Below average — CMS composite of the measures below.
The next survey window likely opens around June 2027
Estimate from public CMS data, current as of October 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Autumn Lake Healthcare At Overlea during CMS and state inspections, most recent first.
A facility failed to maintain a safe and functional environment when a resident room window had a large cracked pane with a glass chip visible and a smoking porch had pooled water, active ceiling dripping, and multiple floor cracks exposing concrete. The porch was being used by about 11 residents, most of whom were wheelchair bound or used walkers, and it also served as a common area for fresh air and socializing.
Missing Resident Rights Training Documentation: Review of 6 staff records found no documented Resident Rights training, even though other required trainings such as abuse, dementia, infection control, and QAPI were present. The packets later provided were inconsistent and unclear, with one sign-in sheet focused on language in care areas and another packet lacking a defined topic, trainer, or clear documentation of Resident Rights education.
Delayed Identification of Authorized Health Care Decision Makers: Two residents with dementia were identified as lacking decision-making capacity at admission, but their records did not clearly identify who was authorized to make health care decisions. The chart listed family contacts, and surrogate decision maker affidavits were not completed until nearly two years after admission.
A resident with cognitive impairment lacked decision-making capacity, and the resident’s surrogate decision maker was identified in the record. The resident’s Seroquel dose was increased, but the chart did not show documented informed consent from the surrogate for the higher dose. When the surveyor reviewed the issue with the DON, the DON said she could not locate documentation of consent.
Facility staff failed to verify whether existing advance directives were in place for residents who lacked decision-making capacity at admission. Surveyors found missing copies and no documented attempts to obtain advance directives or contact family members for several residents with dementia or Alzheimer's disease, despite records noting that advance directives were already in place or that the residents could not participate in screening.
Unsafe and Poorly Maintained Resident Environment: Surveyors observed a resident bedside table with a large tear in the veneer and a dark area that appeared to be mold, a wall clock showing the wrong time because it needed batteries, and a ceiling heater/vent opening at the nursing station without an attached cover or panel. These conditions reflected a failure to maintain a safe, clean, comfortable, and homelike environment.
The facility inaccurately coded an MDS for a resident with a PEG tube, therapeutic enteral diet, and IV hydration, omitting therapeutic diet and marking IV access as no despite documented IV therapy. The facility also coded another resident’s admission MDS as having no dental issues even though the resident had cracked teeth, remaining root tips, and a dental consult recommending extraction. The RN MDS Coordinator acknowledged the coding errors, and the DON said she would investigate the dental concern.
Staff failed to maintain complete care plans for multiple residents. One resident with dementia, depression, mood disturbance, and anxiety had no active Activities care plan in the record, another resident on Eliquis had no anticoagulation care plan or monitoring plan, and a third resident with severe dental issues had a dental care plan and later dental extraction order but no documented evidence of care coordination or follow-up attempts.
Care Plan Not Updated After Diuretic Therapy Was Discontinued: A resident’s comprehensive care plan continued to list diuretic therapy for edema even after Lasix/Furosemide had been discontinued and no active order remained. The MAR showed the last dose was given on the day the medication was stopped, but the care plan was not revised to reflect the change.
A resident was observed receiving oxygen while in no distress, but record review showed there was no current physician order for the oxygen. The care plan directed oxygen therapy as ordered by the physician, and the LNM confirmed the resident had been on oxygen since admission without an order. Facility policy stated oxygen is to be administered under a physician order except in an emergency.
Failure to apply an ordered hand splint: A resident with hemiplegia/hemiparesis and a right-hand contracture was observed twice without the prescribed resting hand splint, despite a TAR entry indicating it was in place. The splint was later found hanging on the wall in a bag, and the UM and DON confirmed concern that it had been signed for without being applied.
Failure to provide nail care for two dependent residents. One resident was observed with long, jagged fingernails with black material underneath, and another resident with a known hand contracture had long fingernails curved toward the palm. Records showed both residents were dependent on staff for personal hygiene, and the same conditions were still present on re-observation. An LPN stated there was no nail care schedule, and the DON was notified.
Oxygen Safety and Signage Deficiencies: Two residents were observed receiving oxygen therapy with missing oxygen-in-use signage on their room doors. One resident also had an unsecured portable O2 tank standing on the floor at the bedside instead of being secured in a cart, stand, or bracket. Facility policy required oxygen warning signs on the room door and clear identification that oxygen was in use.
A resident’s monthly MRR identified a recommendation to consider increasing Methimazole and to monitor TSH at specified intervals, but the FNP’s response indicated acceptance with modifications while leaving the modification section blank. No progress notes or other chart documentation described the modification or the action taken in response to the pharmacist’s recommendation.
A resident receiving Eliquis via PEG tube for DVT prophylaxis did not have documented monitoring for anticoagulant side effects in the clinical record. The UM stated the facility normally documents this monitoring on the MAR or TAR but found no monitoring or care plan for anticoagulant therapy, and the DON later produced a physician order for side effect monitoring that was initiated after the surveyor’s intervention.
A resident with only two small tooth fragments remaining did not receive documented follow-up for an extraction recommended by a dental consult. After a hospitalization and return to the facility, there was no evidence that staff arranged the needed dental follow-up, and MR staff could not provide documentation of follow-up from the original consult.
A hallway handrail was missing on the Ground-TCU unit, leaving an approximately 30-inch gap in the wall between the utility room and med room across from a resident room. The surveyor observed the opening, four holes where a handrail piece appeared to have been removed, and residents who were ambulatory and using walkers and wheelchairs. The Nurse Mgr and Regional LNHA both observed the area and acknowledged that a handrail was needed in that space.
A resident with multiple comorbidities and an existing pressure area was admitted with a Braden score indicating mild risk, but facility staff documented the sacral moisture-associated skin damage without measurements or detailed wound characteristics and care planned the area to be left open to air. Subsequent Braden assessments continued to rate the resident as low risk, and care plans did not include specific q2h turning/repositioning, while CNA documentation showed numerous shifts where the resident was not turned. Later, two new pressure wounds on the coccyx and sacrum were documented without measurements or physician notification, and a wound consultant subsequently identified an unstageable full-thickness sacral pressure injury and a Stage 3 buttock wound, both present for more than five days, with no prior documentation of skin changes by the medical providers, indicating a failure to implement and communicate appropriate pressure ulcer prevention and management.
Facility staff did not ensure that handrails on the third floor were properly repaired and safe for use, as multiple handrails were found with protruding screws and nails, gaps, holes, and loose attachments. These issues were observed in several locations, including near the elevator, outside resident rooms, and between storage areas, with some handrails shaking when touched. The Administrator acknowledged the problem after it was reported by a surveyor.
Two residents with suprapubic catheters did not receive care according to specialist recommendations, including routine flushing and timely catheter changes. Documentation was lacking for both catheter flushes and exchanges over several months, and staff interviews confirmed these lapses. Communication issues with consulting providers and inaccurate information given to a resident's representative further contributed to the deficiency.
Surveyors identified that two residents with suprapubic catheters did not have complete or consistent documentation of catheter changes in their medical records, despite orders and urology consult recommendations for routine exchanges. The DON confirmed that documentation was missing for several months, and staff interviews revealed inconsistent communication and documentation practices between the facility and consulting providers.
