Autumn Lake Healthcare At Chevy Chase
Inspection history, citations, penalties and survey trends for this long-term care facility in Chevy Chase, Maryland.
- Location
- 8700 Jones Mill Road, Chevy Chase, Maryland 20815
- CMS Provider Number
- 215029
- Inspections on file
- 20
- Latest survey
- October 17, 2025
- Citations (last 12 mo.)
- 2
Citation history
Health deficiencies cited at Autumn Lake Healthcare At Chevy Chase during CMS and state inspections, most recent first.
A resident with a history of stroke and intact cognition reported that a GNA was rough and rushed during incontinence care, leading the resident to call 911. Although staff and the DON became aware of the allegation in the morning, the incident was not reported to the state survey agency until several hours later, exceeding the required two-hour reporting window.
A nurse failed to perform hand hygiene between glove changes while providing wound care to a resident with an unstageable pressure ulcer and peripheral vascular disease. The nurse repeatedly changed gloves without washing hands, contrary to facility policy, during a dressing change procedure. Both the nurse and the DON confirmed that hand hygiene should have occurred between glove changes.
Surveyors found that the facility failed to maintain a homelike environment, with multiple rooms missing toilet paper holders, damaged furniture, and exposed plumbing. Common areas such as shower and utility rooms were observed to be unclean and disorganized, with trash, soiled items, and personal belongings improperly stored. Additionally, residents reported being without hot water for several days, confirmed by low water temperatures in multiple rooms, requiring alternative arrangements for bathing.
Staff did not consistently review and update care plans after comprehensive and quarterly assessments. In several cases, residents did not participate in care plan meetings, documentation of meetings and invitations was missing, and quarterly screenings for rehab services were not performed as required. After therapy discharge, recommended nursing interventions were not entered into the EMR or reflected in the care plan.
Surveyors identified multiple deficiencies, including failure to implement and document wound care orders for a resident post-amputation, lack of adherence to physician orders for TEDS application, administration of blood pressure medication outside of ordered parameters without physician notification, and incomplete documentation of ordered showers. These actions and omissions involved several residents and demonstrated lapses in following professional standards and physician instructions.
Two residents were not treated with dignity during care: one was fed by a CNA standing over them instead of sitting at eye level, and another, who required extensive ADL assistance and had significant medical conditions, reported being left on a bedside commode for two hours before receiving help. Both incidents reflect lapses in upholding resident rights to dignity and respect.
A resident's legal representative experienced a significant delay—between 19 and 40 days—in receiving requested medical records, despite having valid POA documentation on file. The facility's process required additional legal review, which was not explained as necessary, and the records were not provided within the facility's stated 2-day timeframe.
Surveyors found that the facility did not ensure resident safety after a staff member accused of abuse was not immediately escorted from the building, and also failed to conduct a thorough investigation into another resident's allegation of rough handling by a GNA. In both cases, required investigative steps and documentation were lacking.
A resident's MDS assessment was inaccurately coded to indicate a fall with injury, despite documentation showing no pain or injury after the fall. Facility records and staff interviews confirmed the error, as the resident's assessments and x-ray results did not support the presence of an injury.
A resident who was always incontinent of bowel and bladder did not have a care plan developed to address these needs. Medical records and the MDS confirmed ongoing incontinence, and staff interviews revealed that the required care plan was not in place, resulting in a deficiency.
A resident with significant medical conditions and limited ROM did not receive ongoing contracture management as recommended by OT after discharge from therapy. The recommended nursing interventions, including daily splint application, were not entered as orders in the EMR or included in the care plan, resulting in a lapse in care.
A resident with multiple comorbidities and a worsening sacral wound did not receive a timely Infectious Disease (ID) consultation, despite repeated orders and elevated CRP levels indicating severe inflammation. The ID consult was delayed by 28 days, and there was no documentation of the consultation in the medical record prior to the resident's hospital transfer and diagnosis of sepsis.
