Autumn Lake Healthcare At Long View
Inspection history, citations, penalties and survey trends for this long-term care facility in Manchester, Maryland.
- Location
- 3332 Main Street, Manchester, Maryland 21102
- CMS Provider Number
- 215017
- Inspections on file
- 18
- Latest survey
- February 18, 2026
- Citations (last 12 mo.)
- 15
Citation history
Health deficiencies cited at Autumn Lake Healthcare At Long View during CMS and state inspections, most recent first.
Two residents' allegations of staff abuse were not reported to the state survey agency within the required timeframe. In one case, a resident with intact cognition reported being pushed by a staff member, but staff delayed reporting due to perceived inconsistencies in the story. In another case, a resident reported rough handling and mocking by a staff member, but the social worker did not report it as abuse because the term was not used. Both incidents were not reported as required by facility policy.
A resident with intact cognition alleged that a GNA pushed them in the head during care, but the GNA was only removed from caring for that resident and their roommate, and continued to provide care to other residents until being suspended after the incident was reported to authorities. Facility policy required broader protective actions during abuse investigations.
The facility failed to complete Quarterly MDS assessments for four residents within the regulatory time frames, essential for appropriate care planning and maintaining current assessment records. The delays ranged from 16 to 42 days after the Assessment Reference Date (ARD), as confirmed by the MDS coordinator.
Facility staff failed to develop and implement comprehensive, person-centered care plans with measurable goals and non-pharmacological approaches for two residents receiving psychotropic medications. The care plans lacked specific behaviors for which the medications were prescribed and did not include non-pharmacological interventions.
The facility failed to include residents in care planning and did not update care plans based on current clinical conditions. A bedbound resident was not invited to care plan meetings, and another resident was unaware of any care plan meetings. Additionally, care plans for mental health diagnoses were not reviewed or updated for two residents.
A staff member was observed standing over a seated resident while assisting them with meals, contrary to the facility's policy requiring staff to sit. This was confirmed by the facility Dietician and discussed with the NHA, DON, and Regional DON.
The facility failed to communicate and document a resident's need for denture care, leading to the loss of the resident's dentures. Despite the resident being admitted with partial lower dentures and requiring assistance for oral hygiene, this information was not included in the care plan or communicated to staff.
The facility failed to provide written notice of transfer to residents and/or their representatives for two residents who were hospitalized. Documentation and interviews revealed that the required written notices were not given, contrary to the facility's policy.
The facility failed to provide written notice of the bed-hold policy to two residents and their representatives during hospitalization. For one resident, the Admissions Director claimed to have sent the policy via email but could not provide evidence. For another resident with severe cognitive impairment, there was no documentation that the policy was mailed to the representative. This violates the facility's policy and federal regulations.
The facility staff failed to complete a Significant Change in Status MDS Assessment within 14 days for a resident admitted to hospice care after a significant decline. Despite clear documentation of the resident's severe decline and hospice admission, the required assessment was not completed.
The facility failed to complete comprehensive MDS assessments within the regulatory time frames for seven residents, with delays ranging from 2 to 10 days. The MDS Coordinator indicated that the delays were partly due to the dependency on a corporate MDS person to sign off on the assessments.
The facility failed to document incontinent care for a dependent resident who was always incontinent and reliant on staff for toileting hygiene. Documentation was missing for multiple shifts over several days, and the administrator could not provide additional records to confirm care was provided.
A resident with Diabetes Mellitus was not receiving insulin prior to a recent hospitalization despite having elevated glucose levels. Medical records showed that the resident's glucose levels continued to rise, reaching critical levels, yet no new orders were given. The resident was eventually hospitalized and started on insulin, highlighting the facility's failure to provide appropriate treatment and care according to professional standards of practice.
The facility failed to implement individualized, non-pharmacological approaches before prescribing trazodone for a resident with insomnia. Despite the resident's activity assessments and lack of documented sleep issues, the NP ordered the medication without trying non-pharmacological interventions or reviewing sleep logs.
The facility failed to properly store medications by not discarding expired medications and not dating medications when opened. This was observed in three medication carts, with expired medications and undated inhalers found. The findings were confirmed by nursing staff, and the Director of Nursing acknowledged the concerns.
The facility failed to maintain accurate medical records for two residents. One resident was documented as using hearing aids, but observations and interviews revealed they had not worn them for months. Another resident's medication record for Escitalopram Oxalate (Lexapro) showed inconsistencies with their documented diagnoses of anxiety and depression. The DON acknowledged the concern regarding the medication documentation.
The facility failed to maintain sanitary conditions for a nebulizer mask, post proper PPE notifications, and ensure staff compliance with PPE requirements. Incidents involved improper storage of a nebulizer mask, missing PPE signs, and staff entering rooms without required PPE.
The facility failed to monitor and prevent the misappropriation of narcotic medication for a resident requiring pain management. An incident involving missing Oxycodone pills revealed discrepancies in the Controlled Substance card count logs and improper signing procedures by nursing staff. The Director of Nursing acknowledged these concerns.
The facility failed to ensure a resident's drug regimen was free from unnecessary drugs and did not notify the attending provider when a medication was not given. Non-pharmacological interventions were not attempted before administering Oxycodone, the removal of a Lidocaine patch was not documented, and an antihypertensive medication was administered despite low BP readings.
