Autumn Lake Healthcare At Glen Burnie
Inspection history, citations, penalties and survey trends for this long-term care facility in Glen Burnie, Maryland.
- Location
- 7355 Furnace Branch Road East, Glen Burnie, Maryland 21060
- CMS Provider Number
- 215266
- Inspections on file
- 17
- Latest survey
- March 5, 2025
- Citations (last 12 mo.)
- 0
Citation history
Health deficiencies cited at Autumn Lake Healthcare At Glen Burnie during CMS and state inspections, most recent first.
The facility failed to update care plans using an interdisciplinary team and did not ensure resident representatives were involved in care plan reviews. A resident with wound issues had an outdated care plan, and another resident's diet orders were not communicated, leading to improper care. Additionally, care plan meetings were not documented or conducted as required for several residents. The DON and staff acknowledged these deficiencies.
The facility failed to provide meals according to the menu and did not respect residents' dietary choices. During a lunch service, a DM substituted a hamburger for the Dijon Pork Loin due to a shortage caused by over-portioning. Ten residents who chose the pork loin received the alternative meal without being informed or given a choice. A resident confirmed she did not request the hamburger. The CDM acknowledged that residents were not informed of the change, although no complaints were reported.
The facility's kitchens exhibited multiple food safety and sanitation deficiencies, including a non-operational plate warming device, unlabeled and improperly stored food, and contaminated kitchen surfaces. Personal items were found on food prep surfaces, and the kitchen ceiling had chipping paint. These issues were confirmed by dietary staff and the Kitchen Account Manager.
The facility failed to ensure consistent attendance of required members at monthly QAPI meetings. A GNA missed four meetings, while the Medical Director and DON each missed one meeting. These absences were confirmed by the DON and Administrator.
The facility failed to implement an effective infection control program, with issues such as outdated oxygen tubing, improper signage for transmission-based precautions, and inadequate use of personal protective equipment for residents requiring enhanced barrier precautions. These deficiencies were observed through staff interviews and medical record reviews, highlighting lapses in protocol adherence.
The facility failed to provide effective communication training for nine staff members, as revealed by missing documentation in their educational files. The Director of HR, responsible for onboarding education, and the DON, overseeing annual education, could not provide additional records, highlighting a deficiency in staff training oversight.
The facility failed to ensure all staff received annual compliance and ethics training, as five staff members lacked documentation of such training. The Director of HR, responsible for onboarding education, and the DON, responsible for annual education, did not have a staff educator in place. Despite additional documentation, the files for these staff members still lacked evidence of the required training.
The facility did not honor the dining preferences of three residents, as documented in their care plans, during a survey. Breakfast trays were delivered to the unit, but only one resident was in the dining area. Interviews revealed that the residents preferred to eat in the dining room, a preference documented in their records. The DON was initially unaware of the documentation but later confirmed the residents' rights to choose their dining location.
A facility failed to provide a resident with necessary information to formulate an advance directive, despite the resident expressing interest in doing so. The resident's records showed two assessments indicating interest, but no follow-up or provision of information was documented. Interviews revealed that Social Services is responsible for offering assistance, but this was not reflected in the resident's documentation, leading to a deficiency noted by surveyors.
A resident on dialysis experienced a dietary change from a renal diet to a regular diet without being notified, as required by facility protocol. The facility's staff failed to document any notification to the resident or their family, which was confirmed by the DON and acknowledged by the Nursing Home Administrator during a complaint investigation.
The facility failed to follow its grievance process, as two residents reported issues with missing and damaged personal items that were not documented or addressed. One resident's missing items were acknowledged by staff but not replaced, while another resident's damaged clothing was reported but not documented. The NHA was unaware of these grievances until the surveyor's intervention, indicating a breakdown in the facility's grievance handling.
The facility failed to implement its policies for abuse, neglect, and exploitation, as well as its policy for employment background investigations. A GNA was employed despite having a criminal background and suspended credentials due to errors in the background check process, including incorrect name entry and misspellings. The HR Director admitted to the mistake, which led to the oversight.
A resident reported a sexual abuse incident involving a GNA to a Kitchen Account Manager weeks after it occurred. Despite notifying the Director of Nursing, the facility delayed reporting to authorities. The resident had already informed the police before the facility's report. Discrepancies in the reporting timeline and staff actions were noted, including a Unit Manager advising against reporting the allegation.
A facility failed to thoroughly investigate abuse allegations involving a resident, lacking key documentation and interviews. In one case, conflicting staff statements were not addressed, and in another, a delayed investigation into a sexual abuse report was noted. The facility's leadership acknowledged the deficiencies but provided no further information.
A facility failed to notify a resident or their representative in writing about the bed hold policy during a transfer to an acute care facility. The medical record lacked evidence of notification, and interviews with LPN staff confirmed the policy was not completed or provided. The DON could not produce written evidence of the notification.
A facility failed to accurately document a resident's dental status in the MDS assessment. The resident had missing and loose teeth, but the MDS did not reflect these issues. Staff interviews confirmed the oversight, and the DON acknowledged the discrepancy.
A facility failed to complete a Level II PASARR evaluation for a resident before admission. The resident's PASARR Level I screening indicated a need for referral to AERS, but this was not done. A Social Services designee confirmed understanding of the referral process, and the DON acknowledged the findings.
The facility failed to provide baseline care plan summaries, including medication lists, to three residents within 48 hours of admission. A resident reported not receiving their care plan summary, and the DON confirmed the lack of documentation. Another resident's care plans were completed late, and for a third resident, there was no evidence that the care plan was reviewed with them or their representative.
The facility failed to develop comprehensive care plans for three residents, leading to deficiencies in addressing their medical, nursing, mental, and psychosocial needs. One resident lacked a care plan for oxygen therapy, another had unaddressed dental issues and a change to palliative care, and a third resident with PTSD and depression had an incomplete care plan. Staff interviews revealed gaps in care plan updates and documentation.
A resident dependent on staff for personal hygiene did not receive scheduled showers, as documented inconsistencies showed only three showers provided over two months. Staff interviews revealed a lack of awareness and adherence to the shower schedule, and the DON confirmed the resident was not offered showers as planned.
A facility failed to provide an ongoing program of activities for a bedbound, alert but non-verbal resident. Despite documented preferences for group activities and religious services, the resident was often left in bed with only the TV on. Staff interviews revealed inconsistencies in activity provision, particularly during the resident's isolation period, contrary to facility policies.
The facility failed to ensure follow-up care for a resident with Crohn's disease and did not carry out a lab order for a resident on anticoagulant therapy. The GI follow-up was not scheduled as recommended, and the lab order was incompletely entered, leading to it not being drawn. These deficiencies were confirmed by the DON and unit manager.
A facility failed to monitor a resident's weight according to its protocol, which required weekly weights for the first four weeks post-admission. The resident, assessed as underweight and at risk of malnutrition, had only two weights recorded over a period of nearly two months. Interviews with the RD and DON confirmed that the expected weight monitoring was not conducted due to nursing staff not obtaining the necessary weights.
Two residents in the facility experienced deficiencies in respiratory care. One resident received oxygen at an incorrect flow rate, and the tubing was not labeled as required. Another resident with a tracheostomy had no comprehensive care plan addressing their respiratory needs, despite having serious medical conditions. These issues were identified during a survey, indicating a failure to meet professional standards in respiratory care.
The facility failed to manage pain appropriately for three residents. A resident with severe trachea pain did not receive documented non-pharmacological interventions before PRN medication, and their care plan was incomplete. Another resident received Oxycodone more than two hours late on multiple occasions, causing significant pain. A third resident with dental issues did not have pain assessments or progress notes documented, despite receiving Tylenol. The DON confirmed these deficiencies.