Staff did not ensure that two shower rooms on the third floor were properly cleaned, as evidenced by persistent stains and soiling observed over two days. The rooms are used daily by residents, and cleaning was not performed as required, with staff acknowledging challenges in cleaning due to inadequate equipment.
Facility staff did not allow residents whose funds were managed by the facility to access their money outside of normal business hours, with no access available on weekends. This affected 94 residents with open accounts, as confirmed by the Business Office Manager.
Surveyors identified multiple deficiencies in food service sanitation, including failure to achieve proper dish sanitization temperatures, excessive buildup of food debris and grease on equipment, improper placement of trashcans near ice machines, unsanitary storage of beverage dispensers, and visibly soiled portable ice chest coolers and knife holders. Maintenance staff could not verify inspection or replacement of backflow prevention devices, and cleaning schedules for certain equipment were not provided.
Staff failed to label basins and urinals in shared bathrooms, leading to potential cross contamination, and did not maintain proper separation between clean and soiled linens in the laundry area due to damaged infrastructure and improper cleaning practices.
Surveyors observed that several residents did not have their call bells within reach, with some call bells found on the floor or on the opposite side of the room. A GNA confirmed the lack of accessible call bells, and the ADON stated that staff are expected to ensure call bells are always available, though they may sometimes fall and are checked during regular rounding.
Staff failed to conduct required annual performance reviews for several GNAs, as confirmed by personnel file review and staff interviews. Three employees who had been employed for over a year did not have documented yearly evaluations.
Surveyors found expired medication and multiple instances of loose, unidentified pills in medication carts and storage areas. Staff present were unable to account for the origin of the loose pills, and expired medication was confirmed during review. These findings indicate lapses in proper medication storage and labeling practices.
Surveyors observed multiple deficiencies in the facility's environment, including broken furniture, missing privacy curtains, non-functioning bathroom fixtures, and accumulation of trash under a resident's bed on repeated occasions. Staff confirmed these issues and described a maintenance reporting process involving binders and an electronic system, but the deficiencies persisted across several rooms and days.
A resident who was totally dependent for bathing did not receive scheduled showers over several weeks, as confirmed by documentation and family interviews. The resident only received bed baths and expressed discomfort and dissatisfaction, while the GNA task records showed no showers were provided during the period in question.
Two resident rooms were found to be dirty and in disrepair, with issues such as sticky floors, brown stains on bathroom walls, broken blinds, damaged ceiling tiles, and cracked flooring. Facility staff acknowledged these environmental concerns during surveyor interviews.
Staff did not create or implement care plans for dental care in two residents with poor dentition and failed to initiate an integumentary care plan for a resident receiving twice-daily skin treatments, as confirmed by record review and DON interview.
Staff failed to clarify a physician's order for a dermatologic cream, resulting in a resident with Atopic Dermatitis not receiving the prescribed treatment due to unclear instructions and the cream being unavailable. Another resident on psychotropic medication was not monitored for extrapyramidal side effects as recommended by pharmacy review, and a third resident did not receive all required iron-related lab monitoring despite provider acceptance of the pharmacist's recommendations. These deficiencies reflect failures in order clarification, treatment administration, and laboratory monitoring by nursing and pharmacy staff.
Staff did not follow up on a pharmacist's recommendation to specify the dosage for a prescribed supplement for a resident. The pharmacy review form was left unsigned, and the supplement order lacked a strength until a dose was added much later. An LPN also documented administering the supplement twice in one day, and the DON could not explain the lack of action on the recommendation.
The facility failed to document and investigate abuse allegations for four residents, with missing or incomplete investigations attributed to previous ownership. Incidents included verbal and physical abuse allegations, inappropriate touching, and incomplete documentation of alleged abuse by a GNA. The NHA was unable to locate necessary investigation files, highlighting issues with documentation during ownership transitions.
The facility failed to maintain complete and accurate medical records for several residents, including missing documentation from medical appointments, discharge details, and wound assessments. Additionally, care conferences were not documented following MDS assessments. The DON confirmed the absence of necessary documentation, indicating a failure to adhere to professional standards.
A resident was found on the floor with low oxygen saturation and required hospital transfer. Although the physician was notified and 911 was called, the resident's representative was not informed of the hospital transfer until several hours later. The facility administrator could not provide evidence of immediate notification.
The facility failed to timely report abuse allegations for two residents. In one case, a GNA allegedly abused a resident, but the report to OHCQ was delayed. In another case, a resident alleged physical abuse by a staff member, but local law enforcement was not contacted. The NHA confirmed the reporting delays and lack of evidence for police contact.
The facility failed to accurately code MDS assessments for two residents. One resident's MDS did not reflect their Hospice care status, while another resident's MDS inaccurately documented behavioral symptoms and medication use. The MDS coordinator confirmed these discrepancies during interviews.
A facility failed to revise a care plan for a resident with a history of banging their arm on the side rail, leading to skin tears. Despite placing padding on the side rail to prevent further injury, the intervention was not included in the care plan. The Director of Nursing confirmed the omission during an interview.
A facility failed to provide complete discharge documentation for a resident who was discharged to an assisted living facility. The medical record lacked a physician's discharge summary, medication instructions, and a summary for the receiving facility. Additionally, there was no nursing documentation regarding the resident's condition at discharge or the items and documentation provided to them and the receiving facility.
A resident with dementia, requiring assistance for bathing, did not receive the expected two showers per week over several months. Despite a care plan indicating the need for staff assistance, documentation showed inadequate showering frequency, with no recorded refusals by the resident. The DON confirmed the deficiency in meeting the showering schedule.
A resident with existing pressure ulcers developed new open areas on the sacrum and right buttocks, which were not assessed by the wound care physician for 24 days despite being documented by nursing staff. The delay in evaluation and treatment was confirmed by the DON, highlighting a deficiency in the care provided.
Two residents in the facility were administered Metoprolol outside of the physician-ordered parameters for blood pressure and heart rate. One resident received the medication twice when their heart rate and blood pressure were below the specified limits, while another resident was given the medication despite a low blood pressure reading. These actions were confirmed by the DON.
A resident with hydronephrosis did not receive a scheduled follow-up urology appointment due to insurance network issues, and no further attempts were made to reschedule. The resident's discharge plan included a urology follow-up and a voiding trial, neither of which were completed during their stay. The DON confirmed these findings.
Unsafe Resident Room Window and Smoking Porch Conditions
Penalty
Summary
The facility failed to maintain a safe and functional environment for residents, staff, and visitors. In Resident room G-5, which was occupied by Residents #63, #74, and #76, the surveyor observed the blinds open and a large crack in the middle window facing the parking lot. The crack extended from the top right-hand corner of the window diagonally toward the lower left side, and a chip of glass was felt in the cracked window, indicating the damage appeared to be on the inside panel of the double-pane window. The Nurse Manager, Maintenance Director, and LNHA later observed the cracked window and stated they were not aware of it before the surveyor identified it. The designated smoking porch also showed unsafe conditions during observation. The surveyor saw large areas of water pooling on the floor and water actively dripping from the ceiling, with an area of the porch carved inward and measuring about 2.5 feet long. The floor had multiple cracks throughout, exposing the concrete underneath. About 11 residents were smoking on the porch at the time, most of whom were wheelchair bound, while some used walkers. The porch was also described as a place where non-smokers routinely came out for fresh air, to socialize, or to visit with others.
