Autumn Lake Healthcare At Glade Valley
Inspection history, citations, penalties and survey trends for this long-term care facility in Walkersville, Maryland.
- Location
- 56 West Frederick Street, Walkersville, Maryland 21793
- CMS Provider Number
- 215313
- Inspections on file
- 18
- Latest survey
- January 23, 2026
- Citations (last 12 mo.)
- 5
Citation history
Health deficiencies cited at Autumn Lake Healthcare At Glade Valley during CMS and state inspections, most recent first.
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.
Surveyors found that infection control protocols were not followed when an unlabeled, uncovered bedpan and bath basin were left improperly stored in a resident's bathroom, and an LPN failed to perform required hand hygiene during a pressure ulcer dressing change for another resident. Both incidents involved staff not adhering to established facility procedures for infection prevention.
A resident sustained a skin tear after coming into contact with a jagged, peeling edge on a shower room shelf. The issue was known to staff and addressed by applying clear tape, but the underlying repair was not completed at the time of the incident. Maintenance relied on staff-reported concerns rather than routine audits, contributing to the deficiency.
The facility did not ensure that GNAs, including both facility and agency staff, received required training in dementia care, abuse prevention, and related areas. Review of employee files and staff interviews confirmed missing documentation and inconsistent tracking of training compliance, with agency staff lacking dementia management training due to lack of awareness of the requirement.
A resident was administered PRN Ativan on three occasions, but documentation showed that non-pharmacological interventions were only attempted before two of those administrations. An LPN confirmed that there was no record of any intervention being tried prior to one of the doses, resulting in a deficiency related to the use of psychotropic medications.
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.
Infection Control Lapses in Resident Care and Wound Management
Penalty
Summary
Surveyors identified two infection prevention and control deficiencies during their review. In one instance, an unlabeled and uncovered bedpan was found placed on a handrail in a resident's bathroom, along with an unlabeled and uncovered bath basin left upside down with bath linens on the floor. The Geriatric Nursing Assistant interviewed was unable to identify the owner of the items and acknowledged that the proper procedure was not followed, as these items should have been cleaned, bagged, and stored in the resident's bedside table drawer. In a separate incident, a Licensed Practical Nurse performed a dressing change for a resident with a pressure ulcer but failed to perform hand hygiene after removing soiled gloves and before donning clean gloves to apply a new dressing. The facility's policy and the nurse's competency documentation both required hand hygiene at this step. The unit manager confirmed the failure to follow proper hand hygiene protocol during the dressing change.
Failure to Maintain Shower Room in Good Repair Resulting in Resident Injury
Penalty
Summary
The facility failed to maintain a resident shower room in good repair, resulting in an unsafe environment for residents. During an interview, a long-term resident reported sustaining a skin tear after their arm rubbed against a jagged edge on a shelf in the shower room. Observation of the shower room revealed that approximately one foot of the laminated edge on the shelf was peeling off, and clear tape had been applied over the edge to create a smoother surface. The nurse unit manager confirmed that the resident had received a skin tear from the sharp edge and that the concern had been logged in the maintenance book, after which the Maintenance Director applied the tape. A review of the resident's medical records showed documentation of a change in condition, specifically a skin tear on the left forearm sustained in the shower. The medication administration note included instructions to monitor and change the dressing every shift. The Maintenance Director reported that he does not conduct routine audits for maintenance issues and relies on concerns being reported in the maintenance log, which he checks several times daily. The deficiency was identified during the survey based on these interviews, observations, and record reviews.
Failure to Provide Required Training for GNAs
Penalty
Summary
The facility failed to ensure that Geriatric Nurse Assistants (GNAs), including both facility and agency staff, received required training in dementia management, abuse, neglect, exploitation, and misappropriation of resident property. Record reviews of four GNA employee files revealed a lack of documentation for this mandatory training. Interviews with the Director of Human Resources confirmed that annual in-service training is a condition of employment, but tracking of compliance was inconsistent, with HR responsible for facility staff and nursing leadership for agency staff. The Director of Nursing acknowledged that agency staff had not received dementia management training because the agency was unaware of the requirement, and there was no current tracking of agency staff training compliance.
