Below average — CMS composite of the measures below.
A standard survey is most likely before around December 2026
Estimate from public CMS data, current as of July 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Autumn Lake Healthcare At Loch Raven during CMS and state inspections, most recent first.
Facility staff did not ensure that 2nd floor residents who could not use stairs were able to receive visitors when the only elevator was out of service for an extended period. Complaints indicated that some family members, who were themselves unable to ambulate stairs, could not visit their relatives on the 2nd floor during this time. The emergency plan directed non-ambulatory 2nd floor residents to remain on that floor unless there was an emergency and did not address how visitation would be maintained when the elevator was inoperable. The Administrator reported that visitors could use the stairs and that an emergency chair system could be used to move residents, but also stated that the chair system was not used for visitation and was unaware of any complaints, despite two having been filed.
Facility staff did not complete required quarterly smoking safety assessments for several residents identified as smokers, including some who had not been reassessed for many months and one who had never been assessed during their stay. This issue was discovered during a complaint survey after the facility’s only elevator was out of service for an extended period, affecting a group of residents on an upper floor who needed to reach a designated smoking area on a lower floor. Review of records and staff interviews, including with the DON and a unit manager, confirmed that the facility’s own practice of quarterly smoking safety assessments for smokers was not followed for half of the affected residents.
Staff failed to conduct complete investigations into two residents’ abuse allegations. In one case, a resident reported that an employee poked their face and made an obscene gesture, but the investigation lacked a statement from the corporate representative who was first notified of the allegation. In another case, a resident reported that someone in blue clothing put a hand by their face and over their mouth, with a specific GNA identified as the alleged perpetrator; however, the investigation did not include statements from two GNAs who were on duty on the unit at the time of the alleged incident, despite leadership having the opportunity to ensure all relevant documents were present.
Staff failed to create person-centered care plans for two residents, one with mobility limitations and one receiving peritoneal dialysis. For the resident with mobility issues, the care plan did not address the resident’s refusal to use a Hoyer lift and preference for pivot transfers, despite therapy prohibiting pivot transfers and staff awareness of the resident’s resistance. For the resident on peritoneal dialysis, the care plan did not specify that the treatment was peritoneal dialysis, nor did it include the treatment schedule or cycle time frames; an LPN Unit Manager acknowledged using a generalized renal care plan without incorporating the specific dialysis prescription.
A resident’s medical record lacked documentation confirming that scheduled showers or bed baths were provided on multiple dates, and there was also no record of any refusals of care on those days. The DON and an LPN unit manager reported that showers were scheduled on specific shifts and that completed showers and refusals should be documented on shower/skin sheets and in the care plan, but the surveyor found gaps where no such entries existed. This resulted in incomplete ADL documentation and failure to maintain medical records according to accepted professional standards.
Staff failed to include the unit census on daily nurse staffing/assignment sheets, with 19 of 19 reviewed sheets missing this information. When a surveyor reviewed staffing records to determine which staff were working during an alleged abuse incident on one unit, the census was not documented for that shift or for multiple subsequent days across all three shifts. A scheduling manager reported not knowing who was responsible for completing the assignment sheets or that census data was required, and the DON stated they had not previously been told that the census needed to be included on the assignment sheets.
Food items were observed stored opened, unsealed, and unlabeled in the kitchen dry storage room, walk-in freezer, and a second-floor nourishment room. Surveyors found tortillas, rice, food thickener, seasoning, tilapia, corn, soup, an unlabeled food substance in a Tupperware container, and RedHot sauce without proper labels or lids. The Dietary Manager and Unit Clerk acknowledged the labeling expectations, and the Unit Clerk agreed with the items identified by the surveyor.
Infection Control Program Not Maintained: Staff failed to follow infection control practices during resident care, including a catheter bag left on the floor, improper wound care technique, and inconsistent use of EBP PPE such as gowns and gloves. Clean linens were observed exposed in a linen room used as a walkway, and an LPN caring for a resident on CDI contact precautions used hand sanitizer instead of washing with soap and water after exiting the room.
Expired supplies were found in the second-floor medication storage room during the annual survey. The expired items included antifungal cream, wound dressings, hydrogel, catheters, COVID-19 antigen self-tests, IV start kits, heparin lock flush syringes, syringes and needles, and Foley-related supplies. The NHA confirmed the items were expired, and the issue was identified in 1 of 1 medication storage rooms reviewed.
Staff did not adhere to a physician's order specifying that an opioid pain medication be administered only for pain levels of 7-10, instead giving the medication to a resident on multiple occasions when pain scores were documented as lower or not provided. An LPN acknowledged awareness of the order but still administered the medication outside the prescribed parameters, and the DON confirmed staff expectations regarding pain assessment and medication administration.
Surveyors found that two residents were not receiving oxygen therapy according to physician orders, with staff unaware of the correct flow rates and not checking flow meters as required. Additionally, a resident with complex medical needs experienced vomiting and lethargy, but the nurse failed to perform a thorough assessment, obtain vital signs or blood sugar, or notify a practitioner before sending the resident to the hospital. Staff interviews confirmed that protocols for monitoring and response were not followed.
The facility failed to provide timely wound care and consistent turning and repositioning for two residents with pressure ulcers. Staff delayed initiating ordered wound treatments for a new admission and did not consistently document or perform required wound care and repositioning for another resident, as confirmed by the DON.
Failure to Treat a Dependent Resident with Dignity During Dining: During a lunch meal observation, independent residents were served as they sat at their tables while two residents needing assistance waited. An aide was assisting one resident while a dependent resident waited for a meal, raised a hand, made incoherent sounds, and reached for the other resident's food before being redirected to wait. The resident was not served until later, and the aide stated she was the only staff assigned to dining and sometimes had to assist 3 or 4 residents at a time.