Failure to Timely Report Allegations of Abuse to State Agency
Penalty
Summary
The facility failed to timely report allegations of abuse involving two residents to the state survey agency as required by its own policy. In the first instance, a resident with intact cognition and a history of acute confusional episodes reported to a registered nurse that a staff member pushed their head, causing them to fall back into bed. Despite the resident being tearful and making the allegation directly to the nurse, the incident was not reported to the state agency until the following day, well beyond the required timeframe. Staff, including the RN, Assistant Director of Nursing, and Director of Nursing, did not report the allegation promptly, citing inconsistencies in the resident's story and a history of accusatory behaviors. The Administrator was not informed of the incident until the next day, delaying the required notification to authorities. In the second case, another resident reported to the social worker that a male staff member was rough during a transfer and mocked them for expressing pain. The social worker did not interpret the complaint as abuse because the resident did not use the word "abuse," and therefore did not report the incident. The Director of Nursing later stated that any suspicions of abuse or neglect should be reported, and the Administrator acknowledged that more questions should have been asked and the incident should have been reported as an allegation. Both cases demonstrate a failure to follow facility policy and regulatory requirements for timely reporting of abuse allegations.
Failure to Remove Staff from Resident Care After Abuse Allegation
Penalty
Summary
The facility failed to protect all residents from potential abuse when a Geriatric Nursing Assistant (GNA) was allowed to continue caring for other residents after an allegation of abuse was made. Specifically, a resident with intact cognition reported to a Registered Nurse (RN) that the GNA pushed them in the head during care, causing the resident to fall back into bed. The RN assessed the resident, found no injuries, and removed the GNA from the assignment for the resident and their roommate. However, the GNA was reassigned to care for other residents and continued working the remainder of the shift and the following day. Facility policy required immediate action to protect all residents from potential harm during an abuse investigation, including removing the alleged perpetrator from resident care assignments. Despite this, the GNA was only removed from the care of the reporting resident and their roommate, not from all resident care duties. The GNA continued to work with other residents until being suspended after the resident called 911 to report the incident the next day.
Failure to Complete Quarterly MDS Assessments on Time
Penalty
Summary
The facility failed to complete Quarterly Minimum Data Set (MDS) assessments for residents within the regulatory time frames, which is essential for appropriate care planning and maintaining current assessment records. This deficiency was identified for four residents during the recertification survey. Specifically, Resident #70's Quarterly MDS assessment was completed 42 days after the Assessment Reference Date (ARD), Resident #52 had two Quarterly MDS assessments completed 20 and 22 days after their respective ARDs, Resident #83's assessment was completed 19 days after the ARD, and Resident #85's assessment was completed 16 days after the ARD. These delays in completing the MDS assessments were confirmed by the MDS coordinator during an interview. The MDS is a federally mandated assessment tool used by nursing home staff to gather information on each resident's strengths and needs, which drives resident care planning decisions. The Quarterly assessment must be completed within 92 days of the MDS Completion Date of the last quarterly MDS assessment and no later than 14 days after the ARD. The facility's failure to adhere to these regulatory time frames for completing the MDS assessments resulted in non-compliance with federal requirements, as evidenced by the late completion of assessments for the four residents reviewed.
Failure to Develop Comprehensive Care Plans for Residents on Psychotropic Medications
Penalty
Summary
Facility staff failed to develop and implement comprehensive, person-centered care plans with measurable goals and non-pharmacological approaches for two residents reviewed for unnecessary medications. Resident #4, who had multiple medical diagnoses including depression, anxiety disorder, and dementia with behavioral disturbance, was receiving psychotropic medications such as Duloxetine and Seroquel. However, the care plans for Resident #4 were not comprehensive or resident-centered, lacking specific behaviors for which the medications were prescribed and non-pharmacological interventions. The care plan goals were not measurable, and the interventions did not address the resident's potential behaviors or provide actions to help with the resident's depression and anxiety. Similarly, Resident #64, who had diagnoses of depression, anxiety, and dementia with behavioral disturbance, was also receiving psychotropic medications including Escitalopram, Olanzapine, and Remeron. The care plans for Resident #64 were also found to be inadequate. The care plans did not identify the resident's specific behaviors for which the medications were prescribed and lacked non-pharmacological interventions. The goals were not measurable, and the interventions did not include actions to assist the resident in managing potential behaviors related to depression and anxiety. The deficiencies were acknowledged by the Director of Nursing (DON) and the Social Services Director (SSD) during interviews. The care plans for both residents failed to provide comprehensive, resident-specific, and measurable goals, and did not include individualized non-pharmacological interventions to address the behaviors for which the psychotropic medications were prescribed.
Failure to Include Residents in Care Planning and Update Care Plans
Penalty
Summary
The facility failed to include residents in the development of their care plans and did not invite them to care plan meetings. Resident #43, who is bedbound, reported not participating in care plan meetings and only receiving a printout of what was discussed. The Social Services Director (SSD) confirmed that care plan meetings are held in the activities room and that bedbound residents are given updates at their bedside. However, there was no credible evidence that Resident #43 was invited to these meetings, and the invitation letters were only addressed to the resident's representative (RP), not the resident themselves. This issue was discussed with the SSD and the Nursing Home Administrator (NHA), but no further documentation was provided to the surveyor by the time of the survey exit. Resident #1, who has been at the facility for over two years, also reported not being aware of any care plan meetings. A review of the resident's progress notes, sign-in sheets, and invitation letters revealed that neither the resident nor their family was present or invited to attend care plan meetings. The SSD stated that residents are informed verbally on the day of the meeting if they are alert and oriented, but no follow-up calls are made to the family if they do not respond to the invitation letters. This lack of documentation and follow-up indicates a failure to ensure resident and family participation in the care planning process. Resident #46's care plan was not updated to reflect their current clinical condition. The resident had an indwelling urinary catheter due to a severe lower urinary tract infection (Pyocystis) and obstructive uropathy. However, the care plan was not revised once the infection was cleared, and it did not include the resident's current clinical indication for the catheter. Additionally, there was no documentation to indicate that Resident #46 was invited to or attended their care plan meetings. The care plan meeting attendance sheets also lacked signatures from the resident and interdisciplinary team members, such as a Geriatric Nursing Assistant (GNA) and food and nutrition services staff. Similar issues were found with Residents #4 and #64, whose care plans for mental health diagnoses were not reviewed or updated to reflect their progress or lack thereof.
