Autumn Lake Healthcare At Birch Manor
Inspection history, citations, penalties and survey trends for this long-term care facility in Sykesville, Maryland.
- Location
- 7309 Second Avenue, Sykesville, Maryland 21784
- CMS Provider Number
- 215136
- Inspections on file
- 19
- Latest survey
- November 20, 2025
- Citations (last 12 mo.)
- 9
Citation history
Health deficiencies cited at Autumn Lake Healthcare At Birch Manor during CMS and state inspections, most recent first.
The facility did not consistently hold or document required interdisciplinary care plan meetings for three residents following their MDS assessments. In each case, there was either no evidence of meetings occurring after admission or quarterly assessments, or documentation was missing. Staff interviews confirmed the absence of these meetings, and residents were often unaware of any care planning discussions.
The facility did not have an effective system to ensure grievances and concerns raised during Resident Council meetings were addressed and followed up on. Nursing-related concerns, such as missed medications and reports of rough staff behavior, were documented but not consistently followed up or logged as grievances. Communication between the Activity Director and DON was inconsistent, leading to unresolved issues persisting over several months.
Surveyors found that the facility did not develop or implement individualized care plans based on comprehensive assessments for several residents. For example, a resident with expressive aphasia did not have their music, TV, or religious preferences reflected in their care plan, and other residents' preferences for religious services and reading materials were omitted despite being documented as important. Additionally, one resident did not have a comprehensive care plan completed within the required timeframe, and there was insufficient documentation of interdisciplinary team involvement in care planning.
Surveyors identified deficiencies in infection prevention and control, including improper disinfection of glucometers by nursing staff using alcohol wipes instead of manufacturer-recommended sanitizing wipes, and improper handling of laundry with clean linen left uncovered near soiled items and soiled materials found on the floor. Additionally, water temperature logs for legionella prevention were incomplete and did not meet the required temperature standard, as confirmed by facility staff.
Surveyors found that several residents with complex medical and cognitive needs did not receive individualized activities as outlined in their care plans and assessments. Activity preferences such as music, religious services, and group participation were not consistently addressed or documented, and staff interviews revealed gaps in understanding and implementation of resident-centered activity planning. Documentation failed to show that planned one-on-one visits and preferred activities were provided or offered, resulting in unmet psychosocial and physical needs.
A resident with a personal funds account managed by the facility did not receive the required quarterly statement, as confirmed by both the resident and the business office manager. Review of records showed the last statement provided was for the previous quarter, and the most recent statement had not been delivered as required.
Surveyors found that the facility failed to maintain clean and functional shower areas, with cracked and discolored tiles, missing shower heads, and out-of-order showers that were still used for resident bathing. Additionally, a resident's privacy curtains remained stained for several days despite staff awareness, indicating a lack of timely response to environmental concerns.
A resident who was unable to make health care decisions was transferred to the hospital, but the responsible representative did not receive complete or accurate written notice regarding the bed hold policy and transfer. Required sections on the transfer and bed hold forms were left blank, and essential contact information for appeals and the State LTC Ombudsman was missing. Staff interviews revealed inconsistent notification practices and lack of documentation, resulting in the representative not being properly informed of the resident's rights and facility policies.
A resident's MDS assessment was inaccurately documented, indicating the presence of natural teeth despite the resident being edentulous and wearing dentures. Staff interviews and record reviews confirmed the resident had no natural teeth, and the MDS Coordinator acknowledged the error. Additionally, the MDS signature page incorrectly identified a Social Services Assistant as a Social Worker.
A resident with an anxiety disorder had a scheduled order for Lorazepam 0.5 mg three times daily. Staff documented administration of the medication for every scheduled dose, but records showed that the last available tablet was used earlier in the day and no additional supply was accessed for the evening dose. Despite this, staff documented that the evening dose was given, with no evidence from pharmacy or automated dispensing records to support this.
A resident who was fully dependent on staff was found using an air mattress without a physician order or monitoring instructions, and the mattress was set at a weight much higher than the resident's actual weight. Staff were unaware of the mattress assignment, and the DON confirmed the resident did not require an air mattress. This resulted in a failure to prevent accident hazards and provide adequate supervision.
A resident with a tracheostomy did not receive respiratory care in accordance with professional standards when a used suction catheter was left on the bedside table after suctioning by an LPN. The facility's policy required sterile technique for tracheostomy care, but this was not followed, resulting in a lapse in infection control.