Surveyors identified that two residents had incomplete or inaccurate medical records. One resident's shower schedule in the kardex did not match the physician's order, and another resident discharged from OT for contracture management did not have the recommended splinting orders entered into the EMR or care plan. Staff interviews confirmed these documentation lapses.
Surveyors found that multiple refrigerators and ice machines in the kitchen and main dining room were not operational, with food stored at improper temperatures and staff unaware of equipment failures. Staff reported broken ice machines to residents, and maintenance was not aware of all issues, indicating a lack of oversight and failure to keep essential equipment in safe working order.
A resident was observed with a mattress that extended about 8 inches beyond the right side of the bed frame. The surveyor and the Director of Maintenance confirmed that the mattress was too large for the bed frame, resulting in a failure to ensure the mattress properly fit the bed frame as required for safety.
A resident was found resting in bed without access to their call light, which was discovered wrapped around a chair arm and out of reach. An LPN confirmed that staff are expected to keep the call device accessible before leaving the room, and medical records included instructions to keep the call light within reach at all times.
A resident was transferred to the hospital without their comprehensive care plan goals included in the required documentation. Both an RN/Unit Supervisor and an LPN confirmed that care plan goals were not sent with residents during transfers, and this issue was reviewed with the DON.
Staff did not provide written notification to a resident and their representative upon the resident's transfer to the hospital, instead relying solely on verbal communication as confirmed by both an RN/Unit Supervisor and an LPN.
A resident who was dependent on staff for ADLs did not receive scheduled showers as ordered, receiving only one shower during the month while daily bed baths were substituted without proper documentation or explanation. The resident's preference for more frequent showers was not honored, and there was no record of refusal or justification for the missed care.
A resident with bowel and bladder incontinence and a stage 4 sacral pressure ulcer did not have documented interventions or services in place to address their incontinence. Review of medical records and staff interviews confirmed the absence of a care plan or treatment for incontinence.
A resident was prescribed Bupropion, an antidepressant, without an accompanying order for side effect monitoring for several weeks. The DON confirmed that monitoring should have been initiated when the medication was ordered, but this was not done until a later date.
During a breakfast meal service, three residents did not receive coffee as listed on their dietary meal tickets due to a delay in the arrival of the beverage cart. The unit was staffed with only two GNAs for 32 residents, and additional staff from other departments assisted with meal delivery. The omission was observed and confirmed by surveyors in the presence of the unit manager, charge nurse, and medication nurse.
Surveyors found that food served to a unit of 32 residents was not maintained at appropriate temperatures, with hot foods cooling significantly and cold beverages warming above recommended levels due to delays between tray preparation and service. The regional dietary manager acknowledged the failure to ensure proper food temperatures at the point of service.
Surveyors identified failures in food storage at appropriate temperatures, use of non-functional kitchen equipment, and improper storage of dry goods. Additionally, two residents did not receive meal trays matching their meal tickets, with missing or incorrect items. Staff acknowledged the discrepancies and were made aware of the issues.
A facility failed to provide an accurate assessment of direct care staff to resident ratios. The administrator was unable to explain the staffing plan documented in the assessment and later admitted it was incorrect, providing hand-written ratios that did not match the official documentation. This discrepancy resulted in a deficiency related to the facility's assessment process.
Staff did not keep isolation carts stocked with required PPE for residents on enhanced barrier precautions, with missing gloves and gowns noted on multiple units. An LPN confirmed the deficiencies, and medication was found improperly stored in one cart. The administrator and DON were informed of these findings.
Surveyors identified that daily nurse staffing postings were incomplete on all units, with missing information such as dates, nurse-to-resident ratios, staff titles, shift supervisors, hours worked, and unit census. The staff scheduler responsible for collecting these forms was unaware of the full requirements and depended on unit managers to complete the postings.
