Autumn Lake Healthcare At Pikesville
Inspection history, citations, penalties and survey trends for this long-term care facility in Pikesville, Maryland.
- Location
- 7 Sudbrook Lane, Pikesville, Maryland 21208
- CMS Provider Number
- 215082
- Inspections on file
- 18
- Latest survey
- July 25, 2025
- Citations (last 12 mo.)
- 35
Citation history
Health deficiencies cited at Autumn Lake Healthcare At Pikesville during CMS and state inspections, most recent first.
Surveyors identified failures in infection prevention and control, including unclear Enhanced Barrier Precautions (EBP) signage in double-occupancy rooms, lack of accessible infection control supplies, and staff confusion about which residents required EBP. Additionally, clean laundry was stored in a room with stained, damp walls and a ceiling hole with debris, raising concerns about contamination.
Facility staff did not administer several medications to a resident within the required 1-hour time frame, resulting in significant medication errors. Multiple medications, including antihypertensives, supplements, and pain relievers, were given at times that did not align with physician orders. The DON was unable to provide an explanation when interviewed about these findings.
Two residents who were highly functioning and in stable health reported that their requests for discharge and independent living were not properly facilitated by staff. Both experienced delays and lack of follow-up due to staff turnover and gaps in social work coverage, resulting in unaddressed discharge planning and incomplete documentation.
The facility did not provide two residents with the required Skilled Nursing Facility Advance Beneficiary Notice of Non-coverage, and one resident did not receive the Notice of Medicare Non-coverage. These forms are necessary to inform beneficiaries about Medicare coverage status, potential financial liability, and appeal rights. The deficiency was confirmed through record review and administrator interview.
Surveyors identified multiple areas within the facility, including a housekeeping closet, utility room, medication room, and a resident bathroom, that were not maintained in a clean or functional state. Issues included standing water with foul odors, clogged drains, unclean toilets, sinks with visible buildup, lack of hand hygiene supplies, and damaged bathroom fixtures. Facility leadership confirmed these observations during the survey.
A staff member failed to immediately report a witnessed incident of alleged verbal and physical abuse by a nurse toward a resident. Although the abuse allegation was later unsubstantiated, the delay in reporting violated the facility's protocol for timely reporting of suspected abuse.
Two residents did not have their comprehensive care plans developed within the required timeframe or with full IDT participation. In both cases, only select staff such as the Activities Director, LPN, Dietician, and Social Work Director were involved, with no documented input from the attending physician, RN, or nurse aide. Additionally, one resident's care plan lacked timely completion and did not include participation from the resident or their representative.
A resident received multiple medications outside the prescribed 1-hour administration window, including garlic orals, hydralazine HCL, zinc, magnesium oxide, naproxen, and forastor. These medications were given several hours late, and the DON was unable to provide an explanation during the survey. This resulted in a failure to meet professional standards for medication administration.
Surveyors found that two residents did not have up-to-date social work documentation or follow-up regarding their requests for discharge, due to a gap in social work staffing and incomplete medical records. The deficiency was confirmed through interviews and review of available documentation.
A resident was observed lying in bed with legs dangling over a significant gap between the mattress and the bed frame footboard. Measurement by the Maintenance Director confirmed an 8 ½ inch gap due to the mattress being the wrong size for the bed frame.
A resident reported and surveyors observed numerous black flying insects present in one room and bathroom, with approximately 14 pests seen flying and on the walls. The deficiency was confirmed through interviews and direct observation, indicating a lapse in the facility's pest control program.
