Autumn Lake Healthcare At Homewood
Inspection history, citations, penalties and survey trends for this long-term care facility in Baltimore, Maryland.
- Location
- 6000 Bellona Avenue, Baltimore, Maryland 21212
- CMS Provider Number
- 215074
- Inspections on file
- 18
- Latest survey
- January 13, 2026
- Citations (last 12 mo.)
- 46
Citation history
Health deficiencies cited at Autumn Lake Healthcare At Homewood during CMS and state inspections, most recent first.
A resident experienced a significant medication error when a nurse administered meropenem, a broad-spectrum carbapenem antibiotic, instead of the cefepime that had been ordered by the physician to treat a UTI. Review of a complaint and the medication administration audit confirmed that the resident received an antibiotic that was not prescribed, constituting a failure to follow the five rights of medication administration, specifically the right medication, although no adverse outcome was documented.
A resident with elevated liver enzymes had a physician order for a right upper quadrant ultrasound, but nursing staff did not complete the ordered test. Review of the medical record showed no ultrasound results, and the DON confirmed that the ordered diagnostic study was never carried out, resulting in a failure to follow the practitioner’s order for necessary testing.
The facility did not complete annual performance reviews for GNAs or provide regular, individualized in-service education based on those reviews. During a survey, it was found that none of the reviewed GNA employee files contained performance reviews, and the DON confirmed that these had not been done for some time, resulting in a lack of tailored training for staff.
Staff did not maintain a safe, clean, and comfortable environment, as evidenced by stained ceiling tiles, peeling paint and laminate, rusted equipment, missing toilet paper, and unpainted spackled walls. Multiple residents were observed using wheelchairs with torn or cracked vinyl armrests, exposing foam padding. The maintenance department was understaffed, with only one staff member and recent changes to the repair reporting system.
The facility did not report multiple allegations of abuse, neglect, and theft to the regulatory agency within the required timeframes. Incidents included residents alleging physical and verbal abuse by staff, missing narcotic medication, and theft of personal items. In several cases, the administration was not promptly informed, resulting in delayed reporting to OHCQ, and in some instances, there was no documentation of when reports were submitted.
The facility did not thoroughly investigate or document multiple allegations of abuse and misappropriation of property, including incidents involving physical abuse by a phlebotomist, missing money, rough handling by an agency GNA, missing narcotic medication, and threatening behavior by staff. Investigations were incomplete, lacking necessary interviews with staff, residents, and witnesses, and in some cases, documentation was missing entirely.
A deficiency occurred when a resident did not receive treatment and care in accordance with physician orders and their own preferences and goals, resulting in care that was not individualized or consistent with documented directives.
Surveyors identified multiple environmental deficiencies, including mold growth on window blinds, air conditioning units, and ceiling tiles, as well as damaged base molding, missing toilet paper holders, and unsanitary shower rooms with broken tiles and soiled washcloths. Facility leadership and staff confirmed these conditions during the survey.
Facility staff did not consistently hold or document interdisciplinary care plan meetings with residents and their representatives following required assessments. Medical record reviews for multiple residents showed missing or insufficient documentation of care plan meetings after several MDS assessments, and staff interviews confirmed these omissions.
The facility did not ensure fall precautions were in place for a resident with a history of falls, as a required floor mat was not positioned correctly. A resident assessed as high risk for unsafe smoking was found with multiple lighters in their room, contrary to the care plan and facility policy. Additionally, two residents who required supervision while smoking were observed smoking unsupervised, with one not using a required smoking apron and both having smoking materials in their possession. Staff interviews confirmed these lapses in supervision and adherence to care plans.
The facility did not consistently provide timely medications to residents, resulting in missed doses of essential treatments such as nicotine patches, IV antibiotics, and blood pressure medications due to delays in reordering and pharmacy delivery. Additionally, narcotic and controlled substance counts were not consistently reconciled by two nurses at shift changes, as required, with multiple missing signatures documented in log binders across all medication carts.
Staff did not properly dispose of expired yogurt and spoiled tomatoes in the kitchen, and failed to maintain sanitary and safe storage conditions in the nourishment room, including a leaking ice machine, mold-like substances, dirty cabinets with inappropriate items, and excessive ice build-up in the freezer.
Staff failed to follow infection control protocols, including improper storage and labeling of personal care items, lack of PPE use during medication administration to a resident with a G-tube and foley catheter, and absence of required signage and orders for residents needing Enhanced Barrier or Contact Precautions. Mold and unsanitary conditions were observed in multiple areas, and staff interviews confirmed awareness of these issues.
Staff failed to notify two residents' representatives and a physician about significant changes in condition, including a BiPAP machine malfunction for a resident with chronic respiratory failure and a hospital transfer for a resident with dementia. In both cases, required notifications were either delayed or not documented, as confirmed by the DON.
A resident with bone cancer, while in pain and expressing distress, was subjected to verbal abuse by a staff member who made a disparaging remark in the presence of another staff member and the resident's family member, who was on the phone. The incident was confirmed by both the family member and the second staff member, and the facility's investigation verified that verbal abuse occurred.
