Autumn Lake Healthcare At Calvert Manor
Inspection history, citations, penalties and survey trends for this long-term care facility in Rising Sun, Maryland.
- Location
- 1881 Telegraph Road, Rising Sun, Maryland 21911
- CMS Provider Number
- 215189
- Inspections on file
- 16
- Latest survey
- December 10, 2025
- Citations (last 12 mo.)
- 2
Citation history
Health deficiencies cited at Autumn Lake Healthcare At Calvert Manor during CMS and state inspections, most recent first.
A resident with Alzheimer's disease, identified as high risk for wandering, made several attempts to leave the unit and had a Wander Guard placed on their ankle. Facility staff did not notify the responsible party of the resident's wandering behavior or the placement of the Wander Guard, and there was no documentation of such notification in the medical record.
Staff failed to provide timely administration of medications, supplements, and wound care for two residents. One resident with dementia did not receive a prescribed medication despite its availability, while another with malnutrition experienced delays in receiving a recommended nutritional supplement and missed several ordered wound treatments. The DON confirmed these lapses in care and documentation.
The facility did not report multiple allegations of abuse, neglect, or mistreatment to the state agency within the required two-hour timeframe. In several cases, residents reported being physically or verbally mistreated, threatened, or sexually assaulted, and these reports were not promptly communicated to the Office of Health Care Quality as mandated. Documentation and staff interviews confirmed that the delays in reporting were due to lapses in following established protocols.
The facility failed to implement care plan interventions for a resident with repeated falls, did not arrange a timely orthopedic follow-up for a resident with a fractured arm, and administered medications late to two residents, including those with respiratory conditions. Additionally, a resident with diarrhea continued to receive a laxative and experienced a delay in treatment for C. difficile due to late physician notification of positive lab results.
Multiple residents and family members reported delays in care, unmet needs, and long wait times due to insufficient nursing staff, especially on weekends and night shifts. Staff interviews confirmed frequent call-outs, high resident-to-staff ratios, and challenges completing daily care tasks, with inconsistent use of agency staff contributing to the deficiency.
Surveyors found that medication carts were left unattended and unlocked, with one instance of keys left in the lock, and a computer screen displaying resident information was also left unlocked. An expired nutritional supplement was discovered in a medication room refrigerator. Staff and leadership confirmed that protocols for securing medications and information were not consistently followed.
The facility did not consistently serve meals according to the posted menu or residents' documented preferences, resulting in several residents receiving food items they did not request or wish to have. Staff substituted menu items due to supply and cost issues without updating meal tickets or informing residents, and some residents continued to receive items they had specifically declined. Staff acknowledged that menu changes and resident preferences were not always communicated or reflected in the meals served.
Surveyors found that food items, including dry pasta and trays of Tater Tots, were stored without required labels or dates in both the storage area and walk-in refrigerator. Staff were unable to provide information on when these items were received or prepared, confirming that proper labeling procedures were not followed.
Two residents did not consistently receive two showers per week as per their preferences, with records and interviews confirming missed scheduled showers and no evidence of make-up showers. Staff and DON acknowledged ongoing issues with shower scheduling and delivery.
A medication cart was observed unattended with an unlocked computer screen displaying confidential resident information, including names, medical record numbers, room numbers, and photos. The nurse responsible left the area to respond to a call light for a resident who nearly fell, leaving the cart and screen unsecured. Facility leadership confirmed that staff are expected to lock carts and blank computer screens when unattended.
A resident reported a significant amount of cash missing from their bedside, with only a portion later returned and no clear resolution or follow-up provided. Staff interviews revealed that the required inventory list documenting the resident's possessions was missing, and there was no documentation of the investigation into the missing money. The process for handling and investigating missing property was inconsistently followed, and discrepancies existed in the reported amounts and handling of the resident's cash.
A resident alleged that a GNA handled her roughly and pinched her during care, resulting in pain. Multiple staff were informed, and a skin assessment was performed, but no injuries were found and no further investigation or reporting occurred. The incident was not documented or communicated to the DON or Administrator as required.
A resident with a physician's order for a right elbow extension splint did not have this intervention or related contracture management included in their care plan. Although the splint order and occupational therapy recommendations were documented, staff confirmed that the care plan was not updated due to an entry error, resulting in the omission of essential care information.
A resident who was dependent on staff for ADLs due to significant self-care deficits did not receive scheduled showers for a month after admission and only received sporadic showers in subsequent months, despite facility policy and staff schedules requiring twice-weekly showers. Staff and DON confirmed the missed care and lack of documentation for refusals.
Staff initiated CPR on a resident with documented DNR and DNI orders, as indicated on the MOLST form, and continued resuscitation efforts until EMS arrived and identified the resident as deceased. Review of records and staff interviews revealed confusion and inconsistent interpretation of the MOLST directives, leading to the failure to honor the resident's end-of-life wishes.
A resident returned from hospitalization with a Foley catheter, but the facility failed to ensure a complete and current medical order specifying the catheter size and balloon information upon re-insertion. Nursing staff reinserted the catheter under a PRN order without verifying or obtaining a new, detailed order, resulting in a gap in proper documentation until a new order was established.
A resident receiving continuous oxygen therapy for COPD did not have their oxygen tubing and humidifier bottle changed or labeled as required, and staff failed to document these actions as ordered by the physician. Additionally, the resident's care plan did not address oxygen therapy with specific goals and interventions, resulting in a lack of comprehensive, person-centered respiratory care.
Facility staff failed to ensure safe and effective pain management for several residents, including delays and omissions in pain medication administration, lack of documentation of non-pharmacological interventions, and failure to assess and document pain levels as required by facility policy and physician orders.
Staff performed CPR on a resident with a documented DNR/DNI order due to a lack of understanding of the MOLST form and failure to check code status before initiating resuscitation. EMS found staff performing CPR despite clear documentation and signs of death. Interviews revealed that LPNs did not routinely verify MOLST forms prior to starting CPR, and staff misunderstood facility policy regarding resuscitation.
