following two separate incidents involving one resident. The resident was admitted on 3/19/24 and had diagnoses including cerebral infarction, aphasia, heart failure, atherosclerotic heart disease, type 2 diabetes mellitus, cardiomyopathy, protein-calorie malnutrition, hypothyroidism, depression, atrial fibrillation, chronic kidney disease stage 4, cognitive communication deficit, traumatic brain injury, and recent pleural effusion. An annual MDS dated 2/12/25 showed a BIMS score of 15/15, while a later quarterly MDS showed a BIMS score of 3/15 after a recent hospital stay, indicating severe cognitive impairment. During survey observations, the resident was described as clean, well-groomed, happy, and hard of hearing, with the daughter often answering for the resident during conversations. One grievance involved an allegation that an LPN called the resident a racist, banged on the resident’s bed, and bullied the resident. The allegation was reported during a care plan meeting after being relayed by a family friend. Facility staff reviewed the grievance, but the documented resolution focused mainly on unrelated concerns about bowls and containers, and the grievance file did not show a resolution for the abuse allegation. Interviews with the ADON, DON, GS, and Administrator confirmed there was no evidence that the allegation of verbal/mental abuse was addressed in the grievance outcome and no evidence that staff received education regarding abuse related to that incident. The Administrator stated the complaint was not considered verbal abuse and said the issue was that the family did not want the LPN assigned to the resident. A second incident involved an allegation of physical abuse that the facility investigated and determined to be inconclusive. Review of that investigation also showed no evidence that staff were educated about abuse after the investigation was completed. In addition, the record review and interviews showed another grievance involving medication administration concerns, where medications were found left in a medicine cup on the bedside table despite documentation on the MAR that the medications had been administered. Staff interviews confirmed the nurse signed the MAR as having given the medications, but the grievance file did not contain evidence of education regarding medication administration. Across the reviewed grievances, surveyors identified repeated gaps in documenting outcomes and in showing staff education after allegations and investigations.
Medication Left Unadministered in Resident Room
Penalty
Summary
The facility failed to administer medication to one resident after a medicine cup containing multiple scheduled medications was found in the resident’s room. The resident had a history that included cerebral infarction, aphasia, heart failure, atherosclerotic heart disease, type 2 diabetes mellitus, cardiomyopathy, protein-calorie malnutrition, hypothyroidism, depression, atrial fibrillation, chronic kidney disease stage 4, cognitive communication deficit, traumatic brain injury, and a recent pleural effusion. The resident’s records showed a change in cognitive status over time, with an annual MDS showing a BIMS score of 15/15 and a later quarterly MDS showing a BIMS score of 3/15 after a recent hospital stay. The grievance investigation found that the resident’s daughter discovered a cup of medications in the room containing Tradjenta, Lasix, amiodarone, Eliquis, and senna. The nurse assigned to the resident on the day of the discovery was identified as the same nurse who signed the MAR indicating the morning medications had been administered. The nurse stated the resident took the medications, while the resident and family denied that the nurse who signed the MAR was the nurse who failed to distribute them. The resident’s family friend stated that another nurse had dropped off the cup of medications, left them in the room, and did not watch the resident take them. Interviews with nursing leadership showed that medication administration was defined as verifying the resident, observing the resident take the medication, and not leaving medications at the bedside before signing the MAR. The ADON, DON, and Administrator all stated that medications should never be left in a medicine cup on a bedside table and that the nurse should remain with the resident until the medication is taken. The facility also stated there was no documentation in the grievance file to support education provided to the nurse or other nursing staff regarding medication administration.
Deficient Food Storage, Labeling, and Temperature Monitoring
Penalty
Summary
Surveyors observed multiple failures in food storage and preparation practices within the facility. In the walk-in refrigerator, nine cartons of milk were found with expiration dates that had already passed. In the walk-in freezer, ten bags of veal meat were stored in a paper box without any label indicating the expiration or use-by date, and staff acknowledged the lack of proper labeling. Additionally, a plate of cold salad in the LTC unit snack refrigerator was not labeled with the date it was prepared or a use-by date. The same refrigerator contained various food items and was found to be dirty, with a brown paper in a brownish liquid, and staff described its condition as "disgusting and dirty." The unit manager stated that housekeeping typically cleaned the refrigerator monthly. Residents reported that their food was usually cold by the time it was served. A review of food service temperature logs revealed multiple instances where required temperature checks were missing for various meals on several dates. The Regional Training manager confirmed that staff were expected to check food temperatures before each meal service and reheat food if temperatures were below acceptable levels, but the logs did not reflect consistent compliance with this protocol.