Failure to Timely Report Alleged Abuse to State Agency
Penalty
Summary
The facility failed to timely report an allegation of abuse to the state survey agency as required by its own policy and federal regulations. According to facility policy, all alleged violations involving abuse or resulting in serious bodily injury must be reported immediately, but not later than two hours after the allegation is made. In this case, a resident with a history of stroke and intact cognition, as indicated by a BIMS score of 15, reported that a geriatric nursing assistant (GNA) was rough and rushed during incontinence care. The resident called 911 to report the incident, prompting police officers to visit the facility. The incident occurred during the overnight shift, and staff became aware of the allegation in the morning when police arrived and the resident was interviewed by the DON and Unit Manager. Despite the facility's policy and staff acknowledgment that abuse allegations should be reported within two hours, the incident was not reported to the state survey agency until several hours after staff became aware of it. The Administrator, who serves as the facility's abuse coordinator, confirmed that the report to the state agency was not made until the afternoon, well beyond the required two-hour timeframe. Documentation and interviews confirm that the delay in reporting constituted a failure to follow established procedures for timely reporting of abuse allegations.
Failure to Perform Hand Hygiene Between Glove Changes During Wound Care
Penalty
Summary
The facility failed to adhere to its infection prevention and control policy during wound care for a resident with a history of peripheral vascular disease and an unstageable pressure ulcer. During an observed dressing change, the registered nurse did not perform hand hygiene between glove changes at multiple points in the procedure, despite the facility's policy requiring hand washing after glove removal and before donning new gloves. The nurse removed gloves and immediately put on new gloves several times without washing hands, including after removing soiled dressings and before handling clean supplies and applying new dressings. The resident involved had moderate cognitive impairment and a large, deep unstageable wound on the sacrum. The nurse's actions were observed and later confirmed in interviews, where both the nurse and the Director of Nursing acknowledged that hand hygiene should have been performed between glove changes. The facility's policy, which was reviewed, clearly outlined the steps for hand hygiene during wound care, but these were not followed during the observed incident.
Failure to Maintain Safe, Clean, and Homelike Environment; Lack of Hot Water for Residents
Penalty
Summary
Surveyors identified multiple deficiencies related to the facility's failure to maintain a safe, clean, and homelike environment for residents. Observations revealed that in several resident rooms, toilet paper rolls were hung using trash bags tied to handrails or towel holders due to missing or broken toilet paper holders. Additional issues included nightstand drawers that did not fit properly or lacked knobs, missing door knobs on bathroom doors, and exposed holes. Several rooms had warped or cracked linoleum, missing or scratched paint, missing guest chairs, and exposed water shutoff valves. These maintenance concerns were observed over multiple days and confirmed by staff interviews, with staff reporting that maintenance issues were to be reported via an online platform, but the Director of Maintenance was unaware of the problems until the survey walkthrough. Further deficiencies were noted in the cleanliness and organization of common areas, including the resident shower room, clean utility room, and soiled utility room. The shower room contained a basin on a trash can, wheelchair pedals, a mop and broom, trash on the floor, a brown substance on the toilet seat, and various personal items and towels scattered in the tub and on the floor. The clean utility room had a used glove on a bin, incomplete paint, missing floor tiles, and staff personal items stored inappropriately. The soiled utility room had a sink full of dirty water, soiled shelves, and miscellaneous items. The Housekeeping Director acknowledged the challenges in monitoring and maintaining cleanliness in these areas. Additionally, residents reported being without hot water for three days, confirmed by surveyors who found water temperatures in several rooms to be significantly below acceptable levels. Residents stated they had to bathe with cold water, and staff confirmed the administration was aware of the issue. Temperature logs showed a drop in water temperature, and the facility was in the process of addressing the problem. During this period, residents were transferred to other units for showers, and water was warmed for bed baths as needed.