A resident was not protected from the wrongful use of their belongings or money, as staff or facility management failed to safeguard personal property or funds, resulting in unauthorized use.
Surveyors identified that MDS assessments were inaccurately coded for three residents, including failures to document regular pain medication, anticonvulsant use, behavioral refusals, and opioid administration, despite clear evidence in medical records and care plans. These errors were confirmed by the MDS Coordinator through record review and staff interviews.
Surveyors identified incomplete and inaccurate medical record documentation for three residents, including a physician's erroneous medication entry, multiple blank spaces on a MAR making it unclear if medications were administered, and missing care plan meeting documentation that was not accessible to the interdisciplinary team.
Staff did not ensure that two residents had their call bell controls within reach, as both were found with the call bells on the floor and inaccessible. A GNA/CMA confirmed that the call lights should have been accessible but were not at the time of observation.
Residents were not given the opportunity or support to organize and participate in resident or family groups, as required. The facility did not facilitate or respect the formation and participation of these groups.
A resident was admitted without a baseline care plan (BLCP) being completed within the required 48-hour timeframe, and no summary or current medication list was provided to the resident or their representative. The DON was unable to locate the BLCP in the medical record and confirmed it was never completed.
Facility staff did not develop a care plan for a resident with an indwelling urinary catheter as required, despite physician orders and documentation in the MDS. Although the IDT agreed to create a care plan, none was implemented for approximately three months after admission, and the DON confirmed the delay when interviewed.
Two residents did not receive proper pain management due to incomplete pain assessments, lack of pain medication parameters, and failure to document or provide non-pharmacological interventions before administering PRN opioids. Staff administered stronger pain medications outside of prescribed parameters and missed a scheduled dose of a long-acting opioid due to medication unavailability, with the DON confirming these deficiencies.
Nursing staff did not consistently monitor or document the behaviors and mental health status of three residents with mental disorders or psychosocial adjustment difficulties. One resident on multiple antidepressants lacked physician orders and monitoring for depression symptoms and medication side effects, while two others with behavioral monitoring orders and care plans had no documentation of required monitoring for extended periods. These deficiencies were confirmed by the DON and administrative staff.
Facility staff did not hold Midodrine as ordered for a resident with orthostatic hypotension when systolic blood pressure readings were above the specified threshold. Despite clear physician instructions, the medication was administered multiple times when it should have been withheld, as confirmed by MAR review and DON interview.
Staff failed to properly secure medications by leaving a narcotic on a resident's bedside table and leaving a treatment cart unlocked and unattended in a hallway. The cart contained various prescription medications, some of which were expired, and an opened bottle of Dakins solution without a cap. Facility policy requires locked storage, and both the DON and ADON confirmed these actions were not in compliance.
A resident with a history of dental pain and missing/broken teeth did not receive timely follow-up for recommended dental extractions after a dental consult. Despite ongoing complaints and a care plan noting oral health issues, staff did not arrange the necessary dental appointment, and the facility's dental provider had no referral on file. The deficiency persisted until identified by surveyors.
Facility staff did not update a resident's hospice status in the care plan and MDS after hospice services ended, resulting in continued documentation of hospice care and exclusion from rehabilitation evaluation. The DON confirmed the information should have been updated in all relevant records.
The facility did not document that two residents who refused the pneumonia vaccine were provided education about its risks and benefits. Review of immunization records showed refusals without evidence of education, and the DON confirmed the absence of required documentation.
A resident admitted in 2024 had no documentation of COVID-19 vaccination or evidence that the vaccine was offered, and no historical vaccination data was present in the records. The DON confirmed that the Infection Preventionist is responsible for monitoring vaccination status but acknowledged the absence of information for this resident.
Two residents experienced deficiencies in nutritional care: one had significant unaddressed weight loss without follow-up or documentation, and another did not receive recommended dietary supplements for malnutrition and dysphagia, as staff failed to implement the dietitian's interventions. The DON confirmed these lapses.
Facility staff failed to provide safe and appropriate respiratory care, including not documenting or administering BiPAP therapy as ordered for a resident with chronic respiratory failure, administering oxygen at incorrect flow rates, lacking physician orders with indications for oxygen use, and not changing oxygen tubing as scheduled. Staff interviews confirmed these deficiencies in documentation, adherence to orders, and equipment maintenance.
Significant Medication Error Involving Wrong Antibiotic Administration
Penalty
Summary
Facility staff failed to ensure that a resident was free from significant medication errors when a nurse did not administer medication as prescribed by the physician. Review of a complaint and the resident’s medication administration audit showed that on 12/6/25 at 6 PM, the resident received meropenem, a broad-spectrum carbapenem antibiotic used to treat severe bacterial infections, instead of cefepime, a fourth-generation cephalosporin antibiotic that had been ordered by the physician for a urinary tract infection. This constituted a failure to follow the five rights of medication administration, specifically administering the wrong medication, and resulted in the resident receiving a medication that was not prescribed, although no negative outcome was documented for the resident. The deficiency was identified through observation, record review, and interviews, which confirmed that the medication was not given as ordered and that the resident’s medication administration record reflected the administration of an unprescribed antibiotic for the urinary tract infection.