Failure to Educate and Offer COVID-19 Vaccine to Staff
Penalty
Summary
The facility failed to ensure that staff were educated about and offered the 2024-2025 COVID-19 vaccine, as required. During a review of six employee files, documentation was missing for five staff members regarding both education and the offer of the most recent COVID-19 immunization. Interviews with the Infection Preventionist revealed a lack of awareness about the annual requirement to provide education and offer the vaccine, resulting in no staff being educated or offered the vaccine for the current year. Only one immunization record was available among the files reviewed. The Nursing Home Administrator also confirmed that she was not previously aware of the annual requirement.
Failure to Complete Timely Significant Change MDS Assessment for Hospice Admission
Penalty
Summary
The facility failed to complete a Significant Change in Status Minimum Data Set (MDS) assessment within the required 14-day timeframe for a resident who was admitted to hospice care. Record review and staff interviews confirmed that the resident was admitted to hospice with an effective order date of 4/21/25, but the Significant Change in Status MDS assessment was not completed and signed until 5/7/25, which was outside the mandated period. This deficiency was identified during a survey and was based on the review of medical records and provider orders for the resident involved in hospice care. The MDS is a federally mandated assessment tool used to guide care planning decisions, and timely completion is required when there is a significant change in a resident's status, such as admission to hospice. The failure to complete the assessment within the specified timeframe was evident in the documentation reviewed for the resident.
Inaccurate MDS Assessments Documented for Multiple Residents
Penalty
Summary
The facility failed to ensure that Minimum Data Set (MDS) assessments were accurately recorded for four residents. In one case, a resident's MDS indicated the use of a limb restraint, but both the resident and family denied any restraint use, and staff confirmed the facility was restraint-free. Another resident's MDS failed to document impaired range of motion (ROM) in the right lower extremity following hip surgery, despite therapy records indicating impairment. Additionally, the completion date for this resident's MDS was inaccurately recorded, as some sections were finalized after the documented completion date. A third resident's discharge MDS incorrectly stated the resident was discharged to an acute hospital, when in fact the resident was discharged home. In another instance, a resident with a history of neck fractures and documented bilateral upper extremity ROM impairment in therapy evaluations was inaccurately recorded in the MDS as having no impairment. Staff interviews revealed that delays in receiving therapy data contributed to these inaccuracies, and staff responsible for MDS completion acknowledged the errors.
Failure to Develop and Implement Comprehensive Person-Centered Care Plans
Penalty
Summary
Facility staff failed to develop and implement comprehensive, person-centered care plans for multiple residents, as evidenced by surveyor observations, medical record reviews, and interviews. For one resident who is legally blind, the care plan did not address their stated preferences for accessible reading materials, music, religious services, or being around pets, despite these being identified as important in the Minimum Data Set (MDS) assessment. The care plan also failed to account for the resident's need for assistance with reading activity calendars due to their visual impairment. Another resident admitted for rehabilitation services reported being unaware of available activities and only occasionally encountering them by chance. Review of this resident's care plan revealed that no activities care plan was in place, and staff confirmed that required MDS sections had not been completed or implemented into the care plan. A third long-term resident expressed a desire for more varied activities, stating that only bingo was offered, which did not align with their preferences documented in the MDS for reading materials and outdoor time. The care plan for this resident only included group activities like bingo, failing to match the resident's stated interests. A fourth resident with severe dysphagia and a history of stroke was observed eating unsupervised on multiple occasions, despite care plan directives for aspiration precautions, one-person assistance, and supervision during meals. The resident was also observed eating in bed, contrary to care plan instructions to be out of bed for meals, and refusals of care were not documented as required. Staff interviews confirmed confusion regarding supervision expectations and inconsistencies between care plan documentation and observed practices.