Failure to Maintain Resident Dignity During Meal Assistance
Penalty
Summary
The facility failed to maintain a resident's dignity by having a staff member stand over a seated resident while assisting them with meals. This incident was observed by two surveyors in the first-floor dining area. The facility's policy requires staff to sit while assisting residents at meals, which was confirmed by the facility Dietician. The Dietician also reported that the staff member involved understood the policy after a conversation. The issue was discussed with the Nursing Home Administrator, Director of Nursing, and Regional Director of Nursing, but no additional information was provided.
Failure to Communicate and Document Resident's Denture Care Needs
Penalty
Summary
The facility failed to communicate to staff that a resident had dentures and did not take reasonable precautions to prevent the resident's dentures from getting lost. This deficiency was identified during a survey when it was found that the resident's care plan did not document the presence of dentures, despite the resident being admitted with partial lower dentures that were used only when eating. The resident required assistance from facility staff for both setup and cleanup when performing oral hygiene, as well as supervision or touching assistance to manage the dentures. However, this information was not communicated to the staff, leading to the loss of the dentures during the resident's stay. Interviews and documentation reviews revealed that the resident's family member reported the loss of the dentures, and the facility's Admission/Readmit Screener document confirmed the resident's need for assistance with dentures. Despite this, the care plan and GNA documentation in TASKS did not reflect the resident's need for denture care. The Director of Nursing (DON) and the Assistant Director of Nursing (ADON) were unable to provide documentation that the resident had dentures and required care for them, indicating a lapse in communication and documentation within the facility.
Failure to Provide Written Notice of Transfer
Penalty
Summary
The facility failed to provide written notice of transfer to residents and/or their representatives as required by regulation. This deficiency was identified for two residents who were hospitalized. For Resident #86, the medical record indicated a recent hospital transfer due to a change in condition. However, the documentation review revealed that the required written notice of transfer was not provided to the resident or their representative. Interviews with the Director of Nursing and the Admissions Director confirmed that the facility's policy was not followed, as the Admissions Director only discussed bed hold policies and did not provide the transfer notice in writing. Similarly, for Resident #85, the medical record showed that the resident was transferred to the hospital following an episode of vomiting and increased neck swelling. Although the resident's representative agreed to the transfer, there was no evidence that a written notice was provided. An interview with an LPN confirmed that only verbal notifications were given, and the Director of Nursing acknowledged that the transfer notice was included in a packet handed to emergency staff but not to the resident or their representative.
Failure to Provide Written Bed-Hold Policy Notice
Penalty
Summary
The facility failed to provide the resident and the resident's representative with the notice of bed-hold policy in writing. This deficiency was evident for two residents reviewed for hospitalization. For Resident #86, the medical record indicated a recent transfer to the hospital due to a change in condition. Although the Admissions Director claimed to have sent the bed-hold policy via email, there was no evidence that the policy was attached to the email. The facility's policy requires that a copy of the bed-hold policy be mailed to the resident's representative on the next business day, which was not followed. The Director of Nursing confirmed that the Admissions Director is responsible for this task, but no credible evidence was provided to show compliance with the policy. For Resident #85, who had severe cognitive impairment, the medical record showed a hospitalization due to increased swelling and vomiting. The nurse's documentation indicated that the bed-hold policy was reviewed with the resident's representative, but there was no evidence that a copy of the policy was mailed. The Admissions Director reported that she reviews the bed-hold policy with the resident's representatives over the phone and sends it via email, but could not provide documentation to support this claim. This lack of written notice is a violation of the facility's policy and federal regulations.
Failure to Complete Significant Change MDS Assessment
Penalty
Summary
The facility staff failed to complete a Significant Change in Status Minimum Data Set (MDS) Assessment within 14 days for a resident who experienced a significant decline and was admitted to hospice care. The resident, admitted in January 2023 with multiple diagnoses including cerebral infarction, high blood pressure, diabetes, and dementia with behavioral disturbance, showed signs of failure to thrive as documented by the Physician's Assistant (PA) on 10/25/23. Despite the resident's ongoing decline and subsequent hospice admission on 11/12/23, the required MDS assessment was not completed within the mandated timeframe. The medical record review revealed that the resident's condition had significantly deteriorated, with decreased intake by mouth, ongoing lethargy, and decreased verbal response. The PA's notes indicated that hospice care was discussed and agreed upon with the resident's Power of Attorney (POA). However, despite the clear documentation of the resident's severe decline and hospice admission, the MDS Nurse/Registered Nurse (RN Staff #5) confirmed that a Significant Change in Status Assessment (SCSA) had not been completed, without providing further explanation.
Failure to Complete MDS Assessments on Time
Penalty
Summary
The facility failed to complete comprehensive Minimum Data Set (MDS) assessments within the regulatory time frames for seven residents. The MDS is a federally mandated assessment tool used to gather information on each resident's strengths and needs, which drives care planning decisions. The report highlights that the Admission MDS assessment must be completed by the end of day 14 from the date of admission, and the Annual MDS assessment must be completed annually unless a Significant Change in Assessment has been completed. However, the facility did not meet these requirements for seven residents, with delays ranging from 2 to 10 days for Annual MDS assessments and 2 to 10 days for Admission MDS assessments. Specific instances include Resident #29's Annual MDS assessment being completed 21 days after the ARD, Resident #52's Annual MDS assessment being 2 days late, and Resident #72's Admission MDS assessment being 2 days late. Other residents, such as Resident #11, #96, #92, and #37, also had their MDS assessments completed late, with delays ranging from 4 to 10 days. Interviews with the MDS Coordinator revealed that the delays were partly due to the dependency on a corporate MDS person to sign off on the assessments, which contributed to the non-compliance with regulatory time frames.
