Autumn Lake Healthcare At Long Green
Inspection history, citations, penalties and survey trends for this long-term care facility in Baltimore, Maryland.
- Location
- 115 East Melrose Avenue, Baltimore, Maryland 21212
- CMS Provider Number
- 215031
- Inspections on file
- 19
- Latest survey
- February 3, 2026
- Citations (last 12 mo.)
- 31
Citation history
Health deficiencies cited at Autumn Lake Healthcare At Long Green during CMS and state inspections, most recent first.
Surveyors found that the facility failed to develop and implement person-centered care plans for two residents. One resident had a long-standing diagnosis of Type 2 DM with orders for blood sugar checks three times weekly, but no corresponding DM care plan was in place. Another resident was admitted S/P surgical repair of the L femur with a documented surgical site requiring wound team follow-up, yet no care plan was initiated for surgical site care. The DON confirmed that baseline care plans are started by the admitting nurse and updated by UMs based on MDS, diagnoses, and changes in condition, but acknowledged that required care plans for these conditions were not completed.
A resident with severe bilateral foot and ankle edema had provider orders for shift-based pedal pulse checks and weekly abdominal girth measurements. While these tasks were marked as completed in the TAR, no actual pedal pulse results or abdominal girth measurements were documented anywhere in the medical record or communicated to the provider. The DON stated that the provider did not initiate the supplemental data command in the PCC EMR, so nursing staff had no designated place to enter the data, and staff confirmed there was no alternate location for recording it. This lack of documentation persisted for months without correction, resulting in failure to provide care according to the physician’s orders.
Several residents reported a lack of clean, well-maintained linen, and observations confirmed that linen carts were understocked and contained discolored, threadbare items. Staff interviews revealed that the available linen was insufficient, and the EVS Supervisor stated that budget limitations and lack of additional funding from administration contributed to the ongoing shortage. Facility leadership acknowledged the deficiency when interviewed by surveyors.
Several residents reported a lack of clean, well-maintained linen, with observations confirming that linen carts were understocked and the available linen was discolored and threadbare. Staff interviews revealed that the facility had not provided sufficient funds to replace damaged linen, resulting in an ongoing shortage and poor quality of linen for residents.
A resident was moved to a different room without receiving written notice or documentation explaining the reason for the change. Staff and the NHA were unaware of the move until it was brought to their attention, and the EMR was not updated to reflect the new room assignment.
The facility failed to maintain a safe and homelike environment, with issues such as damaged furniture, inadequate housekeeping, and improper storage of residents' belongings. Observations revealed maintenance problems, including improperly installed toilets and soiled carpets. Staff interviews indicated understaffing in housekeeping and maintenance, contributing to these deficiencies.
Surveyors identified deficiencies in medication storage and monitoring, including undocumented refrigerator temperatures, expired medications not discarded, and improper labeling and storage of medications. An unopened insulin pen was found unrefrigerated, and several opened medications were undated.
Facility staff failed to follow professional standards in medication administration, with two residents experiencing significant delays in medication sign-off. For one resident, Methadone doses were signed off hours late on multiple occasions. Another resident's medications were signed off over an hour late more than 85 times. Staff interviews revealed that while medications were reportedly given on time, they were often signed off late due to other duties.
The facility failed to ensure residents' dignity and privacy by not covering a resident's foley catheter bag, making it visible from the hallway, and by not properly storing residents' clothing, leaving them in trash bags or boxes. The LPN confirmed the need for foley bags to be covered, and the ADON and Administrator acknowledged the lack of hangers for clothing storage.
Facility staff failed to ensure residents had accessible call bells, affecting three residents. A resident was found without a call bell, which was attached to their roommate's bed. Two other residents had their call bells on the floor, confirmed by a GNA who was in the process of assisting them.
The facility did not complete a thorough investigation of an abuse allegation when a resident reported that their GNA allegedly threw water in their face. The investigation included interviews with staff but failed to include the resident, who had an intact cognitive status. The NHA confirmed the omission of the resident's statement.
