Below average — CMS composite of the measures below.
The next survey window likely opens around May 2027
Estimate from public CMS data, current as of August 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Autumn Lake Healthcare At Glade Valley during CMS and state inspections, most recent first.
Food service safety standards were not followed when a cooked pork loin was found in the refrigerator with an incorrect expiration date and no cooling log, tray line temperature logs were missing required temperatures for multiple meals, and a tray line refrigerator lacked regular temperature monitoring documentation. Surveyors also observed stained coffee cups, a dishwasher that repeatedly failed to reach required temperatures, damaged kitchen surfaces, and no documentation showing regular ice machine cleaning.
Cross Contamination During Linen Processing: A laundry aide processed soiled linens with PPE, then doffed her washable gown, hung it beside the sink, and went to the clean side of the laundry room to fold clean linens without performing hand hygiene. The issue was observed and discussed with the aide and the account manager, and the aide acknowledged the lapse.
Inaccurate MDS documentation was found for three residents. One resident’s OT record showed limited ROM in all extremities, but the MDS only reflected one-sided impairment. Two other residents had MDS entries for insulin, a Foley catheter, and anticoagulant use that were not supported by the MAR or provider orders, and MDS nurses confirmed the entries were recorded in error.
Physician documentation and order management were incomplete for two residents. One resident with IBS and C. diff treatment had continued Flagyl and changes in isolation status without clear provider documentation explaining the current condition or rationale for continuing the antibiotic. Another resident receiving oxygen was observed on a higher flow rate than ordered, and provider notes showed oxygen changes from 2 L/min to 4 L/min and then 3 L/min without signed and dated updated orders.
Failure to treat a resident with dignity was cited when staff entered the resident’s room without knocking or announcing themselves. An LPN and a nursing assistant both responded to the resident’s call light by entering the room without first requesting permission, and the resident reported that staff sometimes did not identify themselves when providing care. The unit manager stated staff were expected to knock and introduce themselves before entering resident rooms.
Failure to promptly notify family after a resident fall. A resident with stroke, depression, and dementia had an unwitnessed fall and later a dx of displaced fx of the right femur neck. An LPN documented that the MD and nursing supervisor were notified soon after the fall, but the family was not notified until hours later; the DON confirmed the family was not notified immediately, and the NHA acknowledged the deficient practice.
A resident with stroke, depression, and dementia was transferred to the hospital after an unwitnessed fall, but the facility did not have evidence of a written notice of transfer provided to the resident or the RP. The chart showed the resident was sent out by ambulance for pain after the fall, and while staff documented that the family was aware and prepared, the DON could only produce a bed hold notice and no transfer notice.
Late completion of required MDS assessments affected 3 residents. An annual MDS and two admission MDS assessments were completed after the required timeframes, with MDS nurses confirming the assessments were late in multiple sections.
A resident’s Significant Change in Status MDS was completed late after hospice admission. Record review showed the resident entered hospice and the MDS was not finished within the required 14-day timeframe. Two MDS nurses confirmed the assessment was completed late.
A resident with developmental/intellectual disability and no adequate decision-making capacity had an Assist Bar/Side Rail assessment that was initially documented without risks, benefits, or informed consent being discussed. Later, the EHR was changed to show those items were completed, while the effective date/time still reflected the admission evening, and the paper chart showed consent was actually obtained by phone the next day with the responsible representative. The DON and UM acknowledged the documentation concerns and that the UM was not present at admission when the changes were made.
Failure to provide and document showers for residents needing ADL assistance. One bedbound resident with total self-care dependence was observed with matted, greasy hair and reported receiving only bed baths, while the ADL record showed incomplete bath documentation and no evidence of baths on unscheduled days. Another resident with weakness, wasting, and palliative care needs reported only one shower since admission; the shower record showed N/A and refusal entries, but no progress notes showing nurse follow-up or validation of refusals, despite the resident needing staff assistance with showering.
A resident with heart failure, AFib, and anticoagulant use had a hemoglobin of 8.6 g/dL documented in the chart, but the abnormal result was not acknowledged in the MD note and no follow-up CBC order was found. In a separate issue, a resident with GAD had lorazepam 0.5 mg BID discontinued by verbal order from a non-psych NP without documentation for the change, without evidence the resident or representative were informed, and then the med was later reordered without charted explanation.
Failure to provide ordered palm guard for contracture: A resident with severe ROM impairment and left-hand contracture was observed with fingers bent into the palm and no device in place, despite a care plan and OT eval noting use of a palm guard to manage contractures. Staff stated therapy had recommended the palm guard to prevent further worsening of ROM, but the order appeared to have been dropped during a hospital transfer.
Failure to Obtain Informed Consent for Side Rail Use: A resident with intellectual disability and developmental delay who lacked decision-making capacity had quarter side rails placed on the bed without documented informed consent at the time of initiation. The initial side rail assessment and admit/readmit screener did not show that risks, benefits, or consent were completed, and the resident's representative was not documented as being present during admission. Later charting was changed to show consent, while staff interviews and observations showed side rails were commonly already in place on beds and were not always removed when not needed.
A resident received opioid pain meds outside the ordered PRN parameters. The MAR showed oxycodone and tramadol were administered when pain scores were below the ordered thresholds, and nursing documentation also noted non-pharmacological interventions as effective at the time oxycodone was given. The DON was informed of the concern, and an RN manager later confirmed awareness and had no additional documentation.
A facility failed to consistently monitor and document medication refrigerator temperatures in one unit medication room. During survey observation, an LPN and the surveyor reviewed the refrigerator log and found multiple missing temperature entries for the month, while the LPN stated the checks were done on night shift but did not explain the missing documentation or how proper storage conditions were verified.
The facility failed to have a qualified food service director. Staff in charge of the kitchen was listed as the FSD, but she only had ServSafe certification and reported she was still training to become a Certified Dietary Manager. The RD reported working only 3 days a week and said she only supervised the kitchen when asked, while the facility could not provide documentation showing the RD served as the required full-time qualified dietetic service supervisor.
A resident’s dinner tray did not match the posted menu or the resident’s meal choice. The tray included egg salad sandwiches, broccoli, and potato salad, but no chips, peach parfait, or milk, even though those items were listed or expected. The NHA reviewed the tray and confirmed the resident should have received the dessert, chips, and milk.
A resident receiving daily Sertraline for depression had psychiatric NP notes that failed to list the antidepressant in the active med list or document it in the A/P during two evaluations for anxiety, depression, and adjustment issues. The NP later acknowledged the omission after reviewing the resident’s current meds, and the DON was informed of the concern.
Staff failed to protect a resident from verbal abuse when a GNA engaged in a verbal argument with the resident during which foul and abusive language was exchanged. The facility’s investigation, based on administrative record review and staff interviews, substantiated that the interaction met the definition of verbal abuse, involving willful use of disparaging or derogatory language within the resident’s hearing. The DON acknowledged the incident as verbal abuse and reported that the resident had a history of berating behaviors toward staff, which preceded the GNA’s reaction.
Staff failed to immediately report an alleged verbal altercation with profane language between a GNA and a resident to facility administration and the state agency. A GNA involved in the incident did not report the altercation, and the GNA who witnessed it also did not notify administration. The allegation was only brought forward when the resident later requested to speak with a manager and reported the abuse to an LPN unit manager and an LPN shift supervisor, resulting in delayed notification to the NHA and delayed submission of the self-report to the state survey agency.
Facility staff failed to thoroughly investigate an abuse allegation after a resident, who could not independently hold a urinal, reported that a GNA intentionally poured urine onto their lap and then flicked urine into their face following a dispute over urinal positioning. The GNA’s statement and the facility’s investigation focused on an accidental spill and the resident throwing the urinal, and the GNA denied intentionally pouring urine on the resident. However, there was no documentation that the GNA was specifically questioned about throwing or flicking urine into the resident’s face, and the written investigation did not address this detailed allegation, despite consistent reports from the resident and the resident’s family member that urine had been thrown into the resident’s face.
A resident who was cognitively intact but physically dependent on staff for bathing and other ADLs did not consistently receive ordered showers, and frequent refusals were not properly documented or addressed. Physician orders required twice-weekly showers with all refusals documented in progress notes, yet multiple scheduled showers were missed, refusals lacked explanatory progress notes, and there was no evidence the physician or the resident’s representative were notified of the ongoing refusals. The ADL care plan was not updated to reflect the resident’s repeated refusal of showers or to include specific goals and interventions to address bathing needs and preferences.