A facility failed to provide trauma-informed care for a resident with PTSD, leading to potential re-traumatization. The resident expressed a desire to leave and dissatisfaction with current care, preferring a VA psychiatrist. Despite psychiatric and psychological services, there was inadequate documentation of mood and behavior monitoring and the effectiveness of prescribed medication.
A resident experienced delays in receiving recommended dental services due to insurance issues and scheduling problems, resulting in ongoing pain and a downgraded diet. Despite a doctor's order for dental procedures and multiple consultations, the facility failed to ensure timely care, as confirmed by staff interviews and medical record reviews.
The facility failed to provide timely dental services for two residents. One resident struggled to get a dental appointment despite having a care plan for dental issues, and their name was missing from the appointment book. Another resident had not seen a dentist in two years, despite having an order for annual consultations. The DON confirmed the oversight and acknowledged the residents should have received dental care.
A facility failed to accurately document a resident's pressure ulcer treatment. The resident had wounds on the sacrum, right heel, and left heel, with the left heel ulcer documented as resolved but later worsening. Despite this, the Treatment Administration Records continued to order Betadine treatment, which was inappropriate for healed skin. A wound consultation doctor confirmed the misuse of Betadine, and the DON acknowledged the treatment order should have been discontinued.
The facility, licensed for 190 beds, failed to employ a full-time qualified social worker, relying instead on part-time workers and a full-time designee without a qualifying degree. This deficiency was identified during a survey, revealing the absence of a full-time social worker since January 2025, potentially affecting all residents.
Surveyors found deficiencies in the facility's maintenance, including exterior debris staining, broken window screens, and stained ceiling tiles from water damage. The Director of Maintenance acknowledged these issues, citing a lack of scheduled repairs. A family member raised concerns about a broken window screen and non-functional window shade in a resident's room. The Nursing Home Administrator was informed of these issues, which were only addressed after surveyor intervention.
The facility failed to complete the annual in-service training for a GNA, as revealed during a survey. The GNA's educational file lacked documentation of the required training. Interviews with the Director of Human Resources and the DON highlighted confusion over who was responsible for staff education, with no staff educator currently in place. Despite additional documentation being provided, no records of the annual training were found.
The facility failed to provide documentation of behavioral health training for three staff members during a survey. Interviews revealed missing training records and a lack of verification for some staff training. Despite additional documentation being provided, the records for these staff members still lacked evidence of behavioral health training.
The facility's assessment inaccurately documented resources, including a special care unit, a full-time social worker, and the infection preventionist (IP) role. The NHA and DON acknowledged errors, such as misidentifying a secure unit as a specialty care unit and failing to list the IP's role. The facility, with over 120 beds, lacked a full-time social worker, relying instead on a contract social worker and PRN staff.
Deficiencies in Care Plan Updates and Interdisciplinary Team Involvement
Penalty
Summary
The facility failed to use an interdisciplinary team to revise care plans to meet residents' needs and did not ensure that residents' representatives were offered opportunities to participate in care plan reviews. This was evident in several cases, including a resident with circulation problems and wound healing issues. Despite a podiatrist's recommendation for hospital transfer due to a wound infection, the care plan was not updated to reflect the change in the resident's condition. The Director of Nursing (DON) acknowledged that the care plan should have been updated following the new skin infection. Another deficiency involved a resident with a diet order that included aspiration precautions and no straw use. The facility failed to communicate these orders to the staff, resulting in the resident using a straw. The dietician and nurse were unable to explain how the information was communicated, and the unit manager confirmed that the order was missed and not included in the care plan. The DON acknowledged that the order was not initiated on the care plan, leading to staff being unaware of the precautions. Additionally, the facility did not conduct care plan meetings as required for several residents. One resident's care plan meeting was repeatedly rescheduled, and there was no documentation of a meeting with the resident's representative. Another resident's care plan was not updated for 17 months, and the facility failed to document care plan meetings for yet another resident. The DON and other staff members acknowledged these deficiencies, indicating a lack of proper documentation and communication regarding care plan meetings and updates.
Failure to Provide Menu-Listed Meals and Respect Dietary Choices
Penalty
Summary
The facility failed to provide meals according to the established menu and did not respect residents' dietary choices during a recertification/complaint survey. The Certified Dietary Manager (CDM) explained that residents typically receive the Regular meal unless they request an alternative. However, during the lunch service, the District Manager (DM) altered a meal ticket to substitute a hamburger for the Dijon Pork Loin, which was the Regular meal option. This substitution occurred because the facility ran out of pork loin due to over-portioning by a dietary staff member. As a result, 10 residents who had chosen the pork loin did not receive it and were instead given the alternative meal without being informed or given a choice. Resident #523, one of the affected residents, confirmed that she did not request the hamburger and did not want it. The Director of Nursing later provided a list of 10 residents who did not receive the pork loin they had selected. The CDM admitted that the residents who received the alternative meal were not informed or given a choice prior to receiving it, although he noted there were no complaints. This incident highlights a failure in meal service management and communication with residents regarding their dietary preferences.
Food Safety and Sanitation Deficiencies in Facility Kitchens
Penalty
Summary
The facility failed to maintain proper food safety and sanitation standards in its kitchens, as observed during a recertification and complaint survey. The surveyor noted several deficiencies, including a non-operational plate warming device, unlabeled food items, and inaccuracies in food discard dates. Additionally, there were instances of adulterated food, uncovered stored food, and kitchen surfaces contaminated with dust and debris. Personal belongings were found on food preparation surfaces, and the kitchen ceiling had chipping paint, all of which were confirmed by dietary staff and the Kitchen Account Manager (KAM). During the initial tour of the main kitchen, the surveyor observed peeling plastic and black debris on the dishwasher, orange splattering on walls and floors, and liquid stains on the ice machine. There were also no paper towels at the handwashing sink, spilled white powder on the floor, and unlabeled food items in the freezer and refrigerator. In the second kitchen, personal items were found on food preparation tables, and the ceiling had peeling paint. The surveyor also noted a broken dish crate with dried food debris and a hand-held device resting on the floor. The surveyor found several issues with food storage and labeling, including containers with blank labels, expired pancake batter, and uncovered food items with no dates. The plate warming system was not functioning properly, as indicated by cold plates and a non-working indicator light. The KAM acknowledged these concerns and attempted to address them with the staff, but the issues persisted, indicating a lack of adherence to professional food safety standards.
Inconsistent Attendance at QAPI Meetings
Penalty
Summary
The facility staff failed to ensure consistent attendance of required committee members at the monthly Quality Assurance and Performance Improvement (QAPI) meetings. The facility's QAPI Plan policy mandates the inclusion of specific members such as the Administrator, Director of Nursing (DON), Quality Assurance (QA) Coordinator, Infection Preventionist (IP), Staff Development, Department Heads, Vendors (including pharmacy), and a Geriatric Nursing Assistant (GNA). However, a review of the facility's QAPI monthly attendance records from January 2024 to December 2024 revealed that a GNA missed four meetings, the Medical Director missed one meeting, and the DON missed one meeting. These absences were confirmed by the DON and Administrator during an interview with the surveyor.
