Average — CMS composite of the measures below.
The next survey window likely opens around November 2026
Estimate from public CMS data, current as of August 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Autumn Lake Healthcare At Perring Parkway during CMS and state inspections, most recent first.
A resident with a history of repeated falls and hospitalizations was admitted with hospital recommendations for 24/7 supervision, but the care plan only addressed call bell use and did not reflect individualized fall interventions. The resident fell multiple times soon after admission, including an unwitnessed bathroom fall that resulted in a subdural hematoma, and later fell again from a wheelchair. Survey observations also found the resident out of view with the door closed or curtain pulled, and the record did not show a root cause analysis or consistent updates to the plan of care.
Facility staff failed to maintain a clean, homelike environment on multiple units. Surveyors observed discarded gloves on floors and at a room entrance, food and crumbs scattered in hallways, a discarded mask on a PPE cart, dirty dishes piled on a cart, linen carts in disarray with briefs, wipes, trash bags, and gloves, and a black cart outside a resident room holding partially eaten food, dirty dishes, silverware, and exposed food. Hallway flooring on one unit also had blackened drip-like stains that remained visible over several observations, and an LPN/Supervisor stepped over gloves left on the floor.
A resident was observed in a hospital gown during a complaint survey after a complaint alleged the resident was not receiving help with personal care needs. The assigned CNA stated she had provided a bed bath, mouth care, and lotion, and confirmed the resident had clothes available but was not assisted to dress in them instead of remaining in a hospital gown. The DON and NHA reviewed the concern and offered no rationale for the deficient practice.
Failure to Provide a Grievance Process: The facility did not have a clear grievance process in place for residents or representatives. A complainant reported sending emails about a resident’s care concerns and receiving no response, and stated staff did not inform them of their right to file a grievance. The DON said repeated food-related complaints were not handled as grievances, did not interview the resident or staff to determine the cause, and could not locate the emails she had received.
Failure to timely report abuse allegations. A resident reported being beaten to a CNA, and a family member later reported abuse to the NHA, but the allegation was not reported to the SA within the required timeframe. Another incident involved the same resident being sent to the ED with bruising to the neck, knee, and elbow, where the ED physician documented an abuse allegation and notified police and the forensic nurse. Interviews with the DON, NHA, and other staff showed conflicting accounts and that the abuse allegations were not reported to the SA as required.
Failure to Investigate Allegations of Abuse: The facility did not ensure all abuse allegations involving a resident were investigated or that the resident was protected from further abuse. A resident was sent to the ED with bruising to the neck, knee, and elbow, and the ED documented an abuse allegation and notified the forensic nurse and police. Interviews showed the DON did not assess the resident or speak with the family, the NHA could not determine the concern, and staff reported additional abuse allegations that were not shown to have been reported to the SA or thoroughly investigated.
Failure to Ensure Appropriate Discharge Planning: A resident with dementia, post-stroke L-sided weakness, and ambulatory dysfunction was discharged without a resident-centered discharge planning process. The care plan lacked ongoing IDT re-evaluations, input from the resident rep, documentation of caregiver/support availability, goals of care and treatment preferences, interest in community return info, and referrals for community resources/DME reflected in the plan; progress notes showed the rep was considering LTC and Medicaid planning, but this was not incorporated into the discharge care plan.
Inaccurate MDS coding affected two residents. One resident’s MDS listed cancer as an active dx even though the record showed only a hx of cancer and no active tx. Another resident was observed with a wound vac, but the quarterly MDS did not code any wounds in Section M, and the record lacked weekly wound documentation.
Staff failed to respond promptly to multiple call bells while several employees remained seated at the nurses station, and a resident was observed wearing an improperly sized incontinence brief. During care, the resident had a bunched-up extra-large brief in place even though staff stated the resident should have been in a large. The resident had a history of sacral ulcers and IAD, and the record did not document abdominal circumference or the correct brief size.
Physician notes were not timely signed or individualized for a resident who had a fall and was hospitalized with a subdural hematoma. The attending MD documented repeated, identical notes, including a readmission note that stated the resident had “no acute injury,” and the notes were signed days after they were created, delaying implementation of any updates to the resident’s care.
Homelike Environment Not Maintained: Surveyors repeatedly noted malodorous odors in the lobby and resident areas, along with worn, stained carpeting on both floors, chipped elevator flooring, damaged reception desk covering, and stained ceiling tiles and vents with debris and gray matter. Facility leadership acknowledged the odor and environmental concerns, and the DES stated odors were usually linked to dirty incontinence products in trash cans in resident rooms.
Failure to Maintain Resident Dignity: A resident with an ADL self-care deficit related to recent illness and deconditioning was observed in the hallway wearing a stained t-shirt on consecutive days, with bare feet on the floor. During a dual observation, the resident was also seen exposed in bed from the waist down, and the room had a strong odor with stained wheelchair linens. The resident’s care plan included staff assistance with bathing, dressing, toileting, bed mobility, ambulation, meal set up, and daily hygiene/grooming.