A facility failed to complete a baseline care plan for a resident admitted with a stage 4 pressure ulcer. The deficiency was identified during an annual survey, revealing that the care plan lacked interventions for the ulcer. Interviews with staff confirmed the absence of a completed care plan, which is required within 48 hours of admission.
The facility failed to develop comprehensive care plans for two residents, one with a stage 4 pressure ulcer and another prescribed psychotropic medications. Despite treatment changes and medication prescriptions, necessary care plans were absent, as confirmed by staff interviews and record reviews.
A resident's elevated BP of 180/92 was not reassessed in a timely manner. The resident was given Hydralazine as ordered, but no follow-up BP was documented until over 12 hours later, with readings of 144/80 and 142/78. The care plan required documentation of the response to hypertension medication, which was not done. The DON confirmed the oversight, noting that the CMA should have informed the nurse, who should have retaken the BP and reported it to the physician.
A facility failed to implement the ordered treatment for a resident with urinary incontinence. The resident was found with a Foley bag filled to the top and taped due to a hole, contrary to the physician's order to change the bag when needed and empty it regularly. The DON was informed, and it was noted that staff was aware of the issue but was busy with other duties. A Unit Manager was also assigned to the unit.
A resident received incorrect oxygen flow rates due to outdated and unlabeled equipment, contrary to physician orders. Observations showed the resident receiving 4.25 to 4.5 L/min instead of the prescribed 2-3 L/min. The facility's policy on labeling and changing oxygen equipment was not followed, and conflicting medical orders were found.
The facility failed to address pharmacy recommendations for two residents, leading to unreviewed medication regimens. One resident's medication frequency was not clarified, and another's duplicate therapy and improper use of pain patches were not corrected. The ADON was unable to provide signed pharmacy reviews, indicating a lack of physician oversight.
A facility failed to respond to pharmacy recommendations for a resident's PRN anxiolytic medication, Diazepam, which lacked a stop date. The Consultant Pharmacist suggested discontinuation or documentation of its use, but no response was provided. The ADON could not find any documentation of the facility's response and had to contact the Psychiatric Nurse Practitioner and the resident's primary physician to address the issue.
The facility failed to maintain sanitary food service practices, with issues such as expired food, unclean kitchen equipment, and improper food storage. Observations included unlabeled food items, a refrigerator at an unsafe temperature, and a lack of cleaning schedules. The facility administrator does not directly supervise kitchen staff but addresses issues as they arise.
A resident's funds were misappropriated when $1000.00 was withdrawn from their account without permission. The Administrator cited a care cost spend down policy for accounts over $2500.00, but no documentation supported this action. Additionally, $800.00 was withdrawn without explanation, though it was later returned to the resident. The issue was discussed with the Administration team.
The facility failed to report allegations of abuse within the required two-hour timeframe. In one case, an allegation of inappropriate sexual relations between two residents was reported late due to the incident occurring on a weekend. In another case, a resident reported being struck by a GNA, but the report to the state agency was delayed despite the resident's representative being notified promptly.
A facility failed to accurately document a resident's weight, leading to discrepancies in the medical records. The resident's daughter reported weight loss, and surveyors found inconsistent weight entries in the EHR, with a rapid and unlikely weight change recorded over a short period. The DON attributed the issue to a documentation error by an RN, which was not corrected.
The facility was found to have deficiencies in infection control and medication handling. Unsanitary conditions were observed in common areas, with food on the floor and trash in hallways. Additionally, an LPN was seen handling medication without gloves, contrary to facility policy. The Administrator and ADON were informed of these issues.
The facility failed to maintain a safe and homelike environment, as several AC units in resident rooms were found with dust, dirt, and debris. The Administrator and DON were informed, and maintenance logs were incomplete, indicating a lapse in regular maintenance.
The facility failed to maintain an effective pest control program, as flies and fruit flies were observed throughout the building, including in resident rooms and common areas. The Administrator and DON were informed, and standing water conducive to fly activity was noted in the kitchen. A resident's behaviors were mentioned as a contributing factor, but the issue persisted.