A resident with severe cognitive impairment and documented dental issues did not receive routine dental services after admission. Despite regular dental provider visits to the facility and monthly tracking, there was no evidence that the resident had been seen by a dentist or dental hygienist, and only records from a prior facility were available. The DON confirmed the lack of dental care since admission.
Several residents did not receive all items listed on their meal tickets during lunch, including missing milk, margarine, butter, and a dessert, despite expressing preferences for these items. Staff confirmed the omissions at the time of service, indicating that meals were not consistently served according to the predetermined menu or resident preferences.
Surveyors found expired Jello cups stored in a unit nourishment room refrigerator. A Geriatric nurse aide identified and disposed of the expired items, which had been missed during routine checks by the unit manager. The DON was later informed of the expired food.
Surveyors found that the facility did not maintain accurate and complete medical records for several residents, including discrepancies between medication orders and administration, inaccurate documentation of tracheostomy care, and missing care planning meeting notes in the electronic medical record. These deficiencies were identified through record reviews and staff interviews.
The facility did not ensure the development and ongoing implementation of a data-driven QAPI program, as required by its own policy, and failed to have an active Performance Improvement Project (PIP) within the past year. The QAPI committee maintained meeting minutes and discussed high-risk topics, but there was no evidence of a structured process to systematically address quality issues or monitor corrective actions.
The facility did not ensure that a certified Infection Preventionist (IP) attended QAPI committee meetings, as required. Instead, the DON, who was not a certified IP, signed in as the IP for several months, and attendance records for other months also lacked evidence of a qualified IP nurse.
A resident with a tracheostomy and chronic respiratory failure was found to have their oxygen concentrator and suction machine plugged into a standard wall outlet instead of a generator-powered outlet. Staff confirmed that only red faceplate outlets were connected to the backup generator, but these were already in use for other equipment. The facility's policy directed staff to move equipment after a power outage rather than ensuring critical devices were always connected to emergency power, and documentation of required safety checks was not provided.
The facility did not follow its grievance policy for two residents who reported missing personal property and concerns about care. In both cases, staff failed to document, investigate, or communicate the outcome of the grievances as required by policy. Key staff members acknowledged that the grievance process was not followed and that there was a lack of awareness and adherence to the established procedures.
A resident with cognitive impairment and multiple medical conditions alleged being physically abused by a staff member, with documented bruising observed by both hospital and facility staff. Despite clear policy requiring immediate reporting, the DON and NHA did not report the abuse allegation to authorities until prompted by a surveyor, resulting in a delay in required notification.
A resident with cognitive impairment and multiple medical conditions alleged being punched and kicked by a staff member, with physical bruising documented by both hospital and facility staff. The allegation was recorded in a physician's note, but the clinical team failed to identify and investigate it as required by facility policy. Leadership confirmed that the abuse allegation was missed during routine review, and no investigation was conducted or documented.
The facility failed to protect residents' personal property by not adhering to its policy requiring an inventory and tracking process for belongings upon admission and discharge. Two residents were affected, with one discharged without a documented inventory, resulting in missing items, and another discharged with another resident's clothing. Staff interviews revealed inconsistent application of the inventory process, indicating a systemic issue. An Ombudsman interview suggested a pattern of issues related to managing residents' belongings, raising concerns about the facility's ability to safeguard property.
The facility failed to report injuries of unknown origin for two residents to the state survey agency within the required timeframe. One resident with cognitive impairment had a hand fracture that was reported two days late, while another resident with severe cognitive impairment had facial bruising that was not reported at all. The clinical team did not believe the latter injury met reporting criteria due to the resident's care plan behaviors.