Advance Directive documentation was missing or misclassified for several residents. Staff treated the MOLST as the Advance Directive for some residents, while records for others showed assessments stating an Advance Directive was in place or that the resident wanted help completing one, but the chart did not contain a completed Advance Directive or documentation of assistance from SW or other staff.
Incomplete Baseline Care Plan for Newly Admitted Resident: A resident admitted with respiratory failure, emphysema, pulmonary hypertension, and major depressive disorder had a baseline care plan that did not include ordered psychotropic, diuretic, and opioid medications. The UM stated the baseline care plan should be completed within 48 hours and reviewed with the resident or representative, but the care plan lacked the medication-related monitoring and nursing considerations tied to diazepam, aripiprazole, duloxetine, trazodone, spironolactone, and oxycodone.
Failure to Hold Timely Quarterly Care Plan Meetings: The facility did not ensure timely quarterly care plan meetings were held so residents and/or resident representatives could participate in the care planning process. Survey review found gaps between MDS assessments and documented care plan meetings for two residents, and the NHA stated the facility had identified an issue with timely care plan meetings and documentation, but could not provide supporting records by exit conference.
A resident who used a wheelchair was not consistently offered the chance to attend group activities, despite an activities assessment showing interest in small groups, crafts, music, TV/movies, dogs, sports, and church. Staff mainly provided in-room coloring and limited documented activity participation, while the resident’s representative and caregiver said the resident would enjoy getting out of the room for music, games, and other group events.
A resident with lymphedema and dependence on staff for personal hygiene was observed with very dry, flaky skin on both lower legs. The condition was not documented in the chart, progress notes, or skin assessments, and the UM acknowledged the dry skin had not been addressed before surveyor intervention, despite the care plan calling for daily skin observation with ADL care.
A resident with cataracts and prior R eye surgery reported that the facility never scheduled the recommended L eye cataract surgery. Eye care notes documented bothersome cataracts, stable VA, and repeated recommendations for ophthalmology consult and cataract extraction, but the EMR did not show a scheduled appt after the most recent eye exam until a later physician order listed one.
Inconsistent incontinence care was identified for a resident who was totally dependent on staff for toileting and incontinent of bowel and bladder. The resident was observed in bed wearing a visibly wet incontinence product, and task records showed care documented only intermittently rather than every shift. An UM confirmed the resident’s dependence and noted documentation gaps, while surveyors also observed daily odors in resident hallways and nearby areas.
Respiratory tubing and humidification equipment were not managed as ordered for two residents. Surveyors observed missing date/time labels on oxygen tubing and humidification bottles, and one resident’s nebulizer machine, face mask, and tubing were laying on the floor. An LPN, UM, DON, and Administrator acknowledged the concerns, and the residents’ records showed orders to change and label the oxygen tubing components.
A medication room observation found a discontinued anticonvulsant and a discharged resident’s glucose monitoring supplies sitting on the counter instead of being placed in the pharmacy return bag. The UM confirmed the items were not stored as expected for medications awaiting final disposition.
A resident reported not having been seen by a dentist in a long time and had been requesting routine dental care for existing dentition and oral hygiene needs. The EMR showed the last dental consult was over a year earlier, with no documented routine dental appointments scheduled. RN and DON interviews confirmed the resident’s request for dental services, but no scheduled dental visit was provided by exit conference.
Failure to follow diet order and allergy information: A resident’s breakfast tray did not match the meal ticket or the resident’s documented preferences. The tray lacked bacon, oatmeal cereal, juice, coffee, and tea, while the ticket listed a CCD with bacon, oatmeal cereal, and beverages, and also incorrectly listed a beef allergy that was not found in the medical record. The resident stated drinks were often not served with meals and that coffee arrived too late or not at all.
A facility failed to follow the posted breakfast menu for two residents. One resident did not receive bacon, oatmeal cereal, or ordered drinks, and another resident did not receive French Toast Casserole listed on the meal ticket and posted menu. Staff confirmed the items were not served because the food truck did not come and the facility did not have the items in stock, and no documentation showed residents were informed of menu changes or offered choices.
A resident with severe cognitive impairment had incomplete documentation in the chart for advanced directives and incapacity determinations: the MOLST referenced a health care agent, but the record lacked an advanced directive, had only one physician incapacity certification, and did not contain physician documentation of review of the resident’s directives. Staff later confirmed the missing documentation was not in the chart. In a separate finding, an order for empagliflozin was documented for diabetes mellitus even though the resident had no diabetes diagnosis in the chart, and the DON and MD confirmed the medication was being used for a different indication.
A resident was observed using tube feeding equipment that was not dated, and the tubing and nutrition bottle were both confirmed to be undated by an assigned staff member. The staff member stated it was the nurse’s responsibility to ensure the tube feeding equipment was dated.