Missing Resident Rights Training Documentation
Penalty
Summary
The facility failed to comply with employee training requirements related to Resident Rights for 6 of 6 staff records reviewed during the annual survey. During record review and staff interviews, the Human Resource Director stated that the employee records for the six staff members were with the Nursing Home Administrator. When the records were provided, they included training for Abuse, Dementia, Infection Control, and QAPI, but no employee training for Resident Rights was documented. The Nursing Home Administrator later provided a Resident Rights packet dated 3/17/2026, but the attached in-service sign-in sheet was titled "Be mindful of the conversations and language used in patient care areas and hallways," rather than Resident Rights. A second Resident Rights packet was then provided, but it lacked a defined topic; one page was dated 11/3/2025 and the other was undated, and neither page identified the trainer or the topic. A review of the facility assessment showed that Resident Rights and facility responsibilities were listed as a primary education requirement, but no additional documentation of Resident Rights training was provided by the time of exit.
Delayed Identification of Authorized Health Care Decision Makers
Penalty
Summary
Facility staff failed to timely identify a surrogate decision maker authorized to exercise the rights of residents who lacked decision-making capacity. Resident #114 was admitted in June 2024 with multiple diagnoses including dementia and was identified at admission as lacking decision-making capacity, but the record only identified the resident's children as points of contact and did not indicate who was responsible for making health care decisions. Resident #13 was admitted in February 2024 with multiple diagnoses including dementia and was also identified at admission as lacking decision-making capacity, but the record listed the resident's child and two other family members as points of contact without identifying who was authorized to make health care decisions. During the survey, the Director of Social Services stated that advance directives are reviewed with the resident or representative upon admission and that, for residents lacking decision-making capacity, the family is contacted to determine whether an advance directive exists. If none is in place, the family is informed that a surrogate decision maker affidavit must be completed. The surveyor informed the Director of Social Services that the records for Resident #13 and Resident #114 did not clearly identify the family member authorized to make health care decisions, and later received surrogate decision maker affidavits showing that Resident #13's family member signed in March 2026 and Resident #114's family member signed in May 2026, nearly two years after each resident was admitted.
Missing Consent for Increased Psychotropic Medication Dose
Penalty
Summary
Facility staff failed to ensure consent for a psychotropic medication was obtained and maintained in the resident’s medical record for one resident reviewed for psychotropic medications. The resident’s family member was identified as the surrogate decision maker in January 2026, and in April 2026 two physicians certified that the resident lacked decision-making capacity due to cognitive impairment. In May 2026, the resident’s dose of Seroquel (Quetiapine) was increased, but the record did not contain documented evidence that the surrogate decision maker provided informed consent for the increased dosage. When the surveyor raised the concern with the DON and regional staff, the DON reviewed the record and stated she was unable to locate documentation showing that the surrogate decision maker had provided informed consent for the increased psychotropic medication dosage.
Failure to Verify Existing Advance Directives at Admission
Penalty
Summary
Facility staff failed to verify whether existing advance directives were in place at admission for residents who lacked decision-making capacity. During the annual survey, this deficient practice was identified for 4 of 6 residents reviewed for advance directives, including residents admitted with diagnoses such as dementia and Alzheimer's disease and documented as lacking decision-making capacity at the time of admission. For two residents, the medical record contained documentation that an advance directive was currently in place, but the records did not include a copy of the directive or evidence that staff attempted to obtain it. For another resident, the record showed no advance directive document and left the remaining screening questions blank, with no evidence that staff attempted to determine whether an advance directive existed. For a fourth resident, the advance directive screening indicated the resident was unable to participate, and the record did not show that staff attempted to determine whether the resident had an existing advance directive. The Director of Social Services stated that staff normally review advance directives on admission and contact family members for residents lacking capacity, but documented evidence of those attempts was not found for the residents reviewed.
Unsafe and Poorly Maintained Resident Environment
Penalty
Summary
The facility failed to maintain a safe, clean, comfortable, and homelike environment as observed during the annual recertification survey. In Resident #146’s room, the three-drawer bedside table had a large tear in the top veneer that was large enough for the resident’s entire hand to fit underneath. When the condition was rechecked, the torn veneer had fallen behind the nightstand and a large dark area that appeared to be mold was visible on top of the table. An LPN then removed the loose piece of veneer from the area. In another resident room, a clock above the sink in room G-7 was observed showing the wrong time, and the resident stated that the clock needed batteries. On the Ground-TCU nursing unit, the surveyor also observed a ceiling vent at the nursing station without an attached cover or panel, leaving an opening visible in the ceiling. The Regional LNHA later stated that the item was not a vent but a heater in the ceiling and that a cover that fit the heater could not be located.
Inaccurate MDS Coding for Nutritional, IV, and Dental Status
Penalty
Summary
The facility failed to accurately code Minimum Data Set (MDS) assessments for one resident with a PEG tube, therapeutic enteral diet, and IV hydration. On the 3/10/2026 annual MDS, Section K was coded for IV feeding and feeding tube while the resident had a PEG tube, but therapeutic diet was not coded, and Section O was coded as no for IV access even though the resident received IV therapy for hydration during the assessment period. The resident’s record also showed a comprehensive care plan addressing IV hydration and PEG tube use. A review of the resident’s prior 6/12/2026 quarterly MDS showed Section K coded yes for feeding tube and therapeutic diet, which contrasted with the annual assessment. During interviews, the RN MDS Coordinator acknowledged the inaccurate coding and stated the assessment would be reviewed with the Regional MDS Director. The record later showed a modification/correction was initiated and completed for the annual MDS to change Section K to include therapeutic diet and Section O to indicate IV access. The facility also failed to accurately code a resident’s dental status on the admission MDS. The resident stated they had remaining teeth that were supposed to be removed and had not had follow-up after returning from a hospitalization, and the surveyor observed only two small tooth fragments remaining in the mouth. The resident’s record included a dental care plan for cracked teeth and an August 2025 dental consult recommending extraction of the remaining root tips, yet the 10/22/2025 admission MDS documented the resident as being admitted without dental issues. The MDS Coordinator stated the resident did not report dental pain or discomfort at admission and said an oral exam was performed only if the resident allowed it.
Incomplete Care Plans and Missing Care Coordination Documentation
Penalty
Summary
Facility staff failed to develop and maintain comprehensive care plans for multiple residents. For a resident with dementia, major depressive disorder, mood disturbance, and anxiety, the clinical record showed a Quarterly Activity Review that referenced an existing Activities care plan and stated the goals, interventions, and approaches were effective, but the record did not contain an active Activities care plan. The Activities Director reviewed the record and stated she could not find an Activities Care Plan, and the DON later produced a copy that listed the goals and interventions as resolved, with no date on the document. For another resident receiving Eliquis for anticoagulation therapy, the record confirmed an active physician order and medication administration, but there was no care plan addressing the risks and interventions associated with anticoagulant therapy. A Unit Manager reviewed the record and stated there was no monitoring or care plan for anticoagulant therapy. For a third resident with cracked teeth and only two small tooth fragments remaining, the record showed a dental care plan directing staff to coordinate and arrange dental care, including transportation as needed, and a later dental order for preoperative labs and extraction of remaining root tips under general anesthesia, but the record did not show evidence of dental care coordination or documented follow-up attempts from the time of the order through the survey period.