Infection Control Deficiencies in LTC Facility
Penalty
Summary
The facility failed to implement an effective infection control program, as evidenced by several deficiencies observed during the survey. One significant issue was the failure to change oxygen tubing for a resident as per the facility's protocol. The tubing was observed to be 16 days old, despite the facility's policy to change it weekly. This oversight was confirmed by a Licensed Practical Nurse (LPN) and was not initially documented in the resident's medical records. Additionally, the facility did not maintain proper transmission-based precautions and enhanced barrier precaution protocols. Posters indicating special droplet/contact precautions were left on the doors of rooms long after a COVID-19 outbreak had been resolved, and residents in those rooms did not have conditions requiring such precautions. This was confirmed through interviews with staff and medical record reviews, revealing a lack of communication and adherence to updated protocols. Further deficiencies were noted in the handling of residents requiring enhanced barrier precautions. For instance, a resident with a positive Clostridium difficile result did not have an order for contact isolation precautions, and staff were not properly disposing of personal protective equipment. Another resident with a gastrostomy tube did not have a care plan for enhanced barrier precautions, and staff were observed not wearing the required personal protective equipment during care. These lapses indicate a failure to consistently apply infection control measures across the facility.
Lack of Effective Communication Training for Staff
Penalty
Summary
The facility failed to ensure that staff received training in effective communication, as evidenced by the lack of documentation for such training in the files of nine staff members reviewed during the Extended Survey investigation. Interviews and record reviews revealed that the Director of Human Resources (HR) was responsible for onboarding education, while the Director of Nursing (DON) or nursing staff handled annual education. However, there was no staff educator in place, and the HR Director could not provide additional training records beyond what was initially available. During the survey, it was discovered that the employee educational files for the nine staff members lacked documentation of effective communication training. Despite the HR Director's efforts to check an old education system and provide additional documentation, the files remained incomplete. The absence of a staff educator and the reliance on the HR Director and nursing staff for training oversight contributed to the deficiency in ensuring effective communication training for the staff.
Deficiency in Staff Compliance and Ethics Training
Penalty
Summary
The facility failed to ensure that all staff received their annual training for the compliance and ethics program, as evidenced by the lack of documentation for five out of nine staff members reviewed during the Extended Survey investigation portion of the recertification/complaint survey. Interviews and record reviews revealed that the Director of Human Resources (HR) was responsible for onboarding education, while the Director of Nursing (DON) or nursing staff handled annual education. However, there was no staff educator currently in place. Despite additional documentation being provided, the files for Staff #42, #43, #44, #46, and #47 still lacked evidence of compliance and ethics training. The Director of HR confirmed that no further training records were available for these staff members.
Failure to Honor Resident Dining Preferences
Penalty
Summary
The facility failed to honor the documented dining preferences of three residents during a recertification/complaint survey. Observations and interviews revealed that breakfast trays were delivered to the unit, but only one resident was present in the dining area. Registered Nurse (RN #28) indicated that most residents stayed in their rooms for breakfast, but did not confirm if this was their preference. Upon interviewing the residents, three of them expressed a preference to eat breakfast in the dining room, which was also documented in their baseline care plans. Further interviews with the Director of Nursing (DON) revealed a lack of awareness regarding the assessment and documentation of residents' dining preferences. The DON initially stated that dining preferences were not documented, but later acknowledged that the preferences were indeed recorded in the medical records. The DON confirmed that residents have the right to choose where they eat, and the failure to honor these preferences was acknowledged during the surveyor's interview.
Failure to Provide Information for Advance Directive Formulation
Penalty
Summary
The facility failed to provide a resident with information necessary to formulate an advance directive, as required by their policy. During the recertification/complaint survey, it was found that a resident did not have documentation related to advance directives in their paper chart or electronic medical record. Interviews with the Unit Manager and the Director of Nursing revealed that the process for new admissions involves Social Services offering information to residents who do not have an advance directive. However, the resident's records showed two assessments indicating interest in developing an advance directive, but no follow-up or provision of information was documented. Social Services staff confirmed that an initial assessment is conducted within 72 hours of admission, and if a resident does not have an advance directive, they are offered assistance in completing one. Despite this process, the resident's records lacked any notes or documentation of follow-up actions after expressing interest in formulating an advance directive. The facility's policy requires that decisions regarding advance directives be periodically reviewed, but this was not evident in the resident's case, leading to the deficiency noted by the surveyors.
Failure to Notify Resident of Dietary Change
Penalty
Summary
The facility failed to notify a resident or their appointed family members after a dietary change, which was identified during a complaint investigation. The resident, who was on dialysis, was initially placed on a renal diet upon admission to the facility. However, the diet was changed to a regular diet with regular texture the following day. Despite this change, there was no documentation in the electronic health record indicating that the resident or their responsible party had been informed of the diet change. The surveyor's review of records and interviews with facility staff revealed that the responsibility for notifying the resident or family members of changes in care or treatment lay with the staff member entering the change notes in the electronic record. The Director of Nursing confirmed that the nurse should have informed the resident and/or the family member and documented the notification, but this did not occur. The Nursing Home Administrator acknowledged the oversight when informed by the surveyor.
Failure to Follow Grievance Process for Residents
Penalty
Summary
The facility failed to adhere to its grievance process, as evidenced by the experiences of two residents. Resident #9 reported missing personal items, including headbands and beads, which were acknowledged by the laundry staff but not replaced. Despite the resident's complaints, there was no documentation of the grievance, and the Nursing Home Administrator (NHA) was unaware of the issue. The laundry manager also confirmed a lack of awareness about the missing items, indicating a breakdown in communication and follow-up within the facility's grievance process. Resident #151 experienced damage to clothing items, with grease and bleach-like stains observed by the surveyor. The resident had previously reported these issues to the unit manager, but no documentation or formal grievance was recorded. The NHA confirmed the absence of any grievance documentation related to the damaged clothing until after the surveyor's intervention. These incidents highlight the facility's failure to properly document and address resident grievances, as required by their policy.
Failure to Implement Background Check Policies
Penalty
Summary
The facility failed to implement its policies for abuse, neglect, and exploitation, as well as its policy for employment background investigations. This was evident in the case of a Geriatric Nursing Assistant (GNA) who was actively employed at the facility despite having a criminal background and suspended credentials. The surveyor discovered that the background check for this employee was improperly conducted, with the last name entered in the first name field and misspelled, resulting in no background information being retrieved. Additionally, the national public sex offender check was performed with the incorrect spelling of the last name, further compromising the accuracy of the background check. The facility's Human Resources Director admitted to the error in inputting the names into the background check system and was unaware that the order of the first and last names mattered. The facility's policies required job reference checks, licensure verifications, and criminal conviction record checks for all personnel applying for employment, but these were not properly executed in this case. The facility's failure to adhere to its own policies resulted in the employment of an individual with a criminal background and suspended credentials, which was only discovered after surveyor intervention.
Failure to Timely Report Abuse Allegation
Penalty
Summary
The facility failed to ensure timely reporting of abuse allegations concerning a resident who reported a sexual abuse incident involving a Geriatric Nursing Assistant (GNA). The resident initially reported the concern to the Kitchen Account Manager approximately two and a half weeks after the incident occurred. Despite the resident's efforts to report the incident to the Director of Nursing, the facility's documentation indicated that the staff became aware of the incident on a later date, and the report to the Office of Health Care Quality was submitted on the same day. The police and ombudsman were notified on the same day as well, but the resident had already reported the incident to the police two days earlier. The investigation revealed discrepancies in the facility's reporting timeline and actions taken by staff. The Kitchen Account Manager informed a Unit Manager, who reportedly advised the resident that it was not necessary to report the allegation. The facility's Administrator confirmed the completeness of the investigative files, which included grievance forms and a concern form documenting the resident's preference for female care providers. An anonymous source provided additional documentation indicating the resident had informed them of the incident prior to the facility's awareness. The surveyor's review highlighted the facility's failure to act promptly and appropriately in response to the resident's allegations.