Failure to Complete Ordered Diagnostic Ultrasound
Penalty
Summary
Facility nursing staff failed to follow a physician’s order to obtain a right upper quadrant ultrasound for a resident whose laboratory tests showed elevated liver enzymes. The resident’s medical record showed that in September 2025 labs revealed elevated liver enzymes, and on 9/18/2025 the physician ordered a right upper quadrant ultrasound. Subsequent review of the medical record revealed no evidence that the ultrasound was completed or that results were obtained. During an interview, the Director of Nursing confirmed that nursing staff did not complete the ordered ultrasound, and the surveyor identified this as a concern related to failure to follow a physician’s order. The deficiency was identified during a complaint survey initiated after a complaint alleging the facility failed to monitor the resident’s status and well-being during the stay. Medical record review on 1/12/26 confirmed the absence of ultrasound results despite the prior order, and the DON’s interview on 1/12/25 further verified that the ordered diagnostic test was not carried out by nursing staff.
Failure to Conduct Annual Performance Reviews and Provide Individualized In-Service Education for GNAs
Penalty
Summary
The facility failed to conduct annual performance reviews for Geriatric Nursing Assistants (GNAs) and did not provide regular, in-service education based on the outcomes of those reviews. This deficiency was identified during a recertification survey, where a review of five randomly selected GNA employee records revealed that none contained documentation of a performance review, despite all being employed for varying lengths of time. The Director of Nursing (DON) confirmed that performance reviews had not been completed for some time and that the process was not current at the time of the survey. Further, the DON acknowledged that in-service education for GNAs could not be tailored to individual needs without the completion of performance reviews. The absence of these reviews and the lack of individualized in-service training was evident for all five GNAs whose records were examined, indicating a systemic issue in the facility's process for monitoring and supporting staff performance.
Failure to Maintain Sanitary and Comfortable Environment
Penalty
Summary
Facility staff failed to provide adequate housekeeping and maintenance services necessary to maintain a sanitary, orderly, and comfortable environment on two of three nursing units. Observations during the survey revealed multiple environmental concerns, including stained ceiling tiles, missing toilet paper, peeling laminate on bed headboards and footboards, peeling paint on window sills, missing strings for over-bed lights, rusted frames on toilet risers, and separated molding by windows. Several rooms had spackled walls that were not painted, further contributing to the lack of a homelike and well-maintained environment. Additionally, several residents were observed using wheelchairs with torn or cracked vinyl on the armrests, with some exposing the underlying foam padding. Interviews with the Maintenance Director indicated that he had only recently started in his role and was the sole maintenance staff member, occasionally receiving assistance from housekeeping. The facility had recently implemented a new system for reporting repairs, but these environmental deficiencies persisted at the time of the survey.
Failure to Timely Report Allegations of Abuse, Neglect, and Misappropriation
Penalty
Summary
The facility failed to report allegations of abuse, neglect, and misappropriation of property to the Office of Health Care Quality (OHCQ) within the required timeframes for multiple residents. In several cases, reports of alleged physical abuse, verbal abuse, and theft were not submitted within the mandated 2-hour window for abuse or 24-hour window for misappropriation. Documentation and interviews confirmed that the initial reports were delayed, with some incidents being reported a day or more after the event, and in one case, the facility could not provide evidence of when the report was submitted. Facility leadership, including the Nursing Home Administrator (NHA) and Director of Nursing (DON), acknowledged these delays during interviews, often noting that they were not employed at the facility at the time of the incidents but confirmed the findings based on available records. Specific incidents included allegations of staff physically and verbally abusing residents, missing narcotic medication, and theft of personal items and money. In one instance, a resident alleged being punched and wrestled by a phlebotomist during a blood draw, while another resident reported being hit by a GNA and threatened with a wheelchair. There were also cases where residents' personal property went missing, and the facility did not notify the regulatory agency promptly. In another case, a resident with cognitive impairment and a history of stroke developed unexplained wrist swelling, and the incident was not reported as required, despite the resident's vulnerability. The facility's investigations often lacked timely documentation, and in some cases, there was no evidence of an investigation or report submission at all. Staff interviews and record reviews consistently revealed that the administration was not made aware of incidents promptly, leading to delays in reporting to OHCQ. The failure to report these incidents within the required timeframes was confirmed by facility leadership during the survey process.