Care Plan Not Updated After Diuretic Therapy Was Discontinued
Penalty
Summary
The facility failed to update and revise a comprehensive care plan for a resident whose diuretic therapy had been discontinued. Resident #30 was admitted to the facility and had a care plan addressing diuretic therapy related to edema, with the plan initiated on 9/24/2025 and a target date of 4/8/2026. Review of the resident’s physician orders showed no active diuretic order, and the discontinued orders showed that Lasix/Furosemide was stopped on 10/1/2025. The MARs for September and October 2025 showed the resident received Lasix/Furosemide, with the last dose given on 10/1/2025. The comprehensive care plan still listed the resident as being on diuretic therapy even though the medication had been discontinued. During interview, the DON was informed that the resident was no longer receiving Lasix/Furosemide and that the care plan had not been revised to reflect the discontinuation. The DON acknowledged the concern, and later provided copies of the orders, MARs, and care plan confirming the resident was no longer receiving the medication.
Oxygen Therapy Provided Without a Physician Order
Penalty
Summary
Services provided by the nursing facility did not meet professional standards of care for oxygen administration for one resident. Resident #10 was observed in bed and in no distress while receiving oxygen therapy on two separate occasions. During record review, the resident did not have a current physician order for oxygen use, even though the comprehensive care plan included an intervention to give oxygen therapy as ordered by the physician, with the intervention initiated on 5/15/2026. During interview, the Nurse Manager confirmed that the resident had been on oxygen since admission and that there was no physician order for oxygen therapy. The resident had been admitted to the facility on [DATE]. The facility policy reviewed by the surveyor stated that oxygen is administered under a physician's order, except in an emergency, and that orders are obtained as soon as practicable when the situation is under control.
Failure to Apply Ordered Hand Splint
Penalty
Summary
The facility failed to apply a physician-ordered resting hand splint to a resident with diagnoses of hemiplegia and hemiparesis following cerebral infarction affecting the right dominant side and contracture of the right hand. During the initial tour, the resident was observed sitting in a wheelchair watching TV with the right hand visibly contracted and the fingers curved toward the palm, and the resident was not wearing the hand splint. The resident’s record included an order for the right hand and wrist resting splint to be worn at least 8 hours daily, after AM care and before PM care, with instructions to notify OT if skin breakdown was observed. On a later observation, the resident was again seen watching TV without the splint, even though the TAR had been signed indicating the splint was applied and in place. The Unit Manager reviewed the TAR and observed that the splint was not on the resident’s hand but was hanging on the wall in a transparent bag, and the DON stated that signing for the splint without putting it on was a problem.
Failure to Provide Nail Care for Dependent Residents
Penalty
Summary
The facility failed to ensure that dependent residents’ grooming needs were met for two residents who were dependent on staff for personal hygiene. Resident #11 was observed lying in bed with fingernails that were long, jagged, and had black material underneath. Resident #43, who had a known contracture to the right hand, was observed sitting in a wheelchair with fingernails on the right hand that were long and curved toward the palm. Clinical record review confirmed both residents were dependent on staff for personal hygiene, and when the surveyor re-observed them two days later, their fingernails remained in the same condition. The Unit Manager stated there was no nail care schedule and that GNA staff were expected to provide nail care on shower days and as needed, and the DON was notified of the findings.
Oxygen Safety and Signage Deficiencies
Penalty
Summary
Facility staff failed to follow professional standards of practice for oxygen administration and oxygen safety for 2 residents reviewed for respiratory care and services. Resident #10 was observed lying in bed in no distress with oxygen therapy in use. At that time, an oxygen concentrator was at the bedside and a portable emergency oxygen tank was standing on the floor at the head of the bed without being secured in a cart, stand, or bracket. The surveyor notified the Nurse Manager, who observed the unsecured tank and removed it from the room, stating that it should have been in a stand. There was also no oxygen-in-use sign on the resident’s room door. Resident #99 was observed sitting in bed in no distress with oxygen therapy in use through an oxygen concentrator, and there was no oxygen-in-use sign on the room door. Review of the facility’s Oxygen Safety and Oxygen Administration policy showed that no smoking signs are to clearly identify oxygen is in use before connecting the oxygen supply and remain in place until oxygen administration has been discontinued, and that oxygen warning signs must be placed on the resident room door where oxygen is in use. The LNHA and Regional LNHA were notified of the concerns with oxygen storage and administration.
Failure to Document Medication Regimen Review Response
Penalty
Summary
The facility failed to document the action taken to address a medication regimen review irregularity for Resident #5. A monthly medication regimen review was completed in June 2026, and the pharmacist’s note stated, “see report for comments and recommendations.” The June 2026 MRR report included a recommendation to consider increasing the resident’s Methimazole dose and to monitor the thyroid stimulating hormone level in six weeks and every 6 months thereafter or as clinically indicated. The Family Nurse Practitioner’s response on the report stated, “I accept the recommendation above with the following modifications,” but the section for documenting the modification was left blank. Review of the resident’s medical record found no progress notes or other documentation describing the modifications or actions taken in response to the recommendation. The DON stated she would investigate further, and later reported that the FNP had failed to document the rationale for the modification on the MRR form and in the resident’s medical record.
Lack of Side Effects Monitoring for Anticoagulant Therapy
Penalty
Summary
The facility failed to provide adequate side effects monitoring for a resident receiving anticoagulant therapy. Resident #11 was receiving Eliquis 5 mg via PEG tube twice daily for DVT prophylaxis, with the medication ordered on 12/03/25. Review of the clinical record did not reveal a process for monitoring side effects associated with anticoagulant therapy. During interview, the Unit Manager stated that the facility’s practice was to monitor residents for side effects and document the monitoring on the MAR or TAR, but after reviewing the record she stated that she did not see any monitoring or care plans for anticoagulant therapy and said, "I will take care of it." The DON later provided a physician order for monitoring of side effects dated 07/02/26 at 1:39 PM, which was initiated after the surveyor’s intervention.
Delayed Dental Follow-Up for Remaining Root Tips
Penalty
Summary
Facility staff failed to assist a resident in arranging timely follow-up dental care after an August 2025 dental consult recommended extraction of remaining root tips. Resident #5 stated that they had been scheduled to have the remaining teeth removed but were hospitalized for a month, and since returning to the facility in October 2025 there had been no follow-up on the extraction. During the surveyor’s observation, the resident had only two small tooth fragments remaining. A review of the medical record on 06/30/26 found no documented evidence of follow-up after the dental consult. The DON stated that after dental appointments, follow-up instructions are given to medical records staff to arrange further appointments, and MR staff later presented an email dated 05/05/2026 related to follow-up for the extraction, but could not provide documented evidence of follow-up from the August 2025 consult.
