Autumn Lake Healthcare At Patuxent River
Inspection history, citations, penalties and survey trends for this long-term care facility in Laurel, Maryland.
- Location
- 14200 Laurel Park Drive, Laurel, Maryland 20707
- CMS Provider Number
- 215141
- Inspections on file
- 19
- Latest survey
- October 17, 2025
- Citations (last 12 mo.)
- 43
Citation history
Health deficiencies cited at Autumn Lake Healthcare At Patuxent River during CMS and state inspections, most recent first.
A resident was found without access to their call bell plunger on two occasions, with the device observed on the floor and later hanging down from the bed. The resident was unable to locate the call bell when asked, indicating staff did not ensure the resident could reach it.
A resident developed a new rash and pressure ulcer that was identified during routine skin assessments, but staff failed to notify the physician of this change. Although the resident had a history of skin issues and was receiving daily topical treatment, the new impairment was not communicated to the physician, and staff applied a non-prescribed cream without proper documentation or notification.
Surveyors identified that facility staff did not develop or implement complete care plans for two residents, failing to address one resident's repeated shower refusals and another resident's transfer assistance needs. Care plans lacked specific interventions, and documentation of care needs was inconsistent, with staff interviews revealing confusion about care instructions and transfer status.
Facility staff did not document the reason for a missed dose of Vitamin C medication for a resident with an active order for anemia treatment. When the MAR indicated to 'See Nurse Note' for the missed dose, the DON was unable to find any supporting nurse note or explanation in the medical record.
Multiple infection control deficiencies were observed, including a trach collar oxygen mask left on the floor for a resident with a tracheostomy, a used Foley catheter placed on a bedside table instead of being discarded, and staff entering rooms of residents on contact precautions without performing hand hygiene or wearing PPE. Staff interviews confirmed lapses in following infection prevention protocols and a lack of understanding of contact precaution requirements.
Multiple residents were served meals that did not match their documented preferences, with frequent omissions, substitutions, and poor food quality reported. Staff interviews revealed miscommunication, supply shortages, and repeated errors on the tray line, resulting in residents receiving unappealing or incorrect food and beverages. The NHA confirmed that meals were not visually appealing and did not match tray tickets, and residents' complaints about meal service were not consistently addressed.
Surveyors found that several residents were using wheelchairs with cracked or missing vinyl on the armrests, and some residents reported that the wheelchairs had been in poor condition for a while. Despite weekly audits by the Director of Maintenance, these issues persisted and were observed on multiple nursing units.
The facility did not report allegations of abuse, neglect, or injury of unknown origin to the regulatory agency within the required 2-hour timeframe for two residents. In one case, a resident with unexplained bruising was not promptly reported, and in another, an allegation of inappropriate touching was not reported within the mandated period. Facility leadership confirmed the delays in reporting.
The facility did not thoroughly investigate multiple abuse allegations, including incidents involving a resident being restrained by staff, a dependent resident found with facial injuries, and a report of inappropriate conduct by staff. In each case, the investigations lacked interviews with all relevant staff or other residents, resulting in incomplete documentation of the alleged events.
A resident requiring extensive ADL assistance after a lumbar fracture did not have documentation showing they were offered or refused showers on assigned days. The DON confirmed there was no record of showers being offered or refused, and only bed baths were documented for a period.
A resident with severe cognitive impairment and a history of falls did not receive neurological checks and vital sign assessments at the required intervals following two separate falls, including one with a head injury. Facility staff failed to document timely neurological evaluations and often reused previous vital signs for multiple checks, contrary to facility policy. Interviews with LPNs, the DON, and the Administrator confirmed that the required protocols for post-fall neurological assessments were not followed.
A resident with significant atherosclerosis and a documented need for routine foot care was not seen by the podiatrist as scheduled for follow-up care. Despite a podiatrist's order for at-risk foot care, facility records and staff interviews confirmed the resident did not receive the required podiatry services on the scheduled date.
A medication cart was left unlocked and unattended in a hallway, allowing access to all medications inside. An LPN and a unit manager were present during the surveyor's observation, and the facility's policy requiring locked storage of drugs and biologicals was not followed.
A resident with a tracheostomy did not attend a scheduled follow-up appointment with a head and neck surgery specialist after being seen by an ENT, as required. Facility staff did not ensure timely access to outside professional services, and this lapse was confirmed by the administrator during a complaint survey.
A resident's medical record lacked documentation of multiple podiatry visits, despite those visits having occurred. The missing records were due to confusion following a change in medical records staff, resulting in incomplete and inaccurate documentation until the issue was identified during a survey.