Inadequate Investigation of Abuse Allegations
Penalty
Summary
The facility failed to conduct a thorough investigation into allegations of abuse involving a resident. The investigation file for one incident lacked critical documentation, including statements from key staff members and evidence of interviews conducted. There was no documentation of an interview attempt with the resident, despite the facility's self-report indicating the resident declined an interview. Additionally, conflicting staff statements regarding the location of an alleged assault were not further investigated, and there was no documentation regarding the deprivation of goods and services allegation. In another incident, the facility did not adequately investigate a resident's report of sexual abuse by a Geriatric Nursing Assistant. The resident initially reported the incident to a staff member, who informed a Unit Manager, but the investigation was not initiated until several weeks later. The investigative file lacked statements from key staff involved in the initial report and did not address discrepancies in the facility's self-report. The GNA in question was not suspended until the investigation began, despite the resident's report to the police. Throughout the survey, the facility's Administrator was unable to provide additional information or clarification regarding the deficiencies identified. The surveyor's concerns were acknowledged by the facility's leadership, but no further information was provided before the surveyor's exit. The lack of thorough investigation and documentation in these cases highlights significant deficiencies in the facility's handling of abuse allegations.
Failure to Notify Resident of Bed Hold Policy
Penalty
Summary
The facility failed to notify a resident or the resident's representative in writing about the bed hold policy when the resident was transferred to an acute care facility. This deficiency was identified during a recertification/complaint survey for a resident who was admitted to the facility and later sent to an acute care facility due to a change in medical condition. The medical record review revealed no written evidence that the resident or their representative received the bed hold policy notice. Interviews with LPN staff indicated that the bed hold policy was not completed or provided to the resident or their representative. The Director of Nursing was unable to produce written evidence of the notification, despite providing a copy of the bed hold policy.
Inaccurate MDS Assessment of Resident's Dental Status
Penalty
Summary
The facility failed to accurately assess and document the dental status of a resident during the annual Minimum Data Set (MDS) assessment. The resident was observed by a surveyor to have missing teeth and loose incisors, yet the MDS assessment completed months earlier did not reflect any oral or dental issues. This discrepancy was confirmed through interviews with the nursing staff and MDS personnel, who acknowledged that the resident's dental problems were not accurately recorded in the MDS. Further investigation revealed that the resident had a doctor's order for a dental consult due to a failing dental bridge, with a recommendation for extraction. However, the dental procedure was pending, and the resident's dental consults were delayed. The Director of Nursing (DON) acknowledged the discrepancy in the MDS documentation, confirming that the resident's dental issues were not accurately captured, which led to the deficiency noted during the survey.
Failure to Complete PASARR Level II Evaluation
Penalty
Summary
The facility failed to ensure the completion of a Level II Preadmission Screening and Resident Review (PASARR) for a resident before their admission. The medical record review revealed that a PASARR Level I screening was conducted on 01/11/2023, which indicated the need for a referral to Adult Evaluation and Review Services (AERS) for a Level II evaluation. However, this referral was not made. During an interview, a Social Services designee confirmed understanding of the process that positive PASARR Level I results should be sent to AERS for further evaluation. The Director of Nursing acknowledged these findings upon review.
Failure to Provide Baseline Care Plan Summaries
Penalty
Summary
The facility failed to ensure that residents and/or their representatives were provided with summaries of their baseline care plans, including a list of medications, within 48 hours of admission. This deficiency was identified during a recertification/complaint survey for three residents. Resident #57 reported not receiving a summary of their baseline care plan or medication list, and a review of their medical record confirmed the absence of documentation indicating that the summary was provided. The Director of Nursing (DON) acknowledged the lack of documentation for Resident #57. For Resident #145, the baseline care plans were initiated but completed late, as confirmed by the DON. Similarly, for Resident #5, although the baseline care plan was completed in the electronic system, there was no documentation to verify that it was presented and reviewed with the resident or their representative within the required timeframe. The DON confirmed the absence of such documentation for Resident #5 as well.
Deficiencies in Comprehensive Care Planning
Penalty
Summary
The facility failed to develop comprehensive person-centered care plans for three residents, leading to deficiencies in addressing their medical, nursing, mental, and psychosocial needs. For one resident, the medical record indicated a physician's order for continuous oxygen therapy due to acute respiratory failure and heart conditions. However, the care plan lacked any focus, goals, or interventions related to the use of supplemental oxygen, as confirmed by the Director of Nursing during an interview. Another resident was observed with significant dental issues, including missing and loose teeth, and had a pending dental procedure. Despite these concerns, the care plan did not reflect the resident's dental issues or the change to palliative care. Interviews with staff revealed that each department was responsible for updating care plans, but the dental issues were not documented in the care conference notes or addressed in the care plan. A third resident with a history of PTSD and depression had an incomplete care plan. Although the resident had been diagnosed with PTSD and exhibited depression, the care plan for trauma-informed care was canceled, and no additional plan was developed. The resident was prescribed an antidepressant for anxiety and agitation, but there was no care plan addressing mood and behavior or the use of psychotropic medication. Interviews with social services staff indicated a lack of assessment for PTSD, and the Director of Nursing acknowledged the deficiency in the care plan for PTSD.
Failure to Provide Scheduled Showers for Dependent Resident
Penalty
Summary
The facility staff failed to ensure that a dependent resident's personal hygiene needs were adequately met by not providing showers as scheduled. The resident, who was totally dependent on staff for personal hygiene, reported not receiving showers for the past two years and expressed a preference for showers over bed baths. The resident's care plan indicated a need for showers per schedule, but the facility's documentation showed inconsistencies in providing these showers. The review of the resident's shower schedule revealed that the resident was supposed to receive showers every Monday and Thursday. However, documentation showed that the resident only received showers twice in January and once in February. There were multiple instances where the staff marked 'Not applicable' or 'No' on the shower sheets without proper documentation or explanation, and there were no records of the resident refusing showers on certain dates as claimed by the staff. Interviews with facility staff, including a Geriatric Nursing Assistant, a Registered Nurse, and the Unit Manager, revealed a lack of awareness and adherence to the resident's shower schedule. The Director of Nursing confirmed the discrepancies in the shower schedule and acknowledged that the resident was not being offered or given showers as per the schedule. The facility's failure to provide the scheduled showers and adequately document refusals or reasons for not providing showers contributed to the deficiency.
Failure to Provide Ongoing Activities for Bedbound Resident
Penalty
Summary
The facility failed to provide an ongoing program to support residents in their choice of activities, as evidenced by the case of a bedbound, alert but non-verbal resident. The resident's healthcare representatives expressed concerns that the facility did not attempt to engage the resident in any activities, despite the resident's preferences for group activities and religious services being documented as very important. Observations confirmed that the resident was often left in bed with only the TV on, and there was no evidence of other activities being provided. Interviews with staff revealed a lack of clarity and consistency in the provision of activities for the resident. The activity director stated that one-to-one activities were scheduled twice a week, but a review of the participation log showed gaps in service, particularly when the resident was placed on isolation precautions. The Director of Nursing confirmed that activities should have continued despite the isolation status, indicating a failure to adhere to the facility's policies for ongoing activity provision.
Failure to Ensure Follow-Up Care and Lab Orders
Penalty
Summary
The facility failed to ensure proper follow-up care for two residents, leading to deficiencies in their treatment plans. For one resident with Crohn's disease, the facility did not schedule a follow-up appointment with a gastrointestinal (GI) specialist as recommended. The resident had been seen by the GI specialist, who ordered as-needed medication and recommended a follow-up in three months. However, the facility did not arrange any further appointments, which was confirmed by the Director of Nursing (DON) during an interview. In another case, the facility did not carry out a physician's order for an anticoagulant lab draw for a resident on Apixaban therapy. The lab order was entered incompletely into the Electronic Health Record (EHR) and was not entered into the Diamond Lab system, resulting in the lab not being drawn. This oversight was confirmed by the unit manager and validated by the DON during interviews with the surveyor. These failures highlight lapses in the facility's processes for ensuring residents receive timely and appropriate medical care.