Failure to Individualize Fall Prevention and Supervision
Penalty
Summary
Facility staff failed to identify and consistently evaluate the contributing factors to a resident’s repeated falls and failed to implement individualized interventions to prevent further incidents. Resident #6 was admitted with a documented history of falls and discharge recommendations from the hospital included 24/7 supervision due to the resident’s falls and debilitated condition. The initial baseline care plan addressed fall risk only by orienting the resident to the call bell. Within less than 24 hours of admission, Resident #6 fell and sustained superficial injuries to the back and reported lightly hitting the head. Additional falls occurred on 5/22/26 and 5/28/26, including an assisted fall during a transfer. The record did not show a root cause analysis or a documented change to the plan of care after these repeated falls in a short time frame. After the 5/30/26 unwitnessed fall in the bathroom, the resident had injuries to the back and forehead and an abnormal neurological exam with an abnormal left pupil, then was sent to the hospital and diagnosed with a subdural hematoma. Upon readmission, the resident was moved to a bed closer to the nursing station, but this intervention was not reflected in the care plan. Survey observations from 6/16/26 through 6/19/26 repeatedly found the resident in the room with the door closed or the curtain pulled, limiting visibility from the hall or nurses’ station, despite the resident being awake. The resident was later observed with the wrong size footwear, was no longer in therapy, and had another fall from the wheelchair at the nurses’ station with an abrasion to the left knee. The attending physician acknowledged that the subdural hematoma was a major injury and stated she expected the resident to be visually monitored, while the DON stated she thought there had been communication from the family about leaving the door closed, but this was not provided to surveyors or reflected in the plan of care.
Unclean and disorganized unit environments
Penalty
Summary
Facility staff failed to maintain a safe, clean, comfortable, and homelike environment, as evidenced by multiple observations on Unit 1 and Unit 2. On Station 2, surveyors observed a trashcan with discarded gloves beside it inside a room, food scattered in the hallway and near the lobby sign by the elevator, a discarded mask on top of a PPE cart, napkin and straw papers with crumbs in front of resident room doors, and a cart with dirty dishes piled on it near the kitchenette. Two linen carts in the hallway were also observed in disarray with items such as briefs, an open box of gloves, wipes, trash bags, and large gloves placed on top of the cart covers. On Station 1, gloves were observed on the floor in two resident rooms, and the hallway leading to one room had several blackened areas that appeared to be dripping stains and remained visible on repeated observations over several days. During one observation, the environmental services District Manager used a floor buffer on the stained area and the floor outside the room was wet, with the previously observed stains no longer present. In addition, a pair of gloves was observed at the entrance to a resident room, and an LPN/Supervisor stepped over the gloves when entering and exiting the room, leaving them on the floor. Surveyors also observed a black cart in front of a resident room with trays containing partially eaten food, dirty dishes, silverware, and exposed food, and the cart remained in place with the prior meal still on it during later observations.
Failure to Maintain Resident Dignity
Penalty
Summary
Facility staff failed to ensure that Resident #5 was treated with dignity when the resident was observed in a hospital gown during the complaint survey. A complaint dated 6/16/26 alleged that the resident was not receiving assistance with personal care needs. During interview, the CNA assigned to the resident on the day of the observation stated that she had provided a bed bath, mouth care, and lotion to the resident, and confirmed that the resident had clothes available but was not assisted to dress in them instead of remaining in a hospital gown. The DON and Nursing Home Administrator reviewed the concern and offered no rationale for the deficient practice.
Failure to Provide a Grievance Process
Penalty
Summary
The facility failed to have a process in place to ensure residents and resident representatives had the right to a grievance process. A review of the facility’s Resident and Family Grievances policy showed that the grievance officer’s name, title, and contact information were not entered on the policy, even though the policy stated that residents or family members may voice grievances about care, treatment, and other concerns, and that staff receiving a grievance should record the details and forward the grievance form to the grievance officer as soon as practicable. For one resident, a complaint investigation showed that the complainant had sent emails to facility staff about concerns and received no response to resolve them. The complainant stated that staff did not inform them of their right to use a grievance process when concerns arose, and they continued to be concerned that the resident was not receiving the full meal listed on the meal ticket. The DON stated that verbal complaints about resident care would not automatically be treated as grievances, that repeated food-related complaints had been received over several months, and that she did not interview the resident or staff to determine the root cause or a solution because she considered it a food concern. She also stated that she had received two emails about the resident’s care but could not recall the concerns and later could not locate the emails. When the concerns were reviewed with the NHA, no rationale was offered for why the complainant had not been afforded the right to file a grievance and receive a resolution.
