Autumn Lake Healthcare At Baltimore Washington
Inspection history, citations, penalties and survey trends for this long-term care facility in Glen Burnie, Maryland.
- Location
- 313 Hospital Drive, Glen Burnie, Maryland 21061
- CMS Provider Number
- 215316
- Inspections on file
- 19
- Latest survey
- February 13, 2026
- Citations (last 12 mo.)
- 28
Citation history
Health deficiencies cited at Autumn Lake Healthcare At Baltimore Washington during CMS and state inspections, most recent first.
Surveyors found that the facility failed to develop and implement complete, accurate care plans for several residents, including one with IV antibiotics and surgical and skin issues without corresponding goals and interventions, another with a care plan for anticoagulant‑related bleeding despite no anticoagulant orders, a resident with a fall history and Eliquis for atrial fibrillation without fall or anticoagulant care plans, and a resident with longstanding rheumatoid arthritis and multiple scheduled and PRN pain medications who had no pain management care plan and whose initial care plan meeting lacked medical or nursing staff participation.
Multiple residents experienced inaccurate MDS assessments and documentation. One resident who was lowered to the floor during a transfer had a witnessed fall documented in the medical record, but the fall was not coded on the Discharge MDS. Another resident admitted to Hospice with an active Hospice care plan was not coded for Hospice services on a Quarterly MDS. Two residents had discrepancies between their immunization records and MDS Section O coding for influenza vaccination, including one who received the vaccine in the facility and another whose historical data showed vaccination despite MDS coding of refusal. A resident with longstanding rheumatoid arthritis and constant pain had inconsistent and sometimes missing pain scores on the MAR and PDPM charting that documented no pain, despite the resident’s report of ongoing pain and frequent requests for pain medication.
A resident with a PEG tube was admitted without timely orders for tube flushing or site monitoring. Staff interviews confirmed that maintenance care, including water flushes and site inspection, was not initiated until several days after admission, resulting in a lapse in appropriate PEG tube maintenance.
A resident with multiple complex medical conditions, including malnutrition and a sacral wound, had an incorrect weight documented in their record, which was referenced by the physician as evidence of weight gain. The DON later corrected the error but did not notify the physician, resulting in the physician being unaware of the resident's actual weight loss over several weeks.
A resident's room was found to have a privacy curtain in disrepair that did not provide adequate privacy during wound care, along with a broken bedside table and closet door, resulting in a failure to maintain a sanitary and comfortable environment.
A resident complained of pain and alleged being hurt by staff during a transfer with a mechanical lift. The physical therapy assistant documented the complaint and informed the Director of Therapy, but the allegation was not immediately reported to administrative staff or authorities as required. The resident continued to report pain and was later admitted to the hospital with diagnoses including neglect.
A resident reported being physically injured by staff during a transfer with a mechanical lift and later expressed ongoing pain and concerns to therapy staff. The allegation was not thoroughly investigated, as the report was not escalated to administrative staff and the resident was not asked for further details. Documentation of staff education or follow-up was lacking, and the resident was later admitted to the hospital with diagnoses including neglect.
Staff did not follow or document required care plan interventions for two residents, including failing to check and record feeding tube placement and residuals for a resident with a gastrostomy tube, and not notifying a nurse when another resident at nutritional risk consumed less than half of their meals on multiple occasions.
A resident with a gastrostomy tube, quadriplegia, malnutrition, and a sacral pressure ulcer experienced significant weight loss over several weeks despite a care plan aimed at weight gain. Facility staff failed to accurately document weights and did not notify the physician or dietician of the weight loss, resulting in a deficiency related to maintaining the resident's nutritional status.
The facility did not ensure accurate and complete documentation of controlled medication administration for two residents. Multiple doses of Oxycodone were signed out by licensed staff but were not recorded in the medication administration records, as confirmed by the DON. This resulted in discrepancies between the controlled substance records and the MARs.
A resident with quadriplegia, contractures, and bilateral foot drop was observed with both feet hanging over the end of the bed, as the bed was too short to accommodate the resident's height and the use of foot drop boots. The resident communicated to the DON that the bed was too small, and this was confirmed during a surveyor's observation.
The facility was found deficient in ensuring qualified staff for food and nutrition services. The food service manager's Certified Dietary Manager (CDM) certificate had expired, and the Registered Dietician (RD) worked only part-time. This lack of qualified staff has the potential to affect all residents.
The facility failed to maintain an effective pest control program, with multiple reports and observations of flies, gnats, and bed bugs affecting residents. Staff interviews revealed a lack of awareness and use of pest log books, and the facility's process for reporting pest issues was inadequate. Pest issues, including bed bugs and mice, remained unresolved for extended periods, highlighting the facility's failure to manage and address pest concerns effectively.
The facility failed to thoroughly investigate multiple allegations of abuse and missing belongings. In one case, a resident reported sexual assault, but the investigation lacked critical details. Another incident involved abuse allegations with missing documentation and follow-up. Additionally, a complaint about missing belongings was not adequately addressed, lacking necessary documentation and statements.
The facility was found to have numerous deficiencies in maintaining a clean and safe environment, with observations of cluttered and unclean resident rooms, exposed sharp metal screws, and widespread environmental issues such as peeling paint and stained ceiling tiles. Residents expressed concerns about the uncleanliness, and staff acknowledged the issues but failed to address them promptly, as evidenced by ongoing complaints in the facility's grievance logs.
The facility failed to provide timely care and follow-up for several residents, leading to significant deficiencies. One resident experienced a fall resulting in facial injuries, and the facility delayed hospital transfer until family intervention. Another resident with mouth sores did not receive prescribed medication for three weeks. A resident with a change in mental status did not receive timely intervention, and a diabetic resident's blood sugar levels were inconsistently monitored. Additionally, a resident did not receive scheduled IV antibiotics on time due to staff shortages, with no documentation explaining the missed doses.
A resident was mistakenly given another resident's medication upon discharge, breaching medical privacy. The error was confirmed by the DON, who acknowledged the possibility of such mistakes during discharge.
The facility failed to report allegations of abuse, neglect, and incidents in a timely manner to the OHCQ. A resident reported a nurse bending their finger, and another resident's daughter alleged neglect after rough handling by a CNA. Injuries of unknown origin were not reported, and missing medications and verbal abuse allegations lacked timely initial reports. These deficiencies were identified during a survey.
A facility failed to provide written notification to a resident and their representative regarding hospital transfers. The resident was transferred twice due to a change in medical condition, but no documentation of the transfer notice was found in the medical record. The DON stated that notifications should be given at the time of transfer, with copies sent to the hospital and family members, but these were missing.
A resident with a Stage II pressure ulcer did not receive appropriate care due to a missed wound treatment order upon admission. The family noticed the outdated dressing, prompting staff to address the oversight. The facility's process for reviewing new admissions failed to ensure the necessary wound care orders were in place.
A facility failed to provide a resident and their representative with a baseline care plan summary, as required by federal regulations. The deficiency was identified during a survey, revealing that the resident was admitted without receiving a summary of the care plan, which should include initial goals, medications, dietary instructions, and services. Interviews with staff showed a lack of awareness about the requirement to provide this summary.
A facility failed to follow professional standards in medication administration, including not verifying orders before administering medications, not documenting controlled medications accurately, and mishandling an insulin pen. An RN administered medications without verifying orders against the MAR, leading to documentation discrepancies. Audits revealed multiple instances where controlled medications were not properly documented in the MAR. Additionally, the RN improperly drew insulin from a pen using a syringe, contrary to recommended practices.
A facility failed to provide appropriate treatment for a resident receiving tube feeding. The resident's Osmolite feeding was observed not running, and the water flush bag was dated incorrectly, indicating it had not been changed for several days. The tube feeding administration record lacked signatures for multiple shifts, except for one. The RD's note indicated the resident's energy needs were to be met via enteral nutrition, but the administration record showed a lack of documentation. The DON and staff acknowledged the issues, noting an incorrect order by the RD.
The facility failed to provide timely and appropriate pain management for two residents. One resident, post-knee replacement, did not receive prescribed Oxycodone in a timely manner despite its availability. Another resident with chronic pain had PRN medications without specific parameters and did not receive non-pharmacological interventions as ordered. Interviews confirmed delays and omissions in pain management.
A registered nurse improperly administered insulin by drawing it from an insulin pen using a syringe instead of the pen's specified needle and dial, believing it ensured an exact dose. This was observed during a survey, and the nurse also failed to use a computer for medication administration and did not sign off medications promptly.
The facility failed to conduct annual performance reviews for GNAs, as required. During a survey, it was found that a GNA hired in early 2022 did not have a record of an annual performance review. The DON stated that evaluations are done yearly or every 90 days by department heads, with HR tracking them. However, the DON could not provide the missing evaluation record, acknowledging the issue.
The facility failed to maintain accurate records for controlled medications, with discrepancies found between the Controlled Medication Utilization Record and the MAR for three residents. The audit revealed that several doses of Oxycodone and Percocet were not properly documented, indicating a lapse in the facility's process for administering and recording controlled medications.
