Autumn Lake Healthcare At Braddock Heights
Inspection history, citations, penalties and survey trends for this long-term care facility in Frederick, Maryland.
- Location
- 6012 Jefferson Boulevard, Frederick, Maryland 21703
- CMS Provider Number
- 215199
- Inspections on file
- 18
- Latest survey
- January 23, 2026
- Citations (last 12 mo.)
- 3
Citation history
Health deficiencies cited at Autumn Lake Healthcare At Braddock Heights during CMS and state inspections, most recent first.
A resident with a degenerative neurological condition, dependent for bed mobility and personal care, was found in bed without their call light within reach, despite the care plan and GNA Kardex directing that the call light be kept accessible at all times due to fall risk and impaired mobility. During an observation, the resident reported being unable to reposition without assistance and voiced concerns about delayed call bell responses. The call device was later observed on a nightstand at the foot of the bed, out of the resident’s reach, indicating staff had not followed the documented interventions for maintaining the call light within reach.
Surveyors found that the facility failed to timely report one allegation of abuse and failed to report another allegation at all. In one case, a resident’s abuse allegation was reported to a staff member, but the NHA did not submit the report to the state agency within the required 2-hour window, despite documentation showing she was notified earlier than she claimed. In another case, a cognitively intact roommate reported that an agency GNA provided rough, abrupt care and spoke angrily to a severely cognitively impaired resident who required total assist with ADLs, but the NHA chose not to report the allegation after asking the reporting resident if they believed it was abuse and deciding it did not meet the definition of abuse.
The facility failed to thoroughly investigate several abuse allegations and to properly document law enforcement notification. In one case, a resident alleged a GNA was rough and hit her during care, but the investigation file lacked staff and resident witness statements, a statement from the alleged perpetrator, resident assessments, and complete reporting documentation. In another case, a resident reported that a staff member purposefully struck his arm and slapped his hand away while handling a urinal; although there were some interview summaries and a witness statement, there was no signed statement from the alleged perpetrator or documentation that such a statement was requested or refused. In a third case, involving a non-communicative resident, the file contained questionnaires but did not identify witnesses, and the records claimed the sheriff’s office was notified without providing objective details such as date/time, officer identity, or report number, and there was no signed statement from the staff member alleged to be involved or documentation of attempts to obtain one.
The facility failed to prevent resident-to-resident abuse involving several residents with cognitive impairments and behavioral issues. One resident with Down's syndrome was slapped by another resident due to noise disturbance, and later smacked another resident in the dining room. Another incident involved a resident with poor impulse control hitting his roommate, who retaliated. These incidents were confirmed by facility investigations and interviews, indicating a deficiency in protecting residents from abuse.
The facility's water management program was incomplete and not aligned with ASHRAE guidelines, posing a potential risk for Legionnaire's disease among 43 residents over 65. The Maintenance Director provided an inadequate water system schematic, lacking details on water entry and pathogen development areas.
A resident's grievance regarding delayed incontinence care was not properly investigated by the facility. The resident activated the call light, but two GNAs at the nurses' station did not respond, leaving the resident waiting for 26 minutes. The resident's care plan required extensive assistance, and past grievances showed similar issues with delayed responses. The facility's administration confirmed that staff should have alerted a nurse or supervisor and acknowledged a lack of staff education on the resident's care needs.
Facility staff failed to provide necessary care to two residents who relied on staff for assistance with activities of daily living. One resident did not receive scheduled showers, and there was confusion regarding staff assignments, leading to a lack of care documentation. Another resident, requiring extensive assistance with toileting, was left soiled after multiple calls for help. The facility administrator acknowledged the resident was soiled for longer than reasonable.
The facility failed to provide written bed hold notices to two residents or their representatives prior to or within 24 hours of emergency hospital transfers, as required by policy. This deficiency was confirmed through a review of medical records and an interview with the Administrator, revealing a lack of documentation for these notifications.
A facility failed to ensure an LPN had the necessary skills to administer insulin correctly to a resident with type 2 diabetes. The LPN did not prime the insulin pen as per manufacturer's instructions, potentially leading to incorrect dosing. Interviews revealed the LPN's training did not cover insulin pen administration, and the facility's assessment tool indicated a gap in training on medication administration.
A resident over the age of 65 was not offered the pneumococcal vaccination in accordance with CDC guidelines and facility policy. The resident had previously received the PCV13 vaccine but was not administered the subsequent PCV20 until the deficiency was identified. The Infection Preventionist confirmed the oversight during an audit, which had the potential to increase the resident's risk of contracting pneumonia.