Failure to Document Non-Pharmacological Interventions Prior to PRN Psychotropic Medication Administration
Penalty
Summary
The facility failed to ensure that non-pharmacological interventions (NPI) were provided or attempted prior to administering a psychotropic medication for one resident. Specifically, a resident was prescribed Ativan (Lorazepam) on an as-needed basis and received doses on three separate occasions. Documentation confirmed that NPIs were attempted before administration on two of those dates, but there was no documentation of any NPI being attempted prior to the administration on the third date. During interviews, an LPN explained that the facility's process is to attempt NPIs before administering psychotropic medications and that such attempts should be documented either in the electronic Medication Administration Record (eMAR) or in a progress note. Upon review of the resident's records, the LPN was unable to find any documentation indicating that an NPI was attempted before the administration of Ativan on the date in question, confirming the deficiency.
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The facility did not ensure that its Infection Preventionist (IP) met required qualifications for managing the Infection Prevention and Control Program. The DON reported serving as the IP but acknowledged lacking the specialized infection control training required for the role, and confirmed that no other staff member was currently qualified. Records showed that the previously qualified IP left several months earlier, and the Administrator and DON confirmed they were still seeking a replacement, leaving the infection control program without a properly trained leader.
Staff failed to consistently secure medications and medical supplies across three units, including an oxygen tank left on the floor behind a resident’s bed without a supporting device, a treatment cart with Collagenase Santyl cream left on top while two residents in power wheelchairs passed by, an unattended and unlocked treatment cart at a nursing station, and another treatment cart with Diclofenac gel and dressings left on top, indicating repeated lapses in maintaining locked and secure storage for drugs, biologicals, and related supplies.
The facility failed to provide sufficient dietitian coverage and timely nutritional assessments for several residents with significant dietary needs. A resident admitted for diabetic management with a high A1C was placed on a regular diet instead of the recommended carb-controlled diet and had only one weight taken in the first two weeks, with no dietitian review of the record. Another resident with prior significant weight loss had no documented dietitian follow-up despite continued weight loss, and a resident admitted with severe protein-calorie malnutrition experienced further significant weight loss without any dietitian assessment. The dietitian reported working limited hours and prioritizing certain high-risk cases, resulting in delayed or missed evaluations for new admissions and residents with ongoing nutritional concerns.
The facility failed to maintain adequate linen and incontinence supplies and did not keep resident care areas in good repair, resulting in delays and alterations in incontinence care and substandard environmental conditions. Staff reported that towels and washcloths were used instead of wipes and then discarded due to heavy soiling, and that linen deliveries to units were late, leaving residents waiting for care. Observations showed very limited numbers of clean washcloths and other linens on units and in the laundry, with no stock of disposable wipes or backup washcloth supply despite repeated reports to housekeeping. Additional observations revealed recliner chairs blocking a dining-area handwashing sink and kitchenette, multiple resident and shared bathrooms with unfinished spackle, chipped paint, musty odors, black substances near showers, missing threshold molding, exposed cracks and nails, and eroded, rusted baseboard heaters. Hallway handrails on both units were worn, chipped, and splintered, and a shower room contained fecal odors, dried brown stains on the toilet, and deteriorated fixtures, all contributing to a failure to provide a safe, clean, and homelike environment.
Facility staff did not thoroughly investigate two separate abuse allegations involving a resident and an injury of unknown origin involving another resident. In both cases, investigations focused on the directly affected resident and included staff interviews, but there were no interviews of other residents on the unit or documented assessments of those residents for signs of abuse or injuries of unknown origin, including residents unable to communicate due to cognitive status.
Two residents who were dependent on staff for oral care, including one with a tracheostomy, were observed with thick, white or milky substances coating their mouths and teeth, indicating inadequate oral hygiene. One resident communicated that staff did not brush their teeth and that staff "need to." In another case, despite oral care supplies being present in the room, the resident’s mouth and teeth remained unclean on multiple observations, with a thick milky substance caking the teeth and stringing between them when the resident tried to open their mouth. These findings showed that staff did not consistently provide oral care to residents who relied on them for this ADL.
