Autumn Lake Healthcare At Bradford Oaks
Inspection history, citations, penalties and survey trends for this long-term care facility in Clinton, Maryland.
- Location
- 7520 Surratts Road, Clinton, Maryland 20735
- CMS Provider Number
- 215165
- Inspections on file
- 18
- Latest survey
- January 8, 2026
- Citations (last 12 mo.)
- 5
Citation history
Health deficiencies cited at Autumn Lake Healthcare At Bradford Oaks during CMS and state inspections, most recent first.
Facility staff failed to notify a resident’s responsible party when the resident’s sacral pressure ulcer worsened from Stage 3 to Stage 4. The resident, admitted with multiple skin injuries and serious comorbidities, initially had an unstageable sacral ulcer that resolved and later reopened, at which time the responsible party was documented as notified and the wound was assessed as Stage 3. After a hospital transfer and return, the wound consultant documented the sacral ulcer as a worsening Stage 4 and new treatments were ordered, but there was no documentation that the responsible party was informed of this change in condition, contrary to the DON’s stated expectations.
A resident was admitted without having a baseline care plan completed and signed within the required 48 hours. Review of the medical record showed that the baseline care plan, which is intended to outline how to provide care for a new resident and is required to be created within 48 hours of admission, was not finalized until more than two weeks after the admission date. The resident’s representative confirmed this delay, and the DON acknowledged that facility policy and requirements call for baseline care plans to be completed, signed, and provided to the resident or representative within 48 hours of admission.
The facility failed to conduct and document required IDT care plan meetings with a resident and their responsible party following quarterly MDS assessments, despite multiple completed assessments and the responsible party reporting they were never invited to such meetings. For another resident with a Stage 3 sacral pressure ulcer, a suprapubic skin tear, and bilateral heel calluses present on admission, the facility initiated a care plan that only noted risk for impaired skin integrity and did not specifically address these existing wounds. When this resident later developed a new wound, the care plan and interventions were not revised to reflect the change in condition, even though the DON stated that care plans are to be updated upon changes in condition.
A resident developed swelling of the left lower lip, and nursing progress notes repeatedly documented that a physician or on-call physician was notified and gave a new order to apply a warm compress, followed later by an order for a cold compress, routine mouth care, and Vaseline. However, review of the physician orders showed that the warm compress order was never entered into the medical record, a fact confirmed by the DON. This failure occurred despite facility policy and an LPN’s statement that telephone orders received after a change in condition must be documented on the physician order form and properly verified and transcribed.
Surveyors found that two residents received multiple scheduled medications late, with delays of several hours, and an LPN left pre-poured medications unattended in a resident's room during administration. The DON confirmed that these practices did not meet professional standards, as medications were not administered or documented at the correct times and were improperly handled during administration.
The facility failed to maintain a sanitary environment, with litter observed in the parking lot and unsanitary conditions in the East hallway. Masks, gloves, and other debris were repeatedly found outside, while inside, stained ceiling tiles, torn flooring, and unclean handrails were noted. Maintenance and Environmental Services staff acknowledged the issues but cited access problems and ongoing renovations as contributing factors.
A facility failed to report an abuse allegation to the state agency within the required timeframe. An LPN reported a resident's abuse allegation to the RN supervisor, but the RN did not document notifying the DON and NHA. The NHA was informed the next day, leading to a delay in reporting to the SA, resulting in a deficiency.
A facility failed to suspend a GNA accused of abuse, allowing her to continue working with vulnerable residents. The investigation was inadequate, lacking documentation and interviews with other staff or residents. The NHA and HR Director could not explain discrepancies in the handling of the allegation, revealing lapses in adherence to abuse policies.
A facility failed to provide a baseline care plan to a resident's representative, which is necessary for proper care upon admission. The representative was not given a copy of the care plan or informed about the resident's medications. This deficiency was confirmed through a review of records and acknowledged by the Regional DON.
The facility staff failed to maintain complete and accurate medical records for two residents. One resident's records showed discrepancies between GNA and nurse documentation regarding turning and repositioning, while another resident's records lacked signatures for bowel, bladder, and personal hygiene care. The Regional DON confirmed these issues, but no rationale was provided for the inconsistencies.
The facility failed to discard expired food items in the dry storage area, including Med Plus 2.0 vanilla nutritional supplements and Thickened Dairy Drink. The Dietary Manager admitted that the items were not in rotation, posing a potential risk to residents consuming these products. The facility's policy mandates proper food storage to prevent deterioration or contamination.