A resident with right-sided hemiplegia and significant mobility limitations, who required substantial assistance for transfers and had a documented care plan intervention for gait belt use, experienced three witnessed falls during transfers while staff failed to consistently use a gait belt. In one fall, the resident’s knees buckled during a bed-to-wheelchair transfer and the GNA reported not using a gait belt, resulting in abrasions to both knees and the left elbow. Another fall occurred during a toilet-to-chair transfer, with no documentation that a gait belt was used, no timely vital signs, and no evidence of physician or representative notification at the time. Therapy staff and the resident reported that a gait belt had been available and that staff were expected to use it for residents needing assistance with transfers, but the resident stated staff sometimes did not use it and had to be reminded.
The facility did not conduct thorough investigations into multiple abuse allegations, with missing documentation, incomplete interviews, and lack of required assessments. In several cases, staff failed to document risk management steps, provide post-incident training, or promptly interview witnesses, resulting in incomplete investigations that did not meet facility standards.
The facility did not report an allegation of missing money made by a second resident to the state authority, despite having reported a similar allegation from the first resident. The administrator acknowledged the omission, which was based on a family member's uncertainty about whether the resident had money in the room.
A resident admitted for short-term rehab with complex medical needs, including unstageable sacral wounds and a history of depression and pain, did not have a baseline care plan developed or implemented within 48 hours of admission. The only care plan documentation was created after discharge and was incomplete, with facility leadership confirming the absence of a care plan during the resident's stay.
A resident admitted for short-term rehabilitation with complex medical needs, including unstageable sacral wounds and a history of depression and pain, did not receive a comprehensive care plan. Despite completion of the MDS assessment, only an incomplete, canceled care plan was found in the record, and facility leadership confirmed that no comprehensive care plan was developed during the resident's stay.
A resident developed a right-hand contracture that was identified by nursing and confirmed by therapy, but the care plan was not updated to reflect this change in condition. Despite IDT care plan meetings and the DON's acknowledgment of responsibility for care plan updates, documentation did not show that the contracture was addressed in the care plan.
The facility failed to ensure that dependent residents received required showers and incontinence care, as evidenced by multiple instances of poor hygiene, missing documentation of care, and lack of records for resident refusals. Reviews of medical records and care plans showed that several shifts lacked documentation of ADL assistance, and staff interviews confirmed these deficiencies.
A resident with multiple chronic conditions did not receive several prescribed medications and treatments, including psychotropic drugs, pain management, wound care, oxygen therapy, and required monitoring. Review of the MAR and TAR confirmed that these omissions occurred on multiple occasions, and the DON verified that the care was not provided as ordered.
Three residents did not receive consistent or timely pressure ulcer care, including missed wound treatments and failure to implement recommended interventions. In each case, documentation showed that wound care orders were not followed or completed as directed, and staff confirmed that required treatments were missed or not documented.
A review of employee files and staff interviews revealed that the facility did not conduct or document annual skill competency assessments for nursing staff. Leadership acknowledged that the process for tracking staff training and competencies was not functioning, and required records were not maintained.
The facility did not ensure or track that all staff, including agency personnel, completed required annual training on dementia care, abuse, neglect, and exploitation. Multiple employee files lacked documentation of this training, and a staff member involved in an abuse allegation had not received the necessary education. Leadership interviews confirmed gaps in the training process and tracking system.
A resident's privacy was not maintained during a dressing change when their frontal private area was exposed due to a partially drawn privacy curtain. Multiple staff members were present, and another GNA entered the room to collect meal trays, walking past the exposed resident despite being informed that personal care was in progress. Staff acknowledged the failure to ensure the resident's dignity and privacy.
Surveyors found that the facility did not have an effective process to ensure residents received their requested alternative menu items. A resident's meal tray did not include the requested sandwich, gravy, or hot tea, and interviews with other residents revealed ongoing issues with the alternative meal request system. The Certified Dietary Manager Consultant confirmed the process was ineffective.
The facility did not provide required Medicare beneficiary protection notices to two residents who were discharged from Medicare Part A services but remained in the facility for non-skilled care. In both cases, either the NOMNC, the SNFABN, or both were not properly issued or documented, and staff were unaware of the need to mail notices when not hand-delivered.
A resident reported black and brown substances in the cracks of a shower room floor. Upon inspection with the nurse unit manager, cracks and visible spots were found in two of three shower stalls. The Maintenance Director was aware of the issue and noted that only the wall tiles had been replaced, with unsuccessful attempts to fix the floor. The NHA confirmed the presence of the substance during a later observation.
The facility did not specify a Grievance Official or provide contact information in its grievance policy, and failed to issue written responses to grievances. Instead, only verbal follow-up was given, and documentation of grievance investigations lacked details on completion and communication to residents.
Surveyors identified that several MDS assessments were inaccurately recorded, including cases where two residents with documented upper or lower extremity range of motion (ROM) impairments had conflicting information between therapy evaluations and MDS entries. Another resident was incorrectly coded as having functional limitations in the MDS despite therapy notes showing full ROM, and a discharged resident was wrongly documented as sent to a hospital instead of home. These errors were confirmed by staff interviews and record reviews.
A resident who was initially certified to require less than 30 days of care did not have a follow-up PASSAR screening completed after remaining in the facility beyond 40 days. The required documentation was not available in the medical record, and the administrator confirmed the absence of the follow-up screening.
Surveyors found that the facility did not ensure therapy recommendations were communicated to nursing staff or implemented for two residents, resulting in the lack of prescribed devices such as an ankle brace and palm guard. Additionally, a resident requiring adaptive utensils for meals did not receive them as ordered, and the care plan lacked documentation of this intervention. These deficiencies were confirmed by staff interviews and observations.
A resident with a Foley catheter was repeatedly observed with the drainage bag placed on their lap above bladder level, contrary to facility policy and standard infection control practices, as confirmed by staff and record review.
Two residents received oxygen therapy without proper adherence to physician orders: one received oxygen without a current order or documentation, and another received a higher flow rate than prescribed. These deficiencies were confirmed through observations, record reviews, and staff interviews.
Staff did not complete required annual performance reviews or provide the full twelve hours of in-service education for two GNAs. The DON confirmed evaluations were missing from files, and the HR director acknowledged only 9.4 hours of training were documented, with no evidence for the remaining hours.
A review of a controlled substance logbook revealed that required signatures from two licensed staff at shift changes were missing or incomplete for one medication cart. The logbook showed entries out of order, some with only one signature, and some with none, despite staff being responsible for signing when taking over the medication cart. The DON confirmed the documentation issues and noted that shared responsibility for the cart may have contributed to the problem.
A resident's medication regimen review identified irregularities by the consultant pharmacist, but the required documentation showing that the attending physician reviewed and addressed these recommendations was missing from the medical record. Staff confirmed the report was not initially in the chart, and when found, lacked evidence of physician review.
Surveyors found expired medications and inhalers without open dates in medication storage rooms and carts. Staff confirmed expired aspirin bottles and an expired inhaler for a resident, as well as multiple opened inhalers for another resident without proper labeling or documentation of use. Nursing staff were unable to identify which inhaler was in use or when some were opened, and the DON confirmed the findings during interviews.
A resident reported that meals were often late and not palatable in taste or temperature. Surveyors observed that breakfast trays were delayed in delivery, with some trays remaining in the cart for extended periods. A test tray was found to be below the facility's minimum temperature standard when served, confirming that food was not provided at a palatable temperature.
Nursing staff inaccurately documented that a resident used an adaptive device at meals over several days, despite the device not being available or used during that period. Observation and interviews with the resident, a family member, and therapy staff confirmed the device was not present or applied as ordered.
Food Service Safety and Sanitation Deficiencies
Penalty
Summary
The facility failed to prepare, distribute, and serve food in accordance with professional standards for food service safety. During the kitchen tour, surveyors observed a metal container of cooked pork loin in the walk-in refrigerator with plastic wrap marked with an expiration date of 4/25. The Food Service Director stated the pork loin had been cooked recently and was being used to cut into pork chops, but the item was removed from the refrigerator and there was no cooling log documentation for that pork loin. The District Manager later reported that a fill-in cook had worked that Saturday. Review of the facility’s tray line temperature logs for May 2026 showed missing documentation for temperatures of pureed or mechanical soft entrees for multiple meals, including several lunch and dinner meals. The logs also did not document temperatures for breakfast or lunch on two Saturdays, and one dinner log listed hotdogs, hamburgers, and baked beans without recording temperatures for any of those items. The District Manager was questioned about the missing temperatures for the pureed items. During lunch service in the main dining room, surveyors observed a refrigerator in the tray line area containing a wet cardboard box of cream cheese packets sitting on a dirty washcloth, and several pudding cups labeled for the day of observation. Although a thermometer was present and the temperature was acceptable at the time, no regular temperature monitoring documentation was found for that refrigerator beyond a January 2026 log. Additional observations found stained coffee cups on a food delivery cart, a dishwasher that repeatedly failed to reach the required rinse temperature of 180 degrees and later had a wash temperature of only 145 degrees before rising, damage and holes in kitchen walls and ceiling areas, and no documentation showing regular cleaning of the ice machine bins for April or May 2026. Staff and management gave conflicting accounts about whether maintenance or dietary was responsible for ice machine cleaning, and no cleaning documentation was produced during the survey.