Failure to Maintain Infection Prevention and Control Standards
Penalty
Summary
The facility failed to maintain an effective infection prevention and control program, as evidenced by multiple deficiencies observed during survey rounds and interviews. Surveyors found that Enhanced Barrier Precautions (EBP) signage was inconsistently applied and did not clearly identify which resident in double-occupancy rooms required precautions. In several cases, EBP signage was present without corresponding infection control supplies available for staff use, and staff were unable to identify which resident the precautions applied to. Medical record reviews revealed discrepancies, including signage for residents not on EBP and lack of clear identification for those who were. Staff interviews confirmed confusion regarding the identification system, with inconsistencies noted in the use of green dots to mark residents requiring EBP. Additionally, the facility failed to maintain proper infection prevention standards in the laundry area. Observations revealed that clean laundry was stored against stained, damp, and peeling cement walls, and directly beneath a large hole in the ceiling with protruding debris. These conditions were present in the room where clean laundry was processed, posing a risk for contamination. The facility administrator was made aware of these environmental concerns during the survey.
Failure to Administer Medications Within Prescribed Time Frames
Penalty
Summary
Facility staff failed to administer medications in accordance with professional standards, resulting in significant medication errors for one resident. The errors were identified through observation, record review, and interview. Specifically, the resident's medications were not given as prescribed by the physician, violating the five rights of medication administration: right person, right medication, right route, right dosage, and right time. On a specific date, multiple medications for the resident were administered outside the required 1-hour time frame. These included garlic orals, hydralazine HCL, zinc, magnesium oxide, naproxen, and forastor capsules, all of which were given at times significantly later or earlier than scheduled. The findings were discussed with the Director of Nursing, who did not provide a response at the time of the interview.
Failure to Facilitate Resident Discharge Choices Due to Staff Turnover and Lack of Follow-Up
Penalty
Summary
The facility failed to ensure that residents' choices regarding discharge were properly facilitated, as evidenced by the experiences of two residents. One resident expressed a desire for a private living arrangement where family and friends could visit without restrictions and where they could have more autonomy, including going outside at will. This resident reported that the discharge process had been initiated three times but was never completed due to staff turnover, leaving them and others waiting for assistance. The Director of Social Work (DOSW), who had only been in her position for thirty days, was not aware of the resident's specific wishes and stated she would follow up. Another resident also reported wanting to leave the facility and live independently, stating that they had not received assistance with the discharge process and had not been followed up with for months. The Nursing Home Administrator confirmed that the previous social worker had left several months prior and that a consultant was only providing services once a month. The current DOSW was unable to provide follow-up documentation for either resident during the period after the previous social worker's departure, indicating a lack of continuity and follow-through in supporting residents' discharge choices.
Failure to Provide Required Medicare Coverage and Liability Notices
Penalty
Summary
The facility failed to provide required Medicare notifications to residents regarding coverage and potential financial liability for services not covered. Specifically, record reviews and staff interviews revealed that two residents were not given the Skilled Nursing Facility Advance Beneficiary Notice of Non-coverage (CMS-10055), which is intended to inform beneficiaries when Medicare may no longer cover their skilled services and to clarify their payment responsibilities if they choose to continue receiving those services. The facility's own completion of the SNF Beneficiary Protection Notification Review form (CMS-20052) confirmed that these notifications were not issued as required. Additionally, one of these residents was not provided with the Notice of Medicare Non-coverage (CMS-10123), which is necessary to inform beneficiaries of their right to appeal and request an expedited review when Medicare coverage is ending. During interviews, the Nursing Home Administrator acknowledged that the required forms were not provided to the affected residents, as indicated on the facility's internal review documentation.
Failure to Maintain Clean and Functional Environment in Resident and Staff Areas
Penalty
Summary
Surveyors observed multiple deficiencies related to the facility's failure to maintain a clean, functional, and homelike environment. During observation rounds, a housekeeping closet on the 1 West Wing was found to have approximately two inches of standing, dark green and black water in the floor drain, emitting a musty, earthy, and decaying wood odor. The Environmental Service Director confirmed the drain was clogged and required cleaning. In the same wing, a utility room contained a toilet bowl filled with dark green and brown water, also producing a musty, earthy odor, which the Maintenance Director acknowledged should not occur and indicated the toilet should be clean. Further observations revealed that the medication room on the 1 West Wing had a sink with a dark green and reddish-brown flaky substance around and inside the drain, and lacked paper towels or similar items for staff handwashing. The Maintenance Director confirmed the sink's condition and the absence of hand hygiene supplies. In a resident room, the bathroom contained a toilet with a cracked water tank, a green, white, and black hard substance on the toilet handle, and a bedside commode over the toilet base with a reddish-brown flaky substance on its front and legs. The Nursing Home Administrator was made aware of these findings during the survey.
