Autumn Lake Healthcare At Silver Spring
Inspection history, citations, penalties and survey trends for this long-term care facility in Silver Spring, Maryland.
- Location
- 2501 Musgrove Road, Silver Spring, Maryland 20904
- CMS Provider Number
- 215224
- Inspections on file
- 16
- Latest survey
- March 27, 2026
- Citations (last 12 mo.)
- 5
Citation history
Health deficiencies cited at Autumn Lake Healthcare At Silver Spring during CMS and state inspections, most recent first.
A resident's right to a safe, comfortable, and homelike environment was not upheld when the facility failed to inventory and safeguard the resident's personal belongings. During a complaint investigation, staff were unable to account for multiple missing items, including clothing and a phone charger, and review of both electronic and paper records showed that no personal belongings inventory had been completed or maintained for the resident, contrary to facility policy requiring such documentation at admission and updates as new items are brought in.
Facility staff did not develop complete, person-centered care plans for two residents. For one resident, ongoing dental issues and denture replacement documented by a contract dental provider were not included in the care plan despite active treatment. For another resident, a diagnosis of CKD Stage 3, identified by the primary provider and during multiple ER visits, was not addressed in either the initial or current care plan. A staff member later confirmed that these needs were missing from the residents’ care plans.
A resident’s monthly Medication Regimen Reviews (MRRs) were not timely addressed by providers, and pharmacist recommendations were not acted upon as required by facility policy. The ADON reported that the pharmacist emails MRRs, which are printed and given to an NP to review and mark agree/disagree/other, with changes then entered into the EMR by the NP or unit managers before the next month’s review. For this resident, one MRR contained a recommendation to discontinue melatonin that was not signed and agreed to by the provider until nearly two months later, and the subsequent MRR repeated the same recommendation but had no provider signature, date, or response documented. The ADON acknowledged both MRRs were missed.
A resident did not have quarterly care plan meetings as required, and neither the resident nor their representative were included in such meetings for nearly ten months. Although the social worker maintained regular communication with the family, no official care plan meeting was documented during this period, as confirmed by facility leadership.
Surveyors observed that the exit doors on the Arcadia unit had damaged plastic kick plates with cracks, chips, and jagged edges, some of which were covered with tape. A resident was seen picking at the broken area, highlighting the unsafe and uncomfortable condition of the doors. Facility leadership was notified of these findings.
The facility failed to employ sufficient qualified staff in the food and nutrition department, affecting all residents. The RD had not been onsite since July 2024 and worked remotely, while the FSD was unqualified per job description and federal requirements. This led to failures in providing palatable food, food choices, snacks, timely meals, and nutritional interventions. Interviews confirmed the RD's absence and the FSD's lack of qualifications.
The facility failed to maintain sanitary kitchen operations, risking foodborne illness for 126 residents. Observations revealed that the dishwasher did not meet required temperature specifications, and dietary staff did not follow proper hand hygiene and glove use when handling ready-to-eat foods. Despite policies in place, these deficiencies persisted, posing a health risk to residents.
The facility failed to maintain a sanitary garbage area over three days, with surveyors observing significant amounts of garbage around the compactor. Items included plastic, paper, and food waste, posing a potential sanitation concern. The Regional CDM, HM, and FSD acknowledged the issue, and the Administrator expected housekeeping to maintain cleanliness.
Two residents in an LTC facility experienced significant weight loss due to inadequate nutritional interventions. One resident with Alzheimer's and dysphagia was not weighed weekly and did not receive prescribed supplements, while another with breast cancer and malnutrition had inaccessible supplements. Staff failed to offer meal alternatives and inaccurately documented intake, with the RD working remotely and not visiting the facility since July.
The facility failed to provide meals that were palatable, attractive, and served at safe temperatures, as reported by multiple residents. Observations revealed deviations from recipes and inappropriate food temperatures. Despite awareness of these issues, they persisted, affecting resident satisfaction and potentially their nutritional intake.
The facility failed to honor residents' food preferences and provide alternatives, leading to dissatisfaction and potential weight loss. Residents reported not being consulted about their preferences and faced difficulties in ordering from the Always Available menu. Observations showed that some residents refused meals without being offered alternatives, and staff did not consistently follow the facility's policy to provide options.
The facility failed to meet the nutritional needs of residents by not providing meals and snacks according to their needs and preferences. Observations revealed that the time span between dinner and breakfast exceeded 15 hours, and residents reported not being offered snacks. Interviews confirmed the lack of snack offerings and extended meal times, with the Resident Council not reviewing or approving the longer time span. The facility's failure could lead to health issues due to nutrient deficiencies.
An LPN failed to follow infection control practices by picking up a dropped Oxycontin tablet with bare fingers and placing it in a medication cup for a resident. The LPN did not sanitize her hands after handling other blister packs and cart drawers. Facility policy requires medications to be handled without bare hands.