Call Light Not Kept Within Reach for Dependent Resident
Penalty
Summary
Surveyors identified a deficiency related to the facility’s failure to ensure a resident’s call device was kept within reach as required by the resident’s care plan and GNA Kardex. During the initial tour and screening, a resident with a degenerative neurological condition, who was dependent on others for personal care and bed mobility, was observed seated upright in bed, awake, alert, and easily engaged in conversation. The resident reported being unable to reposition themself without assistance and expressed concerns about delays in call bell response times. When the surveyor looked for the call device, it was not visible near the resident, and the resident stated they did not know where it was. The surveyor then observed the call device placed on top of the nightstand located at the foot end of the bed, and the resident stated they could not reach it there and that staff must have left it in that location. The resident’s GNA Kardex included instructions to keep the call light within reach at all times, and documented that the resident was dependent for bed mobility and required set-up assistance for eating. The resident’s care plan also identified a problem of risk for falls due to impaired mobility, weakness, and ambulatory dysfunction, with an intervention specifying that the call light should be within reach when the resident was in bed. Despite these documented requirements, the call device was not placed within the resident’s reach at the time of the surveyor’s observation.
Failure to Timely Report and Failure to Report Allegations of Abuse
Penalty
Summary
The deficiency involves the facility’s failure to timely report, and in one case to report at all, allegations of abuse to the state oversight agency. In the first incident, a facility-reported incident file showed that a resident reported an allegation of abuse to a physical therapy assistant at 10:00 AM on 3/17/25. The initial report to the Office of Health Care Quality (OHCQ) was not sent until 2:13 PM the same day, more than four hours after the allegation was first reported to staff. The Nursing Home Administrator (NHA), who served as the facility’s abuse coordinator, acknowledged that the regulatory reporting clock starts as soon as any staff member is made aware of an allegation and that the facility had a two-hour reporting requirement. The NHA confirmed that the allegation was not reported within the mandated timeframe. During interview, the NHA initially stated that the delay occurred because the physical therapy assistant reported the allegation to the director of rehab, who then reported it to her. However, further review of the investigation packet showed that the assistant had directly reported the allegation to the NHA, contradicting the NHA’s explanation. The NHA also stated that the assistant had been educated to report allegations of abuse immediately. These records and interviews established that the facility did not meet the required timeframe for reporting the allegation of abuse to OHCQ, despite the NHA’s awareness of the reporting standard and her role as abuse coordinator. In the second incident, a grievance form documented that a cognitively intact roommate reported observing a GNA provide abrupt and rough care to a resident with severe cognitive impairment, dementia, and a cognitive communication deficit, who required total assistance with personal hygiene and extensive assistance with turning and repositioning, and was unable to use the call bell. The roommate reported that the GNA entered the room in a poor mood, became frustrated with the resident’s inability to cooperate, grabbed the resident hard, spoke angrily, and used force when laying the resident back down and moving the resident’s legs onto the bed. The roommate reported these concerns to the facility social worker the same morning. The social worker stated that the concern was reviewed by the NHA, who asked the reporting resident if they thought the incident was abuse; when the resident said no, the NHA determined it was not abuse and did not report it to OHCQ. In a subsequent interview, the NHA confirmed that she did not report this allegation because she concluded it did not meet the definition of abuse, despite acknowledging that all allegations of abuse were supposed to be reported.
