Autumn Lake Healthcare At Ruxton
Inspection history, citations, penalties and survey trends for this long-term care facility in Towson, Maryland.
- Location
- 7001 Charles Street, Towson, Maryland 21204
- CMS Provider Number
- 215077
- Inspections on file
- 21
- Latest survey
- February 25, 2026
- Citations (last 12 mo.)
- 7
Citation history
Health deficiencies cited at Autumn Lake Healthcare At Ruxton during CMS and state inspections, most recent first.
A resident reported not consistently receiving scheduled showers and not having their preference for daytime showers honored. Staff indicated the resident was scheduled for showers on the 3–11 shift, while the resident preferred showers on the 7–3 shift so they would occur before wound dressing changes. Documentation showed multiple missed scheduled showers over several months and one shower documented that the resident denied receiving. The resident’s family member confirmed the resident had complained to nursing staff and was told showers had to occur at night despite the resident’s stated preference.
A resident’s representative submitted multiple written and oral grievances alleging unaddressed care concerns, including ignored requests for water and repositioning, inadequate pain management, lack of follow-up for infections, barriers to participation in activities, denial of access to staff assignment information, unaddressed ear pain and spasms, unavailability of needed equipment, pest issues, and absence of a complete care plan. Facility grievance forms indicated that a representative would review and contact the complainant within 72 hours and document findings, resolution, referral, and dates received and shared. For these grievances, only findings and resolutions were completed, and forms were signed and dated by a Grievance Officer and an NHA on a date preceding the NHA’s hire, while referral information, date received, and date shared with the complainant were left blank. The representative reported never receiving acknowledgment, investigation updates, or written decisions, and the DON could not explain the documentation discrepancies or provide evidence that the required written decision was issued.
A resident with a left leg wound did not have their dressing changed according to a daily day-shift physician order, as surveyors observed the same dated dressing remaining in place over multiple shifts despite staff documenting diabetic foot and ankle checks that should have revealed the unchanged dressing. In a separate case, another resident’s medications, including oxybutynin, midodrine, tizanidine, and Eliquis, were documented on the MAR as administered several hours after scheduled times without any notation of clinical justification, resident refusal, physician orders to hold, or physician notification, and staff could not explain the delays during interviews.
A resident with an order for PRN Oxycodone for pain rated 5–10 on a 1–10 scale did not receive pain medication before a wound dressing change, despite having requested it in advance. During the observed procedure, the resident reported being in constant pain and confirmed they had asked for pain medication earlier but had not received it. The nurse performing the dressing change stated she was occupied with another resident’s dressing change and therefore did not administer the pain medication before starting this resident’s wound care. Record review confirmed the PRN Oxycodone order, and the DON later acknowledged that the medication should have been given prior to the wound care.
A resident received PRN Oxycodone 15 mg on multiple occasions when their documented pain score was 4, even though the physician’s order specified administration only for pain rated 5–10 on a 1–10 scale. MAR review showed repeated instances where the opioid was given despite the pain level being below the ordered threshold. When interviewed, the DON acknowledged that the medication should not have been administered under those conditions.
Facility staff failed to ensure two residents received required routine and follow-up dental care. One resident, observed to have few or no teeth, had no documented dental consult for over a year and had not been seen by a dentist since the prior year, despite requirements for at least annual oral assessments. Another resident with missing teeth and cavities had sporadic dental encounters, including attempted visits where the resident was unavailable or in isolation, and a recommended dental hygiene visit that was never rescheduled. A nursing note documented that a molar tooth came out while the resident was talking, and the resident was ordered to be seen by dental services, with the next documented dental visit occurring only after this event.
A resident received multiple morning medications, including those for bowel regimen, edema, anxiety, bipolar disorder, cellulitis, and diabetes, several hours after their scheduled administration times. The DON confirmed that medications were documented as late and stated that staff are expected to administer and document medications on time, indicating a failure to meet professional standards of practice.
The facility failed to maintain an effective pest control program, leading to a mice infestation on the third floor affecting several residents. Observations showed no mice traps in rooms, and interviews revealed that residents experienced fear and sleepless nights due to the presence of mice. Despite pest control visits, no traps were placed in the facility except in ceilings, and staff were unaware of effective measures to address the issue.