Failure to Immediately Report Alleged Abuse
Penalty
Summary
Facility staff failed to immediately report an allegation of abuse involving Resident #19. According to the facility's investigation and a statement from a Geriatric Nursing Assistant (GNA), the GNA witnessed a nurse verbally and physically abuse the resident but did not report the incident immediately as required. The facility's administrative review confirmed that staff are trained to report abuse allegations to management without delay, and the expectation was reiterated by the Administrator during interviews. The investigation ultimately found the abuse allegation to be unsubstantiated, but the delay in reporting by the GNA constituted a failure to follow established protocols for timely reporting of suspected abuse.
Failure to Develop Comprehensive Care Plans with Full Interdisciplinary Team Participation
Penalty
Summary
The facility failed to ensure that comprehensive care plans were developed within 7 days of the comprehensive assessment and that these care plans were prepared, reviewed, and revised by the full interdisciplinary team (IDT) as required. For one resident, the care plan conference summary indicated that only the Activities Director, Unit Manager (LPN), Dietician, and Social Work Director participated in updating the care plan, with no documentation of participation or input from the attending physician, a registered nurse, or a nurse aide responsible for the resident. Additionally, there was no evidence that these missing team members communicated their updates to the care plan. For another resident, the comprehensive care plan was not completed within the required 7-day timeframe following the comprehensive assessment. The care plan conference summary lacked documentation of participation from the resident or their representative, and the only signatures present were from the Director of Social Work, Director of Activities, and Dietician. Attempts to contact the resident's family for participation were unsuccessful, and there was no documentation of involvement from the attending physician, registered nurse, or nurse aide. Staff interviews confirmed the absence of documentation supporting full IDT participation in the care plan development.
Failure to Administer Medications According to Professional Standards
Penalty
Summary
Facility staff failed to administer medications in accordance with professional standards, resulting in significant medication errors for one resident. The errors were identified through observation, record review, and interview. Specifically, the resident's medications were not given as prescribed by the physician, with multiple medications administered outside the required 1-hour time frame. The medications affected included garlic orals, hydralazine HCL, zinc, magnesium oxide, naproxen, and forastor, all of which were given at times significantly later than scheduled. The medication administration audit revealed that these deviations from the prescribed schedule occurred on a specific date, with some medications being administered several hours late. During an interview, the Director of Nursing was unable to provide a response regarding these findings. The report documents that the facility did not ensure residents were free from significant medication errors, as required by professional standards and the five rights of medication administration.
Failure to Maintain Accurate Medical Records and Follow-Up for Resident Discharge Requests
Penalty
Summary
Surveyors identified that the facility failed to maintain accurate and up-to-date medical records for two residents. Both residents expressed a desire to leave the facility and reported that their requests for assistance with discharge had not been addressed for an extended period. Interviews revealed that the discharge process for one resident had been initiated multiple times but was not completed due to staff turnover. The other resident also reported a lack of follow-up regarding their request to leave. Documentation provided by the current Director of Social Work showed that the last social work notes for these residents were from several months prior, with no follow-up notes available during the period after the previous social worker left. The facility administrator confirmed that there was a gap in social work coverage following the departure of the previous social worker, which resulted in a lack of documentation and follow-up for the affected residents. The current Director of Social Work had only recently started and was unable to provide documentation of ongoing social work interventions for the residents during the interim period. This lapse in maintaining accurate and complete medical records was discussed with the administration team during the exit conference.
Incompatible Bed Mattress and Frame Resulting in Unsafe Gap
Penalty
Summary
The facility failed to ensure compatibility between a resident's bed mattress and bed frame. During observation rounds, a resident was found lying in bed with their legs dangling over a gap between the end of the mattress and the bed frame footboard. Further inspection and measurement by the Maintenance Director revealed an 8 ½ inch gap, and it was confirmed that the mattress was the wrong size and did not fit the bed frame. This deficiency was identified in one out of 25 resident beds reviewed during the survey. No information regarding the resident's medical history or condition at the time of the deficiency was provided in the report.