Failure to Thoroughly Investigate Multiple Abuse Allegations and Document Law Enforcement Notification
Penalty
Summary
The facility failed to thoroughly investigate multiple allegations of abuse as required by its own process and regulatory expectations. For Facility Reported Incident (FRI) #351276, involving a resident who alleged that a GNA was rough and hit her while providing care, the investigation file lacked staff witness statements, a statement from the alleged perpetrator, and any resident witness statements or resident assessments. The only resident statement present was an undated questionnaire-style document for Resident #40 that lacked the interviewer’s name and signature. The file also did not contain evidence of the alleged perpetrator’s license, education, or work status, nor copies of both the initial and final reports to the Office of Health Care Quality (OHCQ). When questioned, the NHA and DON stated that the former DON wrote the resident’s statement and that other residents were interviewed and assessed, but they could not provide supporting documentation. For FRI #351281, related to a resident admitted in April and discharged in May who reported that a staff member purposefully struck his left arm and handled him too aggressively, the medical record documented the allegation and a provider assessment noting no obvious signs of trauma. The investigation file contained an unsigned and unnamed statement describing the resident’s report, including that staff slapped the resident’s hand away while handling a urinal and that another staff member was present. The file also included a document signed by the NHA summarizing an interview with Staff #15, indicating the staff member claimed the contact was accidental, and an education acknowledgment signed by Staff #15, as well as a signed statement from Staff #14 who reported being in the room and not hearing a slap. However, there was no signed statement from Staff #15 in the file and no documentation that Staff #15 had been asked to provide a signed statement or had declined or was unavailable, despite corporate guidance that investigative statements should be conducted as interviews with factual data and supported by documentation. For FRI #2623047, the initial report to OHCQ documented that the county sheriff’s office was contacted, but did not identify an officer, report number, or other objective evidence of the contact. The investigation file contained questionnaires reflecting resident and staff interviews but did not identify witnesses to the alleged incident. Within the investigation record, the section for law enforcement notification listed the sheriff’s office but left the date and time of contact blank. A follow-up report stated that a non-communicative resident had a skin assessment with no new areas noted, that residents were interviewed or assessed as applicable, and that the alleged perpetrator (Staff #18) was unaware of the incident due to lack of a specific date/time and was suspended pending investigation. The facility could not provide a signed statement from Staff #18 or documentation of attempts to obtain such a statement, and also could not provide objective documentation (such as date/time, name/badge of the officer, or report number) to verify law enforcement notification as reported to OHCQ.
Failure to Prevent Resident-to-Resident Abuse
Penalty
Summary
The facility failed to protect four residents from resident-to-resident abuse, as evidenced by multiple incidents involving physical altercations. Resident 22, who was severely cognitively impaired with a diagnosis of Down's syndrome, was involved in two separate incidents. In the first incident, Resident 11, who had a history of aggression and depression, admitted to slapping Resident 22 after being disturbed by noise. In the second incident, Resident 22, who had a history of physical and verbal behaviors, smacked Resident 35, who was severely cognitively impaired, in the dining room. Another incident involved Resident 106, who was cognitively intact but had poor impulse control, pushing past and hitting Resident 11, who then retaliated. These incidents were documented in the facility's investigation reports, and interviews confirmed the occurrences. The facility's policy on abuse, neglect, and exploitation was reviewed, indicating a failure to prevent resident-to-resident abuse. The facility's investigation revealed that there were no witnesses to some of the altercations, and the residents involved had varying levels of cognitive impairment and behavioral issues. The facility's administrator confirmed that these incidents were considered abuse, highlighting a deficiency in ensuring a safe environment for all residents.
Incomplete Water Management Program for Legionella Prevention
Penalty
Summary
The facility's water management program was found to be incomplete and not consistent with current ASHRAE guidelines, which are essential for evaluating the potential exposure to Legionnaire's disease within healthcare facilities. The deficiency was identified through a review of the facility's policy, interviews, and guidelines from the CDC and ASHRAE. The facility's policy, dated December 4, 2022, stated the intention to establish water management plans to reduce the risk of legionellosis and other pathogens. However, the policy lacked a comprehensive risk assessment and control points identification, which are critical components of a water management program. During an interview, the Maintenance Director confirmed that there had been no Legionnaires outbreaks and provided a hand-drawn schematic of the facility's water system, completed on the day of the interview. However, the document failed to include crucial information on how water enters the facility and potential areas for water pathogens to develop. This oversight created a potential risk for the 43 residents, all over the age of 65, to be exposed to Legionella, as the facility did not adequately address the environmental conditions that could promote the growth and transmission of the bacteria.
Failure to Investigate Resident Grievance and Provide Timely Care
Penalty
Summary
The facility failed to investigate a grievance regarding care concerns for a resident, identified as Resident #14. An observation revealed that the resident activated the call light, which was ignored by two geriatric nursing assistants (GNAs) who were present at the nurses' station. An activity assistant (AA) responded to the call light but was unable to provide the necessary incontinence care and informed the GNAs, who did not take further action. The resident waited 26 minutes for care, during which time one of the GNAs was observed using a computer and cell phone. The resident's care plan indicated a need for extensive assistance with incontinence care, contradicting the GNA's claim that the resident had requested not to have her as an aide. A review of past grievances revealed a similar incident where the resident's call light was not promptly answered during breakfast time, and the investigation by the former Director of Nursing (DON) was inadequate. The DON failed to determine the urgency of the resident's needs or the duration of the wait time. Interviews with the current Administrator and DON confirmed that the GNAs should have alerted a nurse or supervisor about the resident's needs instead of making the resident wait. The Administrator acknowledged that the resident had a behavior of requesting care during mealtimes, which was not documented in the care plan, and staff had not been educated on how to handle the resident's specific care needs.