The facility failed to maintain clean respiratory equipment for four residents, leading to potential exposure to contamination and improper airflow. Observations revealed dusty oxygen concentrators and filters, with staff unaware of cleaning schedules. Additionally, a resident's oxygen mask and tracheostomy collar were improperly stored, contrary to facility policy.
The facility failed to supervise medication administration for three residents, leading to unsupervised medications being left in rooms. A resident with severe cognitive impairment was left with a medication cup, another with intact cognition had pills left unattended, and a third with moderate cognitive impairment had unauthorized medications in their room. These actions were against the facility's policy requiring observation during medication administration.
A resident's family member filed a grievance alleging verbal threats by a CNA, but the facility failed to document and investigate the complaint thoroughly. The cognitively intact resident reported feeling threatened, yet the grievance lacked specific details, and the investigation did not include interviews with other residents. The facility's policy requires thorough documentation and investigation, which was not followed, leading to dissatisfaction with the resolution.
A facility failed to provide an ongoing program of meaningful activities for a resident with severe cognitive impairment, dementia, anxiety, and insomnia. The resident's interests in music and religious activities were not adequately addressed in the care plan, and observations showed the resident was often left alone without engaging activities. The Activity Director confirmed a lack of documentation and awareness of the need to document activities, leading to a deficiency in meeting the resident's needs.
A resident with a history of stroke and hemiplegia was not provided with a recommended carrot orthosis for a hand contracture, as documented in their occupational therapy discharge summary. The resident's care plan and physician's orders did not reflect the need for the orthosis, and staff interviews revealed a lack of awareness and documentation regarding its use. This oversight had the potential to lead to increased contracture, pain, or skin breakdown.
The facility failed to ensure proper PPE use for two residents on precautions. A resident with recurring c-diff had staff entering their room without gowns or gloves, despite posted contact precautions. Another resident with a gastrostomy tube and other conditions had an LPN administering medications without a gown, contrary to enhanced barrier precautions. Staff interviews revealed misunderstandings about PPE requirements, despite clear facility policies.
A resident with schizophrenia, bipolar disorder, and type 2 diabetes refused insulin, leading to a 911 call. The LPN used strategies like offering pudding to encourage medication compliance, but these interventions were not documented in the care plan. The surveyor noted this deficiency during a review with the DON.
A resident with multiple health conditions experienced five falls over four months due to inadequate supervision and failure to follow care plan interventions. Despite being at high risk for falls, the resident was left unattended, resulting in prolonged periods on the floor. Staff interviews revealed that required monitoring was not conducted, contributing to the incidents.
The facility's ineffective pest control program resulted in a mice infestation, with reports and observations of mice in various rooms, including patient areas. Residents and families expressed concerns, and the Nursing Home Administrator acknowledged the issue but indicated it would take time to resolve. An open exit door on the ground floor further exacerbated the problem by allowing easy access for rodents.
The facility failed to report abuse allegations and an injury of unknown origin within required timeframes to the OHCQ. Incidents involving three residents were not reported timely, and investigations were missing. The DON and NHA could not locate necessary documentation, acknowledging the deficiency.
The facility failed to investigate multiple alleged incidents of abuse, neglect, and misappropriation involving several residents. In one case, a resident reported being smacked by a staff member, but no investigation was found. Another resident reported theft and assault, but the facility could not provide documentation. An alleged employee-to-resident abuse incident also lacked investigation, and a misappropriation case was missing critical details. The Administrator mentioned a possible intervention, but it was undocumented.
A resident with multiple diagnoses, including obstructive uropathy and dementia, developed a scrotal ulcer. The ulcer was noted, but treatment was delayed for three days, and there was no documentation of the ulcer's size or description. The DON confirmed the delay and lack of documentation, although the ulcer healed within 15 days.
A facility failed to ensure a physician wrote, dated, and signed progress notes at each visit, as required by policy. A resident's medical records showed significant delays in signing notes, with some signed nearly a month after the visit. The NHA acknowledged the issue, noting the physician had moved out of state.
A resident with chronic pain and anxiety experienced repeated unavailability of prescribed medications, leading to calls to 911. The facility struggled with timely medication orders, particularly over weekends, as acknowledged by the LPN and DON. Despite a QAPI plan initiated in early 2024, the issue persisted, with the resident still facing medication shortages in September 2024.
The facility failed to maintain accurate and timely medical records for two residents. One resident's record was updated posthumously with an activity assessment, while another resident's records contained incorrect vital sign dates, not matching the actual exam dates. These discrepancies were confirmed by the DON and NHA.