Failure to Ensure Resident Access to Call Bell
Penalty
Summary
Facility staff failed to ensure that a resident had access to their call bell plunger, which is necessary for alerting staff when assistance is needed. On two separate occasions, the call bell plunger was observed to be inaccessible: first, it was found on the floor on the right side of the bed, and later it was seen hanging down from the bed near the top of the right-side transition rail. When asked about the location of the call bell, the resident was unable to identify where it was. These observations were made during a complaint survey and confirmed through staff interviews.
Failure to Notify Physician of Change in Skin Condition
Penalty
Summary
The facility failed to ensure that a physician was notified of a change in a resident's skin condition. Weekly skin evaluations for the resident initially showed no issues, but a later assessment identified a rash and pressure ulcer. Despite this change, there was no documented evidence that the physician was informed. Interviews revealed that staff were aware of the skin impairment, with a GNA applying a non-prescribed cream and the nurse unaware of the issue, even though the nurse had documented the skin impairment in a prior assessment. The care plan indicated a history of periodic skin dermatitis, and the resident was on a daily topical treatment, but the new rash and pressure ulcer represented a change that was not communicated to the physician. Observations confirmed the presence of a large dry area and a small open area on the resident's skin. The GNA reported noticing the issue about a month prior and had been applying a cream not ordered for the condition. The nurse and unit manager were not aware of the current skin impairment until informed by the surveyor, and the Director of Nursing confirmed that the new rash should have been reported to the physician. No documentation was provided to show that the physician was notified of the change in the resident's condition.
Failure to Develop and Implement Comprehensive Care Plans for Resident Needs
Penalty
Summary
Facility staff failed to develop and implement comprehensive care plans that addressed all of the residents' needs, as evidenced by two specific cases identified during a complaint survey. In the first case, a resident who frequently refused showers did not have a care plan intervention addressing these refusals. Although the resident was offered showers weekly and received bed baths when showers were refused, the care plan only stated that showers were to be offered twice weekly and did not include strategies or interventions to address or manage the refusals. The Director of Nursing confirmed that the care plan lacked interventions for refusals and acknowledged the need for review. In the second case, a newly admitted resident's transfer status was not assessed or documented in the care plan in a timely manner. The admission screener did not contain information on the resident's ability to transfer, and although the MDS assessment indicated the resident was dependent for transfers, the care plan did not include a transfer intervention until after an incident resulting in injury. Documentation of the resident's transfer assistance needs was inconsistent throughout the month, and staff interviews revealed confusion and lack of clarity regarding the resident's transfer status and the appropriate method for transfers. The care plan was only updated to include a transfer intervention after the injury occurred. Multiple staff interviews confirmed that there was a lack of communication and documentation regarding transfer status, with some staff unsure where to find this information in the medical record. The Director of Nursing and other staff acknowledged that the care plan should have included the resident's transfer status to guide care. The failure to timely and accurately update care plans to reflect residents' needs, including interventions for shower refusals and transfer assistance, led to deficiencies in meeting regulatory requirements for comprehensive, individualized care planning.
Failure to Document Missed Medication Dose in Medical Record
Penalty
Summary
Facility staff failed to maintain the accuracy of a resident's medical record by not documenting the reason for a missed dose of medication. During a complaint survey, a resident reported not receiving their prescribed Vitamin C medication for several days. Review of the medical record showed an active order for Vitron-C Oral Tablet to be administered every other day for anemia. Examination of the Medication Administration Record (MAR) revealed that on one date, the nurse's initials were accompanied by the number '9', which, according to the MAR legend, indicated 'See Nurse Note.' However, upon request, the Director of Nursing (DON) was unable to locate any corresponding nurse note or documentation explaining whether the medication was given or the reason for the missed dose. The absence of this documentation in the medical record was acknowledged by the DON.
Infection Control Lapses in Tracheostomy, Foley Catheter, and Contact Precaution Care
Penalty
Summary
The facility failed to maintain infection prevention and control practices in several instances involving residents with specialized care needs. One resident with a tracheostomy was observed with their trach collar oxygen mask lying on the floor next to the bed on two separate occasions, with the mask dated several days prior. The mask was not replaced until after the issue was brought to the attention of the unit manager, who confirmed the mask had been on the floor and acknowledged the importance of infection prevention in this context. Another deficiency was observed with a resident who had a Foley catheter. A used Foley catheter with visible urine in the tubing and collection bag was found placed directly on the bedside table next to personal care items, rather than being immediately discarded in a biohazard receptacle as required by facility policy. The nurse responsible admitted to forgetting to dispose of the catheter and acknowledged that this action was against infection control policy, which was confirmed by both the Infection Preventionist and the Director of Nursing. Additional infection control lapses were identified with two residents on contact precautions. Staff were observed entering rooms with posted contact precaution signage without performing hand hygiene or donning required personal protective equipment (PPE), and in one case, a staff member handled items on the floor and exited the room without PPE or hand hygiene. Staff interviews revealed a lack of understanding or adherence to contact precaution protocols, and in some cases, staff were unaware of the reasons for the precautions. These failures were confirmed by supervisory staff and the infection prevention team during interviews.