Cross Contamination During Linen Processing
Penalty
Summary
The facility failed to ensure linens were processed in a manner that prevents cross contamination. During observation on 5/28/26 at 12:20 PM, the laundry aide donned appropriate PPE while sorting and loading soiled linens into the washer, but after doffing a washable gown and hanging it on a hook beside the sink, she went to the clean side of the laundry room and began folding clean linens. At 12:40 PM, she was brought back to the soiled area, and the observation that she had not performed hand hygiene before entering the clean side and folding clean linens was discussed with her and the account manager. The laundry aide acknowledged the issue and washed her hands.
Inaccurate MDS Documentation
Penalty
Summary
The facility failed to ensure that Minimum Data Set (MDS) assessments were accurately documented for 3 residents reviewed for resident assessment. For one resident, the medical record included an OT evaluation and plan of treatment noting limited ROM in all extremities, but the MDS recorded one-sided impairment in upper- and lower-extremity ROM. Staff interviews confirmed that the OT documentation showed impairment affecting both sides of the resident’s upper and lower extremities and that the MDS should have reflected impairment across all extremities. For two other residents, the MDS assessments documented services and treatments that were not supported by the records. One resident’s MDS recorded an indwelling Foley catheter and an insulin injection during the assessment observation period, but the MAR, treatment record, and provider orders showed no insulin use and no Foley catheter during that period. Another resident’s MDS documented anticoagulant use during the observation period, but the MAR and order summary showed no anticoagulant administration or provider order during that time. MDS nurses confirmed that these entries were recorded in error.
Physician Documentation and Order Updates Not Completed for C. diff Treatment and Oxygen Therapy
Penalty
Summary
The facility failed to ensure that a physician documented the resident’s current health status and wrote, signed, and dated new orders during required visits for two residents. For one resident with irritable bowel syndrome and treatment for C. diff, the record showed an active metronidazole order for C. diff colitis after the resident had been moved off contact precautions when lab results indicated colonization rather than active infection. Multiple provider notes continued to reference the resident as positive for C. diff and continuing Flagyl, but the record did not contain documentation explaining the rationale for continuing the antibiotic after the change in status. For that same resident, the Infection Preventionist stated the resident was initially positive for C. diff, placed in a private room on contact isolation, and started on antibiotics, then later found to be colonized and removed from precautions. She also stated the medical provider must have decided to continue the antibiotic treatment, but there was no documentation showing the medical director discussed the decision with other providers or documented the resident’s current condition. The DON acknowledged that multiple medical providers had failed to document the resident’s current health status and stated that addendums or clarifying notes were needed to reflect the resident’s status. For the second resident, who was newly admitted and receiving oxygen, the resident was observed on oxygen at 3 L/min while the current order specified 2 L/min and did not allow titration. Nursing staff confirmed the resident was receiving oxygen above the ordered rate, and the DON later reported that a provider had ordered oxygen increased to 3 L/min after a low O2 saturation episode during rehab, but the orders and care plan were not updated. The record also showed earlier provider notes documenting oxygen increases to 4 L/min and then 3 L/min, yet the providers did not sign and date new orders when the oxygen administration changed.
Failure to Knock and Announce Before Entering a Resident’s Room
Penalty
Summary
The facility failed to treat a resident with respect and dignity by not consistently knocking and requesting permission before entering the resident’s room. During an interview, the resident stated that staff sometimes failed to tell residents their names when entering rooms to provide care, even when residents requested it. While the resident had activated the call light, an LPN entered the room in response without knocking or asking permission before entering. On another observation, a nursing assistant entered the resident’s room to answer the call bell without knocking or announcing herself. When questioned, the nursing assistant said she had been in the room earlier and did not need to knock again. The unit manager stated that staff were expected to knock on residents’ doors and introduce themselves before entering residents’ rooms.
Failure to Promptly Notify Family After Resident Fall
Penalty
Summary
The facility failed to notify residents' representatives when a resident's status changed, as identified in 2 related complaints involving one resident. Resident #125, an [AGE]-year-old admitted in October 2025 with diagnoses including cerebral infarction, depression, and dementia, later had a new diagnosis of displaced fracture of the base of the neck of the right femur added on 2/02/26. Complaint review and record review showed the resident had an unwitnessed fall on 1/23/26 at approximately 1:45 AM. A Change in Condition form completed by an LPN documented that the resident was found on the floor and that the physician was notified at 3:13 AM, the nursing supervisor at 3:15 AM, and the resident's family at 7:00 AM. During interview, the DON confirmed that the resident's family was not notified immediately after the fall occurred, and the NHA later acknowledged the deficient practice.
Failure to Provide Written Transfer Notice
Penalty
Summary
The facility failed to provide a written notice of transfer to the resident’s representative when Resident #125 was transferred to the hospital after an unwitnessed fall. Resident #125 was an [AGE]-year-old resident admitted in October 2025 with diagnoses including cerebral infarction (stroke), depression, and dementia, and a displaced fracture of the base of the neck of the right femur was added to the diagnosis list on 2/02/26. Review of the record showed that after the fall on 1/23/26 at approximately 1:45 AM, a nurse documented that the resident was transferred to the hospital by ambulance at 9:52 AM for pain status post fall, with staff monitoring the resident until EMS arrived and the family aware and prepared for transfer. However, review of the electronic and paper records did not reveal any written notice of transfer to the resident or the resident’s representative. The DON later produced evidence of a bed hold notice, but no evidence of a notice of transfer, and the NHA acknowledged the deficient practice.
Late Completion of Required MDS Assessments
Penalty
Summary
The facility failed to complete comprehensive MDS assessments within required regulatory time frames for 3 of 6 residents reviewed for Resident Assessment. Record review and staff interviews showed that Resident #42’s annual MDS was completed after the ARD and signed late in multiple sections, with the annual assessment due within 366 days of the prior comprehensive assessment but not completed on time. Staff #31 and #32, both MDS nurses, confirmed that the annual MDS for Resident #42 was completed late. The record review also showed that Resident #5’s admission MDS was completed 19 days after admission and signed late in sections Z0500B and V0200B2, making it 5 days late. For Resident #26, the admission MDS was completed and signed after the required 14-day timeframe, with section Z0500B completed 22 days after admission and section V0200B2 completed 9 days late. Staff #31 and #32 confirmed during interview that Resident #26’s admission MDS was due within 14 days of admission and was completed late.
Late Significant Change in Status MDS Assessment After Hospice Admission
Penalty
Summary
The facility failed to complete a Significant Change in Status MDS assessment within 14 days of a resident’s admission to hospice care. Record review showed an attending provider’s order for a hospice care consultation for Resident #8, and further review confirmed that the resident was admitted to hospice care effective 5/7/26. The Significant Change in Status MDS assessment for Resident #8 was completed and signed in sections Z0500B and V0200B2 on 5/25/26, which was 18 days after hospice admission and 4 days late. During interview, both MDS nurses confirmed that the resident’s Significant Change in Status MDS assessment was completed late.
Altered Side Rail Assessment Documentation
Penalty
Summary
The facility failed to ensure nursing staff maintained professional standards in documentation of assessments related to side rail use for one resident with a developmental/intellectual disability and lacking adequate decision-making capacity. The resident was admitted in the evening, and an Assist Bar/Side Rail evaluation was completed with an effective date and time of 5/13/26 at 8:50 PM and later locked at 2:36 AM on 5/14/26. In the original electronic record, the sections for discussing potential risks, benefits, and obtaining informed consent were marked No, indicating those items were not documented as completed at that time. During survey review, the Director of Nursing acknowledged concerns with the assessment. The paper chart contained a Consent for Use of Bed Rails signed by the Unit Nurse Manager and indicating consent was obtained by phone with the resident’s responsible representative on 5/14/26. When the electronic assessment was reviewed again later the same day, it had been changed to show that risks and benefits were discussed and informed consent was obtained, with the signature changed to the Unit Nurse Manager and a signature date of 5/29/26, while the effective date and time remained 5/13/26 at 8:50 PM. The Unit Nurse Manager later confirmed she was not present on the evening of admission and had not spoken with the nurse before the changes were made to the assessment.