Failure to Honor Resident’s Shower Preferences and Schedule
Penalty
Summary
Facility staff failed to honor a resident’s stated preference and schedule for showers, resulting in missed showers and showers being scheduled at undesired times. During a wound dressing change observation, the resident reported that they were supposed to receive two showers twice a week in the evening but did not always receive them. The staff member performing the dressing change stated the resident was scheduled for showers on the 3–11 shift, while the resident stated a preference for showers on the 7–3 shift so that showers would occur before wound dressings were changed, not after. The resident explained that even if the old dressing became wet, it would have to be removed anyway, so getting it wet would not matter. Review of the facility’s Documentation Survey Report showed multiple dates on which the resident did not receive scheduled showers, including several dates over a three‑month period. The record also showed a shower documented on one date that the resident denied receiving. The resident’s sister reported that the resident had complained to nursing staff about not being showered and that staff told the resident showers had to be taken at night, despite the resident’s expressed preference for daytime showers.
Failure to Follow Grievance Process and Communicate Outcomes to Resident Representative
Penalty
Summary
The deficiency involves the facility’s failure to follow its grievance process and to honor a resident’s and resident representative’s right to voice grievances without discrimination or reprisal. A resident representative submitted multiple Complaint/Grievance Forms in January and February 2025 regarding the resident’s care, treatment, staff behavior, and quality of life. These grievances included concerns about staff not responding to requests for water during a period when the resident was on large amounts of antibiotics and had limited upper body mobility, staff failing to turn and reposition the resident during the night shift despite requests, and repeated unfulfilled requests to place the resident in a chair so the resident could participate in activities. Additional grievances documented by the representative included allegations of inadequate pain management, lack of follow-up or care planning for a right foot infection despite prescribed antibiotics and ongoing pain, and absence of a podiatry consult or appointment. The representative also reported being denied access to daily nursing staff information until they produced POA documentation, complaints of increasing spasms and ear pain that were reported to the physician without resolution by a later date, and being told that a specific chair to get the resident out of bed was unavailable even though the representative observed the chair in the hallway outside the room. Further grievances described concerns about rodents in the resident’s room, multiple infections acquired within one month (bedsores, UTI, right foot infection, possible finger infection, and apparent infections in both ears), and a request for a meeting with the complete care team due to concerns that a comprehensive care plan meeting all of the resident’s needs had not been developed and implemented. Record review showed that the facility’s Complaint/Grievance Forms state that a facility representative will review and contact the complainant within 72 hours, and that the bottom portion of the form is to be completed by the facility representative, including findings, how the issue was resolved, referral information, date received, and date shared with the complainant. For this resident, the facility completed only the findings and resolution sections and the forms were signed by a Grievance Officer (signature unknown to staff) and by NHA #1, all dated 2/6/2025, even though NHA #1’s hire date was 2/24/2025. The sections for “Referred to,” “Date Form Received,” and “Date shared with the person filing the complaint/grievance” were left blank. The resident representative reported that the facility never acknowledged receipt of the grievances, did not inform them of the progress of any investigation, and did not share findings or resolutions. The DON confirmed the grievance process as written, but could not explain the documentation discrepancies or the lack of acknowledgment and communication, and documentation of a written decision to the resident representative, as required by the facility’s Resident and Family Grievances policy, was not provided.
Failure to Follow Physician Orders for Wound Care and Timely Medication Administration
Penalty
Summary
The deficiency involves failure to provide treatment and care according to physician orders and resident needs for wound care and medication administration. For one resident with a left leg wound, the surveyor observed on two separate occasions that the wound dressing bore the same date, indicating it had not been changed for six shifts over a two-day period. The dressing was ordered by the primary physician to be changed daily on the day shift, and there was also an order for diabetic foot care checks requiring nursing staff to assess the resident’s feet and ankles. Documentation showed staff had signed off that they performed these checks, which would have required them to see the date on the dressing, yet the dressing remained unchanged. The DON acknowledged that the dressing should have been changed according to the physician’s order. The deficiency also includes failure to administer medications as ordered for another resident. Review of the medical record and MAR audit showed that multiple medications, including oxybutynin, midodrine, tizanidine, and Eliquis, were documented as given several hours after their scheduled administration times on two separate days. There was no documentation that any of these medications were held per physician order, refused by the resident, or delayed for a clinical reason, and no documentation that the physician was notified of the delayed administration. During interviews, the nurse involved and the DON were unable to provide any reason or supporting documentation explaining the late administration times recorded on the MAR.