Failure to Provide Palatable, Appealing, and Accurate Meal Service
Penalty
Summary
The facility failed to provide residents with food and beverages that were palatable, appealing, and matched their documented preferences as indicated on tray tickets. Multiple residents received meals that did not correspond to their selections, such as being served the wrong type of bread, juice, or milk, and missing items like bananas, yogurt, or house shakes. Several residents reported receiving food that was cold, tasteless, or of poor quality, including bread with mold, mushy vegetables, and melted ice cream. In some cases, residents received food items they specifically disliked or could not consume, such as oatmeal or milk, despite their tray tickets indicating otherwise. Observations and interviews revealed that the discrepancies were due to a combination of staff errors on the tray line, miscommunication between dietary staff and GNAs, and supply shortages or substitutions without resident input. Staff admitted to running out of certain items, such as house shakes and bananas, due to delivery schedules and back orders. Additionally, some staff members were identified as making repeated mistakes and were subsequently removed from the tray line. The dietary manager acknowledged substituting items based on general preferences rather than individual resident requests, such as providing vanilla instead of chocolate frozen nutritional treats. The Nursing Home Administrator confirmed during direct observation that meals served to residents did not match tray tickets and were not visually appealing. Residents expressed dissatisfaction with the quality, temperature, and presentation of their meals, and some reported not receiving alternative items when they voiced concerns. The surveyor documented that these issues persisted even after staff were made aware of the problems, indicating ongoing failures in meal service and communication.
Failure to Maintain Wheelchairs in Sanitary and Comfortable Condition
Penalty
Summary
The facility failed to maintain wheelchairs in a sanitary, comfortable, and well-maintained condition, as evidenced by observations on two of three nursing units. Multiple residents were observed using wheelchairs with cracked or missing vinyl on the armrests, with some armrests missing approximately one inch of vinyl and others showing cracks along the edges and outer surfaces. Residents reported that the wheelchairs had been in this condition for some time, and one resident stated that the wheelchair was given to them in that state. Another resident mentioned that while the armrest had been tightened recently, no replacement was discussed. The Director of Maintenance reported conducting weekly audits of wheelchairs, including checks of brakes, backrests, armrests, wheels, and leg rests. Despite these audits, the deficiencies in wheelchair maintenance were present and observed by surveyors. The Nursing Home Administrator was informed of these concerns following the observations and interviews.
Failure to Timely Report Allegations of Abuse, Neglect, or Injury of Unknown Origin
Penalty
Summary
The facility failed to report allegations of abuse, neglect, or injury of unknown origin to the regulatory agency, the Office of Health Care Quality (OHCQ), within the required 2-hour timeframe for two residents. In one case, a resident was noted to have swelling and dark discoloration on the right thumb, with pain and tenderness, and a staff member observed bruises on both arms but did not immediately report this to the nurse due to her being occupied. The incident, classified as an injury of unknown origin, was not reported to OHCQ on the day it was first observed. In another instance, a visitor alleged that a resident had been inappropriately touched, and the facility became aware of this allegation but did not report it to OHCQ within the mandated 2-hour window. The initial report was sent the following day, outside the required timeframe. Interviews with facility leadership confirmed that both incidents were not reported in a timely manner as required by regulations.
Failure to Thoroughly Investigate Allegations of Abuse
Penalty
Summary
The facility failed to provide documentation that allegations of abuse were thoroughly investigated for three residents during a complaint survey. In one case, an incident was reported in which three staff members allegedly held a resident down while the resident resisted. The facility's investigation included interviews with seven residents but did not include any staff interviews. In another case, a resident with a traumatic subarachnoid hemorrhage, quadriplegia, and contractures was found with facial swelling and discoloration. The investigation included interviews with other residents and three staff members from the day shift, but did not include the GNA who cared for the resident overnight or other staff from previous shifts. In the third case, a resident's visitor reported inappropriate touching. The investigation consisted only of a statement from the ADON and an interview with the resident, who reported feeling uncomfortable but denied being touched. No staff or other resident interviews were conducted for this incident. In each instance, the investigations were incomplete, lacking interviews with all relevant staff or other residents who may have had information about the alleged incidents. The Nursing Home Administrator confirmed during interviews that these investigations were not thorough and stated that she was not employed at the facility at the time the incidents occurred.