Failure to Conduct Thorough Investigations of Abuse and Misappropriation Allegations
Penalty
Summary
The facility failed to provide thorough documentation and investigation of multiple allegations of abuse and misappropriation of property involving several residents. In one instance, a resident alleged physical abuse by a phlebotomist during a blood draw, but the facility's investigation did not include interviews with other residents on the unit who may have had concerns about the phlebotomist. In another case, a resident reported missing money from their purse, but the investigation lacked interviews with all relevant staff from previous shifts and included unsigned staff statements, resulting in an incomplete review. Additional deficiencies were noted in the handling of other incidents. For example, a resident alleged being hit by an LPN, but the facility could not provide any investigation documentation for review. Another resident was observed with a bruise and reported rough handling during ADL care by an agency GNA, but the investigation file was incomplete, lacking staff and resident interviews. In a separate incident, narcotic medication was reported missing, but the facility did not interview all staff who had access to the medication cart during the relevant period, and there was a delay in reporting the discrepancy to nursing administration. Further, the facility did not complete a thorough investigation into a resident's report of missing personal items and money after a hospital stay, as statements from the resident and alleged perpetrator were missing. In another case, a staff member was accused of making a threatening gesture and statement toward a resident, but the investigation did not include statements from named witnesses. In all these cases, the facility's failure to conduct comprehensive investigations and document findings contributed to the identified deficiencies.
Failure to Provide Care According to Orders and Resident Preferences
Penalty
Summary
A deficiency was identified when treatment and care were not provided in accordance with physician orders, as well as the resident's preferences and goals. The report notes a failure to ensure that care was individualized and aligned with the documented directives and wishes of the resident, as required.
Environmental Deficiencies: Mold, Damaged Fixtures, and Unsanitary Conditions
Penalty
Summary
Surveyors observed multiple deficiencies related to the facility's failure to maintain a safe, functional, sanitary, and comfortable environment for residents, staff, and visitors. In the Human Resources Director's office, black specks resembling mold were found on the window blinds and air conditioning unit, which also had visible condensation. Staff confirmed the presence of mold and stated it had been reported to administration. In the bathroom near the nurse's station, the base molding was detached, exposing debris and an open area behind the wall, and the toilet paper holder was missing its rod. The sink lacked a gooseneck faucet. The Nursing Home Administrator (NHA) was present during these observations and acknowledged the conditions. Further observations included shower rooms with mold-like substances in the grout, chipped and broken ceramic tiles, and exposed mastic. Soiled washcloths were found on the floor and in a bariatric shower chair, and the ceiling in one shower room had visible cracks. In the activity room, a ceiling tile was completely covered in what appeared to be black mold and was sagging, with staff stating it had been in that condition for a month. The NHA confirmed these findings and noted ongoing issues with the building's gutters, which had not yet been addressed.
Failure to Hold and Document Interdisciplinary Care Plan Meetings After Resident Assessments
Penalty
Summary
Facility staff failed to consistently hold and document care plan meetings that included the interdisciplinary team, residents, and their representatives following comprehensive and quarterly assessments, as required. Medical record reviews for five residents revealed missing or insufficient documentation of care plan meetings after multiple Minimum Data Set (MDS) assessments, including annual and quarterly reviews. In several cases, there was no evidence in the electronic medical record or social work documentation that care plan meetings occurred, and when meetings were held, documentation was sometimes limited to handwritten notes not entered into the official record. Staff interviews confirmed the absence of required documentation and, in some instances, the lack of meetings altogether. For example, one resident's records showed no care plan meeting documentation for several assessment periods, and the social work director acknowledged that notes were not entered into the electronic record. Another resident, who had multiple hospital transfers and readmissions, had only two care plan meeting notes documented despite several MDS assessments. Similar patterns were observed for other residents, with gaps between assessments and documented care plan meetings. The DON and social work staff confirmed that care plan meetings should occur after each quarterly MDS assessment, but acknowledged the lack of evidence to support that this was consistently done.
Failure to Implement Fall Precautions and Smoking Supervision
Penalty
Summary
The facility failed to implement and maintain fall precautions as ordered by the physician for a resident with a history of falls. The resident, admitted with diagnoses including cerebral infarction, cognitive impairment, osteoarthritis, and bipolar disorder, experienced multiple falls from bed. Despite a physician's order and care plan intervention for floor mats to be placed on both sides of the bed, observation revealed that only one mat was on the floor while the other was propped against the wall. Staff interviews confirmed the mat was not in place as required, and the Director of Nursing acknowledged the mat should have been on the floor. The facility did not follow the smoking plan of care for a resident assessed as high risk for unsafe smoking practices. The resident was found to have multiple lighters in their room, contrary to the care plan and facility policy, which required smoking materials to be kept at the nurse’s station and not on the resident’s person. Staff interviews provided conflicting information about the policy, but the Nursing Home Administrator ultimately confirmed that lighters should not be kept by residents and validated the concern that the resident was not following the care plan. Additionally, the facility failed to provide required supervision for residents identified as needing assistance while smoking. Two residents, both assessed as requiring supervision and the use of a smoking apron, were observed smoking unsupervised in the designated area, with one resident not wearing the required apron. Both residents also had smoking materials in their possession, despite care plans stating these should be kept at the nurse’s station. Staff interviews confirmed that supervision was not consistently provided, and the Nursing Home Administrator acknowledged the lack of supervision and the presence of smoking materials with residents who required oversight.
