Autumn Lake Healthcare At Oak Manor
Inspection history, citations, penalties and survey trends for this long-term care facility in Burtonsville, Maryland.
- Location
- 3415 Greencastle Road, Burtonsville, Maryland 20866
- CMS Provider Number
- 215315
- Inspections on file
- 19
- Latest survey
- July 1, 2025
- Citations (last 12 mo.)
- 1 (1 serious)
Citation history
Health deficiencies cited at Autumn Lake Healthcare At Oak Manor during CMS and state inspections, most recent first.
A cognitively impaired resident with Alzheimer's and a high risk for wandering was able to exit the facility unsupervised due to a low-volume door alarm that was not clearly audible to staff. The resident was discovered missing after staff responded to a faint alarm and found an exit door open and unlocked. Despite a care plan and wander guard in place, the resident was not located until the following day, after an extensive search involving staff and law enforcement.
A resident experienced a significant, unaddressed weight loss over one month, with no documentation by the physician or dietitian of interventions or follow-up, despite care plan requirements to notify and act on such changes.
A resident requiring feeding assistance was left without a meal and unattended for an extended period during dinner, despite multiple staff being present in the dining room. The resident remained without food until another staff member, after serving trays elsewhere, began to assist. Staff interviews confirmed low staffing and a lack of timely feeding support for residents needing assistance.
Surveyors observed that two clean utility rooms contained dirty intravenous poles and an oxygen concentrator, all with visible solid matter and lacking labels to indicate cleanliness. Staff confirmed these items were improperly placed in clean areas and should have been in soiled utility rooms until cleaned and labeled.
A physician order for a GI consultation for a resident with poor oral intake and weight loss was not completed or scheduled as required. The DON confirmed the consultation should have been arranged, but no evidence was found in the medical record that this had occurred.
A resident with diverticulitis experienced significant, ongoing weight loss and difficulty with food intake, yet staff failed to implement new interventions or notify the physician despite multiple system alerts and an existing care plan identifying the risk. Interviews confirmed that required monitoring and follow-up actions were not carried out.
Two residents with significant weight loss did not have required physician documentation of their medical history and treatment plans. In both cases, despite ongoing monitoring and interventions by dietary staff, there was a lack of physician or nurse practitioner notes summarizing the treatment approach or relevant diagnoses in the medical records.
Surveyors found that three hot food items served in the dining area were below the required temperature of 135°F, with potatoes at 119.8°F, spinach at 109.2°F, and veal at 123.1°F. These findings were confirmed by dietary management staff.
Surveyors identified several breaches in food service sanitation, including unlabeled repoured applesauce containers on a dirty utility table, soiled linens stored in the dry storage room, food and liquid spills on the kitchen floor, a red substance spilled on refrigerator shelves, and an unkempt dish rinsing area with food particles left in the strainer. These conditions reflect a failure to follow professional standards for food safety and cleanliness.
The facility failed to document and address significant weight loss in two residents, including lack of evidence that interventions were implemented, physicians were notified, or interdisciplinary teams were informed. Medical records did not reflect required actions or monitoring, and staff interviews confirmed that documentation and notifications were not completed as per protocol.
During a dinner service, a staff member assisted a resident with feeding after picking up utensils from the floor for another resident, but failed to sanitize her hands before resuming care. The staff member believed using a napkin was sufficient and did not perform proper hand hygiene.
Surveyors found that several residents were not consistently served meals according to their food preferences, as menu slips focused on dietary restrictions rather than individual choices. Staff, including dietary aides and nursing personnel, confirmed that they did not routinely verify or accommodate resident preferences during meal service, and the dietary manager acknowledged the absence of a system to ensure preferences were honored.
A resident left the facility without a physician's order for a therapeutic leave of absence, due to a lack of supervision. The resident, assessed as low risk for elopement, left to attend a church service in the community after being unaware of its cancellation within the facility. The resident was found by police and returned without injuries. The facility's policy requires a physician's order for such absences, which was not obtained.