A facility failed to provide quarterly financial statements for a resident's personal funds held by the business office. The resident's family member reported not receiving the statements, and the Business Manager stated she did not send them unless requested. The DON reviewed the concern and acknowledged that quarterly statements should be sent to residents.
A resident’s clothing was reported missing after laundry handling, including sweatpants, jeans, pajamas, and a sweater. The resident’s representative said the missing items had been reported to laundry staff, but the items were not found or replaced, and the resident’s inventory list was not updated to reflect new belongings. A laundry aide acknowledged awareness of the missing clothing but had not reported it to the unit manager or laundry supervisor.
A resident with moderate cognitive impairment and documented incapacity was allowed to sign blank financial and Medicaid forms, including authorization to access bank funds and redirect SSA checks, without the facility confirming valid consent from the RR. The BOM said the resident’s VA benefits were not used, and a financial consulting firm used the blank signed pages as Medicaid consent, assuming the resident had capacity.
A resident receiving daily oral chemotherapy had the medication administered throughout the look-back period, but the MDS with the relevant ARD did not code the chemo in Section O. The MDS coordinator stated that chemotherapy given within the ARD should be coded and agreed the assessment should have included it.
The facility failed to create baseline care plans that reflected two residents’ immediate needs after admission. One resident was admitted with a stage 4 sacrum pressure ulcer present on admission, but the baseline care plan did not include the wound. Another resident was admitted with active CML and was receiving chemotherapy medication, but the baseline comprehensive care plan did not include the CML diagnosis or related plan of care.
A resident was found unresponsive, placed on oxygen, and transferred to the hospital, where the resident was admitted to the ICU with respiratory distress. Review of the care plan showed it had not been revised after the change in condition, and the DON confirmed the care plan was not updated to reflect the event.
Failure to implement ordered fall mats for residents with fall risk. Two residents with a history of falls were observed without the required mats in place despite care plan interventions and an order to lower the bed and use a fall mat. One resident had multiple recent falls and confusion, and an LPN supervisor was later seen carrying mats toward the room after surveyors noted they were absent. The UM confirmed the mats were not in place and that no request had been made for one resident's mats.
Two residents receiving PD had deficient care related to dialysis storage, infection control, and catheter documentation. PD supplies were stored in a resident’s room in a way that blocked the doorway view, a resident on contact isolation shared a room with another PD resident despite other rooms being available, the facility had no dialysis-specific infection control policy, and daily PD catheter site care and dressing changes were not consistently documented.
Missing Annual Nursing Aide Performance Reviews: The facility failed to complete annual nursing aide performance reviews for 2 of 5 files reviewed. Record review showed missing annual performance review documentation for multiple GNAs, and HR stated there was no process or tracking system in place for annual reviews, relying instead on memory and verbal reminders to supervisors.
A resident with an opioid addiction and methadone use had an order for an opioid PRN for severe pain, but staff administered it multiple times when the documented pain score was 0. The attending MD said he would not expect the medication to be given at a pain score of 0, while an LPN said the resident was demanding about pain meds and sometimes refused to give a pain score; she did not document or report the issue. The DON acknowledged the concerns.
Meals Served Did Not Match Meal Tickets: Staff failed to serve meals according to meal tickets for multiple residents. One resident ordered to receive Magic Cups with all meals for malnutrition was served breakfast without the supplement, while another resident who disliked bread and had asked not to receive it was still served bread. A third resident was served a meal that did not include bread even though the meal ticket called for it, and the dietary manager acknowledged the mismatch between the tickets and what was served.
A resident who was found unresponsive and transferred to the hospital had inaccurate transfer documentation, including the wrong RP name, and a bed hold form signed without evidence the resident was able to sign it. In a separate record review, an LPN and other staff failed to document all opioid doses on the MAR, with 16 doses signed out on the controlled substance log but missing from the chart.
Missing QAPI Training Documentation for Staff: The facility failed to provide required QAPI training documentation for 5 of 5 GNA employee files reviewed. The DON said the prior nurse educator had maintained education records, but after that person left, records were difficult to locate and HR was now responsible. The Administrator said the facility used Carefeed for annual training, but QAPI training was still missing from the files, and HR and the ADON were unable to produce prior QAPI training records.
Missing Infection Control Training Documentation: The facility failed to provide required infection control training records for several GNAs during the annual survey. The surveyor reviewed employee files and Carefeed records for multiple staff members and found no evidence of infection control training for 2024, while the DON, HR, and ADON were unable to locate prior documentation. Training was assigned in Carefeed only after the surveyor requested the files, and the in-service records provided did not show infection control training for the affected GNAs.
Missing Compliance and Ethics Training in Employee Files: Review of employee records found that three GNAs did not have documentation of required Compliance and Ethics training. The DON said the prior nurse educator had maintained education records and that HR was now responsible, while the Administrator said annual training was tracked in Carefeed. However, Carefeed did not show 2024 Compliance and Ethics training for the affected GNAs, and the training was only assigned after the surveyor requested the files.
Missing Required Annual In-Service Training for GNAs: The facility failed to show that five GNAs completed the required 12 hours of annual in-service training. The surveyor reviewed employee files and Carefeed records and found no evidence of the required training for 2024 and 2025. The DON said the prior nurse educator had kept the education records, HR was now responsible, and the ADON later produced limited in-service documentation that still did not show the required annual hours.
Missing Dementia Training Documentation: The facility failed to maintain required dementia training records for 4 of 5 GNAs whose files were reviewed. The DON said the prior nurse educator had kept staff education records, but after that person left, records were difficult to locate and HR was now responsible. Although the Administrator said annual training was tracked in Carefeed, review of the files and Carefeed did not show dementia training for the affected GNAs, and the ADON acknowledged the missing training.