Failure to Provide Timely Medications and Incomplete Narcotic Reconciliation
Penalty
Summary
The facility failed to provide timely pharmaceutical services to meet the needs of residents, as evidenced by multiple instances where residents did not receive their prescribed medications as ordered. For one resident with a physician's order for a daily Nicotine Transdermal Patch, medical record review showed repeated missed doses due to delays in reordering and pharmacy delivery. Nursing notes and the Medication Administration Record (MAR) documented several occasions over multiple months where the patch was not available, and staff interviews confirmed that medications were not always reordered in a timely manner, sometimes due to lapses in communication between staff members responsible for medication administration and reordering. Another resident with a complex medical history, including bacteremia and sepsis, did not receive prescribed IV Vancomycin on several occasions because the medication was not available from the pharmacy or in the facility's automated dispensing system. Documentation in the MAR and nursing notes confirmed missed doses and delays in pharmacy delivery, with blank spaces and notations indicating the medication was not administered. A third resident, admitted with conditions such as hypertension and acute kidney failure, also experienced missed doses of blood pressure medication due to unavailability, as documented in the MAR and confirmed by staff interviews. The facility's own Medication Reordering Policy required nurses to reorder medications when six or fewer doses remained, but staff and leadership acknowledged ongoing issues with timely reordering and medication availability. Additionally, the facility failed to ensure that narcotic medications were consistently reconciled by two nurses at each change of shift, as required for controlled substances. Review of narcotic and controlled substance log binders for all medication carts revealed numerous missing signatures from both oncoming and off-going nurses across multiple shifts and halls. Staff interviews and facility policy confirmed that both nurses were expected to sign off on the narcotic count at each shift change, but this was not consistently done, resulting in incomplete documentation and lack of accountability for controlled medication storage and administration.
Failure to Properly Dispose of Expired Food and Maintain Safe Food Storage Conditions
Penalty
Summary
Facility staff failed to ensure proper disposal of expired and spoiled food items and did not store food in accordance with professional standards for food service safety. During a kitchen tour, multiple yogurt containers with best by dates that had already passed were found in the walk-in cooler. The Dietary Manager acknowledged that these yogurts needed to be discarded. On a subsequent kitchen tour, an open case of tomatoes was found in the walk-in cooler, with several tomatoes displaying white fuzzy material around the stems, indicating spoilage. The Dietary Manager confirmed the tomatoes were bad and removed them for disposal. Additionally, in the nourishment room, there were two vinyl floor tiles placed in front of a leaking ice machine, with a puddle of water and black specks resembling mold on the wall and floor base molding. No caution signs were present to indicate the wet floor. The under-counter cabinets in the nourishment room were observed to be dirty, containing a butcher knife, water spill marks, a red solo cup, a plastic plate cover lid, and a zip lock bag with sweetener packets. The freezer section of the nourishment refrigerator had at least a one-inch ice build-up on all walls. These observations were confirmed with the Nursing Home Administrator during the survey.
Widespread Infection Control Failures and Lapses in Precaution Implementation
Penalty
Summary
Facility staff failed to follow infection control practices and guidelines, resulting in multiple deficiencies related to the prevention and transmission of infection and disease. Observations revealed unsanitary conditions, such as unlabeled and improperly stored basins, urinals, and urine collection hats in resident rooms and bathrooms, as well as soiled gloves and washcloths left in inappropriate places. Mold-like substances were observed in several areas, including shower rooms, the activity room office, and the HR office, with staff confirming awareness of these issues. The facility's own policy required single-resident use and proper storage of bedpans and urinals, which was not followed. During medication administration to a resident with a gastrostomy tube and foley catheter, staff failed to don appropriate PPE and did not post Enhanced Barrier Precautions (EBP) signage as required. Although records indicated an order for EBP and an updated care plan, these precautions were not implemented at the time of observation. Interviews with staff and the DON confirmed that PPE should have been used and signage should have been present for residents with such medical devices. The facility also failed to ensure that residents with infectious diseases or those requiring EBP had appropriate physician orders, care plans, and signage. For example, a resident with a history of sepsis and multiple infections did not have an order or care plan for contact precautions, and staff were unclear about the reason for precautions. Additionally, several residents identified as EBP candidates did not have the required orders or signage on their doors, and staff confirmed these omissions during interviews. These failures were evident across multiple hallways and affected several residents reviewed during the survey.
Failure to Notify Representatives and Physicians of Changes in Resident Condition
Penalty
Summary
Facility staff failed to notify a resident's representative and physician when a BiPAP machine malfunctioned for a resident with chronic respiratory failure and obstructive sleep apnea. The medical record showed that the BiPAP was not administered due to device dysfunction, and while the supplier was contacted and a replacement was arranged, there was no documentation that the resident's representative or physician was informed of the situation or the change in the resident's respiratory support status. Additionally, staff did not notify another resident's representative in a timely manner when the resident, who had dementia, was transferred to the hospital after being found unarousable. The representative was only informed after the hospital had already made contact. Documentation confirmed the delay in notification, and the DON verified that timely notification did not occur in both cases.