A facility failed to follow up on a pharmacist's recommendation to add Divalproex to a resident's medical records. The recommendation, made in January, was not addressed by the attending physician until June. The DON and attending physician cited communication issues, with the DON acknowledging the oversight.
Facility staff administered PRN Oxycodone outside prescribed parameters for a resident with chronic pain, failing to follow physician orders. The medication was given for pain scores below the required level, and staff did not document non-pharmacological interventions as ordered. The Unit Manager and DON confirmed these deficiencies.
A facility failed to monitor side effects for a resident on Quetiapine Fumarate, an antipsychotic medication. Despite a psychiatric recommendation for monitoring, no side effect monitoring was in place, confirmed by an LPN and acknowledged by the DON. An order for side effect observation had been discontinued earlier, and even after surveyor intervention, only behavior monitoring was initiated.
An LPN failed to perform hand hygiene before administering medications and used a pen to poke a blister pack to retrieve a tablet, which is not standard practice. The DON confirmed that hand hygiene is expected before, during, and after medication administration.
During a survey, it was observed that two handrails near the kitchen were not firmly secured, with loose screws causing them to be movable. The Director of Maintenance and the Administrator were informed of the issue, acknowledging the concern.
The facility failed to serve meals simultaneously to residents seated at the same table, affecting their dignity. During dining observations, it was noted that residents at two tables experienced delays of 12-14 minutes in receiving their meals. This delay caused dissatisfaction among residents, with one expressing frustration over consistent mishandling of meal service. Staff interviews revealed that nursing staff alternated in assisting the dining hall and retrieving missing food items, contributing to the delay.
The facility failed to develop comprehensive care plans for residents, leading to deficiencies in wound management, incontinence care, catheter hygiene, and pain management. A resident was hospitalized due to improper wound care, while another experienced inadequate incontinence care due to incorrect task frequency settings. Additionally, catheter hygiene and non-pharmacological pain interventions were not included in care plans, despite medical orders.
The facility failed to update care plans for two residents, leading to inaccuracies in their medical records. One resident's care plan incorrectly indicated the need for a tracheostomy and oxygen therapy, while another's inaccurately documented pressure ulcers. Staff acknowledged the discrepancies, noting that care plans should be reviewed quarterly and updated as needed.
The facility failed to provide adequate rehabilitation and restorative services for two residents, leading to a deficiency in maintaining their functional abilities. One resident's occupational therapy was prematurely discontinued despite progress, while another resident's physical therapy evaluation was not scheduled timely. The facility lacked a functional maintenance or restorative program, and there was no documentation in the care plan for such programs.
A resident reported environmental concerns in their room, leading a surveyor to find sharp metal screws protruding from a broken baseboard heat cover. The Unit Manager and Director of Social Work acknowledged the hazard, but it remained unaddressed during a follow-up observation. The facility Administrator confirmed the issue.
The facility failed to provide appropriate catheter care for three residents, leading to deficiencies in their care. A resident with a suprapubic catheter lacked a care plan and medical orders for several months. Another resident experienced repeated Foley catheter issues without proper evaluation or documentation, resulting in a urinary tract infection. Additionally, a Foley catheter bag was observed on the floor for a third resident, with no medical order for catheter care. The DON confirmed these deficiencies.
The facility failed to provide adequate nutrition, resulting in significant weight loss for two residents. One resident, with a history of stroke and dysphagia, lost over 12% of body weight in six months due to insufficient meal portions. Another resident experienced an 11% weight loss in a month, with no physician notification or care plan update. The DON acknowledged the deficiencies after surveyor intervention.
The facility failed to securely store and properly label medications, with instances of medications left unattended in residents' rooms and expired or undated medications found in medication carts. Additionally, the facility was unable to account for missing narcotics delivered by the pharmacy, indicating a lapse in secure handling and documentation of controlled substances.
The facility failed to maintain accurate and complete medical records for three residents. A resident's medical record showed a blood pressure reading after being transferred to the hospital, indicating a data entry error. Another resident had a specialty air mattress without an active medical order, despite its use for wound healing. Additionally, enteral feeding orders for a third resident were unsigned for 22 days due to incomplete order confirmation by nursing staff.
Failure to Develop and Implement Comprehensive, Accurate Care Plans for Multiple Residents
Penalty
Summary
The deficiency involves the facility’s failure to develop and implement comprehensive, individualized care plans with measurable goals and interventions for multiple residents. For one resident who returned from the hospital on 1/24/2026, the surveyor observed an IV antibiotic mini bag at the bedside, but record review showed there was no comprehensive care plan addressing the IV antibiotic therapy or care of the IV access site. The same resident had an incomplete care plan for a mid‑back surgical site and dermatitis that lacked goals and interventions. The DON stated that the care plan had not been reactivated when the resident returned from the hospital. Another resident had an active care plan that included interventions for monitoring signs and symptoms of abnormal bleeding and bruising related to anticoagulant use, but record review showed there were no active or discontinued physician orders for any anticoagulant medication during the resident’s stay. The hospital discharge summary indicated a history of DVT and that the resident was not anticoagulated. The DON acknowledged that the clinical team was responsible for implementing and updating care plans, yet the care plan still contained anticoagulant‑related interventions that did not match the resident’s actual medication regimen. A further resident with a documented fall on 11/10/2024 and a diagnosis of history of falling did not have any problem, goal, or interventions in the comprehensive care plan for an actual fall or risk for falls. This same resident had a physician order for Eliquis 5 mg twice daily for atrial fibrillation, but there was no comprehensive care plan addressing the anticoagulant medication or the cardiac arrhythmia. In addition, another resident with a primary diagnosis of rheumatoid arthritis, constant pain, and multiple standing and PRN pain medications (including Hydrocodone‑Acetaminophen, Lyrica, Lidocaine patch, Capsaicin, and Extra Strength Tylenol) had no pain management care plan. The initial care plan update completed 72 hours after admission did not mention pain or pain relief measures, and a progress note indicated no medical or nursing staff attended that care plan meeting. When questioned, an employee stated they did not know why pain management was not included in the care plan.
Inaccurate MDS Coding and Pain Assessment Documentation for Multiple Residents
Penalty
Summary
The deficiency involves inaccurate completion of Minimum Data Set (MDS) assessments for multiple residents. One resident experienced a change in condition when two GNAs were transferring the resident from bed to wheelchair, the resident’s knees buckled, and the resident was lowered to the floor. A change in condition evaluation documented this witnessed fall, but the subsequent Discharge – Return Anticipated MDS assessment did not code the fall in Section J. Another resident had a physician order for admission to Hospice and an active Hospice care plan, yet the Quarterly MDS assessment did not code the resident as receiving Hospice services in Section O. Additional inaccuracies were identified in MDS coding related to influenza vaccination status. One resident’s medical record showed that the resident received the influenza vaccine in the facility, but the MDS assessment documented that the resident had not received the vaccine and that it was “not offered.” Another resident’s immunization record documented that the resident had refused the influenza vaccine on admission, with education provided on risks and benefits, and also showed in historical data that the resident had already received the influenza vaccine for the current season. However, the MDS assessment coded that the resident had not received the vaccine and that it was “offered and declined,” failing to reflect the documented administration in historical data. A further deficiency was identified in the assessment and documentation of pain for a resident with a long-standing diagnosis of rheumatoid arthritis who reported being in constant pain and stated that they had informed staff of their pain intensity. The resident had a standing order for Hydrocodone-Acetaminophen every eight hours with a requirement to record pain level on the MAR using a 0–9 scale, but the MAR showed inconsistent pain level entries, numerous “0” pain scores despite the resident’s report of never being without pain, and instances where pain level was not recorded at all. Skilled Nursing Charting PDPM entries also indicated that the resident reported no pain, which conflicted with the resident’s statements. The resident additionally had a PRN order for Extra Strength Tylenol for chronic pain, which was administered only once during the first two weeks of the month, despite the resident’s report of requesting pain medication almost daily.
Failure to Provide Timely Maintenance Care for PEG Tube
Penalty
Summary
Facility staff failed to provide appropriate maintenance care for a resident's percutaneous endoscopic gastrostomy (PEG) tube. Upon admission, the resident had a PEG tube in place, but there were no orders for monitoring or flushing the tube until several days after admission. The medical record review revealed that orders for flushing the PEG tube with water, inspecting the site for signs of infection, and completing tube site care were not entered until nearly a week after the resident's admission. There was no documentation of the tube being flushed or monitored prior to these orders being added to the Medication Administration Record. Interviews with facility staff, including the unit manager and the DON, confirmed that they would have expected PEG tube care orders, including maintenance flushing and site monitoring, to be in place upon admission. The resident was able to eat and drink by mouth, and the PEG tube was not being used for feeding, but staff acknowledged that maintenance flushes should still have been performed. The lack of timely orders and documentation resulted in a failure to ensure proper maintenance care for the resident's PEG tube.