Failure to Develop Person-Centered Care Plans for Diabetes and Post-Surgical Wound
Penalty
Summary
The deficiency involves the facility’s failure to develop and implement person-centered care plans addressing all identified diagnoses and conditions for two residents. For one resident with a documented diagnosis of Type 2 Diabetes Mellitus, medical record review showed an onset date of 10/5/2017 and a MAR order to check blood sugar three times a week. Despite this established diagnosis and ongoing blood sugar monitoring, there was no corresponding care plan for Diabetes Mellitus. The DON confirmed that a care plan for this diagnosis could not be provided because it had not been completed and acknowledged that not having a care plan developed and updated based on the resident’s diagnosis and change in condition was an issue. The second resident was admitted status post surgical repair of the left femur, with a surgical site described as having Steri-strips and bruising per provider note. Review of the EHR showed that a person-centered care plan had not been initiated to address care of the surgical site, even though the resident was admitted with this condition and was being seen by the wound team for the surgical site. During interview, the DON stated that this resident should have had a care plan initiated for the surgical site. Staff interviews also clarified that the admitting nurse is responsible for the baseline care plan and that UMs are responsible for updating care plans based on the MDS, diagnoses, and any change in condition, but these processes did not result in care plans for the identified conditions for these two residents.
Failure to Document Ordered Pedal Pulses and Abdominal Girth Measurements
Penalty
Summary
Surveyors identified a deficiency involving the facility’s failure to ensure that ordered clinical assessments were properly documented and available for provider review for one resident with severe bilateral foot and ankle edema. The resident’s medical record showed a provider order, dated 11/13/2025, for pedal pulses to be taken every shift and documented as positive or negative, and another order, dated 9/24/2025, for weekly abdominal girth measurements. Although the Task Administration Record (TAR) indicated that these tasks were marked as completed, there were no actual pedal pulse findings or abdominal girth measurements recorded in the TAR, the resident’s chart, or any other communication to the provider. During interviews, the DON reported that the provider had failed to initiate the supplemental data command in the PCC electronic medical record, leaving nursing staff without a designated place to enter the measurements, and an employee confirmed there was no separate location on the unit to record this data. The DON was unable to explain why, over approximately two months for pedal pulses and four months for abdominal girth measurements, neither nursing staff nor the provider took action to correct the documentation issue or establish a means for recording the ordered measurements. These findings show that the facility did not provide treatment and care according to the physician’s orders, as the required assessment data for pedal pulses and abdominal girth was not documented or communicated to the provider despite the presence of active orders and indications in the TAR that the tasks had been completed.
Inadequate Supply of Clean, Well-Maintained Linen
Penalty
Summary
The facility failed to provide an adequate supply of clean, well-maintained linen to meet the needs of its residents. Multiple residents reported complaints regarding the lack of sufficient and well-maintained linen, with observations confirming that linen carts on all units were inadequately stocked and contained discolored, threadbare items. Staff interviews corroborated these findings, with a laundry technician confirming that the available linen was insufficient and in poor condition. The technician also noted that the situation had deteriorated compared to previous management. Further investigation revealed that the Environmental Services (EVS) Supervisor was allocated a limited monthly budget for linen replacement and had not received additional funds from facility administration despite requests. The EVS Supervisor confirmed ongoing communication with their supervisor about the linen shortage but was instructed to follow administration's guidance. Facility leadership acknowledged the deficiency when interviewed by the survey team, confirming the lack of adequate, well-maintained linen for residents.