Failure to Document Shower Offer and Refusal for Dependent Resident
Penalty
Summary
The facility failed to document that a resident was offered and/or received a shower on their assigned shower days. The resident, who was admitted for rehabilitation following a lumbar vertebra compression fracture and had intermittent confusion requiring extensive assistance with activities of daily living (ADLs), did not have any record of bathing on two specific days and only received bed baths for a subsequent two-week period. There was no documentation indicating that the resident was offered a shower or that a shower was refused, despite the resident being assigned specific shower days. The Director of Nursing confirmed that there was no documentation of showers being offered or refused for this resident.
Failure to Complete and Document Neurological Checks After Resident Falls
Penalty
Summary
The facility failed to ensure that neurological evaluations were comprehensively conducted according to facility policy and procedure after falls for a resident with a history of falls and significant medical conditions, including Alzheimer's disease, muscle weakness, and a cervical fracture. The facility's policy required neurological checks at specific intervals and the inclusion of vital signs with each check following a known or suspected head injury. However, documentation revealed that after two separate falls, neurological checks were not performed or documented at the required intervals, and vital signs were not consistently obtained with each check as required by policy. For one fall, there was a significant delay between the initial and subsequent neurological checks, with vital signs not updated for several hours. In another incident, there was no evidence that neurological checks were performed every 15 minutes as required after the resident was found on the floor with a head injury, and vital signs from previous assessments were reused for multiple checks. Staff interviews confirmed that neurological checks and vital signs were not always completed or documented at the correct times, and that staff sometimes entered data later or failed to update the timing of vital signs. The Director of Nursing and the Administrator both acknowledged that the neurological checks were not completed correctly and that the use of previous vital signs for current assessments was inappropriate. The facility's own staff, including LPNs and a Doctor of Nursing Practice, confirmed that the expected protocol was not followed, and that neurological checks and vital signs should be performed and documented at the required intervals after a fall involving a potential head injury.
Failure to Provide Scheduled Podiatry Care
Penalty
Summary
Facility staff failed to ensure that a resident received podiatry services as ordered. Medical record review showed that the resident, who had a history of significant atherosclerosis and was identified as needing professional foot and nail care to prevent infection or ulceration, was last seen by the podiatrist on 2/4/25. The podiatrist's evaluation indicated a follow-up appointment was scheduled for 4/8/25 for at-risk foot care. However, upon review of facility records and interviews with staff, it was confirmed that the resident was not seen by the podiatrist on the scheduled follow-up date, and there was no documentation of podiatry care provided after the last visit.
Unattended and Unlocked Medication Cart
Penalty
Summary
Facility staff failed to keep a medication cart locked when it was left unattended in the hallway outside a resident's room. During the surveyor's observation, the medication cart was found unlocked and unattended, allowing access to all drawers and medications inside. The unit manager and an agency LPN were present during the observation, with the LPN questioning whether someone had tampered with the cart, but the surveyor confirmed the lock was not engaged prior to opening the drawers. The facility's medication storage policy requires all drugs and biologicals to be stored in locked compartments, with access limited to authorized personnel, but this protocol was not followed in this instance. No specific residents were directly involved or affected at the time of the deficiency, and no additional medical history or resident condition was noted in the report.
Failure to Ensure Timely Outside Specialist Services for Resident with Tracheostomy
Penalty
Summary
Facility staff failed to obtain outside professional services in a timely manner for a resident who was admitted with a tracheostomy. The resident was seen by an ENT specialist, who changed the tracheostomy and scheduled a follow-up appointment with a head and neck surgery specialist. However, the resident did not attend the scheduled specialist appointment, and this failure was confirmed by the facility administrator during an interview. The deficiency was identified during a complaint survey and was based on medical record review and staff interview. The resident's medical record indicated the need for ongoing specialist care related to the tracheostomy, but the facility did not ensure the resident attended the required follow-up appointment as ordered by the ENT specialist.
Failure to Maintain Complete and Accurate Medical Records
Penalty
Summary
The facility failed to maintain complete and accurate medical records in accordance with accepted professional standards for one resident. Medical record review revealed that the resident, who had been admitted in 2010, did not have documentation of podiatry visits after a specific date, despite having received podiatry care on multiple occasions. During the survey, staff were unable to locate records of podiatry visits that occurred after the last documented date. It was later confirmed through interviews and provision of evaluation forms that several podiatry visits had taken place, but these records had not been uploaded into the resident's medical record due to confusion following a change in medical records staff. The deficiency was identified when the surveyor could not find documentation of the podiatry visits until after intervention.
Latest citations in Maryland
The facility did not ensure that its Infection Preventionist (IP) met required qualifications for managing the Infection Prevention and Control Program. The DON reported serving as the IP but acknowledged lacking the specialized infection control training required for the role, and confirmed that no other staff member was currently qualified. Records showed that the previously qualified IP left several months earlier, and the Administrator and DON confirmed they were still seeking a replacement, leaving the infection control program without a properly trained leader.