Staff failed to maintain complete and accurate medical records for multiple residents, including missing and inconsistent documentation of wound care, delayed pain assessment after discovery of an injury of unknown origin in a cognitively impaired resident, and inaccurate recording of a PPD test result that was documented as negative despite no evidence the injection was administered and no supporting nurse’s note. Residents reported not receiving certain treatments, while MAR entries either lacked signatures for completion or contained conflicting information about whether care was provided.
Surveyors found that the facility failed to consistently implement and communicate correct transmission-based precautions and PPE use. One resident with a Foley catheter related to wounds had no precaution signage posted, while another resident in a double room had a contact precautions sign at the door, yet the NP entered without PPE and the GNA provided high-contact care wearing only gloves. Staff in that room stated the resident was not on contact precautions and later reversed the sign to show no PPE requirement. Therapy staff reported they rely solely on posted signs to determine PPE, and surveyors identified broader issues with inaccurate signage and staff awareness of which residents required contact precautions.
Surveyors found that MDS assessments were inaccurately coded for two residents. In one case, a resident sustained a femoral neck fracture after a fall, but the subsequent significant change MDS did not code the fall as a major injury and failed to capture prn Tylenol use documented on the MAR within the look-back period. In the other case, a quarterly MDS indicated opioid use for a resident, but the MAR for the same period showed no prescribed opioid, indicating incorrect coding of high-risk drug classes.
A resident who had recently been admitted and experienced a fall received multiple doses of the narcotic analgesic Tramadol, but the facility failed to accurately document all administered doses on the Medication Administration Record (MAR). Review showed only one Tramadol dose recorded on the MAR, while the Controlled Drug Receipt/Record/Disposition Form on the med cart reflected three doses given over two days. In interview, the DON stated staff are expected to document narcotic administration on the MAR and confirmed that two administered doses were not recorded there, resulting in an incomplete and inaccurate medical record.
Unqualified Infection Preventionist Overseeing Infection Control Program
Penalty
Summary
The facility failed to ensure that its designated Infection Preventionist (IP) met the mandatory qualifications for overseeing the Infection Prevention and Control Program. During an interview on 3/24/26 at 10:00 AM, the DON confirmed that she/he was serving as the facility’s IP but had not completed the specialized training in infection control required for the position. The DON further stated that no other staff member currently met the qualifications to serve as IP. Record review showed that the previously qualified IP left the facility in October 2025, and as of the survey date, the position remained unfilled by a qualified individual. At 1:30 PM on the same day, the Administrator and DON confirmed they were still in the process of finding a qualified IP for the facility, leaving the Infection Prevention and Control Program without a properly trained and qualified leader. No specific residents, medical histories, or clinical conditions were described in relation to this deficiency.
Unsecured Medications, Treatment Carts, and Oxygen Equipment
Penalty
Summary
Facility staff failed to ensure that drugs, biologicals, and related medical supplies were securely stored and properly maintained on multiple units. On one unit, an oxygen tank assigned to a resident was observed sitting on the floor behind the resident’s bed without any supporting device. On another unit, a treatment cart was observed with a tube of Collagenase Santyl cream labeled for a specific resident left on top of the cart, while residents in power wheelchairs passed by and staff were present at the nursing station. These observations showed that medications and oxygen equipment were not consistently secured as required. Further observations on additional units revealed an unattended and unlocked treatment cart at a nursing station, and on a separate occasion, a treatment cart with Diclofenac gel labeled for a resident left on top along with multiple packs of dressings. These incidents occurred across three units and on more than one date, demonstrating repeated failures to keep medications and treatment supplies in locked compartments or otherwise secured from unauthorized access.