Failure to Hold and Document Required Interdisciplinary Care Plan Meetings
Penalty
Summary
The facility failed to hold and document required interdisciplinary care plan meetings for three residents following their comprehensive and quarterly MDS assessments. For one resident with a history of traumatic brain injury, anxiety, depression, seizure disorder, and cognitive impairment, the only documented care plan meeting occurred at admission, with no evidence of subsequent meetings despite multiple MDS assessments. Staff interviews confirmed that no further interdisciplinary care plan meetings had taken place, and a note provided as evidence was unrelated to care planning and not part of the medical record. Another resident, who had resided in the facility for several years, had an MDS assessment completed, but there was no documentation of a care plan meeting following this assessment. Staff responsible for scheduling care plan meetings reported leaving messages for the resident's family but did not document these contacts, and acknowledged that no care plan meeting had occurred since the previous year. The lack of documentation persisted through the time of the survey, with no additional evidence provided to show that a meeting had taken place. A third resident, who had been in the facility since the beginning of the year, also had an MDS assessment completed, but there was no indication that a care plan meeting was held afterward. The resident was unaware of any care plan meetings, and staff interviews confirmed that while meetings were supposed to be scheduled based on MDS schedules, there was no documentation to support that a meeting had occurred. These findings demonstrate that the facility did not consistently conduct or document care plan meetings as required for residents following their MDS assessments.
Failure to Address and Follow Up on Resident Council Grievances
Penalty
Summary
The facility failed to maintain an effective system to ensure that grievances and concerns raised during Resident Council meetings were addressed and followed up on. Review of Resident Council meeting minutes from October 2024 through May 2025 revealed that the documentation did not consistently include sections for follow-up on previously raised issues, particularly for nursing-related concerns. Specific concerns, such as residents not receiving pain medication when supplies ran out and reports of nursing staff being mean or rough, were documented in the minutes but lacked evidence of follow-up or resolution in subsequent meeting notes or grievance logs. In several instances, concerns raised in one meeting were not addressed in the following meetings or documented in the facility's grievance logs, and there was no indication that department heads, including the DON, were consistently made aware of these issues. Interviews with the Activity Director and DON revealed inconsistent communication practices regarding how concerns from Resident Council were relayed to department heads. The Activity Director reported emailing department heads and discussing concerns, but documentation of responses was inconsistent, and the DON was unaware of several concerns raised. Additionally, some concerns that could be interpreted as allegations of abuse were not escalated or documented as such. The lack of a structured process for tracking and addressing grievances resulted in unresolved issues persisting across multiple months, with no clear documentation of investigation or resolution.
Failure to Develop and Implement Resident-Centered Care Plans
Penalty
Summary
Surveyors identified that the facility failed to develop and implement comprehensive, resident-centered care plans that accurately reflected the assessed needs and preferences of multiple residents. For one resident with expressive aphasia and total dependence on staff for activities of daily living, the care plan did not include specific information about the resident's music preferences, television programs, or religious denomination, despite these being documented as important in assessments. The care plan also lacked documentation of certain activities, such as hand massages, that were reportedly provided. The Activity Director acknowledged that care plans did not always reflect assessment findings and that staff often relied on assumptions rather than resident input. Another resident with a history of traumatic brain injury, anxiety, depression, and cognitive impairment reported not participating in activities due to a lack of interest and was unaware of care planning meetings. The care plan for this resident did not address their stated preferences for religious services and access to reading materials, which were documented as very important in the MDS assessment. Similarly, a resident with a history of stroke and cognitive deficits stated that they used personal devices for entertainment and required assistance to attend activities, but their care plan did not specify their preferences for church attendance or reading materials, despite these being identified during assessments and interviews. Additionally, a resident admitted to the facility had only a baseline care plan documented, with no comprehensive care plan completed within the required timeframe following the comprehensive assessment. There was also a lack of documentation indicating that the interdisciplinary team regularly attended care plan meetings. Staff interviews confirmed these deficiencies, and facility leadership acknowledged the concerns raised by surveyors regarding the lack of individualized, assessment-based care planning.
Infection Control and Environmental Sanitation Deficiencies
Penalty
Summary
The facility failed to maintain safe and sanitary conditions to prevent the spread of infection, as evidenced by improper disinfection of blood glucose meters and inadequate laundry handling practices. Nursing staff were observed using alcohol wipes to disinfect glucometers, despite the manufacturer's instructions and facility policy requiring the use of Super Sani-cloth sanitizing wipes. Interviews with nursing staff confirmed the use of alcohol wipes, and the infection preventionist acknowledged that alcohol wipes were not recommended. Additionally, clean linen was observed uncovered and stored in close proximity to dirty laundry, with soiled items found on the floor in the laundry area. The environmental services supervisor confirmed that clean linen should be covered when moved and that the observed practices did not meet facility expectations. Black marks were also noted on the plastic door flaps separating clean and dirty laundry areas, indicating a lack of proper cleaning. The facility also failed to consistently monitor and maintain water temperatures as part of its legionella prevention measures. The maintenance director reported that water temperatures were recorded at the boiler, but documentation showed that temperatures were only recorded for 16 out of 31 days in May, and none of the recorded temperatures reached the required 116 degrees Fahrenheit. The administrator confirmed that the facility aimed to follow CDC guidelines by maintaining the boiler at 116 degrees, but the logs did not support that this standard was met.