Failure to Review and Revise Care Plans After Assessments
Penalty
Summary
Facility staff failed to ensure that resident care plans were reviewed and revised by the interdisciplinary team after each assessment, including both comprehensive and quarterly review assessments. For one resident, there was no documentation verifying participation in care plan meetings, and the Director of Social Work was unable to provide proof that required meetings were conducted or that invitations were consistently sent. Another resident reported concerns about not having quarterly care plan meetings, and documentation could only be provided for a single meeting within the required timeframe. Additionally, quarterly screenings for rehabilitation services were not consistently performed as expected. For a third resident, after discharge from physical and occupational therapy for contracture management, the recommended nursing interventions were not entered into the electronic medical record, and the care plan was not updated to reflect these recommendations. The Director of Rehabilitation and the occupational therapist were unable to confirm when the last quarterly evaluation was conducted, and orders for nursing to follow the discharge recommendations were never placed. These findings demonstrate a pattern of incomplete care plan reviews, lack of interdisciplinary team involvement, and insufficient documentation following assessments and therapy discharges.
Failure to Follow Physician Orders and Maintain Professional Documentation Standards
Penalty
Summary
The facility failed to implement and document physician-ordered wound and skin care for a resident admitted after a surgical amputation and with an identified pressure ulcer. The resident was admitted with 22 staples to the amputated toe site and a heel wound, but no wound care orders were entered for either site during the resident's month-long stay. Although the wound care nurse documented weekly measurements and care for the heel, there was no formal order or documentation system in place for staff to consistently sign off on completed treatments. The Director of Nursing was unaware of these omissions until notified by surveyors. Another resident with a history of cerebrovascular disease had a physician's order for daily application and removal of Thrombo-Embolic Deterrent Stockings (TEDS), but was repeatedly observed not wearing them. There was no documentation of refusal or physician notification regarding the lack of TEDS application, and staff could not provide supporting documentation for these omissions. Additionally, a resident with an order for clonidine to be administered via PEG tube with specific blood pressure and heart rate parameters received the medication multiple times when their systolic blood pressure was below the ordered threshold, without documentation that the physician was notified of these out-of-range readings. The facility also failed to maintain professional standards in documenting showers for a resident with an order for showers on specific days. On several occasions, the treatment administration record indicated that the shower was not given, but no reason was documented for the omission. There were also days when the shower order was not documented at all. The Director of Nursing confirmed that staff were expected to document the reason for missed showers and to document all care provided according to orders.
Failure to Maintain Resident Dignity During Care Activities
Penalty
Summary
The facility failed to ensure that residents were treated with dignity during daily care activities. In one instance, a CNA was observed feeding a resident while standing over them at the bedside, rather than sitting at the resident's level. The CNA stated that the chair available was too wide to fit in the area and was unaware that standing while feeding was a dignity issue. Despite being informed of the concern, the CNA continued to stand while feeding the resident. In another case, a resident with a history of muscle spasm, congestive heart failure, fluid overload, and a left leg below-the-knee amputation reported being left on a bedside commode for two hours during the night before receiving assistance back to bed. The resident expressed feeling disrespected and described the treatment as inhuman. The incident was not previously known to the facility's administration or DON until brought up during the survey.
Delay in Providing Medical Records to Resident's Legal Representative
Penalty
Summary
The facility failed to provide timely access to a resident's medical records to the resident's established legal representative, as required. A request for medical records was made by the resident's Power of Attorney (POA), with all necessary authorization paperwork already on file and accepted by the facility. Despite this, the process for releasing records involved additional review by the legal department, which was not explained as necessary given the existing POA documentation. The business office manager could not provide a clear turnaround time for record requests and acknowledged that the process could cause delays. Documentation showed that the request for records was made on 6/11/24, but the records were not provided to the POA until sometime in July 2024, resulting in a delay of at least 19 days and possibly up to 40 days. The facility's own policy stated that records should be available within 2 days after receipt of payment, but in this case, there was no financial liability attached to the request. Both staff and the complainant confirmed the significant delay, and no further documentation was provided to clarify the exact date the records were delivered.