Failure to Maintain Adequate Supply of Clean, Well-Maintained Linen
Penalty
Summary
The facility failed to provide an adequate supply of clean, well-maintained linen to meet the needs of its residents. Multiple residents reported complaints regarding the lack of available and well-maintained linen, with some stating that the linen provided was in poor condition, discolored, and threadbare. Observations by the survey team confirmed that linen carts on all units were insufficiently stocked and the available linen was not in acceptable condition. Interviews with staff, including a laundry technician and the EVS Supervisor, corroborated the shortage and poor quality of linen, with staff indicating that they had to work with the limited and substandard supplies available. The EVS Supervisor reported receiving a fixed monthly budget for linen replacement from an external service provider, with the expectation that the facility would provide additional funds as needed. However, the supervisor stated that no additional funds had been provided by the facility administration during their tenure, despite requests. The issue was acknowledged by both the facility's administration and district management during interviews, confirming the ongoing deficiency in maintaining an adequate and well-maintained linen supply for residents.
Failure to Provide Written Notice of Room Change
Penalty
Summary
A deficiency occurred when a resident was moved from one room to another without receiving written notice of the room change, including the reason for the change, as required. Medical record review showed that the resident had been residing in the same room and bed for several months, with the electronic medical record (EMR) still reflecting the original room assignment. Observations confirmed that the resident was no longer in the documented room, and another resident reported that the individual had moved to the adjacent room. Staff confirmed the resident's new location, but there was no documentation in the EMR indicating that the resident or their representative had been notified in writing prior to the move, nor was there evidence that the move was requested by the resident. Further interviews with staff revealed that the room change likely occurred over a specific period, but the nursing home administrator was unaware of the move until informed by the surveyor. The administrator and staff confirmed that the resident was residing in a different room than what was documented, and acknowledged the lack of written notification or documentation regarding the change. The deficiency was identified during a complaint survey and was evident for one resident reviewed for a facility-reported incident.
Facility Fails to Maintain Safe and Homelike Environment
Penalty
Summary
The facility failed to maintain a safe, clean, and homelike environment for its residents, as evidenced by numerous deficiencies observed during the survey. In several rooms, there were issues such as chipped wood on door frames, lifting floor tiles, stained and dirty flooring, and damaged furniture. Additionally, there were reports of inadequate housekeeping services, with food found under beds and personal belongings improperly stored in shared closets. These conditions were confirmed through observations and interviews with residents and staff, highlighting a lack of adequate maintenance and housekeeping services. Further observations revealed significant maintenance issues throughout the facility. Toilets were improperly installed on wooden blocks, creating potential hazards, and some were loose with cracked lids. The carpet on the second floor was heavily soiled, and residents in wheelchairs were seen moving through the dirt. In one instance, a resident reported a broken faucet handle, preventing the use of cold water, which was later repaired. The facility's maintenance system appeared inadequate, with the Assistant Maintenance Director noting the absence of a Director of Maintenance and reliance on informal communication methods to address issues. The survey also identified problems with the storage of residents' personal items, with some rooms lacking sufficient space and organization for clothing and belongings. Residents' rooms were observed with peeling paint, missing floor tiles, and exposed cords, indicating a lack of regular maintenance checks. Interviews with staff revealed that the facility was understaffed in both housekeeping and maintenance departments, contributing to the ongoing issues. These deficiencies were acknowledged by the facility's administration during the exit conference, but no specific corrective actions were detailed in the report.
Medication Storage and Monitoring Deficiencies
Penalty
Summary
The facility failed to maintain appropriate temperature monitoring for the medication refrigerator, as evidenced by the absence of documentation in the temperature log from 07/28/24 to 07/29/24. Additionally, expired medications were found in the second-floor medication storage room, including adhesive remover wipes, self-adhesive fabric, and fluocinonide ointment. These items were not properly discarded, indicating a lapse in the facility's protocol for handling expired medications. Furthermore, the surveyors observed improper labeling and storage of medications. In the treatment cart, several opened medications were undated, and one ointment had a resident's name altered with a black marker. On the first floor, a new unopened Lantus insulin pen was improperly stored with opened pens instead of being refrigerated. The Assistant Director of Nursing confirmed the lapses in protocol, acknowledging that house-stocked medications should be dated upon opening and used within 30 days, and that unopened insulin pens should be refrigerated.