Insufficient Dietitian Coverage and Delayed Nutritional Assessments
Penalty
Summary
The deficiency involves the facility’s failure to employ sufficient food and nutrition staff, including adequate dietitian coverage, to ensure timely assessment and appropriate diets for residents with significant nutritional and diabetic needs. A resident admitted over two weeks earlier with multiple comorbidities and an A1C of 11.5% had a hospital discharge recommendation for a carbohydrate-controlled diet, but was placed on a regular diet at admission with no acknowledgment of the recommended diet until one week later, when the resident requested larger portions. As of the survey date, the dietitian had not yet seen or reviewed this resident’s medical record, and the resident reported not having seen a dietitian and being very frustrated with the meals. During the first two weeks after admission, only one weight was obtained for this resident, despite physician notes stating the resident’s weight was “stable.” Further review of other residents showed additional failures in timely dietitian assessment and follow-up. One resident, readmitted in January and previously seen by the dietitian in September for a 6.4 lb weight loss over 30 days, had no documented follow-up despite continued weight loss totaling 22 lbs since the last dietitian review. Another resident admitted at the end of February with severe protein-calorie malnutrition had not been seen by the dietitian after about a month in the facility, despite a documented 14 lb (7%) weight loss over two weeks. The dietitian reported working only 12 hours per week at the facility and stated that she must prioritize which residents to see, focusing first on residents with tube feedings and those identified in risk meetings, resulting in delayed or absent assessments for new admissions and residents with ongoing weight loss and malnutrition diagnoses.
Linen Shortages and Poor Environmental Maintenance Compromise Resident Care and Comfort
Penalty
Summary
The deficiency involves the facility’s failure to maintain an adequate supply of clean linens and appropriate incontinence wipes, resulting in delays and alterations in residents’ incontinence care, as well as the use of towels and washcloths in place of disposable wipes. During the initial tour, the surveyor observed that the linen supply on one nursing unit hallway was low. Complaint reviews included concerns about delays in incontinence care and bed linens not being changed regularly, with residents left without clean bedding. A complainant reported that there was not enough clean linen available for residents. Staff interviews confirmed that towels, sheets, and washcloths were being used to wipe residents for incontinence care due to the absence of wipes, and that many of these linens were being thrown away when soiled. Staff also reported a shortage of linen, that linen deliveries to the units were late, and that residents who preferred to get up before breakfast had to wait for care when linen was delayed. Further observations showed that the clean supply room contained no disposable wipes or cloths for incontinence care, and a resident reported that staff did not use wipes, that the resident had to purchase their own, and that heavily soiled towels or washcloths were discarded. A tour of all nursing unit linen carts and closets revealed only six clean washcloths and limited supplies of towels, gowns, and bed linens. In the laundry room, only three washcloths were present, and the laundry assistant stated that there were only three washcloths available for each nursing unit that morning, that the facility was short on linen supply, and that these concerns had been repeatedly reported to the Director of Housekeeping over the preceding month and again that morning. The laundry assistant confirmed there was no additional laundry in process. The DON stated that wipe squares should be used for incontinence care, but no such wipes were found in the clean medical supply room, and no backup supply of washcloths was present in the emergency linen supply. The Director of Housekeeping confirmed there was no backup supply of washcloths. The deficiency also includes environmental and maintenance issues affecting resident bathrooms, handrails, and common areas. In the main dining area, a recliner chair was observed positioned directly in front of the handwashing sink, and two recliner chairs were stored in front of the nutrition area kitchenette. Multiple resident bathrooms and shared bathrooms were repeatedly observed over several days with unfinished spackle on walls that needed resurfacing and painting, chipped paint around sinks, uneven boards nailed to walls under sinks that appeared to partially cover holes, musty odors, black substances between shower bases and walls, missing threshold transition molding exposing cracks, missing tiles, and a nail, as well as eroded and chipped paint on baseboard heaters with exposed dark brown metal and rust-like material. Hallway handrails on both nursing units were observed to be worn, with chips, splintering, holes, and areas where the wood finish had worn off. A shower room was observed with a foul fecal odor, dried brown stains on the back of the toilet seat and in the toilet bowl, and a baseboard heater with eroded, chipped paint and rust-like material, along with chipped paint on the handrail. These conditions were acknowledged by the Director of Maintenance and other leadership, and some areas were noted to be in the process of renovation, but the observed deficiencies remained present during the survey period. Overall, the facility did not maintain a safe, clean, comfortable, and homelike environment in good repair across both nursing units and the dining area. The lack of adequate linen and incontinence supplies, combined with the poor condition of resident bathrooms, handrails, and certain common areas, constituted the basis for the cited deficiency. The observations and staff and resident reports consistently described shortages of essential hygiene supplies, delayed care related to linen availability, and multiple unresolved environmental and maintenance issues in resident care areas and shared spaces.