Failure to Ensure Visitation Rights During Elevator Outage
Penalty
Summary
Facility staff failed to ensure that residents residing on the 2nd floor who could not safely ambulate using stairs were able to exercise their right to have visitors when the facility’s only elevator malfunctioned. Complaint reviews showed that family members were unable to visit their relatives on the 2nd floor when the elevator was inoperative, and these family members themselves were unable to use the stairs. An incident report documented that the facility’s only elevator was malfunctioning for an extended period, from 3/28/26 to 4/23/26. During this time, residents who could not use the stairs remained on the 2nd floor, and some of their family members could not access them due to the lack of elevator service. Review of the facility’s emergency plan revealed that it instructed that 2nd floor residents who could not safely use the stairs should remain on the 2nd floor unless there was an emergency, and it did not include any provisions for maintaining visitation when the elevator was inoperable. In an interview, the Administrator stated that visitors could use the stairs to visit 2nd floor residents and that residents could be transported using an emergency chair system to meet visitors who could not use the stairs. However, the Administrator acknowledged that the emergency chair system was not used for visitation purposes during the elevator outage and reported being unaware of any complaints about the inoperative elevator, despite two complaints having been received by OHCQ. No additional documentation was provided to show a plan to support visitation for 2nd floor residents during the elevator malfunction.
Failure to Complete Required Quarterly Smoking Safety Assessments
Penalty
Summary
Facility staff failed to update smoking safety assessments at least once every three months for multiple residents identified as smokers. During a complaint survey focused on smoking safety, surveyors reviewed an incident involving the facility’s only elevator being inoperative for nearly a month, which affected residents who lived on the 2nd floor and needed to access the 1st-floor smoking area. The facility’s investigation identified a group of 10 residents on the 2nd floor who smoked and required additional accommodations to safely ambulate to the designated smoking area. Review of these residents’ medical records showed that 5 of the 10 did not receive quarterly smoking safety assessments as required by the facility’s practice. Specifically, four residents had not received a smoking assessment since May 2025, and one resident had no documented smoking assessment at any time during their stay. During interviews, the Unit Manager stated that residents identified as smokers are to be assessed quarterly for smoking safety. When the surveyor pointed out the missing assessments, the DON reviewed the records and confirmed that these residents had not received the required quarterly smoking assessments. This lack of timely reassessment occurred in the context of an extended elevator outage that necessitated special consideration for safe smoking access for residents residing on the 2nd floor.
Incomplete Investigations of Resident Abuse Allegations
Penalty
Summary
Facility staff failed to complete thorough investigations of two separate resident allegations that were reported to the state agency. For the first incident, a resident alleged that on a specific date and time an employee poked two fingers into their face and showed them their middle finger. The five-day follow-up documented the allegation, but the investigation file did not clearly identify who was the first point of contact for the report. During interview, the Administrator stated that a corporate representative was initially made aware of the alleged incident, but there was no statement from this corporate representative included in the investigation file. The Administrator described their usual investigation process as interviewing involved parties, identifying and interviewing witnesses, reviewing staffing for the date of the alleged incident, and interviewing the resident’s roommate and other nearby residents if there were no direct witnesses. In the second incident, a resident reported that during a specific shift someone wearing blue put a hand by their face and over their mouth, and a particular GNA was identified as the alleged perpetrator. Review of the staffing sheet for the time of the alleged incident showed that two GNAs were working on the unit where the incident was reported to have occurred. However, the investigation file contained no statements or interviews from these two GNAs. Prior to the surveyor’s review of the investigation, the DON and a regional nurse were given the opportunity to review the investigation to ensure all necessary documents were available, yet the statements from the two GNAs remained absent. These omissions demonstrated that the facility did not conduct complete investigations into the reported allegations.
Failure to Develop Person-Centered Care Plans for Mobility and Peritoneal Dialysis Needs
Penalty
Summary
Facility staff failed to develop and implement person-centered care plans that addressed all identified needs for two residents, one with mobility limitations and one receiving peritoneal dialysis. For the resident with mobility limitations, the care plan included interventions for resistance to care and adjustment issues, but did not address the resident’s specific resistance to use of a Hoyer lift and the resident’s insistence on pivot transfers from bed to wheelchair. The Unit Manager confirmed that the resident was resistant to care, did not like the Hoyer lift, and preferred pivot transfers, but also stated that physical therapy had prohibited pivot transfers. Despite this known conflict between the resident’s preferences and therapy restrictions, the care plan lacked individualized interventions related to the resident’s resistance to the Hoyer lift and continued request for pivot transfers. For the resident receiving peritoneal dialysis, review of the electronic health record showed an order for peritoneal dialysis, but the resident’s care plans did not include a person-centered care plan specific to this treatment. The existing dialysis care plan did not specify the type of dialysis treatment being provided, did not document when the resident was scheduled to receive the treatment, and did not include time frames for the dialysis cycles. During an interview, the LPN Unit Manager stated that they do not place the dialysis prescription details into the care plan and instead use a generalized renal care plan by selecting standard items, confirming that the care plan was not individualized to the resident’s ordered peritoneal dialysis regimen.
Failure to Document Resident Showers and Refusals
Penalty
Summary
Facility staff failed to maintain complete and accurate documentation of bathing care for a resident, specifically regarding showers and refusals of showers. During a complaint survey, the surveyor requested verification that Resident #5 was receiving scheduled showers. The DON stated that the resident was scheduled for showers on the 3 pm–11 pm shift on Tuesdays and Fridays, and provided shower sheets for several dates in October and early November. However, there was no documentation to verify that the resident received a shower or bed bath on 10/17/25, 10/21/25, and 10/24/25. The DON explained that when a resident receives a shower it is documented on a skin sheet, and that refusals of showers should be documented both in the plan of care and on the shower sheet. Despite this, the surveyor did not receive any documentation indicating that the resident either received bathing care or refused showers on the missing dates. This lack of documentation showed that the facility did not safeguard resident-identifiable information and maintain medical records in accordance with accepted professional standards, as there was no record confirming whether the resident’s scheduled showers or refusals occurred on the identified dates.