Medication Administration Deficiency
Penalty
Summary
The facility staff failed to adhere to professional standards of nursing practice in administering medications to residents, as evidenced by the medication administration audit record (MAAR) review. For Resident #9, there were multiple instances where the 9:00 am dosage of Methadone was not signed off as administered until significantly later, ranging from over an hour to several hours past the scheduled time. This discrepancy was confirmed during an interview with an LPN, who admitted to not signing off medications immediately after administration, despite the standard practice of administering medication within one hour before or after the scheduled time. Similarly, for Resident #88, the MAAR review revealed that medications were signed off as given one hour or more past the prescribed time on over 85 occasions between March and April. Interviews with the ADON, a CMA, and an LPN indicated that while medications were reportedly given on time, they were often signed off late due to staff assisting with other tasks, such as meal service. The standard practice of signing off medications immediately after administration was not consistently followed, contributing to the deficiency.
Deficiencies in Resident Dignity and Privacy
Penalty
Summary
The facility failed to uphold residents' rights to dignity and privacy, as evidenced by two main deficiencies. Firstly, a resident with a foley catheter bag had their drainage bag uncovered, with the amber-colored liquid visible from the hallway due to the open door. This was observed during a surveyor's rounds, and the Unit Manager LPN confirmed that foley bags should be covered, indicating a lapse in maintaining the resident's dignity and privacy. Secondly, the facility did not ensure that residents' clothing was properly stored. During observation rounds, it was noted that 30 out of 33 residents had their clothing in trash bags, boxes, or stacked in armoires, rather than being hung up or put away in drawers. Interviews with the ADON and the facility's Administrator revealed that there was a lack of hangers available for residents' use, and the GNAs were not following the process of hanging or folding the clothing properly. This oversight further contributed to the failure in maintaining residents' dignity.
Inaccessible Call Bells for Residents
Penalty
Summary
The facility staff failed to ensure that residents had their call bells readily accessible when assistance was required, affecting three residents. Resident #11 was observed in bed with a torn diaper and without a call bell, which was found attached to their roommate's bed. The Unit Manager confirmed that each resident should have their own call bell but could not explain why both call bells were with the roommate. Additionally, Residents #13 and #14 were found with their call bells on the floor, making them inaccessible. Geriatric Nursing Assistant #9 confirmed the call bells were on the floor and was in the process of providing assistance to the residents.
Failure to Interview Resident in Abuse Investigation
Penalty
Summary
The facility failed to conduct a thorough investigation of an abuse allegation involving a resident. On May 26, 2024, a resident reported to the Nursing Home Administrator (NHA) that their assigned Geriatric Nursing Assistant (GNA) allegedly threw a cup of water in their face. The facility's investigation included interviews with the alleged perpetrator, another GNA, and the nursing supervisor of the involved staff members. However, the investigation did not include an interview with the alleged victim, despite the resident having an intact cognitive status, as indicated by a Brief Interview for Mental Status (BIMS) score of 15 out of 15. During an interview on July 30, 2024, the NHA acknowledged that a thorough investigation should have included a statement from the resident. This oversight was confirmed by the NHA, who admitted that the resident's account was missing from the investigation documentation.
Failure to Complete Baseline Care Plan for Pressure Ulcer
Penalty
Summary
The facility failed to complete a baseline care plan for a resident admitted with a stage four pressure ulcer. This deficiency was identified during the facility's annual survey, where it was found that the baseline care plan for the resident, who was admitted in March 2024, did not include any interventions for the pressure ulcer on the left buttock. A baseline care plan is crucial as it serves as a written guideline of care based on the individual resident's needs and is developed by an interdisciplinary team. Interviews with facility staff, including the Regional Nurse and the Assistant Director of Nursing (ADON), revealed that they were unable to provide a completed baseline care plan for the resident's pressure ulcer. The absence of a care plan was confirmed during a medical record review conducted on July 22, 2024. The lack of a completed care plan indicates a failure to meet the requirement of having a baseline care plan in place within 48 hours of the resident's admission.