A resident with RSV was not properly isolated due to staff failing to follow droplet precautions. Despite clear signage and available PPE, an LPN and the Activities Director entered the resident's room without the necessary protective equipment, risking cross-contamination. The facility's infection control policies were not adhered to, as confirmed by staff interviews.
Failure to Notify Responsible Party of Worsening Pressure Ulcer
Penalty
Summary
Facility staff failed to notify the responsible party when a resident’s sacral pressure ulcer worsened. The resident was admitted from the hospital with multiple skin injuries, including an unstageable sacral pressure ulcer, and had diagnoses such as COPD, peripheral vascular disease, and pressure-induced deep tissue damage to the right heel and another site. The sacral pressure ulcer was documented as resolved and later reopened, at which time a Change in Condition form indicated that the responsible party was notified in person, and the wound consultant assessed the reopened ulcer as a Stage 3 pressure ulcer. The wound consultant continued weekly evaluations, and the resident was later transferred to the hospital for a change in condition and then returned to the facility. Following the resident’s return, the wound consultant evaluated the sacral ulcer again and documented that it had worsened to a Stage 4 pressure ulcer, and a new treatment order for Santyl and calcium alginate dressing was implemented. However, review of the clinical record did not show any documentation that the responsible party was informed of this worsening of the sacral pressure ulcer. In an interview, the DON stated that her expectation was that nursing staff notify the responsible party of any change in condition, and that worsening of a pressure ulcer to Stage 4 was considered a change in condition for which the responsible party should have been notified. After further review of the record, the DON confirmed there was no documentation that the responsible party had been notified of the worsening pressure ulcer.
Failure to Complete Baseline Care Plan Within 48 Hours of Admission
Penalty
Summary
The facility failed to develop and implement a baseline care plan within 48 hours of admission for one resident. Record review on 1/8/26 at 11:30 AM showed that this resident was admitted on 10/13/25, but the baseline care plan was not completed and signed until 10/28/25, which exceeded the required 48-hour timeframe. The baseline care plan is described in the report as a document that outlines how to provide care for a new nursing home resident, created within 48 hours of admission to reduce the risk of adverse events and ensure the resident receives quality care. This delay in completing the baseline care plan was confirmed by the resident’s representative. During an interview on 1/8/25 at 12:23 PM, the DON acknowledged that baseline care plans are required to be completed and signed within 48 hours of admission and that a copy must be provided to the resident or their representative, thereby confirming that the facility did not meet this requirement for the identified resident.
Failure to Conduct IDT Care Plan Meetings and Update Wound Care Plans
Penalty
Summary
The facility failed to hold and document required care plan meetings with the Interdisciplinary Team (IDT) and the resident or responsible party (RP) within 7 days of quarterly MDS assessments for one resident, and failed to review and revise care plans to address identified skin conditions and new wounds for another resident. For Resident #2, who had diagnoses including COPD, peripheral vascular disease, and multiple pressure-related injuries (sacral pressure ulcer, deep tissue damage of the right heel and another site) and later expired, quarterly MDS assessments were completed on three separate dates. However, there was no evidence in the clinical record that care conferences were held with the resident/RP and the IDT around the time of these assessments. The RP reported not being invited to participate in care plan meetings, the Social Services Director could not find documentation of care conferences or invitations to the RP, and the Administrator, despite stating he believed conferences were held and that attempts had been made to contact the RP, did not provide any supporting documentation by the time of survey exit. The facility also failed to ensure that a resident’s care plan was specific to existing wounds and revised when a new wound developed. For Resident #5, a family member submitted a complaint regarding wound care, and review of wound progress notes showed that on admission the resident had a Stage 3 pressure ulcer to the sacrum, a suprapubic skin tear, and calluses on both heels. The care plan initiated after admission only identified the resident as being at risk for alteration in skin integrity and did not specify or address these ongoing skin conditions. Further review of wound progress notes showed that the resident acquired a new wound on a later date, yet the care plan and its interventions were not revised to reflect this change in condition. During interview, the DON stated that care plans were initiated on admission by the admitting nurse and updated by the Unit Manager or designated staff when there was a change in condition or as needed, and was informed of the failure to include and update the resident’s wound conditions in the care plan.