Staff failed to consistently secure medications and medical supplies across three units, including an oxygen tank left on the floor behind a resident’s bed without a supporting device, a treatment cart with Collagenase Santyl cream left on top while two residents in power wheelchairs passed by, an unattended and unlocked treatment cart at a nursing station, and another treatment cart with Diclofenac gel and dressings left on top, indicating repeated lapses in maintaining locked and secure storage for drugs, biologicals, and related supplies.
The facility failed to provide sufficient dietitian coverage and timely nutritional assessments for several residents with significant dietary needs. A resident admitted for diabetic management with a high A1C was placed on a regular diet instead of the recommended carb-controlled diet and had only one weight taken in the first two weeks, with no dietitian review of the record. Another resident with prior significant weight loss had no documented dietitian follow-up despite continued weight loss, and a resident admitted with severe protein-calorie malnutrition experienced further significant weight loss without any dietitian assessment. The dietitian reported working limited hours and prioritizing certain high-risk cases, resulting in delayed or missed evaluations for new admissions and residents with ongoing nutritional concerns.
The facility failed to maintain adequate linen and incontinence supplies and did not keep resident care areas in good repair, resulting in delays and alterations in incontinence care and substandard environmental conditions. Staff reported that towels and washcloths were used instead of wipes and then discarded due to heavy soiling, and that linen deliveries to units were late, leaving residents waiting for care. Observations showed very limited numbers of clean washcloths and other linens on units and in the laundry, with no stock of disposable wipes or backup washcloth supply despite repeated reports to housekeeping. Additional observations revealed recliner chairs blocking a dining-area handwashing sink and kitchenette, multiple resident and shared bathrooms with unfinished spackle, chipped paint, musty odors, black substances near showers, missing threshold molding, exposed cracks and nails, and eroded, rusted baseboard heaters. Hallway handrails on both units were worn, chipped, and splintered, and a shower room contained fecal odors, dried brown stains on the toilet, and deteriorated fixtures, all contributing to a failure to provide a safe, clean, and homelike environment.
Facility staff did not thoroughly investigate two separate abuse allegations involving a resident and an injury of unknown origin involving another resident. In both cases, investigations focused on the directly affected resident and included staff interviews, but there were no interviews of other residents on the unit or documented assessments of those residents for signs of abuse or injuries of unknown origin, including residents unable to communicate due to cognitive status.
Two residents who were dependent on staff for oral care, including one with a tracheostomy, were observed with thick, white or milky substances coating their mouths and teeth, indicating inadequate oral hygiene. One resident communicated that staff did not brush their teeth and that staff "need to." In another case, despite oral care supplies being present in the room, the resident’s mouth and teeth remained unclean on multiple observations, with a thick milky substance caking the teeth and stringing between them when the resident tried to open their mouth. These findings showed that staff did not consistently provide oral care to residents who relied on them for this ADL.
Staff failed to maintain complete and accurate medical records for multiple residents, including missing and inconsistent documentation of wound care, delayed pain assessment after discovery of an injury of unknown origin in a cognitively impaired resident, and inaccurate recording of a PPD test result that was documented as negative despite no evidence the injection was administered and no supporting nurse’s note. Residents reported not receiving certain treatments, while MAR entries either lacked signatures for completion or contained conflicting information about whether care was provided.
Surveyors found that the facility failed to consistently implement and communicate correct transmission-based precautions and PPE use. One resident with a Foley catheter related to wounds had no precaution signage posted, while another resident in a double room had a contact precautions sign at the door, yet the NP entered without PPE and the GNA provided high-contact care wearing only gloves. Staff in that room stated the resident was not on contact precautions and later reversed the sign to show no PPE requirement. Therapy staff reported they rely solely on posted signs to determine PPE, and surveyors identified broader issues with inaccurate signage and staff awareness of which residents required contact precautions.
Surveyors found that MDS assessments were inaccurately coded for two residents. In one case, a resident sustained a femoral neck fracture after a fall, but the subsequent significant change MDS did not code the fall as a major injury and failed to capture prn Tylenol use documented on the MAR within the look-back period. In the other case, a quarterly MDS indicated opioid use for a resident, but the MAR for the same period showed no prescribed opioid, indicating incorrect coding of high-risk drug classes.
A resident who had recently been admitted and experienced a fall received multiple doses of the narcotic analgesic Tramadol, but the facility failed to accurately document all administered doses on the Medication Administration Record (MAR). Review showed only one Tramadol dose recorded on the MAR, while the Controlled Drug Receipt/Record/Disposition Form on the med cart reflected three doses given over two days. In interview, the DON stated staff are expected to document narcotic administration on the MAR and confirmed that two administered doses were not recorded there, resulting in an incomplete and inaccurate medical record.