Failure to Develop Comprehensive Care Plans for Residents
Penalty
Summary
The facility failed to develop and implement comprehensive care plans for two residents, leading to deficiencies in their care. Resident #98 was admitted with a stage 4 pressure ulcer on the left buttock, but a review of the medical records revealed no comprehensive care plan addressing this condition. Despite several treatment order changes documented in the Treatment Administration Record, the necessary care plan was not found. Interviews with the Regional Nurse and the Assistant Director of Nursing confirmed the absence of a care plan for the pressure ulcer, and by the time of the survey exit, the resident still lacked a plan of care for this critical condition. Similarly, Resident #88 was prescribed psychotropic medications, yet there was no comprehensive, patient-centered care plan for their administration. The surveyor's review of the medication administration record and electronic medical record confirmed this oversight. During an interview, the Assistant Director of Nursing acknowledged that residents on psychotropic medications should have a care plan, but none was in place for this resident. These findings highlight the facility's failure to ensure that care plans were developed and implemented for residents with specific medical needs.
Failure to Reassess Elevated Blood Pressure
Penalty
Summary
The facility staff failed to reassess a resident's blood pressure (BP) when it was outside of the resident's usual parameters. On 07/23/24 at 10:07 pm, the resident's BP was recorded as 180/92, which was elevated. However, no follow-up BP was documented after this abnormal reading. The resident was prescribed Hydralazine 100 mg at 10 pm, and the medication was administered as ordered. The resident's care plan for coronary heart disease required that medication for hypertension be given as ordered and the response to the medication be documented. Despite this, there was no documentation of a follow-up BP or a clinical note in the electronic medical record (EMR) or paper chart. The Director of Nursing (DON) was informed of the elevated BP and the lack of follow-up documentation. It was noted that the Certified Medication Aide (CMA) should have notified the nurse of the elevated BP, and the nurse should have retaken the BP and reported the findings to the physician. The follow-up BP was eventually taken over 12 hours later, with results of 144/80 and 142/78, indicating a delay in reassessment and documentation.
Failure to Implement Ordered Treatment for Urinary Incontinence
Penalty
Summary
The facility failed to implement the ordered treatment for a resident with urinary incontinence. During observation rounds, a resident was found sitting in the hallway with a Foley bag that was filled to the top with yellow-colored fluid and had a large piece of tape attached to it. The resident reported that the Foley bag had a hole, and instead of changing it, the nurse had taped it. A review of the medical record revealed a physician's order to change the catheter/Foley bag when needed and to empty the Foley drainage bag at least once every eight hours or when it becomes half to 2/3 full. The Director of Nursing (DON) was informed of the findings, and during a follow-up interview, it was revealed that staff was aware of the full and possibly leaking catheter but was occupied with passing out medications. The staffing schedule indicated that a Unit Manager was also assigned to the unit.
Failure to Provide Proper Respiratory Care
Penalty
Summary
The facility staff failed to provide necessary respiratory care services for a resident by not properly labeling oxygen administration equipment and not administering oxygen as prescribed. During observations, the resident was receiving oxygen at a flow rate of 4.25 to 4.5 liters per minute, which was not in accordance with the physician's order of 2 to 3 liters per minute. The oxygen tubing was found to be labeled with a date from nearly two months prior, and the humidifier bottle was not labeled at all. Interviews with the LPN and ADON revealed that the facility's policy required oxygen tubing to be changed weekly and labeled with the date and initials, which was not adhered to in this case. The resident's medical record showed conflicting orders for oxygen administration, with an outdated order from June still active alongside a more recent order from November. The ADON acknowledged that the older order should have been discontinued but could not explain why it remained active. The facility's policy on oxygen administration emphasized the need for adherence to physician orders and proper labeling of equipment, which was not followed, leading to the deficiency observed by the surveyor.