Failure to Monitor Resident's Weight as per Facility Protocol
Penalty
Summary
The facility failed to adequately monitor the weight of a resident who was assessed as underweight and at risk of malnutrition. According to the facility's policy and standard practice, residents should be weighed on admission, weekly for the first four weeks, and then monthly. However, for this particular resident, only two weights were recorded during the current admission period, which spanned from December 2024 to February 2025. The resident was readmitted with a weight of 105 lbs, but subsequent weekly weights were not documented as required. Interviews with facility staff, including the Registered Dietician (RD) and the Director of Nursing (DON), confirmed that the expected protocol was not followed. The RD stated that she did not receive the necessary weights from the nursing staff, which led to a lapse in monitoring the resident's nutritional status. The DON reiterated the facility's policy of weekly weights for the first four weeks post-admission, but this was not adhered to in the case of the resident in question.
Deficiencies in Respiratory Care and Care Planning
Penalty
Summary
The facility staff failed to provide appropriate respiratory care for two residents, leading to deficiencies in oxygen administration and care planning. For one resident, the oxygen was administered at a flow rate of 1.5 liters per minute, contrary to the physician's order of 2 liters per minute. Additionally, the oxygen tubing was not labeled with the date and initials of the nurse who changed it, as required by facility protocol. This oversight was confirmed by both the Unit Manager and the Registered Nurse during interviews with the surveyor. Another resident with a tracheostomy was observed using oxygen via a trach collar, but the care plan did not include any focus, goals, or interventions for respiratory or tracheostomy care. Despite having multiple medical diagnoses, including chronic respiratory failure and cancer, the resident's care plan was not comprehensive or resident-centered. The Director of Nursing acknowledged the omission and confirmed that the care plan should have addressed the resident's tracheostomy and oxygen therapy needs. The lack of proper labeling and adherence to physician orders, along with the incomplete care plan, demonstrate a failure to provide respiratory care consistent with professional standards. These deficiencies were identified during a recertification and complaint survey, highlighting the need for improved documentation and adherence to care protocols for residents requiring respiratory support.
Inadequate Pain Management and Documentation in LTC Facility
Penalty
Summary
The facility staff failed to provide appropriate pain management for three residents, as identified during a recertification and complaint survey. Resident #115 experienced severe pain around the trachea area, but the staff did not document attempts of non-pharmacological interventions before administering PRN pain medications, as required by physician orders. Additionally, the care plan for Resident #115 was incomplete, lacking specific goals and interventions for pain management, and did not address non-pharmacological interventions or monitoring for medication side effects. Resident #431 did not receive their scheduled Oxycodone medication on time, with delays of more than two hours on seven occasions in June 2024. The Director of Nursing confirmed that the facility's policy requires medications to be administered within an hour before or after the scheduled time, indicating a failure to adhere to this policy. This resulted in the resident experiencing significant pain due to the late administration of their pain medication. Resident #38 had a physician order for a dental consult due to a loose dental bridge and required implants removal. However, the facility did not conduct a pain assessment or document progress notes regarding the resident's dental pain. The resident received Tylenol on several occasions, but there was no documentation of pain assessment or the effectiveness of the medication. The resident's diet consistency was downgraded due to dental pain, as confirmed by an LPN and the Director of Nursing.
Failure to Provide Trauma-Informed Care for Resident with PTSD
Penalty
Summary
The facility failed to provide culturally competent, trauma-informed care for a resident with PTSD, leading to potential re-traumatization. The resident expressed feelings of having nothing to do and a desire to leave the facility. Despite receiving psychiatric and psychological services, there was a lack of documentation regarding the monitoring of mood and behavior changes, as well as the effectiveness of psychoactive medication prescribed for anxiety and agitation. The resident had a history of PTSD and was not initially on psychoactive medication, but later started on Lexapro 5 mg daily. The resident's psychiatric evaluations noted anxiety, agitation, and attempts to elope, yet there was no documentation of mood and behavior monitoring. The resident expressed a preference to be seen by a psychiatrist from the Veterans Administration, indicating dissatisfaction with the current care. Psychological services confirmed the resident's depression at various times, but the facility did not adequately document or address the resident's mental health needs, contributing to the deficiency in providing trauma-informed care.
Failure to Provide Timely Dental Care
Penalty
Summary
The facility failed to ensure that a resident received timely dental services, as evidenced by the case of a resident who was observed with missing teeth and loose incisors. The resident, admitted in April 2022, had a doctor's order from July 2024 recommending the extraction of a failing dental bridge. However, the procedure was delayed, and the resident's diet was downgraded due to pain from dental issues. The resident's medical records indicated that a dental appointment in August 2024 was not completed due to insurance clarification issues, and subsequent appointments were either delayed or rescheduled. Interviews with facility staff revealed that the resident experienced pain due to dental implant issues and had VA insurance, which contributed to treatment delays. Despite a consult recommending a follow-up visit in January 2025, the appointment was rescheduled, and the resident continued to experience dental pain. The unit manager confirmed the delays in dental consultations and appointments, highlighting the facility's failure to provide prompt dental care as required.
Failure to Provide Timely Dental Services
Penalty
Summary
The facility failed to ensure timely dental services for residents requiring routine or emergent care, as evidenced by the cases of two residents. One resident expressed difficulty in obtaining a dental appointment for missing and cavity-ridden teeth. Despite a care plan indicating the need for dental care and transportation arrangements, the resident's name was not found in the dental appointment book for the past three months. The Director of Nursing (DON) confirmed that the resident was not on the list for dental services until the surveyor's intervention. Another resident reported not having seen a dentist in two years, despite having an order for annual dental consultations. The resident had been at the facility for over a year, with previous dental consultations ordered but not fulfilled. The DON acknowledged that the resident should have been seen annually and confirmed that the dental service provider had no record of seeing the resident for any consultations.
Inaccurate Documentation of Pressure Ulcer Treatment
Penalty
Summary
The facility failed to ensure accurate documentation of a resident's health condition, specifically regarding pressure ulcers. A review of the medical records for a resident revealed that upon admission, the resident had wounds on the sacrum, right heel, and left heel. The left heel pressure ulcer was documented as resolved on July 24, 2024, but was noted to have worsened again by August 28, 2024. Despite this, the Treatment Administration Records (TAR) for July and August 2024 continued to document an order for Betadine treatment and leaving the wound open to air, which was inappropriate for healed skin. A wound consultation doctor confirmed that Betadine should not be used on healed skin and that treatment orders should be revised based on the wound's condition. The Director of Nursing acknowledged that the treatment order should have been discontinued when the wound was resolved, validating the surveyor's concerns about inaccurate documentation.
Facility Lacks Full-Time Qualified Social Worker
Penalty
Summary
The facility failed to employ a full-time qualified social worker despite having more than 120 licensed beds, specifically 190 certified beds. During the recertification and complaint survey, it was discovered that the facility's licensed social worker only visited once a month, and the facility relied on three part-time social workers. Additionally, a full-time social services designee was employed, but she did not possess a qualifying bachelor's degree or license. Interviews with the Nursing Home Administrator (NHA) and the Director of Nursing (DON) confirmed this arrangement, and the facility was unable to provide documentation proving the designee's qualifications. The deficiency was further highlighted when the NHA and DON acknowledged that the facility had been without a qualified full-time licensed social worker since January 2025, following the departure of the previous social worker on January 17, 2025. The lack of a full-time social worker led to an extended survey, and the facility was informed of the concern during the exit conference. The absence of a qualified full-time social worker had the potential to affect all residents in the facility.