A review of staff records found that an annual performance evaluation was not completed for a GNA who worked PRN. The DON confirmed that the evaluation was overlooked and no documentation was available.
A resident with diabetes had a physician order for insulin to be held if blood sugar was below 150. Despite this, an RN administered insulin when the resident's blood sugar was 134, while the previous day an LPN had correctly held the dose for a similar reading. The discrepancy was confirmed by the unit manager and ADON, and the RN later claimed the administration was a documentation error, though the record included an injection site.
Required members of the QAA committee, including the medical director, NHA, DON, and ADON, did not consistently attend scheduled meetings as evidenced by review of attendance records and staff confirmation.
Failure to Notify Responsible Party of Change in Resident Condition
Penalty
Summary
Facility staff failed to notify a resident's responsible party of a significant change in condition. The resident, who was admitted with Alzheimer's disease and assessed as high risk for wandering and elopement, was observed on the day of admission making several attempts to leave the unit. In response, staff placed a Wander Guard device on the resident's right ankle. However, there was no documentation in the medical record indicating that the responsible party was informed of the resident's wandering behavior or the placement of the Wander Guard. During interviews, the responsible party confirmed not being notified, and the Director of Nursing verified the absence of documentation regarding this notification.
Failure to Administer Medications, Supplements, and Treatments as Ordered
Penalty
Summary
Facility staff failed to administer medications, treatments, and supplements as ordered for two residents. For one resident with dementia, Donepezil 5 mg was not administered as ordered on the evening of 9/11/25, despite the medication being available in the Omnicell system. The Director of Nursing confirmed that the medication was not given as prescribed by the physician. Another resident, admitted with malnutrition, did not receive a recommended house supplement shake in a timely manner. Although the Registered Dietitian recommended the supplement and the Nurse Practitioner agreed, the supplement was not ordered until three days later and not administered until four days after the recommendation. Additionally, this resident did not receive ordered wound treatments for a left foot wound on several documented shifts, with no evidence of administration in the treatment record. The Director of Nursing confirmed the lack of documentation for these missed treatments.
Failure to Timely Report Alleged Abuse and Mistreatment
Penalty
Summary
The facility failed to timely report multiple incidents of alleged abuse, neglect, or mistreatment to the Office of Health Care Quality (OHCQ) as required by regulation. In several cases, residents reported being physically mistreated, threatened, or sexually assaulted by staff or unidentified individuals. These allegations were communicated to facility staff, including nurse aides, charge nurses, and unit managers, who then relayed the information to the Director of Nursing (DON) or the facility administrator. However, the initial reports to the state agency were not made within the mandated two-hour window, with delays ranging from several minutes to several hours. Specific incidents included a resident reporting being lifted and dropped by a staff member, another resident alleging rough handling and verbal abuse, and multiple reports of sexual assault or inappropriate touching. In each case, the timeline of internal reporting and subsequent notification to OHCQ exceeded the required timeframe. Documentation and interviews confirmed that the DON and other staff were aware of the two-hour reporting requirement but failed to meet it consistently. In one instance, a resident's complaint of being pinched and roughly handled was not escalated to the DON or reported to OHCQ at all until brought to attention by a surveyor. The facility's investigation files and staff interviews corroborated the late reporting, with the DON acknowledging the delays and confirming the accuracy of the timelines. The failure to promptly report these allegations as required by regulation was evident for six of ten residents reviewed for abuse during the survey.
Failure to Implement Care Plans, Arrange Follow-Up, Timely Medication Administration, and Prompt Lab Reporting
Penalty
Summary
The facility failed to implement and monitor care plan interventions, arrange necessary follow-up appointments, administer medications in a timely manner, and promptly report and act on laboratory results for multiple residents. One resident experienced repeated falls, with documentation indicating that interventions such as hipsters and soft helmets were included in the care plan but were not ordered by a physician, resulting in staff not implementing or monitoring these safety measures. Another resident who suffered a fractured arm did not have a timely orthopedic follow-up appointment arranged as ordered by the physician, and when the family could not keep the scheduled appointment, the recommended emergency room visit was not carried out. Medication administration was also deficient for two residents. One resident's morning medications were consistently administered 2-3 hours late, outside the facility's policy window of one hour before or after the scheduled time. Another resident, who required timely administration of inhaled medications for respiratory conditions, received these medications several hours late on multiple occasions, with staff acknowledging that both residents and staff had raised concerns about the timeliness of medication passes. Additionally, the facility failed to hold a prescribed laxative for a resident experiencing diarrhea and delayed notifying the physician of a positive C. difficile laboratory result. The resident continued to receive the laxative for several days while having diarrhea, and the positive lab result was not communicated to the physician for six days, resulting in a delay in starting appropriate treatment. Staff interviews confirmed that the laxative should have been held and the physician notified promptly, and that the delay in treatment initiation was not in accordance with facility policy.
Insufficient Nursing Staff to Meet Resident Needs
Penalty
Summary
The facility failed to provide sufficient nursing staff to meet the needs of residents, as evidenced by interviews, clinical record reviews, and complaint investigations involving multiple residents. Residents and family members reported frequent staffing shortages, particularly on weekends and night shifts, resulting in delayed assistance with activities of daily living such as toileting, dressing, and hygiene. One resident with a BIMS score of 14 reported being left in the same nightgown from the previous day and sometimes lying in body waste before being cleaned. Another resident described waiting up to an hour for call bell responses, and family members noted that staff were unable to assist with getting residents out of bed or providing timely meals due to insufficient staffing. Several complaints documented similar concerns, including instances where only two staff members were available to care for multiple halls of residents, leading to high resident-to-staff ratios. Staff interviews corroborated these findings, with GNAs and the staffing coordinator acknowledging frequent call-outs, reliance on agency staff, and occasions where a single GNA was responsible for up to 30 residents. Staff reported difficulty completing daily care tasks when staffing was inadequate, and the use of agency staff was described as inconsistent, with some agency personnel unwilling to perform all required duties. The DON was made aware of these ongoing staffing concerns during the survey.