Failure to Thoroughly Investigate Abuse Allegations and Injuries of Unknown Origin
Penalty
Summary
Facility staff failed to thoroughly investigate allegations of potential abuse involving one resident and an injury of unknown origin involving another resident. For one resident, there were two separate allegations of abuse occurring on different days in early February. The facility’s investigation packets included interviews with staff who cared for or were scheduled to work with this resident on the days of the alleged incidents, and the investigations focused solely on this resident. However, there were no interviews conducted with other residents on the unit to inquire about abusive or neglectful treatment by the staff who were working during the times of the allegations. The surveyors noted that, although the allegations were not validated, there was no documentation that other residents were interviewed, if able, or assessed for signs or symptoms of injury. In a separate incident, another resident was identified on March 4 with a new bruise on the right eye, documented as a change in condition at 4:09 AM. This resident had a BIMS score of 99, indicating the resident was unable to complete an interview and therefore could not report how the injury occurred. The facility’s investigation identified a potential cause of the injury but did not reach a definitive resolution. Additionally, there were no interviews of other residents on the unit regarding possible abuse, nor were there documented assessments of other residents for injuries of unknown origin, particularly for those unable to speak for themselves, as in this resident’s case.
Failure to Provide Oral Care to Dependent Residents
Penalty
Summary
The deficiency involves the facility’s failure to provide oral care to residents who were dependent on staff for activities of daily living, specifically oral hygiene. One resident with a tracheostomy was observed with a thick, sticky white substance in the mouth and was noted to intermittently chew on nearby bedding. This resident made good eye contact and, when asked if staff brushed their teeth, shook their head no and mouthed that staff “need to.” According to the resident’s Minimum Data Set (MDS) dated 2/11/26, the resident was dependent on staff for oral care. Another resident, also dependent on staff for oral care per the 3/11/26 MDS, was observed sitting propped up in bed and able to respond with smiles. During the initial observation, the inside of this resident’s lips and upper and lower teeth had a thick, clear, white milky substance visible when the resident tried to open their mouth to smile. Oral care supplies were present in the nightstand, but the resident’s mouth and teeth were not clean. On a subsequent observation with the DON, NHA, and Corporate VP of clinical services, the same resident again had a thick, clear, milky substance between the lips and caking the teeth, which would string between the teeth when the resident attempted to open their mouth, demonstrating a lack of consistent oral care for residents dependent on staff for this ADL.
Incomplete and Inaccurate Medical Record Documentation for Treatments and Assessments
Penalty
Summary
Facility staff failed to maintain complete and accurate medical records and documentation for multiple residents. For one resident with wound care needs, review of the MAR showed that wound care and related treatments were signed as completed on the dates initially reported, despite the resident’s ongoing complaints that wound dressings were not being changed. When additional dates were reviewed, there were missing staff signatures for wound care on two specific dates, as well as three instances where application of A&D ointment to the resident’s feet was not signed off out of 24 days reviewed. Another resident with severe cognitive impairment, as evidenced by a BIMS score of 00, was found to have an injury of unknown origin (a bruise on the left hand). Documentation showed that a change in condition was initiated late in the morning, but a formal pain evaluation was not initiated and completed until that night, and the resident was unable to explain how the injury occurred or verbalize pain using a standard pain scale. For a third resident, documentation related to the admission PPD test was inconsistent and incomplete. The MAR contained an entry indicating “9” for the administration date, meaning “see nurse’s note,” but there was no corresponding nurse’s note. Despite the absence of a signed administration of the PPD injection, staff documented the PPD result as “negative” on the scheduled read date. The resident reported never receiving the PPD injection, and the DON confirmed that the facility had been out of PPD solution at the time, so the test would not have been administered. These findings demonstrate failures in accurate documentation of treatments and assessments, including wound care, pain assessment, and TB screening, as well as missing or incomplete supporting notes in the medical record.