Failure to Provide Resident-Centered Activities Program
Penalty
Summary
Surveyors identified that the facility failed to provide an ongoing, resident-centered activities program that met the physical, mental, and psychosocial well-being and individual interests of residents. Multiple residents with varying medical conditions, including expressive aphasia, traumatic brain injury, stroke, and cognitive impairment, were not provided with activities tailored to their preferences as documented in their assessments and care plans. For example, one resident who was totally dependent on staff and unable to communicate verbally had care plans that did not specify preferred activities, such as music type, TV programs, or religious denomination, despite these being identified as important in assessments. Documentation did not support that planned one-on-one visits or preferred activities were consistently provided. Another resident, who had a high cognitive function score and expressed little interest or pleasure in activities, reported never being offered activities and was unaware of the Resident Council or key staff. The care plan indicated daily visits and encouragement to join group activities, but activity records showed that on most days, no activities were documented, and there was no evidence of offers or refusals. Similarly, a resident with a traumatic brain injury and cognitive impairment had a care plan emphasizing the importance of religious services, but there was no documentation of attendance, offers, or refusals for such activities. Additionally, a resident with a history of stroke who required assistance to attend activities reported not participating due to lack of staff support. The care plan included specific interventions such as providing daily puzzles and twice-weekly one-on-one visits, but records did not show these were provided. Staff interviews revealed a lack of understanding of documentation requirements and inconsistent consideration of resident preferences when planning activities. The facility's documentation practices did not reflect the provision of individualized activities as outlined in care plans, nor did they consistently record resident participation, refusals, or unavailability.
Failure to Provide Quarterly Personal Funds Statements
Penalty
Summary
The facility failed to provide quarterly personal funds statements to a resident whose funds were managed by the facility. The resident, who was cognitively intact and acted as their own responsible party, reported not receiving a new statement since January, despite being entitled to quarterly updates. Review of the resident's records confirmed that the last signed statement was for the period ending December 31, and no statement had been provided for the subsequent quarter. The business office manager acknowledged being behind in distributing the required statements and confirmed that the resident had not yet received the most recent quarterly statement. The process for delivering statements involved hand delivery and obtaining the resident's signature, with copies kept in a binder. The deficiency was further confirmed during interviews and a review of the facility's records, which showed the lapse in providing timely statements to the resident.
Failure to Maintain Clean and Functional Resident Shower Areas and Privacy Curtains
Penalty
Summary
Surveyors identified deficiencies related to the facility's failure to maintain a clean, comfortable, and homelike environment for residents. On multiple occasions, surveyors observed cracked and discolored tiles, missing shower heads, and out-of-order showers in spa rooms on the first, second, and third floors. Despite staff being aware of these maintenance issues, there was a lack of timely repair and incomplete documentation in the maintenance logs. Some showers in disrepair were still being used for resident bathing, and dirty washcloths were found in the shower stalls during observations. Additionally, a resident's privacy curtains were noted to have dark brown stains during the initial and subsequent observations over several days. Although the environmental services department was reportedly responsible for changing stained curtains, the stained curtains in the resident's room remained unaddressed until after surveyor intervention. Staff interviews confirmed awareness of the issue, but there was a lack of follow-through to resolve it in a timely manner.
Failure to Provide Complete Bed Hold and Transfer Notices to Resident Representative
Penalty
Summary
The facility failed to provide complete and accurate written notice of the bed hold policy and transfer to a resident's responsible representative during a hospitalization event. The resident in question was not capable of making health care decisions, and a responsible representative had been identified. When the resident was transferred to the hospital, documentation indicated that the bed hold policy and reason for transfer/discharge were sent to the representative, but the method of delivery was unclear, and the actual forms lacked required information. Review of the Notification of Resident Hospital Transfer form revealed that critical sections, such as the reason for transfer and the location of transfer, were left blank. The form also failed to include necessary contact information for appealing the transfer, such as the name, address, or telephone number of the entity handling appeals, and the contact information for the State Long-Term Care Ombudsman. The bed hold notice form was also incomplete, missing essential details such as the reason for the notice, whether a bed hold was requested, the per diem rate, and the actual bed hold policy attachment. Additionally, the bed hold policy referenced outdated information, stating that the state pays for 14 days of bed hold, which has not been the case since 2012. Interviews with staff revealed inconsistent practices regarding notification. The social worker reported only sending the bed hold notice if specifically requested by the representative and did not document phone calls to the family. There was also a lack of clarity and documentation regarding whether the required notifications had actually been sent, and staff were unable to provide current per diem rates when asked. These actions and omissions resulted in the failure to ensure that the resident's representative received all required information regarding transfer, appeal rights, and bed hold policies.