Medication Storage and Expired Supplement Deficiencies
Penalty
Summary
Surveyors identified multiple deficiencies related to the secure storage and management of medications and nutritional supplements. During facility tours, three medication carts were observed to be left unattended and unlocked, with one instance where the keys were left in the lock. In another case, a medication cart was left unlocked in a hallway across from the nursing station, and a staff member locked it only after being observed. Additionally, a medication cart was found unattended and unlocked outside a resident's room, with the computer screen displaying resident information also left unlocked and unattended. Upon inspection, the drawers containing medications were accessible. Surveyors also found an expired container of Nutren 2.0 nutritional supplement in a medication room refrigerator on the East Nursing Unit. The expired supplement was observed during a dual inspection with a unit manager, who acknowledged the finding and removed the item. Interviews with nursing staff and facility leadership confirmed that the expectation is for medication carts and computer screens to be locked and secured when unattended, but these protocols were not consistently followed during the survey.
Failure to Serve Meals According to Menu and Resident Preferences
Penalty
Summary
The facility failed to ensure that residents were served meals according to predetermined menus that incorporated their preferences. Multiple residents received meal trays that did not match their meal tickets or the posted menu. For example, residents expecting scrambled eggs, breakfast ham, and orange juice were instead served French toast, egg patties, and cranberry juice without having requested these substitutions. Staff interviews revealed that changes were made to the menu due to supply issues, such as running out of orange juice or substituting egg patties for scrambled eggs due to cost, without updating meal tickets or informing residents. Additionally, some residents continued to receive items they had specifically requested not to be served, and meal tickets sometimes contained errors or were not updated to reflect actual substitutions. Staff acknowledged that menu changes were not consistently communicated to residents and that meal tickets were not always updated to match what was actually served. In several instances, residents expressed disappointment or confusion about receiving meals that did not align with their preferences or dietary restrictions as indicated on their meal tickets. The surveyor's observations and interviews with both residents and staff confirmed that the facility did not consistently follow or update menus, nor did it ensure that residents' dietary preferences and needs were met as required.
Failure to Label and Date Food Items in Storage and Refrigeration
Penalty
Summary
Surveyors observed that the facility failed to ensure proper labeling and dating of food items in both dry storage and the walk-in refrigerator. During the initial kitchen tour, two bags of dry pasta were found on a storage shelf without any labels or dates indicating when they were received, opened, or their expiration. Staff confirmed that the origin and expiration of these items were unknown, leading to their removal from storage. Additionally, six trays of Tater Tots were found in the walk-in refrigerator without any indication of their preparation date. Staff present at the time were unable to provide information on when the Tater Tots were prepared and acknowledged that the trays should have been labeled. The lack of labeling made it impossible to determine how long the food had been stored, and these findings were confirmed by staff during the survey process.
Failure to Provide Showers According to Resident Preference
Penalty
Summary
Facility staff failed to ensure that residents received two showers per week according to their preferences. One resident reported typically receiving only one shower per week despite expressing a desire for two, and review of shower records confirmed that the resident did not consistently receive the scheduled showers, with no documentation of refusals. The resident's shower sheets for three months showed fewer than the expected number of showers, and there was no evidence that missed showers were made up on weekends as required. Staff interviews confirmed that showers were not provided on several assigned days, and the unit manager acknowledged ongoing issues with residents not receiving scheduled showers. Another resident stated that they were supposed to receive a weekly shower but had not received one for two consecutive weeks, with the possibility of a third missed week. Clinical records indicated that the resident was offered four showers in one month, received two, and refused one, but there was no evidence of make-up showers for the missed weeks. The DON was informed of these inconsistencies and acknowledged that showers were not being provided consistently, with no documentation of make-up showers for the affected residents.
Resident Information Left Exposed on Unattended Computer Screen
Penalty
Summary
A deficiency was identified when a surveyor observed a medication cart outside a resident room with an unattended, unlocked computer screen displaying confidential resident information. The exposed information included resident names, medical record numbers, room numbers, and photos for multiple residents. The computer screen was left open and visible to the public, and the cart was not secured at the time of observation. The concern was immediately acknowledged by the unit manager present during the observation. Further inquiry with a registered nurse revealed that the nurse had left the cart and computer screen unattended to respond to a resident's call light due to a fall incident. The nurse confirmed that facility policy requires nurses to lock the cart and computer screen when leaving them unattended and demonstrated the locking mechanism to the surveyor. Both the Director of Nursing and Assistant Director of Nursing later confirmed that the expectation is for medication carts to be locked, all items covered, and computer screens to be blanked when unattended.
Failure to Protect Resident Property and Maintain Inventory Documentation
Penalty
Summary
The facility failed to exercise reasonable care for the protection of a resident's property from loss or theft. A resident reported that $840 in cash, which was stored in wallets at the bedside, was stolen. The resident stated that $135 was later returned, but the remaining balance was unaccounted for. The resident reported the incident to the unit manager, but did not receive follow-up information regarding the outcome of the investigation. The resident was provided with a locked drawer, but expressed concerns about its security, stating that it could be easily opened with a small tool. Interviews with staff revealed inconsistencies and gaps in the facility's process for documenting and investigating missing property. A GNA stated that missing items are typically reported to a nurse and documented on an inventory list, but the inventory list for this resident could not be located. An LPN confirmed the absence of the inventory list in the resident's chart and described a process for investigating missing money that included notifying social work and other departments. The social worker acknowledged awareness of the missing money but was not involved in the investigation and stated that there was no documentation of the investigation. A review of the grievance form showed discrepancies in the reported amounts of missing money and no supporting documentation to clarify the resident's possessions upon admission.