Failure to Prevent Elopement of Cognitively Impaired Resident
Penalty
Summary
A cognitively impaired resident with a diagnosis of Alzheimer's Disease and a BIMS score indicating severe cognitive impairment was identified as being at risk for wandering, with a care plan in place that included a wander guard. Despite these measures, the resident was able to exit the facility unsupervised. On the day of the incident, the resident was last seen by a charge nurse in their room. Later, a GNA arriving for her shift heard a soft alarm, which she initially mistook for a call light. Upon investigation with an LPN, they discovered an exit door slightly open and another door leading outside that was unlocked, with the alarm still sounding faintly. After realizing the resident was missing, staff initiated a head count and notified the RN supervisor, who activated the facility's missing resident protocol. The facility conducted a search of the building and surrounding neighborhood, and local law enforcement was called to assist. The resident's family was notified, and the search continued into the evening with the involvement of police and specialized search equipment. The resident was eventually found the next morning in a wooded area near the facility by a staff member. The investigation revealed that the resident was able to leave through an exit door due to a very low-volume alarm that was barely audible from the nursing station. The resident had not previously eloped. The incident highlighted a failure to prevent a resident at risk for wandering from exiting the facility unsupervised, as well as issues with the effectiveness and audibility of the door alarm system at the time of the event.
Failure to Address and Document Significant Weight Loss
Penalty
Summary
A resident experienced a significant weight loss of 13 pounds (10%) within one month, as documented in the medical record. The resident's nutrition care plan included an intervention to notify the physician and dietitian of any significant weight changes. However, there was no documentation that the significant weight loss was addressed by either the physician or the dietitian. The discharge summary from the previous provider noted the resident's morbid obesity but did not address the recent weight loss. Interviews with the Medical Director and the dietitian confirmed that the weight loss was not specifically addressed or documented. The dietitian stated that the usual process would be to discuss supplements with the resident and initiate them if desired, but could not confirm if this occurred due to lack of documentation. Both staff members indicated that significant weight loss is typically discussed in risk management meetings, but there was no evidence in the record that interventions or changes were made in response to this resident's weight loss.
Failure to Provide Dignified Dining Experience and Timely Feeding Assistance
Penalty
Summary
During a dinner observation, a resident was seated in a geri-chair at a dining table with another resident who was independently feeding themselves. The resident in the geri-chair did not have a plate of food in front of them and was left waiting to be fed, with only two cups (one containing juice) placed on the table. Staff in the dining room were observed assisting other residents, including responding to a juice spill and discarding utensils that had fallen on the floor, but did not sanitize their hands before continuing to assist with feeding. Despite four staff members being present in the dining room, none attempted to feed the resident in the geri-chair during this time. The resident remained without a meal and unattended for approximately 26 minutes until another staff member, who had been serving trays to residents in their rooms, began to feed them. Staff interviews confirmed that staffing levels were low and that many residents required assistance with feeding. It was also stated that all staff are expected to assist with feeding residents, but this expectation was not met during the observed dining period.
Failure to Maintain Sanitary Conditions in Clean Utility Rooms
Penalty
Summary
The facility failed to maintain a sanitary environment in two out of two clean utility rooms observed during the recertification survey. On the second floor, Forest View clean utility room, two intravenous poles were found with brown and gray colored solid matter covering their bases, and neither pole had a label indicating they were clean. On the first floor, Chapel Valley clean utility room, three intravenous poles with brown and white colored substances at their bases and one oxygen concentrator covered with gray solid matter were observed, with none of these items labeled as clean. During an interview, the Central Supply Clerk confirmed that these items were dirty and should not have been placed in the clean utility room, stating that they should have been placed in the soiled utility room and labeled or bagged after cleaning.
Failure to Obtain Ordered GI Consultation
Penalty
Summary
A physician order was present in the medical record for a gastrointestinal (GI) consultation for a resident experiencing poor oral intake and weight loss. Review of the resident's medical record did not show any evidence that the GI consultation had been completed or scheduled as ordered. During an interview, the Director of Nursing confirmed that the consultation should have been scheduled and indicated that she would investigate the matter. The deficiency was identified due to the facility's failure to obtain the GI consultation as requested by the physician.