Failure to Address Pharmacy Recommendations
Penalty
Summary
The facility failed to respond to pharmacy recommendations after a monthly clinical review, and did not ensure that the attending physician reviewed these recommendations. This deficiency was identified for two residents during the survey. For one resident, the pharmacist recommended clarifying the frequency of a medication used for constipation, but there was no documented response from the facility. The Assistant Director of Nursing (ADON) was unable to provide any response documentation and had to contact the Nurse Practitioner and the resident's primary physician to address the issue belatedly. For another resident, the ADON was initially unable to provide the pharmacy reviews and later presented them unsigned, indicating that the physician had not reviewed them. The pharmacy recommendations highlighted issues such as duplicate medication therapy and improper use of pain patches, as well as missing blood work. Despite these recommendations, no changes were made to the resident's medication regimen, and the ADON was uncertain if the recommendations had been addressed.
Failure to Respond to Pharmacy Recommendations for PRN Anxiolytic
Penalty
Summary
The facility failed to respond to pharmacy recommendations regarding the use of unnecessary medications for a resident. During the facility's annual survey, it was found that a resident had a PRN order for an anxiolytic medication, Diazepam, without a stop date. The Consultant Pharmacist had recommended discontinuing the PRN Diazepam or documenting the indication for its use, the intended duration of therapy, and the rationale for the extended period. However, there was no response from the facility to these recommendations. The Assistant Director of Nursing (ADON) was unable to provide any documentation of the facility's response to the pharmacy review and had to contact the Psychiatric Nurse Practitioner and the resident's primary physician to address the issue.
Deficiencies in Food Safety and Sanitation Practices
Penalty
Summary
The facility failed to ensure sanitary practices in food service safety, maintain a clean working environment, and manage food storage properly. During an initial observation of the kitchen, the surveyor found that dry cereal bins lacked expiration dates, and a can of pears was expired. The kitchen ovens were observed to be brown, greasy, and dirty, and there was no cleaning schedule available. Additionally, the dishwashing area was unkempt, with food particles and a cigarette butt present. Staff acknowledged the issues but did not provide a cleaning schedule. Further observations revealed that nourishment rooms in two clinical units had food items without labels or expiration dates, and a refrigerator was found to be at an unsafe temperature of 52 degrees. A resident's food item was noted to be over three days old. The facility administrator stated that he does not directly supervise the contracted kitchen staff but would address issues if they arise. These deficiencies were discussed with the administrative staff during the exit interview.
Misappropriation of Resident Funds
Penalty
Summary
The facility failed to protect a resident from the misappropriation of their funds. During a survey, it was discovered that $1000.00 was withdrawn from the account of a resident without their permission. The Administrator explained that the facility conducts a care cost spend down if a resident's account exceeds $2500.00, but there was no documentation supporting that the resident owed any money to the facility. Furthermore, the Administrator could not provide an explanation or documentation for the withdrawal of $800.00 from the resident's account, although he did present a returned check for the same amount to the resident. This incident was discussed with the Administration team during the survey exit meeting.
Failure to Timely Report Allegations of Abuse
Penalty
Summary
The facility failed to report allegations of abuse within the required two-hour timeframe to the Survey Agency, the Office of Health Care Quality (OHCQ). In the first incident, an allegation of inappropriate sexual relations between two residents occurred, and the facility's documentation showed that the administrator did not submit the initial report to OHCQ until over four hours after the incident. During an interview, both the Director of Nursing (DON) and the administrator acknowledged their awareness of the reporting requirements but could not provide a reason for the delay other than the incident occurring on a weekend. In the second incident, a resident reported being struck by their assigned GNA. The facility's investigation revealed that the Shift Supervisor was notified of the incident in the morning, but the initial report to the state agency was not submitted until late afternoon, well beyond the two-hour requirement. The DON confirmed the reporting timeframe during an interview and noted that the resident's representative was notified shortly after the incident, but the report to OHCQ was delayed.