Failure to Include Unit Census on Daily Nurse Staffing Sheets
Penalty
Summary
Facility staff failed to include the unit census on daily nurse staffing/assignment sheets, as identified in 19 of 19 staffing sheets reviewed during a complaint survey. On review of the Unit 2 staffing sheet for the 3:00 pm–11:00 pm shift on 12/03/25, the census field was blank, and the surveyor was using this sheet to determine which staff were working during an alleged abuse incident. Further review of Unit 2 staffing sheets dated 12/04/25 through 12/09/25 for all three shifts (7:00 am–3:00 pm, 3:00 pm–11:00 pm, and 11:00 pm–7:00 am) showed that none of these assignment sheets included the census. During an interview, the Scheduling Manager stated they were unsure who was responsible for completing the assignment sheets on the units and were not aware that the census needed to be included. The DON stated that during the previous survey they had not been informed that the census needed to be included on the assignment sheet. No specific resident medical histories or conditions were described in the report, and the deficiency centers on incomplete staffing documentation and lack of clarity regarding responsibility for completing census information on assignment sheets.
Food Items Stored Opened and Unlabeled in Kitchen and Nourishment Room
Penalty
Summary
Food items were found stored in a manner that did not maintain their integrity in the kitchen and in a second-floor nourishment room. During an initial observation of the kitchen dry storage room, surveyors found a bag of soft tortillas that was opened and unlabeled, a large box of rice that was opened, unsealed, and unlabeled, a large box of food thickener that was opened, unsealed, and unlabeled, and a packet of ranch dressing seasoning that was opened and labeled with two dates on white tape, but the dates were not identified as to what they represented. In the walk-in freezer, surveyors observed tilapia and a box of corn that were both opened, unsealed, and unlabeled. The Dietary Manager, who was present, stated that opened items were expected to be sealed and labeled, and she could not identify what the dates on the ranch dressing seasoning packet meant because they were not the kitchen’s labeling system. In the second-floor nourishment room, surveyors observed a cup of soup that was not labeled and did not have a lid, an unlabeled food substance in a Tupperware container, and an opened and unlabeled bottle of RedHot sauce. The Unit Clerk, who was present during the observation, stated that any food item placed into the refrigerator was expected to be labeled with the resident’s name and the date. The surveyor identified the items of concern to the Unit Clerk, and she agreed with the findings.
Infection Control Program Not Maintained
Penalty
Summary
The facility failed to maintain an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable diseases and infections. During the recertification survey, multiple infection control concerns were observed involving catheter care, wound care, Enhanced Barrier Precautions (EBP), linen storage, and hand hygiene practices. Resident #102’s urinary catheter bag was observed lying on the floor beside the bed. When the surveyor pointed this out, a staff member acknowledged the bag should not have been on the floor and said it would be taken care of after the surveyor’s intervention. In another observation, a wound nurse reported that he should have washed or sanitized his hands between glove changes and that wound cleansing should be done from top to bottom, but he had used the same bandage scissors to remove the old dressing and cut the new dressing gauze without allowing the disinfectant the required drying time. He was also unable to explain EBP and stated he did not wear a gown because he was not planning to provide wound care at that time. A GNA also acknowledged she should have worn a gown during wound care for the resident but did not do so. The infection control nurse stated staff should have worn gowns and gloves and sanitized between glove changes, but she did not keep documentation of her infection control rounds. Resident #41 had an active order for EBP to be maintained for a feeding tube. The EBP sign outside the room indicated gloves and a gown were required, yet one staff member provided toileting care wearing gloves only, and another staff member administered medication via the feeding tube wearing gloves only and stated she was unaware gowns were needed for feeding tube care. The clean linen room was also observed being used as a walkway to the housekeeping director’s office, with the clean linen cart cover folded up and clean linens exposed on the cart and folding table, while the door from the office area to the clean linen room was not closed. For Resident #17, who had an order for contact isolation for C. difficile infection, an LPN emptied the bedside commode contents and then used hand sanitizer after exiting the room. When asked about hand hygiene after contact precautions for CDI, the LPN stated the process was to use hand sanitizer rather than washing with soap and water.
Expired Supplies Found in Medication Storage Room
Penalty
Summary
Expired drugs and biologicals were found in the second floor medication storage room during the annual survey. A tour of the room on [DATE] at 10:57 AM revealed multiple expired items, including 6 tubes of antifungal cream with 1% clotrimazole that expired 5/2024, wound dressings, Dynagel moisturizing wound hydrogel, silicone self-adhesive catheters, COVID-19 BinaxNOW antigen self-tests, IV start kits, heparin lock flush syringes, syringes and needles, foam and alginate wound dressings, Hydralock super absorbent wound dressings, urinary drain bags, a Foley catheter, and a Foley catheter insertion tray. The expired supplies were identified in 1 of 1 medication storage rooms reviewed. The facility failed to discard the expired supplies that remained stored in the medication room. On [DATE] at 11:46 AM, the Nursing Home Administrator was interviewed and confirmed that the items were expired. The administrator was made aware of the concern at that time and again at exit on [DATE].