Facility Fails to Maintain Exterior and Interior Environments
Penalty
Summary
The facility failed to maintain the exterior environment and make necessary repairs in resident areas, as observed during a recertification and complaint survey. Surveyors noted black and green debris staining on the exterior surfaces of the main building, broken and frayed window screens, and windows with a white, cloudy appearance. The Director of Maintenance acknowledged these issues, stating that the facility had not scheduled power washing or window replacements, despite recommendations from an outside contractor. A family member also expressed concerns about a broken window screen and a non-functional interior window shade in a resident's room. Inside the facility, surveyors observed stained ceiling tiles from water damage in shared bathrooms of resident rooms, as well as a damaged headboard in a resident's room. The Maintenance Director explained that the water damage was due to an overflowing toilet on the floor above, and acknowledged that the maintenance logs and electronic repair system were in place to address such issues. However, he was unaware of the stained ceiling tiles as no work order had been submitted. The Nursing Home Administrator was informed of these environmental concerns, including the damaged headboard, stained and loose ceiling tiles, and other maintenance issues. The Administrator stated that they would follow up with the maintenance department to address these concerns. The report indicates that these deficiencies were only addressed after surveyor intervention, highlighting a lack of proactive maintenance and repair efforts by the facility.
Failure to Complete Annual Nurse Aide Training
Penalty
Summary
The facility failed to complete the annual nurse aide in-service training for one of the three nurse aides reviewed during the recertification/complaint survey. This deficiency was identified for Staff #6, a GNA, whose employee educational file lacked documentation of the required annual training. Interviews with the Director of Human Resources (Staff #41) and the Director of Nursing (DON) revealed that there was confusion and lack of oversight regarding the responsibility for staff education. Staff #41, responsible for onboarding education, indicated that the DON or nursing staff were supposed to handle annual education, but there was no staff educator currently in place. Despite additional documentation being provided, no records of the annual training for Staff #6 were found, confirming the deficiency.
Lack of Behavioral Health Training Documentation for Staff
Penalty
Summary
The facility failed to ensure that all staff received behavioral health training, as required by the facility assessment. During the Extended Survey investigation portion of the recertification/complaint survey, it was found that three out of nine staff members reviewed did not have documentation of behavioral health training. Interviews with the Director of Human Resources and the Director of Nursing revealed that there were missing training records and a lack of verification for some staff training. Despite additional documentation being provided, the records for the three staff members still lacked evidence of behavioral health training. The Director of Human Resources, who oversees staff education, confirmed that there were no additional training records available for these staff members.
Inaccurate Facility Assessment and Resource Documentation
Penalty
Summary
The facility failed to accurately assess and update its Facility Assessment, which is crucial for determining the resources necessary to care for residents competently. The assessment inaccurately documented the presence of a special care unit, the availability of a full-time social worker, and the role of the infection preventionist (IP). Specifically, the Nursing Home Administrator (NHA) and the Director of Nursing (DON) acknowledged that the facility's secure unit was incorrectly identified as a specialty care unit. Additionally, the assessment inaccurately listed a full-time social worker, whereas the facility only had a contract social worker visiting once per month and two PRN social workers. Furthermore, the Facility Assessment failed to identify the role of the IP, which was covered by LPN #27 and the DON. The surveyor informed the NHA and the DON that a facility with a bed capacity of 120 or more is required to have a full-time qualified social worker, and the omission of the IP's role was a significant oversight. These inaccuracies in the Facility Assessment have the potential to affect all residents in the facility, as they rely on accurate assessments to ensure appropriate care and resource allocation.
Latest citations in Maryland
The facility did not ensure that its Infection Preventionist (IP) met required qualifications for managing the Infection Prevention and Control Program. The DON reported serving as the IP but acknowledged lacking the specialized infection control training required for the role, and confirmed that no other staff member was currently qualified. Records showed that the previously qualified IP left several months earlier, and the Administrator and DON confirmed they were still seeking a replacement, leaving the infection control program without a properly trained leader.
Staff failed to consistently secure medications and medical supplies across three units, including an oxygen tank left on the floor behind a resident’s bed without a supporting device, a treatment cart with Collagenase Santyl cream left on top while two residents in power wheelchairs passed by, an unattended and unlocked treatment cart at a nursing station, and another treatment cart with Diclofenac gel and dressings left on top, indicating repeated lapses in maintaining locked and secure storage for drugs, biologicals, and related supplies.
The facility failed to provide sufficient dietitian coverage and timely nutritional assessments for several residents with significant dietary needs. A resident admitted for diabetic management with a high A1C was placed on a regular diet instead of the recommended carb-controlled diet and had only one weight taken in the first two weeks, with no dietitian review of the record. Another resident with prior significant weight loss had no documented dietitian follow-up despite continued weight loss, and a resident admitted with severe protein-calorie malnutrition experienced further significant weight loss without any dietitian assessment. The dietitian reported working limited hours and prioritizing certain high-risk cases, resulting in delayed or missed evaluations for new admissions and residents with ongoing nutritional concerns.
The facility failed to maintain adequate linen and incontinence supplies and did not keep resident care areas in good repair, resulting in delays and alterations in incontinence care and substandard environmental conditions. Staff reported that towels and washcloths were used instead of wipes and then discarded due to heavy soiling, and that linen deliveries to units were late, leaving residents waiting for care. Observations showed very limited numbers of clean washcloths and other linens on units and in the laundry, with no stock of disposable wipes or backup washcloth supply despite repeated reports to housekeeping. Additional observations revealed recliner chairs blocking a dining-area handwashing sink and kitchenette, multiple resident and shared bathrooms with unfinished spackle, chipped paint, musty odors, black substances near showers, missing threshold molding, exposed cracks and nails, and eroded, rusted baseboard heaters. Hallway handrails on both units were worn, chipped, and splintered, and a shower room contained fecal odors, dried brown stains on the toilet, and deteriorated fixtures, all contributing to a failure to provide a safe, clean, and homelike environment.
Facility staff did not thoroughly investigate two separate abuse allegations involving a resident and an injury of unknown origin involving another resident. In both cases, investigations focused on the directly affected resident and included staff interviews, but there were no interviews of other residents on the unit or documented assessments of those residents for signs of abuse or injuries of unknown origin, including residents unable to communicate due to cognitive status.
Two residents who were dependent on staff for oral care, including one with a tracheostomy, were observed with thick, white or milky substances coating their mouths and teeth, indicating inadequate oral hygiene. One resident communicated that staff did not brush their teeth and that staff "need to." In another case, despite oral care supplies being present in the room, the resident’s mouth and teeth remained unclean on multiple observations, with a thick milky substance caking the teeth and stringing between them when the resident tried to open their mouth. These findings showed that staff did not consistently provide oral care to residents who relied on them for this ADL.
Staff failed to maintain complete and accurate medical records for multiple residents, including missing and inconsistent documentation of wound care, delayed pain assessment after discovery of an injury of unknown origin in a cognitively impaired resident, and inaccurate recording of a PPD test result that was documented as negative despite no evidence the injection was administered and no supporting nurse’s note. Residents reported not receiving certain treatments, while MAR entries either lacked signatures for completion or contained conflicting information about whether care was provided.