Inaccurate Documentation of Resident's Weight
Penalty
Summary
The facility failed to ensure that a resident's medical records were accurately documented in accordance with accepted professional standards. This deficiency was identified during a survey when the surveyors reviewed the medical records of a resident who had reportedly lost weight. The resident's daughter mentioned the weight loss during an interview, prompting the surveyors to examine the Minimum Data Set (MDS) assessment and the Electronic Health Record (EHR) for the resident. The MDS assessment indicated a significant weight loss, and upon reviewing the EHR, surveyors found discrepancies in the recorded weights over a short period. The discrepancies included a rapid and unlikely weight loss of approximately 12 pounds in one day, with weights recorded using different types of scales, such as a standing scale, mechanical lift, Hoyer lift, and a wheelchair scale. The Director of Nursing (DON) acknowledged the inconsistency and attributed it to a documentation error by a registered nurse, which the facility failed to correct. The dietician's note also highlighted a weight warning and the need for a reweigh, but no follow-up notes were found addressing the discrepancy.
Infection Control and Medication Handling Deficiencies
Penalty
Summary
The facility failed to maintain proper infection control practices, as evidenced by observations of unsanitary conditions and improper handling of medications. On one occasion, food resembling meatballs was found on the floor in the Atrium near the dining room, with splatters noted on the baseboards. The Administrator was informed and housekeeping services were called to clean the area. Additionally, a hallway leading to the laundry area and kitchen was observed to be dirty, with trash on the floor and large dark marks. A clean linen cart was left uncovered in the hallway, and a fan was blowing air, causing trash and particles to circulate. The Administrator was again informed of the issue. In another instance, an LPN was observed handling a medication capsule with bare hands, without wearing gloves, while administering Gabapentin to a resident. The LPN acknowledged that it was not appropriate to handle medications without gloves, despite claiming to have washed his hands. The Assistant Director of Nursing confirmed that it is never appropriate for staff to handle medications without gloves. The facility's policy on medication administration explicitly states that care should be taken not to touch medication with bare hands.
Deficiency in Maintaining Safe and Homelike Environment
Penalty
Summary
The facility failed to maintain a safe and homelike environment for its residents, as evidenced by the condition of air conditioning (AC) units in several resident rooms. During a survey, it was observed that AC units in rooms #121, #123, #124, and #126 had dust, dirt, and debris on the front and inside the screen filters. Additionally, a tan/brown substance was noted on the AC unit in another room, and the unit in room #219 also had dust, dirt, and debris inside. These observations were made during a tour of the building, and the facility's maintenance logs were found to be incomplete, with missing records for February, March, and June 2024. The Administrator and Director of Nursing were informed of these findings, and the Maintenance Assistant was summoned to assess the situation. The Administrator confirmed the issues and acknowledged the need for cleaning the AC units. Despite the facility's claim of conducting monthly maintenance on the AC units, the lack of comprehensive maintenance logs suggests a failure in maintaining the physical environment of the residents' rooms. This deficiency was discussed with the administration team at the time of the survey exit.
Pest Control Deficiency Due to Flies and Fruit Flies
Penalty
Summary
The facility failed to maintain an effective pest control program, as evidenced by the presence of flies and fruit flies throughout the building during a survey. Observations were made of flies in the conference room on multiple dates, and in resident rooms and hallways on July 25, 2024. The Administrator and Director of Nursing were informed of these findings, and the Administrator confirmed the presence of flies. A review of the pest control service summary report revealed an invoice for general pest control maintenance on July 24, 2024, and noted standing water in the main kitchen on June 17, 2024, which was conducive to small fly activity. Standing water was again observed in the kitchen on July 30, 2024, near resident rooms and the conference room where flies were present. During the survey, multiple observations of flies and fruit flies were made throughout the building. On the first day of the survey, surveyors noted flies and fruit flies in a facility room, including in a resident's room where they were seen circling and landing on the resident and their bedside table. A sticky paper with dead flies was also observed near the resident's bed. The Nursing Home Administrator was informed of the issue on July 19, 2024, and again on July 31, 2024. The Administrator acknowledged the problem and mentioned that the resident's behaviors might contribute to the issue, but stated he would investigate further.
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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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