Failure to Provide and Document Showers for Residents Needing ADL Assistance
Penalty
Summary
The facility failed to ensure that residents who required assistance with ADLs received showers. Resident #85 was observed with matted, greasy hair and stated that he/she had only received bed baths. The resident’s MDS indicated he/she did not walk, was bedbound, and relied on staff for all self-care needs. February 2026 ADL documentation showed the resident was scheduled for bed baths on Wednesdays and Sunday evenings, but the record reflected only 3 bed baths, 2 entries marked N/A, 1 refusal, and 2 blank days. Staff later stated the resident had been scheduled for bed baths instead of showers per preference, but the earlier review did not show a bed bath on any day when one was not scheduled. Resident #8, admitted with diagnoses including muscle weakness, muscle wasting and atrophy, and encounter for palliative care, stated that only one shower had been provided since admission. The shower task record for the prior 30 days showed a preferred schedule of Tuesday and Friday evenings, with entries of N/A, refusal, and one shower documented, but no other dates/entries found. A nurse confirmed the documentation and stated there were no progress notes showing that refusals or N/A entries were reported to the nurse by nursing aides. The resident’s assessment indicated the resident needed setup or cleanup assistance to complete showering, and the DON acknowledged that aides should not document N/A and that nurses were expected to make a second attempt to offer showers, but there was no documentation that nurses validated the refusals.
Unaddressed abnormal hemoglobin and interrupted lorazepam orders
Penalty
Summary
The facility failed to identify and follow up on a significant abnormal lab value for a resident admitted with heart failure, atrial fibrillation, and long-term anticoagulant use. The resident had a hemoglobin level of 8.6 g/dL on 8/04/25, which was documented in the medical record as moderate anemia, but there was no evidence of follow-up CBC orders after that result. A physician progress note dated 11/23/25 included the hemoglobin value in the laboratory data, but the narrative portion did not acknowledge the abnormal result or address it in any way. The deficiency was identified during review of a complaint involving the resident’s urgent transfer to the hospital on 2/01/26. During the survey review, the resident’s record was examined on 6/01/26 and no evidence was found that the low hemoglobin had been recognized or acted upon. The DON acknowledged the finding during interview, and the NHA also acknowledged the deficient practice. The facility also failed to keep psychiatric medication orders active in the absence of documentation supporting a dose reduction plan. A resident with generalized anxiety disorder was receiving lorazepam 0.5 mg twice daily, but the psychiatric NP note did not document any plan to reduce the dose. The lorazepam order was discontinued by verbal order from a non-psychiatric NP, with no documentation explaining why it was stopped or that the resident or representative were informed. The medication was later reordered by a physician, but the record did not show that the physician saw the resident on that date or that there was documentation explaining why the medication was restarted.
Failure to Provide Ordered Palm Guard for Contracture
Penalty
Summary
The facility failed to ensure that a resident with limited range of motion received treatment and services to prevent further decline in ROM. During an observation on 5/26/26 at 11:29 AM, Resident #106’s fingers were bent at the knuckles and pressed into the left palm, and the resident was unable to straighten them. No device was available at that time. A later observation on 5/27/26 at 1:57 PM showed the resident sitting in the common area on the sugar loaf unit and still not wearing a device for the left-hand contracture. Record review showed a care plan initiated on 3/16/19 and revised on 10/26/22 that identified alterations in functional mobility related to contracture deformity and stated the resident would tolerate a palm guard on the left hand. An OT evaluation dated 2/24/26 documented severe impairment of ROM in both shoulders, the left elbow/forearm, wrist, and fingers, and noted that the resident was using a palm guard on the left upper extremity to manage contractures. However, surveyor observations did not show the resident wearing the device. The regional director of therapy stated that therapy had recommended the palm guard to prevent further worsening of ROM, and the unit manager stated the resident had previously been ordered to wear the palm guard, but the order appeared to have been dropped during a hospital transfer.
Failure to Obtain Informed Consent for Side Rail Use
Penalty
Summary
The facility failed to ensure informed consent was obtained before the use of quarter side rails for one resident with intellectual disability and developmental delay who lacked decision-making capacity. The resident was admitted to the facility and, on the initial side rail evaluation completed by a nurse, the sections documenting discussion of the risks and benefits of side rail use and informed consent were marked "No." The resident could not be interviewed by the surveyor, and the medical record showed the resident was rarely or never understood on the MDS assessment. The record also showed an Admit/Readmit Screener indicating bilateral side rails, but the sections for indication and consent were not checked. The facility's policy required a person-centered approach, attempted alternatives before bed rail use, and informed consent from the resident or representative before installation and use. The record did not show that the resident's responsible representative or family was present during the initial admission assessment or contacted by the admitting nurse that evening. During interviews, the Unit Nurse Manager stated that staff show the resident and family the side rails, explain the risks, and obtain a signed consent form, and if family is not present they call them later. A paper consent form was later found in the chart showing consent obtained by phone the next day, and the electronic side rail assessment was later changed to indicate risks, benefits, and informed consent had been discussed and obtained. Surveyor observations also found quarter side rails in the up position on both beds in a vacant room, and staff stated that side rails were often already on the bed and were lowered or strapped down rather than removed when not needed.
Opioid Pain Medications Given Outside Ordered Parameters
Penalty
Summary
The facility failed to ensure that pain medications were administered within the ordered parameters for one resident reviewed for unnecessary medications. The resident had an order for oxycodone 5 mg every 6 hours as needed for pain greater than 6 out of 10, but the MAR documented administration when pain was rated at 4 on 3/4/26. The record also showed an oxycodone order in effect from 3/10/26 through 3/17/26 for pain greater than 6 out of 10, yet the MAR documented doses given on 3/13 for pain rated 2, on 3/14 for pain rated 3, on 3/15 for pain rated 5, and on 3/16 for pain rated 4. The medical record further showed a current order for tramadol 50 mg every 8 hours as needed for pain greater than 7 out of 10, in effect since 3/20/26. The April MAR documented tramadol given on 4/24/26 when the resident’s pain was rated 2, and the May MAR documented tramadol given on 5/10/26 when pain was rated 0. At the same time the oxycodone was administered, nursing staff documented non-pharmacological interventions as effective. On 5/29/26, the surveyor reviewed the concern with the DON regarding administration of opioid pain medication outside the ordered parameters, and on 6/01/26 the unit nurse manager confirmed awareness of the concern and stated there was no additional documentation to provide.
Missing Documentation for Medication Refrigerator Temperatures
Penalty
Summary
The facility failed to ensure that medication refrigerator temperatures were consistently monitored and documented to verify that medications requiring refrigeration were stored within appropriate temperature ranges. This deficiency was identified in 1 of 2 medication storage refrigerators reviewed, specifically the refrigerator in the Sugarloaf Unit medication storage room. During observation on 5/28/26, the surveyor and an LPN reviewed the Sugarloaf Unit medication storage room and medication refrigerator. The refrigerator temperature log was not kept near the refrigerator, and the unit manager left to retrieve it. Review of the May 2026 log showed missing documented refrigerator temperatures on 7 dates: 5/6/26, 5/8/26, 5/10/26, 5/16/26, 5/17/26, 5/18/26, and 5/20/26. The LPN stated that daily refrigerator temperature checks were part of night-shift unit rounds and that the log was kept in a book on the unit, but did not answer when asked about the missing entries or how it was ensured that refrigerated medications were stored under appropriate conditions. The DON was made aware of the missing documentation on 5/29/26.
Qualified Food Service Director Not Established
Penalty
Summary
The facility failed to have a qualified food service director. During the initial kitchen tour, Staff #6 identified herself as the person in charge, but her name tag stated Account Manager and she reported she was only in training to become a Certified Dietary Manager and did not yet have that certification. The facility’s list of key personnel identified Staff #6 as the Food Service Director, but the credentials later provided for her were only a ServSafe certification, which does not meet the federal or state requirements for a qualified dietetic supervisor. The survey also found that the registered dietitian did not function as the full-time supervisory person required by Maryland regulations for a nursing home with more than 50 beds. The RD reported working at the facility 3 days a week and said she only acted as a kitchen supervisor when specifically asked to assist. The food service contractor and NHA stated the RD was at the facility 32 hours per week and performed sanitation audits and menu reviews, but no contract information or documentation was provided to verify the actual hours worked or to show that the RD served as the required full-time qualified dietetic service supervisor.
Menu Items Not Served as Posted
Penalty
Summary
Menus were not followed as posted for one resident. During an interview, the resident reported that choices were sometimes served differently than expected. On observation, the resident’s dinner tray contained two egg salad sandwiches, broccoli, and potato salad, but no dessert. Review of the resident’s meal change ticket showed the resident had requested the B meal, which included an egg salad sandwich with chips. The posted menu for that meal listed alternative items of egg salad sandwich, broccoli salad, and macaroni salad, and also included a chilled peach parfait and milk. The resident’s tray did not include chips, the peach parfait, or milk. When the Nursing Home Administrator reviewed the posted menu and the tray with the surveyor in the resident’s presence, the administrator confirmed the resident should have received the dessert, chips, and milk, and the resident stated a preference for the parfait and chips but not the milk.