Missing Hallway Handrail on Ground-TCU Unit
Penalty
Summary
A handrail was missing from the wall on the Ground-TCU Nursing Unit, creating a 30-inch gap between the utility room and the medication room across from Resident room G-9. During the annual recertification survey, the surveyor observed the gap and four holes in the wall where a handrail piece appeared to have been removed. Residents on the unit were observed to be ambulatory and using walkers and wheelchairs, and the unit census was 15 residents with a capacity of 17. The surveyor notified the Nurse Manager, who observed the missing handrail area and stated she would notify Maintenance. Environmental Services staff in the hall stated that there used to be a water fountain in that space. The Regional LNHA later observed the gap and the four holes and stated that a water fountain had been removed from the wall and that a handrail needed to be installed in that space. The LNHA also provided an email requesting a replacement handrail.
Failure to Implement Pressure Ulcer Prevention and Timely Wound Management
Penalty
Summary
The deficiency involves the facility’s failure to implement appropriate pressure ulcer prevention and management for a resident who was admitted with multiple serious medical conditions and an existing pressure area. The resident was admitted from the hospital with septic shock, UTI, severe cognitive-communication deficits, diabetes, anorectal cancer with prior radiation and chemotherapy, an indwelling Foley catheter, and a gluteal cleft/coccyx pressure area being treated with Santyl. The hospital documented a Braden score of 15 (mild risk). On admission, the facility physician determined the resident could understand medical information and make decisions, and the BIMS score was 12/15, indicating moderate cognitive impairment. The facility’s pressure injury policy required a systematic approach including prompt assessment, treatment, and modification of interventions as appropriate. On admission, nursing notes documented the resident as cognitively impaired, requiring two-person assistance for transfers and toileting, and having an indwelling Foley catheter. That same night, nursing staff identified an open area on the sacral region attributed to moisture-associated skin damage (MASD), but there were no documented measurements, nor any description of odor, drainage, or wound depth. The baseline care plan intervention for this sacral MASD was to leave the area open to air, and subsequent Braden assessments on three dates in November classified the resident as low risk for pressure injury, despite the existing skin breakdown and functional limitations. The care plans and nursing interventions did not include specific preventative measures such as scheduled turning and repositioning every two hours. Later in November, weekly skin evaluations documented two new pressure wounds on the coccyx and sacrum, but again without measurements or documentation of odor, drainage, or depth, and without evidence that the physician was notified at the time of discovery. A Braden assessment on the same date showed a score of 10, indicating high risk for pressure wound development. The wound consultant’s assessment the following day identified an unstageable full-thickness sacral pressure wound measuring 6 cm by 3 cm with unknown depth and moderate serous drainage, and a Stage 3 full-thickness pressure wound on the left buttock, both described as being greater than five days in duration. Review of physician and nurse practitioner notes showed no documentation of skin changes during this period, and both the nurse practitioner and attending physician reported they had not been alerted to skin issues in November. CNA documentation showed that on multiple shifts over a 20–21 day period, staff recorded that the resident was not turned and repositioned, with numerous day, evening, and night shifts indicating “no” for turning and repositioning, demonstrating a lack of consistent implementation of pressure-relief interventions.
Handrails Not Properly Secured and Maintained on Third Floor
Penalty
Summary
Facility staff failed to ensure that handrails on the third floor were properly repaired and safe for resident use. Multiple handrails were observed with screws and nails that were not flush with the surface, creating a potential for injury to residents' hands. Specific observations included handrails with protruding screws, a gap near the elevator, a nail sticking out, a hole in the handrail, and several areas where the handrails were loose or not secured to the wall. The handrail between the Storage Room and EVS Room was noted to shake with minimal pressure, and the handrail near the Central Supply Room was also loose with an unflushed screw. These deficiencies were widespread on the third floor and were confirmed through both observation and staff interview. The Administrator acknowledged the issue when informed by the surveyor, stating that attempts were being made to secure the handrails with screws, but the surveyor pointed out that the screws were not flush and posed a risk of injury.
Failure to Provide Proper Suprapubic Catheter Care and Documentation
Penalty
Summary
The facility failed to provide proper care and treatment for residents with suprapubic catheters, as evidenced by the lack of adherence to physician and specialist recommendations for catheter flushing and routine catheter changes. For one resident with a history of benign prostatic hyperplasia and urinary retention, medical records showed that urology and pelvic medicine specialists repeatedly recommended flushing the suprapubic catheter twice daily and exchanging the catheter every 4-6 weeks. However, documentation revealed significant lapses, including no record of catheter changes for several months and a prolonged period without ordered or documented flushes following a hospitalization. The care plan also indicated a need for monthly catheter changes, but there was no evidence these were performed as required. Interviews with the DON confirmed that there was no documentation of catheter flushes or changes during the specified periods, and that communication issues with multiple consulting providers contributed to the lack of consistent care. The DON acknowledged that catheter changes were expected to be performed by facility staff unless otherwise specified by the consulting provider, but could not provide records to support that these tasks were completed. The consulting provider also clarified that unless specifically documented, catheter changes were not performed by their team and were the responsibility of the facility per the resident's care plan. A second resident with a history of obstructive and reflux uropathy and overactive bladder also did not receive routine suprapubic catheter changes as ordered. The resident's medical record showed an order for catheter changes every four weeks, but this was discontinued and changed to 'as needed,' with no documentation of changes for several months. Urology consultation notes continued to recommend routine exchanges every 4-6 weeks, but there was no evidence these were carried out. Staff communication with the resident's representative incorrectly indicated that monthly changes were being performed by urology staff, despite a lack of supporting documentation.
Failure to Maintain Complete Medical Records for Suprapubic Catheter Care
Penalty
Summary
The facility failed to maintain complete and accurate medical records in accordance with accepted professional standards for two residents with suprapubic catheters (SPC). For one resident with a history of benign prostatic hyperplasia and urinary retention, the facility was unable to provide medical health information to the hospital emergency room staff upon transfer. Review of the resident's records showed inconsistent documentation of SPC changes, with the last recorded change in December, and no documentation of changes from January through May, despite care plan and urology consult recommendations for routine exchanges every 4-6 weeks. The Director of Nursing (DON) confirmed that there was no documentation available to support that the SPC was changed during this period and indicated that different urology providers had varying communication methods, which contributed to the lack of documentation. For another resident with obstructive and reflux uropathy and an overactive bladder, the facility's records also lacked documentation of SPC changes as ordered. The resident had an order for SPC changes every four weeks, which was later changed to 'as needed.' However, there was no documentation in the Treatment Administration Records (TARs) of any SPC changes from January through July, despite ongoing urology consult notes recommending routine exchanges every 4-6 weeks. The DON was unable to provide documentation to confirm that the SPC was changed as recommended during this time frame. Interviews with facility staff and urology consultants revealed that while providers may have performed SPC changes during consultation visits, these were not consistently documented in the residents' medical records. The lack of documentation meant that the facility could not demonstrate compliance with physician orders or care plan interventions regarding SPC management for the affected residents.