Failure to Notify Physician of Incorrect Weight Documentation
Penalty
Summary
The facility failed to notify a resident's physician regarding an incorrect weight documentation, which led to a misinterpretation of the resident's clinical status. The resident, who had diagnoses including quadriplegia, a recent gastrostomy tube placement, a sacral pressure ulcer, malnutrition, and contractures, was identified as being at nutritional risk with a care plan targeting safe weight gain. On 02/26/25, nursing staff documented a weight of 119.4 pounds for the resident, which was later found to be an error and intended for another resident's record. This incorrect weight was referenced by the physician in a subsequent assessment, leading to the belief that the resident was gaining weight. On 03/11/25, the DON corrected the error by striking out the incorrect weight entry but did not notify the resident's physician of this change. Subsequent weights showed a significant weight loss of 6.6 pounds (5.5%) over a three-week period. The failure to communicate the documentation error and the resident's actual weight trajectory to the physician resulted in a lack of timely physician awareness regarding the resident's nutritional status and weight loss.
Failure to Maintain Sanitary and Comfortable Resident Environment
Penalty
Summary
Facility staff failed to provide necessary housekeeping and maintenance services to maintain a sanitary, orderly, and comfortable environment for a resident. During a wound care dressing change observation, the privacy curtain in the resident's room was found to be in disrepair, hanging on the floor, and unable to provide complete privacy. Additionally, the bedside table had two out of three drawers that would not close, and the closet door was also in disrepair and could not close completely. These deficiencies were directly observed during the provision of care and were confirmed by staff interview.
Failure to Timely Report Suspected Abuse Allegation
Penalty
Summary
Facility staff failed to immediately report an allegation of suspected resident abuse to the administrator and State Survey Agency within the required 2-hour timeframe. A resident complained of soreness in the right hip after an incident involving a Hoyer lift, stating that staff had hurt them. The physical therapy assistant (PTA) documented these complaints in progress notes and informed the Director of Therapy, but did not notify other facility administrative staff. The resident continued to express pain and reluctance to participate in therapy, and later submitted a concern form to a nursing unit manager. The unit manager addressed the concerns several days after the initial complaint, but there was no documentation of staff education or immediate reporting of the abuse allegation as required. Review of the resident's medical record showed ongoing complaints of pain and a request to go to the emergency room, which was eventually granted. The hospital record indicated diagnoses including atypical chest pain, ambulatory dysfunction, and neglect of an adult. The facility's failure to promptly report the suspected abuse and the results of the investigation to the proper authorities constituted a deficiency in meeting regulatory requirements for timely reporting of abuse allegations.
Failure to Investigate Resident's Allegation of Injury During Transfer
Penalty
Summary
The facility failed to thoroughly investigate an allegation made by a resident who reported being physically injured by staff during a transfer with a Hoyer lift. The resident complained of soreness in the right hip following the incident and later reported to a physical therapy assistant that aides had hurt them. The physical therapy assistant informed the Director of Therapy but did not notify other administrative staff, and the resident was not asked to elaborate on the allegation. Documentation shows that the concern was not escalated or formally investigated as required for abuse allegations. Further review revealed that a nursing unit manager addressed some of the resident's concerns days later, including instructing staff to be more gentle and educating the resident on safety procedures, but there was no documentation of staff education or follow-up regarding the abuse allegation. The resident subsequently requested to go to the emergency room, where they were admitted with diagnoses including atypical chest pain, ambulatory dysfunction, and neglect of an adult. The facility's records did not show that the required investigation or documentation of the alleged abuse was completed.
Failure to Implement and Document Care Plan Interventions for Two Residents
Penalty
Summary
Facility staff failed to implement parts of comprehensive care plans for two residents, as identified during a complaint survey. For one resident with quadriplegia, a recent gastrostomy tube placement, and contractures, the care plan included specific nursing interventions such as checking the feeding tube for placement and gastric residuals and recording the results. However, a review of medication and treatment administration records over several months showed that nursing staff did not document these required checks and recordings, indicating that this aspect of the care plan was not followed. For another resident with dementia, congestive heart failure, COPD, diabetes, and nutritional risk, the care plan required staff to notify the nurse if the resident consumed less than 50% of a meal. Meal intake records revealed that the resident ate less than half of their meals on 34 occasions over nearly a month, but there was no documentation that the nurse was notified as required by the care plan. These findings demonstrate that staff did not consistently implement or document key interventions outlined in the residents' individualized care plans.
Failure to Maintain Nutritional Status After Feeding Tube Placement
Penalty
Summary
A deficiency was identified when the facility failed to maintain or improve a resident's nutritional status following the placement of a gastrostomy tube. The resident, who had diagnoses including quadriplegia, malnutrition, a sacral pressure ulcer, and contractures, was admitted with a care plan to address nutritional risk and weight gain. The care plan included interventions such as administering the prescribed diet, providing tube feeding if meal intake was less than 50%, monitoring weights and labs, notifying the physician and dietician of significant weight loss, and administering supplements as ordered. Despite these interventions, the resident experienced a significant weight loss over a three-week period, dropping from 113.8 pounds to 112.8 pounds, with a mistaken entry of 119.4 pounds later corrected by the DON. The DON acknowledged that the incorrect weight entry was not communicated to the resident's physician at the time it was discovered. The resident's weights were inconsistently documented, and the significant weight loss was not promptly addressed according to the care plan's requirements. The failure to notify the physician and dietician of the weight loss and to ensure accurate and timely documentation contributed to the deficiency in maintaining the resident's nutritional status.
Failure to Accurately Document Controlled Medication Administration
Penalty
Summary
The facility failed to maintain complete and accurate clinical records for residents, specifically regarding the administration and documentation of controlled medications. For one resident, a review of the controlled medication utilization record showed that two doses of Oxycodone were signed out by licensed nursing staff, but only one dose was documented as administered in the medication administration record (MAR). The Director of Nursing confirmed that there was no nursing documentation for the remaining dose that was signed out. For another resident, the controlled medication utilization record indicated that ten doses of Oxycodone were signed out, but only three doses were documented as administered in the MAR. The Director of Nursing confirmed that there was no nursing documentation for the seven remaining doses that were signed out. These findings demonstrate a lack of a system to ensure that clinical records accurately reflect medication administration, as required by facility policy and professional standards.
Resident's Bed Inadequate for Physical Needs
Penalty
Summary
Facility staff failed to ensure that a resident's bed adequately met the resident's needs. During a complaint survey, it was observed that the resident, who has quadriplegia, a gastrostomy tube, and contractures of both ankles, had both feet hanging over the bottom of the bed and foot board. The resident also suffers from bilateral ankle foot drop and wears foot drop prevention boots daily, which further extend the length of the legs. The resident was able to communicate to the DON that the bed was too small. These findings were based on complaint, observation, review of clinical records, and resident interview.
Deficiency in Qualified Food and Nutrition Staff
Penalty
Summary
The facility failed to ensure that it had qualified staff with the appropriate competencies and skill sets to carry out food and nutrition services, which has the potential to affect all residents. During an interview, the food service manager, identified as staff #51, revealed that although they possess a Serve Safe certificate, their Certified Dietary Manager (CDM) certificate had expired due to not maintaining the required continuing education units (CEUs). The manager has initiated steps to renew the certification by sending transcripts to the program to start taking classes. Additionally, the Registered Dietician (RD), identified as staff #12, works part-time for 16 hours, and a Consultant Registered Dietician, identified as staff #53, works 8 hours. The surveyor noted that the lack of an active CDM certificate does not meet the facility's requirement for having qualified staff to carry out food and nutrition services.
Inadequate Pest Control Program
Penalty
Summary
The facility failed to maintain an effective pest control program, as evidenced by multiple reports and observations of pest issues, including flies, gnats, and bed bugs, affecting various residents and areas within the facility. Residents reported the presence of pests in their rooms and bathrooms, with some experiencing discomfort such as itching. The surveyor observed gnats and flies in several rooms and common areas, confirming the residents' complaints. Despite these issues, the facility's pest control measures were inadequate, with no effective process in place to report and manage pest issues timely. Interviews with staff revealed a lack of awareness and utilization of pest log books, which were intended to document pest sightings and concerns. The Unit Manager was unaware of the purpose of the pest log book, and the Director of Maintenance confirmed that the maintenance department did not check any paper logs on the nursing units. The facility's process for reporting pest issues relied on an electronic system, but there was no evidence of consistent use or follow-up on reported concerns. The pest control company's contract indicated that pest monitoring logs were to be checked during each visit, but the surveyor found no staff reporting of pest issues in the log books. The facility's records showed multiple incidents of pest issues, including bed bugs and mice, with some concerns remaining unresolved for extended periods. The surveyor noted that the first bed bug treatment for a reported issue did not occur until 14 days after the concern was raised. Additionally, mice issues continued to be reported over several months. The surveyor's observations and interviews with staff and residents highlighted the facility's failure to effectively manage and address pest issues, resulting in an environment that was not free from pests.