Failure to Provide Resident-Centered Activities and Document Participation or Refusals
Penalty
Summary
The facility failed to implement an ongoing, resident-centered activities program designed to meet the interests and support the physical, mental, and psychosocial well-being of each resident, as evidenced by the experiences of four residents. One resident, who is legally blind and has resided at the facility for over a year, expressed that access to reading materials, music, animals, and religious services was very important. However, there was no documentation of activity participation or 1:1 visits for most of the reviewed period, and staff could not provide records of activity refusals. The care plan for this resident included interventions such as 1:1 visits and assistance to activities, but these were not documented as being carried out. Another resident, admitted for rehabilitation and with moderately impaired cognition, reported being unaware of activities in the facility. The resident's MDS assessment did not include the required activity preferences section, and there was no activities care plan in place. Activity attendance records showed only one documented activity, and staff could not provide documentation of refusals despite stating that the resident often refused activities. Similarly, a long-term resident with intact cognition reported rarely getting out of bed and not receiving in-room activities. The annual MDS assessment for this resident also lacked the required activity preferences section, and there was no documentation of activity participation or refusals. A fourth resident, also with intact cognition, expressed a desire for more varied activities beyond bingo and indicated a preference for reading materials and outdoor time. The care plan for this resident focused on group activities and bingo, which did not align with the resident's stated preferences. Observations confirmed the absence of reading materials in the resident's room, and activity records did not show that reading materials or outdoor opportunities were offered. These findings were confirmed by interviews with staff and the DON, and no further information or documentation was provided by the facility prior to the end of the survey.
Failure to Prevent Significant Medication Errors in Ativan Administration
Penalty
Summary
A deficiency was identified when a resident with a history of anxiety and receiving regular dialysis treatments did not consistently receive Ativan (Lorazepam) as ordered. Medical record review showed that the resident was prescribed Ativan 0.5 mg at bedtime and a combination of 1.0 mg and 0.5 mg prior to dialysis sessions. However, documentation on drug control sheets failed to confirm that the evening dose of Ativan was removed from the supply on seven specific dates, despite staff recording its administration on the medication administration record (MAR). Additionally, on three occasions, a 1.0 mg dose was removed and presumably administered instead of the ordered 0.5 mg dose, indicating the resident may have received double the intended dose on those evenings. Further review revealed that duplicate orders for Ativan 0.5 mg to be given with 1.0 mg on dialysis days resulted in staff documenting administration of two 0.5 mg tablets and one 1.0 mg tablet on certain mornings, leading to a total of 2.0 mg being given instead of the ordered 1.5 mg. The discrepancies between the MAR and the drug control sheets, as well as the lack of documentation for medication removal, indicate failures in both medication administration and controlled substance documentation for this resident.
Failure to Accurately Document Medication Administration and Resident Care Activities
Penalty
Summary
Staff failed to accurately document medication administration and care activities for multiple residents. For one resident with an order for Ativan (Lorazepam), a controlled substance, the medication administration record showed consistent documentation of administration, but the corresponding controlled drug sheets lacked entries for seven specific dates, indicating no documentation that the medication was removed from supply on those occasions. Despite requests, no additional documentation was provided to account for these discrepancies. In another case, a resident with severe dysphagia and a care plan requiring supervision and assistance during meals was observed feeding themselves unsupervised in bed. The care plan specified that the resident should be out of bed for meals and that any refusals should be documented. However, staff documented that the resident was out of bed for breakfast, contrary to direct observation, and failed to record the resident's refusal to get out of bed. Additionally, documentation for activities of daily living (ADL) was incomplete for several residents. One resident's records had blank spaces for personal hygiene care and repositioning tasks across multiple shifts. Another resident, dependent on staff for total care, reported not receiving a shower for at least two weeks, and observations confirmed poor hygiene. The medical record indicated a shower was given, but the resident denied this, and no supporting shower sheet was found. The DON confirmed the lack of accurate documentation for these care activities.