Failure to Maintain Cleanliness in Shower Rooms
Penalty
Summary
Facility staff failed to ensure that the third-floor shower rooms were cleaned for resident use, as evidenced by observations and interviews during a complaint survey. On two consecutive days, surveyors observed large stains under the sink, water and stains around the commode in one shower room, and multiple round brown stains on the floor in front of the sink and in the shower stall of another shower room. The stains remained present on the second day, and a surveyor was able to remove one of the brown spots with a wet paper towel, indicating the area had not been properly cleaned. Geriatric Nursing Assistant (GNA) stated that the shower rooms are used daily by residents, and the Environmental Services (EVS) Director confirmed that showers should be cleaned daily, with deep cleaning on weekends, but noted difficulties in cleaning due to the condition of mop heads.
Residents Denied Access to Managed Funds Outside Business Hours
Penalty
Summary
Facility staff failed to ensure that residents whose funds were managed by the facility had access to their money at any time. During an interview, the Business Office Manager stated that residents could only access their funds during normal business hours, which are 8:30 AM to 5:00 PM, Monday through Friday, and that no one could access funds on weekends. Prior to the COVID-19 pandemic, the Receptionist would provide residents with money, including on weekends if present, but this practice had ceased. At the time of the survey, there were 94 open resident accounts with balances being managed by the facility, and none of these residents could access their funds outside of business hours.
Multiple Food Service Sanitation and Equipment Deficiencies Identified
Penalty
Summary
Facility staff failed to ensure that the high temperature dishwasher reached the required final rinse temperature of 180°F for proper sanitization, as observed during multiple cycles where temperatures only reached 162°F and 163°F. The dishwasher was also found to have excessive food debris and grease buildup both inside and outside the unit. Additionally, clean dish warming carts were observed to be visibly soiled, and the 3-compartment sink's sanitizing solution was found to be too strong, exceeding 400 ppm. The grease trap interceptor was unable to handle the flowrate of greywater discharge, resulting in overflow onto the kitchen floor. A trashcan was placed less than five inches from the ice machine and in front of a cracked wall-mounted ice scoop holder, and a beverage dispenser was stored in unsanitary conditions near a food prep area. The maintenance director was unable to verify that backflow prevention devices on various waterlines had been replaced or inspected by a licensed plumber. Surveyors also observed a visibly soiled, broken non-commercial portable ice chest cooler used for resident ice storage, placed on an unclean rolling cart, and noted that cleaning schedules for this equipment were not provided. Excessive buildup of dirt, dust, debris, and food spills was found on a wall-mounted knife holder. These findings were evident for all food service and kitchen equipment observed during the survey, indicating a failure to store, prepare, distribute, and serve food in accordance with professional standards for food service safety procedures.
Failure to Prevent Cross Contamination in Shared Bathrooms and Laundry Areas
Penalty
Summary
Facility staff failed to properly label residents' basins and urinals in shared bathrooms on the second floor, resulting in the potential for cross contamination of bodily fluids. During observation rounds, multiple unlabeled basins and a urinal were found in shared bathrooms between resident rooms. When questioned, a Geriatric Nursing Assistant stated that staff typically write room numbers on basins to identify ownership, but this was not done at the time of observation. The Assistant Director of Nursing/Infection Preventionist acknowledged the issue and indicated that it had been previously addressed with staff. Additionally, the facility did not ensure that clean linens were kept separate from contaminated linens in the laundry area. The dividing wall between the dirty and clean laundry rooms was damaged, with exposed wall frames and a gap caused by water damage. Grey water was observed splashing onto the drywall, saturating it and extending moisture to the ceiling. The washing machine drain line was improperly supported, and the washing machines themselves had significant residue buildup on both interior and exterior surfaces. Staff acknowledged the accumulation and the need for cleaning.
Failure to Ensure Call Bells Accessible to Residents
Penalty
Summary
Facility staff failed to ensure that residents had their call bells within reach to notify staff when assistance was needed. During observation rounds, five residents were found without accessible call bells: some had their call bells on the floor, while others had them placed out of reach on the opposite side of the room. These findings were confirmed by a Geriatric Nursing Assistant present during the observations. The Assistant Director of Nursing acknowledged that all residents should have their call bells accessible at all times, but noted that call bells can occasionally fall and that staff are expected to check on residents and their call bells during regular two-hour rounding.
Failure to Complete Annual Performance Reviews for GNAs
Penalty
Summary
Facility staff failed to conduct yearly performance reviews for Geriatric Nursing Assistants (GNAs) as required. During a review of five nursing assistant personnel files, it was found that three employees who had been employed for over a year did not have annual performance evaluations documented in their files. Interviews with the Assistant Director of Nursing, who was responsible for staff development, and the Nursing Home Administrator confirmed that annual evaluations for GNAs were not being completed. These findings were based on direct review of personnel files and staff interviews, with no evidence provided that the required yearly performance reviews had been performed for the identified staff members.
Medication Storage and Labeling Deficiencies Identified
Penalty
Summary
Surveyors identified that the facility failed to comply with professional standards for medication storage and labeling. On the 2nd floor, a blister pack of Famotidine 20 mg tablets was found to be expired, and this was confirmed by the LPN present. Additionally, on the 3rd floor, 11 loose pills were discovered in a medication cart, with the RN unable to specify their origin, only stating that they might have fallen out of packets. On the ground floor, 4 loose pills were also found in a medication cart, and the LPN present could not determine their source. In both instances of loose pills, staff indicated that such findings would be reported to the unit manager. These observations were made during reviews of medication storage areas and carts, and the deficiencies were confirmed through staff interviews and direct observation. No information about the medical history or condition of any residents was provided in the report.
Failure to Maintain Clean, Comfortable, and Home-like Environment
Penalty
Summary
Facility staff failed to consistently maintain a clean, comfortable, and home-like environment for residents, as evidenced by multiple observations during a recertification survey. Specific deficiencies included a clothing armoire door hanging off in a resident room, accumulation of trash such as empty bottles, snack packs, and tissues under a resident's bed on multiple days, a broken toilet paper dispenser, and a non-functioning light bulb in a shared bathroom. Additional issues noted were the absence of privacy curtains in a resident room, a loose faucet that could not be turned off, a missing drawer in a resident's dresser, and stains on the wall behind a commode. These conditions were confirmed by a GNA during the surveyor's rounds. Interviews with facility staff revealed that maintenance concerns are reported via binders on each unit, with urgent issues communicated directly to the Maintenance Director. However, staff do not determine what constitutes an urgent issue and simply document all concerns in the binder. The Maintenance Director stated that room audits are conducted based on identified issues, with a goal of auditing one room daily and every resident's room quarterly. Maintenance issues are addressed by the maintenance assistant, and staff use both binders and an electronic system (TELS) to report problems. Despite these processes, the observed deficiencies indicate lapses in maintaining a safe and comfortable environment.