Failure to Maintain Effective Pest Control Program
Penalty
Summary
The facility failed to maintain an effective pest control program, resulting in the presence of pests in a resident's room and bathroom. During an interview, a resident reported that numerous black flying bugs were present in the room and would fly around their head while eating. Subsequent observation confirmed the presence of approximately 14 black, winged pests flying and resting on the walls in the resident's room and bathroom. These findings were based on direct observations and interviews conducted during the survey. The deficiency was specifically noted in one resident's bathroom out of 25 observed during the survey, with both the resident and staff acknowledging the presence of pests in the affected area.
Latest citations in Maryland
The facility did not ensure that its Infection Preventionist (IP) met required qualifications for managing the Infection Prevention and Control Program. The DON reported serving as the IP but acknowledged lacking the specialized infection control training required for the role, and confirmed that no other staff member was currently qualified. Records showed that the previously qualified IP left several months earlier, and the Administrator and DON confirmed they were still seeking a replacement, leaving the infection control program without a properly trained leader.
Staff failed to consistently secure medications and medical supplies across three units, including an oxygen tank left on the floor behind a resident’s bed without a supporting device, a treatment cart with Collagenase Santyl cream left on top while two residents in power wheelchairs passed by, an unattended and unlocked treatment cart at a nursing station, and another treatment cart with Diclofenac gel and dressings left on top, indicating repeated lapses in maintaining locked and secure storage for drugs, biologicals, and related supplies.
The facility failed to provide sufficient dietitian coverage and timely nutritional assessments for several residents with significant dietary needs. A resident admitted for diabetic management with a high A1C was placed on a regular diet instead of the recommended carb-controlled diet and had only one weight taken in the first two weeks, with no dietitian review of the record. Another resident with prior significant weight loss had no documented dietitian follow-up despite continued weight loss, and a resident admitted with severe protein-calorie malnutrition experienced further significant weight loss without any dietitian assessment. The dietitian reported working limited hours and prioritizing certain high-risk cases, resulting in delayed or missed evaluations for new admissions and residents with ongoing nutritional concerns.
The facility failed to maintain adequate linen and incontinence supplies and did not keep resident care areas in good repair, resulting in delays and alterations in incontinence care and substandard environmental conditions. Staff reported that towels and washcloths were used instead of wipes and then discarded due to heavy soiling, and that linen deliveries to units were late, leaving residents waiting for care. Observations showed very limited numbers of clean washcloths and other linens on units and in the laundry, with no stock of disposable wipes or backup washcloth supply despite repeated reports to housekeeping. Additional observations revealed recliner chairs blocking a dining-area handwashing sink and kitchenette, multiple resident and shared bathrooms with unfinished spackle, chipped paint, musty odors, black substances near showers, missing threshold molding, exposed cracks and nails, and eroded, rusted baseboard heaters. Hallway handrails on both units were worn, chipped, and splintered, and a shower room contained fecal odors, dried brown stains on the toilet, and deteriorated fixtures, all contributing to a failure to provide a safe, clean, and homelike environment.
Facility staff did not thoroughly investigate two separate abuse allegations involving a resident and an injury of unknown origin involving another resident. In both cases, investigations focused on the directly affected resident and included staff interviews, but there were no interviews of other residents on the unit or documented assessments of those residents for signs of abuse or injuries of unknown origin, including residents unable to communicate due to cognitive status.
Two residents who were dependent on staff for oral care, including one with a tracheostomy, were observed with thick, white or milky substances coating their mouths and teeth, indicating inadequate oral hygiene. One resident communicated that staff did not brush their teeth and that staff "need to." In another case, despite oral care supplies being present in the room, the resident’s mouth and teeth remained unclean on multiple observations, with a thick milky substance caking the teeth and stringing between them when the resident tried to open their mouth. These findings showed that staff did not consistently provide oral care to residents who relied on them for this ADL.