Failure to Investigate and Report Alleged Abuse
Penalty
Summary
A resident reported to a surveyor that a GNA had pulled her by the feet and legs, causing ongoing pain, and had pinched her thighs while assisting with personal care. The resident also stated that the GNA appeared irritated during the interaction and that her thigh made contact with the bedrail. The resident informed the Unit Manager of these concerns, and the Unit Manager, along with a Nurse Practitioner, performed a skin assessment but found no visible injuries. The Unit Manager asked the resident to demonstrate how she was pinched, but the resident declined, and no further action was taken. There was no documentation in the medical record regarding a change in condition or the incident. Multiple staff members, including a Physical Therapist Aide and a Social Worker, were made aware of the resident's allegations and communicated them to the Unit Manager. The incident was not reported to the Director of Nursing or the Administrator, and the accused GNA was not informed of the allegations. The Director of Nursing later acknowledged that the incident should have been investigated and reported as alleged abuse, but this was not done at the time.
Failure to Include Splint Care in Resident's Care Plan
Penalty
Summary
The facility failed to ensure that a resident's care plan was comprehensive and person-centered, specifically regarding the management of a right elbow contracture with a prescribed splint. Medical records showed that a physician's order for a right elbow extension splint, including specific instructions for use, hygiene, and monitoring, was initiated. However, upon review, it was found that the resident's care plan did not include any information about the splint use or contracture management, despite the order being in place and relevant discharge recommendations from occupational therapy. Interviews with facility staff, including an LPN and a unit manager, confirmed that care interventions are discussed in meetings and that unit managers are responsible for updating care plans. The unit manager acknowledged that the splint order should have been reflected in the care plan. The DON later confirmed that the splint and associated care had been entered on the kardex but not on the care plan due to an entry error, and this information was not available on the care plan at the time of the survey.
Failure to Provide Scheduled Showers to Dependent Resident
Penalty
Summary
A deficiency was identified when a resident, who was dependent on staff for activities of daily living (ADL) due to self-care performance deficits related to activity intolerance, fatigue, and musculoskeletal issues, did not receive regular showers as required. The resident was admitted for rehabilitation and had a care plan in place that included staff assistance with personal hygiene, such as bathing and grooming. Despite this, documentation showed that the resident did not receive a shower for an entire month after admission and only received sporadic showers in the following months. Staff interviews confirmed that residents are scheduled to receive showers twice a week, with documentation of both completed showers and refusals in the electronic medical record. However, review of the shower schedule and records indicated that the resident did not receive showers according to the established schedule, and there was no documentation of refusals for the missed showers. The DON verified that the resident did not receive the scheduled showers and acknowledged awareness of the issue.
Failure to Honor DNR/DNI Orders Resulting in Unwarranted CPR
Penalty
Summary
Facility staff failed to accurately interpret and follow a resident's Maryland Orders for Life Sustaining Treatment (MOLST) form, resulting in the initiation of cardiopulmonary resuscitation (CPR) on a resident who had a documented Do Not Resuscitate (DNR) and Do Not Intubate (DNI) order. When emergency medical services (EMS) arrived in response to a call, they found multiple staff members performing CPR and providing supplemental ventilation to the resident, despite the presence of rigor mortis and a MOLST form indicating No CPR and DNI. The EMS officials confirmed the resident's status and discontinued resuscitation efforts upon review of the MOLST form. Record review revealed two MOLST forms in the resident's closed records, both indicating No CPR and DNI, with one marked as void per protocol. Staff interviews demonstrated inconsistent understanding of the MOLST form directives, with both a registered nurse and the Assistant Director of Nursing stating that no CPR or intubation should be performed for residents with such orders. The facility's policy on residents' rights and advanced directives did not specify that CPR must be attempted on all residents regardless of MOLST status.
Failure to Ensure Complete Medical Orders for Foley Catheter Upon Re-Insertion
Penalty
Summary
The facility failed to ensure that a complete and current medical order for a Foley catheter was in place for a resident upon their return from hospitalization and after the re-insertion of the catheter. Medical record review showed a gap in active Foley catheter orders between 12/4/24 and 2/17/25, despite documentation that the resident had a Foley catheter both upon arrival to and discharge from the hospital. Upon the resident's return, there was no medical order specifying the catheter size and balloon information, and a progress note indicated that the catheter was reinserted without a standing order detailing these specifics. Interviews with nursing staff confirmed that the facility's expectation is for every resident with a Foley catheter to have a medical order specifying the catheter size and balloon information. However, the nurse who reinserted the catheter did so under a PRN order and assumed the same type was used, without verifying or obtaining a new, complete order. The lack of a complete and current medical order for the Foley catheter persisted until a new order was written on 2/17/25.
Failure to Provide Safe and Appropriate Respiratory Care
Penalty
Summary
The facility failed to provide safe and appropriate respiratory care for a resident by not properly labeling and changing oxygen tubing and humidifier bottles as required, not following physician's orders for oxygen administration, and not developing a comprehensive, person-centered care plan for oxygen therapy. During observation, a resident with COPD was found using a nasal cannula connected to an oxygen concentrator set at 2LPM, with a humidifier bottle that was almost empty and dated more than a week prior. The oxygen tubing was not labeled with the date it was last changed, and the resident could not recall when it had been replaced. Staff confirmed that both the humidifier bottle and oxygen tubing should be changed weekly and labeled, but this was not done. Review of the resident's medical record revealed active physician orders for continuous oxygen therapy and weekly changes of the humidifier bottle and oxygen tubing, but there was no documentation on the MAR or TAR that these changes had been performed as ordered. Additionally, the resident's care plan did not address oxygen therapy with specific goals and interventions, indicating a lack of a comprehensive, resident-centered approach to respiratory care. The DON verified the absence of documentation and acknowledged that oxygen therapy should be included in the care plan.