Failure to Administer PRN Pain Medication Prior to Wound Care
Penalty
Summary
A resident receiving wound care experienced inadequate pain management when a nurse performed a wound dressing change without administering ordered pain medication beforehand. During an observed dressing change, the resident stated they had requested pain medication at 2:30 PM but had not received it prior to the start of the procedure. The nurse explained that she had been performing another resident’s dressing change and therefore did not provide the medication before beginning this resident’s wound care, then asked if the resident was in pain; the resident replied that they were in pain all the time. Review of the clinical record showed a physician’s order for Oxycodone 15 mg by mouth every 4 hours as needed for pain rated 5–10 on a 1–10 scale. In an interview, the DON confirmed that the pain medication should have been administered prior to the wound care. These findings were based on resident interview, staff interview, direct observation of the wound dressing change, and review of the resident’s clinical record.
PRN Oxycodone Administered Outside Ordered Pain Parameters
Penalty
Summary
Facility staff failed to ensure that a resident’s pain medication was administered according to the physician’s order, resulting in multiple doses of Oxycodone being given outside the prescribed parameters. The physician’s order dated 2/4/26 specified Oxycodone 15 mg by mouth every 4 hours as needed for pain rated 5–10 on a 1–10 scale. Review of the Medication Administration Record showed that on 2/6/26 at 8:25 PM; 2/10/26 at 10:37 AM and 5:55 PM; 2/11/26 at 1:50 AM; 2/13/26 at 9:17 PM; 2/14/26 at 1:30 AM and 6:05 AM; and 2/15/26 at 4:33 PM and 8:55 PM, the resident’s pain level was documented as 4, yet the Oxycodone was administered. These administrations did not comply with the physician’s order limiting use of the medication to higher pain scores. During an interview, the DON was informed of these findings and acknowledged that the medication should not have been administered under those circumstances.
Failure to Provide Routine and Follow-Up Dental Services
Penalty
Summary
Facility staff failed to ensure residents received required routine and follow-up dental care, resulting in missed or delayed dental assessments and services. One resident was observed during the initial tour to have few, if any, teeth, and review of the clinical record showed no dental consult in over a year, despite the requirement for at least an annual inspection of the mouth and jaw and diagnosis of any dental disease. When interviewed, the DON confirmed that there was no documentation of a dental consult or examination in the record and that the resident had not been seen by a dentist or dental company since 2023. Another resident with missing teeth and cavities had no clear documentation of routine dental services since admission. The record showed multiple attempted and completed dental encounters: an attempted visit where the resident was not found in the room or hallways, a completed dental exam with notation for a next-visit prophylaxis, and a later attempted dental hygiene encounter that could not be completed due to isolation. There was no documentation that this missed hygiene visit was rescheduled. A change in condition note documented that a left upper molar tooth came out while the resident was talking, with no bleeding or pain noted, and the resident was ordered to be seen by dental services. The last documented dental visit occurred after this tooth loss, and the surveyor identified that the recommended dental hygiene appointment had not been rescheduled following the missed visit.
Failure to Administer Medications on Schedule
Penalty
Summary
A resident reported receiving medications several hours late. Review of the resident's Medication Administration Audit Report confirmed that multiple morning medications, including Metamucil, Lasix, Buspirone, Lamotrigine, Bactrim DS, and Mounjaro, were administered significantly later than their scheduled times. Specifically, medications scheduled for 9:00 AM were given between 11:37 AM and 2:23 PM on the same day. During an interview, the Director of Nursing acknowledged that the medications were documented as being administered late and stated that while it is possible the medications were given on time but documented late, the expectation is for medications to be administered and documented at the scheduled time. The findings were based on resident interviews, record reviews, and staff interviews, confirming that the facility failed to ensure medications were administered in accordance with professional standards of practice.