Inadequate Investigation of Abuse Allegations and Missing Belongings
Penalty
Summary
The facility failed to thoroughly investigate allegations of abuse and missing belongings, as evidenced by multiple incidents involving residents. In one case, a resident reported being sexually assaulted by an employee, but the investigation lacked critical details such as the identity of the interviewer and signatures on interview notes. The Director of Nursing (DON) was unable to provide information on who conducted the interviews, and the investigation was deemed incomplete by the surveyor. Another incident involved a resident alleging abuse by staff, but the investigation file was missing key documentation, including statements from involved staff and residents. The investigation lacked time stamps, interviewer identities, and follow-up on claims made by the resident. The DON acknowledged the concerns raised by the surveyor, indicating a lack of thoroughness in the investigation process. Additionally, a complaint about missing personal belongings was not adequately addressed. The facility failed to maintain an inventory sheet or obtain statements from staff who witnessed the resident's belongings at the time of transfer. The DON confirmed the absence of necessary documentation, and the Nursing Home Administrator acknowledged the issue but did not provide evidence of a thorough investigation.
Facility Fails to Maintain Clean and Safe Environment
Penalty
Summary
The facility failed to maintain a clean, homelike environment, as evidenced by numerous observations of unclean and unsafe conditions throughout the facility. During the initial tour, surveyors observed resident rooms with cluttered belongings, splattered food, debris, and sticky floors. Resident #31 expressed concerns about the uncleanliness of their room, which was confirmed by the facility Administrator. Additionally, the surveyor noted a lack of bed linens on several mattresses and exposed sharp metal screws in Resident #7's room, posing a safety hazard. Further observations revealed widespread environmental issues, including peeling paint, broken cove molding, stained ceiling tiles, and mismatched lighting in various rooms. The surveyor documented numerous instances of visibly dirty floors, walls, and baseboard heating units, as well as broken furniture and fixtures. Residents reported having to clean their own areas due to the facility's inadequate housekeeping, and staff acknowledged the concerns but failed to address them promptly. The facility's grievance logs indicated ongoing complaints about cleanliness and maintenance issues, dating back several months. Despite these documented concerns, the facility did not take effective action to resolve the problems, resulting in continued deficiencies. The surveyor's observations highlighted a pattern of neglect in maintaining a safe and comfortable environment for residents, with multiple staff members acknowledging the issues but not implementing corrective measures.
Multiple Deficiencies in Resident Care and Documentation
Penalty
Summary
The facility failed to provide timely care and follow-up for several residents, leading to significant deficiencies. One resident experienced a fall resulting in facial injuries, including a left orbital and jaw fracture. Despite the fall occurring in the morning, the facility did not transfer the resident to the hospital until the family intervened hours later. The Director of Nursing admitted that the staff was unaware of the fall until later, and there was a lack of documentation on the care provided immediately after the incident. Another resident with mouth sores did not receive the prescribed medication for three weeks, despite a nurse practitioner's order for treatment. The medication was ordered but never administered, and the Director of Nursing confirmed this oversight. Additionally, a resident with a change in mental status, later diagnosed with a urinary tract infection, did not receive timely intervention. The staff failed to document the change in condition or administer the prescribed anti-anxiety medication until the following day, after the family called 911. Further deficiencies included a diabetic resident whose blood sugar levels were not consistently monitored as ordered, and the facility failed to implement a physician's order for pressure relief. The resident's heels were not elevated as required, and staff signed off on the task without verifying its completion. Another resident did not receive their scheduled IV antibiotics on time due to staff shortages, and there was no documentation explaining the missed doses. These incidents highlight significant lapses in care and documentation within the facility.
Medication Privacy Breach
Penalty
Summary
The facility staff failed to protect the privacy of residents' medical information by mistakenly giving a discharged resident the medication of another resident. This incident involved Resident #161, who was discharged from the facility and received a bottle of Metoprolol with another resident's name, Resident #200, on it. The error was reported by a complainant who received the medication upon Resident #161's discharge and noticed the incorrect labeling. The surveyor's investigation confirmed that Resident #200 had been in the facility and was prescribed Metoprolol during their stay. The Director of Nursing acknowledged the possibility of such an error occurring when residents are discharged with their medications. The incident was validated by the DON, highlighting a breach in maintaining the confidentiality of residents' medical records.
Failure to Timely Report Abuse and Incidents
Penalty
Summary
The facility staff failed to report allegations of abuse and neglect within the required timeframe to the Office of Health Care Quality (OHCQ). In one instance, a resident reported that a nurse bent their finger back while administering medication, but the initial report to the state agency was not sent within the mandated two-hour window. Another case involved a resident's daughter alleging that a CNA was rough with her parent, leading to neglect. The facility administration was aware of the complaint but delayed reporting it to the state and local law enforcement by two days. Additionally, the facility did not report injuries of unknown origin to the OHCQ. A resident was found with a bruise on their chest after a fall, but there was no documentation of the incident being reported to the state agency. The facility's investigation suggested the bruise could be due to Senile Purpura, but the lack of timely reporting and documentation was noted as a deficiency. The facility also failed to submit initial reports for incidents involving missing medications and allegations of verbal abuse. Oxycodone delivered to the facility for two residents was reported missing, but there was no evidence of an initial report to the OHCQ. In another case, a resident reported being cursed at by a staff member, but the initial investigation report was not submitted promptly. These failures to report in a timely manner were identified as deficiencies during the survey.
Failure to Notify Resident of Hospital Transfer
Penalty
Summary
The facility failed to provide timely written notification to a resident and their representative regarding the resident's transfer to a hospital. This deficiency was identified during a recertification/complaint survey for one of the four residents reviewed for hospitalization. Specifically, the medical record of a resident revealed that they were transferred to the hospital on two occasions due to a change in medical condition, but there was no documentation of a transfer notice being given to the resident or their representative. The Director of Nursing (DON) stated that the facility's protocol requires that a notification of transfer be given to the resident at the time of transfer, with cognitively intact residents signing the notice and a copy being sent with them to the hospital. For residents unable to sign, a copy is sent to their family members for signature, and the facility retains a copy in the resident's medical chart. However, in this case, the notification documents for the resident's hospital transfers were missing from the medical chart, and the administrator confirmed that they could not be found.
Failure to Provide Appropriate Pressure Ulcer Care
Penalty
Summary
The facility failed to provide appropriate care and treatment for a resident with a pressure ulcer, as identified during a recertification/complaint survey. The deficiency involved a resident who was admitted with a Stage II pressure ulcer on the left lateral malleolus. Upon admission, there were no orders for wound treatment, despite the hospital discharge summary indicating the need for specific wound care. The resident's family member noticed that the wound dressing was outdated and brought it to the attention of the nursing staff, who confirmed there was no order for dressing changes. The nursing staff, including a registered nurse, explained the process for planning care for new admissions, which involves reviewing discharge summaries and reconciling orders with the physician. However, in this case, the wound treatment order was missed during the admission process, and the Director of Nursing was informed of this oversight. The lack of a wound care order resulted in the resident's pressure ulcer not being appropriately managed until the family member intervened.
Failure to Provide Baseline Care Plan Summary
Penalty
Summary
The facility failed to provide a resident and their representative with a summary of the baseline care plan, as required by federal regulations. This deficiency was identified during a recertification/complaint survey for one resident. The medical record review revealed that the resident was admitted to the facility, but there was no evidence that a copy of the baseline care plan summary was offered to the resident or their representative during the care conference. The baseline care plan summary should include initial goals, a list of current medications and dietary instructions, and services and treatments to be administered by the facility. Interviews with facility staff highlighted a lack of awareness and understanding regarding the requirement to provide a baseline care plan summary. An LPN staff member indicated that while the nursing staff initiates the baseline care plan and other departments are involved in its completion, they were not aware of the need to provide a summary. The Director of Nursing stated that the baseline care plan is created and discussed during the care plan meeting, but the surveyor noted that the facility did not offer a copy of the baseline care plan summary to the resident or their representative.
Medication Administration Deficiencies
Penalty
Summary
The facility staff failed to adhere to professional standards of nursing practice during medication administration, as observed in several instances. A registered nurse (RN) was seen preparing medications for a resident without verifying the current orders against the Medication Administration Record (MAR), relying instead on a binder and medication pack information. The nurse admitted to not using the facility-provided laptop to verify orders due to being in a hurry and familiarity with the resident's medications. This resulted in discrepancies in the documentation, as the controlled medication utilization record was signed, but the MAR was not updated accordingly. Further audits revealed significant discrepancies between the Controlled Medication Utilization Record and the MAR for multiple residents. For one resident, nine entries of as-needed Oxycodone did not match the MAR, while another resident had 16 entries of as-needed Percocet that were not signed in the MAR. A third resident had 21 entries of as-needed Oxycodone that were not documented in the MAR. These discrepancies indicate a failure to properly document the administration of controlled medications, as required by professional standards. Additionally, the RN was observed mishandling an insulin pen by drawing insulin into a syringe, which is not an endorsed practice by insulin manufacturers. The nurse justified this action by expressing concerns about the accuracy of the dose delivered by the pen. This improper handling of the insulin pen was contrary to the recommended use, which involves attaching a specified needle to the pen and dialing the ordered dose. These actions demonstrate a lack of adherence to established protocols for medication administration, contributing to the deficiencies identified during the survey.