Failure to Address Significant Weight Loss in Resident
Penalty
Summary
Facility staff failed to address the nutritional needs of a resident with a known history of significant weight loss. The resident, diagnosed with diverticulitis, experienced ongoing difficulty with food intake, including being unable to keep food down and having large bowel movements after eating. Medical records showed a substantial decrease in weight over several months, with the system generating multiple significant weight loss alerts. Despite these warnings, there was no documentation of new interventions or physician notification after an initial order for a nutritional supplement was made. Interviews with staff revealed that while there were processes in place for monitoring and documenting weight changes, these were not followed for this resident. The Registered Dietician was responsible for making dietary recommendations and notifying the physician, but could not explain why further actions were not taken. Nursing staff described the process for recording weights and responding to alerts, but were unable to account for the lack of response to the resident's ongoing weight loss.
Physician Documentation Lapses for Residents with Significant Weight Loss
Penalty
Summary
The facility failed to ensure that physicians documented the medical history and treatment plans for residents experiencing significant weight loss. In one case, a resident experienced a 17.5-pound (10.7%) weight loss over a three-month period, as documented by the dietician. Despite ongoing dietary interventions and regular monitoring by the dietician and staff, there was no physician or nurse practitioner note in the medical record detailing the treatment plan or summarizing the medical conditions impacting the resident's weight fluctuations. The medical director confirmed that no such progress note had been written for this resident. In another instance, a resident with a complex medical history, including edema, gout, diverticulitis, asthma, nicotine dependence, hyperlipidemia, and lack of coordination, experienced significant weight loss. The medical director acknowledged during an interview that a diagnosis of Anasarca was not documented in the resident's medical chart, despite being aware of the condition. The absence of documentation regarding the resident's medical history and treatment plan was confirmed during the survey, and the medical director admitted to the oversight.
Failure to Serve Hot Foods at Safe and Appetizing Temperatures
Penalty
Summary
Surveyor observation determined that the facility failed to provide palatable food at an appetizing and safe temperature for residents. During a test tray check at the end of food service in the Chapel Way dining area, three hot food items were measured using the facility's thermometer by a staff member. The potatoes registered at 119.8°F, the spinach at 109.2°F, and the meat (veal) at 123.1°F, all of which were below the required internal temperature of 135°F for hot foods. The Regional Dietary Manager confirmed these temperatures during an interview.
Failure to Maintain Sanitary Food Service Practices and Cleanliness
Penalty
Summary
Surveyors observed multiple lapses in sanitary practices and cleanliness within the facility's kitchen during an initial tour with the Regional Dietary Manager. Specifically, seven repoured and unlabeled applesauce containers were found on a dirty utility table, a large white laundry basket containing soiled white linens was present in the dry storage room, and food along with a liquid substance was noted on the kitchen floor near the walk-in freezer. Additionally, a red substance had spilled over metal shelves in the walk-in refrigerator, and the area designated for rinsing dirty dishes was unkempt with food particles left in the strainer. These findings indicate that the facility failed to maintain food service safety and a clean working environment in accordance with professional standards.
Failure to Document and Address Significant Weight Loss in Residents
Penalty
Summary
The facility failed to properly document and address significant weight loss in two residents, as required by accepted professional standards. For one resident, there was a documented weight loss of 13 pounds (10%) within one month, but the medical record lacked evidence that the physician or dietitian was notified, and there was no documentation of interventions or changes to the resident's care plan. The dietitian confirmed during an interview that he could not provide documentation of any actions taken in response to the weight loss and admitted that such changes and interventions were not recorded. For another resident, records showed a substantial weight fluctuation following a hospital discharge, with a notable decrease over subsequent months. Despite this, there was no documentation that the resident's weight loss was monitored, addressed, or that the physician was notified. Interviews with the registered dietitian and nurse unit manager revealed that required forms and notifications were not completed, and review of risk management meeting minutes showed no mention of the resident's weight loss. The director of nursing was unable to provide documentation of any change in condition or physician notification related to the resident's weight loss.
Failure to Perform Hand Hygiene After Handling Contaminated Items
Penalty
Summary
Facility staff failed to adhere to infection control practices during a dinner service observation. A resident spilled juice onto their plate while feeding themselves, prompting a staff member to remove the plate. Before returning to assist the resident, the staff member picked up utensils that had fallen onto the floor from another resident and discarded them, but did not perform hand hygiene before resuming assistance. The staff member acknowledged the lapse when interviewed, stating she believed using a napkin was sufficient and that she would use proper infection control practices in the future. These actions were directly observed by surveyors, who noted the lack of hand sanitization between handling potentially contaminated items and providing direct care to a resident.