Failure to Ensure Resident Safety and Thorough Abuse Investigations
Penalty
Summary
The facility failed to ensure resident safety and proper investigation procedures in response to allegations of staff abuse involving two residents. In the first instance, a nurse was directed to leave the facility immediately following an abuse allegation made by a resident. However, the nurse remained in the building for nearly two hours after being instructed to leave, citing the need to complete a narcotic count and hand over keys. The nurse was not escorted out, and the facility's administration acknowledged that the staff member should have been escorted to ensure resident safety. The abuse allegation was ultimately unsubstantiated, but the staff member was later terminated for insubordination. In the second instance, the facility did not conduct a thorough investigation after a resident reported to their representative that a Geriatric Nursing Assistant was rough during repositioning and turned the resident onto a side they did not want to be on. Facility documentation did not show that the specific allegation was addressed, nor did it indicate that the staff member involved was interviewed or provided a statement regarding the incident. When asked for further documentation, the facility administrator was unable to provide any additional evidence that the allegation was investigated as required.
Inaccurate MDS Coding for Resident Fall Event
Penalty
Summary
The facility failed to ensure the accuracy of the Minimum Data Set (MDS) assessment for one resident reviewed for accidents. Specifically, the MDS Quarterly Assessment coded the resident as having experienced a fall with injury, despite documentation in nurse notes and pain assessments indicating that the resident had no pain and no physical injury following the fall. The facility's matrix also incorrectly indicated a fall with injury for this resident. Further review of the care plan and progress notes confirmed that the resident did not report pain and had no injury on multiple assessments following the incident. An x-ray ordered after the resident reported arm pain was negative for fracture. Interviews with the Nursing Home Administrator and the MDS Coordinator confirmed that the MDS was coded incorrectly, as the resident did not have a fall with injury. The MDS Coordinator acknowledged that the assessment was inaccurate, as pain and injury were not present according to the documentation. The deficiency was discussed with the administration team during the exit conference.
Failure to Develop Care Plan for Bowel and Bladder Incontinence
Penalty
Summary
A review of medical records for a resident revealed that the individual was incontinent of both bowel and bladder. Despite this, there was no evidence that a care plan had been developed to address the resident's bowel and bladder incontinence. The Minimum Data Set (MDS) confirmed that the resident was always incontinent of both bowel and bladder, and this condition had been present since admission. Interviews with facility staff indicated that the interdisciplinary team is responsible for reviewing each resident's plan of care quarterly and annually, with the nurse unit manager specifically tasked with ensuring the nursing portion is current. However, upon review, both the surveyor and the nurse unit manager acknowledged that a care plan for incontinence was missing for this resident, confirming the deficiency.
Failure to Implement Contracture Management Orders for Resident with Limited ROM
Penalty
Summary
A deficiency was identified when a resident with a history of morbid obesity, protein-calorie malnutrition, and a PEG tube, who was bed-bound and had limited range of motion (ROM) in all extremities, did not receive appropriate ongoing contracture management. The resident had previously received Physical Therapy (PT) and Occupational Therapy (OT) services for contracture management, with OT goals to prevent further contractures. Upon discharge from therapy, recommendations were made for nursing staff to apply splints daily and remove them at night. However, there was no evidence that these recommendations were entered as orders in the electronic medical record (EMR), nor were they reflected in the resident's care plan. During the survey, staff interviews revealed that neither the Director of Rehab nor the Occupational Therapist could confirm when the last quarterly evaluation was completed for the resident, and they were initially unable to clarify who was responsible for entering therapy discharge orders into the EMR. It was later confirmed that the orders for nursing to implement the OT discharge recommendations were never placed, resulting in a lack of follow-through on the prescribed contracture management interventions for the resident.