Failure to Follow Physician's Order for Pain Medication Administration
Penalty
Summary
Facility staff failed to follow a physician's order regarding pain management for a resident. The medical record review showed that the resident was prescribed an opioid 10 mg to be administered as needed every 4 hours, but only for pain levels rated between 7 and 10. Despite this, staff administered the medication on multiple occasions when the resident's documented pain level was below 7, including several instances where the pain level was recorded as 0 or 6, and once as low as 4. These deviations from the prescribed parameters were documented in the medication administration record for both May and June. During interviews, an LPN acknowledged awareness of the physician's order to administer the medication only for pain levels of 7-10 but admitted to giving the medication when the resident either did not provide a pain score or when a lower pain score was documented. The LPN also confirmed that no pain assessment was documented in the progress notes for these instances. The DON confirmed that staff were expected to assess and document the resident's pain level and administer medication according to the physician's parameters, acknowledging the concern when presented with the findings.
Failure to Follow Physician Orders for Oxygen Therapy and Inadequate Response to Change in Condition
Penalty
Summary
Surveyor observations, medical record reviews, and staff interviews revealed that the facility failed to follow physician orders for oxygen therapy for two residents. One resident was observed receiving oxygen at 3.5 liters per minute (LPM) when the physician's order specified 2 LPM, and another was receiving 2.5 LPM instead of the ordered 2 LPM. Nursing staff were unaware of the correct flow rates and reported checking oxygen flow meters only weekly or every other day, rather than every shift as required by the orders. Staff were unable to state when the oxygen flow rates were last checked, and adjustments were only made after surveyor intervention. Additionally, the facility failed to appropriately assess and report a change in condition for a resident with multiple complex medical issues, including end-stage renal disease, diabetes, and a sacral pressure ulcer. The resident reported vomiting multiple times, but there was no evidence of a thorough assessment or notification to a practitioner at that time. Later, when the resident was found lethargic, the nurse did not obtain vital signs or a blood sugar level before sending the resident to the hospital. Documentation of the change in condition was incomplete, and the nurse did not fully assess the resident prior to transfer. Interviews with facility staff confirmed that the expected protocols for monitoring oxygen therapy and responding to changes in resident condition were not followed. The DON acknowledged that nurses would not have known the correct oxygen flow rates if checks were only performed weekly, and the unit manager stated that a full assessment and practitioner notification should have occurred for the resident with vomiting and lethargy. The nurse involved in the change in condition incident was an agency nurse and was unavailable for interview.
Failure to Provide and Document Pressure Ulcer Care and Prevention
Penalty
Summary
The facility failed to provide timely and appropriate pressure ulcer care for two residents. For one newly admitted resident with a sacral pressure ulcer, staff did not initiate the physician-ordered wound care regimen until two days after admission, despite documentation of the wound on the admission assessment and a standing order for daily treatment. The resident was later sent to the hospital with worsening wounds and a diagnosis of sepsis. Additionally, recommended diagnostic tests by a wound specialist were not completed before the resident's transfer to the hospital. For another resident, the facility did not consistently document or provide daily wound care and failed to ensure regular turning and repositioning as ordered. Multiple instances were identified where wound care was not documented in the treatment administration record, and several shifts lacked documentation of turning and repositioning. The DON confirmed that staff are expected to document wound care and repositioning, but acknowledged the missing documentation and lapses in care.
Failure to Treat a Dependent Resident with Dignity During Dining
Penalty
Summary
The facility failed to treat a dependent resident with dignity during dining. During a lunch meal observation on the second floor, independent residents were served as they sat at their tables, while one table had two residents who needed assistance with meals. Staff #8 was assisting one resident while Resident #41 waited for their meal and was observed raising a hand, making incoherent sounds, and reaching for the other resident's food. Staff #8 redirected Resident #41 and told the resident to wait for their turn. Resident #41 was not served until 12:31 PM, after which Staff #8 began assisting the resident with the meal. During interview, Staff #8 stated she was the only staff assigned to dining and was responsible for feeding residents who needed assistance, and that dependent residents sometimes had to wait longer because she could only assist one resident at a time; she reported that for this meal she had only 2 residents needing assistance, but at times she could have up to 3 or 4 residents requiring help.
Failure to Provide Quarterly Financial Statements
Penalty
Summary
The facility failed to properly hold, secure, and manage a resident's personal money deposited with the nursing home by not providing quarterly financial statements. This was identified for Resident #10, one of 3 residents reviewed for accounting and records during the recertification survey. The resident's family member stated that they were not receiving quarterly statements from the facility's business office. The Business Manager stated that quarterly statements had not been sent to the resident's representative and that she only sent the resident's quarterly statements if they were requested. The DON reviewed the concern and stated that the business office manager should send the statements quarterly to residents.
Lost Resident Clothing
Penalty
Summary
The facility failed to protect a resident’s clothing from loss. Resident #13’s representative reported that the resident was admitted with gray sweatpants, one pair of jeans, funnel pajamas, and one sweater, and stated that these items were lost during laundry. The representative also reported that concerns about the missing clothing had been communicated to laundry staff, but the facility had not found the items or replaced them. Record review showed an admission inventory list dated 5/16/25 that included a sweater and one pair of jeans, but there was no updated inventory list for Resident #13 despite the facility’s stated process to update inventories as new items are received. The laundry aide acknowledged being aware that the resident’s representative had mentioned missing clothes, stated that laundry staff look for missing items and notify the unit manager or laundry supervisor if they are not found, and confirmed that she had not reported the missing clothing to anyone yet.