Failure to Consistently Honor Resident Food Preferences
Penalty
Summary
The facility failed to honor residents' food preferences, as evidenced by observations, interviews, and medical record reviews. During meal service, residents reported that they were often served food items that did not match their stated preferences, and the menu slips on resident trays primarily listed dietary restrictions due to diagnoses or allergies, rather than individual food preferences. Staff interviews confirmed that menu slips did not consistently include residents' preferred food items, and staff would serve meals without verifying if residents received their preferred choices. For example, one resident expressed dissatisfaction with receiving a biscuit instead of toast and a boiled egg instead of scrambled eggs, while another resident noted a preference for boiled eggs and a dislike for cream of wheat, which was not always honored. Further, the Certified Dietary Manager acknowledged that the current system focused on avoiding restricted foods but lacked a process to ensure residents' preferences were consistently met. Observations showed that most menu slips did not disclose food preferences, and staff relied on the slips for guidance without additional verification. The lack of a check and balance system contributed to residents not consistently receiving meals according to their preferences, as confirmed by both dietary and nursing staff.
Failure to Supervise Resident Leading to Unauthorized Leave
Penalty
Summary
The facility staff failed to provide adequate supervision to prevent an accident involving a resident who was assessed to be at low risk for elopement. The resident, who was admitted for rehabilitation, left the facility without a physician's order for a therapeutic leave of absence. The incident occurred when the resident, unaware of the cancellation of a church service within the facility, decided to attend a church in the community. The resident was found outside the facility by the police and returned without injuries. Upon review, it was discovered that the resident did not have a physician's order for a leave of absence at the time of the elopement. The facility's Therapeutic Leave Policy requires a physician's order and documentation in the medical record for any leave of absence. The deficiency was confirmed during an interview with a nurse consultant, who acknowledged the failure to provide supervision for the resident.
Latest citations in Maryland
The facility did not ensure that its Infection Preventionist (IP) met required qualifications for managing the Infection Prevention and Control Program. The DON reported serving as the IP but acknowledged lacking the specialized infection control training required for the role, and confirmed that no other staff member was currently qualified. Records showed that the previously qualified IP left several months earlier, and the Administrator and DON confirmed they were still seeking a replacement, leaving the infection control program without a properly trained leader.
Staff failed to consistently secure medications and medical supplies across three units, including an oxygen tank left on the floor behind a resident’s bed without a supporting device, a treatment cart with Collagenase Santyl cream left on top while two residents in power wheelchairs passed by, an unattended and unlocked treatment cart at a nursing station, and another treatment cart with Diclofenac gel and dressings left on top, indicating repeated lapses in maintaining locked and secure storage for drugs, biologicals, and related supplies.
The facility failed to provide sufficient dietitian coverage and timely nutritional assessments for several residents with significant dietary needs. A resident admitted for diabetic management with a high A1C was placed on a regular diet instead of the recommended carb-controlled diet and had only one weight taken in the first two weeks, with no dietitian review of the record. Another resident with prior significant weight loss had no documented dietitian follow-up despite continued weight loss, and a resident admitted with severe protein-calorie malnutrition experienced further significant weight loss without any dietitian assessment. The dietitian reported working limited hours and prioritizing certain high-risk cases, resulting in delayed or missed evaluations for new admissions and residents with ongoing nutritional concerns.
The facility failed to maintain adequate linen and incontinence supplies and did not keep resident care areas in good repair, resulting in delays and alterations in incontinence care and substandard environmental conditions. Staff reported that towels and washcloths were used instead of wipes and then discarded due to heavy soiling, and that linen deliveries to units were late, leaving residents waiting for care. Observations showed very limited numbers of clean washcloths and other linens on units and in the laundry, with no stock of disposable wipes or backup washcloth supply despite repeated reports to housekeeping. Additional observations revealed recliner chairs blocking a dining-area handwashing sink and kitchenette, multiple resident and shared bathrooms with unfinished spackle, chipped paint, musty odors, black substances near showers, missing threshold molding, exposed cracks and nails, and eroded, rusted baseboard heaters. Hallway handrails on both units were worn, chipped, and splintered, and a shower room contained fecal odors, dried brown stains on the toilet, and deteriorated fixtures, all contributing to a failure to provide a safe, clean, and homelike environment.