Failure to Document Telephone Order for Warm Compress
Penalty
Summary
The deficiency involves the facility’s failure to document a physician’s order for a warm compress in accordance with professional standards and facility policy. A resident was noted on multiple occasions to have swelling of the left lower lip with skin intact, no pain observed, and no tongue swelling or airway compromise. Progress notes dated over several days documented that the physician or on-call physician was notified of the change in condition and that new orders were received to apply a warm compress to the affected area. A subsequent note indicated that the physician was again notified and a new order was received to apply a cold compress, provide routine mouth care, and apply Vaseline to moisten the mouth. On review of the physician orders, surveyors found no evidence that the warm compress order was ever written in the medical record, despite repeated nursing documentation that such an order had been received. The DON confirmed that the warm compress order was not documented for this resident. Facility policy for consulting physician/practitioner orders required that telephone orders be documented on the physician order form with time, date, name and title of the person providing the order, and the signature and title of the person receiving the order, as well as verification by the attending physician and appropriate transcription. An LPN stated that when a change in condition occurs and a telephone order is received, nurses are expected to record the order in the medical record, which did not occur for the warm compress order in this case.
Failure to Adhere to Professional Standards in Medication Administration
Penalty
Summary
Surveyors identified that the facility failed to adhere to professional standards of practice in medication administration for multiple residents. One resident reported ongoing concerns about medications being administered late, which was confirmed by a review of the medical record showing that several scheduled morning medications, including those for hypertension, COPD, atrial fibrillation, and bowel regimen, were documented as given over two hours past the scheduled time. Another resident's medication administration audit revealed that numerous morning medications, including those for pain management, nerve pain, hypertension, asthma, GERD, and wound support, were also administered significantly later than scheduled, with some medications given several hours late. The Director of Nursing acknowledged these delays and attributed some of the issues to agency nurses not documenting medication administration at the time it occurred, despite the facility's standard practice requiring real-time documentation. Additionally, during a medication administration observation, an LPN was seen preparing and bringing scheduled medications into a resident's room while the resident was receiving morning care. During this process, one pill was dropped onto the bed, and the nurse left the room to retrieve a replacement, leaving the cup with the prepared medications unattended on the bedside table. The nurse admitted that leaving pre-poured medications unattended was not the accepted standard of practice. The DON confirmed that medications should never be left unattended and that the standard is to sign off medications at the time of administration. These findings were based on resident interviews, direct observation, and medical record reviews, and were discussed with the facility's administration team. The deficiencies involved both the timing of medication administration and the improper handling of medications during administration, affecting residents with complex medical needs such as hypertension, COPD, atrial fibrillation, pain management, and wound care.
Facility Fails to Maintain Sanitary Environment
Penalty
Summary
The facility failed to maintain a safe and sanitary environment for residents, visitors, and staff, as evidenced by multiple observations of litter and debris in the parking lot and unsanitary conditions in the East hallway. Over several days, surveyors observed masks, gloves, and various paper packaging littering the parking lot, with additional trash such as a pile of nonsterile gloves and a piece of cardboard. Interviews with the Maintenance Director revealed that the parking lot was supposed to be cleaned daily, but the issue persisted despite staff being informed. Inside the facility, the East hallway exhibited several maintenance and cleanliness issues, including a ceiling vent with a gap and black spots, stained ceiling tiles, and a torn flooring tile. Boxes of medical supplies were left piled up near a dummy waiter, and the hallway walls and handrails were stained with a reddish-brown substance. Environmental Services staff were supposed to clean these areas daily, but the Director of Environmental Services noted issues with access due to equipment blocking the way. The Director of Maintenance acknowledged the need for vent cleaning but did not provide a reason for the neglect. The Nursing Home Administrator was aware of the trash issue but did not offer a rationale for the ongoing housekeeping concerns.
Failure to Timely Report Abuse Allegation
Penalty
Summary
The facility failed to ensure timely reporting of an abuse allegation to the state agency (SA) within the required timeframe. A Licensed Practical Nurse (LPN) became aware of a resident's allegation of abuse against a Geriatric Nursing Assistant (GNA) during the evening shift. The LPN reported the allegation to the Registered Nurse (RN) on duty, who was the supervisor for that shift. However, the RN did not document the date, time, and manner of notifying the Director of Nursing (DON) and the Nursing Home Administrator (NHA) about the incident. The facility's documentation indicated that the abuse allegation was reported to the SA the following day, outside the required 2-hour timeframe. The Nursing Home Administrator stated that he was informed of the allegation by the previous DON the day after the incident and denied being notified by the RN on the day of the incident. He acknowledged awareness of the regulatory requirement to report such allegations within two hours but noted that staff often do not report incidents to him immediately if he is not in the building. This lack of immediate reporting and documentation led to a delay in notifying the SA, resulting in a deficiency in the facility's process for handling abuse allegations.