Mice Infestation on Third Floor Due to Ineffective Pest Control
Penalty
Summary
The facility failed to maintain an effective pest control program, resulting in a mice infestation on the third floor, affecting six residents. Observations revealed no mice traps in residents' rooms, workstations, or breakrooms. Interviews with staff and residents indicated that mice were seen frequently, causing fear and sleepless nights among residents. The facility's policy to provide a safe environment was not upheld, as evidenced by the presence of mice and unsealed gaps in the walls. Residents reported seeing mice in their rooms, with some residents bringing their own traps due to the facility's inaction. The Director of Maintenance was unaware of the residents' concerns, and the pest control log showed visits from a pest control company, but no traps were placed in the facility except in the ceilings. The Director of Nursing acknowledged residents' concerns, but no effective measures were taken to address the infestation. Interviews with staff revealed a lack of awareness and action regarding the mice problem. The Administrator and Director of Maintenance confirmed the presence of mice and visible entrance points, yet no comprehensive pest control measures were implemented. The facility's failure to address the infestation led to ongoing distress and fear among residents, compromising their comfort and safety.
Failure to Maintain Clean Respiratory Equipment
Penalty
Summary
The facility failed to provide respiratory care in accordance with professional standards for four residents, leading to potential exposure to contaminated respiratory equipment and improper airflow. Resident 18, who was admitted with pneumonia and COPD, had a dusty oxygen concentrator that was not cleaned as per the facility's policy. The Assistant Director of Nursing (ADON) confirmed the dustiness but was unaware of the cleaning frequency required for the concentrators. Resident 22, admitted with obesity and congestive heart failure, also had a dusty oxygen concentrator and filter with a significant dust buildup. Licensed Practical Nurse (LPN) 1 verified the condition but did not know the cleaning schedule. Similarly, Resident 120, with COPD and asthma, had a dusty oxygen concentrator and filter, which was confirmed by LPN1 and the Director of Nursing (DON), both of whom were unaware of the cleaning requirements. Resident 357, admitted with a traumatic subdural hemorrhage, had an oxygen mask and tracheostomy collar improperly stored on a bedside table and machine hook, respectively. LPN4 and the ADON acknowledged the improper storage, with the ADON stating that such equipment should be stored in a clean plastic bag. The DON added that if left out of a bag, the equipment would need replacement.
Medication Administration Supervision Deficiency
Penalty
Summary
The facility failed to ensure proper supervision during medication administration for three residents, leading to potential risks of unwarranted medication side effects and mismanaged medical conditions. Resident 122, who was severely cognitively impaired and dependent on staff for daily activities, was left with a medication cup containing approximately 10 dosage forms on a bedside table. The nurse documented the administration of medications before the resident actually took them, contrary to the facility's policy requiring observation of medication consumption. Resident 97, with intact cognition but a history of refusing medications, was found with a medicine cup containing eight pills left unattended in the room. The resident had no order to self-administer medications, and there was no assessment of the resident's ability to store or self-administer medications safely. The nurse admitted to leaving the pills unsupervised, which was against the facility's policy. Resident 103, who had moderate cognitive impairment, was found with bottles of Claritin and Citrical on the bedside table without orders for these medications. The resident was not capable of self-administering medications, and the medications were likely brought in by the resident's daughter. The facility's policy requires medications to be administered by nursing staff and not stored in the resident's room without a physician's order.
Inadequate Grievance Investigation and Documentation
Penalty
Summary
The facility failed to adequately document and investigate a grievance filed by a resident's family member, which involved allegations of verbal threats made by a Certified Nurse Aide (CNA) towards the resident. The resident, who was cognitively intact with a Brief Interview for Mental Status (BIMS) score of 15 out of 15, reported feeling threatened by the CNA's comments following a state agency complaint investigation. The grievance was filed by the resident's family member, who expressed concerns about the CNA's attitude and potential for retaliation. The grievance documentation was incomplete, lacking specific allegations and details provided by the family member. The Somerset Unit Manager (SUM) only interviewed the resident and did not inquire specifically about the CNA or interview other residents who had received care from the CNA. The Assistant Director of Nursing/Infection Preventionist (ADON/IP) and the Director of Nursing (DON) acknowledged that the grievance was not thoroughly investigated, and additional residents should have been interviewed as part of the investigation. The facility's policy on resident and family grievances requires thorough documentation and investigation of grievances, including taking immediate actions to prevent further potential violations of resident rights. However, the facility did not adhere to this policy, as evidenced by the lack of a comprehensive investigation and failure to address the specific allegations of verbal threats made by the CNA. The family member expressed dissatisfaction with the facility's resolution, which involved reassigning the CNA to a different unit without addressing the potential for further abuse or retaliation.