Failure to Document Incontinent Care for Dependent Resident
Penalty
Summary
The facility failed to document that incontinent care was provided to a dependent resident, identified as Resident #298. This resident was noted to be always incontinent and dependent on staff for toileting hygiene according to the Minimum Data Set (MDS). The review of Geriatric Nursing Assistant (GNA) task documentation revealed that there was no documentation of bowel and bladder incontinent care for Resident #298 on multiple shifts over several days. Specifically, there was no documentation for the day and evening shifts on 9/4/24, the day shift on 9/5/24, the evening shift on 9/6/24, and the day shift on 9/7/24. During an interview, GNA #33 reported that she documents resident care throughout her shift and, if unable to do so immediately, she documents at the end of her shift. However, the facility's administrator was unable to provide any additional documentation to confirm that incontinent care was provided to Resident #298 for the specified dates and shifts. This lack of documentation indicates a failure to ensure that the resident received the necessary care, as required by the facility's protocols and regulatory standards.
Failure to Address Elevated Glucose Levels in Diabetic Resident
Penalty
Summary
The facility failed to provide treatment and care in accordance with professional standards of practice for a resident diagnosed with Diabetes Mellitus. The resident, who had been at the facility for more than two years, was not receiving insulin prior to a recent hospitalization despite having elevated glucose levels. On 02/14/24, a lab report revealed a glucose level of 328 mg/dl, but neither the provider's encounter notes nor the nurse's progress notes addressed this elevated glucose level. Subsequent medical records showed that the resident's glucose levels continued to rise, reaching a critical level of 455 mg/dl on 03/06/24, yet no new orders were given by the MD. The resident's glucose level was found to be over 600 mg/dl upon hospital admission on 03/11/24, and the resident's Hgb A1C was 12, indicating an average elevated glucose level over the previous three months. The primary care physician reported that the resident's diabetes was being monitored with an A1C test and believed that the elevated white blood cell count was causing the elevated blood sugar. However, the medical records did not show any action taken to address the elevated glucose levels. The resident was eventually hospitalized from 03/11/24 to 03/17/24, during which time they were started on insulin and continued to receive insulin and an oral hypoglycemic medication daily. This deficiency highlights the facility's failure to provide appropriate treatment and care according to the resident's medical needs and professional standards of practice.
Failure to Implement Non-Pharmacological Interventions Before Psychotropic Medication
Penalty
Summary
The facility failed to implement individualized, non-pharmacological approaches to care prior to the use of psychotropic medication for a resident. The resident, who had been at the facility for more than two years, was diagnosed with multiple medical conditions. Despite the resident denying anxiety or depression and showing no documented signs of being awake at night, the Nurse Practitioner (NP) ordered trazodone for insomnia without evidence of trying non-pharmacological interventions or reviewing sleep logs. The resident's activity assessments indicated a preference for in-room activities and independent leisurely pursuits, but there was no documentation of non-pharmacological interventions being attempted before the medication was prescribed. The NP's progress notes and nurse's progress notes from the days following the trazodone prescription indicated that the resident's sleep patterns were being monitored, but there was no prior documentation of non-pharmacological interventions. The Director of Nursing (DON) and Assistant Director of Nursing (ADON) were informed of the concern, but no additional documentation was provided to support the implementation of non-pharmacological interventions before the use of psychotropics. This deficiency was identified through resident and staff interviews, as well as medical record reviews.
Failure to Properly Store and Discard Medications
Penalty
Summary
The facility failed to properly store medications by not discarding expired medications and not dating medications when opened. This deficiency was observed in three medication carts during the survey. On Unit 1A, an open bottle of Promethazine DM Oral solution labeled with a resident's name had an expiration date of January 2024 but was not discarded. Additionally, a Trelegy Ellipta inhaler labeled with another resident's name was not discarded six weeks after opening as per the manufacturer's instructions. These findings were confirmed by a registered nurse who discarded the expired medications appropriately. On Unit 1B, a bottle of Olopatadine eye drops labeled with a resident's name was found to be expired and should have been discarded six weeks after opening. This was confirmed by an LPN who indicated the expired eye drops would be discarded and replacements ordered. On Unit 2B, an opened Advair Diskus inhaler was not labeled with the date when opened, making it impossible to determine if it had expired. Another Advair inhaler labeled with a resident's name was not discarded one month after opening as required. These findings were confirmed by an LPN who indicated the inhalers would be discarded appropriately. The Director of Nursing acknowledged these concerns when discussed.
Inaccurate Medical Records and Medication Documentation
Penalty
Summary
The facility failed to maintain complete and accurate medical records for two residents. For one resident, the Minimum Data Set (MDS) assessment indicated the use of hearing aids, and an order was in place for the application and removal of the hearing aids daily. However, observations and interviews revealed that the resident had not been wearing the hearing aids for several months, despite nurses consistently documenting that the hearing aids were being used. This discrepancy was confirmed by both the resident's son and facility staff, who could not provide a rationale for the inaccurate documentation. For another resident, the medication administration record (MAR) showed an order for Escitalopram Oxalate (Lexapro) for unspecified dementia and anxiety. However, the medical record indicated that the resident's diagnosis included anxiety disorder and depression, with instructions to continue Lexapro. The Director of Nurses acknowledged the concern regarding the indication for the use of Escitalopram as transcribed in the MAR. This inconsistency in the medical records highlights the facility's failure to ensure accurate and complete documentation for resident care.