Failure to Timely Report Abuse Allegations
Penalty
Summary
The facility failed to have a process in place to ensure that allegations of abuse were reported to the State Agency within the required timeframe. The deficiency involved Resident #3 and was based on record review and staff interviews showing that the facility became aware of an abuse allegation when a family member reported it to the NHA on 4/13/26 at 3:00 PM, while a CNA also stated that the resident had reported being beaten by 6 women during care the prior evening and that the nurse on duty was told. Although the facility policy required all allegations of abuse to be reported to the NHA and the State Agency, the email confirmation showed the allegation was not reported to the State Agency until 5:12 PM that same day. The record also showed another allegation involving Resident #3 related to the resident’s discharge and a subsequent ED visit. A progress note indicated the resident’s representative wanted the resident discharged, and another note showed the resident was supposed to discharge on [DATE]. Complaint #3034284 documented that the resident was taken to the local hospital ED on 6/2/26, where there was an allegation that the resident had been abused at the facility. ED records included photos of bruising on both sides of the neck, the right knee, and the elbow, and the ED physician documented that an allegation of abuse was reported, the forensic nurse was notified, and police were contacted. Interviews with the DON, NHA, Social Services Director, CNA II #25, and UM #9 showed conflicting accounts of what occurred when the family member arrived and called police, including concerns about a staff member talking rudely, accusations that the resident had been abused, and prior concerns about the same CNA. The DON stated she was unaware of either abuse allegation when asked, and the NHA stated she was not aware that the resident had reported the allegation to the CNA. The report states that allegations of abuse were not reported to the State Agency as required.
Failure to Investigate Allegations of Abuse
Penalty
Summary
The facility failed to have a process in place to ensure that all allegations of abuse were investigated and that appropriate interventions were put into place to ensure residents were free of abuse. This was identified for Resident #3, whose record showed a progress note that the resident's representative wanted the resident discharged, and another note from the NP indicated the resident was supposed to discharge on [DATE]. A complaint dated 6/4/26 documented that Resident #3 was taken to the ED on 6/2/26 with an allegation of abuse at the facility. Hospital records from the ED visit documented bruising on both sides of the resident's neck, a bruise to the right knee, and a bruise on the elbow. The ED physician documented that abuse was alleged, the forensic nurse was notified, and police were contacted, with the report stating the abuse occurred at the facility where the resident was residing. Interviews showed that the DON knew the resident's family member called 911 and that police had been contacted, but she did not assess the resident or speak with the family to determine what happened. The NHA attempted to speak with the family member by phone but was unable to determine the concern. A CNA assigned to Resident #3 reported that the family member accused him of abuse in the hallway and that he told the nurse and a supervisor, but no one removed the alleged perpetrator from access to the resident or other vulnerable residents and no thorough investigation was completed. The CNA also reported a prior allegation involving an inappropriate comment while feeding the resident, and another staff member recalled a separate allegation that someone pulled on the resident's arm and caused pain; however, the facility did not show that these allegations were reported to the SA or that investigations were completed.
Failure to Ensure Appropriate Discharge Planning
Penalty
Summary
The facility failed to have a process in place to ensure that a resident was appropriately discharged from the facility. For one discharge reviewed, the resident had provider certifications dated 2/25/26 and 3/3/26 stating the resident was incapable of making decisions due to dementia. The resident’s history and physical documented dementia, left-sided weakness after a stroke, and ambulatory dysfunction, and the resident was in the facility for rehabilitation services. A care plan was initiated on 3/9/26 for discharge home when rehab/self-care goals were met, with interventions to assess future placement, complete a post-discharge plan, and discuss the discharge process with the resident/representative. The discharge planning documentation did not show an ongoing resident-centered process. There was no evidence that the interdisciplinary team documented regular re-evaluations of discharge needs, caregiver or support person availability and ability to provide care, input from the resident representative, the resident’s goals of care and treatment preferences, interest in community return information, or referrals for community resources and medical equipment with updates to the care plan. Progress notes showed the Social Services Director documented that the resident representative was considering long-term care and later discussed completing the Medicaid application if the plan was for the resident to stay long-term, but this was not reflected on the discharge care plan. The Social Services Director later stated she ordered durable medical equipment and made a referral to home health, and also stated she was not aware of the regulatory requirements for discharging a resident from the facility.
Inaccurate MDS Coding for Diagnosis and Skin Conditions
Penalty
Summary
The facility failed to accurately code an active diagnosis on the MDS for one resident. The medical record review for Resident #6 showed that the comprehensive assessment completed on 5/18/26 documented cancer in Section I as an active diagnosis, indicating the resident had or was treated within the past 7 days for cancer. However, review of the medical record, including the hospital discharge information, did not identify active cancer treatment and instead reflected only a history of cancer. The facility also failed to accurately code skin conditions on the MDS for another resident. Resident #7 was observed in bed with a wound vac sitting on a chair beside the bed and connected to tubing protruding from the left side of the bed. Despite this observation, the June quarterly MDS did not code or document any wounds in Section M. The assessment also contained inconsistent dates in Section M, with most entries dated 5/15/26 while the number of unhealed pressure ulcers was dated 5/29/26, and the record lacked weekly wound documentation for the resident.