Failure to Provide Safe and Effective Pain Management
Penalty
Summary
Facility staff failed to provide safe and appropriate pain management for multiple residents, as evidenced by delayed, missed, or improperly documented pain medication administration. One resident, following hip surgery, experienced severe pain and reported waiting several hours for pain medication upon admission, with no pain medication administered for over five hours despite a pain score of 5/10 escalating to 8/10. The resident also reported that non-pharmacological interventions, such as an ice pack, were not provided as requested, and there was no documentation that such interventions were attempted prior to administering PRN pain medication, as required by physician orders. Additionally, pain medication was administered late on another occasion, and there were no active orders for mild to moderate pain prior to a new order being placed after surveyor observation. Another resident with a history of severe leg pain was given PRN acetaminophen and morphine sulfate outside of the ordered pain score parameters on multiple occasions. Documentation was lacking for non-pharmacological interventions prior to PRN pain medication administration, as required by the physician's orders. Staff interviews confirmed that pain medications were administered outside of the prescribed parameters and that documentation of non-pharmacological interventions was inconsistent or missing after a certain date. The expectation for staff to document both the interventions and any deviations from the ordered parameters was not met. A third resident, who reported shoulder pain, had an active order for topical lidocaine cream for pain, but there was no documentation that the medication was ever administered. Furthermore, there was no evidence of pain level assessment or use of a pain scale in the resident's records, despite facility policy requiring consistent pain assessment. Staff were unable to demonstrate or provide documentation of pain assessments, and it was revealed that the order for pain assessment was not renewed after a hospital stay, resulting in a lack of ongoing pain assessment and management for this resident.
Failure to Honor MOLST/DNR Orders Due to Staff Misunderstanding
Penalty
Summary
Facility staff lacked the necessary knowledge to correctly interpret and follow the Maryland Orders for Life Sustaining Treatment (MOLST) form, resulting in the initiation of cardiopulmonary resuscitation (CPR) on a resident who had a documented Do Not Resuscitate (DNR) and Do Not Intubate (DNI) order. When Emergency Medical Services (EMS) arrived, they found several staff members performing CPR and providing supplemental ventilation to the resident, despite the presence of rigor mortis and clear documentation on the MOLST form indicating that no resuscitative efforts were to be made. Staff later admitted to misunderstanding the MOLST form, believing that the DNI option only meant not to intubate, not that all resuscitative efforts, including CPR, were to be withheld. Additionally, staff reported that it was facility policy to attempt resuscitation regardless of any valid MOLST or DNR paperwork, which was not supported by the written policy reviewed. Interviews with nursing staff revealed that they did not routinely check the MOLST form before initiating CPR on unresponsive residents. Both interviewed LPNs described their process for responding to an unresponsive resident, which included starting CPR without first verifying the resident's code status or reviewing the MOLST form. The Assistant Director of Nursing was made aware of these concerns and expressed surprise at the staff's lack of knowledge regarding the proper protocol for honoring MOLST and DNR orders.
Missed Annual Performance Evaluation for GNA
Penalty
Summary
A review of staff records revealed that the facility failed to conduct an annual performance evaluation for one Geriatric Nursing Assistant (GNA) in 2023. Specifically, during a review of three randomly selected GNA employee files, it was found that there was no performance evaluation on file for one staff member who worked on an as-needed (PRN) basis. In an interview, the Director of Nursing (DON) confirmed that the responsibility for ensuring annual performance evaluations lies with the DON and unit managers, and acknowledged that the evaluation for this staff member was overlooked. No additional documentation of the required evaluation was provided.
Failure to Follow Insulin Administration Parameters
Penalty
Summary
A deficiency was identified when a resident with diabetes mellitus had an active medical order for Lyumjev KwikPen insulin, specifying administration of 15 units subcutaneously with meals and to hold the dose if blood sugar (BS) was less than 150. On review of the medical record, it was found that on one occasion, a registered nurse (RN) administered the insulin despite the resident's blood sugar being documented at 134, which was below the ordered threshold. The previous day, a licensed practical nurse (LPN) had correctly held the insulin when the resident's blood sugar was 138, in accordance with the order parameters. Interviews with the unit manager and assistant director of nursing (ADON) confirmed the discrepancy between the medication order and the administration record. The RN who documented the administration later stated that it was a typo, but the record also included documentation of the injection site, further supporting that the medication may have been given. This failure to follow the prescribed parameters resulted in the resident not being free from unnecessary medication, as required.
Failure to Ensure Required QAA Committee Member Attendance
Penalty
Summary
The facility failed to ensure that the required members consistently participated in the Quality Assessment and Assurance (QAA) committee meetings. Review of attendance sheets from January 2024 through February 2025 revealed that the medical director did not attend the February 2024 meeting, the Nursing Home Administrator (NHA) missed the meetings in April, September, and October 2024, and both the Director of Nursing (DON) and Assistant Director of Nursing (ADON) were absent from the August 2024 meeting. These findings were confirmed by the QAPI representative upon review of the records, and the NHA acknowledged her absences during the survey exit conference, citing health reasons.
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The facility did not ensure that its Infection Preventionist (IP) met required qualifications for managing the Infection Prevention and Control Program. The DON reported serving as the IP but acknowledged lacking the specialized infection control training required for the role, and confirmed that no other staff member was currently qualified. Records showed that the previously qualified IP left several months earlier, and the Administrator and DON confirmed they were still seeking a replacement, leaving the infection control program without a properly trained leader.
Staff failed to consistently secure medications and medical supplies across three units, including an oxygen tank left on the floor behind a resident’s bed without a supporting device, a treatment cart with Collagenase Santyl cream left on top while two residents in power wheelchairs passed by, an unattended and unlocked treatment cart at a nursing station, and another treatment cart with Diclofenac gel and dressings left on top, indicating repeated lapses in maintaining locked and secure storage for drugs, biologicals, and related supplies.
The facility failed to provide sufficient dietitian coverage and timely nutritional assessments for several residents with significant dietary needs. A resident admitted for diabetic management with a high A1C was placed on a regular diet instead of the recommended carb-controlled diet and had only one weight taken in the first two weeks, with no dietitian review of the record. Another resident with prior significant weight loss had no documented dietitian follow-up despite continued weight loss, and a resident admitted with severe protein-calorie malnutrition experienced further significant weight loss without any dietitian assessment. The dietitian reported working limited hours and prioritizing certain high-risk cases, resulting in delayed or missed evaluations for new admissions and residents with ongoing nutritional concerns.