Facility staff did not thoroughly investigate two separate abuse allegations involving a resident and an injury of unknown origin involving another resident. In both cases, investigations focused on the directly affected resident and included staff interviews, but there were no interviews of other residents on the unit or documented assessments of those residents for signs of abuse or injuries of unknown origin, including residents unable to communicate due to cognitive status.
Two residents who were dependent on staff for oral care, including one with a tracheostomy, were observed with thick, white or milky substances coating their mouths and teeth, indicating inadequate oral hygiene. One resident communicated that staff did not brush their teeth and that staff "need to." In another case, despite oral care supplies being present in the room, the resident’s mouth and teeth remained unclean on multiple observations, with a thick milky substance caking the teeth and stringing between them when the resident tried to open their mouth. These findings showed that staff did not consistently provide oral care to residents who relied on them for this ADL.
Staff failed to maintain complete and accurate medical records for multiple residents, including missing and inconsistent documentation of wound care, delayed pain assessment after discovery of an injury of unknown origin in a cognitively impaired resident, and inaccurate recording of a PPD test result that was documented as negative despite no evidence the injection was administered and no supporting nurse’s note. Residents reported not receiving certain treatments, while MAR entries either lacked signatures for completion or contained conflicting information about whether care was provided.
Surveyors found that the facility failed to consistently implement and communicate correct transmission-based precautions and PPE use. One resident with a Foley catheter related to wounds had no precaution signage posted, while another resident in a double room had a contact precautions sign at the door, yet the NP entered without PPE and the GNA provided high-contact care wearing only gloves. Staff in that room stated the resident was not on contact precautions and later reversed the sign to show no PPE requirement. Therapy staff reported they rely solely on posted signs to determine PPE, and surveyors identified broader issues with inaccurate signage and staff awareness of which residents required contact precautions.
Surveyors found that MDS assessments were inaccurately coded for two residents. In one case, a resident sustained a femoral neck fracture after a fall, but the subsequent significant change MDS did not code the fall as a major injury and failed to capture prn Tylenol use documented on the MAR within the look-back period. In the other case, a quarterly MDS indicated opioid use for a resident, but the MAR for the same period showed no prescribed opioid, indicating incorrect coding of high-risk drug classes.
A resident who had recently been admitted and experienced a fall received multiple doses of the narcotic analgesic Tramadol, but the facility failed to accurately document all administered doses on the Medication Administration Record (MAR). Review showed only one Tramadol dose recorded on the MAR, while the Controlled Drug Receipt/Record/Disposition Form on the med cart reflected three doses given over two days. In interview, the DON stated staff are expected to document narcotic administration on the MAR and confirmed that two administered doses were not recorded there, resulting in an incomplete and inaccurate medical record.
Unqualified Infection Preventionist Overseeing Infection Control Program
Penalty
Summary
The facility failed to ensure that its designated Infection Preventionist (IP) met the mandatory qualifications for overseeing the Infection Prevention and Control Program. During an interview on 3/24/26 at 10:00 AM, the DON confirmed that she/he was serving as the facility’s IP but had not completed the specialized training in infection control required for the position. The DON further stated that no other staff member currently met the qualifications to serve as IP. Record review showed that the previously qualified IP left the facility in October 2025, and as of the survey date, the position remained unfilled by a qualified individual. At 1:30 PM on the same day, the Administrator and DON confirmed they were still in the process of finding a qualified IP for the facility, leaving the Infection Prevention and Control Program without a properly trained and qualified leader. No specific residents, medical histories, or clinical conditions were described in relation to this deficiency.
Unsecured Medications, Treatment Carts, and Oxygen Equipment
Penalty
Summary
Facility staff failed to ensure that drugs, biologicals, and related medical supplies were securely stored and properly maintained on multiple units. On one unit, an oxygen tank assigned to a resident was observed sitting on the floor behind the resident’s bed without any supporting device. On another unit, a treatment cart was observed with a tube of Collagenase Santyl cream labeled for a specific resident left on top of the cart, while residents in power wheelchairs passed by and staff were present at the nursing station. These observations showed that medications and oxygen equipment were not consistently secured as required. Further observations on additional units revealed an unattended and unlocked treatment cart at a nursing station, and on a separate occasion, a treatment cart with Diclofenac gel labeled for a resident left on top along with multiple packs of dressings. These incidents occurred across three units and on more than one date, demonstrating repeated failures to keep medications and treatment supplies in locked compartments or otherwise secured from unauthorized access.