Improper handling of resident financial consent and benefits
Penalty
Summary
Facility staff failed to ensure that a resident was free of exploitation when financial and Medicaid-related forms were handled without confirming the resident’s capacity to consent. Resident #114’s record showed moderate cognitive impairment on the MDS, and the paper chart contained physician and NP certifications dated 10/6/23 stating the resident was incapable of making decisions, including medical decisions. Despite this, the Business Office Manager stated that the facility had residents sign Medicaid forms when admitted, sometimes without dating them, and she could not recall whether the resident signed at admission or later when Medicaid was applied for. She also stated that if a resident lacked capacity, the facility would talk to a Resident Representative for consent, but she was unaware that Resident #114 lacked capacity. The financial packet reviewed for the resident included a Medicare card, a VA benefit card, 13 blank documents signed by the resident without dates, and blank pages from a Maryland Medicaid application with two signatures. The signed forms included consent for the facility to apply for Medicaid and appeal if needed, authorization to access the resident’s bank account, forms requesting Social Security benefit checks be sent to the facility, and a Resident’s Funds Management Services form that was blank when signed. The BOM stated the resident had a Resident Representative who lived with the resident and was difficult to contact, and that the representative was not aware of what was happening until Social Security checks stopped. The BOM also stated she had not tried to use the resident’s VA benefits, and the financial consulting firm said it used the blank signature pages as the consent to apply for Medicaid, assuming the resident had capacity because no form indicating incapacity had been received.
MDS Assessment Did Not Code Chemotherapy Medication
Penalty
Summary
Facility staff failed to accurately code Resident #7’s status on the Minimum Data Set (MDS) assessment. Medical record review showed the resident had an order for Dasatinib, a chemotherapy medication taken by mouth every day, and that the medication was administered daily throughout August 2025. However, the MDS assessment with an Assessment Reference Date (ARD) of 8/9/25 did not code the chemotherapy medication in Section O. During interview, the MDS coordinator stated that if a resident were receiving chemotherapy medication within the ARD of the MDS, it should be coded, and agreed that Resident #7’s MDS should have included it.
Failure to Include Admission Conditions in Baseline Care Plans
Penalty
Summary
The facility failed to create and implement a baseline care plan within 48 hours of admission for a resident with a stage 4 sacrum pressure ulcer. Record review showed the resident was admitted with the pressure ulcer present on admission, the admission MDS and weekly wound assessment documented the stage 4 sacrum ulcer, and the physician admission history and physical also noted the resident was admitted from the hospital with a pressure ulcer on the sacrum. Although the resident’s care plan included a focus on the stage 4 sacrum pressure ulcer, the baseline care plan from admission did not reflect the existing wound. The facility also failed to include Chronic Myeloid Leukemia (CML) in the baseline comprehensive care plan for another resident admitted with an active diagnosis of CML and receiving chemotherapy medication at the facility. Review of that resident’s baseline comprehensive care plan did not reveal a care plan focus for CML or the resident’s diagnosis. The DON stated that if a resident were admitted with a diagnosis being treated at the facility, the baseline comprehensive care plan would be expected to include it.
Care Plan Not Revised After Respiratory Distress and Hospitalization
Penalty
Summary
The facility failed to revise a resident’s care plan after a change in condition. Resident #3 was found unresponsive on 06/21/2025 at 8:20 PM. At that time, vital signs were within normal limits, blood glucose was 157 mg/dL, the resident was placed on oxygen via non-rebreather mask, oxygen saturation was 100%, EMS was called, and the resident was transferred to the hospital. A follow-up note documented that the resident had been admitted to the ICU and diagnosed with respiratory distress. Review of the resident’s care plan on 09/05/2025 showed the last revision was completed on 04/17/2025 and included a goal that the resident would have no signs and symptoms of poor oxygen absorption. There was no evidence that the care plan was revised to reflect the respiratory distress event or the hospitalization. During interview, the DON confirmed that the care plan was not revised after the event and acknowledged that it should have been revised to reflect the change in condition.
Failure to Implement Ordered Fall Mats for Residents at Risk for Falls
Penalty
Summary
The facility failed to implement fall-related interventions that had been identified as necessary for residents with a history of falls. Resident #55, who had multiple diagnoses including a history of repeated falls and was noted by staff to have become confused since admission, experienced falls on 08/16/25, 08/17/25, 08/27/25, 08/28/25, 08/31/25, and 09/04/25. Although the interdisciplinary team met on 08/19/25 to discuss the resident's falls, no adjustments were made to the care plan at that time. The care plan later included bilateral fall mats with initiation dates of 08/28/25 and 09/01/25, but survey observations on 09/04/25 and 09/05/25 found no safety mats in the room. On 09/05/25, the night LPN supervisor was observed carrying fall mats toward the resident's room after the surveyor had already noted the mats were absent. The DON stated that residents with a history of falls should have safety interventions in the care plan and that staff were expected to perform frequent rounding on residents with multiple falls, while the UM acknowledged responsibility for ordering the mats and failing to follow up to ensure they were in place. Resident #11 also had a documented fall-related intervention that was not in place. The medical record showed an order dated 1/18/2024 stating to lower the bed to the ground and have a fall mat in place. The resident was observed lying in bed on 09/04/25 and again on 09/05/25, and no fall mat was seen in the room during either observation. Further record review showed the resident's care plan included interventions related to previous falls, and the most recent fall assessment dated 8/15/2025 scored the resident at 10, indicating moderate fall risk. During a room tour with the UM on 09/08/25, the UM confirmed there were no fall mats in place and stated that no request had been made for fall mats for the resident.
Dialysis Care Deficiencies
Penalty
Summary
Safe and appropriate dialysis care/services were not provided for two residents receiving peritoneal dialysis. For one resident, multiple boxes of PD supplies were delivered and stored inside the resident’s room, with some boxes placed on a stand and others on the floor. The arrangement of the supplies blocked the view of the resident from the doorway. The Nurse Unit Manager stated that residents receiving PD were placed in larger rooms and that supplies were kept in the resident’s room because the facility did not have sufficient space and had no additional designated storage area for PD supplies. For another resident diagnosed with C. difficile infection and placed on contact isolation, the resident was sharing a room with another resident who also received PD and was on enhanced barrier precautions. The surveyor found that other unoccupied rooms were available, including rooms occupied by a single resident receiving PD who was not on contact isolation. Facility staff stated that the two residents remained together because one did not use the restroom and the other used a bedside commode, and that they had been told residents could stay in the same room as long as they were not sharing a bathroom. The facility also lacked a dialysis-specific infection control policy. Review of the infection prevention and control program did not show a separate policy for dialysis, and staff stated that no separate dialysis infection control policy existed. In addition, care plans for both residents required daily checking and changing of the PD catheter dressing site with documentation, but the medical records did not show daily catheter site checks and dressing changes. The flow sheets contained an exit site condition section, but entries were incomplete or only noted the word "clear," and the UM confirmed that catheter care was documented only on the flow sheet and that staff were not documenting catheter care.