The facility failed to maintain adequate linen and incontinence supplies and did not keep resident care areas in good repair, resulting in delays and alterations in incontinence care and substandard environmental conditions. Staff reported that towels and washcloths were used instead of wipes and then discarded due to heavy soiling, and that linen deliveries to units were late, leaving residents waiting for care. Observations showed very limited numbers of clean washcloths and other linens on units and in the laundry, with no stock of disposable wipes or backup washcloth supply despite repeated reports to housekeeping. Additional observations revealed recliner chairs blocking a dining-area handwashing sink and kitchenette, multiple resident and shared bathrooms with unfinished spackle, chipped paint, musty odors, black substances near showers, missing threshold molding, exposed cracks and nails, and eroded, rusted baseboard heaters. Hallway handrails on both units were worn, chipped, and splintered, and a shower room contained fecal odors, dried brown stains on the toilet, and deteriorated fixtures, all contributing to a failure to provide a safe, clean, and homelike environment.
Facility staff did not thoroughly investigate two separate abuse allegations involving a resident and an injury of unknown origin involving another resident. In both cases, investigations focused on the directly affected resident and included staff interviews, but there were no interviews of other residents on the unit or documented assessments of those residents for signs of abuse or injuries of unknown origin, including residents unable to communicate due to cognitive status.
Two residents who were dependent on staff for oral care, including one with a tracheostomy, were observed with thick, white or milky substances coating their mouths and teeth, indicating inadequate oral hygiene. One resident communicated that staff did not brush their teeth and that staff "need to." In another case, despite oral care supplies being present in the room, the resident’s mouth and teeth remained unclean on multiple observations, with a thick milky substance caking the teeth and stringing between them when the resident tried to open their mouth. These findings showed that staff did not consistently provide oral care to residents who relied on them for this ADL.
Staff failed to maintain complete and accurate medical records for multiple residents, including missing and inconsistent documentation of wound care, delayed pain assessment after discovery of an injury of unknown origin in a cognitively impaired resident, and inaccurate recording of a PPD test result that was documented as negative despite no evidence the injection was administered and no supporting nurse’s note. Residents reported not receiving certain treatments, while MAR entries either lacked signatures for completion or contained conflicting information about whether care was provided.
Surveyors found that the facility failed to consistently implement and communicate correct transmission-based precautions and PPE use. One resident with a Foley catheter related to wounds had no precaution signage posted, while another resident in a double room had a contact precautions sign at the door, yet the NP entered without PPE and the GNA provided high-contact care wearing only gloves. Staff in that room stated the resident was not on contact precautions and later reversed the sign to show no PPE requirement. Therapy staff reported they rely solely on posted signs to determine PPE, and surveyors identified broader issues with inaccurate signage and staff awareness of which residents required contact precautions.
Surveyors found that MDS assessments were inaccurately coded for two residents. In one case, a resident sustained a femoral neck fracture after a fall, but the subsequent significant change MDS did not code the fall as a major injury and failed to capture prn Tylenol use documented on the MAR within the look-back period. In the other case, a quarterly MDS indicated opioid use for a resident, but the MAR for the same period showed no prescribed opioid, indicating incorrect coding of high-risk drug classes.
A resident who had recently been admitted and experienced a fall received multiple doses of the narcotic analgesic Tramadol, but the facility failed to accurately document all administered doses on the Medication Administration Record (MAR). Review showed only one Tramadol dose recorded on the MAR, while the Controlled Drug Receipt/Record/Disposition Form on the med cart reflected three doses given over two days. In interview, the DON stated staff are expected to document narcotic administration on the MAR and confirmed that two administered doses were not recorded there, resulting in an incomplete and inaccurate medical record.
Unqualified Infection Preventionist Overseeing Infection Control Program
Penalty
Summary
The facility failed to ensure that its designated Infection Preventionist (IP) met the mandatory qualifications for overseeing the Infection Prevention and Control Program. During an interview on 3/24/26 at 10:00 AM, the DON confirmed that she/he was serving as the facility’s IP but had not completed the specialized training in infection control required for the position. The DON further stated that no other staff member currently met the qualifications to serve as IP. Record review showed that the previously qualified IP left the facility in October 2025, and as of the survey date, the position remained unfilled by a qualified individual. At 1:30 PM on the same day, the Administrator and DON confirmed they were still in the process of finding a qualified IP for the facility, leaving the Infection Prevention and Control Program without a properly trained and qualified leader. No specific residents, medical histories, or clinical conditions were described in relation to this deficiency.
Unsecured Medications, Treatment Carts, and Oxygen Equipment
Penalty
Summary
Facility staff failed to ensure that drugs, biologicals, and related medical supplies were securely stored and properly maintained on multiple units. On one unit, an oxygen tank assigned to a resident was observed sitting on the floor behind the resident’s bed without any supporting device. On another unit, a treatment cart was observed with a tube of Collagenase Santyl cream labeled for a specific resident left on top of the cart, while residents in power wheelchairs passed by and staff were present at the nursing station. These observations showed that medications and oxygen equipment were not consistently secured as required. Further observations on additional units revealed an unattended and unlocked treatment cart at a nursing station, and on a separate occasion, a treatment cart with Diclofenac gel labeled for a resident left on top along with multiple packs of dressings. These incidents occurred across three units and on more than one date, demonstrating repeated failures to keep medications and treatment supplies in locked compartments or otherwise secured from unauthorized access.