Infection Control and PPE Deficiencies
Penalty
Summary
The facility failed to replace and store a nebulizer mask in a sanitary manner for Resident #28, who was observed with a nebulizer mask dated 3/9/24 lying bare on a nightstand. The mask should have been changed weekly and stored in a sealable plastic bag. Staff confirmed the mask was outdated and not stored properly, and immediate action was taken to replace it after the surveyor's intervention. Resident #28 had an order for Budesonide Inhalation Suspension via nebulizer three times a day for COPD, highlighting the importance of proper nebulizer mask maintenance to prevent infection spread. The facility also failed to post proper PPE notifications and ensure staff compliance with PPE requirements. Resident #38's room had two doors, but only one had a sign indicating the necessary PPE for contact/droplet precautions due to a COVID-19 diagnosis. The second door, which provided unobstructed access to the room, lacked a sign and could not be locked. The Infection Preventionist confirmed the oversight and initiated corrective measures. Additionally, an LPN was observed entering Resident #85's room without a gown, despite an Enhanced Barrier Precaution (EBP) sign on the door, and provided care without the required PPE. Another incident involved GNA #16 entering Resident #1's room without a gown, despite an EBP sign on the door. The GNA provided incontinent care wearing only gloves and later admitted not seeing the sign. The resident had recently acquired an open wound, necessitating EBP. The Infection Preventionist confirmed the resident's EBP status and the presence of the sign, indicating a lapse in staff adherence to PPE protocols.
Failure to Monitor and Prevent Misappropriation of Narcotic Medication
Penalty
Summary
The facility failed to monitor and prevent the misappropriation of resident property, specifically narcotic medication, for one resident. Resident #153, who had been receiving long-term care for over three years and required pain management with Oxycodone, experienced an incident where a card of Oxycodone pills went missing. The medication card, which initially contained 30 pills, was found to be missing with approximately 23 pills remaining. The incident was reported on 05/12/2023, and it was discovered that agency nurses had incorrectly counted the narcotics during their shifts on 05/10/2023. Nurses were subsequently educated on the standard procedure for medication custody handoff. Further investigation revealed discrepancies in the Controlled Substance card count logs across multiple nursing units. On Unit 2-B, the log for 04/16/24 showed missing signatures for the oncoming night nurse, despite indicating a correct count. Similarly, on Unit 1-A, the log showed pre-signing by the off-going nurse without the oncoming nurse's signature. Interviews with staff confirmed these lapses in procedure, with one nurse admitting to the bad habit of pre-signing the count. The Director of Nursing acknowledged these concerns and indicated that they would be addressed.
Failure to Ensure Drug Regimen Free from Unnecessary Drugs and Proper Documentation
Penalty
Summary
The facility failed to ensure that a resident's drug regimen was free from unnecessary drugs and did not notify a resident's attending provider when a medication was not given. For Resident #198, the facility did not attempt non-pharmacological interventions before administering Oxycodone for pain, as required by the resident's care plan. This was confirmed by the Director of Nursing (DON) during an interview, who acknowledged that non-pharmacological interventions should have been attempted first. For Resident #4, the facility did not document the removal of a Lidocaine patch as ordered. The medical record showed that the patch was applied daily but lacked documentation of its removal each night. This concern was also acknowledged by the DON during an interview. Resident #85 was administered an antihypertensive medication despite having blood pressure readings that fell below the parameters set by the attending provider. Additionally, there was no evidence that the attending provider was notified of the low blood pressure readings or the instances when the medication was withheld. Interviews with staff and the DON confirmed that the attending provider should have been notified of these changes in the resident's condition.
Latest citations in Maryland
The facility did not ensure that its Infection Preventionist (IP) met required qualifications for managing the Infection Prevention and Control Program. The DON reported serving as the IP but acknowledged lacking the specialized infection control training required for the role, and confirmed that no other staff member was currently qualified. Records showed that the previously qualified IP left several months earlier, and the Administrator and DON confirmed they were still seeking a replacement, leaving the infection control program without a properly trained leader.
Staff failed to consistently secure medications and medical supplies across three units, including an oxygen tank left on the floor behind a resident’s bed without a supporting device, a treatment cart with Collagenase Santyl cream left on top while two residents in power wheelchairs passed by, an unattended and unlocked treatment cart at a nursing station, and another treatment cart with Diclofenac gel and dressings left on top, indicating repeated lapses in maintaining locked and secure storage for drugs, biologicals, and related supplies.
The facility failed to provide sufficient dietitian coverage and timely nutritional assessments for several residents with significant dietary needs. A resident admitted for diabetic management with a high A1C was placed on a regular diet instead of the recommended carb-controlled diet and had only one weight taken in the first two weeks, with no dietitian review of the record. Another resident with prior significant weight loss had no documented dietitian follow-up despite continued weight loss, and a resident admitted with severe protein-calorie malnutrition experienced further significant weight loss without any dietitian assessment. The dietitian reported working limited hours and prioritizing certain high-risk cases, resulting in delayed or missed evaluations for new admissions and residents with ongoing nutritional concerns.
The facility failed to maintain adequate linen and incontinence supplies and did not keep resident care areas in good repair, resulting in delays and alterations in incontinence care and substandard environmental conditions. Staff reported that towels and washcloths were used instead of wipes and then discarded due to heavy soiling, and that linen deliveries to units were late, leaving residents waiting for care. Observations showed very limited numbers of clean washcloths and other linens on units and in the laundry, with no stock of disposable wipes or backup washcloth supply despite repeated reports to housekeeping. Additional observations revealed recliner chairs blocking a dining-area handwashing sink and kitchenette, multiple resident and shared bathrooms with unfinished spackle, chipped paint, musty odors, black substances near showers, missing threshold molding, exposed cracks and nails, and eroded, rusted baseboard heaters. Hallway handrails on both units were worn, chipped, and splintered, and a shower room contained fecal odors, dried brown stains on the toilet, and deteriorated fixtures, all contributing to a failure to provide a safe, clean, and homelike environment.