Staff failed to maintain complete and accurate medical records for multiple residents, including missing and inconsistent documentation of wound care, delayed pain assessment after discovery of an injury of unknown origin in a cognitively impaired resident, and inaccurate recording of a PPD test result that was documented as negative despite no evidence the injection was administered and no supporting nurse’s note. Residents reported not receiving certain treatments, while MAR entries either lacked signatures for completion or contained conflicting information about whether care was provided.
Surveyors found that the facility failed to consistently implement and communicate correct transmission-based precautions and PPE use. One resident with a Foley catheter related to wounds had no precaution signage posted, while another resident in a double room had a contact precautions sign at the door, yet the NP entered without PPE and the GNA provided high-contact care wearing only gloves. Staff in that room stated the resident was not on contact precautions and later reversed the sign to show no PPE requirement. Therapy staff reported they rely solely on posted signs to determine PPE, and surveyors identified broader issues with inaccurate signage and staff awareness of which residents required contact precautions.
Surveyors found that MDS assessments were inaccurately coded for two residents. In one case, a resident sustained a femoral neck fracture after a fall, but the subsequent significant change MDS did not code the fall as a major injury and failed to capture prn Tylenol use documented on the MAR within the look-back period. In the other case, a quarterly MDS indicated opioid use for a resident, but the MAR for the same period showed no prescribed opioid, indicating incorrect coding of high-risk drug classes.
A resident who had recently been admitted and experienced a fall received multiple doses of the narcotic analgesic Tramadol, but the facility failed to accurately document all administered doses on the Medication Administration Record (MAR). Review showed only one Tramadol dose recorded on the MAR, while the Controlled Drug Receipt/Record/Disposition Form on the med cart reflected three doses given over two days. In interview, the DON stated staff are expected to document narcotic administration on the MAR and confirmed that two administered doses were not recorded there, resulting in an incomplete and inaccurate medical record.
Unqualified Infection Preventionist Overseeing Infection Control Program
Penalty
Summary
The facility failed to ensure that its designated Infection Preventionist (IP) met the mandatory qualifications for overseeing the Infection Prevention and Control Program. During an interview on 3/24/26 at 10:00 AM, the DON confirmed that she/he was serving as the facility’s IP but had not completed the specialized training in infection control required for the position. The DON further stated that no other staff member currently met the qualifications to serve as IP. Record review showed that the previously qualified IP left the facility in October 2025, and as of the survey date, the position remained unfilled by a qualified individual. At 1:30 PM on the same day, the Administrator and DON confirmed they were still in the process of finding a qualified IP for the facility, leaving the Infection Prevention and Control Program without a properly trained and qualified leader. No specific residents, medical histories, or clinical conditions were described in relation to this deficiency.
Unsecured Medications, Treatment Carts, and Oxygen Equipment
Penalty
Summary
Facility staff failed to ensure that drugs, biologicals, and related medical supplies were securely stored and properly maintained on multiple units. On one unit, an oxygen tank assigned to a resident was observed sitting on the floor behind the resident’s bed without any supporting device. On another unit, a treatment cart was observed with a tube of Collagenase Santyl cream labeled for a specific resident left on top of the cart, while residents in power wheelchairs passed by and staff were present at the nursing station. These observations showed that medications and oxygen equipment were not consistently secured as required. Further observations on additional units revealed an unattended and unlocked treatment cart at a nursing station, and on a separate occasion, a treatment cart with Diclofenac gel labeled for a resident left on top along with multiple packs of dressings. These incidents occurred across three units and on more than one date, demonstrating repeated failures to keep medications and treatment supplies in locked compartments or otherwise secured from unauthorized access.