Failure to Provide Scheduled Showers to Dependent Resident
Penalty
Summary
Facility staff failed to provide adequate personal hygiene care to a dependent resident by not offering or providing scheduled showers. The resident, who is totally dependent for bathing and requires extensive assistance for all activities of daily living as documented in the Minimum Data Set (MDS), did not receive any showers between 3/25/2025 and 4/18/2025, despite being scheduled for showers every Tuesday and Friday. This was confirmed through review of the Geriatric Nursing Assistant (GNA) task documentation on the Task Administration Record (TAR), which showed no showers were documented during this period. Interviews with the resident's family revealed that the resident expressed dissatisfaction with only receiving bed baths and desired a shower. The resident's son reported that the resident's spouse, who is physically unable to assist with showers, provided a sponge bath instead, during which the water and washcloth became black with dirt. The resident also reported feeling itchy due to lack of proper washing. The Director of Nursing (DON) confirmed the absence of shower documentation for the resident during the specified timeframe.
Failure to Maintain Clean and Homelike Resident Rooms
Penalty
Summary
Surveyors observed that two out of eleven ground floor rooms reviewed were not maintained in a clean, comfortable, and homelike condition. Specifically, one room was found to have a dirty and sticky floor, brown stains smeared on the bathroom wall, broken window blinds, ceiling tiles coming apart, a toilet pipe not fixed in the wall with surrounding wall cracks, and a cracked and broken floor at the bathroom entry. These environmental deficiencies were confirmed during interviews and observations with the Administrator, Maintenance Director, and Account Manager of the Healthcare Services Group, who acknowledged the concerns raised by the surveyors. No information was provided regarding the medical history or condition of the residents occupying the affected rooms at the time of the deficiency.
Failure to Develop and Implement Care Plans for Dental and Integumentary Needs
Penalty
Summary
Facility staff failed to develop and implement individualized care plans addressing dental and integumentary needs for three out of five residents reviewed during the recertification survey. Specifically, two residents with poor dentition did not have care plans for dental care documented in their electronic medical records, and another resident receiving physician-ordered skin treatments twice daily did not have an integumentary care plan initiated. These omissions were confirmed through medical record reviews and an interview with the DON, who acknowledged that care plans should have been in place for each of the affected residents.
Failure to Clarify Orders, Provide Treatments, and Complete Monitoring
Penalty
Summary
Facility staff failed to clarify a physician's order for a dermatologic cream for a resident diagnosed with Atopic Dermatitis, resulting in unclear instructions regarding the application site. During observations, the prescribed cream was not available on the treatment or medication carts, and staff were unable to locate it. The resident's skin was observed to be extremely dry and scaly, with ashen arms and a dry face, indicating the treatment was not administered as ordered. The lack of clarity in the order and failure to reorder the cream contributed to the resident not receiving the prescribed therapeutic treatment. Additionally, staff did not monitor a resident prescribed psychotropic medication for extrapyramidal side effects (EPS), despite a pharmacy recommendation to do so. There was no documentation of EPS monitoring in the medication administration records for several months. In another case, a pharmacist recommended specific laboratory monitoring for a resident on iron supplementation, which was accepted by the provider. However, the required iron-related labs (ferritin, TIBC, TSAT) were not ordered, and only a CBC, CMP, and lipid panel were completed. These failures demonstrate lapses in following through on medication regimen review recommendations and ensuring appropriate monitoring and treatment according to physician orders.
Failure to Act on Pharmacy Recommendation for Supplement Dosage
Penalty
Summary
Facility staff failed to act upon a pharmacist's recommendation to specify the dosage for a prescribed supplement, Cyanocobalamin, for one resident. The pharmacist's recommendation, dated 02/19/25, was not addressed by nursing staff, and the pharmacy review form remained unsigned. The process described by the DON involved receiving recommendations via email, printing and forwarding them to physicians, and then checking for new orders before filing the signed form, but this process was not followed in this instance. The supplement order lacked a specified strength, and a dose was not added until over two months later. Additionally, an LPN signed off that the supplement was administered twice on the same day, and the DON was unable to explain why the recommendation was not addressed.
Failure to Document and Investigate Abuse Allegations
Penalty
Summary
The facility failed to provide documentation that allegations of abuse were thoroughly investigated for four residents during a complaint survey. In the case of one resident, an allegation of verbal and physical abuse was reported by a hospital social worker, but the facility's documentation only included an initial and 5-day email confirmation without the actual investigation. The Nursing Home Administrator (NHA) could not locate the investigative file, attributing the issue to previous ownership. Another incident involved a resident alleging inappropriate touching by another resident, which led to a physical altercation. The NHA was unable to find the investigation report, again citing previous ownership as a reason. In another case, a resident alleged abuse by a geriatric nursing assistant, but the investigation was incomplete, lacking comprehensive interviews and documentation. The NHA confirmed the investigation's incompleteness and noted that he was not employed at the facility during that time. Additionally, the facility could not locate the investigation for another resident's abuse allegation, with the NHA indicating that it occurred under prior ownership. Despite reaching out to the previous administration, the investigation could not be found. These deficiencies highlight a lack of thorough documentation and investigation of abuse allegations, particularly during transitions of facility ownership.
Deficiencies in Medical Record Documentation
Penalty
Summary
The facility failed to maintain complete and accurate medical records for several residents, as evidenced by the findings during a complaint survey. For one resident, there was no documentation from a neurology appointment, despite notes indicating the resident left and returned to the facility on the day of the appointment. The Director of Nursing confirmed the absence of this documentation. Another resident's medical record lacked nursing documentation of their discharge to an assisted living facility, including details about the resident's condition, how they left, and what documentation was provided. The Nursing Home Administrator later provided a discharge summary but confirmed the absence of nursing notes regarding the discharge. A third resident had a physician's order for a CT scan of the chest, but the medical record did not contain the results or documentation explaining why the scan was not performed as scheduled. The Director of Nursing and medical records staff could not find documentation to explain the delay, although a later CT scan was documented. Additionally, a fourth resident's medical record showed inconsistencies and lack of documentation regarding the monitoring and assessment of pressure wounds. The record failed to provide clear ongoing documentation of the progress or lack of progress related to the resident's wounds. Furthermore, the facility did not document care conferences to update a resident's plan of care following MDS assessments. The Director of Nursing, who was not employed at the facility during the time of these deficiencies, confirmed the absence of documentation after reviewing the medical records. These deficiencies highlight the facility's failure to adhere to professional standards for maintaining accurate and complete medical records.
Failure to Immediately Inform Resident Representative of Hospital Transfer
Penalty
Summary
The facility staff failed to immediately inform the resident representative of a resident's transfer to the hospital. The incident involved a resident who was found lying on the floor with no apparent injuries but had an oxygen saturation level of 75%, which is below the normal range of 95%-100%. A respiratory assessment revealed diminished lung sounds and grunting-like breathing. The physician was notified and ordered oxygen administration, with instructions to send the resident to the emergency room if there was no improvement. Although the resident's oxygen saturation improved to 85%, 911 was called for ER evaluation. The progress notes did not indicate that the resident's representative was updated about the hospital transfer until 6:00 AM, several hours after the initial incident. The facility administrator could not provide additional evidence that the representative was informed immediately of the hospital transfer.