Failure to Provide Meaningful Activities for Resident with Cognitive Impairment
Penalty
Summary
The facility failed to ensure an ongoing program of meaningful activities for a resident with severe cognitive impairment, dementia, anxiety, and insomnia. The resident was assessed to have a Brief Interview for Mental Status score of zero out of 15, indicating severe cognitive impairment, and was dependent on staff for all activities of daily living except eating. The resident expressed interest in music and religious activities, going outside, and participating in favorite activities, but these preferences were not adequately addressed in the care plan. Observations revealed that the resident was often left alone in their room, facing the wall or the TV, with no music or religious activities provided. The resident was observed singing gospel music when spoken to, indicating an interest in music, yet the care plan did not include music therapy sessions or one-to-one visits. The Activity Director confirmed that the resident preferred to stay in their room and did not leave the unit for activity groups. However, there was no documentation of one-to-one visits or music therapy sessions, and the Activity Director was unaware of the need to document these activities. The facility's policy required an ongoing program to support residents' choice of activities based on their comprehensive assessment, care plan, and preferences. However, the policy was not followed, as the resident's interests in music and religious activities were not adequately addressed, and there was a lack of documentation for the activities provided. The Activity Director acknowledged the need for more frequent music therapy sessions and documentation of activities, but these were not implemented at the time of the survey.
Failure to Apply Splint for Resident's Hand Contracture
Penalty
Summary
The facility failed to ensure a splint was applied to address a hand contracture for a resident, identified as R71, who was reviewed for limited range of motion. R71 was admitted with diagnoses including stroke with resulting hemiplegia and hemiparesis on the left side, muscle spasm, muscle weakness, and vascular dementia. The resident was assessed to be cognitively intact with impaired range of motion on one side of the body. The occupational therapy discharge summary recommended the use of a carrot orthosis at all times except during bathing, but this was not reflected in the resident's care plan or physician's orders. Observations and interviews revealed that R71 had not been using the carrot orthosis for some time, and the resident's left hand was contracted into a fist, causing discomfort and pain. The resident reported that range of motion exercises were no longer performed since therapy discharge, and the splint had not been used for months. The occupational therapist confirmed that the resident's hand seemed tighter and recommended further intervention, such as nerve blocks or consultation with a hand specialist. Interviews with facility staff, including the LPN, unit manager, and director of nursing, indicated a lack of awareness and documentation regarding the use of the carrot orthosis. The facility's policies on prevention in decline in range of motion and use of assistive devices were not consistently followed, as there was no physician's order for the orthosis, and the care plan was not updated to reflect the current needs of the resident. This oversight had the potential to lead to increased contracture, pain, or skin breakdown for the resident.
Failure to Adhere to PPE Protocols for Residents on Precautions
Penalty
Summary
The facility failed to ensure appropriate personal protective equipment (PPE) was worn for two residents under transmission-based or enhanced barrier precautions. For Resident 107, who was diagnosed with recurring clostridium difficile (c-diff), staff members repeatedly entered the resident's room without donning the required gown and gloves, despite a sign indicating contact precautions. Certified Nurse Aides (CNAs) were observed entering and exiting the room without PPE and without performing hand hygiene, indicating a lack of awareness or communication regarding the resident's precautionary status. In the case of Resident 205, who required enhanced barrier precautions due to multiple pressure ulcers, a gastrostomy tube, and an indwelling urinary catheter, a Licensed Practical Nurse (LPN) was observed administering medications via the gastrostomy tube while only wearing gloves, contrary to the facility's policy that required a gown for such procedures. The LPN misunderstood the need for a gown, believing it was only necessary for urinary catheter care, despite the posted instructions for enhanced barrier precautions. Interviews with staff revealed a lack of understanding and communication regarding the necessity of PPE for residents on contact or enhanced barrier precautions. The Assistant Director of Nursing/Infection Preventionist and the Director of Nursing confirmed the requirements for PPE use, which were not adhered to by the staff. The facility's policies clearly outlined the need for PPE to prevent the transmission of infections, but these were not followed, leading to potential risks of infection spread among residents and staff.