Failure to Suspend Staff Accused of Abuse
Penalty
Summary
The facility staff failed to ensure that an alleged perpetrator, GNA12, had no further access to vulnerable residents during an investigation of an abuse allegation. On 7/13/24, LPN5 became aware of an allegation of abuse involving GNA12 and resident R40. Although LPN5 reassigned GNA12 to prevent her from caring for R40, she continued to work her shift and had access to other vulnerable residents. This was contrary to the facility's policy, which requires immediate suspension of staff accused of abuse. The investigation into the allegation was inadequate. While LPN5 reported the incident to RN6, the evening shift supervisor, there was no documentation of RN6's actions following the report. RN6 claimed to have informed the DON and NHA and instructed GNA12 to go home, but she did not document these actions. Furthermore, the investigation did not include interviews with other staff or residents to determine if GNA12 had abused other residents, nor was there a thorough review of the type of care she provided. The NHA and Director of Human Resources were unable to provide a clear rationale for the discrepancies in the investigation and the handling of the alleged abuse. The NHA stated that staff accused of abuse should be suspended immediately, but GNA12 continued to work her shift after the allegation was reported. The Director of Human Resources confirmed that GNA12's time punches indicated she worked on the day of the allegation, contradicting the NHA's assertion that she was suspended immediately. These failures highlight significant lapses in the facility's adherence to its abuse policies and procedures.
Failure to Provide Baseline Care Plan to Resident's Representative
Penalty
Summary
The facility failed to provide a baseline care plan to a resident's representative, which is a requirement to ensure proper care upon admission. This deficiency was identified for one resident who was reviewed for care to prevent pressure ulcers. The complaint revealed that the resident's representative was not given a copy of the baseline care plan or informed about the medications the resident was taking. A review of the closed record and the electronic medical record confirmed the absence of documentation showing that the baseline care plan or medication list was provided to the resident or their representative. The Regional Director of Nursing confirmed these findings during the review process.
Incomplete and Inaccurate Medical Records for Residents
Penalty
Summary
The facility staff failed to ensure the completeness and accuracy of medical records for two residents. For one resident, there was a discrepancy between the documentation by geriatric nursing assistants (GNAs) and nurses regarding the turning and repositioning of the resident to prevent skin breakdown. The GNAs documented that the resident was not turned and repositioned on several specific dates, while the nurses documented on the Treatment Administration Record (TAR) that the resident was being turned and repositioned on those same dates. The Regional Director of Nursing (DON) acknowledged the inconsistency but could not provide a rationale for the conflicting information. For another resident, the medical record review revealed that tasks related to bowel and bladder care and personal hygiene were not signed off as completed on multiple occasions. The resident, who required assistance with activities of daily living, had family concerns about not being changed regularly. The Regional DON and the administrator confirmed that the lack of signatures meant it could not be verified whether the care was provided or if the nurse failed to document it.
Expired Food Items Found in Storage
Penalty
Summary
The facility failed to ensure that food items in the dry storage area were discarded upon reaching their use-by dates, as observed during a survey. Specifically, two cases of Med Plus 2.0 vanilla nutritional supplements and one case of Thickened Dairy Drink were found with expired use-by dates. The Dietary Manager acknowledged the oversight and indicated that the items were not in rotation, which could potentially make residents who consume these products sick. The facility's policy on food safety requires that food be stored in a manner that prevents deterioration or contamination, including from the growth of microorganisms.
Failure to Follow Droplet Precautions for Resident with RSV
Penalty
Summary
The facility failed to adhere to infection control procedures related to droplet precautions for a resident diagnosed with respiratory syncytial virus (RSV). The resident, who was cognitively intact and dependent on staff for daily activities, had a physician's order for droplet precautions. Despite clear signage on the resident's door and the availability of personal protective equipment (PPE) outside the room, staff members did not consistently follow the required precautions. Specifically, an LPN entered the resident's room to assist with a meal without wearing a gown or eye protection, and the Activities Director also entered the room without the necessary PPE. Interviews with the Director of Nursing and the involved staff confirmed the lapses in following the facility's infection control policies. The facility's policy on transmission-based precautions required staff to wear a gown, mask, gloves, and eye protection when entering the room of a resident on droplet precautions. The failure to comply with these procedures had the potential to cause cross-contamination with other residents and staff, as the facility's policies were not adequately followed by the staff members involved.
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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