Psychiatric Notes Omitted Current Antidepressant
Penalty
Summary
The facility failed to ensure psychiatric provider notes were accurately documented for one resident who was receiving Sertraline daily for depression. Medical record review showed the medication had been ordered since 3/2/26 and was being administered daily on the MAR. However, when the resident was seen by psychiatric NP #5 on 3/6/26 for agitation, anxiety, and depression, the note listed a diagnosis of adjustment disorder with mixed anxiety and depressed mood but did not include Sertraline or any other antidepressant in the active medication list, and the Assessment and Plan did not document that the resident was receiving or needed an antidepressant. The same issue was present in the psychiatric follow-up note from 4/24/26, which again documented evaluation for anxiety, depression, and adjustment issues and again listed adjustment disorder with mixed anxiety and depressed mood, but failed to include Sertraline or any antidepressant in the active medications or Assessment and Plan. During interview on 5/29/26, NP #5 stated she reviews the resident’s medications before seeing the resident and, when asked, identified Sertraline as a current medication, but acknowledged it was not included in either note and stated she would correct her notes. The DON was informed of the concern later that morning.
Failure to Protect a Resident From Verbal Abuse by a GNA
Penalty
Summary
Facility staff failed to protect a resident from verbal abuse by a Geriatric Nursing Assistant (GNA). Administrative record review of a facility-reported incident and staff interviews showed that on 6/19/25 at approximately 6:30 PM, there was a verbal argument between Staff #4, a GNA, and Resident #7 during which foul language was exchanged. The facility’s investigation substantiated that this interaction met the definition of verbal abuse, which includes the willful use of disparaging, derogatory, or threatening oral, written, or gestured language toward residents or within their hearing. The Director of Nursing acknowledged that the incident constituted verbal abuse and noted that Resident #7 had a history of berating behaviors toward staff and had tormented Staff #4, who then reacted, resulting in the abusive exchange. The deficiency centers on the failure of the GNA to refrain from using foul and abusive language toward the resident during the altercation, thereby not ensuring the resident remained free from verbal abuse as required.
Failure to Timely Report Alleged Verbal Abuse to Administration and State Agency
Penalty
Summary
Facility staff failed to immediately report an allegation of verbal abuse involving a resident and a GNA to facility administration and the state survey agency. According to the investigation documentation for a facility-reported incident, a verbal altercation with profane words exchanged occurred between a GNA (Staff #4) and Resident #7 at approximately 6:30 PM, and was witnessed by another GNA (Staff #2). Following this altercation, the involved GNA did not report the incident to administration, and the witnessing GNA also failed to notify facility administration of the verbal altercation. Later that same day, Resident #7 requested to speak to a manager and, during that interaction, reported alleged abuse by the GNA to an LPN Unit Manager (Staff #1) and an LPN Shift Supervisor (Staff #14). The LPN Unit Manager documented that the complaint was taken to the Nursing Home Administrator at approximately 7:15 PM, and the facility’s initial self-report indicated the administrator was notified at approximately 7:30 PM. The facility’s initial self-report was then sent to the State Survey Agency, the Office of Health Care Quality, at 9:20 PM, which was more than two hours after the alleged abuse was witnessed. This delay in reporting was attributed to the failure of the GNA involved in the altercation and the GNA who witnessed the event to promptly notify administration. During a later interview, the DON acknowledged these concerns and stated that the witnessing GNA heard the resident berate the GNA and heard raised voices but did not understand the foul language or what was being said.
Failure to Thoroughly Investigate Allegation of Staff Intentionally Throwing Urine on Resident
Penalty
Summary
Facility staff failed to conduct a thorough investigation of an allegation of abuse involving a resident who reported that a GNA intentionally poured and then flicked urine on them, including onto their face. The incident began when the resident, who was unable to hold a urinal independently due to having only one usable hand, requested assistance from an agency GNA on the night shift. According to the GNA’s written statement, she initially attempted to assist the resident to use the urinal, realized she was not wearing gloves, tried to place the urinal in the resident’s hand, and the resident pulled their arm back aggressively, causing her to drop the urinal and spill urine. The GNA reported that the resident then yelled at her and threw the urinal at her as she left the room, causing urine to splash on her, the wall, and the ceiling. The facility’s investigation documentation reflected these accounts and noted that the GNA denied intentionally pouring urine on the resident. In contrast, the resident consistently reported to the DON, a police officer, and later to surveyors that the GNA intentionally poured urine onto their lap after the resident protested that the urinal was not positioned properly, and then, after the resident threw the urinal at the wall, the GNA picked it up and flicked urine at the resident, causing urine to splash onto the resident’s face. The resident’s family member also reported to the facility that the resident said a nurse threw urine in their face. Despite these specific allegations that urine was intentionally thrown or flicked into the resident’s face, the facility’s investigation records did not show that Staff #5 was ever questioned about throwing or flicking urine at the resident’s face, nor did the written investigation address this aspect of the allegation. The final investigation documentation focused on whether urine was accidentally spilled and whether the resident threw the urinal, and concluded the allegation was inconclusive, without evidence that the specific claim of urine being thrown into the resident’s face was investigated.
Failure to Provide and Document Assisted Bathing and Shower Care for a Dependent Resident
Penalty
Summary
The deficiency involves the facility’s failure to provide appropriate assistance with activities of daily living (ADLs), specifically bathing and showers, for a resident who was dependent on staff for this care. The resident was admitted for rehabilitation following an acute hospitalization with diagnoses including bilateral lower extremity DVT, status post IVC filter placement, an unstable T9 fracture, back pain, and weakness. The admission assessment documented that the resident was cognitively intact with a BIMS score of 15 and required extensive assistance for dressing, toileting, and personal hygiene, and was totally dependent on staff for bathing with one-person physical assist. The care plan identified an ADL self-care performance deficit related to deconditioning and weakness, with an intervention that the resident required maximum assistance of one with bathing. Review of the electronic medical record, including GNA task documentation, TARs, and progress notes, showed multiple missed or refused showers that were not properly documented or followed up. In August, September, and October, the resident had physician orders for showers twice weekly on the day shift, with instructions to document all refusals with a progress note. Documentation showed the resident did not receive scheduled showers on multiple dates and was marked as refusing showers on several others. However, progress notes were either missing or incomplete for many of these refusals, and there was no documentation explaining why the resident refused showers on the majority of the dates indicated. Further review revealed that the facility did not follow the physician’s order to document all shower refusals in progress notes and did not document any notification to the physician regarding the resident’s frequent refusals. The resident’s ADL care plan was not updated to reflect the pattern of frequent shower refusals, and there were no measurable goals or interventions added to address the resident’s bathing needs and preferences in light of these refusals. Additionally, there was no documentation that the resident’s representative had been informed of the frequent refusal of showers. During an interview, the DON acknowledged that the resident never or rarely took a shower and believed this was documented, but no additional documentation was provided by the time of survey exit.
Failure to Use Gait Belt During Transfers Resulting in Multiple Falls
Penalty
Summary
The deficiency involves the facility’s failure to ensure the use of a gait belt during transfers for a resident with significant right-sided hemiplegia/hemiparesis following a stroke, resulting in three avoidable falls, one with injury. The resident was admitted in mid-October 2025 after an acute hospitalization with diagnoses including hemiplegia and hemiparesis following cerebral infarction affecting the right dominant side, generalized muscle weakness, difficulty in walking, aphasia, anxiety, and pain following cerebral infarction. The resident was documented as cognitively intact and required substantial/maximal assistance for bed mobility, sit-to-stand, transfers, and walking 10 feet. The admission assessment also documented a prior fall within the month before admission. On admission, an ADL care plan initiated on 10/15/25 documented that the resident required moderate assistance of one person with transfers and the use of a gait belt. Despite this, on 10/24/25 the resident experienced a witnessed fall in the bathroom while transferring from a wheelchair to the toilet with a GNA. The nurse’s note documented the fall and that the resident was assisted from the floor, completed toileting, and was placed in bed for examination, but no Fall Assessment was completed following this event. The following day, a care plan note documented the witnessed bathroom fall and added an intervention specifying that a gait belt was to be used with all transfers, indicating that the resident had already had an actual fall. On 11/6/25, the resident had another witnessed fall during a transfer from bed to wheelchair with a GNA. The nurse documented that the resident’s knees buckled, the resident went to the floor, and sustained abrasions on both knees. The nurse further documented that, per the GNA, a gait belt was not used during this transfer. A telemedicine visit by an APN documented a fall with injury, including abrasions to both knees and the left elbow, and treatment was ordered. A subsequent nursing review documented small bilateral skin tears to the knees. In a later interview, the GNA assigned to the resident on that date stated they were not aware at the time that a gait belt was supposed to be used for this resident and did not think the resident had been issued a gait belt, despite having received gait belt training at the facility. On 11/27/25, the resident experienced a third witnessed fall while transferring from the toilet to a chair, during which the GNA lowered the resident to the floor. Documentation indicated there was no injury. A Change in Condition review and Fall Assessment documented a witnessed fall with no injury, baseline pain, and normal range of motion, but there was no documentation that a gait belt had been used during this transfer. Further review found no documentation that the physician or the resident’s representative had been notified of this fall, and no vital signs were obtained at the time of the fall; the review instead listed vital signs from 12/11/25. The review was signed on 12/11/25, despite an effective date of 11/27/25, and there was no evidence of a thorough assessment at the time of the fall. Therapy staff interviews confirmed that a gait belt had been implemented for the resident from admission and that the resident’s family had provided a gait belt. The COTA and PT stated that residents requiring minimal, moderate, maximum, or contact guard assistance with transfers should use a gait belt, and that this resident had his/her own gait belt and signage placed on the wheelchair, overbed tray, and door after the first fall instructing staff to use a gait belt. The PT stated that after evaluation, a communication form with functional status is placed in the paper chart, and that all GNAs should know that residents needing one- or two-person assistance for transfers require a gait belt. The resident reported having had a gait belt since admission, that staff knew they were supposed to use it but sometimes did not, and that the resident still had to remind staff to use the gait belt during transfers. The DON acknowledged that staff were expected to know which residents required gait belts based on documentation and training, and was made aware that staff had transferred this resident without a gait belt on multiple occasions, resulting in three avoidable falls, including one with injury, and that fall assessment documentation was incomplete.