Insufficient Dietitian Coverage and Delayed Nutritional Assessments
Penalty
Summary
The deficiency involves the facility’s failure to employ sufficient food and nutrition staff, including adequate dietitian coverage, to ensure timely assessment and appropriate diets for residents with significant nutritional and diabetic needs. A resident admitted over two weeks earlier with multiple comorbidities and an A1C of 11.5% had a hospital discharge recommendation for a carbohydrate-controlled diet, but was placed on a regular diet at admission with no acknowledgment of the recommended diet until one week later, when the resident requested larger portions. As of the survey date, the dietitian had not yet seen or reviewed this resident’s medical record, and the resident reported not having seen a dietitian and being very frustrated with the meals. During the first two weeks after admission, only one weight was obtained for this resident, despite physician notes stating the resident’s weight was “stable.” Further review of other residents showed additional failures in timely dietitian assessment and follow-up. One resident, readmitted in January and previously seen by the dietitian in September for a 6.4 lb weight loss over 30 days, had no documented follow-up despite continued weight loss totaling 22 lbs since the last dietitian review. Another resident admitted at the end of February with severe protein-calorie malnutrition had not been seen by the dietitian after about a month in the facility, despite a documented 14 lb (7%) weight loss over two weeks. The dietitian reported working only 12 hours per week at the facility and stated that she must prioritize which residents to see, focusing first on residents with tube feedings and those identified in risk meetings, resulting in delayed or absent assessments for new admissions and residents with ongoing weight loss and malnutrition diagnoses.
Linen Shortages and Poor Environmental Maintenance Compromise Resident Care and Comfort
Penalty
Summary
The deficiency involves the facility’s failure to maintain an adequate supply of clean linens and appropriate incontinence wipes, resulting in delays and alterations in residents’ incontinence care, as well as the use of towels and washcloths in place of disposable wipes. During the initial tour, the surveyor observed that the linen supply on one nursing unit hallway was low. Complaint reviews included concerns about delays in incontinence care and bed linens not being changed regularly, with residents left without clean bedding. A complainant reported that there was not enough clean linen available for residents. Staff interviews confirmed that towels, sheets, and washcloths were being used to wipe residents for incontinence care due to the absence of wipes, and that many of these linens were being thrown away when soiled. Staff also reported a shortage of linen, that linen deliveries to the units were late, and that residents who preferred to get up before breakfast had to wait for care when linen was delayed. Further observations showed that the clean supply room contained no disposable wipes or cloths for incontinence care, and a resident reported that staff did not use wipes, that the resident had to purchase their own, and that heavily soiled towels or washcloths were discarded. A tour of all nursing unit linen carts and closets revealed only six clean washcloths and limited supplies of towels, gowns, and bed linens. In the laundry room, only three washcloths were present, and the laundry assistant stated that there were only three washcloths available for each nursing unit that morning, that the facility was short on linen supply, and that these concerns had been repeatedly reported to the Director of Housekeeping over the preceding month and again that morning. The laundry assistant confirmed there was no additional laundry in process. The DON stated that wipe squares should be used for incontinence care, but no such wipes were found in the clean medical supply room, and no backup supply of washcloths was present in the emergency linen supply. The Director of Housekeeping confirmed there was no backup supply of washcloths. The deficiency also includes environmental and maintenance issues affecting resident bathrooms, handrails, and common areas. In the main dining area, a recliner chair was observed positioned directly in front of the handwashing sink, and two recliner chairs were stored in front of the nutrition area kitchenette. Multiple resident bathrooms and shared bathrooms were repeatedly observed over several days with unfinished spackle on walls that needed resurfacing and painting, chipped paint around sinks, uneven boards nailed to walls under sinks that appeared to partially cover holes, musty odors, black substances between shower bases and walls, missing threshold transition molding exposing cracks, missing tiles, and a nail, as well as eroded and chipped paint on baseboard heaters with exposed dark brown metal and rust-like material. Hallway handrails on both nursing units were observed to be worn, with chips, splintering, holes, and areas where the wood finish had worn off. A shower room was observed with a foul fecal odor, dried brown stains on the back of the toilet seat and in the toilet bowl, and a baseboard heater with eroded, chipped paint and rust-like material, along with chipped paint on the handrail. These conditions were acknowledged by the Director of Maintenance and other leadership, and some areas were noted to be in the process of renovation, but the observed deficiencies remained present during the survey period. Overall, the facility did not maintain a safe, clean, comfortable, and homelike environment in good repair across both nursing units and the dining area. The lack of adequate linen and incontinence supplies, combined with the poor condition of resident bathrooms, handrails, and certain common areas, constituted the basis for the cited deficiency. The observations and staff and resident reports consistently described shortages of essential hygiene supplies, delayed care related to linen availability, and multiple unresolved environmental and maintenance issues in resident care areas and shared spaces.