Insufficient Dietitian Coverage and Delayed Nutritional Assessments
Penalty
Summary
The deficiency involves the facility’s failure to employ sufficient food and nutrition staff, including adequate dietitian coverage, to ensure timely assessment and appropriate diets for residents with significant nutritional and diabetic needs. A resident admitted over two weeks earlier with multiple comorbidities and an A1C of 11.5% had a hospital discharge recommendation for a carbohydrate-controlled diet, but was placed on a regular diet at admission with no acknowledgment of the recommended diet until one week later, when the resident requested larger portions. As of the survey date, the dietitian had not yet seen or reviewed this resident’s medical record, and the resident reported not having seen a dietitian and being very frustrated with the meals. During the first two weeks after admission, only one weight was obtained for this resident, despite physician notes stating the resident’s weight was “stable.” Further review of other residents showed additional failures in timely dietitian assessment and follow-up. One resident, readmitted in January and previously seen by the dietitian in September for a 6.4 lb weight loss over 30 days, had no documented follow-up despite continued weight loss totaling 22 lbs since the last dietitian review. Another resident admitted at the end of February with severe protein-calorie malnutrition had not been seen by the dietitian after about a month in the facility, despite a documented 14 lb (7%) weight loss over two weeks. The dietitian reported working only 12 hours per week at the facility and stated that she must prioritize which residents to see, focusing first on residents with tube feedings and those identified in risk meetings, resulting in delayed or absent assessments for new admissions and residents with ongoing weight loss and malnutrition diagnoses.
Linen Shortages and Poor Environmental Maintenance Compromise Resident Care and Comfort
Penalty
Summary
The deficiency involves the facility’s failure to maintain an adequate supply of clean linens and appropriate incontinence wipes, resulting in delays and alterations in residents’ incontinence care, as well as the use of towels and washcloths in place of disposable wipes. During the initial tour, the surveyor observed that the linen supply on one nursing unit hallway was low. Complaint reviews included concerns about delays in incontinence care and bed linens not being changed regularly, with residents left without clean bedding. A complainant reported that there was not enough clean linen available for residents. Staff interviews confirmed that towels, sheets, and washcloths were being used to wipe residents for incontinence care due to the absence of wipes, and that many of these linens were being thrown away when soiled. Staff also reported a shortage of linen, that linen deliveries to the units were late, and that residents who preferred to get up before breakfast had to wait for care when linen was delayed. Further observations showed that the clean supply room contained no disposable wipes or cloths for incontinence care, and a resident reported that staff did not use wipes, that the resident had to purchase their own, and that heavily soiled towels or washcloths were discarded. A tour of all nursing unit linen carts and closets revealed only six clean washcloths and limited supplies of towels, gowns, and bed linens. In the laundry room, only three washcloths were present, and the laundry assistant stated that there were only three washcloths available for each nursing unit that morning, that the facility was short on linen supply, and that these concerns had been repeatedly reported to the Director of Housekeeping over the preceding month and again that morning. The laundry assistant confirmed there was no additional laundry in process. The DON stated that wipe squares should be used for incontinence care, but no such wipes were found in the clean medical supply room, and no backup supply of washcloths was present in the emergency linen supply. The Director of Housekeeping confirmed there was no backup supply of washcloths. The deficiency also includes environmental and maintenance issues affecting resident bathrooms, handrails, and common areas. In the main dining area, a recliner chair was observed positioned directly in front of the handwashing sink, and two recliner chairs were stored in front of the nutrition area kitchenette. Multiple resident bathrooms and shared bathrooms were repeatedly observed over several days with unfinished spackle on walls that needed resurfacing and painting, chipped paint around sinks, uneven boards nailed to walls under sinks that appeared to partially cover holes, musty odors, black substances between shower bases and walls, missing threshold transition molding exposing cracks, missing tiles, and a nail, as well as eroded and chipped paint on baseboard heaters with exposed dark brown metal and rust-like material. Hallway handrails on both nursing units were observed to be worn, with chips, splintering, holes, and areas where the wood finish had worn off. A shower room was observed with a foul fecal odor, dried brown stains on the back of the toilet seat and in the toilet bowl, and a baseboard heater with eroded, chipped paint and rust-like material, along with chipped paint on the handrail. These conditions were acknowledged by the Director of Maintenance and other leadership, and some areas were noted to be in the process of renovation, but the observed deficiencies remained present during the survey period. Overall, the facility did not maintain a safe, clean, comfortable, and homelike environment in good repair across both nursing units and the dining area. The lack of adequate linen and incontinence supplies, combined with the poor condition of resident bathrooms, handrails, and certain common areas, constituted the basis for the cited deficiency. The observations and staff and resident reports consistently described shortages of essential hygiene supplies, delayed care related to linen availability, and multiple unresolved environmental and maintenance issues in resident care areas and shared spaces.