Failure in Tube Feeding Administration and Documentation
Penalty
Summary
The facility failed to provide appropriate treatment and services to a resident receiving tube feeding, as observed during a recertification/complaint survey. The deficiency was identified for one resident who was on both an oral diet and enteral nutrition via a PEG tube. The surveyor observed that the resident's Osmolite tube feeding was not running on multiple occasions, and the water flush bag was dated incorrectly, indicating it had not been changed since 8/20/24. Additionally, the tube feeding administration record was not signed from 8/12/24 to 8/23/24, except for one signature on 8/13/24. The surveyor confirmed with RN #9 that the dates on the Osmolite bottle and water flush bag were inconsistent, and the tube feeding machine was not properly monitored. The Registered Dietitian's note indicated that the resident's energy needs were to be met via enteral nutrition, but the administration record showed a lack of documentation. The Director of Nursing and Staff #10 acknowledged the issues, with Staff #10 noting that the order was written incorrectly by the RD. The deficiency highlights a failure in maintaining accurate records and ensuring proper administration of tube feeding and water flushes for the resident.
Inadequate Pain Management for Residents
Penalty
Summary
The facility failed to provide timely and appropriate pain management for two residents during a recertification/complaint survey. Resident #161, who was admitted after a right knee replacement, was prescribed Oxycodone for pain management. Despite the availability of the medication in the facility's Omnicell system, the resident did not receive the medication until the following day, resulting in unmanaged pain. The Director of Nursing confirmed the delay in administering the pain medication. Resident #10, who suffers from chronic pain, had orders for three different PRN pain medications without specific parameters and no routine pain medication to manage the pain consistently. The resident also had an order for non-pharmacological interventions prior to PRN medication, which were not administered as required. Interviews with the resident and staff confirmed that the resident experienced delays in receiving pain medication and did not receive non-pharmacological interventions before medication administration.
Improper Insulin Administration by RN
Penalty
Summary
The facility staff failed to ensure that a registered nurse possessed the necessary skills to administer insulin correctly, as observed during a recertification/complaint survey. Specifically, RN #9 was seen drawing insulin from an insulin pen using a one cubic centimeter (cc) syringe instead of using the pen's specified needle and dial to set the dose. This action was taken because RN #9 believed that the resident would not receive the exact dose if the pen was used. The insulin was then administered to Resident #8 using the one cc syringe on the right arm, as per the resident's request. During an interview, the Director of Nursing (DON) and the corporate nurse confirmed that the correct procedure for insulin administration involved using the pen's specified needle and dial. They were informed of RN #9's incorrect method of drawing insulin. The report also noted that RN #9 was passing medications from memory without using a computer and not signing off medications in a timely manner, which contributed to the deficiency identified by the surveyors.
Failure to Conduct Annual Performance Reviews for GNAs
Penalty
Summary
The facility staff failed to conduct performance reviews of Geriatric Nursing Assistants (GNAs) at least once every 12 months, as required. This deficiency was identified during a recertification/complaint survey when the records of three randomly selected GNAs were reviewed for annual training requirements. Specifically, the personal file of one GNA, hired on February 15, 2022, did not contain a record of an annual performance review. During an interview, the Director of Nursing (DON) stated that performance evaluations are conducted yearly or every 90 days by department heads, and the Human Resources department is responsible for tracking and alerting staff about due evaluations. However, the DON was unable to provide the missing evaluation record for the GNA in question, acknowledging the concern.
Discrepancies in Controlled Medication Records
Penalty
Summary
The facility failed to maintain accurate drug records for controlled medications, specifically Oxycodone and Percocet, for three residents during a recertification/complaint survey. The Controlled Medication Utilization Record did not match the Medication Administration Record (MAR) for several entries, indicating discrepancies in the documentation of administered doses. For Resident #66, nine out of 23 recorded doses of Oxycodone did not match the MAR. Similarly, for Resident #21, 16 out of 27 recorded doses of Percocet were not signed in the MAR. Resident #86 had 21 out of 53 recorded doses of Oxycodone that did not match the MAR. During an interview, the Director of Nursing and a corporate nurse confirmed that nurses are required to sign and date the controlled sheet when removing medication and to sign the MAR after administration. However, an audit revealed that the administered narcotics did not match the records, indicating a failure in the facility's process for documenting controlled medication administration. This deficiency highlights a significant lapse in the facility's pharmaceutical services, potentially affecting the safety and well-being of the residents involved.
Failure to Address Pharmacy Recommendation for Medication
Penalty
Summary
The facility failed to follow up on a pharmacy recommendation for a resident during a recertification/complaint survey. The issue was identified for one of the five residents reviewed for unnecessary medication. Specifically, the pharmacist recommended on January 2, 2024, that an order for Divalproex, a medication used to treat bipolar disorder and epileptic seizures, be added to the electronic medical records (PCC) if the resident was receiving it. However, this recommendation was not addressed by the attending physician, and the medication was only started on June 4, 2024. Interviews with the Director of Nursing (DON) and the attending physician revealed a breakdown in communication and responsibility. The DON stated that pharmacy recommendations are passed to nursing staff, who then communicate them to the attending physician. The attending physician confirmed that he relies on the nursing staff to present pharmacy recommendations to him for review and action. The DON acknowledged the concern when made aware of the oversight, indicating that the recommendation was not followed up as required.
Inappropriate Administration of PRN Oxycodone
Penalty
Summary
The facility staff failed to adhere to physician orders by administering PRN Oxycodone outside the prescribed parameters for a resident. The resident, who was admitted with multiple medical diagnoses including chronic pain, had an active order for Oxycodone to be given every 4 hours as needed for pain levels between 6 and 10. However, the medication was administered on several occasions when the resident's pain score was below the prescribed threshold, indicating the administration of unnecessary medication. Additionally, the facility staff did not document any non-pharmacological interventions that were supposed to be attempted prior to administering the PRN pain medication, as per the physician's orders. The Unit Manager and the Director of Nursing confirmed the inappropriate administration of Oxycodone and the lack of documentation for non-pharmacological interventions. The Unit Manager acknowledged that nurses were expected to follow the physician's parameters and should have sought alternative pain management options for lower pain scores.
Failure to Monitor Psychotropic Medication Side Effects
Penalty
Summary
The facility failed to ensure proper monitoring for side effects of psychotropic medication use for a resident during a recertification/complaint survey. Specifically, the medical record review for Resident #254 revealed that there was no monitoring in place for side effects of the antipsychotic medication Quetiapine Fumarate, which was prescribed to be administered twice daily. This lack of monitoring was confirmed by a Licensed Practical Nurse and acknowledged by the Director of Nursing. The treatment administration record indicated that an order for observing side effects had been discontinued earlier in the month. Despite a psychiatric note recommending monitoring of the efficacy of psychiatric medication, no additional side effect monitoring was implemented until after surveyor intervention. Even then, the monitoring was limited to behavior, with no comprehensive side effect monitoring reinstated. The surveyor expressed continued concern over the absence of side effect monitoring, which was again acknowledged by the Director of Nursing.
Infection Control Breach During Medication Administration
Penalty
Summary
The facility failed to ensure proper infection prevention and control practices during medication administration. A Licensed Practical Nurse (LPN #13) was observed not performing hand hygiene before preparing medications for Resident #21. Additionally, the LPN used a pen to poke a blister pack to retrieve a tablet, which is not a standard practice. When questioned by the surveyor, the LPN admitted to using a pen when the blister pack was difficult to open, although it was not a regular practice. During an interview with the Director of Nursing (DON) and a corporate nurse, they confirmed that nurses are expected to perform hand hygiene before, during, and after medication administration. They were informed of the LPN's failure to adhere to these protocols and the inappropriate method used to access medication from the blister pack.
Loose Handrails Observed During Survey
Penalty
Summary
The facility failed to ensure that two handrails were firmly secured, as observed during a recertification/complaint survey. On August 27, 2024, at 11:11 AM, a surveyor noted that two handrails located against the wall next to the facility's kitchen appeared off-centered. Upon closer inspection, it was found that two metal screws were loose, protruding through the handrail into a block of wood and then into the wall, causing the handrails to be movable and not firmly secured. The surveyor conducted an environmental tour and shared these concerns with the facility's Director of Maintenance, who acknowledged the issue and reported being unaware of the loose condition of the handrails. On September 9, 2024, the surveyor also shared these concerns with the facility Administrator, who confirmed understanding of the surveyor's concerns.
Failure to Serve Meals Simultaneously Affects Resident Dignity
Penalty
Summary
The facility failed to maintain or enhance the dignity and respect of residents by not serving food to residents seated at the same table simultaneously. During a dining observation, it was noted that residents at two different tables experienced delays in receiving their meals. Specifically, at table #2, one resident received their meal 12 minutes after the others, and at table #4, one resident was served 12-14 minutes later than their tablemate. This delay affected four out of nineteen residents in the dining room, causing dissatisfaction among the residents. Resident #356 expressed frustration with the staff for consistently mishandling their meal service, while Resident #90 was upset about the untimely delivery of their food tray. Interviews with staff revealed that the nursing staff alternated in assisting the dining hall and retrieving missing food items or trays from other areas or the kitchen. These actions contributed to the delay in meal service, impacting the residents' dining experience and their right to a dignified existence.