Delayed Call Bell Response and Improper Brief Sizing
Penalty
Summary
The facility failed to provide residents with a quality of care and dignity by not responding timely to call bells. During initial observations, a surveyor heard and saw a call bell sounding outside a resident room while a staff member walked past it and continued toward the elevator. At the nursing station, three call bells were still alarming while five staff members remained seated nearby, including an evening supervisor. The surveyor remained in the area while the alarms continued, and staff did not immediately respond. The facility also failed to provide a resident with the appropriate size adult incontinence brief. During direct observation of care for one resident, a CNA brought in a blue brief, but when the resident was undressed a tan/yellow brief was already in place. The brief was bunched up around the sides and between the legs. The CNA stated the resident should be in a large, but staff had placed the resident in an extra-large brief the prior night. Another CNA later stated the resident had been placed in the larger tan brief and could not explain how staff determined the correct brief size. The resident involved had a history of sacral ulcers and incontinence associated dermatitis. The DON acknowledged that different brands and colors of briefs were used, and the medical record did not contain documentation of abdominal circumference or the size brief to be used. The concerns about delayed response to call bells and use of inappropriate brief sizes were reviewed with the DON and NHA at exit.
Physician Notes Were Not Timely Signed or Individualized
Penalty
Summary
The physician failed to have signed progress notes and orders entered timely after seeing the resident, and the notes were not individualized to reflect the resident’s actual condition. Review of the medical record for Resident #7 showed attending notes by Attending #21 on 5/20, 6/1, and 6/17, and all three notes contained the same information. After Resident #7 sustained a fall on 5/31/26 and was hospitalized with a subdural hematoma, the 6/1/26 readmission note stated the resident had “no acute injury” and included a plan for 24/7 supervision. The record also showed that the physician notes were signed on dates later than when they were created. The 5/20/26 history and physical was signed on 5/24/26, the 6/1/26 readmission note was not signed until 6/10/26, and the 6/17/26 progress note was signed on 6/18/26. During interview, Attending #21 reviewed the notes and the resident’s status and stated it was her “fault” that the note was not comprehensive and did not capture the resident’s actual status.
Homelike Environment Not Maintained
Penalty
Summary
The facility failed to ensure a homelike environment, as surveyors repeatedly observed malodorous odors and poor environmental conditions throughout both floors of the building during the recertification survey. On initial tour, a malodorous smell was present in the lobby area, and similar odors were later noted in the hallway near a resident room, near the first-floor elevator, and again in the lobby. The Administrator acknowledged the odor concern and stated it may have been due to nearby resident rooms adjacent to the lobby area. The Director of Environmental Services reported that odor control was part of his responsibilities and that odors were usually attributed to dirty incontinence care products in trash cans in resident rooms. Surveyors also observed widespread physical deterioration and soiling of the environment. Carpeting on both floors was worn, with areas where the pattern was no longer visible, along with dark gray areas, staining, and debris. Additional observations included dark staining in the doorways of multiple resident rooms, chipped flooring in the elevator, damage to the front reception desk with chipped and missing covering and a visible hole, and stained or dirty ceiling tiles and vents in resident hallways and above the floor 2 nursing station. Surveyors also noted black debris and thick gray matter within vents and debris along the edges of adjacent ceiling tiles. The facility’s Supervisor of Maintenance and DES acknowledged the concerns, and the Supervisor of Maintenance was observed cleaning the vents.
Failure to Maintain Resident Dignity
Penalty
Summary
The facility failed to ensure dignity was maintained for Resident #24. During the initial tour, the resident was observed sitting in a wheelchair in the hallway outside the room with bare feet on the floor and multiple orange stains on the t-shirt being worn. The next day, the resident was again observed in the hallway in the same stained t-shirt. During a dual observation with the Administrator, the resident was seen from the hallway lying in bed exposed with no clothing on from the waist down. When the concern was brought to the Administrator, a GNA was asked to assist with privacy, and the resident was covered with a blanket and the privacy curtain was pulled. At the time of interview, a strong odor was present in the room, and the linens on the resident’s wheelchair had brown stains. The Administrator observed the stained t-shirt and offered to have it changed, and the resident accepted. The medical record showed the resident had an ADL self-care deficit related to recent illness and subsequent deconditioning, with care planned for staff assistance with bathing, dressing, toileting, bed mobility, ambulation, meal set up, and daily hygiene, grooming, dressing, oral care, and eating as needed.
Advance Directive Documentation Missing or Misclassified
Penalty
Summary
The facility failed to ensure residents’ rights to formulate an Advance Directive and to maintain accurate documentation in the medical record for 4 of 6 residents reviewed for Advance Directives. For two residents, the electronic medical record and hard chart did not contain Advance Directive documentation, and staff identified the MOLST form as the Advance Directive. The administrator confirmed that the MOLST form was being considered an Advance Directive, although the surveyor informed staff that MOLST and Advance Directives are different documents under CMS regulations. For another resident, the record contained an Advance Directive admission assessment and a Social Service Assessment stating that an Advance Directive was in place and on file, but the electronic and paper records did not contain Advance Directive documents; the DON later provided only a MOLST form. For a fourth resident, Social Service documentation stated that the resident had been provided a copy of an Advance Directive for completion and wanted assistance with creating one, but the record did not show a completed Advance Directive or documentation that staff assisted with the process. The resident also needed help reading written material and was their own representative at the time of the assessments.