Inaccurate MDS Assessment Documentation for Dental Status
Penalty
Summary
The facility failed to ensure that Minimum Data Set (MDS) assessments were accurately documented for a resident reviewed for dental care. Observations showed that the resident was edentulous and wore complete dentures, which were not present at the time of observation. The nursing admission assessment confirmed the absence of natural teeth. However, the MDS assessment incorrectly indicated that the resident had natural teeth, contradicting both the resident's statement and the nursing assessment. Interviews with staff further confirmed that the resident had no natural teeth, and the MDS Coordinator acknowledged the documentation error in the MDS assessment. Additionally, the MDS assessment's signature page listed sections as being completed by a staff member identified as a Social Worker, when in fact this individual was a Social Services Assistant. This misidentification was confirmed by both the Social Services Director and the MDS Coordinator, who recognized the inaccurate information on the MDS assessment's signature page.
Failure to Administer and Document Scheduled Medication as Ordered
Penalty
Summary
Staff failed to provide medication as ordered for a resident with an anxiety disorder who had a physician's order for Lorazepam 0.5 mg three times daily. Medical record review showed that the medication was documented as administered every day in April, but the controlled drug administration record indicated that the last tablet from a 30-tablet supply was removed at 2:00 PM on 4/28, with no tablets left for the 8:00 PM dose that same day. A new supply was not received until the following morning, and there was no documentation that the interim supply was accessed for the missed dose. Despite the lack of available medication, staff documented that the 8:00 PM dose on 4/28 was administered as ordered. Review of pharmacy and automated dispensing records did not show that the interim supply was accessed for this dose, and the pharmacy was unable to provide documentation to account for the administration. The deficiency was identified through interviews and record reviews, which confirmed that the medication was not re-ordered in a timely manner and that staff failed to obtain it from the interim supply, yet still documented its administration.
Failure to Ensure Proper Use and Monitoring of Air Mattress
Penalty
Summary
A deficiency was identified when a resident, who was totally dependent on staff for activities of daily living and had no current or recent pressure ulcers, was found in bed with an air mattress that was unplugged and not inflated. The air mattress was later plugged in by a nurse and observed to be set at 240 lbs, despite the resident's most recent recorded weight being 115.8 lbs. The medical record only contained an order for a pressure reducing mattress, not specifically for an air mattress, and there was no order or documentation for monitoring the use of the air mattress. Further review revealed that staff were unaware of how the air mattress was assigned to the resident, and the unit nurse manager was not informed that the bed had an air mattress. The air mattress was used without an appropriate physician order, without monitoring instructions, and was set at an incorrect weight setting. The DON confirmed that air mattresses were typically reserved for residents with Stage 3 or 4 pressure ulcers and that this resident did not require one. The lack of an order and monitoring for the air mattress, as well as improper setup, constituted a failure to ensure the area was free from accident hazards and that adequate supervision was provided to prevent accidents.
Failure to Maintain Sterile Technique in Tracheostomy Care
Penalty
Summary
A deficiency was identified when a resident with a tracheostomy did not receive respiratory care consistent with professional standards of practice. The resident, who required oxygen via tracheostomy and was observed to have shortness of breath with audible breath sounds, was under the care of staff trained in tracheostomy care and suctioning. Documentation showed that suctioning was performed by a licensed practical nurse during the night shift, and the facility's policy required the use of sterile technique for this procedure. However, a used suction catheter was observed left on the resident's bedside table, indicating a lapse in infection control and sterile technique. The nurse responsible for the care acknowledged providing suctioning and confirmed that the procedure should be sterile, as outlined in facility policy. The presence of the dirty catheter at the bedside and its subsequent removal only after being noticed by surveyors demonstrated a failure to maintain proper infection control practices during respiratory care for the resident.