Failure to Provide Adequate Care for Residents
Penalty
Summary
Facility staff failed to provide necessary care to two residents who relied on staff for assistance with activities of daily living. For one resident, there was a failure to assign an aide on a night shift, resulting in care not being provided. The resident's care plan indicated the need for assistance with bathing and personal hygiene, with scheduled shower days on Wednesdays and Fridays. However, documentation revealed that the resident did not receive showers as scheduled, with only two showers documented over an eight-day period. Additionally, there was confusion regarding staff assignments, as a GNA who was supposed to care for the resident did not clock in, and another GNA was not aware of the assignment, leading to a lack of care documentation. Another resident, who required extensive assistance with toileting, reported being left soiled after calling for help multiple times. The resident used the call bell on several occasions, but staff failed to provide timely assistance. The resident was eventually changed by a third GNA, but the facility was unable to determine the exact duration the resident was left soiled. The facility administrator acknowledged that the resident was soiled for longer than reasonable. These incidents highlight a failure in the facility's staffing and care documentation processes, resulting in inadequate care for residents who depend on staff for their daily needs.
Failure to Provide Bed Hold Notices for Hospital Transfers
Penalty
Summary
The facility failed to provide a written bed hold notice to two residents, R23 and R55, or their representatives, prior to or within 24 hours of their emergency transfers to the hospital. This oversight was identified during a review of the facility's policy titled 'Bed Hold Notice Upon Transfer,' which mandates that such a notice be given at the time of transfer. The policy specifies that the notice should include the duration of the bed-hold policy, information on the return of the resident to the next available bed, and documentation of the notice in the medical record. Resident R23 experienced multiple hospitalizations for various medical conditions, including an intertrochanteric fracture, infections, and septic shock, yet there was no documentation of a bed hold notice being provided for any of these transfers. Similarly, Resident R55 was transferred to the hospital due to agitation and aggressiveness, but again, no bed hold notice was documented. An interview with the facility's Administrator confirmed the lack of documentation for these notifications, indicating a systemic failure to comply with the facility's policy.
LPN Lacks Competency in Insulin Pen Administration
Penalty
Summary
The facility failed to ensure that a Licensed Practical Nurse (LPN) possessed the necessary competencies and skills to properly administer insulin to a resident with type 2 diabetes mellitus. During an observation, the LPN did not prime the insulin pen with the required two units to ensure the needle was functioning correctly, instead priming it with only one unit. This action was contrary to the manufacturer's instructions, which could potentially result in the resident receiving an incorrect dose of insulin. The LPN admitted to not recalling any specific training on insulin pen administration during her orientation. Interviews with the Assistant Director of Nursing (ADON) and the Director of Nursing (DON) revealed that the LPN's competency assessment did not include insulin pen administration. The DON acknowledged that the medication administration observation form needed revision to incorporate insulin pen administration. The facility's documentation confirmed that the LPN was observed administering medications satisfactorily, but insulin pen administration was not part of the evaluation. The facility's assessment tool indicated that staff training should include medication administration, yet this was not adequately addressed in the LPN's training.
Failure to Offer Pneumococcal Vaccination
Penalty
Summary
The facility failed to offer a resident, identified as R37, the opportunity to be vaccinated against pneumococcal disease in accordance with nationally recognized standards. The facility's policy, dated 12/18/22, mandates offering pneumococcal vaccines to residents in line with CDC guidelines. According to the CDC, adults aged 65 years or older should receive pneumococcal vaccination. R37, who was over the age of 65 upon admission, had previously received the PCV13 vaccine on 02/03/16 but had not been offered the subsequent recommended vaccinations until the deficiency was identified. The Infection Preventionist (IP) confirmed during an interview that R37 had received the PCV13 and that the PCV20 was administered only recently, after an audit revealed the oversight. The IP acknowledged that R37 was missed during the recent audit for the PCV20 vaccine, which led to the delay in offering the appropriate vaccination. This oversight had the potential to increase the risk for the resident to contract pneumonia, as the facility did not adhere to its policy and CDC guidelines in a timely manner.
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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Every citation, penalty and Plan of Correction is sourced from public CMS records (latest release May 27, 2026) and official state health department websites — never guesswork.
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