Failure to Conduct Thorough Abuse Investigations
Penalty
Summary
The facility failed to conduct thorough investigations into multiple allegations of abuse involving four residents. In several cases, required documentation such as real-time nurse progress notes, risk management assessments, and notifications to key administrative staff were missing from the electronic health record. Investigations often lacked essential components, including timely and complete interviews with involved parties and witnesses, as well as proper documentation of the investigative process. In one instance, a staff member accused of abuse had not received post-incident training, and there was no evidence of a psychological evaluation or care plan update for the resident involved. In another case, the investigation file was incomplete and inaccurate, with missing dates and times for interviews and a lack of follow-up on staff admissions regarding the incident. The investigation did not include necessary assessments such as skin and pain evaluations for the resident, nor did it provide evidence of post-incident staff education or referral to psychological services. The facility's documentation also failed to address the resident's chronic pain and polyarthritis, which were relevant to the allegation. Additional deficiencies included delayed or absent interviews with potential witnesses, such as a roommate who was not promptly interviewed despite being cognitively intact and available. In several investigations, the rationale for not substantiating abuse was based on residents' confusion or inconsistent accounts, rather than a comprehensive review of all available evidence. These actions and omissions resulted in incomplete investigations that did not meet the facility's stated standards for responding to abuse allegations.
Failure to Report Resident Allegation of Missing Money
Penalty
Summary
The facility failed to report a resident's allegation of missing money to the appropriate state authority. Specifically, after one resident reported money missing from a locked drawer, the facility's investigation did not include asking other residents if they also had missing money. During an interview, the Nursing Home Administrator confirmed that another resident, who was the roommate of the first, also reported missing money on the same date, but this allegation was not reported to the state. The administrator explained that the omission was due to a conversation with the resident's family member, who questioned whether the resident actually possessed money in the room. The discrepancy between reporting one resident's allegation and not the other's was acknowledged by the administrator.
Failure to Develop and Implement Baseline Care Plan Upon Admission
Penalty
Summary
The facility failed to develop and implement a baseline care plan for a resident admitted for short-term rehabilitation following hospitalization for weakness related to COVID-19 infection and chemotherapy for cancer. The resident also had unstageable sacral wounds and a history of depression, anxiety, and pain. Upon review, it was found that no baseline care plan was created within 48 hours of admission, as required. The only documentation found was a one-page care plan initiated after the resident had already been discharged, which was subsequently canceled and contained only a single intervention related to skin integrity. Interviews with the DON and NHA confirmed that no baseline care plan was completed for the resident during their stay. The DON was unable to provide evidence of a completed care plan, and the NHA acknowledged the deficiency, clarifying that any access to the record after discharge was for review purposes only. The lack of a baseline care plan meant that essential care instructions and continuity of care were not established for the resident during their admission.
Failure to Develop and Implement Comprehensive Care Plan
Penalty
Summary
The facility failed to develop and implement a comprehensive care plan for a resident who was admitted for short-term managed care rehabilitation following hospitalization for weakness related to a recent COVID-19 infection and chemotherapy for cancer. The resident also had unstageable sacral wounds and a history of depression, anxiety, and pain. Despite the completion of a Minimum Data Set (MDS) assessment, the medical record review revealed that only a single-page, incomplete care plan was initiated after the resident's discharge, which included just one intervention related to skin integrity and was subsequently canceled. No evidence was found of a comprehensive care plan being created during the resident's stay. Interviews with facility leadership, including the DON and NHA, confirmed that no comprehensive care plan was developed for the resident. The DON acknowledged the absence of the care plan and provided only the incomplete document to the surveyor. The NHA also confirmed awareness of the deficiency and clarified that no attempt was made to create documentation after the resident's discharge. The facility's policy required a comprehensive care plan to be developed within seven days after the MDS assessment, but this was not followed in the resident's case.
Failure to Update Care Plan After Resident's Change in Condition
Penalty
Summary
The facility failed to ensure that care plans were reviewed and revised after a change in a resident's condition. Specifically, a resident who had been residing in the facility since March 2022 was referred by a nurse to therapy for a right-hand contracture, with the referral dated 9/12/24. A subsequent therapy evaluation on 10/11/24 confirmed the presence of the contracture. Despite this change in condition, a review of the resident's records showed that the care plan was not updated to reflect the new contracture. Interdisciplinary team (IDT) care plan meetings were held on 1/16/25 and 4/10/25, but there was no documentation indicating that the care plan had been revised to address the right-hand contracture. The Director of Nursing (DON) confirmed in an interview that it was her or the unit manager's responsibility to update care plans with every change in a resident's condition, but the records did not show that this was done for the resident's contracture.
Failure to Provide and Document Required ADL and Incontinence Care
Penalty
Summary
The facility failed to provide adequate assistance with Activities of Daily Living (ADL), specifically showers and incontinence care, to residents who were dependent on staff. One resident, who was documented as requiring staff assistance for most self-care needs, was observed multiple times with visible signs of poor hygiene, such as white flaky particles in facial hair and on clothing. Despite provider orders and a shower schedule indicating the resident was to receive showers twice weekly, records showed a significant lack of completed showers over several months, and there was no documentation of the resident refusing showers as required by facility policy. Another resident, dependent on staff for toileting, was the subject of a complaint alleging prolonged periods in soiled diapers. Review of medical records and task documentation revealed multiple shifts with no documentation of toileting or incontinence care provided. The DON confirmed that for several shifts within a 17-day period, there was no record of care being given, and the required documentation was missing. A third resident, also requiring substantial to maximal assistance for toileting, had a care plan specifying frequent checks and changes, especially after meals and at night. However, documentation for the last week of January showed four shifts with no record of incontinence care being provided. The DON reviewed staffing sheets and medical records and was unable to find documentation for the identified shifts, confirming the lack of evidence that care was provided as required.
Failure to Administer Medications and Treatments as Ordered
Penalty
Summary
A deficiency was identified when a resident with a medical history of kidney failure, congestive heart failure, COPD, depression, and chronic pain did not receive multiple medications and treatments as ordered by their physician. Review of the Medication Administration Records (MAR) and Treatment Administration Records (TAR) for March 2025 revealed several missed doses of prescribed medications, including Mirtazapine, Rocklatan Ophthalmic Solution, Buspirone, and Trospium Chloride. Additionally, required monitoring and treatments such as behavior monitoring for medication side effects, fluid restriction for CHF, oxygen therapy, pain and vital signs monitoring, wound care, topical applications, and use of pressure-reducing devices were not completed on multiple occasions. The Director of Nursing (DON) confirmed upon review that the medications and treatments had not been administered on the specified dates. The Nursing Home Administrator (NHA) was also made aware of the issue and acknowledged the concern regarding the failure to provide care and treatment as ordered. The deficiency was based on direct record review and staff interviews, which verified that the resident did not receive the required medications and treatments according to physician orders.