Failure to Thoroughly Investigate Abuse Allegations and Injuries of Unknown Origin
Penalty
Summary
Facility staff failed to thoroughly investigate allegations of potential abuse involving one resident and an injury of unknown origin involving another resident. For one resident, there were two separate allegations of abuse occurring on different days in early February. The facility’s investigation packets included interviews with staff who cared for or were scheduled to work with this resident on the days of the alleged incidents, and the investigations focused solely on this resident. However, there were no interviews conducted with other residents on the unit to inquire about abusive or neglectful treatment by the staff who were working during the times of the allegations. The surveyors noted that, although the allegations were not validated, there was no documentation that other residents were interviewed, if able, or assessed for signs or symptoms of injury. In a separate incident, another resident was identified on March 4 with a new bruise on the right eye, documented as a change in condition at 4:09 AM. This resident had a BIMS score of 99, indicating the resident was unable to complete an interview and therefore could not report how the injury occurred. The facility’s investigation identified a potential cause of the injury but did not reach a definitive resolution. Additionally, there were no interviews of other residents on the unit regarding possible abuse, nor were there documented assessments of other residents for injuries of unknown origin, particularly for those unable to speak for themselves, as in this resident’s case.
Failure to Provide Oral Care to Dependent Residents
Penalty
Summary
The deficiency involves the facility’s failure to provide oral care to residents who were dependent on staff for activities of daily living, specifically oral hygiene. One resident with a tracheostomy was observed with a thick, sticky white substance in the mouth and was noted to intermittently chew on nearby bedding. This resident made good eye contact and, when asked if staff brushed their teeth, shook their head no and mouthed that staff “need to.” According to the resident’s Minimum Data Set (MDS) dated 2/11/26, the resident was dependent on staff for oral care. Another resident, also dependent on staff for oral care per the 3/11/26 MDS, was observed sitting propped up in bed and able to respond with smiles. During the initial observation, the inside of this resident’s lips and upper and lower teeth had a thick, clear, white milky substance visible when the resident tried to open their mouth to smile. Oral care supplies were present in the nightstand, but the resident’s mouth and teeth were not clean. On a subsequent observation with the DON, NHA, and Corporate VP of clinical services, the same resident again had a thick, clear, milky substance between the lips and caking the teeth, which would string between the teeth when the resident attempted to open their mouth, demonstrating a lack of consistent oral care for residents dependent on staff for this ADL.
Incomplete and Inaccurate Medical Record Documentation for Treatments and Assessments
Penalty
Summary
Facility staff failed to maintain complete and accurate medical records and documentation for multiple residents. For one resident with wound care needs, review of the MAR showed that wound care and related treatments were signed as completed on the dates initially reported, despite the resident’s ongoing complaints that wound dressings were not being changed. When additional dates were reviewed, there were missing staff signatures for wound care on two specific dates, as well as three instances where application of A&D ointment to the resident’s feet was not signed off out of 24 days reviewed. Another resident with severe cognitive impairment, as evidenced by a BIMS score of 00, was found to have an injury of unknown origin (a bruise on the left hand). Documentation showed that a change in condition was initiated late in the morning, but a formal pain evaluation was not initiated and completed until that night, and the resident was unable to explain how the injury occurred or verbalize pain using a standard pain scale. For a third resident, documentation related to the admission PPD test was inconsistent and incomplete. The MAR contained an entry indicating “9” for the administration date, meaning “see nurse’s note,” but there was no corresponding nurse’s note. Despite the absence of a signed administration of the PPD injection, staff documented the PPD result as “negative” on the scheduled read date. The resident reported never receiving the PPD injection, and the DON confirmed that the facility had been out of PPD solution at the time, so the test would not have been administered. These findings demonstrate failures in accurate documentation of treatments and assessments, including wound care, pain assessment, and TB screening, as well as missing or incomplete supporting notes in the medical record.