Incomplete Baseline Care Plan for Newly Admitted Resident
Penalty
Summary
The facility failed to ensure that Resident #99’s baseline care plan was thoroughly completed and included resident-specific initial goals based on admission orders needed to properly care for the resident immediately upon admission. The resident was admitted with diagnoses including acute and chronic respiratory failure with hypoxia, emphysema, absence of part of the lung, pulmonary hypertension, and major depressive disorder. During the admission period, the resident had physician orders for psychotropic medications including diazepam, aripiprazole, duloxetine, and trazodone, as well as spironolactone and oxycodone. A review of the baseline care plan showed that it did not include the resident’s psychotropic, diuretic, and opioid medications. The Unit Manager stated that the baseline care plan should be completed and implemented within 48 hours and that nursing staff were responsible for reviewing it with the resident and/or resident representative, providing a copy of the care plan and order summary, and answering questions. The surveyor and Unit Manager confirmed that the resident’s baseline care plan was not thoroughly completed upon admission to include the medications the resident was taking, despite the need for specific monitoring and nursing considerations associated with those medications.
Failure to Hold Timely Quarterly Care Plan Meetings
Penalty
Summary
The facility failed to ensure residents and/or resident representatives were offered the opportunity to participate in the care planning process by holding timely quarterly care plan meetings. During the annual survey, the surveyor reviewed care planning records for 4 residents and found this issue for 2 residents. The facility’s Social Worker and Nursing Home Administrator stated that initial care plan meetings are held within 7-14 days of admission and then quarterly, usually within the timeframe of the MDS assessments, with meetings also held for changes in condition or at the request of the resident or resident representative. For one resident, care plan meetings were documented on 2/1/2024, 6/20/2024, and 9/18/2025, while the electronic record showed multiple quarterly and annual MDS assessments between those dates, but no care plan meetings were found during several of those assessment timeframes. For the second resident, care plan meetings were documented on 6/9/2024, 11/22/2024, 2/26/2025, 4/24/2025, and 10/9/2025, while the record showed annual and quarterly MDS assessments on 3/19/2024, 5/2/2024, 8/3/2024, 11/3/2024, 12/20/2024, 3/20/2025, 6/20/2025, and 9/20/2025; the surveyor did not find care plan meetings held quarterly during the timeframe of several of those assessments. The NHA stated the facility completed a care plan meeting audit because it identified an issue with timely care plan meetings and documentation, but by exit conference the facility was unable to provide supporting documentation for timely quarterly care plan meetings for either resident.
Failure to Offer Resident Access to Group Activities
Penalty
Summary
The facility failed to ensure that a resident was offered the opportunity to participate in facility-sponsored group activities. Resident #54 used a wheelchair and needed staff assistance with transportation around the facility. The resident representative stated that the resident had been given coloring activities in the room but had not been observed being offered group activities or attending them, and said the resident would likely enjoy getting out of the room for group activities. Record review showed that Resident #54’s admission and annual activities assessment identified preferred activities including small groups, crafts, music, watching TV/movies, dogs, sports, and being invited to church. The activity care plan included a focus that the resident preferred not to attend group activities due to little motivational interest, with a goal to adjust positively to the facility by participating in independent or group activities of interest and an intervention to encourage participation in group activities of interest. Activity documentation reflected that staff reviewed the Daily Chronicle, provided coloring packets, and recorded limited participation such as prayer room visits, watching TV, and attendance at a Veterans Day ceremony, while the activity director stated staff should let residents know the daily activities and offer assistance to those who need it.
Unaddressed Dry Skin on Lower Extremities
Penalty
Summary
The facility failed to ensure Resident #24’s dry skin condition was identified and addressed. During observation, the resident was seen in a wheelchair and later in bed with very dry, visibly flaky skin on both lower extremities, and the resident had no socks or shoes on during the initial tour. The resident’s record showed a diagnosis of lymphedema and that the resident was dependent on staff for personal hygiene, but there was no documentation that the dry, flaky skin on the lower legs had been identified or addressed in the medical record, progress notes, or weekly skin assessments. The resident’s care plan included a problem related to a history of skin breakdown and risk for skin alteration due to limited mobility, intermittent incontinence, bilateral lower extremity edema, and lymphedema, with an intervention to observe skin condition with ADL care daily and report abnormalities. During interview, the UM confirmed the lower extremity skin was dry and stated lotion would be ordered, and also acknowledged the condition had not been addressed before surveyor intervention. After the surveyor raised the issue, an order for ammonium lactate cream was entered for dry skin.