Unqualified Infection Preventionist Overseeing Infection Control Program
Penalty
Summary
The facility failed to ensure that its designated Infection Preventionist (IP) met the mandatory qualifications for overseeing the Infection Prevention and Control Program. During an interview on 3/24/26 at 10:00 AM, the DON confirmed that she/he was serving as the facility’s IP but had not completed the specialized training in infection control required for the position. The DON further stated that no other staff member currently met the qualifications to serve as IP. Record review showed that the previously qualified IP left the facility in October 2025, and as of the survey date, the position remained unfilled by a qualified individual. At 1:30 PM on the same day, the Administrator and DON confirmed they were still in the process of finding a qualified IP for the facility, leaving the Infection Prevention and Control Program without a properly trained and qualified leader. No specific residents, medical histories, or clinical conditions were described in relation to this deficiency.
Unsecured Medications, Treatment Carts, and Oxygen Equipment
Penalty
Summary
Facility staff failed to ensure that drugs, biologicals, and related medical supplies were securely stored and properly maintained on multiple units. On one unit, an oxygen tank assigned to a resident was observed sitting on the floor behind the resident’s bed without any supporting device. On another unit, a treatment cart was observed with a tube of Collagenase Santyl cream labeled for a specific resident left on top of the cart, while residents in power wheelchairs passed by and staff were present at the nursing station. These observations showed that medications and oxygen equipment were not consistently secured as required. Further observations on additional units revealed an unattended and unlocked treatment cart at a nursing station, and on a separate occasion, a treatment cart with Diclofenac gel labeled for a resident left on top along with multiple packs of dressings. These incidents occurred across three units and on more than one date, demonstrating repeated failures to keep medications and treatment supplies in locked compartments or otherwise secured from unauthorized access.
Insufficient Dietitian Coverage and Delayed Nutritional Assessments
Penalty
Summary
The deficiency involves the facility’s failure to employ sufficient food and nutrition staff, including adequate dietitian coverage, to ensure timely assessment and appropriate diets for residents with significant nutritional and diabetic needs. A resident admitted over two weeks earlier with multiple comorbidities and an A1C of 11.5% had a hospital discharge recommendation for a carbohydrate-controlled diet, but was placed on a regular diet at admission with no acknowledgment of the recommended diet until one week later, when the resident requested larger portions. As of the survey date, the dietitian had not yet seen or reviewed this resident’s medical record, and the resident reported not having seen a dietitian and being very frustrated with the meals. During the first two weeks after admission, only one weight was obtained for this resident, despite physician notes stating the resident’s weight was “stable.” Further review of other residents showed additional failures in timely dietitian assessment and follow-up. One resident, readmitted in January and previously seen by the dietitian in September for a 6.4 lb weight loss over 30 days, had no documented follow-up despite continued weight loss totaling 22 lbs since the last dietitian review. Another resident admitted at the end of February with severe protein-calorie malnutrition had not been seen by the dietitian after about a month in the facility, despite a documented 14 lb (7%) weight loss over two weeks. The dietitian reported working only 12 hours per week at the facility and stated that she must prioritize which residents to see, focusing first on residents with tube feedings and those identified in risk meetings, resulting in delayed or absent assessments for new admissions and residents with ongoing weight loss and malnutrition diagnoses.
Linen Shortages and Poor Environmental Maintenance Compromise Resident Care and Comfort
Penalty
Summary
The deficiency involves the facility’s failure to maintain an adequate supply of clean linens and appropriate incontinence wipes, resulting in delays and alterations in residents’ incontinence care, as well as the use of towels and washcloths in place of disposable wipes. During the initial tour, the surveyor observed that the linen supply on one nursing unit hallway was low. Complaint reviews included concerns about delays in incontinence care and bed linens not being changed regularly, with residents left without clean bedding. A complainant reported that there was not enough clean linen available for residents. Staff interviews confirmed that towels, sheets, and washcloths were being used to wipe residents for incontinence care due to the absence of wipes, and that many of these linens were being thrown away when soiled. Staff also reported a shortage of linen, that linen deliveries to the units were late, and that residents who preferred to get up before breakfast had to wait for care when linen was delayed. Further observations showed that the clean supply room contained no disposable wipes or cloths for incontinence care, and a resident reported that staff did not use wipes, that the resident had to purchase their own, and that heavily soiled towels or washcloths were discarded. A tour of all nursing unit linen carts and closets revealed only six clean washcloths and limited supplies of towels, gowns, and bed linens. In the laundry room, only three washcloths were present, and the laundry