Failure to Thoroughly Investigate Abuse Allegations and Injuries of Unknown Origin
Penalty
Summary
Facility staff failed to thoroughly investigate allegations of potential abuse involving one resident and an injury of unknown origin involving another resident. For one resident, there were two separate allegations of abuse occurring on different days in early February. The facility’s investigation packets included interviews with staff who cared for or were scheduled to work with this resident on the days of the alleged incidents, and the investigations focused solely on this resident. However, there were no interviews conducted with other residents on the unit to inquire about abusive or neglectful treatment by the staff who were working during the times of the allegations. The surveyors noted that, although the allegations were not validated, there was no documentation that other residents were interviewed, if able, or assessed for signs or symptoms of injury. In a separate incident, another resident was identified on March 4 with a new bruise on the right eye, documented as a change in condition at 4:09 AM. This resident had a BIMS score of 99, indicating the resident was unable to complete an interview and therefore could not report how the injury occurred. The facility’s investigation identified a potential cause of the injury but did not reach a definitive resolution. Additionally, there were no interviews of other residents on the unit regarding possible abuse, nor were there documented assessments of other residents for injuries of unknown origin, particularly for those unable to speak for themselves, as in this resident’s case.
Failure to Provide Oral Care to Dependent Residents
Penalty
Summary
The deficiency involves the facility’s failure to provide oral care to residents who were dependent on staff for activities of daily living, specifically oral hygiene. One resident with a tracheostomy was observed with a thick, sticky white substance in the mouth and was noted to intermittently chew on nearby bedding. This resident made good eye contact and, when asked if staff brushed their teeth, shook their head no and mouthed that staff “need to.” According to the resident’s Minimum Data Set (MDS) dated 2/11/26, the resident was dependent on staff for oral care. Another resident, also dependent on staff for oral care per the 3/11/26 MDS, was observed sitting propped up in bed and able to respond with smiles. During the initial observation, the inside of this resident’s lips and upper and lower teeth had a thick, clear, white milky substance visible when the resident tried to open their mouth to smile. Oral care supplies were present in the nightstand, but the resident’s mouth and teeth were not clean. On a subsequent observation with the DON, NHA, and Corporate VP of clinical services, the same resident again had a thick, clear, milky substance between the lips and caking the teeth, which would string between the teeth when the resident attempted to open their mouth, demonstrating a lack of consistent oral care for residents dependent on staff for this ADL.
Incomplete and Inaccurate Medical Record Documentation for Treatments and Assessments
Penalty
Summary
Facility staff failed to maintain complete and accurate medical records and documentation for multiple residents. For one resident with wound care needs, review of the MAR showed that wound care and related treatments were signed as completed on the dates initially reported, despite the resident’s ongoing complaints that wound dressings were not being changed. When additional dates were reviewed, there were missing staff signatures for wound care on two specific dates, as well as three instances where application of A&D ointment to the resident’s feet was not signed off out of 24 days reviewed. Another resident with severe cognitive impairment, as evidenced by a BIMS score of 00, was found to have an injury of unknown origin (a bruise on the left hand). Documentation showed that a change in condition was initiated late in the morning, but a formal pain evaluation was not initiated and completed until that night, and the resident was unable to explain how the injury occurred or verbalize pain using a standard pain scale. For a third resident, documentation related to the admission PPD test was inconsistent and incomplete. The MAR contained an entry indicating “9” for the administration date, meaning “see nurse’s note,” but there was no corresponding nurse’s note. Despite the absence of a signed administration of the PPD injection, staff documented the PPD result as “negative” on the scheduled read date. The resident reported never receiving the PPD injection, and the DON confirmed that the facility had been out of PPD solution at the time, so the test would not have been administered. These findings demonstrate failures in accurate documentation of treatments and assessments, including wound care, pain assessment, and TB screening, as well as missing or incomplete supporting notes in the medical record.