Insufficient Dietitian Coverage and Delayed Nutritional Assessments
Penalty
Summary
The deficiency involves the facility’s failure to employ sufficient food and nutrition staff, including adequate dietitian coverage, to ensure timely assessment and appropriate diets for residents with significant nutritional and diabetic needs. A resident admitted over two weeks earlier with multiple comorbidities and an A1C of 11.5% had a hospital discharge recommendation for a carbohydrate-controlled diet, but was placed on a regular diet at admission with no acknowledgment of the recommended diet until one week later, when the resident requested larger portions. As of the survey date, the dietitian had not yet seen or reviewed this resident’s medical record, and the resident reported not having seen a dietitian and being very frustrated with the meals. During the first two weeks after admission, only one weight was obtained for this resident, despite physician notes stating the resident’s weight was “stable.” Further review of other residents showed additional failures in timely dietitian assessment and follow-up. One resident, readmitted in January and previously seen by the dietitian in September for a 6.4 lb weight loss over 30 days, had no documented follow-up despite continued weight loss totaling 22 lbs since the last dietitian review. Another resident admitted at the end of February with severe protein-calorie malnutrition had not been seen by the dietitian after about a month in the facility, despite a documented 14 lb (7%) weight loss over two weeks. The dietitian reported working only 12 hours per week at the facility and stated that she must prioritize which residents to see, focusing first on residents with tube feedings and those identified in risk meetings, resulting in delayed or absent assessments for new admissions and residents with ongoing weight loss and malnutrition diagnoses.
Linen Shortages and Poor Environmental Maintenance Compromise Resident Care and Comfort
Penalty
Summary
The deficiency involves the facility’s failure to maintain an adequate supply of clean linens and appropriate incontinence wipes, resulting in delays and alterations in residents’ incontinence care, as well as the use of towels and washcloths in place of disposable wipes. During the initial tour, the surveyor observed that the linen supply on one nursing unit hallway was low. Complaint reviews included concerns about delays in incontinence care and bed linens not being changed regularly, with residents left without clean bedding. A complainant reported that there was not enough clean linen available for residents. Staff interviews confirmed that towels, sheets, and washcloths were being used to wipe residents for incontinence care due to the absence of wipes, and that many of these linens were being thrown away when soiled. Staff also reported a shortage of linen, that linen deliveries to the units were late, and that residents who preferred to get up before breakfast had to wait for care when linen was delayed. Further observations showed that the clean supply room contained no disposable wipes or cloths for incontinence care, and a resident reported that staff did not use wipes, that the resident had to purchase their own, and that heavily soiled towels or washcloths were discarded. A tour of all nursing unit linen carts and closets revealed only six clean washcloths and limited supplies of towels, gowns, and bed linens. In the laundry room, only three washcloths were present, and the laundry assistant stated that there were only three washcloths available for each nursing unit that morning, that the facility was short on linen supply, and that these concerns had been repeatedly reported to the Director of Housekeeping over the preceding month and again that morning. The laundry assistant confirmed there was no additional laundry in process. The DON stated that wipe squares should be used for incontinence care, but no such wipes were found in the clean medical supply room, and no backup supply of washcloths was present in the emergency linen supply. The Director of Housekeeping confirmed there was no backup supply of washcloths. The deficiency also includes environmental and maintenance issues affecting resident bathrooms, handrails, and common areas. In the main dining area, a recliner chair was observed positioned directly in front of the handwashing sink, and two recliner chairs were stored in front of the nutrition area kitchenette. Multiple resident bathrooms and shared bathrooms were repeatedly observed over several days with unfinished spackle on walls that needed resurfacing and painting, chipped paint around sinks, uneven boards nailed to walls under sinks that appeared to partially cover holes, musty odors, black substances between shower bases and walls, missing threshold transition molding exposing cracks, missing tiles, and a nail, as well as eroded and chipped paint on baseboard heaters with exposed dark brown metal and rust-like material. Hallway handrails on both nursing units were observed to be worn, with chips, splintering, holes, and areas where the wood finish had worn off. A shower room was observed with a foul fecal odor, dried brown stains on the back of the toilet seat and in the toilet bowl, and a baseboard heater with eroded, chipped paint and rust-like material, along with chipped paint on the handrail. These conditions were acknowledged by the Director of Maintenance and other leadership, and some areas were noted to be in the process of renovation, but the observed deficiencies remained present during the survey period. Overall, the facility did not maintain a safe, clean, comfortable, and homelike environment in good repair across both nursing units and the dining area. The lack of adequate linen and incontinence supplies, combined with the poor condition of resident bathrooms, handrails, and certain common areas, constituted the basis for the cited deficiency. The observations and staff and resident reports consistently described shortages of essential hygiene supplies, delayed care related to linen availability, and multiple unresolved environmental and maintenance issues in resident care areas and shared spaces.
Failure to Thoroughly Investigate Abuse Allegations and Injuries of Unknown Origin
Penalty
Summary
Facility staff failed to thoroughly investigate allegations of potential abuse involving one resident and an injury of unknown origin involving another resident. For one resident, there were two separate allegations of abuse occurring on different days in early February. The facility’s investigation packets included interviews with staff who cared for or were scheduled to work with this resident on the days of the alleged incidents, and the investigations focused solely on this resident. However, there were no interviews conducted with other residents on the unit to inquire about abusive or neglectful treatment by the staff who were working during the times of the allegations. The surveyors noted that, although the allegations were not validated, there was no documentation that other residents were interviewed, if able, or assessed for signs or symptoms of injury. In a separate incident, another resident was identified on March 4 with a new bruise on the right eye, documented as a change in condition at 4:09 AM. This resident had a BIMS score of 99, indicating the resident was unable to complete an interview and therefore could not report how the injury occurred. The facility’s investigation identified a potential cause of the injury but did not reach a definitive resolution. Additionally, there were no interviews of other residents on the unit regarding possible abuse, nor were there documented assessments of other residents for injuries of unknown origin, particularly for those unable to speak for themselves, as in this resident’s case.