Infection Control Lapses in Hand Hygiene, Barrier Precautions, and Laundry Handling
Penalty
Summary
The facility failed to implement an effective infection prevention and control program, as evidenced by multiple observed lapses in infection control practices among staff. In one instance, a nurse was observed preparing and administering medications to a resident, washing the resident's feet, and applying medicated cream without performing hand hygiene between glove changes. The nurse also removed unused gloves from the clean supply, handled them with unwashed hands, and returned them to the box, further breaching infection control protocols. The nurse only performed hand hygiene after handling dirty laundry, not between other critical steps as required. The unit nurse manager confirmed that staff are expected to perform hand hygiene between glove changes, which was not followed in this case. Another deficiency was observed with a geriatric nurse aide providing morning care to a resident on Enhanced Barrier Precautions (EBP) due to a wound and dialysis access. The aide wore gloves but failed to wear a gown during high-contact care activities, despite signage and policy requiring both gloves and gowns for such residents. The aide acknowledged removing the gown after it became wet and continuing care without replacing it. Additionally, the facility's laundry practices were found deficient, with soiled linen bins lacking lids and proper labeling, and clean laundry bins being brought into the soiled area without clear separation. Staff reported that bins have never had lids and are only cleaned biweekly, and the Director of Environmental Services confirmed the ongoing issue with uncovered soiled linens.
Failure to Thoroughly Investigate Allegations of Abuse
Penalty
Summary
The facility failed to thoroughly investigate multiple allegations of abuse involving four residents. In one case, a resident reported being struck by a staff member during feeding, resulting in visible redness and pain near the eye. The facility's documentation lacked timely and complete follow-up, including missing a required follow-up change in condition form and failing to ask the resident about the injury. The Director of Nursing confirmed that the necessary follow-up was not completed, and no additional information was provided to address the lack of a thorough investigation. Another incident involved a resident who was reported by a hospital emergency department to have been pushed, resulting in significant bruising and bleeding. The facility's investigation file contained incomplete and improperly identified medical records, lacked any witness or staff interviews, and did not include a review of the resident's facility medical records. The Nursing Home Administrator acknowledged the absence of a proper investigation and could not provide further evidence to support the facility's response to the allegation. Additional deficiencies were found in the investigation of an allegation of inappropriate touching and an incident where a resident with a history of stroke and hemiplegia reported rough handling by staff. In both cases, the facility's investigation documentation was incomplete, with missing or undated interview records, unclear identification of involved staff, and inconsistencies in the reporting of events. The investigations failed to identify alleged perpetrators, lacked supporting documentation such as police reports, and did not reconcile clinical findings with the reported allegations. These failures resulted in incomplete and insufficient investigations into serious allegations of abuse.
Failure to Provide and Document Required ADL Care for Dependent Residents
Penalty
Summary
The facility failed to provide adequate activities of daily living (ADL) care to dependent residents, as evidenced by multiple instances of missed or insufficient care. Several residents who were incontinent or required total assistance did not consistently receive timely incontinence care, bathing, or grooming. For example, one resident was observed with a soaked bedsheet and urine odor, and documentation showed that incontinent care was not recorded for all shifts on over half of the days reviewed. The DON confirmed the lack of documentation for this resident's care. Another resident, who required staff assistance for showers and had a care plan specifying two showers per week, received only three showers over a month, with missed opportunities to re-offer showers after refusals, particularly on dialysis days. In another case, a resident fully dependent on staff for eating had 15 shifts with no documentation of assistance and three shifts with only set-up, despite being unable to feed themselves. The DON acknowledged that documentation should have indicated when family provided care, but this was not consistently done. Additional deficiencies included residents with hemiplegia and high cognitive function scores who reported not receiving bed baths, changes, or showers as scheduled, despite being fully dependent on staff. Documentation sometimes indicated care was provided when residents denied receiving it, and required supporting documentation, such as shower sheets, was missing. Staff interviews revealed that care was sometimes delayed or omitted, with some staff waiting for residents to request assistance rather than proactively providing scheduled care.