Failure to Provide Consistent Pressure Ulcer Care and Prevention
Penalty
Summary
The facility failed to provide appropriate pressure ulcer care and prevent new ulcers from developing for three residents. In the first case, a resident with a moisture-related skin injury was admitted and later returned from the hospital with a stage 2 pressure injury. Although the wound care team recommended treatment with a specific cream every shift, there was no evidence that this treatment or any alternative was implemented prior to a formal order being placed, and administration of the cream was not documented before that date. The DON confirmed that the wound care recommendations were not followed. In the second case, a resident with a history of cancer, depression, and a burn injury was admitted with three unstageable pressure ulcers and was identified as being at risk for further skin breakdown. Multiple wound care orders were documented, but several treatments were missed according to the medication and treatment administration records. There was also a lack of documentation confirming that all steps of the wound care process, such as cleaning and dressing the wounds, were completed. The DON acknowledged that the records indicated missed treatments and could not provide evidence that the required care was given. The third case involved a resident with an identified alteration in skin integrity at the sacrum. The care plan included daily wound care, but the treatment administration record showed that wound care was not documented on several days. The unit manager confirmed that care was not provided on those dates and no additional evidence was available. The deficiency was discussed with the Nursing Home Administrator, and no further documentation was provided.
Failure to Maintain Annual Nursing Staff Competency Documentation
Penalty
Summary
The facility failed to conduct annual performance reviews to ensure nursing staff maintained appropriate skill competencies. During the recertification survey, a review of five employee files revealed that none contained documentation of annual skill competency assessments. Interviews with the Director of Human Resources confirmed that staff are required to complete annual online in-service training and maintain competencies as a condition of employment. However, the Director of Nursing was unable to provide documentation of staff competencies and acknowledged that the process for tracking staff training and competencies was not functioning. Additionally, the Director of Human Resources admitted that the facility did not maintain employee records related to competencies.
Failure to Ensure and Track Required Staff Training on Dementia and Abuse
Penalty
Summary
The facility failed to develop and implement a system to ensure that all staff, including agency staff, received and completed required annual training on dementia management, abuse, neglect, exploitation, and misappropriation of resident property. Record reviews of five randomly selected employee files revealed that none had documentation of completion for most of the required training. Interviews with the Director of Human Resources and the Director of Nursing indicated that while a process existed for notifying staff and tracking training completion through Carefeed, there was a lack of confidence in the system, and no clear follow-up for non-compliance. Additionally, there was no process in place to ensure agency staff received the required training, and their compliance was not being tracked. Further review of an employee file related to an allegation of abuse showed that the implicated geriatric nursing assistant had not received the required dementia or abuse education for the relevant year. This was confirmed by both the Director of Human Resources and the Director of Nursing, who acknowledged that the staff member had not completed the mandatory training within the designated timeframe. The deficiency was evident in both routine staff files and in the context of a specific abuse allegation.
Failure to Provide Privacy During Resident Dressing Change
Penalty
Summary
During an observation of a dressing change for Resident #108, the resident's frontal private area was exposed due to the privacy curtain being only partially drawn around the bed. Present in the room were an LPN, a unit manager, and an unidentified GNA. While the dressing change was ongoing, another unidentified GNA entered the room to collect meal trays, walking past the exposed resident despite being informed by the surveyor that personal care was being provided. The unit manager later acknowledged that staff failed to ensure the resident's dignity and privacy during the procedure. The deficiency was identified based on direct observation and staff interviews, with no further evidence provided by the end of the survey.
Failure to Provide Residents with Requested Alternative Menu Choices
Penalty
Summary
Surveyors determined that the facility failed to ensure residents received their chosen alternative menu items, as required to support resident self-determination and choice. During a dining observation, one resident's dinner tray included two meal tickets: one indicating a request for a peanut butter & jelly sandwich with extra gravy and hot tea, but the tray instead contained steak and rice without gravy, and no sandwich or hot tea. This demonstrated that the resident's specific meal preferences were not honored. Interviews with other residents at the same table revealed similar issues. One resident reported not always receiving requested alternative meals, despite submitting a meal ticket and later handing it directly to kitchen staff. Another resident stated they no longer submit alternative food requests because their previous requests were not fulfilled. A third resident indicated the system for requesting menu alternatives was ineffective, leading them to make verbal requests directly to kitchen staff instead of using the formal process. The Certified Dietary Manager Consultant confirmed that the current system for handling alternative meal requests was not effective.
Failure to Issue Required Medicare Beneficiary Protection Notices
Penalty
Summary
The facility failed to provide required Beneficiary Protection Notifications to residents who were discharged from Medicare Part A services but continued to reside in the facility for non-skilled care, despite having Medicare benefit days remaining. Specifically, for one resident, although a Notice of Medicare Non-Coverage (NOMNC) was signed and delivered via telephone to the resident's representative, there was no evidence that the NOMNC was subsequently mailed or otherwise delivered as required by facility policy. Additionally, the Skilled Nursing Facility Advance Beneficiary Notice (SNFABN), which should inform the resident or representative about potential financial liability for non-covered services, was not issued. For another resident, the facility's records did not show that either the NOMNC or SNFABN was provided before the end of Medicare Part A services, even though the resident remained in the facility and had not exhausted benefit days. Staff interviews confirmed a lack of awareness regarding the requirement to mail the NOMNC when not hand-delivered and an absence of documentation for both required notices for the second resident.
Failure to Maintain Clean and Homelike Shower Room Environment
Penalty
Summary
The facility failed to maintain a clean and homelike environment in one of its two shower rooms, as evidenced by observations and interviews. A long-term resident reported the presence of a black and brown substance in the cracks of the shower room floor. Upon inspection with the nurse unit manager, cracks along the grout edge and visible black and brown spots were found in two of the three shower stalls. The Maintenance Director confirmed awareness of the issue, noting that while wall tiles had been replaced, the floor tiles had not, and previous attempts to address the problem with silicone and grout were unsuccessful. The Nursing Home Administrator also confirmed the presence of the black and brown substance during a subsequent observation. These findings indicate that the facility did not ensure the shower room environment was maintained in a clean and safe condition for residents.
Failure to Identify Grievance Official and Provide Written Grievance Responses
Penalty
Summary
The facility failed to properly identify a Grievance Official in its grievance policy and did not ensure that grievances were followed up with written responses. A review of the facility's grievance policy revealed that it listed placeholders such as 'Name and Title' and 'List contact information' instead of specifying the actual grievance officer's name and contact details. The policy defined the role of the Grievance Official but did not provide the required identifying information. During interviews, the Nursing Home Administrator (NHA) confirmed that she was the grievance officer, but acknowledged that the policy did not reflect this information. Additionally, a review of five grievance investigations from February 2025 showed that none documented who completed the investigations, when they were completed, or whether written decisions were provided to residents. The NHA confirmed that residents only received verbal follow-up regarding their grievances and that written responses were not provided. No further evidence was provided to demonstrate compliance with the requirement for written grievance decisions.
Inaccurate MDS Assessments for Range of Motion and Discharge Status
Penalty
Summary
The facility failed to ensure that Minimum Data Set (MDS) assessments were accurately recorded for several residents. In multiple cases, there were discrepancies between therapy evaluations, provider documentation, and the MDS records. For one resident, therapy evaluations documented impaired range of motion (ROM) in the lower extremity and full ROM in the upper extremities, but the MDS assessments incorrectly indicated upper extremity impairment. Another resident with documented right-hand contractures and provider orders for a contracture management device had MDS assessments that failed to reflect upper extremity limitations and instead incorrectly noted lower extremity impairment. A third resident had consistent therapy documentation of full ROM in both upper extremities, yet the MDS assessments repeatedly recorded functional limitations in the upper extremity. Additionally, a closed record review revealed that a resident who was discharged home was incorrectly coded in the MDS as having been discharged to a short-term general hospital. These errors were confirmed through interviews with staff, including the MDS coordinator, who acknowledged the inaccuracies after reviewing the relevant documentation. The deficiencies were identified through record reviews, interviews, and observations conducted by surveyors.
Failure to Complete Timely PASSAR Screening After 40 Days
Penalty
Summary
The facility failed to complete a required Pre-admission Screening and Resident Review (PASSAR) for mental disorders or intellectual disabilities within 40 days of admission for one resident. Medical records showed that the resident had an initial PASSAR completed prior to admission, with the attending physician certifying that the resident was likely to require less than 30 days of care. However, after the resident remained in the facility beyond 40 days, there was no evidence of a follow-up PASSAR being completed as required. The administrator confirmed during interviews that the follow-up PASSAR could not be located and was not available for review.