Removal Plan
- Submit a new plan for the residents who go to the dining room and their seating.
- Communicate the information with the kitchen.
Deficiencies in Resident Care Planning
Penalty
Summary
The facility failed to develop and implement comprehensive care plans for several residents, leading to deficiencies in care. Resident #191 was admitted to the hospital with a septic wound infection, which was allegedly due to improper wound management by the facility. Upon review, it was found that there was no care plan addressing the resident's multiple wounds or the use of a wound vacuum device, despite the expectation that such a plan should have been developed. Resident #7 experienced issues with incontinence care, as they reported being wet and uncomfortable due to insufficient care. The care plan indicated that incontinence checks and brief changes should occur every two hours, but documentation showed that care was only provided once per shift. This discrepancy was confirmed by staff, who acknowledged that the task frequency was incorrectly set, leading to inadequate care for the resident. Resident #254's care plan lacked interventions for catheter hygiene care, despite having an active medical order for a Foley catheter. The Director of Nursing confirmed the absence of a medical order for catheter care, and the care plan did not address this need. Additionally, Resident #10's care plan did not include non-pharmacological interventions for pain management, as ordered by the physician. This oversight was validated by staff, indicating a failure to update the care plan to reflect the physician's order.
Failure to Update Resident Care Plans
Penalty
Summary
The facility failed to revise and update comprehensive care plans for two residents, leading to deficiencies identified during a recertification/complaint survey. For one resident, the care plan inaccurately indicated the presence of a tracheostomy and the need for oxygen therapy, despite the resident not having these conditions at the time of observation. The resident confirmed that they had a tracheostomy and used oxygen therapy approximately two years ago, but these were no longer applicable. The unit manager and the Director of Nursing (DON) acknowledged that the care plan should have been resolved and updated to reflect the resident's current condition. Another resident's care plan inaccurately documented the presence of stage II and III pressure ulcers, although the resident did not have any pressure ulcers and was not receiving treatment for them. This discrepancy was confirmed through interviews with the resident and an LPN. The DON explained that care plans are reviewed quarterly and updated as needed, but the care plan for this resident had not been updated to reflect the absence of pressure ulcers. These findings highlight the facility's failure to maintain accurate and current care plans for its residents.
Deficiency in Rehabilitation and Restorative Services
Penalty
Summary
The facility failed to meet the rehabilitation needs of two residents, leading to a deficiency in maintaining their functional abilities. Resident #41, who had a history of rheumatoid arthritis, right shoulder pain, and lupus, was admitted to the facility and required maximum assistance with activities of daily living (ADLs). Despite making progress in occupational therapy (OT) from maximum to moderate assistance, the resident's OT sessions were prematurely discontinued after only two weeks, without reaching the highest practicable level of physical well-being. The Rehabilitation Manager and Director of Nursing acknowledged the resident's progress and the need for continued therapy, but the necessary services were not provided. Resident #65, with a history of cervical stenosis, also required maximum assistance with ADLs. Although the resident was advised by a physical therapist to be active for at least four hours a day, this was not happening, and the resident's concerns were communicated to the nursing staff. A new order for a physical therapy (PT) evaluation was issued, but it was not scheduled in a timely manner. Additionally, the facility lacked a functional maintenance or restorative program, and there was no documentation in the care plan for a built-in nursing restorative program. The Director of Nursing was unable to provide the location of such a program in the care plan, highlighting a deficiency in the facility's rehabilitation and restorative services.
Hazardous Conditions in Resident Room
Penalty
Summary
During a recertification/complaint survey, it was found that a resident's room was not maintained free from accident hazards. A resident expressed concerns about environmental conditions behind their bed, prompting a surveyor to investigate. The surveyor observed three sharp metal screws, each approximately 1 inch in length, protruding from a broken area of the baseboard heat cover, which also had sharp edges exposed. This observation was confirmed by the Unit Manager and Director of Social Work, who acknowledged the issue. Despite this acknowledgment, a subsequent observation by the surveyor later in the day revealed that the hazardous condition remained unaddressed. The facility Administrator was also informed and confirmed the surveyor's concerns during a dual observation.
Deficiencies in Catheter Care for Residents
Penalty
Summary
The facility failed to provide appropriate catheter care for three residents, leading to deficiencies in their care. Resident #156 was admitted with a suprapubic catheter but did not have a care plan or medical orders for catheter care for several months. The care plan was only initiated months after admission, and there was a lack of documentation for cleaning, monitoring, and infection control. The Director of Nursing (DON) confirmed that the care plan should have been initiated upon admission and that staff were expected to document catheter care. Resident #154 experienced repeated issues with a Foley catheter not draining, leading to a urinary tract infection. Despite these issues, there was no documentation of catheter evaluation or consultation with a physician or urologist. The DON acknowledged that catheter care should have been documented and discussed with medical professionals. Additionally, Resident #254's Foley catheter bag was observed on the floor, and there was no medical order for catheter care in the resident's records. The DON confirmed the absence of a medical order and acknowledged the surveyor's concerns.
Failure to Maintain Adequate Nutrition Leads to Significant Weight Loss
Penalty
Summary
The facility staff failed to maintain adequate meal proportions for residents, resulting in significant weight loss. Resident #60, who had a history of stroke with dysphagia, alcohol abuse, and depression, experienced a weight loss of more than 12% over six months. Observations revealed that the resident's meal trays were insufficient, consisting only of three scoops of pureed diet, leading the resident to seek additional food. Despite a physician's order for a pureed texture thin consistency meal with supplements, the resident's weight continued to decline. The Director of Nursing acknowledged the inadequacy of the food provided after being alerted by the surveyor. Resident #175 also experienced significant weight loss, with an 11% decrease in body weight within a month. Although the dietician noted the weight change and ordered supplements, there was no documentation that the physician was notified of the weight loss. Additionally, the resident's care plan, which identified a high risk for malnutrition, was not revised following the weight loss. The Director of Nursing confirmed the lack of documentation regarding the physician's notification and care plan updates.
Medication Storage and Security Deficiencies
Penalty
Summary
The facility failed to ensure the secure storage and proper labeling of medications, as well as to minimize the loss or diversion of narcotic medications. During the survey, it was observed that medications and medical supplies were improperly stored in residents' rooms without staff supervision. For instance, an open bottle of Dakins solution and other wound care supplies were found in a resident's room, and the resident expressed discomfort with the storage of these items. Despite being informed, the Unit Manager initially failed to remove all the items promptly. Additionally, medications were found unattended in other residents' rooms, and pills were discovered on the floor, indicating a lack of secure storage. In the medication rooms and carts, the surveyors found expired and undated medications, as well as medications belonging to discharged residents. For example, expired Aspirin and undated Polyethylene Glycol were found in medication carts, and expired glucometer solution was discovered. The facility's staff, including a Registered Nurse and the Assistant Director of Nursing, acknowledged these issues and removed the expired and undated medications. However, the presence of these items indicates a failure in maintaining proper medication management protocols. The facility also failed to provide secure storage for narcotics, leading to the loss of Oxycodone delivered by the pharmacy. The narcotics were delivered but could not be located afterward, and there was a discrepancy between the nurses involved regarding the receipt and logging of the medications. The incident was reported to law enforcement and the board of nursing, but the facility was unable to account for the missing narcotics, highlighting a significant lapse in the secure handling and documentation of controlled substances.
Deficiencies in Medical Record Maintenance
Penalty
Summary
The facility failed to maintain medical records in accordance with professional standards for three residents. For Resident #187, a discrepancy was found in the medical records where a blood pressure reading was documented after the resident had been transferred to the hospital and was no longer in the facility. This error was confirmed by the Director of Nursing (DON) as a data entry mistake. This indicates a lack of accuracy in the documentation process. For Resident #31, there was a lack of an active medical order for a specialty air mattress, despite its presence and use for wound healing as recommended by a wound care provider. The care plan mentioned a different type of bed, and the discrepancy was confirmed by a Geriatric Nursing Assistant and acknowledged by the DON. Additionally, for Resident #10, the enteral feeding orders were not signed for 22 days, which was due to an incomplete process of order confirmation by the nursing staff, as revealed in an interview with the DON and Registered Dietician.
Latest citations in Maryland
The facility did not ensure that its Infection Preventionist (IP) met required qualifications for managing the Infection Prevention and Control Program. The DON reported serving as the IP but acknowledged lacking the specialized infection control training required for the role, and confirmed that no other staff member was currently qualified. Records showed that the previously qualified IP left several months earlier, and the Administrator and DON confirmed they were still seeking a replacement, leaving the infection control program without a properly trained leader.
Staff failed to consistently secure medications and medical supplies across three units, including an oxygen tank left on the floor behind a resident’s bed without a supporting device, a treatment cart with Collagenase Santyl cream left on top while two residents in power wheelchairs passed by, an unattended and unlocked treatment cart at a nursing station, and another treatment cart with Diclofenac gel and dressings left on top, indicating repeated lapses in maintaining locked and secure storage for drugs, biologicals, and related supplies.