Missing Annual Nursing Aide Performance Reviews
Penalty
Summary
The facility failed to conduct annual nursing aide performance reviews for 2 of 5 nursing aide annual performance reviews reviewed during the annual survey. During record review, the surveyor requested employee files for GNA #9, GNA #11, GNA #20, GNA #21, and GNA #22, including documentation of annual review, annual training, and immunizations. A review of the files for GNA #11, GNA #21, and GNA #22 did not reveal nurse aide annual performance reviews. When the DON was informed of the missing annual performance reviews, the surveyor interviewed HR #17, who stated she was responsible for maintaining nursing aide annual performance reviews. HR #17 reported there was no process in place for annual reviews, that she relied on remembering when staff reviews were due, that she verbally informed supervisors of upcoming reviews, and that there was no filing system to track annual performance reviews. The surveyor also interviewed UM #6, who directed the surveyor to HR #17 regarding the facility's process for conducting nurse aide annual performance reviews. UM #16 provided documentation for GNA #22 but stated she could not provide annual performance reviews for GNA #11 and GNA #21.
Unnecessary opioid administration
Penalty
Summary
Ensure each resident's drug regimen was free from unnecessary drugs was not met for one resident. Record review showed the resident had an order for an opioid 10 mg every 4 hours as needed for pain rated 7 to 10, dated 5/7/25. However, staff administered the medication on multiple occasions when the resident's documented pain score was 0, including several administrations in May 2025 and two in June 2025. During interview, the attending physician stated he was aware the resident had an opioid addiction and was on methadone, and he would not expect staff to give a pain medication when the resident reported a pain score of 0. An LPN who gave one of the doses for a pain score of 0 said it may have been an error, but she was not sure, and reported the resident was demanding about pain medication and sometimes refused to give a pain score. She also stated she had not documented this or notified anyone. The DON stated she was aware of the resident's behaviors regarding pain medications and would not expect staff to administer a pain medication when it was not indicated, and to call a supervisor if the resident was acting out.
Meals Served Did Not Match Meal Tickets
Penalty
Summary
The facility failed to serve residents meals based on their meal tickets, affecting 3 of 8 residents observed during dining. Resident #6 was served breakfast with a pureed meal but no Magic Cup, even though the meal ticket on the tray stated the resident should receive a Magic Cup with all meals. The resident reported that the facility often failed to serve Magic Cups during breakfast. A review of the medical record showed an order entered on 7/21/25 directing that the resident receive a Magic Cup with all meals for malnutrition, and a dietary progress note from the same date documented nutrition interventions including Magic Cups three times with meals. During another dining observation, Resident #40 was seen removing 2 slices of bread from the plate, and the meal ticket indicated no bread. When interviewed, the resident stated they disliked bread, had asked several times not to be served bread because of their diagnoses, and said the facility constantly served bread with meals. Resident #14 was served lasagna without bread, although the meal ticket next to the plate indicated a slice of bread should have been included. The dietary manager stated she was aware of Resident #40's preference and dislike for bread and acknowledged that the residents' meal tickets did not match what was served. The DON and Facility Administrator were notified of the findings.
Incomplete medical records and inaccurate documentation of transfer and opioid administration
Penalty
Summary
The facility failed to maintain complete and accurately documented medical records for a resident who was transferred to the hospital after being found unresponsive. The resident’s quarterly BIMS score was 15, indicating cognitive intactness, and the chart documented that the resident was found unresponsive, had vital signs within normal limits, a blood glucose of 157 mg/dL, received oxygen via non-rebreather mask, and was transferred by EMS. However, the transfer documentation contained an incorrect Responsible Party name that did not match the resident’s face sheet, and the DON later acknowledged that the wrong name had been entered in the record. The record also contained a bed hold policy form dated and signed on the day of the transfer, but the resident stated that the signature was not recognized and that he/she did not recall signing it. The DON stated there was no supporting documentation showing the resident was alert and capable of signing the form at the time of transfer. The DON further stated that the resident had been documented as unresponsive when transferred and that the form had been completed by an agency nurse on the resident’s behalf. The facility also failed to document all administered doses of an opioid for another resident. The physician ordered one opioid dose for pain rated 4-6 and another for pain rated 7-10. Review of the May 2025 MAR and controlled substance sign-out sheets showed 16 additional doses signed out on the controlled substance sheet that were not documented on the MAR. Staff stated they were expected to sign off the controlled substance log, then sign off on the MAR and document the resident’s pain level, but the MAR did not reflect all doses administered.
Missing QAPI Training Documentation for Staff
Penalty
Summary
The facility failed to provide required QAPI training to staff, as evidenced by a review of 5 of 5 employee files for GNA #9, GNA #11, GNA #20, GNA #21, and GNA #22. On 09/08/2025, the surveyor requested the employee files from the DON and asked that they include documentation of annual review, annual training, and immunizations. On 09/09/2025, the file review did not reveal QAPI training for any of the five GNAs, and the surveyor informed the DON and ADON #1 that the training was missing. During interviews, the DON stated that the previous nurse educator had been responsible for maintaining nursing staff education records, but since that person left, she was having difficulty locating the records and said HR was now responsible. The Administrator later stated the facility used Carefeed for annual staff training and reviewed the annual training requirements on his computer, but QAPI training for 2024 and 2025 was still missing from the GNA files. HR #17 was unable to locate prior QAPI training for the requested employees, and the ADON #1 provided in-service documentation from 01/17/25 and 01/27/25 that did not show QAPI training.