Failure to Implement and Communicate Therapy Recommendations and Provide Adaptive Equipment
Penalty
Summary
The facility failed to ensure that therapy recommendations were effectively communicated to nursing staff and implemented in the care of multiple residents. For one long-term resident, a physical therapy discharge summary recommended the use of an ankle brace and a hemi walker as part of a functional maintenance program. However, there was no physician order or care plan documentation for the ankle brace, and nursing staff were unaware of its use, despite therapy staff confirming the recommendation. The resident reported that the ankle brace was kept in the therapy room rather than being available for use during ambulation. Another resident with a right-hand contracture was observed multiple times without a splint or palm guard in place, despite a provider's order for a palm guard to prevent further contracture. A previous therapy referral for splinting was not addressed, and occupational therapy only provided recommendations for self-feeding setup without addressing the contracture. Nursing staff confirmed the absence of the device during observation and only located it after being prompted. A third resident had a physician's order for foam utensil adaptors to be used at meals to promote independence, but the care plan did not include this intervention, and the adaptive device was not available during meal observation. The resident, their spouse, and therapy staff confirmed the device had not been available for a week, and the unit manager acknowledged the deficiency. These findings demonstrate a lack of effective processes to ensure therapy recommendations and adaptive equipment are consistently communicated, documented, and provided as ordered.
Improper Positioning of Foley Catheter Drainage Bag
Penalty
Summary
A deficiency was identified when a resident with a history of urinary retention had a physician's order for a Foley catheter with bedside straight drainage. The facility's policy and CDC guidelines require that the catheter drainage bag be kept below the level of the bladder to prevent urine backflow and reduce the risk of urinary tract infections. However, during multiple observations, the resident was seen seated in a Geri chair with the Foley bag containing urine placed on their lap, above the level of the bladder. Record review confirmed the catheter care policy, which specifically instructs staff to ensure the drainage bag remains below the bladder. The issue was discussed with the unit manager, who confirmed the deficiency. No additional evidence was provided to refute the findings by the end of the survey.
Failure to Ensure Physician Orders and Accurate Administration of Oxygen Therapy
Penalty
Summary
The facility failed to ensure safe and appropriate respiratory care for two residents by not having a current physician's order for oxygen administration and by not following the prescribed oxygen flow rates. One long-term resident was observed receiving oxygen via nasal cannula at 2L/min without a corresponding physician's order in place. Review of the resident's records showed that the previous oxygen order had been discontinued upon hospital transfer, and no new order was documented upon the resident's return to the facility. Additionally, there was no documentation of oxygen administration in the medication administration record for several weeks, despite evidence from vital signs and nursing assessments that the resident was receiving oxygen during that period. Another resident was observed receiving oxygen at a rate of 3.5L/min, while the physician's order specified 2L/min. The resident was aware of the prescribed rate, but the oxygen concentrator was set higher than ordered. This discrepancy was confirmed by an LPN during the survey. In both cases, the facility did not ensure that oxygen therapy was administered according to physician orders, nor did it maintain accurate documentation of the care provided.
Failure to Complete Annual Evaluations and In-Service Training for GNAs
Penalty
Summary
Facility staff failed to conduct annual performance evaluations and provide the required twelve hours of annual in-service education for geriatric nursing assistants, as evidenced by a review of two personnel files. Both files lacked documentation of yearly evaluations and did not show completion of the mandated in-service training hours. The Director of Nursing confirmed that annual reviews are expected to be completed and maintained in employee files, while the Director of Human Resources acknowledged that only 9.4 hours of online training were provided, with no documentation for the remaining required hours. No additional evidence was presented to demonstrate compliance with the annual training requirement.
Failure to Ensure Proper Controlled Substance Logbook Signatures at Shift Change
Penalty
Summary
The facility failed to ensure that the controlled substance logbook for one of four medication carts was properly signed by two licensed staff at each change of shift. During a review of the controlled substance logbook for cart #2 in the Catoctin unit, it was found that several entries were not in chronological order, some dates had only one signature from a licensed staff member, and some dates had no signatures at all. The logbook is intended to document the count and transfer of controlled substances between staff, and the expectation is that both the nurse counting out and the nurse counting in sign the log at each shift change. Interviews with an LPN assigned to the cart confirmed that nurses are responsible for signing the logbook whenever they take the keys for the cart, regardless of the time. The DON acknowledged the issues with missing signatures and explained that the responsibility for cart #2 was shared between two nurses, which may have contributed to the incomplete documentation. The findings were confirmed through review of the logbook and interviews with staff, including the DON.
Failure to Ensure Physician Review of Pharmacist-Identified Medication Irregularities
Penalty
Summary
The facility failed to ensure that the attending physician reviewed, acted upon, and documented irregularities identified by the pharmacist during the monthly medication regimen review for one resident. A consultant pharmacist completed a medication regimen review and noted irregularities, instructing to see the report comments and recommendations. However, the report was not found in the resident's medical record during the initial review, and when later produced, it lacked evidence that the attending provider had reviewed or addressed the pharmacist's recommendations. Staff interviews confirmed that the report was missing from the resident's hard chart and that the required physician review and documentation had not occurred.
Expired and Unlabeled Medications Found During Survey
Penalty
Summary
Surveyors identified that the facility failed to ensure proper storage and labeling of medications, as required by professional standards. During inspections of medication storage rooms and carts, expired medications were found, including three bottles of aspirin and an inhaler labeled for a specific resident that was past its expiration date. Additionally, several inhalers were found without documentation of the date they were opened, despite labeling instructions indicating that the medication should be discarded one month after opening or when the dose counter reached zero. In one instance, three opened inhalers for a resident were present in a medication cart, with two of them past the discard date and the third lacking an open date. Staff were unable to confirm which inhaler was currently being administered or when the third inhaler was opened. Interviews with nursing staff and the DON confirmed the observations, with staff acknowledging the presence of expired medications and the lack of proper labeling for opened inhalers. The DON also confirmed that the staff member responsible for overseeing medical records and supplies was on sick leave at the time of the inspection. The findings were based on direct observation and staff interviews, and the issues were present in one of two medication storage rooms and three of four medication carts inspected during the survey.
Failure to Deliver Meals at Palatable Temperatures and in a Timely Manner
Penalty
Summary
The facility failed to ensure that meals were delivered to residents in a timely manner and at a palatable temperature. During an interview, a long-term resident reported that food was often late and not palatable in taste or temperature. Observations revealed that breakfast trays were not promptly removed from the delivery cart, with the last tray being delivered significantly after the trays arrived on the unit. Documentation showed that the breakfast tray line started at 7:00 AM, but trays were not received on the unit until 7:20 AM, and the last tray was not delivered until 7:56 AM. A test tray was prepared and observed as part of the survey process. The test tray remained in the delivery cart for 71 minutes before being removed, and when checked, the temperature of the eggs and oatmeal was below the facility's stated goal for palatability (120°F), measuring 107.4°F and 109.1°F respectively. The test tray was then consumed by the survey team, who confirmed that the food was not at a palatable temperature. These findings indicate that the facility did not have an effective process to ensure timely meal delivery and maintenance of appropriate food temperatures.
Inaccurate Documentation of Adaptive Device Use for Pressure Ulcer Care
Penalty
Summary
The facility failed to ensure accurate care documentation for a resident receiving pressure ulcer care. A physician's order directed that foam adaptors be applied at meal times to promote optimum intake and independence. However, review of the Medication Administration Record showed that nursing staff documented the use of the adaptive device for each shift over a nine-day period, despite the device not being available to the resident during that time. Direct observation confirmed the resident ate dinner without the adaptive utensils, and both the resident, their spouse, and the therapy director verified that the device had not been available for the past week. The therapy director also stated the device was supposed to be stored at the resident's bedside. The unit manager acknowledged and confirmed the deficiency during an interview.
What surveyors are citing around you — mapped
All 10 risk areas, ranked with evidence
Repeat citations, what's rising near you, and quality measures — ranked so department heads know exactly where to look first.
Illustrative
What surveyors actually found near you
We read the 368 citations issued within 25 miles in the last 12 months — including the 5 immediate-jeopardy cases — and tell you exactly what happened, in plain English, matched to your record.
Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
Walk-in cooler logs missing for 12 days; expired supplements in the medication room fridge.
Illustrative
A prioritized, do-first checklist
Every risk area becomes concrete audit steps drawn from real citations at facilities like yours — run them this week, before your window opens.
Illustrative
Risk indicators are statistical estimates from public CMS data — not predictions, findings, or compliance advice.
Nursing homes near Walkersville
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Homewood Living Frederick | 2.8 mi | ★★★★★ | 0 | 0 |
| Northampton Manor Nursing And Rehabilitation Cente | 3.9 mi | ★★★★★ | 26 | 0 |
| Autumn Lake Healthcare At Ballenger Creek | 4.2 mi | ★★★★★ | 6 | 0 |
| Citizens Care And Rehabilitation Center Of Frederi | 5.2 mi | ★★★★★ | 16 | 0 |
| Frederick Crossing Of Journey | 6.1 mi | ★★★★★ | 40 | 0 |
Every risk area ranked, a do-first checklist, and your local survey patterns
Built specifically for Autumn Lake Healthcare At Glade Valley.
100% money-back within 48 hours.
Trusted data, never guesswork. Every citation, penalty, rating and Plan of Correction on this page is sourced from public CMS records (latest release August 2026) and official state health department websites.