Failure to Implement and Communicate Correct Transmission-Based Precautions
Penalty
Summary
Surveyors identified a deficiency in the facility’s infection prevention and control program related to inconsistent and incorrect implementation of transmission-based precautions and PPE use. During a complaint investigation focused on residents on transmission-based precautions, one resident with a visible Foley catheter was observed in the room with physical therapy, but there were no signs posted indicating any need for PPE, despite the resident being a new admission with a Foley catheter placed related to wounds. In another double-occupancy room, a contact precautions sign was posted at the doorway, but the nurse practitioner was in the room on a personal phone with no PPE, and the assigned GNA was repositioning the resident in bed while wearing only gloves. When questioned, the NP, RN, and GNA all stated that the resident in the room was not on contact precautions, and the GNA reported that signs were hanging at all doors and that this particular resident’s sign was “just wrong.” The surveyor observed the GNA later return to the room and turn the sign around to indicate no PPE requirement. Subsequent interviews revealed that therapy staff relied on posted signage to determine PPE use and that if the sign was wrong, the PPE used would be wrong. Overall, surveyors found problems with signage accuracy and staff awareness of which residents required contact precautions, as well as observed failures to follow appropriate PPE use for residents who should have been on contact precautions.
Inaccurate MDS Coding for Falls, Pain Management, and High-Risk Medications
Penalty
Summary
Facility staff failed to ensure Minimum Data Set (MDS) assessments were accurately coded for two residents reviewed during a complaint survey. For one resident, a facility-reported incident showed that the resident was found seated on the floor beside the bed and was diagnosed with a non-displaced femoral neck impaction fracture of the left hip following an x-ray. Despite this fall with a major injury, the subsequent significant change MDS dated 11/4/25 did not code the fall with major injury in Section J1900C. Review of the resident’s Medication Administration Records for October and November 2025 showed administration of Tylenol on 10/31/25 at 9:30 PM, which fell within the 5-day look-back period for the MDS, but Section J0100 (prn pain) of the same significant change MDS did not capture the use of Tylenol. For another resident, review of a quarterly MDS with an assessment reference date of 10/15/25 showed that Section N0415 (High-Risk Drug Classes) documented the use of an opioid medication. However, review of the resident’s October 2025 Medication Administration Record did not show that the resident had been prescribed an opioid during that period. In both cases, MDS staff later confirmed that these were errors in MDS coding, demonstrating that the assessments did not accurately reflect the residents’ clinical status and medication use as documented in their medical records.
Incomplete Documentation of Narcotic Administration on MAR
Penalty
Summary
The facility failed to maintain complete and accurate medical records in accordance with accepted professional standards for one resident receiving narcotic medication. The resident, admitted in March 2026, had a fall on 3/6/26 and was sent to the hospital on 3/9/26. Review of the March 2026 Medication Administration Record (MAR) showed documentation of a single 25 mg dose of Tramadol administered on 3/8/26 at 9:23 AM. However, review of the resident’s Controlled Drug Receipt/Record/Disposition Form, kept on the nurse’s medication cart and not in the medical record, showed that Tramadol 25 mg was administered three times between 3/8/26 and 3/9/26: at 11:00 AM and 9:00 PM on 3/8/26, and at 9:00 AM on 3/9/26. In interview, the DON stated that staff are expected to document narcotic administration on the MAR and confirmed that only one of the three Tramadol doses reflected on the controlled drug record was documented on the resident’s MAR. This discrepancy between the controlled substance record and the MAR, with missing documentation of two administered doses of Tramadol on the official medical record, constituted the failure to maintain a complete and accurate medical record for the resident.
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