Surveyors found that the facility failed to consistently implement and communicate correct transmission-based precautions and PPE use. One resident with a Foley catheter related to wounds had no precaution signage posted, while another resident in a double room had a contact precautions sign at the door, yet the NP entered without PPE and the GNA provided high-contact care wearing only gloves. Staff in that room stated the resident was not on contact precautions and later reversed the sign to show no PPE requirement. Therapy staff reported they rely solely on posted signs to determine PPE, and surveyors identified broader issues with inaccurate signage and staff awareness of which residents required contact precautions.
Surveyors found that MDS assessments were inaccurately coded for two residents. In one case, a resident sustained a femoral neck fracture after a fall, but the subsequent significant change MDS did not code the fall as a major injury and failed to capture prn Tylenol use documented on the MAR within the look-back period. In the other case, a quarterly MDS indicated opioid use for a resident, but the MAR for the same period showed no prescribed opioid, indicating incorrect coding of high-risk drug classes.
A resident who had recently been admitted and experienced a fall received multiple doses of the narcotic analgesic Tramadol, but the facility failed to accurately document all administered doses on the Medication Administration Record (MAR). Review showed only one Tramadol dose recorded on the MAR, while the Controlled Drug Receipt/Record/Disposition Form on the med cart reflected three doses given over two days. In interview, the DON stated staff are expected to document narcotic administration on the MAR and confirmed that two administered doses were not recorded there, resulting in an incomplete and inaccurate medical record.
Unqualified Infection Preventionist Overseeing Infection Control Program
Penalty
Summary
The facility failed to ensure that its designated Infection Preventionist (IP) met the mandatory qualifications for overseeing the Infection Prevention and Control Program. During an interview on 3/24/26 at 10:00 AM, the DON confirmed that she/he was serving as the facility’s IP but had not completed the specialized training in infection control required for the position. The DON further stated that no other staff member currently met the qualifications to serve as IP. Record review showed that the previously qualified IP left the facility in October 2025, and as of the survey date, the position remained unfilled by a qualified individual. At 1:30 PM on the same day, the Administrator and DON confirmed they were still in the process of finding a qualified IP for the facility, leaving the Infection Prevention and Control Program without a properly trained and qualified leader. No specific residents, medical histories, or clinical conditions were described in relation to this deficiency.
Unsecured Medications, Treatment Carts, and Oxygen Equipment
Penalty
Summary
Facility staff failed to ensure that drugs, biologicals, and related medical supplies were securely stored and properly maintained on multiple units. On one unit, an oxygen tank assigned to a resident was observed sitting on the floor behind the resident’s bed without any supporting device. On another unit, a treatment cart was observed with a tube of Collagenase Santyl cream labeled for a specific resident left on top of the cart, while residents in power wheelchairs passed by and staff were present at the nursing station. These observations showed that medications and oxygen equipment were not consistently secured as required. Further observations on additional units revealed an unattended and unlocked treatment cart at a nursing station, and on a separate occasion, a treatment cart with Diclofenac gel labeled for a resident left on top along with multiple packs of dressings. These incidents occurred across three units and on more than one date, demonstrating repeated failures to keep medications and treatment supplies in locked compartments or otherwise secured from unauthorized access.
Insufficient Dietitian Coverage and Delayed Nutritional Assessments
Penalty
Summary
The deficiency involves the facility’s failure to employ sufficient food and nutrition staff, including adequate dietitian coverage, to ensure timely assessment and appropriate diets for residents with significant nutritional and diabetic needs. A resident admitted over two weeks earlier with multiple comorbidities and an A1C of 11.5% had a hospital discharge recommendation for a carbohydrate-controlled diet, but was placed on a regular diet at admission with no acknowledgment of the recommended diet until one week later, when the resident requested larger portions. As of the survey date, the dietitian had not yet seen or reviewed this resident’s medical record, and the resident reported not having seen a dietitian and being very frustrated with the meals. During the first two weeks after admission, only one weight was obtained for this resident, despite physician notes stating the resident’s weight was “stable.” Further review of other residents showed additional failures in timely dietitian assessment and follow-up. One resident, readmitted in January and previously seen by the dietitian in September for a 6.4 lb weight loss over 30 days, had no documented follow-up despite continued weight loss totaling 22 lbs since the last dietitian review. Another resident admitted at the end of February with severe protein-calorie malnutrition had not been seen by the dietitian after about a month in the facility, despite a documented 14 lb (7%) weight loss over two weeks. The dietitian reported working only 12 hours per week at the facility and stated that she must prioritize which residents to see, focusing first on residents with tube feedings and those identified in risk meetings, resulting in delayed or absent assessments for new admissions and residents with ongoing weight loss and malnutrition diagnoses.
Linen Shortages and Poor Environmental Maintenance Compromise Resident Care and Comfort
Penalty
Summary
The deficiency involves the facility’s failure to maintain an adequate supply of clean linens and appropriate incontinence wipes, resulting in delays and alterations in residents’ incontinence care, as well as the use of towels and washcloths in place of disposable wipes. During the initial tour, the surveyor observed that the linen supply on one nursing unit hallway was low. Complaint reviews included concerns about delays in incontinence care and bed linens not being changed regularly, with residents left without clean bedding. A complainant reported that there was not enough clean linen available for residents. Staff interviews confirmed that towels, sheets, and washcloths were being used to wipe residents for incontinence care due to the absence of wipes, and that many of these linens were being thrown away when soiled. Staff also reported a shortage of linen, that linen deliveries to the units were late, and that residents who preferred to get up before breakfast had to wait for care when linen was delayed. Further observations showed that the clean supply room contained no disposable wipes or cloths for incontinence care, and a resident reported that staff did not use wipes, that the resident had to purchase their own, and that heavily soiled towels or washcloths were discarded. A tour of all nursing unit linen carts and closets revealed only six clean washcloths and limited supplies of towels, gowns, and bed linens. In the laundry room, only three washcloths were present, and the laundry assistant stated that there were only three washcloths available for each nursing unit that morning, that the facility was short on linen supply, and that these concerns had been repeatedly reported to the Director of Housekeeping over the preceding month and again that morning. The laundry assistant confirmed there was no additional laundry in process. The DON stated that wipe squares should be used for incontinence care, but no such wipes were found in the clean medical supply room, and no backup supply of washcloths was present in the emergency linen supply. The Director of Housekeeping confirmed there was no backup supply of washcloths. The deficiency also includes environmental and maintenance issues affecting resident bathrooms, handrails, and common areas. In the main dining area, a recliner chair was observed positioned directly in front of the handwashing sink, and two recliner chairs were stored in front of the nutrition area kitchenette. Multiple resident bathrooms and shared bathrooms were repeatedly observed over several days with unfinished spackle on walls that needed resurfacing and painting, chipped paint around sinks, uneven boards nailed to walls under sinks that appeared to partially cover holes, musty odors, black substances between shower bases and walls, missing threshold transition molding exposing cracks, missing tiles, and a nail, as well as eroded and chipped paint on baseboard heaters with exposed dark brown metal and rust-like material. Hallway handrails on both nursing units were observed to be worn, with chips, splintering, holes, and areas where the wood finish had worn off. A shower room was observed with a foul fecal odor, dried brown stains on the back of the toilet seat and in the toilet bowl, and a baseboard heater with eroded, chipped paint and rust-like material, along with chipped paint on the handrail. These conditions were acknowledged by the Director of Maintenance and other leadership, and some areas were noted to be in the process of renovation, but the observed deficiencies remained present during the survey period. Overall, the facility did not maintain a safe, clean, comfortable, and homelike environment in good repair across both nursing units and the dining area. The lack of adequate linen and incontinence supplies, combined with the poor condition of resident bathrooms, handrails, and certain common areas, constituted the basis for the cited deficiency. The observations and staff and resident reports consistently described shortages of essential hygiene supplies, delayed care related to linen availability, and multiple unresolved environmental and maintenance issues in resident care areas and shared spaces.