Failure to Revise Care Plan for Medication Refusal
Penalty
Summary
The facility failed to revise the care plan for a resident who had a history of schizophrenia, bipolar disorder, and type 2 diabetes, to include interventions for medication refusals. On a specific date, the resident called 911 because they had not received their insulin all day. A review of the medication administration record showed that the resident had refused their 6:00 AM Levemir injection, which is a long-acting insulin used to control blood sugar levels. Interviews with staff revealed that when the resident refused insulin, the LPN would contact the doctor and encourage the resident to take the medication, sometimes using strategies like offering pudding, which had been effective in the past. However, the care plan did not document these interventions. The surveyor discussed this oversight with the Director of Nursing, highlighting the failure to ensure that the care plan included strategies to address the resident's medication refusals.
Inadequate Supervision Leads to Multiple Falls
Penalty
Summary
Facility staff failed to ensure the safety of a resident by not providing adequate supervision, resulting in the resident experiencing five falls over a four-month period. The resident, who was admitted with diagnoses including delirium, right-side stroke, osteoarthritis, depression, and heart failure, was identified as high risk for falls. Despite having a care plan in place that included interventions such as psychiatric evaluation for restlessness, reinforcement of call bell use, and monitoring every two hours at night, these measures were not effectively implemented. On one occasion, the resident fell and was left on the floor for hours, with the police eventually being called to assist. Interviews with staff revealed that the back hallway corner nurse's station, which was supposed to be monitored during evening and night shifts, was often left unattended. This lack of supervision contributed to the resident's falls, as staff were unaware of the resident's calls for help. The Director of Nursing confirmed the incidents and acknowledged the failure to conduct required rounds, which were part of the care plan interventions. The facility's inability to follow the care plan and provide adequate supervision led to the repeated falls and the resident being left unattended for extended periods.
Ineffective Pest Control Program Leads to Mice Infestation
Penalty
Summary
The facility failed to maintain an effective pest control program, resulting in a significant infestation of mice throughout the building. Numerous reports and observations indicated the presence of mice in various rooms, including patient rooms and common areas. Residents and their families expressed concerns about the mice, with some taking measures such as setting traps in their rooms. The Nursing Home Administrator acknowledged the issue but indicated that resolving it would take time. Documentation from the pest control company and facility logs confirmed multiple sightings and reports of mice over several months, with specific rooms and areas being repeatedly affected. The deficiency was further exacerbated by a lack of proper facility management, as evidenced by an exit door on the ground floor being propped open, allowing easy access for rodents. Despite being informed of this issue, the door continued to be left open, as noted by the Director of Maintenance. This oversight allowed for continued entry of pests into the facility, undermining the efforts of the pest control company. The administrative staff was made aware of these concerns during the exit conference, highlighting the facility's failure to address the pest problem effectively.
Failure to Timely Report Abuse Allegations
Penalty
Summary
The facility failed to report allegations of abuse and an injury of unknown origin within the required timeframes to the Office of Health Care Quality (OHCQ). This deficiency was identified during a complaint survey involving three residents across multiple facility-reported incidents. For Resident #10, there were two separate incidents where the resident alleged being smacked in the head by a person drawing blood. In both cases, the facility did not provide the surveyor with the date of the incident or evidence of an investigation, and the reports were not submitted to OHCQ in a timely manner. The Director of Nursing (DON) and the Nursing Home Administrator (NHA) were unable to locate the investigation files for these incidents. Additionally, the facility failed to report an alleged physical abuse incident involving Resident #8 within the required two-hour timeframe. The initial report was sent to OHCQ late, and no email confirmations were provided to verify the submission time. The DON and the administrator acknowledged the deficiency but could not locate the incident report or the investigation. Another incident involving Resident #2, related to alleged employee-to-resident abuse, was also not reported timely, and the facility investigation could not be found. These failures to report and document investigations highlight significant lapses in the facility's compliance with regulatory requirements.
Failure to Investigate Alleged Incidents
Penalty
Summary
The facility failed to thoroughly investigate multiple incidents of alleged abuse, neglect, and misappropriation of property involving several residents. In one case, a resident reported to their spouse that a staff member who drew their blood had smacked them in the head. However, there was no date of the incident on the report, and no investigation was provided to determine the date or details of the incident. Interviews with the Director of Nursing (DON) and the Nursing Home Administrator (NHA) revealed that they could not locate the investigation files related to this incident. Similar issues were found with another incident involving the same resident, where again, no investigation could be found. Another incident involved a resident who reported to the police that someone had taken their purse and struck them with it. The facility was unable to provide the incident report or investigation documentation. Additionally, an alleged employee-to-resident abuse incident was reported, but the facility could not find the investigation. Lastly, a misappropriation of a resident's funds was reported, but the investigation lacked critical details such as room numbers for resident statements and interventions to prevent future occurrences. The Administrator mentioned that a lock-box might have been provided to the resident, but this was not documented in the investigation.