Facility staff did not thoroughly investigate two separate abuse allegations involving a resident and an injury of unknown origin involving another resident. In both cases, investigations focused on the directly affected resident and included staff interviews, but there were no interviews of other residents on the unit or documented assessments of those residents for signs of abuse or injuries of unknown origin, including residents unable to communicate due to cognitive status.
Two residents who were dependent on staff for oral care, including one with a tracheostomy, were observed with thick, white or milky substances coating their mouths and teeth, indicating inadequate oral hygiene. One resident communicated that staff did not brush their teeth and that staff "need to." In another case, despite oral care supplies being present in the room, the resident’s mouth and teeth remained unclean on multiple observations, with a thick milky substance caking the teeth and stringing between them when the resident tried to open their mouth. These findings showed that staff did not consistently provide oral care to residents who relied on them for this ADL.
Staff failed to maintain complete and accurate medical records for multiple residents, including missing and inconsistent documentation of wound care, delayed pain assessment after discovery of an injury of unknown origin in a cognitively impaired resident, and inaccurate recording of a PPD test result that was documented as negative despite no evidence the injection was administered and no supporting nurse’s note. Residents reported not receiving certain treatments, while MAR entries either lacked signatures for completion or contained conflicting information about whether care was provided.
Surveyors found that the facility failed to consistently implement and communicate correct transmission-based precautions and PPE use. One resident with a Foley catheter related to wounds had no precaution signage posted, while another resident in a double room had a contact precautions sign at the door, yet the NP entered without PPE and the GNA provided high-contact care wearing only gloves. Staff in that room stated the resident was not on contact precautions and later reversed the sign to show no PPE requirement. Therapy staff reported they rely solely on posted signs to determine PPE, and surveyors identified broader issues with inaccurate signage and staff awareness of which residents required contact precautions.
Surveyors found that MDS assessments were inaccurately coded for two residents. In one case, a resident sustained a femoral neck fracture after a fall, but the subsequent significant change MDS did not code the fall as a major injury and failed to capture prn Tylenol use documented on the MAR within the look-back period. In the other case, a quarterly MDS indicated opioid use for a resident, but the MAR for the same period showed no prescribed opioid, indicating incorrect coding of high-risk drug classes.
A resident who had recently been admitted and experienced a fall received multiple doses of the narcotic analgesic Tramadol, but the facility failed to accurately document all administered doses on the Medication Administration Record (MAR). Review showed only one Tramadol dose recorded on the MAR, while the Controlled Drug Receipt/Record/Disposition Form on the med cart reflected three doses given over two days. In interview, the DON stated staff are expected to document narcotic administration on the MAR and confirmed that two administered doses were not recorded there, resulting in an incomplete and inaccurate medical record.
Unqualified Infection Preventionist Overseeing Infection Control Program
Penalty
Summary
The facility failed to ensure that its designated Infection Preventionist (IP) met the mandatory qualifications for overseeing the Infection Prevention and Control Program. During an interview on 3/24/26 at 10:00 AM, the DON confirmed that she/he was serving as the facility’s IP but had not completed the specialized training in infection control required for the position. The DON further stated that no other staff member currently met the qualifications to serve as IP. Record review showed that the previously qualified IP left the facility in October 2025, and as of the survey date, the position remained unfilled by a qualified individual. At 1:30 PM on the same day, the Administrator and DON confirmed they were still in the process of finding a qualified IP for the facility, leaving the Infection Prevention and Control Program without a properly trained and qualified leader. No specific residents, medical histories, or clinical conditions were described in relation to this deficiency.
Unsecured Medications, Treatment Carts, and Oxygen Equipment
Penalty
Summary
Facility staff failed to ensure that drugs, biologicals, and related medical supplies were securely stored and properly maintained on multiple units. On one unit, an oxygen tank assigned to a resident was observed sitting on the floor behind the resident’s bed without any supporting device. On another unit, a treatment cart was observed with a tube of Collagenase Santyl cream labeled for a specific resident left on top of the cart, while residents in power wheelchairs passed by and staff were present at the nursing station. These observations showed that medications and oxygen equipment were not consistently secured as required. Further observations on additional units revealed an unattended and unlocked treatment cart at a nursing station, and on a separate occasion, a treatment cart with Diclofenac gel labeled for a resident left on top along with multiple packs of dressings. These incidents occurred across three units and on more than one date, demonstrating repeated failures to keep medications and treatment supplies in locked compartments or otherwise secured from unauthorized access.
Insufficient Dietitian Coverage and Delayed Nutritional Assessments
Penalty
Summary
The deficiency involves the facility’s failure to employ sufficient food and nutrition staff, including adequate dietitian coverage, to ensure timely assessment and appropriate diets for residents with significant nutritional and diabetic needs. A resident admitted over two weeks earlier with multiple comorbidities and an A1C of 11.5% had a hospital discharge recommendation for a carbohydrate-controlled diet, but was placed on a regular diet at admission with no acknowledgment of the recommended diet until one week later, when the resident requested larger portions. As of the survey date, the dietitian had not yet seen or reviewed this resident’s medical record, and the resident reported not having seen a dietitian and being very frustrated with the meals. During the first two weeks after admission, only one weight was obtained for this resident, despite physician notes stating the resident’s weight was “stable.” Further review of other residents showed additional failures in timely dietitian assessment and follow-up. One resident, readmitted in January and previously seen by the dietitian in September for a 6.4 lb weight loss over 30 days, had no documented follow-up despite continued weight loss totaling 22 lbs since the last dietitian review. Another resident admitted at the end of February with severe protein-calorie malnutrition had not been seen by the dietitian after about a month in the facility, despite a documented 14 lb (7%) weight loss over two weeks. The dietitian reported working only 12 hours per week at the facility and stated that she must prioritize which residents to see, focusing first on residents with tube feedings and those identified in risk meetings, resulting in delayed or absent assessments for new admissions and residents with ongoing weight loss and malnutrition diagnoses.