Delayed Infectious Disease Consultation and Documentation Failure for Resident with Worsening Wound
Penalty
Summary
The facility failed to ensure the timely scheduling of an Infectious Disease (ID) consultation for a resident admitted with multiple comorbidities, including an infection following a fasciotomy and a urinary tract infection. Upon admission, the resident had a wound vac at the surgical site, and over the first two months, the sacral wound worsened, with increasing size and persistent infection despite ongoing IV antibiotics. Elevated C-reactive protein (CRP) levels were documented, indicating severe inflammation, and the need for an ID consult was repeatedly noted in both physician and nursing progress notes. The resident's responsible party was kept informed of the need for the consult, and the wound continued to be monitored and cultured as infection persisted. Despite multiple documented requests and orders for an ID consultation starting on 8/19, the consult was not completed until 28 days later. There was no documentation of the actual ID consultation report in the resident's electronic health record, and the Director of Nursing (DON) was unable to provide this documentation when requested. The delay in obtaining the required specialist consultation and the lack of documentation occurred prior to the resident's hospital transfer and subsequent admission with a diagnosis of sepsis.
Incomplete and Inaccurate Medical Record Documentation
Penalty
Summary
The facility failed to ensure that medical records were complete and accurately documented for two residents. For one resident, there was a discrepancy between the active physician order for showers, which specified Tuesdays and Fridays, and the kardex task, which indicated Mondays and Thursdays. The Director of Nursing confirmed that the kardex should reflect the physician's order, but this was not the case. For another resident who was bed-bound with limited range of motion and had received PT and OT services for contracture management, the discharge recommendations from OT included daily application and nightly removal of splints by nursing staff. However, there were no orders placed in the medical record for nursing to carry out these recommendations, nor were the recommendations reflected in the care plan. Interviews with the Director of Rehab and OT staff revealed that the orders were never entered into the EMR, and there was confusion regarding responsibility for entering such orders.
Failure to Maintain Safe and Functional Kitchen Equipment
Penalty
Summary
Surveyors identified that essential kitchen equipment was not maintained in safe working order. During multiple observations, refrigerator #3 in the back room was found to be operating at 51°F, with food items inside that were warm to the touch, indicating improper cold storage. Refrigerator #4 was unplugged and being used to store dry goods, despite being labeled as a refrigerator. The facility dietary manager was unaware of the malfunctioning refrigerator, and temperature logs did not reflect the actual temperature observed. Additionally, the kitchen's ice machine was not operational, and staff relied on other units to provide ice to residents. Work orders for repairs were pending at the time of the survey. Further investigation revealed that the main dining room ice machine was also not functioning. An anonymous complaint indicated that staff often told residents the ice machine was broken when they requested ice water. The Director of Maintenance was unaware of the issue with the main dining room ice machine, and direct observation confirmed it was not dispensing ice. These findings demonstrate a failure to ensure that essential kitchen equipment was kept in safe and functional condition, as required.
Improper Mattress Fit on Bed Frame
Penalty
Summary
During a random observation on the Annapolis Unit, a resident was found in bed with a mattress that extended approximately 8 inches beyond the right side of the bed frame. This observation was confirmed by both the surveyor and the Director of Maintenance, who noted that the mattress was too large for the bed frame. The report documents that the facility failed to ensure the mattress properly fit the bed frame, as required for resident safety. No additional information about the resident's medical history or condition at the time of the deficiency was provided in the report.
Failure to Ensure Resident Access to Call Light
Penalty
Summary
Facility staff failed to ensure that a resident had access to their call light, as observed during a survey. On 04/16/25, a surveyor found the resident resting in bed without the call light within reach; the device was discovered wrapped around the arm of a chair near the bed, out of the resident's reach. When questioned, an LPN confirmed that staff are expected to keep the call device accessible to residents before leaving the room. Review of the resident's medical records showed explicit instructions to keep the call light within reach at all times. The deficiency was reported to the facility administrator.
Failure to Send Comprehensive Care Plan Goals During Resident Transfer
Penalty
Summary
The facility failed to include the resident's comprehensive care plan goals in the required documentation during a transfer to the hospital. Record review showed that one resident was hospitalized, and interviews with both a Registered Nurse/Unit Supervisor and a Licensed Practical Nurse confirmed that the care plan goals were not sent with the resident upon transfer. The surveyor discussed this concern with the Director of Nursing.