Failure to Protect Resident from Verbal Abuse by Staff
Penalty
Summary
Facility staff failed to protect a resident from verbal abuse during care provision. On the evening of the incident, two staff members were providing care to a resident who was experiencing significant pain and vocalizing distress, stating that they were dying due to cancer. One staff member responded to the resident by saying, "well go ahead and die then so you can stop all this screaming." This statement was overheard by the resident's family member, who was on the phone with the resident at the time. The family member later visited the facility and received confirmation from the second staff member present that the statement had indeed been made. The resident involved had been admitted with a diagnosis of malignant neoplasm of the bone (bone cancer). The facility's investigation included statements from the family member and the second staff member, both corroborating the incident. The facility's policy defines verbal abuse as the use of disparaging or derogatory terms directed at residents or their families. The administrator confirmed the occurrence of verbal abuse by the staff member during an interview.
Failure to Protect Resident's Belongings or Money
Penalty
Summary
A deficiency was identified regarding the protection of residents from the wrongful use of their belongings or money. The report notes that there was a failure to safeguard a resident's personal property or funds, resulting in unauthorized or inappropriate use. Specific actions or omissions by staff or facility management led to this breach, directly impacting the resident's rights and property. No additional details about the resident's medical history or condition at the time of the deficiency are provided in the report.
Inaccurate Coding of MDS Assessments for Multiple Residents
Penalty
Summary
Facility staff failed to ensure that Minimum Data Set (MDS) assessments were accurately coded for three residents during the recertification/complaint survey. For one resident with diagnoses including polyneuropathy, chronic pain, osteoarthritis, and gout, the MDS incorrectly indicated that the resident did not receive regular pain medication, despite documentation showing the use of Diclofenac gel four times daily and Gabapentin twice daily. The MDS also failed to code the use of anticonvulsant medication. These errors were confirmed by the MDS Coordinator upon review. Another resident's admission MDS did not capture a documented refusal of medication and weight, even though behavior notes and a care plan addressed non-compliance with the treatment plan. The MDS Coordinator confirmed this omission and stated that the existence of a care plan was mistakenly considered sufficient. Additionally, a third resident's MDS inaccurately reported the number of injections received and failed to document opioid administration, despite medical records showing multiple injections and opioid use. These inaccuracies were verified through staff interviews and medical record reviews.
Incomplete and Inaccurate Medical Record Documentation
Penalty
Summary
The facility failed to maintain complete and accurate medical records in accordance with accepted professional standards for three residents. For one resident, the physician's notes incorrectly documented the administration of Pravastatin 20 mg nightly for secondary stroke prevention, despite the resident not being prescribed this medication since readmission. The Chief Clinical Officer confirmed this was a documentation error and the resident was not supposed to be on Pravastatin. Another resident's Medication Administration Record (MAR) contained multiple blank spaces for several medications, including Seroquel, Metformin, Pregabalin, Senna, Trulicity, Enoxaparin, Normal Saline Solution flush, Humalog insulin sliding scale, and silver sulfadiazine cream. The DON stated that blank spaces on the MAR indicated it could not be determined if the medications were given or signed off. Additionally, a third resident's medical record lacked evidence of care plan meetings in both the miscellaneous section and social work documentation. The Social Work Director reported that notes from a care plan meeting were handwritten in a personal notepad and not entered into the electronic medical record, making them unavailable to other disciplines. These findings demonstrate failures in maintaining legible, accurate, and accessible medical records for residents.
Failure to Ensure Call Bell Accessibility for Residents
Penalty
Summary
Facility staff failed to ensure that residents had access to their call bell controls, as observed during the initial tour. Specifically, one resident was found with the call bell cord and plunger on the floor near the headboard and out of reach, and the resident was unaware of its location. Another resident's call bell was also observed on the floor and out of reach. During an interview, a Geriatric Nursing Assistant/Certified Medication Tech confirmed that the call light should be within reach and acknowledged that it was not accessible to the resident at that time. These findings were identified for two residents out of a sample of sixty-four during the survey, and the facility was informed of these observations at the exit conference.
Failure to Honor Resident Rights to Organize and Participate in Groups
Penalty
Summary
The facility failed to honor the right of residents to organize and participate in resident and family groups. This deficiency was identified when it was observed that residents were not provided the opportunity or support to form or participate in such groups within the facility. The report notes that the facility did not facilitate or respect the organization and participation of these groups as required.