Failure to Timely Report Abuse Allegations
Penalty
Summary
The facility failed to provide timely documentation of abuse allegations to the appropriate agencies for two residents during a complaint survey. For one resident, an incident was reported where a geriatric nursing assistant allegedly abused the resident during care. The initial report to the Office of Healthcare Quality (OHCQ) was not filed within the required two-hour window, as it was submitted at 5:25 PM, despite the incident occurring early in the morning. The Nursing Home Administrator (NHA) confirmed the delay in reporting and noted that he was not employed at the facility at the time of the incident. In another case, a resident alleged that a staff member scratched, grabbed, and shoved them after requesting to be sent to the hospital. Although the facility submitted the initial and final reports to OHCQ, they failed to contact local law enforcement as required. The Administrator was unable to provide additional evidence to confirm that the police were contacted, indicating a lapse in the facility's reporting protocol.
Inaccurate MDS Assessments for Two Residents
Penalty
Summary
The facility staff failed to ensure that Minimum Data Set (MDS) assessments were accurately coded for two residents during a complaint survey. For one resident, the quarterly MDS assessment did not capture that the resident was receiving Hospice services, despite being admitted to Hospice on a previous date. This oversight was confirmed by the MDS coordinator during an interview. For another resident, there were discrepancies in the MDS coding related to behavioral symptoms and medication administration. The resident exhibited verbal aggression towards staff, which was documented in progress notes, but the MDS assessment inaccurately indicated no such behaviors. Additionally, the MDS documented the use of a hypnotic medication, but the Medication Administration Record did not reflect this. The MDS coordinator clarified that the medication Lorazepam, which the resident was receiving, was intended for anxiety, not as a hypnotic, according to the physician's order. These errors were confirmed by the MDS coordinator.
Failure to Revise Care Plan for Resident with History of Injury
Penalty
Summary
The facility staff failed to revise a resident's care plan, which was evident during a complaint survey for one of the residents. The incident involved a resident who alleged that a GNA hurt their arm. The facility's investigation revealed that the resident had a history of banging their arm on the side rail, and padding had been placed on the side rail to prevent further injury. However, the care plan did not include the intervention of padding the side rail, despite the resident's history of skin tears and behavior problems related to banging their arm on the side rails. An interview with the Director of Nursing confirmed that the padding was not added to the care plan.
Incomplete Discharge Documentation for Resident
Penalty
Summary
The facility failed to ensure a complete recapitulation of a resident's stay was conducted following their discharge. This deficiency was identified during a complaint survey for a resident who was admitted in July 2017 for physical and occupational therapy after an above-the-knee amputation. The resident was discharged to an assisted living facility, but the medical record lacked a physician's discharge summary and documentation of medications to be taken post-discharge. Additionally, there was no summary provided to the receiving facility. Further investigation revealed that the last documented note in the resident's medical record was dated after the discharge date, and there was no nursing documentation regarding the resident's condition at discharge, how they left the facility, or what items and documentation were provided to them and the receiving facility. The Director of Nursing confirmed the absence of a discharge summary, and the Nursing Home Administrator later provided a discharge summary but acknowledged the lack of nursing notes and a physician's discharge summary.
Failure to Provide Adequate Showering for a Resident with Dementia
Penalty
Summary
The facility staff failed to provide showers twice weekly to a resident diagnosed with dementia, who was admitted to the facility with a need for supervision and/or touching assistance for showering and bathing. The resident's care plan, initiated shortly after admission, specified the requirement of one staff member's participation in bathing. However, documentation revealed that the resident received no showers for the last five days of October 2023, only one shower in November 2023, two showers in December 2023, and four showers in January 2024. There was no documentation of the resident refusing showers during this period. The Director of Nursing confirmed that the resident did not receive the expected two showers per week from October 2023 until January 2024.
Failure to Timely Assess and Treat Pressure Ulcers
Penalty
Summary
The facility staff failed to provide adequate treatment and services to prevent and heal pressure ulcers for a resident. The resident was admitted with pressure ulcers on both heels and was under the care of a wound care physician who conducted weekly assessments. However, on 8/19/24, a nurse's note documented new open areas on the resident's sacrum and right buttocks. Despite notifying the doctor and receiving recommendations for treatment, the wounds were not assessed by the wound care physician until 9/12/24, 24 days after they were first noted. The delay in assessment and treatment of the sacral and right buttock wounds was confirmed by the Director of Nursing during an interview. The lack of timely evaluation and documentation of the wounds' status by the wound care physician contributed to the deficiency in care provided to the resident, as the wounds were not properly monitored or managed for nearly a month after their discovery.
Failure to Adhere to Medication Parameters for Two Residents
Penalty
Summary
The facility failed to ensure that the drug regimens for two residents were free from unnecessary drugs, as evidenced by the administration of Metoprolol outside of the physician-ordered parameters. Resident #15, who was admitted with a diagnosis of hypertension, was ordered Metoprolol 25 mg daily with instructions to hold the medication if the blood pressure was less than 110 or the heart rate was less than 60. However, the resident was administered Metoprolol on two occasions, on 4/8/24 and 4/13/24, when the heart rate and blood pressure were below the specified parameters, respectively. This was confirmed by the Director of Nursing during an interview. Similarly, Resident #6, also diagnosed with hypertension, was ordered Metoprolol 50 mg daily with the same parameters to hold the medication. On 2/16/25, the resident received Metoprolol despite having a blood pressure reading of 107/73, which was below the ordered threshold. This administration was also confirmed by the Director of Nursing. These instances indicate a failure to adhere to physician orders, resulting in the administration of medication outside of the prescribed parameters.
Failure to Schedule Follow-Up Urology Appointment
Penalty
Summary
The facility staff failed to schedule a follow-up appointment with a urology consultant for Resident #15, who was admitted with a diagnosis of hydronephrosis. The resident's hospital discharge summary indicated the need for an outpatient urology follow-up for moderate right hydronephrosis and a voiding trial, with a referral for a urology appointment already made. A nurse's note documented that a follow-up urology appointment was initially scheduled but later canceled due to out-of-network insurance issues. No further attempts were made to reschedule the appointment during the resident's stay, and there was no evidence of a voiding trial or completed follow-up with a urologist. The Director of Nursing confirmed these findings during an interview with the surveyor.
What surveyors are citing around you — mapped
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Illustrative
What surveyors actually found near you
We read the 1,287 citations issued within 25 miles in the last 12 months — including the 7 immediate-jeopardy cases — and tell you exactly what happened, in plain English, matched to your record.
Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
Walk-in cooler logs missing for 12 days; expired supplements in the medication room fridge.
Illustrative
A prioritized, do-first checklist
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Illustrative
Risk indicators are statistical estimates from public CMS data — not predictions, findings, or compliance advice.
Nursing homes near Baltimore
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Autumn Lake Healthcare Post-acute Care Center | 1.4 mi | ★★★★★ | 27 | 0 |
| Future Care Cold Spring | 1.8 mi | ★★★★★ | 0 | 0 |
| Autumn Lake Healthcare At Perring Parkway | 2.2 mi | ★★★★★ | 27 | 0 |
| Good Samaritan Nursing Home Operator, Llc | 2.5 mi | ★★★★★ | 27 | 0 |
| Rossville Rehabilitation And Healthcare Center | 2.8 mi | ★★★★★ | 33 | 1 |
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Trusted data, never guesswork. Every citation, penalty, rating and Plan of Correction on this page is sourced from public CMS records (latest release October 2026) and official state health department websites.