Failure to Provide Routine Dental Services to Resident with Dental Concerns
Penalty
Summary
The facility failed to provide routine dental services to a Medicaid-funded resident with severe cognitive impairment. The resident was admitted in early 2023 and had documented dental concerns, including obvious or likely cavities, broken natural teeth, and mouth or facial pain, discomfort, or difficulty with chewing, as noted in a comprehensive assessment. The responsible party reported ongoing concerns about dental care and stated that they had not received updates regarding dental services or a dental visit for the resident. Despite the facility's process of having a dentist or dental hygienist visit 1 to 2 times per month and maintaining monthly reports of residents seen, there was no evidence in the medical record or dental service reports that the resident had received dental care since admission. The only dental documentation available pertained to services provided at a previous facility, not the current one. The DON confirmed that the resident had not been seen by a dentist or dental hygienist since admission.
Failure to Serve Meals According to Prescribed Menus and Resident Preferences
Penalty
Summary
The facility failed to ensure that residents were served meals according to predetermined menus that incorporated their preferences and met their nutritional needs. During lunch observations, multiple residents did not receive all items listed on their meal tickets. One resident's tray was missing milk and margarine, while another did not receive milk and butter, despite expressing a desire for these items. A third resident's tray was missing whole milk, margarine, and a dessert item called magic cup, all of which were specified on the meal ticket. These discrepancies were confirmed by staff present during the meal service. The observations were corroborated by both the residents and staff, who acknowledged the missing food items at the time of service. The failure to provide the correct menu items as ordered and preferred by the residents demonstrates a lack of adherence to the planned menu and dietary requirements. This practice has the potential to affect all residents receiving meals in the facility.
Expired Food Items Found in Unit Refrigerator
Penalty
Summary
A deficiency was identified when four cups of Jello with an expiration date of 4/24/25 were found stored in the nourishment room refrigerator on the 2nd-floor unit during an observation with a Geriatric nurse aide. The staff member acknowledged that the Jello was expired and appeared watery before disposing of it. The unit manager reported that she checks the refrigerator every morning but missed the expired Jello. The Director of Nursing was later informed of the issue by staff. This deficiency was observed in one out of three units during the recertification survey, and the findings were based on direct observation and staff interviews.
Failure to Maintain Accurate and Complete Medical Records
Penalty
Summary
The facility failed to ensure that resident records were accurate, complete, and maintained in accordance with accepted professional standards and practices. For one resident with dementia, mood disorder, chronic pain, and kidney disease, discrepancies were found between physician and nurse practitioner notes and the actual medication orders and administration records. Specifically, the physician's note referenced a PRN order for Lorazepam, but the resident was receiving it on a scheduled basis, and the medication administration record did not reflect a PRN order. Additionally, the nurse practitioner's notes indicated that certain lab tests were to be performed, but there was no documentation that these labs were ordered or completed as stated. Another nurse practitioner's note referenced a medication (Lidocaine) that was not actually ordered or administered, and the practitioner acknowledged this was likely a documentation error due to not updating the note template. For a resident with a tracheostomy, documentation in the Treatment Administration Record (TAR) inaccurately reflected that a registered nurse had performed tracheostomy care, when in fact the care was provided by a respiratory therapist. The nurse confirmed that she documented the care as completed, even though she had not performed it, resulting in the TAR not accurately reflecting the resident's care experience. The Director of Nursing and Regional Director of Nursing also acknowledged that the documentation did not match the actual care provided. In another case, a resident who had been readmitted from the hospital did not have care planning meeting notes documented in the electronic medical record. When the surveyor was unable to locate the documentation, the Social Services Director provided a handwritten note as evidence of a care planning meeting, but confirmed that this note was not considered part of the official medical record. The Director of Nursing confirmed that care planning meeting notes are expected to be documented in the resident's medical record, but this was not done in this instance.