Missing Infection Control Training Documentation
Penalty
Summary
The facility failed to provide required infection control training to staff as part of its infection prevention and control program. During the annual survey, the surveyor requested employee files for GNA #9, GNA #11, GNA #20, GNA #21, and GNA #22, including annual review, annual training, and immunization documentation. A review of the files for GNA #11, GNA #21, and GNA #22 did not reveal infection control training. When the surveyor informed the DON and ADON #1, the DON stated that the previous nurse educator had maintained nursing staff education records and that, since that person left, she was having difficulty locating the records. The DON also stated that HR was now responsible for maintaining education records. The Administrator later stated that the facility used Carefeed for annual staff training and that it had been updated in June 2025 to include all required annual training. However, a review of Carefeed with HR #17 did not show infection control training for GNA #11, GNA #21, and GNA #22 for 2024. The facility had assigned infection control training through Carefeed on 09/08/25 after the surveyor had already requested the employee files. HR #17 stated they rechecked but could not locate any prior infection control training for the GNAs. The ADON then provided in-service training documentation from 01/17/25 and 01/27/25, but that documentation also did not show infection control training for GNA #11, GNA #21, and GNA #22, and the ADON acknowledged that this was all the education she was able to find.
Missing Compliance and Ethics Training in Employee Files
Penalty
Summary
The facility failed to provide required Compliance and Ethics training for staff, as shown by review of employee files for GNA #11, GNA #21, and GNA #22. During the annual survey, the surveyor requested employee files for five GNAs and found that three of the five files did not contain documentation of Compliance and Ethics training. The missing training was identified during review of the employee records on the morning of 09/09/2025, after the surveyor had requested the files the previous day. When the surveyor informed the DON and ADON about the missing training, the DON stated that the previous nurse educator had maintained nursing staff education records and that, since the educator left, she was having difficulty locating the records. The DON said HR was now responsible for maintaining education records. The Administrator later stated the facility used Carefeed for annual staff training and that it had been updated in June 2025 to include required annual training, but review of Carefeed with HR #17 did not show Compliance and Ethics training for 2024 for GNA #11, GNA #21, and GNA #22. Carefeed showed the facility assigned Compliance and Ethics training on 09/08/25 after the surveyor had already requested the employee files. The ADON later provided in-service training documentation from 01/17/25 and 01/27/25, but that documentation also did not show Compliance and Ethics training for the three GNAs.
Missing Required Annual In-Service Training for GNAs
Penalty
Summary
The facility failed to provide geriatric nursing assistants (GNAs) with the required minimum of 12 hours of annual in-service training. During the annual survey, the surveyor requested employee files for GNA #9, GNA #11, GNA #20, GNA #21, and GNA #22, including annual review, annual training, and immunization documentation. A review of those files did not reveal evidence of 12 hours of nurse aide in-service training for any of the five GNAs. When the surveyor informed the DON and ADON about the missing training records, the DON stated that the previous nurse educator had maintained nursing staff education records and that, since that person left, she was having difficulty locating the records. The DON said HR was now responsible for maintaining education records. HR later reviewed training records in Carefeed for the five GNAs and could not find evidence of the required 12 hours of nurse aide training for 2024 and 2025. The facility had assigned mandatory in-service training through Carefeed after the surveyor had already requested the employee files, and the ADON later provided documentation for in-service training conducted on 01/17/25 and 01/27/25, but that documentation still did not show that the five GNAs completed the required 12 hours of training in 2024 and 2025.
Missing Dementia Training Documentation
Penalty
Summary
The facility failed to provide required dementia training to staff, and this deficiency was identified in 4 of 5 employee files reviewed during the annual survey. On 09/08/2025, the surveyor requested employee files for GNA #9, GNA #11, GNA #20, GNA #21, and GNA #22, including annual review, annual training, and immunization documentation. On 09/09/2025, review of the files for GNA #11, GNA #20, GNA #21, and GNA #22 did not reveal dementia training. The DON stated the previous nurse educator had maintained nursing staff education records and that, since the educator’s departure, she was having difficulty locating the records. The DON also stated HR was now responsible for maintaining education records. During the survey, the Administrator stated the facility used Carefeed for annual staff training and that it had been updated in June 2025 to include all required annual training. However, dementia training for 2024 and 2025 was missing from the GNA employee files. Review of Carefeed with HR #17 for GNA #11, GNA #20, GNA #21, and GNA #22 did not show evidence of dementia training for 2024, and the facility had assigned dementia training through Carefeed on 09/08/25 after the surveyor had already requested the files. HR #17 stated they were unable to locate any prior compliance and ethics training for the GNAs. The ADON later provided in-service training documentation from 01/17/25 and 01/27/25, but review of that training also did not show evidence of dementia training for GNA #11, GNA #20, GNA #21, and GNA #22, and the ADON acknowledged the missing training.
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Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
Walk-in cooler logs missing for 12 days; expired supplements in the medication room fridge.
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Nursing homes near Baltimore
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Autumn Lake Healthcare At Parkville | 0 mi | ★★★★★ | 18 | 0 |
| Autumn Lake Healthcare At Perring Parkway | 1.7 mi | ★★★★★ | 17 | 0 |
| Towson Rehabilitation And Healthcare Center | 1.9 mi | ★★★★★ | 18 | 0 |
| Edenwald | 2.2 mi | ★★★★★ | 3 | 0 |
| Holly Hill Healthcare Center | 2.7 mi | ★★★★★ | 1 | 0 |
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