Failure to Provide Oral Care to Dependent Residents
Penalty
Summary
The deficiency involves the facility’s failure to provide oral care to residents who were dependent on staff for activities of daily living, specifically oral hygiene. One resident with a tracheostomy was observed with a thick, sticky white substance in the mouth and was noted to intermittently chew on nearby bedding. This resident made good eye contact and, when asked if staff brushed their teeth, shook their head no and mouthed that staff “need to.” According to the resident’s Minimum Data Set (MDS) dated 2/11/26, the resident was dependent on staff for oral care. Another resident, also dependent on staff for oral care per the 3/11/26 MDS, was observed sitting propped up in bed and able to respond with smiles. During the initial observation, the inside of this resident’s lips and upper and lower teeth had a thick, clear, white milky substance visible when the resident tried to open their mouth to smile. Oral care supplies were present in the nightstand, but the resident’s mouth and teeth were not clean. On a subsequent observation with the DON, NHA, and Corporate VP of clinical services, the same resident again had a thick, clear, milky substance between the lips and caking the teeth, which would string between the teeth when the resident attempted to open their mouth, demonstrating a lack of consistent oral care for residents dependent on staff for this ADL.
Incomplete and Inaccurate Medical Record Documentation for Treatments and Assessments
Penalty
Summary
Facility staff failed to maintain complete and accurate medical records and documentation for multiple residents. For one resident with wound care needs, review of the MAR showed that wound care and related treatments were signed as completed on the dates initially reported, despite the resident’s ongoing complaints that wound dressings were not being changed. When additional dates were reviewed, there were missing staff signatures for wound care on two specific dates, as well as three instances where application of A&D ointment to the resident’s feet was not signed off out of 24 days reviewed. Another resident with severe cognitive impairment, as evidenced by a BIMS score of 00, was found to have an injury of unknown origin (a bruise on the left hand). Documentation showed that a change in condition was initiated late in the morning, but a formal pain evaluation was not initiated and completed until that night, and the resident was unable to explain how the injury occurred or verbalize pain using a standard pain scale. For a third resident, documentation related to the admission PPD test was inconsistent and incomplete. The MAR contained an entry indicating “9” for the administration date, meaning “see nurse’s note,” but there was no corresponding nurse’s note. Despite the absence of a signed administration of the PPD injection, staff documented the PPD result as “negative” on the scheduled read date. The resident reported never receiving the PPD injection, and the DON confirmed that the facility had been out of PPD solution at the time, so the test would not have been administered. These findings demonstrate failures in accurate documentation of treatments and assessments, including wound care, pain assessment, and TB screening, as well as missing or incomplete supporting notes in the medical record.
Failure to Implement and Communicate Correct Transmission-Based Precautions
Penalty
Summary
Surveyors identified a deficiency in the facility’s infection prevention and control program related to inconsistent and incorrect implementation of transmission-based precautions and PPE use. During a complaint investigation focused on residents on transmission-based precautions, one resident with a visible Foley catheter was observed in the room with physical therapy, but there were no signs posted indicating any need for PPE, despite the resident being a new admission with a Foley catheter placed related to wounds. In another double-occupancy room, a contact precautions sign was posted at the doorway, but the nurse practitioner was in the room on a personal phone with no PPE, and the assigned GNA was repositioning the resident in bed while wearing only gloves. When questioned, the NP, RN, and GNA all stated that the resident in the room was not on contact precautions, and the GNA reported that signs were hanging at all doors and that this particular resident’s sign was “just wrong.” The surveyor observed the GNA later return to the room and turn the sign around to indicate no PPE requirement. Subsequent interviews revealed that therapy staff relied on posted signage to determine PPE use and that if the sign was wrong, the PPE used would be wrong. Overall, surveyors found problems with signage accuracy and staff awareness of which residents required contact precautions, as well as observed failures to follow appropriate PPE use for residents who should have been on contact precautions.
Inaccurate MDS Coding for Falls, Pain Management, and High-Risk Medications
Penalty
Summary
Facility staff failed to ensure Minimum Data Set (MDS) assessments were accurately coded for two residents reviewed during a complaint survey. For one resident, a facility-reported incident showed that the resident was found seated on the floor beside the bed and was diagnosed with a non-displaced femoral neck impaction fracture of the left hip following an x-ray. Despite this fall with a major injury, the subsequent significant change MDS dated 11/4/25 did not code the fall with major injury in Section J1900C. Review of the resident’s Medication Administration Records for October and November 2025 showed administration of Tylenol on 10/31/25 at 9:30 PM, which fell within the 5-day look-back period for the MDS, but Section J0100 (prn pain) of the same significant change MDS did not capture the use of Tylenol. For another resident, review of a quarterly MDS with an assessment reference date of 10/15/25 showed that Section N0415 (High-Risk Drug Classes) documented the use of an opioid medication. However, review of the resident’s October 2025 Medication Administration Record did not show that the resident had been prescribed an opioid during that period. In both cases, MDS staff later confirmed that these were errors in MDS coding, demonstrating that the assessments did not accurately reflect the residents’ clinical status and medication use as documented in their medical records.
Incomplete Documentation of Narcotic Administration on MAR
Penalty
Summary
The facility failed to maintain complete and accurate medical records in accordance with accepted professional standards for one resident receiving narcotic medication. The resident, admitted in March 2026, had a fall on 3/6/26 and was sent to the hospital on 3/9/26. Review of the March 2026 Medication Administration Record (MAR) showed documentation of a single 25 mg dose of Tramadol administered on 3/8/26 at 9:23 AM. However, review of the resident’s Controlled Drug Receipt/Record/Disposition Form, kept on the nurse’s medication cart and not in the medical record, showed that Tramadol 25 mg was administered three times between 3/8/26 and 3/9/26: at 11:00 AM and 9:00 PM on 3/8/26, and at 9:00 AM on 3/9/26. In interview, the DON stated that staff are expected to document narcotic administration on the MAR and confirmed that only one of the three Tramadol doses reflected on the controlled drug record was documented on the resident’s MAR. This discrepancy between the controlled substance record and the MAR, with missing documentation of two administered doses of Tramadol on the official medical record, constituted the failure to maintain a complete and accurate medical record for the resident.
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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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