Failure to Complete Baseline Care Plan and Provide Medication Summary Upon Admission
Penalty
Summary
The facility failed to complete a baseline care plan (BLCP) within 48 hours of admission for one resident, as required. Review of the medical record for this resident showed no evidence that a BLCP was created or documented. The BLCP is intended to include initial goals based on admission orders, physician orders, dietary orders, therapy services, and social services. Additionally, there was no documentation that a summary of the BLCP or a current medication list was provided to the resident or their representative. Interviews with the Director of Nursing (DON) revealed uncertainty regarding the required timeframe for BLCP completion, with the DON incorrectly stating it was within 72 hours instead of 48. The DON also indicated that the admitting nurse initiates the BLCP and that each discipline contributes, but was unable to locate the BLCP in the resident's record or provide evidence that a copy was given to the resident or representative. Ultimately, the DON confirmed that a BLCP was never completed for the resident in question.
Failure to Develop Timely Care Plan for Catheter Use
Penalty
Summary
Facility staff failed to develop a care plan to address a resident's use of an indwelling urinary catheter, despite a physician's order for catheterization and documentation in the Minimum Data Set (MDS) assessments indicating the presence of a catheter. The Care Area Assessment (CAA) from the resident's Admission MDS noted that the Interdisciplinary Team (IDT) agreed to create a care plan for the catheter, but a review of the clinical record revealed that no such care plan was in place for approximately three months following admission. During the survey, the Director of Nursing (DON) was interviewed and initially did not provide evidence of a care plan addressing catheter use. When a care plan was later produced, it was found to have been initiated only after a significant delay, well after the resident's admission and the original physician's order. The DON acknowledged that the resident went without a required care plan for catheter use during this period.
Failure to Provide Safe and Appropriate Pain Management
Penalty
Summary
The facility failed to provide safe and appropriate pain management for two residents by not properly assessing pain, not following physician orders for pain medication parameters, and not documenting or providing non-pharmacological interventions prior to administering PRN pain medications. For one resident, pain assessments were only documented on the day shift, despite orders to assess pain every shift, and pain scores were not consistently recorded. Additionally, the order for oxycodone lacked specific pain parameters after a certain date, and non-pharmacological interventions were not documented as attempted before administering PRN pain medications for several months. For another resident, the MAR showed that PRN oxycodone was administered multiple times without documentation of non-pharmacological interventions being attempted first, as required by the care plan and physician orders. The resident's orders included both Tylenol and oxycodone for different pain levels, but staff administered oxycodone for pain scores that should have been managed with Tylenol, and there was no documentation of Tylenol being given for those pain levels. The DON confirmed that non-pharmacological interventions should be offered and documented prior to PRN pain medication administration and that pain medication parameters should be specified in the orders. Additionally, a scheduled dose of Oxycontin was not administered to a resident because the medication was not available, and the pharmacy had to be contacted for delivery. Staff interviews revealed that medication reordering was based on nursing judgment, and delays could occur due to the need for physician-signed forms for narcotic medications. The DON acknowledged awareness of the missed dose and the issues with pain medication administration and documentation.
Failure to Monitor and Document Behavioral Health Interventions
Penalty
Summary
Nursing staff failed to adequately monitor and document the behaviors and mental health status of three residents with mental disorders or psychosocial adjustment difficulties. One resident, who was prescribed multiple antidepressant medications for depression, did not have a physician order for monitoring signs and symptoms of depression or medication side effects, despite a care plan intervention requiring such monitoring. The lack of monitoring was confirmed by the Director of Nursing, who acknowledged that appropriate orders and monitoring were not in place prior to the surveyor's inquiry. Two additional residents with orders and care plans for behavioral monitoring related to psychiatric or behavioral issues did not have documentation of behavior monitoring as required. For one resident, there was an order to monitor target behaviors every shift, but no documentation was found for several months until after the surveyor raised the issue. Another resident had a physician order and care plan for monitoring specific behaviors associated with schizophrenia, but the required monitoring was not documented on the Medication Administration Record. These failures were confirmed by facility administrative staff during the survey.
Failure to Hold Medication per Physician Order
Penalty
Summary
Facility staff failed to follow physician orders regarding the administration of Midodrine for a resident with orthostatic hypotension. The resident had a specific order to hold the medication if the systolic blood pressure was above 130. Clinical record review showed multiple instances in June and July where the resident's systolic blood pressure exceeded 130, yet the medication was still administered. This was confirmed through review of the Medication Administration Records and an interview with the Director of Nursing, who, along with the surveyor, identified the occurrences where the medication was given contrary to the physician's order.
Improper Storage and Security of Medications and Biologicals
Penalty
Summary
Facility staff failed to properly store and secure medications and biologicals as required. In one instance, a narcotic medication, Methadone 115mg, was left on a resident's bedside table after a staff member administered care, rather than ensuring the medication was taken or following an order to leave it at bedside. The staff member acknowledged that leaving the medication unattended was not appropriate. The Director of Nursing confirmed that medications should not be left at the bedside unless specifically ordered. Additionally, a treatment cart was observed unlocked and unattended in a hallway, allowing access to various prescription creams, ointments, and other medications. The cart contained expired items, including iodoform packing strips and Nystatin Zinc tubs, as well as an opened bottle of Dakins solution without a cap. An agency nurse present at the time stated she had not checked the cart that morning. Facility policy requires that only authorized personnel have access to locked compartments, and both the Director of Nursing and Assistant Director of Nursing confirmed the cart should have been locked.