Linen Shortages and Poor Environmental Maintenance Compromise Resident Care and Comfort
Penalty
Summary
The deficiency involves the facility’s failure to maintain an adequate supply of clean linens and appropriate incontinence wipes, resulting in delays and alterations in residents’ incontinence care, as well as the use of towels and washcloths in place of disposable wipes. During the initial tour, the surveyor observed that the linen supply on one nursing unit hallway was low. Complaint reviews included concerns about delays in incontinence care and bed linens not being changed regularly, with residents left without clean bedding. A complainant reported that there was not enough clean linen available for residents. Staff interviews confirmed that towels, sheets, and washcloths were being used to wipe residents for incontinence care due to the absence of wipes, and that many of these linens were being thrown away when soiled. Staff also reported a shortage of linen, that linen deliveries to the units were late, and that residents who preferred to get up before breakfast had to wait for care when linen was delayed. Further observations showed that the clean supply room contained no disposable wipes or cloths for incontinence care, and a resident reported that staff did not use wipes, that the resident had to purchase their own, and that heavily soiled towels or washcloths were discarded. A tour of all nursing unit linen carts and closets revealed only six clean washcloths and limited supplies of towels, gowns, and bed linens. In the laundry room, only three washcloths were present, and the laundry assistant stated that there were only three washcloths available for each nursing unit that morning, that the facility was short on linen supply, and that these concerns had been repeatedly reported to the Director of Housekeeping over the preceding month and again that morning. The laundry assistant confirmed there was no additional laundry in process. The DON stated that wipe squares should be used for incontinence care, but no such wipes were found in the clean medical supply room, and no backup supply of washcloths was present in the emergency linen supply. The Director of Housekeeping confirmed there was no backup supply of washcloths. The deficiency also includes environmental and maintenance issues affecting resident bathrooms, handrails, and common areas. In the main dining area, a recliner chair was observed positioned directly in front of the handwashing sink, and two recliner chairs were stored in front of the nutrition area kitchenette. Multiple resident bathrooms and shared bathrooms were repeatedly observed over several days with unfinished spackle on walls that needed resurfacing and painting, chipped paint around sinks, uneven boards nailed to walls under sinks that appeared to partially cover holes, musty odors, black substances between shower bases and walls, missing threshold transition molding exposing cracks, missing tiles, and a nail, as well as eroded and chipped paint on baseboard heaters with exposed dark brown metal and rust-like material. Hallway handrails on both nursing units were observed to be worn, with chips, splintering, holes, and areas where the wood finish had worn off. A shower room was observed with a foul fecal odor, dried brown stains on the back of the toilet seat and in the toilet bowl, and a baseboard heater with eroded, chipped paint and rust-like material, along with chipped paint on the handrail. These conditions were acknowledged by the Director of Maintenance and other leadership, and some areas were noted to be in the process of renovation, but the observed deficiencies remained present during the survey period. Overall, the facility did not maintain a safe, clean, comfortable, and homelike environment in good repair across both nursing units and the dining area. The lack of adequate linen and incontinence supplies, combined with the poor condition of resident bathrooms, handrails, and certain common areas, constituted the basis for the cited deficiency. The observations and staff and resident reports consistently described shortages of essential hygiene supplies, delayed care related to linen availability, and multiple unresolved environmental and maintenance issues in resident care areas and shared spaces.
Failure to Thoroughly Investigate Abuse Allegations and Injuries of Unknown Origin
Penalty
Summary
Facility staff failed to thoroughly investigate allegations of potential abuse involving one resident and an injury of unknown origin involving another resident. For one resident, there were two separate allegations of abuse occurring on different days in early February. The facility’s investigation packets included interviews with staff who cared for or were scheduled to work with this resident on the days of the alleged incidents, and the investigations focused solely on this resident. However, there were no interviews conducted with other residents on the unit to inquire about abusive or neglectful treatment by the staff who were working during the times of the allegations. The surveyors noted that, although the allegations were not validated, there was no documentation that other residents were interviewed, if able, or assessed for signs or symptoms of injury. In a separate incident, another resident was identified on March 4 with a new bruise on the right eye, documented as a change in condition at 4:09 AM. This resident had a BIMS score of 99, indicating the resident was unable to complete an interview and therefore could not report how the injury occurred. The facility’s investigation identified a potential cause of the injury but did not reach a definitive resolution. Additionally, there were no interviews of other residents on the unit regarding possible abuse, nor were there documented assessments of other residents for injuries of unknown origin, particularly for those unable to speak for themselves, as in this resident’s case.
Failure to Provide Oral Care to Dependent Residents
Penalty
Summary
The deficiency involves the facility’s failure to provide oral care to residents who were dependent on staff for activities of daily living, specifically oral hygiene. One resident with a tracheostomy was observed with a thick, sticky white substance in the mouth and was noted to intermittently chew on nearby bedding. This resident made good eye contact and, when asked if staff brushed their teeth, shook their head no and mouthed that staff “need to.” According to the resident’s Minimum Data Set (MDS) dated 2/11/26, the resident was dependent on staff for oral care. Another resident, also dependent on staff for oral care per the 3/11/26 MDS, was observed sitting propped up in bed and able to respond with smiles. During the initial observation, the inside of this resident’s lips and upper and lower teeth had a thick, clear, white milky substance visible when the resident tried to open their mouth to smile. Oral care supplies were present in the nightstand, but the resident’s mouth and teeth were not clean. On a subsequent observation with the DON, NHA, and Corporate VP of clinical services, the same resident again had a thick, clear, milky substance between the lips and caking the teeth, which would string between the teeth when the resident attempted to open their mouth, demonstrating a lack of consistent oral care for residents dependent on staff for this ADL.