Failure to Implement and Communicate Correct Transmission-Based Precautions
Penalty
Summary
Surveyors identified a deficiency in the facility’s infection prevention and control program related to inconsistent and incorrect implementation of transmission-based precautions and PPE use. During a complaint investigation focused on residents on transmission-based precautions, one resident with a visible Foley catheter was observed in the room with physical therapy, but there were no signs posted indicating any need for PPE, despite the resident being a new admission with a Foley catheter placed related to wounds. In another double-occupancy room, a contact precautions sign was posted at the doorway, but the nurse practitioner was in the room on a personal phone with no PPE, and the assigned GNA was repositioning the resident in bed while wearing only gloves. When questioned, the NP, RN, and GNA all stated that the resident in the room was not on contact precautions, and the GNA reported that signs were hanging at all doors and that this particular resident’s sign was “just wrong.” The surveyor observed the GNA later return to the room and turn the sign around to indicate no PPE requirement. Subsequent interviews revealed that therapy staff relied on posted signage to determine PPE use and that if the sign was wrong, the PPE used would be wrong. Overall, surveyors found problems with signage accuracy and staff awareness of which residents required contact precautions, as well as observed failures to follow appropriate PPE use for residents who should have been on contact precautions.
Inaccurate MDS Coding for Falls, Pain Management, and High-Risk Medications
Penalty
Summary
Facility staff failed to ensure Minimum Data Set (MDS) assessments were accurately coded for two residents reviewed during a complaint survey. For one resident, a facility-reported incident showed that the resident was found seated on the floor beside the bed and was diagnosed with a non-displaced femoral neck impaction fracture of the left hip following an x-ray. Despite this fall with a major injury, the subsequent significant change MDS dated 11/4/25 did not code the fall with major injury in Section J1900C. Review of the resident’s Medication Administration Records for October and November 2025 showed administration of Tylenol on 10/31/25 at 9:30 PM, which fell within the 5-day look-back period for the MDS, but Section J0100 (prn pain) of the same significant change MDS did not capture the use of Tylenol. For another resident, review of a quarterly MDS with an assessment reference date of 10/15/25 showed that Section N0415 (High-Risk Drug Classes) documented the use of an opioid medication. However, review of the resident’s October 2025 Medication Administration Record did not show that the resident had been prescribed an opioid during that period. In both cases, MDS staff later confirmed that these were errors in MDS coding, demonstrating that the assessments did not accurately reflect the residents’ clinical status and medication use as documented in their medical records.
Incomplete Documentation of Narcotic Administration on MAR
Penalty
Summary
The facility failed to maintain complete and accurate medical records in accordance with accepted professional standards for one resident receiving narcotic medication. The resident, admitted in March 2026, had a fall on 3/6/26 and was sent to the hospital on 3/9/26. Review of the March 2026 Medication Administration Record (MAR) showed documentation of a single 25 mg dose of Tramadol administered on 3/8/26 at 9:23 AM. However, review of the resident’s Controlled Drug Receipt/Record/Disposition Form, kept on the nurse’s medication cart and not in the medical record, showed that Tramadol 25 mg was administered three times between 3/8/26 and 3/9/26: at 11:00 AM and 9:00 PM on 3/8/26, and at 9:00 AM on 3/9/26. In interview, the DON stated that staff are expected to document narcotic administration on the MAR and confirmed that only one of the three Tramadol doses reflected on the controlled drug record was documented on the resident’s MAR. This discrepancy between the controlled substance record and the MAR, with missing documentation of two administered doses of Tramadol on the official medical record, constituted the failure to maintain a complete and accurate medical record for the resident.
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