Failure to Maintain Safe Operating Condition of Hoyer Lift
Penalty
Summary
A deficiency was identified when the facility failed to maintain the safe operating condition of patient care equipment, specifically a Hoyer lift used for resident mobility assistance. Record review of the grievance log revealed that a grievance was filed by a social service designee and investigated by a registered nurse, who confirmed that one of two facility Hoyer lifts was not in safe operating condition due to dead batteries. Interviews with the complainant and the county ombudsman validated the grievance, and it was confirmed that the director of nursing and the nursing home administrator were aware of the issue. No harm was reported to the resident involved.
Failure to Safeguard Resident's Personal Food Due to Inconsistent Policy Implementation
Penalty
Summary
The facility failed to ensure the safety and availability of a resident's personal property, specifically food brought in by family members. A long-term resident reported difficulty chewing facility-provided food, leading their family to bring in outside food. The family later discovered that the food they had brought was missing from the unit's refreshment refrigerator. Review of the facility's 'Food from Home Policy' indicated that all food items brought in by families must be labeled with content and date, and are to be discarded if not consumed within three days. Interviews with staff revealed inconsistencies in the application of this policy. The kitchen staff reported discarding any items without an expiration date, while nursing staff stated that only the date the food was placed in the refrigerator was required, not an expiration date. This discrepancy led to the removal of food items that may have been within the allowed timeframe, resulting in the resident's food being discarded and unavailable. The concern regarding inconsistent policy implementation was discussed with facility leadership, but no further information was provided before the survey concluded.
Failure to Ensure Resident Access to Call Bell and Lighting Controls
Penalty
Summary
Surveyors determined that the facility failed to provide reasonable accommodations to maintain residents' independence by not ensuring access to call lights and lighting controls. Specifically, one resident was observed on two separate occasions seated in a wheelchair at the bedside with the call bell tied to the left side bed rail, making it inaccessible to the resident. On both occasions, staff members confirmed that the call bell was out of reach and repositioned it closer to the resident only after being prompted by the surveyor. Additionally, the issue of inaccessible lighting controls was noted in all rooms observed, though the report focuses on the repeated failure to ensure the call bell was within reach for the resident in question. The Nursing Home Administrator confirmed that the expectation is for the call bell to be accessible to residents at all times, but the deficiency was observed multiple times during the survey period.
Failure to Ensure Proper Discussion and Documentation of Advance Directives
Penalty
Summary
The facility failed to ensure that a resident's health care advance directives were properly discussed and documented. A review of the medical record for a resident with adequate decision-making capacity showed that staff had documented the presence of an advance directive during admission and in a subsequent social service assessment. However, upon further review, no advance directive was found in either the electronic medical record or the paper chart. Instead, only a durable power of attorney document, which did not address health care decisions, was located in the record. Interviews with the Social Service Designee (SSD) revealed that there was confusion regarding the correct documentation, and the SSD acknowledged that the document on file was not related to health care. There was also no documentation indicating that the family was informed about the missing or incorrect paperwork. The deficiency was identified when surveyors noted the discrepancy between the documentation stating an advance directive was on file and the actual absence of such a document in the resident's records.
Failure to Maintain Cleanliness and Timely Linen Changes for Residents
Penalty
Summary
The facility failed to provide a clean, comfortable, and homelike environment for its residents, as evidenced by multiple observations and interviews. One resident's room was found to have dark debris, dried food particles, and dried sticky fluid on the floor, which had reportedly been present for at least two weeks. Both a housekeeping technician and the director of environmental services confirmed the room's unclean condition and acknowledged that resident rooms were supposed to be cleaned daily, but this had not occurred. Another resident, who is dependent on staff for total care due to a history of stroke and has a BIMS score of 15, reported that their bed linens were not changed regularly, typically only every couple of weeks. Over several days, surveyors observed the resident's bed linens to be visibly stained, soiled, and containing skin debris, food particles, and a urine-soaked incontinence pad. Despite the facility's policy to change linens on shower days and when soiled, the resident's sheets remained unchanged for several days, as confirmed by both the resident and staff interviews.