Failure to Provide Written Notification of Resident Transfer
Penalty
Summary
Facility staff failed to provide written notification of transfer to a resident and their responsible representative when the resident was hospitalized. Record review showed that the resident was transferred to the hospital, and interviews with both a Registered Nurse/Unit Supervisor and a Licensed Practical Nurse confirmed that only verbal notification was given to the resident's representative regarding the transfer and its reasoning. There was no evidence that written notification was provided as required.
Failure to Provide Scheduled Showers and Proper Documentation for Dependent Resident
Penalty
Summary
Facility staff failed to provide scheduled showers to a resident who was dependent on staff for activities of daily living (ADLs), specifically bathing. The resident reported receiving only one shower during the month of April, despite a documented preference and physician order for showers twice weekly. Instead, the resident received daily bed baths, with no documentation explaining the substitution of bed baths for showers or any record of resident refusal. Review of the treatment administration record and geriatric nursing assistant documentation confirmed the lack of scheduled showers and absence of required documentation for missed or substituted care.
Failure to Provide Incontinence Care and Services
Penalty
Summary
Facility staff failed to provide appropriate treatment and services for a resident who was incontinent of bowel and bladder and had a stage 4 sacral pressure ulcer. Review of the resident's medical records, including treatment administration records, physician orders, and the care plan, revealed no documentation of interventions or services to address the resident's incontinence. Interviews with the Director of Social Work and the Nurse Unit Manager confirmed that there was no plan in place to manage the resident's incontinence, and both acknowledged that such a plan should have existed. The deficiency was identified during a review of the resident's chart and confirmed through staff interviews.
Failure to Ensure Timely Monitoring for Antidepressant Medication
Penalty
Summary
A review of the medical record for Resident #16 revealed an active order for Bupropion, an antidepressant, to be administered once daily starting on 3/24/2025. Despite the known need for monitoring due to potential side effects associated with antidepressant use, there was no order for antidepressant monitoring documented in the resident's medical record until 4/16/2025. An interview with the Director of Nursing confirmed that the facility's expectation is for side effect monitoring to be ordered when an antipsychotic is prescribed. This lapse resulted in a period during which the resident was receiving Bupropion without the required monitoring for side effects.
Failure to Serve Preferred Hot Beverage at Breakfast
Penalty
Summary
Surveyors determined that the facility failed to provide residents with their preferred hot beverage, specifically coffee, during breakfast as indicated on their dietary meal tickets. On the morning of the observation, the dietary food carts were delivered to the unit, but the cart containing coffee, tea, and condiments arrived later than the food trays. As a result, three residents who had coffee listed on their meal tickets did not receive coffee with their breakfast meal. The unit was staffed with only two GNAs for 32 residents, and additional staff from other departments were brought in to assist with meal delivery. The deficiency was observed during a breakfast meal service in the Arcadia unit, where seven residents required maximum assistance with feeding. Despite the presence of the unit manager, charge nurse, and medication nurse, the delay in the arrival of the beverage cart led to the omission of serving coffee to the affected residents. These findings were reviewed with the DON and the administrator later that morning.
Failure to Serve Food at Safe and Palatable Temperatures
Penalty
Summary
Surveyors observed that the facility failed to ensure food was delivered to residents at appropriate and palatable temperatures. During a kitchen tour and tray line observation, surveyors, along with the food service manager, regional food service director, and registered dietician, measured the temperatures of various food items prepared for the Garden View unit. While food items in the kitchen were within acceptable temperature ranges, delays occurred between tray preparation and service. The food cart was followed to the unit, and there was a gap between the arrival of the food and the start of tray service. When the test tray was finally served, the temperatures of hot food items had dropped significantly below the required levels, and cold beverages were above the recommended cold temperature. The regional dietary manager acknowledged that the facility did not ensure proper food temperatures at the point of service. The deficiency was identified for one out of four units, affecting a unit with 32 residents. The administrator confirmed awareness of the issue, and the findings were discussed during the exit interview. No specific resident medical history or conditions were mentioned in relation to the deficiency.