Failure to Schedule Ophthalmology Follow-Up for Cataract Surgery
Penalty
Summary
The facility failed to ensure Resident #57 received proper treatment and scheduled follow-up appointments to maintain vision. During interview, the resident stated he had cataract surgery on the right eye and was supposed to have cataract surgery on the left eye, but the facility never scheduled the surgery. Record review showed an eye care note from 4/22/2024 documenting mixed cataracts in both eyes, bothersome vision, stable visual acuity, and a recommendation for cataract surgery with an ophthalmology consult and follow-up in 4-5 months. Further record review showed another eye care note from 6/27/2025 documenting a mixed cataract in the left eye and stating the resident had cataract surgery on the right eye months earlier and was supposed to return for the left eye but was never scheduled according to the patient. That note again recommended cataract surgery and an ophthalmology consult, with follow-up in 5-6 months and a request to schedule an outside ophthalmology appointment for further evaluation and extraction of bothersome cataracts. Review of the electronic medical record did not reveal an appointment scheduled after the 6/27/2025 eye exam, and the DON confirmed the concern and stated they would look into it. A physician order dated 12/1/2025 later showed an ophthalmology appointment scheduled for 12/5/2025 at 11:00 AM.
Inconsistent Incontinence Care Documentation and Wet Brief Observed
Penalty
Summary
Consistent incontinence care was not provided for Resident #4, who was documented in the medical record as totally dependent on staff for toileting needs and incontinent of bowel and bladder. During the initial tour on 11/24/25, the resident was observed in bed wearing a visibly wet, yellow incontinence care product. Review of the task documentation later showed incontinence care entries only on selected dates and times in late November and early December, with no evidence that care was documented consistently each shift. During interview, the Unit Manager confirmed that all GNAs are required to document care every shift and acknowledged that Resident #4 was dependent on staff for incontinence care and was incontinent. The Unit Manager reviewed the documentation with the surveyor and stated that it did not appear to have been documented, noting that the 3-11 shift was at 82% for documentation the prior day. The surveyor also noted that daily odors were present throughout resident hallways and adjacent areas during the recertification survey.
Respiratory tubing and humidification equipment were not labeled or properly stored
Penalty
Summary
Respiratory care was not provided in accordance with the facility’s documented orders for two residents. For Resident #98, the surveyor observed on 11/24/2025 that the nasal cannula oxygen tubing had no label showing the date or time it was placed or when it would expire, and the humidification bottle for oxygen also had no date or time label. At the same time, Resident #98’s nebulizer machine and face mask were observed laying directly on the floor next to the bed. An LPN observed the concerns and stated the tubing and mask should not be stored on the floor. The DON later stated the expectation was for respiratory tubing to be dated and timed with a label and confirmed that respiratory nebulizer equipment should not be stored on the floor’s surface. The record for Resident #98 showed an order beginning 11/03/2025 for oxygen tubing change weekly and to label each component with date and initials. For Resident #10, the surveyor observed on the initial tour that the oxygen tubing had no labeling present. The medical record showed an order beginning 7/23/25 for oxygen tubing change weekly and to label each component with date and initials. On 11/26/2025, the surveyor again observed Resident #10’s respiratory tubing with no label showing date or time, and the humidification bottle was sitting directly on the floor attached to the concentrator by extension tubing. A UM observed the concern and acknowledged it, stating they would take care of it. The Administrator was also informed and acknowledged the concern. The concern was again shared during the exit conference on 12/01/2025.
Improper Storage of Medications Awaiting Disposition
Penalty
Summary
The facility failed to ensure an appropriate storage method was used for medications awaiting final disposition in the Station 2 medication room. During observation, a bottle of levetiracetam oral solution for Resident #79 and a white paper bag containing a ONETOUCH Ultra 2 device, strips, and lancets for Resident #100 were found sitting on the medication room counter rather than being stored for return to pharmacy. Review of the records showed that Resident #79's levetiracetam oral solution had been discontinued on 11/20/2025, and Resident #100 had been discharged on 10/14/2025. During interview, the Unit Manager confirmed the items were on the counter and stated that discontinued medications and remaining medications for discharged residents were expected to be placed in a pharmacy-provided white plastic bag labeled return to pharmacy so they could be identified as ready for pickup by the pharmacy representative.
Failure to Assist Resident With Routine Dental Care
Penalty
Summary
The facility failed to assist Resident #57 in obtaining routine dental care. During an interview, the resident stated that they had not been examined by a dentist in a long time and had been requesting dental services for existing dentition and general oral hygiene. A review of the electronic medical record showed the last documented dental consult was dated 2/16/2024, and there was no documentation of any scheduled routine dental appointments. An interview with RN #21 confirmed that Resident #57 had requested to see the dentist. The DON stated that the facility provides dental services and that the dental company would see residents for emergency services without joining, while residents who did not qualify could be assisted with locating outside dental services. Despite the resident’s request and the lack of recent documented dental care, no scheduled dental appointment was provided to the surveyor by exit conference.