Failure to Implement and Communicate Correct Transmission-Based Precautions
Penalty
Summary
Surveyors identified a deficiency in the facility’s infection prevention and control program related to inconsistent and incorrect implementation of transmission-based precautions and PPE use. During a complaint investigation focused on residents on transmission-based precautions, one resident with a visible Foley catheter was observed in the room with physical therapy, but there were no signs posted indicating any need for PPE, despite the resident being a new admission with a Foley catheter placed related to wounds. In another double-occupancy room, a contact precautions sign was posted at the doorway, but the nurse practitioner was in the room on a personal phone with no PPE, and the assigned GNA was repositioning the resident in bed while wearing only gloves. When questioned, the NP, RN, and GNA all stated that the resident in the room was not on contact precautions, and the GNA reported that signs were hanging at all doors and that this particular resident’s sign was “just wrong.” The surveyor observed the GNA later return to the room and turn the sign around to indicate no PPE requirement. Subsequent interviews revealed that therapy staff relied on posted signage to determine PPE use and that if the sign was wrong, the PPE used would be wrong. Overall, surveyors found problems with signage accuracy and staff awareness of which residents required contact precautions, as well as observed failures to follow appropriate PPE use for residents who should have been on contact precautions.
Inaccurate MDS Coding for Falls, Pain Management, and High-Risk Medications
Penalty
Summary
Facility staff failed to ensure Minimum Data Set (MDS) assessments were accurately coded for two residents reviewed during a complaint survey. For one resident, a facility-reported incident showed that the resident was found seated on the floor beside the bed and was diagnosed with a non-displaced femoral neck impaction fracture of the left hip following an x-ray. Despite this fall with a major injury, the subsequent significant change MDS dated 11/4/25 did not code the fall with major injury in Section J1900C. Review of the resident’s Medication Administration Records for October and November 2025 showed administration of Tylenol on 10/31/25 at 9:30 PM, which fell within the 5-day look-back period for the MDS, but Section J0100 (prn pain) of the same significant change MDS did not capture the use of Tylenol. For another resident, review of a quarterly MDS with an assessment reference date of 10/15/25 showed that Section N0415 (High-Risk Drug Classes) documented the use of an opioid medication. However, review of the resident’s October 2025 Medication Administration Record did not show that the resident had been prescribed an opioid during that period. In both cases, MDS staff later confirmed that these were errors in MDS coding, demonstrating that the assessments did not accurately reflect the residents’ clinical status and medication use as documented in their medical records.
Incomplete Documentation of Narcotic Administration on MAR
Penalty
Summary
The facility failed to maintain complete and accurate medical records in accordance with accepted professional standards for one resident receiving narcotic medication. The resident, admitted in March 2026, had a fall on 3/6/26 and was sent to the hospital on 3/9/26. Review of the March 2026 Medication Administration Record (MAR) showed documentation of a single 25 mg dose of Tramadol administered on 3/8/26 at 9:23 AM. However, review of the resident’s Controlled Drug Receipt/Record/Disposition Form, kept on the nurse’s medication cart and not in the medical record, showed that Tramadol 25 mg was administered three times between 3/8/26 and 3/9/26: at 11:00 AM and 9:00 PM on 3/8/26, and at 9:00 AM on 3/9/26. In interview, the DON stated that staff are expected to document narcotic administration on the MAR and confirmed that only one of the three Tramadol doses reflected on the controlled drug record was documented on the resident’s MAR. This discrepancy between the controlled substance record and the MAR, with missing documentation of two administered doses of Tramadol on the official medical record, constituted the failure to maintain a complete and accurate medical record for the resident.
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