Failure to Implement Facility-Wide QAPI Program with Active PIP
Penalty
Summary
The facility failed to develop and implement an ongoing, facility-wide, data-driven Quality Assurance and Performance Improvement (QAPI) program that included at least one current Performance Improvement Project (PIP) within the past 12 months. Upon review, the facility provided its QAPI policy, which outlined the process for identifying areas for improvement, including high-risk, high-volume, and problem-prone areas, and emphasized the importance of considering the incidence, prevalence, and severity of problems affecting resident outcomes. However, during an interview, the Nursing Home Administrator (NHA) confirmed that no PIP had been identified or implemented in the last year. Further review of the QAPI committee's documentation revealed that while meeting minutes and highlights of high-risk topics such as falls, wounds, and maintenance concerns were maintained, there was no evidence of a structured approach to systematically identify and address quality issues. The NHA stated that QAPI meetings primarily served as notification forums, and daily clinical meetings were used to review clinical concerns and interventions. No documentation was provided to demonstrate that the facility was systematically investigating root causes, implementing interventions, or monitoring the effectiveness of corrective actions as required by their own policy.
Failure to Ensure Qualified Infection Preventionist Attended QAPI Meetings
Penalty
Summary
The facility failed to ensure that a qualified Infection Preventionist (IP) attended the Quality Assurance and Performance Improvement (QAPI) committee meetings as required. Review of QAPI meeting attendance records for the period from December 2024 through May 2025 showed that the Director of Nursing (DON) signed as the IP for the months of December 2024, January 2025, and February 2025. However, the Nursing Home Administrator (NHA) confirmed that the DON was not a certified IP nurse during those months. Further review of attendance records for October 2024 also revealed the absence of a qualified IP nurse at the QAPI meeting. These findings were based on interviews and record reviews conducted by surveyors.
Failure to Ensure Critical Respiratory Equipment Connected to Emergency Power
Penalty
Summary
The facility failed to ensure that critical medical equipment for a resident requiring continuous respiratory support was plugged into generator-powered outlets. Specifically, a resident with a history of traumatic brain injury and chronic respiratory failure, who had a tracheostomy and required continuous oxygen, was found to have their oxygen concentrator and suction machine plugged into a standard wall outlet via a power strip, rather than into the generator-supplied (red) outlets. The generator-powered outlets in the room were already in use for other medical equipment, leaving no available emergency outlet for the resident's life-sustaining devices. During interviews and observations, staff, including a respiratory therapist and the maintenance assistant, confirmed that only outlets with red faceplates were connected to the backup generator and should be used for critical equipment during a power outage. The Director of Nursing (DON) initially stated that it was not an issue since there was no current power outage and that equipment would be moved to generator outlets if needed. However, when asked to demonstrate this process, staff realized that moving the equipment would require additional steps, such as obtaining a portable oxygen tank, and that the generator outlets were already at capacity. The facility's policy instructed staff to move equipment to generator-powered outlets after a power outage, rather than requiring proactive connection of critical equipment. The Nursing Home Administrator (NHA) stated that safety checks were performed every shift to ensure life-sustaining equipment was plugged into emergency outlets, but was unaware that the resident's equipment had been found plugged into a standard outlet. Requested documentation of these safety checks was not provided to the surveyor by the time of survey exit.
Failure to Implement Grievance Policy for Resident Complaints
Penalty
Summary
The facility failed to implement its grievance policy for two residents who reported concerns regarding personal property and care. In the first instance, a long-term resident reported missing clothing to the Environmental Services Supervisor (EVS) and the resident's family also raised the issue. The EVS Supervisor acknowledged the concern but did not complete a grievance form or escalate the issue to the Director of Nursing or the Nursing Home Administrator, as required by facility policy. The Social Service Director confirmed that no grievance form was filed for this incident, and the most recent grievance form related to clothing was from several months prior, indicating the current concern was not documented or processed according to policy. In the second case, a newly admitted resident's family member reported that the resident was found in soiled clothing and an unkempt state two days after admission, despite having notified staff and meeting with several facility personnel about the issue. The family described the meeting as confrontational and did not receive any follow-up communication from the facility regarding their complaint. The Social Service Director and the designated Grievance Official both confirmed that no grievance was logged or investigated for this incident, and the Grievance Log contained no entries for the relevant period. Staff interviews revealed a lack of awareness and adherence to the grievance policy, with some staff admitting they had never read the policy. Facility policy requires that all grievances, whether verbal or written, be documented, investigated, and tracked, with written notice of the outcome provided to the complainant. In both cases, the facility did not follow these procedures, as grievances were not formally recorded, investigated, or communicated to the residents or their families. The Director of Nursing and the Nursing Home Administrator acknowledged that the grievance process was not followed and needed improvement.