Failure to Follow Diet Order and Allergy Information
Penalty
Summary
The facility failed to provide a diet that met a resident’s special dietary needs and preferences. During breakfast observation, the resident stated that he or she was not allergic to beef, but the meal ticket listed a beef allergy and the tray did not match the ticketed meal. The resident reported that bacon and oatmeal cereal were supposed to be served, but the tray contained scrambled eggs, two sausage patties, and one piece of white toast, with no bacon, oatmeal cereal, juice, coffee, or tea. The resident also stated that drinks were not being provided with meals and that coffee was wanted with breakfast, but it was brought too late or not at all, leaving the resident finished eating or with cold food while waiting. The resident’s meal ticket for breakfast listed a carbohydrate controlled diet, four slices of bacon, 12 oz of oatmeal cereal, 12 oz of coffee or hot tea, 8 oz of orange juice, and allergies to dairy and beef. At the time of observation, the resident still had not received juice, coffee, or tea. Review of the medical record showed a diet order for a regular diet with regular texture and double portions, and the chart listed allergies to beans, cheese, and lactose, with no documentation of a beef allergy. Staff confirmed that the meal ticket stated the resident was to receive a carbohydrate controlled diet, bacon, oatmeal cereal, and drinks, and the DON confirmed that beef was not listed as an allergy in the medical record.
Menu Items Not Served as Posted
Penalty
Summary
The facility failed to follow the posted menu for residents’ meals. During observational rounds, Resident #8 stated that breakfast was supposed to include bacon and oatmeal cereal, but the tray did not contain bacon or oatmeal cereal. The resident also stated that drinks were not being served with meals and that coffee was wanted with breakfast, but it was often brought too late or not at all, leaving the resident either finished with the meal or eating cold food while waiting. Resident #8’s tray contained scrambled eggs, 2 sausage patties, and 1 piece of white toast, with no juice, coffee, tea, or oatmeal cereal, even though the meal ticket called for 4 slices of bacon, 12 oz of oatmeal cereal, 12 oz of coffee or hot tea, and 8 oz of orange juice. Resident #58 stated that French Toast Casserole was not received for breakfast, and the meal ticket for that resident listed French Toast Casserole - 2 squares. The posted menu in the hallway listed French Toast Casserole, bacon, hot or cold cereal, and a choice of milk, juice, coffee, or tea. Staff confirmed that residents did not receive the breakfast items listed on the menu and stated that bacon and French Toast Casserole were not in stock because the food truck did not come and the supply company was out of stock. No documentation or verification was provided showing that residents were informed of menu changes or offered resident choices when items were unavailable.
Incomplete advance directive documentation and inaccurate medication indication
Penalty
Summary
The facility failed to ensure Resident #10’s medical record contained complete and accurate documentation related to advanced directives and incapacity determinations. The resident was admitted with severe cognitive impairment and had a MOLST form in the record that identified a health care agent, but the record did not contain an advanced directive, and only one certification of incapacity signed by one physician was present. The resident’s face sheet listed a healthcare surrogate, and the hospital discharge summary documented that a surrogate decision maker existed before admission, but no physician documentation was found showing review of the resident’s advanced directives in the facility record. During surveyor review, facility staff confirmed that the second certification of incapacity and the advanced directive should have been in the hard chart, but they could not locate them. The DSS stated the MOLST being followed had last been completed by the hospital, and the DON and physician acknowledged that the medical director was being contacted because the second certification could not be found. The surveyor later obtained two certifications of incapacity dated the same day as surveyor intervention, and a MOLST form was then observed signed by the physician indicating the basis for the orders was the patient’s surrogate. The facility also failed to ensure the accuracy of a medication order for Resident #24. The resident had an order for empagliflozin 10 mg daily documented for diabetes mellitus, but the resident’s diagnosis list, care plan, and physician progress notes did not show a diagnosis of diabetes. The DON stated the resident did not appear to be diabetic, and the medical director confirmed the medication was not being given for diabetes mellitus. After surveyor intervention, the order was revised to list congestive heart failure as the indication.
Undated Tube Feeding Equipment
Penalty
Summary
The facility failed to ensure tube feeding equipment was properly dated for Resident #9, who was observed using a tube feeding that was not dated. During the observation on 11/24/2025 at 10:27 AM, the tubing and nutrition bottle were both found to be undated. Staff #10, who was assigned to the resident, confirmed the equipment was undated and stated it was the nurse’s responsibility to ensure the tube feeding equipment was dated. The Director of Nursing was made aware of the findings on 11/25/2025 at 10:48 AM.
What surveyors are citing around you — mapped
All 10 risk areas, ranked with evidence
Repeat citations, what's rising near you, and quality measures — ranked so department heads know exactly where to look first.
Illustrative
What surveyors actually found near you
We read the 1,453 citations issued within 25 miles in the last 12 months — including the 6 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
Every risk area becomes concrete audit steps drawn from real citations at facilities like yours — run them this week, before your window opens.
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 At Parkville | 1.7 mi | ★★★★★ | 0 | 0 |
| Autumn Lake Healthcare At Loch Raven | 1.7 mi | ★★★★★ | 34 | 0 |
| Good Samaritan Nursing Home Operator, Llc | 1.7 mi | ★★★★★ | 4 | 0 |
| Autumn Lake Healthcare At Overlea | 2.2 mi | ★★★★★ | 5 | 0 |
| Future Care Cold Spring | 2.3 mi | ★★★★★ | 29 | 0 |
Every risk area ranked, a do-first checklist, and your local survey patterns
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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 August 2026) and official state health department websites.