Failure to Initiate Grievance Process for Missing Resident Property
Penalty
Summary
The facility failed to implement its grievance policy when a resident reported missing personal property. Upon admission, the resident brought a wheelchair with leg rests, which were later reported missing for approximately one month. The resident informed the physical therapist, who attempted to locate the missing leg rests and provided alternative leg rests in the meantime. Interviews with staff revealed that although the concern was known to both the physical therapist and a unit nurse, there was no written documentation or formal initiation of the grievance process regarding the missing property. Further interviews confirmed that the standard procedure for missing property was to initiate the grievance process by the first staff member made aware of the issue. The Director of Rehabilitation acknowledged that this process was not followed in the case of the missing wheelchair leg rests. As a result, the facility did not make prompt efforts to resolve the resident's grievance in accordance with its established policy.
Late Completion of Admission MDS Assessment
Penalty
Summary
The facility failed to complete a comprehensive Minimum Data Set (MDS) assessment within the required regulatory time frame for one resident. Specifically, the admission MDS assessment, which is mandated to be completed by the end of day 14 following admission, was not finalized until day 18, resulting in a four-day delay. This was confirmed through record review and staff interviews, with the MDS Coordinator acknowledging the late completion. The deficiency was identified during a review of residents assessed for accidents, and the late assessment led to a lapse in maintaining current and accurate assessment records necessary for appropriate care planning.
Failure to Hold Interdisciplinary Care Plan Meetings After MDS Assessments
Penalty
Summary
The facility failed to ensure that interdisciplinary care plan meetings were held following Minimum Data Set (MDS) assessments for a resident reviewed for unnecessary medications. Medical record review showed that the resident had a quarterly MDS assessment completed in March and a significant change MDS assessment completed in May. However, there was no documentation indicating that care plan meetings were scheduled or conducted after either assessment. When the surveyor requested records of care plan meetings since January, the Director of Nursing confirmed that no such meetings had occurred for this resident during that period. This deficiency was identified through medical record review and staff interviews, which confirmed the absence of required interdisciplinary care plan meetings following the completion of MDS assessments.
Failure to Implement and Document Accident Prevention Interventions
Penalty
Summary
The facility failed to implement and document care plan interventions designed to prevent accidents for three residents identified as being at risk. For two residents with a history of falls, both had physician orders and care plans requiring the use of low beds with bilateral floor mats. However, during multiple observations, these fall mats were not present, despite staff having documented on the Treatment Administration Record (TAR) that the interventions were in place. The absence of the mats was confirmed by the unit nurse manager, and there was no indication that the mats had been removed for care or other reasons during the observed periods. For a third resident assessed as being at risk for elopement, the care plan and orders required the use of a wander guard bracelet and a check of its functionality every shift. While the resident was observed wearing the bracelet and staff documented its placement, there was no documentation of functionality checks after the order for this was discontinued. The unit nurse manager confirmed that both placement and functionality checks should be documented, but only placement was being recorded. These failures demonstrate that the facility did not ensure that care plan interventions to prevent accidents were consistently implemented or documented as required.
Failure to Provide Physician-Ordered Pain Management and Documentation
Penalty
Summary
The facility failed to provide appropriate pain management services as ordered by physicians for two residents. In the first case, a resident with an order for PRN oxycodone for severe pain reported experiencing severe pain and waiting several hours for medication, only to be told by nursing staff that the medication was unavailable. Review of medication records and the narcotic sign-out sheet confirmed that the last dose had been administered earlier that morning and that no further medication was available in the facility at the time of the resident's request. In the second case, a resident with chronic pain had physician orders requiring non-pharmacological interventions (NPIs) to be attempted prior to administering PRN pain medication. Review of the medical record and medication administration records revealed that there was no documentation of pain assessments or attempts at NPIs before administering the PRN pain medication on several occasions. The lack of documentation included missing information on pain location, type, and whether NPIs were attempted prior to medication administration.