assistant stated that there were only three washcloths available for each nursing unit that morning, that the facility was short on linen supply, and that these concerns had been repeatedly reported to the Director of Housekeeping over the preceding month and again that morning. The laundry assistant confirmed there was no additional laundry in process. The DON stated that wipe squares should be used for incontinence care, but no such wipes were found in the clean medical supply room, and no backup supply of washcloths was present in the emergency linen supply. The Director of Housekeeping confirmed there was no backup supply of washcloths. The deficiency also includes environmental and maintenance issues affecting resident bathrooms, handrails, and common areas. In the main dining area, a recliner chair was observed positioned directly in front of the handwashing sink, and two recliner chairs were stored in front of the nutrition area kitchenette. Multiple resident bathrooms and shared bathrooms were repeatedly observed over several days with unfinished spackle on walls that needed resurfacing and painting, chipped paint around sinks, uneven boards nailed to walls under sinks that appeared to partially cover holes, musty odors, black substances between shower bases and walls, missing threshold transition molding exposing cracks, missing tiles, and a nail, as well as eroded and chipped paint on baseboard heaters with exposed dark brown metal and rust-like material. Hallway handrails on both nursing units were observed to be worn, with chips, splintering, holes, and areas where the wood finish had worn off. A shower room was observed with a foul fecal odor, dried brown stains on the back of the toilet seat and in the toilet bowl, and a baseboard heater with eroded, chipped paint and rust-like material, along with chipped paint on the handrail. These conditions were acknowledged by the Director of Maintenance and other leadership, and some areas were noted to be in the process of renovation, but the observed deficiencies remained present during the survey period. Overall, the facility did not maintain a safe, clean, comfortable, and homelike environment in good repair across both nursing units and the dining area. The lack of adequate linen and incontinence supplies, combined with the poor condition of resident bathrooms, handrails, and certain common areas, constituted the basis for the cited deficiency. The observations and staff and resident reports consistently described shortages of essential hygiene supplies, delayed care related to linen availability, and multiple unresolved environmental and maintenance issues in resident care areas and shared spaces.
Failure to Thoroughly Investigate Abuse Allegations and Injuries of Unknown Origin
Penalty
Summary
Facility staff failed to thoroughly investigate allegations of potential abuse involving one resident and an injury of unknown origin involving another resident. For one resident, there were two separate allegations of abuse occurring on different days in early February. The facility’s investigation packets included interviews with staff who cared for or were scheduled to work with this resident on the days of the alleged incidents, and the investigations focused solely on this resident. However, there were no interviews conducted with other residents on the unit to inquire about abusive or neglectful treatment by the staff who were working during the times of the allegations. The surveyors noted that, although the allegations were not validated, there was no documentation that other residents were interviewed, if able, or assessed for signs or symptoms of injury. In a separate incident, another resident was identified on March 4 with a new bruise on the right eye, documented as a change in condition at 4:09 AM. This resident had a BIMS score of 99, indicating the resident was unable to complete an interview and therefore could not report how the injury occurred. The facility’s investigation identified a potential cause of the injury but did not reach a definitive resolution. Additionally, there were no interviews of other residents on the unit regarding possible abuse, nor were there documented assessments of other residents for injuries of unknown origin, particularly for those unable to speak for themselves, as in this resident’s case.
Failure to Provide Oral Care to Dependent Residents
Penalty
Summary
The deficiency involves the facility’s failure to provide oral care to residents who were dependent on staff for activities of daily living, specifically oral hygiene. One resident with a tracheostomy was observed with a thick, sticky white substance in the mouth and was noted to intermittently chew on nearby bedding. This resident made good eye contact and, when asked if staff brushed their teeth, shook their head no and mouthed that staff “need to.” According to the resident’s Minimum Data Set (MDS) dated 2/11/26, the resident was dependent on staff for oral care. Another resident, also dependent on staff for oral care per the 3/11/26 MDS, was observed sitting propped up in bed and able to respond with smiles. During the initial observation, the inside of this resident’s lips and upper and lower teeth had a thick, clear, white milky substance visible when the resident tried to open their mouth to smile. Oral care supplies were present in the nightstand, but the resident’s mouth and teeth were not clean. On a subsequent observation with the DON, NHA, and Corporate VP of clinical services, the same resident again had a thick, clear, milky substance between the lips and caking the teeth, which would string between the teeth when the resident attempted to open their mouth, demonstrating a lack of consistent oral care for residents dependent on staff for this ADL.