Deficient Food Storage, Equipment Maintenance, and Meal Tray Accuracy
Penalty
Summary
The facility failed to properly store food items at appropriate temperatures, maintain functional kitchen equipment, and ensure dry food items were stored in suitable containers. During a kitchen tour, a walk-in refrigerator was found at 42°F, while another refrigerator used for juice and milk was within acceptable range. However, a third refrigerator labeled 'Back Room' was found at 51°F, with its contents, including applesauce, grape jelly, soy sauce, mayonnaise, and iced tea, warm to the touch and not in compliance with food safety storage procedures. A fourth refrigerator was unplugged and used to store dry goods, such as pasta and bread, at 65°F, indicating it was not operational. Additionally, the kitchen's ice machine was not working, and the facility was relying on other units to provide ice for residents' meals. The dietary manager was unaware of the non-functional refrigerator, and temperature logs did not match actual readings. The facility also failed to ensure that residents' meal trays matched the items listed on their meal tickets. During meal service, two residents did not receive the correct items as specified: one resident was missing coffee, sugar packets, milk, and condiments, while another received skim milk instead of whole milk and was missing coffee. A geriatric nursing assistant acknowledged the discrepancies after being shown the trays and stated that it was their responsibility to verify tray accuracy. Both the administrator and director of nursing were made aware of these observations.
Inaccurate Facility Assessment for Direct Care Staffing Ratios
Penalty
Summary
The facility failed to provide an accurate and comprehensive facility-wide assessment regarding direct care staff to resident ratios. During the survey, the administrator provided a copy of the facility assessment, which was found to have been completed and reviewed by the quality assurance committee. Upon review, the assessment included a staffing template for both licensed nurses and direct care staff, separated by skilled rehab and long-term care units. When questioned, the administrator was unable to explain the staffing plan as described in the assessment and later admitted that the staffing plan documented was incorrect. The administrator then provided a hand-written staffing to resident ratio for all units, but this information did not match the ratios documented in the facility's assessment. This discrepancy between the documented staffing plan and the actual staffing ratios, as well as the administrator's inability to explain or reconcile the information, led to the determination that the facility failed to provide an accurate facility assessment for direct care staff to resident ratios.
Failure to Maintain Isolation Carts with Required PPE for EBP Residents
Penalty
Summary
Facility staff failed to maintain isolation carts with the required personal protective equipment (PPE) for residents on enhanced barrier precautions (EBP) across two of five units observed. During initial observations, EBP signs were posted on several room doors, but some rooms lacked an isolation cart entirely, while others had carts missing essential PPE such as gloves. In one instance, a resident's medication was found stored inside an isolation cart, which is not appropriate for PPE storage. These deficiencies were confirmed by an LPN during interviews, who acknowledged the missing PPE and the presence of medication in the cart. Follow-up observations revealed that isolation gowns were also missing from the carts outside certain rooms, and this issue persisted over multiple checks on the same day. The LPN again confirmed the absence of gowns when asked to review the cart. Both the administrator and the director of nursing were made aware of these observations at the time they occurred.
Incomplete Daily Nurse Staffing Postings
Penalty
Summary
Facility staff failed to ensure that daily nurse staffing postings were complete and accurate across all five units, as observed and confirmed during a survey. The surveyor found that several daily staffing sheets were missing critical information, including dates, nurse-to-resident ratios, staff titles, current dates, shift supervisor names, actual hours worked, and unit census. The staff scheduler, responsible for collecting and storing these forms, stated she was unaware that this information was required and relied on unit managers to complete the postings. These omissions were identified through record reviews and staff interviews, demonstrating a lack of compliance with daily staffing posting requirements.
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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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