Failure to Thoroughly Investigate Abuse Allegations and Injuries of Unknown Origin
Penalty
Summary
Facility staff failed to thoroughly investigate allegations of potential abuse involving one resident and an injury of unknown origin involving another resident. For one resident, there were two separate allegations of abuse occurring on different days in early February. The facility’s investigation packets included interviews with staff who cared for or were scheduled to work with this resident on the days of the alleged incidents, and the investigations focused solely on this resident. However, there were no interviews conducted with other residents on the unit to inquire about abusive or neglectful treatment by the staff who were working during the times of the allegations. The surveyors noted that, although the allegations were not validated, there was no documentation that other residents were interviewed, if able, or assessed for signs or symptoms of injury. In a separate incident, another resident was identified on March 4 with a new bruise on the right eye, documented as a change in condition at 4:09 AM. This resident had a BIMS score of 99, indicating the resident was unable to complete an interview and therefore could not report how the injury occurred. The facility’s investigation identified a potential cause of the injury but did not reach a definitive resolution. Additionally, there were no interviews of other residents on the unit regarding possible abuse, nor were there documented assessments of other residents for injuries of unknown origin, particularly for those unable to speak for themselves, as in this resident’s case.
Failure to Provide Oral Care to Dependent Residents
Penalty
Summary
The deficiency involves the facility’s failure to provide oral care to residents who were dependent on staff for activities of daily living, specifically oral hygiene. One resident with a tracheostomy was observed with a thick, sticky white substance in the mouth and was noted to intermittently chew on nearby bedding. This resident made good eye contact and, when asked if staff brushed their teeth, shook their head no and mouthed that staff “need to.” According to the resident’s Minimum Data Set (MDS) dated 2/11/26, the resident was dependent on staff for oral care. Another resident, also dependent on staff for oral care per the 3/11/26 MDS, was observed sitting propped up in bed and able to respond with smiles. During the initial observation, the inside of this resident’s lips and upper and lower teeth had a thick, clear, white milky substance visible when the resident tried to open their mouth to smile. Oral care supplies were present in the nightstand, but the resident’s mouth and teeth were not clean. On a subsequent observation with the DON, NHA, and Corporate VP of clinical services, the same resident again had a thick, clear, milky substance between the lips and caking the teeth, which would string between the teeth when the resident attempted to open their mouth, demonstrating a lack of consistent oral care for residents dependent on staff for this ADL.
Incomplete and Inaccurate Medical Record Documentation for Treatments and Assessments
Penalty
Summary
Facility staff failed to maintain complete and accurate medical records and documentation for multiple residents. For one resident with wound care needs, review of the MAR showed that wound care and related treatments were signed as completed on the dates initially reported, despite the resident’s ongoing complaints that wound dressings were not being changed. When additional dates were reviewed, there were missing staff signatures for wound care on two specific dates, as well as three instances where application of A&D ointment to the resident’s feet was not signed off out of 24 days reviewed. Another resident with severe cognitive impairment, as evidenced by a BIMS score of 00, was found to have an injury of unknown origin (a bruise on the left hand). Documentation showed that a change in condition was initiated late in the morning, but a formal pain evaluation was not initiated and completed until that night, and the resident was unable to explain how the injury occurred or verbalize pain using a standard pain scale. For a third resident, documentation related to the admission PPD test was inconsistent and incomplete. The MAR contained an entry indicating “9” for the administration date, meaning “see nurse’s note,” but there was no corresponding nurse’s note. Despite the absence of a signed administration of the PPD injection, staff documented the PPD result as “negative” on the scheduled read date. The resident reported never receiving the PPD injection, and the DON confirmed that the facility had been out of PPD solution at the time, so the test would not have been administered. These findings demonstrate failures in accurate documentation of treatments and assessments, including wound care, pain assessment, and TB screening, as well as missing or incomplete supporting notes in the medical record.
Failure to Implement and Communicate Correct Transmission-Based Precautions
Penalty
Summary
Surveyors identified a deficiency in the facility’s infection prevention and control program related to inconsistent and incorrect implementation of transmission-based precautions and PPE use. During a complaint investigation focused on residents on transmission-based precautions, one resident with a visible Foley catheter was observed in the room with physical therapy, but there were no signs posted indicating any need for PPE, despite the resident being a new admission with a Foley catheter placed related to wounds. In another double-occupancy room, a contact precautions sign was posted at the doorway, but the nurse practitioner was in the room on a personal phone with no PPE, and the assigned GNA was repositioning the resident in bed while wearing only gloves. When questioned, the NP, RN, and GNA all stated that the resident in the room was not on contact precautions, and the GNA reported that signs were hanging at all doors and that this particular resident’s sign was “just wrong.” The surveyor observed the GNA later return to the room and turn the sign around to indicate no PPE requirement. Subsequent interviews revealed that therapy staff relied on posted signage to determine PPE use and that if the sign was wrong, the PPE used would be wrong. Overall, surveyors found problems with signage accuracy and staff awareness of which residents required contact precautions, as well as observed failures to follow appropriate PPE use for residents who should have been on contact precautions.
Inaccurate MDS Coding for Falls, Pain Management, and High-Risk Medications
Penalty
Summary
Facility staff failed to ensure Minimum Data Set (MDS) assessments were accurately coded for two residents reviewed during a complaint survey. For one resident, a facility-reported incident showed that the resident was found seated on the floor beside the bed and was diagnosed with a non-displaced femoral neck impaction fracture of the left hip following an x-ray. Despite this fall with a major injury, the subsequent significant change MDS dated 11/4/25 did not code the fall with major injury in Section J1900C. Review of the resident’s Medication Administration Records for October and November 2025 showed administration of Tylenol on 10/31/25 at 9:30 PM, which fell within the 5-day look-back period for the MDS, but Section J0100 (prn pain) of the same significant change MDS did not capture the use of Tylenol. For another resident, review of a quarterly MDS with an assessment reference date of 10/15/25 showed that Section N0415 (High-Risk Drug Classes) documented the use of an opioid medication. However, review of the resident’s October 2025 Medication Administration Record did not show that the resident had been prescribed an opioid during that period. In both cases, MDS staff later confirmed that these were errors in MDS coding, demonstrating that the assessments did not accurately reflect the residents’ clinical status and medication use as documented in their medical records.
Incomplete Documentation of Narcotic Administration on MAR
Penalty
Summary
The facility failed to maintain complete and accurate medical records in accordance with accepted professional standards for one resident receiving narcotic medication. The resident, admitted in March 2026, had a fall on 3/6/26 and was sent to the hospital on 3/9/26. Review of the March 2026 Medication Administration Record (MAR) showed documentation of a single 25 mg dose of Tramadol administered on 3/8/26 at 9:23 AM. However, review of the resident’s Controlled Drug Receipt/Record/Disposition Form, kept on the nurse’s medication cart and not in the medical record, showed that Tramadol 25 mg was administered three times between 3/8/26 and 3/9/26: at 11:00 AM and 9:00 PM on 3/8/26, and at 9:00 AM on 3/9/26. In interview, the DON stated that staff are expected to document narcotic administration on the MAR and confirmed that only one of the three Tramadol doses reflected on the controlled drug record was documented on the resident’s MAR. This discrepancy between the controlled substance record and the MAR, with missing documentation of two administered doses of Tramadol on the official medical record, constituted the failure to maintain a complete and accurate medical record for the resident.
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