Incomplete and Inaccurate Medical Record Documentation for Treatments and Assessments
Penalty
Summary
Facility staff failed to maintain complete and accurate medical records and documentation for multiple residents. For one resident with wound care needs, review of the MAR showed that wound care and related treatments were signed as completed on the dates initially reported, despite the resident’s ongoing complaints that wound dressings were not being changed. When additional dates were reviewed, there were missing staff signatures for wound care on two specific dates, as well as three instances where application of A&D ointment to the resident’s feet was not signed off out of 24 days reviewed. Another resident with severe cognitive impairment, as evidenced by a BIMS score of 00, was found to have an injury of unknown origin (a bruise on the left hand). Documentation showed that a change in condition was initiated late in the morning, but a formal pain evaluation was not initiated and completed until that night, and the resident was unable to explain how the injury occurred or verbalize pain using a standard pain scale. For a third resident, documentation related to the admission PPD test was inconsistent and incomplete. The MAR contained an entry indicating “9” for the administration date, meaning “see nurse’s note,” but there was no corresponding nurse’s note. Despite the absence of a signed administration of the PPD injection, staff documented the PPD result as “negative” on the scheduled read date. The resident reported never receiving the PPD injection, and the DON confirmed that the facility had been out of PPD solution at the time, so the test would not have been administered. These findings demonstrate failures in accurate documentation of treatments and assessments, including wound care, pain assessment, and TB screening, as well as missing or incomplete supporting notes in the medical record.
Failure to Implement and Communicate Correct Transmission-Based Precautions
Penalty
Summary
Surveyors identified a deficiency in the facility’s infection prevention and control program related to inconsistent and incorrect implementation of transmission-based precautions and PPE use. During a complaint investigation focused on residents on transmission-based precautions, one resident with a visible Foley catheter was observed in the room with physical therapy, but there were no signs posted indicating any need for PPE, despite the resident being a new admission with a Foley catheter placed related to wounds. In another double-occupancy room, a contact precautions sign was posted at the doorway, but the nurse practitioner was in the room on a personal phone with no PPE, and the assigned GNA was repositioning the resident in bed while wearing only gloves. When questioned, the NP, RN, and GNA all stated that the resident in the room was not on contact precautions, and the GNA reported that signs were hanging at all doors and that this particular resident’s sign was “just wrong.” The surveyor observed the GNA later return to the room and turn the sign around to indicate no PPE requirement. Subsequent interviews revealed that therapy staff relied on posted signage to determine PPE use and that if the sign was wrong, the PPE used would be wrong. Overall, surveyors found problems with signage accuracy and staff awareness of which residents required contact precautions, as well as observed failures to follow appropriate PPE use for residents who should have been on contact precautions.
Inaccurate MDS Coding for Falls, Pain Management, and High-Risk Medications
Penalty
Summary
Facility staff failed to ensure Minimum Data Set (MDS) assessments were accurately coded for two residents reviewed during a complaint survey. For one resident, a facility-reported incident showed that the resident was found seated on the floor beside the bed and was diagnosed with a non-displaced femoral neck impaction fracture of the left hip following an x-ray. Despite this fall with a major injury, the subsequent significant change MDS dated 11/4/25 did not code the fall with major injury in Section J1900C. Review of the resident’s Medication Administration Records for October and November 2025 showed administration of Tylenol on 10/31/25 at 9:30 PM, which fell within the 5-day look-back period for the MDS, but Section J0100 (prn pain) of the same significant change MDS did not capture the use of Tylenol. For another resident, review of a quarterly MDS with an assessment reference date of 10/15/25 showed that Section N0415 (High-Risk Drug Classes) documented the use of an opioid medication. However, review of the resident’s October 2025 Medication Administration Record did not show that the resident had been prescribed an opioid during that period. In both cases, MDS staff later confirmed that these were errors in MDS coding, demonstrating that the assessments did not accurately reflect the residents’ clinical status and medication use as documented in their medical records.
Incomplete Documentation of Narcotic Administration on MAR
Penalty
Summary
The facility failed to maintain complete and accurate medical records in accordance with accepted professional standards for one resident receiving narcotic medication. The resident, admitted in March 2026, had a fall on 3/6/26 and was sent to the hospital on 3/9/26. Review of the March 2026 Medication Administration Record (MAR) showed documentation of a single 25 mg dose of Tramadol administered on 3/8/26 at 9:23 AM. However, review of the resident’s Controlled Drug Receipt/Record/Disposition Form, kept on the nurse’s medication cart and not in the medical record, showed that Tramadol 25 mg was administered three times between 3/8/26 and 3/9/26: at 11:00 AM and 9:00 PM on 3/8/26, and at 9:00 AM on 3/9/26. In interview, the DON stated that staff are expected to document narcotic administration on the MAR and confirmed that only one of the three Tramadol doses reflected on the controlled drug record was documented on the resident’s MAR. This discrepancy between the controlled substance record and the MAR, with missing documentation of two administered doses of Tramadol on the official medical record, constituted the failure to maintain a complete and accurate medical record for the resident.
Trusted data from CMS and state health departments
Every citation, penalty and Plan of Correction is sourced from public CMS records (latest release May 27, 2026) and official state health department websites — never guesswork.
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