The facility failed to provide sufficient dietitian coverage and timely nutritional assessments for several residents with significant dietary needs. A resident admitted for diabetic management with a high A1C was placed on a regular diet instead of the recommended carb-controlled diet and had only one weight taken in the first two weeks, with no dietitian review of the record. Another resident with prior significant weight loss had no documented dietitian follow-up despite continued weight loss, and a resident admitted with severe protein-calorie malnutrition experienced further significant weight loss without any dietitian assessment. The dietitian reported working limited hours and prioritizing certain high-risk cases, resulting in delayed or missed evaluations for new admissions and residents with ongoing nutritional concerns.
The facility failed to maintain adequate linen and incontinence supplies and did not keep resident care areas in good repair, resulting in delays and alterations in incontinence care and substandard environmental conditions. Staff reported that towels and washcloths were used instead of wipes and then discarded due to heavy soiling, and that linen deliveries to units were late, leaving residents waiting for care. Observations showed very limited numbers of clean washcloths and other linens on units and in the laundry, with no stock of disposable wipes or backup washcloth supply despite repeated reports to housekeeping. Additional observations revealed recliner chairs blocking a dining-area handwashing sink and kitchenette, multiple resident and shared bathrooms with unfinished spackle, chipped paint, musty odors, black substances near showers, missing threshold molding, exposed cracks and nails, and eroded, rusted baseboard heaters. Hallway handrails on both units were worn, chipped, and splintered, and a shower room contained fecal odors, dried brown stains on the toilet, and deteriorated fixtures, all contributing to a failure to provide a safe, clean, and homelike environment.
Facility staff did not thoroughly investigate two separate abuse allegations involving a resident and an injury of unknown origin involving another resident. In both cases, investigations focused on the directly affected resident and included staff interviews, but there were no interviews of other residents on the unit or documented assessments of those residents for signs of abuse or injuries of unknown origin, including residents unable to communicate due to cognitive status.
Two residents who were dependent on staff for oral care, including one with a tracheostomy, were observed with thick, white or milky substances coating their mouths and teeth, indicating inadequate oral hygiene. One resident communicated that staff did not brush their teeth and that staff "need to." In another case, despite oral care supplies being present in the room, the resident’s mouth and teeth remained unclean on multiple observations, with a thick milky substance caking the teeth and stringing between them when the resident tried to open their mouth. These findings showed that staff did not consistently provide oral care to residents who relied on them for this ADL.
Staff failed to maintain complete and accurate medical records for multiple residents, including missing and inconsistent documentation of wound care, delayed pain assessment after discovery of an injury of unknown origin in a cognitively impaired resident, and inaccurate recording of a PPD test result that was documented as negative despite no evidence the injection was administered and no supporting nurse’s note. Residents reported not receiving certain treatments, while MAR entries either lacked signatures for completion or contained conflicting information about whether care was provided.
Surveyors found that the facility failed to consistently implement and communicate correct transmission-based precautions and PPE use. One resident with a Foley catheter related to wounds had no precaution signage posted, while another resident in a double room had a contact precautions sign at the door, yet the NP entered without PPE and the GNA provided high-contact care wearing only gloves. Staff in that room stated the resident was not on contact precautions and later reversed the sign to show no PPE requirement. Therapy staff reported they rely solely on posted signs to determine PPE, and surveyors identified broader issues with inaccurate signage and staff awareness of which residents required contact precautions.
Surveyors found that MDS assessments were inaccurately coded for two residents. In one case, a resident sustained a femoral neck fracture after a fall, but the subsequent significant change MDS did not code the fall as a major injury and failed to capture prn Tylenol use documented on the MAR within the look-back period. In the other case, a quarterly MDS indicated opioid use for a resident, but the MAR for the same period showed no prescribed opioid, indicating incorrect coding of high-risk drug classes.
A resident who had recently been admitted and experienced a fall received multiple doses of the narcotic analgesic Tramadol, but the facility failed to accurately document all administered doses on the Medication Administration Record (MAR). Review showed only one Tramadol dose recorded on the MAR, while the Controlled Drug Receipt/Record/Disposition Form on the med cart reflected three doses given over two days. In interview, the DON stated staff are expected to document narcotic administration on the MAR and confirmed that two administered doses were not recorded there, resulting in an incomplete and inaccurate medical record.
Unqualified Infection Preventionist Overseeing Infection Control Program
Penalty
Summary
The facility failed to ensure that its designated Infection Preventionist (IP) met the mandatory qualifications for overseeing the Infection Prevention and Control Program. During an interview on 3/24/26 at 10:00 AM, the DON confirmed that she/he was serving as the facility’s IP but had not completed the specialized training in infection control required for the position. The DON further stated that no other staff member currently met the qualifications to serve as IP. Record review showed that the previously qualified IP left the facility in October 2025, and as of the survey date, the position remained unfilled by a qualified individual. At 1:30 PM on the same day, the Administrator and DON confirmed they were still in the process of finding a qualified IP for the facility, leaving the Infection Prevention and Control Program without a properly trained and qualified leader. No specific residents, medical histories, or clinical conditions were described in relation to this deficiency.
Unsecured Medications, Treatment Carts, and Oxygen Equipment
Penalty
Summary
Facility staff failed to ensure that drugs, biologicals, and related medical supplies were securely stored and properly maintained on multiple units. On one unit, an oxygen tank assigned to a resident was observed sitting on the floor behind the resident’s bed without any supporting device. On another unit, a treatment cart was observed with a tube of Collagenase Santyl cream labeled for a specific resident left on top of the cart, while residents in power wheelchairs passed by and staff were present at the nursing station. These observations showed that medications and oxygen equipment were not consistently secured as required. Further observations on additional units revealed an unattended and unlocked treatment cart at a nursing station, and on a separate occasion, a treatment cart with Diclofenac gel labeled for a resident left on top along with multiple packs of dressings. These incidents occurred across three units and on more than one date, demonstrating repeated failures to keep medications and treatment supplies in locked compartments or otherwise secured from unauthorized access.
Insufficient Dietitian Coverage and Delayed Nutritional Assessments
Penalty
Summary
The deficiency involves the facility’s failure to employ sufficient food and nutrition staff, including adequate dietitian coverage, to ensure timely assessment and appropriate diets for residents with significant nutritional and diabetic needs. A resident admitted over two weeks earlier with multiple comorbidities and an A1C of 11.5% had a hospital discharge recommendation for a carbohydrate-controlled diet, but was placed on a regular diet at admission with no acknowledgment of the recommended diet until one week later, when the resident requested larger portions. As of the survey date, the dietitian had not yet seen or reviewed this resident’s medical record, and the resident reported not having seen a dietitian and being very frustrated with the meals. During the first two weeks after admission, only one weight was obtained for this resident, despite physician notes stating the resident’s weight was “stable.” Further review of other residents showed additional failures in timely dietitian assessment and follow-up. One resident, readmitted in January and previously seen by the dietitian in September for a 6.4 lb weight loss over 30 days, had no documented follow-up despite continued weight loss totaling 22 lbs since the last dietitian review. Another resident admitted at the end of February with severe protein-calorie malnutrition had not been seen by the dietitian after about a month in the facility, despite a documented 14 lb (7%) weight loss over two weeks. The dietitian reported working only 12 hours per week at the facility and stated that she must prioritize which residents to see, focusing first on residents with tube feedings and those identified in risk meetings, resulting in delayed or absent assessments for new admissions and residents with ongoing weight loss and malnutrition diagnoses.