Failure to Timely Report Alleged Abuse
Penalty
Summary
The facility failed to report an allegation of abuse involving a resident with a history of traumatic brain injury, anxiety, depression, seizure disorder, and cognitive impairment. The resident was taken to a hospital emergency room after becoming combative and reported to hospital staff that they had been hit and punched by staff at the facility. Hospital staff documented two small bruises on the resident. Upon readmission, facility staff also noted bruising during a head-to-toe skin check. A physician's note documented the resident's allegation that a black male staff member had punched and kicked them after the resident requested medication for a migraine. Despite these documented allegations and physical findings, the Nursing Home Administrator and Director of Nursing were unaware of the abuse report and had not reported the incident to the state agency or other required authorities as per facility policy. The policy required immediate reporting, but the allegation was not reported until prompted by the surveyor, several days after the initial incident and documentation. The failure to report was confirmed through interviews and record reviews.
Failure to Investigate Resident Abuse Allegation
Penalty
Summary
The facility failed to investigate an allegation of abuse involving a resident with a history of traumatic brain injury, anxiety, depression, seizure disorder, and cognitive impairment. The resident was sent to the hospital after a combative episode, where they reported to hospital staff that they had been hit and punched by facility staff. Hospital staff documented two small bruises on the resident, one under the left eye and one on the back. Upon readmission, a nurse and wound nurse noted a healing bruise near the left eye and another on the chest. A physician's progress note documented that during a telehealth visit, the resident alleged being punched and kicked by a black male staff member after requesting medication for a migraine. The facility's policy requires immediate investigation of any abuse allegations, including those reported by residents or documented as physical marks. However, the DON and NHA were unaware of the abuse allegation until the surveyor brought it to their attention, despite the allegation being documented in the physician's note. The DON acknowledged that the clinical team is responsible for reviewing physician notes and that the note containing the allegation was missed during the 24-hour look-back review process. Interviews with facility leadership revealed that no investigation was initiated because the team did not recognize the abuse allegation in the physician's documentation. The resident confirmed to the surveyor that they had not been followed up with regarding the abuse allegation. At the time of the survey exit, the facility had not produced any evidence of an investigation into the reported abuse, despite the requirement to do so per facility policy.
Failure to Protect Residents' Personal Property
Penalty
Summary
The facility failed to protect residents' personal property, as evidenced by the lack of adherence to its policy requiring an inventory and tracking process for resident belongings upon admission and discharge. Specifically, two residents were affected by this deficiency. One resident was discharged without a documented inventory or signed acknowledgment of their belongings, resulting in missing items such as a phone, prescription glasses, and clothing. The facility did not provide any resolution or communication regarding these missing items, and the Director of Social Services was unaware of the policy requiring an inventory to be completed and signed upon discharge. Additionally, there was no documentation of a grievance related to the missing items. Another resident was discharged with another resident's clothing, and similarly, there was no documented inventory or signed acknowledgment verifying that belongings were returned. Staff interviews revealed inconsistent application of the inventory process, indicating a systemic issue within the facility's procedures. An interview with the Ombudsman suggested a pattern of issues related to the management of residents' personal belongings, further raising concerns about the facility's ability to safeguard resident property. These findings collectively indicate a failure to comply with regulatory expectations under F584, which mandates a secure, clean, and homelike environment, including reasonable measures to protect resident belongings from loss or theft.
Failure to Timely Report Injuries of Unknown Origin
Penalty
Summary
The facility failed to report alleged violations involving abuse, neglect, exploitation, or mistreatment, including injuries of unknown source, to the state survey agency within the required timeframe for two residents. Resident #33 was observed with a swelling and pain in their left hand, which was later identified as a minimally displaced acute fracture. This injury of unknown origin was not reported to the state survey agency until two days after it was observed. Resident #33 had a history of unspecified dementia with behavioral disturbances and major depression with psychotic symptoms, indicating cognitive impairment. Resident #5, who had severe cognitive impairment due to dementia and Alzheimer's disease, was found with bruising on their forehead, nose, and below the right eye. Despite the visible injuries and the resident's inability to explain the cause due to cognitive impairment, the facility did not report the incident to the state survey agency. The Regional Director of Nursing and the Nursing Home Administrator stated that the clinical team did not believe the injury met the criteria for reporting, as it was considered consistent with the resident's care plan behaviors.
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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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