Failure to Arrange Timely Dental Services After Consultant Recommendation
Penalty
Summary
A deficiency was identified when the facility failed to arrange for timely dental services for a resident following a dental consultant's recommendation. The resident, who had a history of oral/dental health problems including missing and broken teeth, complained of tooth pain to both staff and family. The care plan documented ongoing oral health issues and required staff to monitor and report symptoms such as pain, missing or broken teeth, and other oral abnormalities. Despite a dental consult identifying the need for extractions of fractured and retained root tips, there was no evidence that the facility made arrangements for the recommended dental treatment. Interviews with the resident, the resident's son, and facility staff revealed that the resident continued to experience dental pain and had not received follow-up care after the dental consult. The DON and unit manager confirmed that no appointment had been set for the necessary dental extractions, and the facility's dental service provider had not received a referral for the resident. The lack of follow-up persisted until the surveyor's intervention, indicating a failure to provide or obtain necessary dental services within a reasonable timeframe as required.
Failure to Update Resident Hospice Status in Records
Penalty
Summary
Facility staff failed to ensure timely updates to a resident's hospice status, as evidenced by discrepancies in the medical record, care plan, and Minimum Data Set (MDS). Documentation from a contracted company indicated that hospice care for the resident began on 03/29/25 and ended on 05/29/25. However, the resident's care plan still listed hospice care as active, and the MDS completed after the hospice discharge also indicated ongoing hospice care. Additionally, the resident was not evaluated for rehabilitation services because staff believed the resident was still under hospice care. The Director of Nursing confirmed that the hospice discharge information should have been updated in all relevant records and lists, but this was not done.
Lack of Documentation for Pneumonia Vaccine Education
Penalty
Summary
The facility failed to provide education regarding the risks and benefits of the pneumonia vaccine to two residents who refused the immunization. During a review of five residents' immunization records, it was found that both residents had documented refusals for the pneumonia vaccine, but there was no evidence in the medical records indicating when the vaccine was offered or that any education about the vaccine's risks and benefits was provided. In an interview, the DON confirmed that education should be given and documented for refusals, but acknowledged that such documentation was not present for these residents.
Failure to Monitor and Document COVID-19 Vaccination Status
Penalty
Summary
The facility failed to properly monitor and document the COVID-19 vaccination status for one resident out of five whose immunization records were reviewed during a recertification and complaint survey. Specifically, a resident admitted in July 2024 had no evidence in their records of receiving the COVID-19 vaccine, nor was there documentation that the vaccine had been offered or that historical vaccination data had been obtained. During an interview, the DON confirmed that the Infection Preventionist is responsible for monitoring vaccination status upon admission, but acknowledged that there was no information available for this resident's COVID-19 vaccination status.
Failure to Address Weight Loss and Implement Dietitian Recommendations
Penalty
Summary
The facility failed to address significant weight loss and did not follow dietitian recommendations for two residents reviewed for nutrition. For one resident, a notable weight loss of 12.2 lbs (7.17%) was documented over a period of just over a month, but there was no evidence of a follow-up nutrition evaluation or documentation regarding this change. Interviews with staff confirmed that the expected protocol—re-weighing, notifying the dietitian and provider, and documenting the change—was not followed, and the Director of Nursing validated that no documentation or intervention occurred after the weight loss was identified. For another resident with diagnoses of malnutrition and dysphagia, the dietitian recommended offering pudding and shakes twice daily to increase caloric intake. However, these recommendations were not implemented, as there were no physician orders for the suggested supplements after the assessment. The resident was admitted to hospice care and subsequently died in the facility. The Director of Nursing confirmed that staff did not follow the dietitian's recommendations for this resident.
Failure to Provide Safe and Appropriate Respiratory Care
Penalty
Summary
Facility staff failed to provide appropriate respiratory care to meet the needs of several residents, as evidenced by multiple deficiencies in documentation, administration, and maintenance of respiratory equipment. For one resident with chronic respiratory failure and obstructive sleep apnea, there were repeated failures to document the administration of BiPAP therapy across several months, including specific dates in November 2022, January 2023, November 2024, and June 2025. Additionally, there was an instance where the BiPAP was not administered due to equipment malfunction, and the absence of documentation made it unclear whether the therapy was provided as ordered. Other deficiencies included the administration of oxygen at incorrect flow rates and the lack of physician orders specifying the indication for oxygen therapy. One resident was observed receiving oxygen at a higher flow rate than prescribed, and the physician order did not include the required indication for use. Another resident's oxygen tubing was not changed according to the prescribed schedule, with tubing dated beyond the weekly change requirement, and the oxygen was administered at a higher rate than ordered. Staff interviews confirmed these findings, including the lack of proper documentation, failure to follow physician orders, and improper maintenance of respiratory equipment.
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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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