Linen Shortages and Poor Environmental Maintenance Compromise Resident Care and Comfort
Penalty
Summary
The deficiency involves the facility’s failure to maintain an adequate supply of clean linens and appropriate incontinence wipes, resulting in delays and alterations in residents’ incontinence care, as well as the use of towels and washcloths in place of disposable wipes. During the initial tour, the surveyor observed that the linen supply on one nursing unit hallway was low. Complaint reviews included concerns about delays in incontinence care and bed linens not being changed regularly, with residents left without clean bedding. A complainant reported that there was not enough clean linen available for residents. Staff interviews confirmed that towels, sheets, and washcloths were being used to wipe residents for incontinence care due to the absence of wipes, and that many of these linens were being thrown away when soiled. Staff also reported a shortage of linen, that linen deliveries to the units were late, and that residents who preferred to get up before breakfast had to wait for care when linen was delayed. Further observations showed that the clean supply room contained no disposable wipes or cloths for incontinence care, and a resident reported that staff did not use wipes, that the resident had to purchase their own, and that heavily soiled towels or washcloths were discarded. A tour of all nursing unit linen carts and closets revealed only six clean washcloths and limited supplies of towels, gowns, and bed linens. In the laundry room, only three washcloths were present, and the laundry assistant stated that there were only three washcloths available for each nursing unit that morning, that the facility was short on linen supply, and that these concerns had been repeatedly reported to the Director of Housekeeping over the preceding month and again that morning. The laundry assistant confirmed there was no additional laundry in process. The DON stated that wipe squares should be used for incontinence care, but no such wipes were found in the clean medical supply room, and no backup supply of washcloths was present in the emergency linen supply. The Director of Housekeeping confirmed there was no backup supply of washcloths. The deficiency also includes environmental and maintenance issues affecting resident bathrooms, handrails, and common areas. In the main dining area, a recliner chair was observed positioned directly in front of the handwashing sink, and two recliner chairs were stored in front of the nutrition area kitchenette. Multiple resident bathrooms and shared bathrooms were repeatedly observed over several days with unfinished spackle on walls that needed resurfacing and painting, chipped paint around sinks, uneven boards nailed to walls under sinks that appeared to partially cover holes, musty odors, black substances between shower bases and walls, missing threshold transition molding exposing cracks, missing tiles, and a nail, as well as eroded and chipped paint on baseboard heaters with exposed dark brown metal and rust-like material. Hallway handrails on both nursing units were observed to be worn, with chips, splintering, holes, and areas where the wood finish had worn off. A shower room was observed with a foul fecal odor, dried brown stains on the back of the toilet seat and in the toilet bowl, and a baseboard heater with eroded, chipped paint and rust-like material, along with chipped paint on the handrail. These conditions were acknowledged by the Director of Maintenance and other leadership, and some areas were noted to be in the process of renovation, but the observed deficiencies remained present during the survey period. Overall, the facility did not maintain a safe, clean, comfortable, and homelike environment in good repair across both nursing units and the dining area. The lack of adequate linen and incontinence supplies, combined with the poor condition of resident bathrooms, handrails, and certain common areas, constituted the basis for the cited deficiency. The observations and staff and resident reports consistently described shortages of essential hygiene supplies, delayed care related to linen availability, and multiple unresolved environmental and maintenance issues in resident care areas and shared spaces.
Failure to Thoroughly Investigate Abuse Allegations and Injuries of Unknown Origin
Penalty
Summary
Facility staff failed to thoroughly investigate allegations of potential abuse involving one resident and an injury of unknown origin involving another resident. For one resident, there were two separate allegations of abuse occurring on different days in early February. The facility’s investigation packets included interviews with staff who cared for or were scheduled to work with this resident on the days of the alleged incidents, and the investigations focused solely on this resident. However, there were no interviews conducted with other residents on the unit to inquire about abusive or neglectful treatment by the staff who were working during the times of the allegations. The surveyors noted that, although the allegations were not validated, there was no documentation that other residents were interviewed, if able, or assessed for signs or symptoms of injury. In a separate incident, another resident was identified on March 4 with a new bruise on the right eye, documented as a change in condition at 4:09 AM. This resident had a BIMS score of 99, indicating the resident was unable to complete an interview and therefore could not report how the injury occurred. The facility’s investigation identified a potential cause of the injury but did not reach a definitive resolution. Additionally, there were no interviews of other residents on the unit regarding possible abuse, nor were there documented assessments of other residents for injuries of unknown origin, particularly for those unable to speak for themselves, as in this resident’s case.
Failure to Provide Oral Care to Dependent Residents
Penalty
Summary
The deficiency involves the facility’s failure to provide oral care to residents who were dependent on staff for activities of daily living, specifically oral hygiene. One resident with a tracheostomy was observed with a thick, sticky white substance in the mouth and was noted to intermittently chew on nearby bedding. This resident made good eye contact and, when asked if staff brushed their teeth, shook their head no and mouthed that staff “need to.” According to the resident’s Minimum Data Set (MDS) dated 2/11/26, the resident was dependent on staff for oral care. Another resident, also dependent on staff for oral care per the 3/11/26 MDS, was observed sitting propped up in bed and able to respond with smiles. During the initial observation, the inside of this resident’s lips and upper and lower teeth had a thick, clear, white milky substance visible when the resident tried to open their mouth to smile. Oral care supplies were present in the nightstand, but the resident’s mouth and teeth were not clean. On a subsequent observation with the DON, NHA, and Corporate VP of clinical services, the same resident again had a thick, clear, milky substance between the lips and caking the teeth, which would string between the teeth when the resident attempted to open their mouth, demonstrating a lack of consistent oral care for residents dependent on staff for this ADL.
Incomplete and Inaccurate Medical Record Documentation for Treatments and Assessments
Penalty
Summary
Facility staff failed to maintain complete and accurate medical records and documentation for multiple residents. For one resident with wound care needs, review of the MAR showed that wound care and related treatments were signed as completed on the dates initially reported, despite the resident’s ongoing complaints that wound dressings were not being changed. When additional dates were reviewed, there were missing staff signatures for wound care on two specific dates, as well as three instances where application of A&D ointment to the resident’s feet was not signed off out of 24 days reviewed. Another resident with severe cognitive impairment, as evidenced by a BIMS score of 00, was found to have an injury of unknown origin (a bruise on the left hand). Documentation showed that a change in condition was initiated late in the morning, but a formal pain evaluation was not initiated and completed until that night, and the resident was unable to explain how the injury occurred or verbalize pain using a standard pain scale. For a third resident, documentation related to the admission PPD test was inconsistent and incomplete. The MAR contained an entry indicating “9” for the administration date, meaning “see nurse’s note,” but there was no corresponding nurse’s note. Despite the absence of a signed administration of the PPD injection, staff documented the PPD result as “negative” on the scheduled read date. The resident reported never receiving the PPD injection, and the DON confirmed that the facility had been out of PPD solution at the time, so the test would not have been administered. These findings demonstrate failures in accurate documentation of treatments and assessments, including wound care, pain assessment, and TB screening, as well as missing or incomplete supporting notes in the medical record.
Failure to Implement and Communicate Correct Transmission-Based Precautions
Penalty
Summary
Surveyors identified a deficiency in the facility’s infection prevention and control program related to inconsistent and incorrect implementation of transmission-based precautions and PPE use. During a complaint investigation focused on residents on transmission-based precautions, one resident with a visible Foley catheter was observed in the room with physical therapy, but there were no signs posted indicating any need for PPE, despite the resident being a new admission with a Foley catheter placed related to wounds. In another double-occupancy room, a contact precautions sign was posted at the doorway, but the nurse practitioner was in the room on a personal phone with no PPE, and the assigned GNA was repositioning the resident in bed while wearing only gloves. When questioned, the NP, RN, and GNA all stated that the resident in the room was not on contact precautions, and the GNA reported that signs were hanging at all doors and that this particular resident’s sign was “just wrong.” The surveyor observed the GNA later return to the room and turn the sign around to indicate no PPE requirement. Subsequent interviews revealed that therapy staff relied on posted signage to determine PPE use and that if the sign was wrong, the PPE used would be wrong. Overall, surveyors found problems with signage accuracy and staff awareness of which residents required contact precautions, as well as observed failures to follow appropriate PPE use for residents who should have been on contact precautions.
Inaccurate MDS Coding for Falls, Pain Management, and High-Risk Medications
Penalty
Summary
Facility staff failed to ensure Minimum Data Set (MDS) assessments were accurately coded for two residents reviewed during a complaint survey. For one resident, a facility-reported incident showed that the resident was found seated on the floor beside the bed and was diagnosed with a non-displaced femoral neck impaction fracture of the left hip following an x-ray. Despite this fall with a major injury, the subsequent significant change MDS dated 11/4/25 did not code the fall with major injury in Section J1900C. Review of the resident’s Medication Administration Records for October and November 2025 showed administration of Tylenol on 10/31/25 at 9:30 PM, which fell within the 5-day look-back period for the MDS, but Section J0100 (prn pain) of the same significant change MDS did not capture the use of Tylenol. For another resident, review of a quarterly MDS with an assessment reference date of 10/15/25 showed that Section N0415 (High-Risk Drug Classes) documented the use of an opioid medication. However, review of the resident’s October 2025 Medication Administration Record did not show that the resident had been prescribed an opioid during that period. In both cases, MDS staff later confirmed that these were errors in MDS coding, demonstrating that the assessments did not accurately reflect the residents’ clinical status and medication use as documented in their medical records.
Incomplete Documentation of Narcotic Administration on MAR
Penalty
Summary
The facility failed to maintain complete and accurate medical records in accordance with accepted professional standards for one resident receiving narcotic medication. The resident, admitted in March 2026, had a fall on 3/6/26 and was sent to the hospital on 3/9/26. Review of the March 2026 Medication Administration Record (MAR) showed documentation of a single 25 mg dose of Tramadol administered on 3/8/26 at 9:23 AM. However, review of the resident’s Controlled Drug Receipt/Record/Disposition Form, kept on the nurse’s medication cart and not in the medical record, showed that Tramadol 25 mg was administered three times between 3/8/26 and 3/9/26: at 11:00 AM and 9:00 PM on 3/8/26, and at 9:00 AM on 3/9/26. In interview, the DON stated that staff are expected to document narcotic administration on the MAR and confirmed that only one of the three Tramadol doses reflected on the controlled drug record was documented on the resident’s MAR. This discrepancy between the controlled substance record and the MAR, with missing documentation of two administered doses of Tramadol on the official medical record, constituted the failure to maintain a complete and accurate medical record for the resident.
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