Incomplete and Inaccurate Medical Record Documentation for Treatments and Assessments
Penalty
Summary
Facility staff failed to maintain complete and accurate medical records and documentation for multiple residents. For one resident with wound care needs, review of the MAR showed that wound care and related treatments were signed as completed on the dates initially reported, despite the resident’s ongoing complaints that wound dressings were not being changed. When additional dates were reviewed, there were missing staff signatures for wound care on two specific dates, as well as three instances where application of A&D ointment to the resident’s feet was not signed off out of 24 days reviewed. Another resident with severe cognitive impairment, as evidenced by a BIMS score of 00, was found to have an injury of unknown origin (a bruise on the left hand). Documentation showed that a change in condition was initiated late in the morning, but a formal pain evaluation was not initiated and completed until that night, and the resident was unable to explain how the injury occurred or verbalize pain using a standard pain scale. For a third resident, documentation related to the admission PPD test was inconsistent and incomplete. The MAR contained an entry indicating “9” for the administration date, meaning “see nurse’s note,” but there was no corresponding nurse’s note. Despite the absence of a signed administration of the PPD injection, staff documented the PPD result as “negative” on the scheduled read date. The resident reported never receiving the PPD injection, and the DON confirmed that the facility had been out of PPD solution at the time, so the test would not have been administered. These findings demonstrate failures in accurate documentation of treatments and assessments, including wound care, pain assessment, and TB screening, as well as missing or incomplete supporting notes in the medical record.
Failure to Implement and Communicate Correct Transmission-Based Precautions
Penalty
Summary
Surveyors identified a deficiency in the facility’s infection prevention and control program related to inconsistent and incorrect implementation of transmission-based precautions and PPE use. During a complaint investigation focused on residents on transmission-based precautions, one resident with a visible Foley catheter was observed in the room with physical therapy, but there were no signs posted indicating any need for PPE, despite the resident being a new admission with a Foley catheter placed related to wounds. In another double-occupancy room, a contact precautions sign was posted at the doorway, but the nurse practitioner was in the room on a personal phone with no PPE, and the assigned GNA was repositioning the resident in bed while wearing only gloves. When questioned, the NP, RN, and GNA all stated that the resident in the room was not on contact precautions, and the GNA reported that signs were hanging at all doors and that this particular resident’s sign was “just wrong.” The surveyor observed the GNA later return to the room and turn the sign around to indicate no PPE requirement. Subsequent interviews revealed that therapy staff relied on posted signage to determine PPE use and that if the sign was wrong, the PPE used would be wrong. Overall, surveyors found problems with signage accuracy and staff awareness of which residents required contact precautions, as well as observed failures to follow appropriate PPE use for residents who should have been on contact precautions.
Inaccurate MDS Coding for Falls, Pain Management, and High-Risk Medications
Penalty
Summary
Facility staff failed to ensure Minimum Data Set (MDS) assessments were accurately coded for two residents reviewed during a complaint survey. For one resident, a facility-reported incident showed that the resident was found seated on the floor beside the bed and was diagnosed with a non-displaced femoral neck impaction fracture of the left hip following an x-ray. Despite this fall with a major injury, the subsequent significant change MDS dated 11/4/25 did not code the fall with major injury in Section J1900C. Review of the resident’s Medication Administration Records for October and November 2025 showed administration of Tylenol on 10/31/25 at 9:30 PM, which fell within the 5-day look-back period for the MDS, but Section J0100 (prn pain) of the same significant change MDS did not capture the use of Tylenol. For another resident, review of a quarterly MDS with an assessment reference date of 10/15/25 showed that Section N0415 (High-Risk Drug Classes) documented the use of an opioid medication. However, review of the resident’s October 2025 Medication Administration Record did not show that the resident had been prescribed an opioid during that period. In both cases, MDS staff later confirmed that these were errors in MDS coding, demonstrating that the assessments did not accurately reflect the residents’ clinical status and medication use as documented in their medical records.
Incomplete Documentation of Narcotic Administration on MAR
Penalty
Summary
The facility failed to maintain complete and accurate medical records in accordance with accepted professional standards for one resident receiving narcotic medication. The resident, admitted in March 2026, had a fall on 3/6/26 and was sent to the hospital on 3/9/26. Review of the March 2026 Medication Administration Record (MAR) showed documentation of a single 25 mg dose of Tramadol administered on 3/8/26 at 9:23 AM. However, review of the resident’s Controlled Drug Receipt/Record/Disposition Form, kept on the nurse’s medication cart and not in the medical record, showed that Tramadol 25 mg was administered three times between 3/8/26 and 3/9/26: at 11:00 AM and 9:00 PM on 3/8/26, and at 9:00 AM on 3/9/26. In interview, the DON stated that staff are expected to document narcotic administration on the MAR and confirmed that only one of the three Tramadol doses reflected on the controlled drug record was documented on the resident’s MAR. This discrepancy between the controlled substance record and the MAR, with missing documentation of two administered doses of Tramadol on the official medical record, constituted the failure to maintain a complete and accurate medical record for the resident.
Trusted data from CMS and state health departments
Every citation, penalty and Plan of Correction is sourced from public CMS records (latest release May 27, 2026) and official state health department websites — never guesswork.
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