Delayed Wound Care Implementation for Resident with Scrotal Ulcer
Penalty
Summary
The facility failed to timely implement wound care orders for a resident with a scrotal ulcer. The deficiency was identified during a complaint survey, where it was found that a resident, admitted in July 2021 with multiple diagnoses including obstructive and reflux uropathy, dementia, and Down syndrome, developed an ulcer on the dorsal scrotum. The resident was admitted with a Foley catheter due to obstructive and reflux uropathy. On September 28, 2021, the ulcer was noted, but there was no further documentation in the progress notes or skin sheets related to the ulcer. The Treatment Administration Record for October 2021 showed an order for Calmoseptine ointment to be applied to the sacrum and groin every shift. However, treatment for the ulcer was not initiated until October 1, 2021, three days after the ulcer was first noted. During an interview, the Director of Nursing confirmed the lack of documentation regarding the size and description of the ulcer and acknowledged the delay in treatment initiation. The ulcer was reported to have healed within 15 days, and it was suggested that the ulcer was likely caused by the Foley catheter tubing.
Physician's Failure to Timely Sign Progress Notes
Penalty
Summary
The facility staff failed to ensure that the physician wrote, dated, and signed progress notes at each resident's visit, as required by policy. This deficiency was identified during a complaint survey for one resident. The medical record review revealed that the physician's notes for this resident were not signed on the date of the visit. Specifically, notes dated 2/21/24, 2/28/24, 3/6/24, 3/8/24, and 3/13/24 were signed days after the actual visit dates, with delays ranging from several days to nearly a month. The Nursing Home Administrator acknowledged the issue, noting that the physician had moved out of state and was no longer employed at the facility. The facility's policy clearly stated that physicians should date, write, and sign a progress note for each visit, which was not adhered to in this case.
Medication Availability Deficiency
Penalty
Summary
The facility failed to ensure the availability of pain and anxiety medications for a resident, leading to multiple incidents where the resident was unable to receive prescribed medications. The resident, who had a history of chronic pain syndrome, opioid dependence, cerebral infarction, anxiety disorder, and Parkinson's disease, frequently experienced unavailability of medications such as Oxycontin and Lorazepam. This resulted in the resident calling 911 on several occasions due to the lack of pain medication, as documented in the medical records and complaint reviews. Interviews with the resident and staff revealed that the issue was partly due to agency staff not ordering medications in a timely manner, leading to shortages, especially over weekends. The Licensed Practical Nurse (LPN) and Director of Nursing (DON) acknowledged the problem, noting that the resident's behavior was unpredictable when medications were not available. The DON admitted that medications should be ordered before they run low to ensure they are on hand, but the process was described as an ongoing struggle between the facility and the pharmacy. The facility's Quality Assurance and Performance Improvement (QAPI) plan, initiated in January 2024, aimed to address the medication availability issue. However, the problem persisted, as evidenced by the resident's continued calls to 911 due to medication shortages as recently as September 2024. The Nursing Home Administrator and Corporate Nurse were informed of the ongoing concern, highlighting the facility's failure to maintain a consistent supply of necessary medications for the resident.
Inaccurate and Delayed Medical Record Documentation
Penalty
Summary
The facility failed to maintain complete, accurate, and up-to-date medical records for its residents, as evidenced by the review of two residents during a complaint survey. For one resident, the medical record indicated a discharge to the hospital, but the resident had passed away shortly after. Despite this, an initial activity assessment was uploaded into the resident's medical record after the resident's death, indicating a delay in documentation. This discrepancy was identified during a review of the resident's medical record and confirmed through an interview with the Director of Nursing (DON) and the activity director. For another resident, the medical records contained multiple inaccuracies related to the documentation of vital signs. Several physician notes had vital signs dated incorrectly, not reflecting the actual date of the resident's examination. These inaccuracies were discovered during a review of the resident's medical record, where it was found that the vital signs were dated on the day the resident was transferred to the hospital, rather than the date of the exam. The DON and the Nursing Home Administrator (NHA) were shown these discrepancies, confirming the findings.
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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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