Failure to Provide Necessary Behavioral Health Services and Medication Administration
Penalty
Summary
The facility failed to ensure that necessary behavioral health care and services were provided to a resident with a documented history of anxiety disorder, insomnia, and moderate depression. The resident had been assessed using the Minimum Data Set (MDS), which indicated moderate depression, and was noted by staff to have anxiety issues. The psychiatric nurse practitioner evaluated the resident and prescribed Ativan and Melatonin, with a recommendation for continued behavioral health services. However, review of the controlled drug sheets revealed that the evening dose of Ativan was not documented as removed from the supply on seven occasions in June, despite the resident expressing uncertainty about receiving the medication as ordered. No additional documentation was provided to confirm administration of the medication on those dates. Further review of the medical record showed that a psychologist had seen the resident and recommended follow-up psychotherapy within 2-3 weeks, stating that the resident's condition would deteriorate without continued treatment. Despite this, there was no documentation of any follow-up behavioral health visits by the psychologist, psychiatric nurse practitioner, or other behavioral health providers after the initial session. The absence of both medication administration documentation and timely behavioral health follow-up constituted a failure to provide necessary behavioral health care and services as required.
Pharmacist Failed to Identify Medication Errors Due to Incomplete Record Review
Penalty
Summary
The facility failed to ensure that a licensed pharmacist conducted a thorough monthly drug regimen review by not reviewing sufficient sections of a resident's medical record to identify significant medication errors. For one resident receiving behavioral health services, there were documented errors involving the administration of Ativan, including missed evening doses on seven occasions and the administration of an extra 0.5 mg dose on five occasions during the month reviewed. These discrepancies were identified through a review of both the drug control sheets, which were kept in a bound book on medication carts and not included in the electronic health record, and the Medication Administration Record (MAR). Further review revealed that there were duplicate active orders for Ativan, leading to confusion and incorrect dosing, with staff administering a total of 2.0 mg instead of the ordered 1.5 mg on certain days. The pharmacist responsible for the monthly medication regimen review completed the review remotely and did not identify these errors, as she relied on the recap summary and MAR, which she believed to be identical, and did not compare them with the drug control sheets. The pharmacist confirmed that the duplicate order did not appear on the summary she reviewed and acknowledged that she was not in the building to check the drug control sheets at the time of the review.
Failure to Timely Report and Investigate Alleged Abuse
Penalty
Summary
The facility failed to ensure that an incident of alleged abuse involving a resident with severely impaired mental cognition was thoroughly investigated and reported to the state agency in a timely manner. A family member of the resident reported to a nurse that another resident may have been inappropriately touching the resident. The nurse documented and signed a statement regarding the allegation, but there was a two-day delay before the Director of Nursing submitted the initial report to the state agency. The Director of Nursing acknowledged this delay during an interview, despite stating that the concern was investigated and reported immediately.
Failure to Provide Consistent Negative Pressure Wound Therapy and Documentation
Penalty
Summary
The facility failed to provide care consistent with professional standards of practice for a resident with a diabetic foot wound requiring Negative Pressure Therapy (VAC). The resident had a history of Type 2 Diabetes Mellitus with a foot ulcer, recent surgical amputation, and other significant medical conditions. Physician orders required continuous VAC therapy to the right foot, with nursing staff responsible for assessing and documenting the VAC's functioning every shift. However, documentation was missing for several consecutive days, and there was no evidence that the VAC was assessed or functioning properly during this period. Progress notes and the Treatment Administration Record lacked entries confirming the required care was provided on multiple days. Interviews with nursing staff, the wound specialist, and the Director of Nursing confirmed that the VAC was not consistently monitored or documented, and that the wound care provided over the weekend was substandard. The wound specialist noted that the VAC appeared to have not been working for several days prior to her assessment, and the resident's surgical site deteriorated as a result. The DON acknowledged that the lack of documentation indicated a failure to provide care in accordance with professional standards, as required for wound healing and prevention of further complications.
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 433 citations issued within 25 miles in the last 12 months — including the 4 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 Frederick
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Northampton Manor Nursing And Rehabilitation Cente | 3.7 mi | ★★★★★ | 26 | 0 |
| Autumn Lake Healthcare At Glade Valley | 4.2 mi | ★★★★★ | 29 | 0 |
| Frederick Crossing Of Journey | 5.2 mi | ★★★★★ | 37 | 0 |
| Homewood Living Frederick | 5.3 mi | ★★★★★ | 0 | 0 |
| Citizens Care And Rehabilitation Center Of Frederi | 5.5 mi | ★★★★★ | 14 | 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 October 2026) and official state health department websites.