Failure to Inventory and Safeguard Resident Personal Belongings
Penalty
Summary
The facility failed to honor a resident's right to a safe, clean, comfortable, and homelike environment by not securing and accounting for the resident's personal belongings. During a complaint investigation, it was discovered that the facility could not account for several of the resident's items, including a phone charger, three white tee shirts, three ball caps, and a pair of sweatpants. Review of the resident's medical record and paper chart revealed that there was no personal belongings inventory sheet on file, despite the facility's policy requiring that all resident personal items be inventoried at admission and that documentation be retained in the medical record, with additional possessions added over time. In an interview, the Administrator confirmed that a search of both the electronic and paper medical records found no inventory sheet for this resident. This deficiency arose from the facility's failure to complete and maintain the required personal belongings inventory for the resident, which resulted in the inability to verify or locate the resident's missing items when the complaint was investigated.
Failure to Incorporate Dental and CKD Needs Into Comprehensive Care Plans
Penalty
Summary
Facility staff failed to develop and initiate comprehensive person-centered care plans that addressed all identified needs for two residents. For one resident, medical record review on 03/26/2026 showed that although contract dental services had been actively treating the resident, identifying dental issues, and working to replace the resident’s dentures, these dental problems and related interventions were not included in the resident’s care plan. The dental provider had documented completed and pending dental work, but this information was not reflected in the care planning documentation. For another resident, medical record review on 03/27/2026 revealed that a diagnosis of Chronic Kidney Disease (CKD), Stage 3, made by the primary provider and also identified during two emergency room visits at an acute care hospital within the prior eight months, was not incorporated into either the initial or current care plan. During an interview on 03/27/2026 at 2:20 PM, Employee #8 confirmed that the care plans for both residents were missing these identified elements.
Failure to Timely Address Pharmacist Medication Regimen Review Recommendations
Penalty
Summary
The deficiency involves the facility’s failure to ensure timely completion and follow-up of monthly Medication Regimen Reviews (MRRs) by a provider, and failure to respond to consulting pharmacist recommendations as required by facility policy. For one resident reviewed for unnecessary medications, the medical record showed MRR entries for two consecutive months documented only as “See [pharmacist’s] report,” without the actual reports initially available. The ADON described the facility’s MRR process, stating that the pharmacist emails the MRRs, she prints the recommendations, and then gives them to the NP to address, with the expectation that the provider will check agree/disagree/other, sign, and date the form. She further stated that some recommendations are implemented in the EMR by the NP, while others are passed to unit managers to enter, and that MRRs are to be completed before the next month’s review. When the surveyor requested the resident’s MRRs, the 1/8 MRR was not provided until the following day, and the 2/9 MRR was initially unavailable. Review of the 1/8 MRR showed a pharmacist recommendation to discontinue melatonin, with the provider marking “agree” and signing on 3/3, nearly two months after the recommendation. The 2/9 MRR, when later produced, contained the same recommendation to discontinue melatonin, but had no provider signature, date, or box checked, and the ADON acknowledged that both MRRs had been missed, noting she had been on vacation. The facility’s policy states that MRR irregularities must be reported to the attending physician, medical director, and DON, must be acted upon, and that non-urgent recommendations must be addressed and documented prior to the next scheduled review, which did not occur in this case.
Failure to Hold Timely Care Plan Meetings with Resident and Representative
Penalty
Summary
The facility failed to ensure that care plan meetings were scheduled quarterly and that both the resident and their representative were included in these meetings. Medical record review for one resident showed that the last official care plan meeting occurred nearly ten months prior, with the most recent documentation being a 'social determinants of health' note, which did not constitute a full care plan meeting. Interviews with the facility social worker confirmed regular communication with the family but no recent official care plan meeting. This deficiency was identified during a complaint investigation, and both the DON and Nursing Home Administrator acknowledged the lack of recent care plan meetings with the family.
Damaged Exit Door Kick Plates Create Unsafe Environment
Penalty
Summary
The facility failed to maintain the doors exiting the Arcadia unit in good repair, resulting in an environment that was not safe or comfortable for residents. Observations revealed that the double doors had plastic kick plates attached with multiple screws, and the right door had black tape covering the top and right side of the kick plate where it was coming loose. There were numerous cracks, chips, and jagged edges where the plastic had broken around the screws. At one point, a resident was observed standing at the door and picking at the jagged edges of the broken plastic kick plate. Facility leadership, including the NHA and DON, were notified of these concerns and observations.
Deficiency in Food and Nutrition Services Due to Lack of Qualified Staff
Penalty
Summary
The facility failed to employ sufficient staff with the appropriate competencies and skills to carry out the functions of the food and nutrition department, potentially affecting all residents. The Registered Dietitian (RD), who was supposed to provide oversight, had not been to the facility since July 2024 and worked part-time remotely. The Food Service Director (FSD) was also found to be unqualified for the position, as their ServSafe Certification did not meet the facility's job description or federal requirements. This lack of qualified personnel resulted in failures to provide palatable food, food alternates, snacks, and meals without extended timeframes between dinner and breakfast, as well as nutritional interventions to prevent unplanned weight loss. Interviews and document reviews revealed that the RD completed all work offsite and was not available for the survey conducted from December 3 to December 6, 2024. The Administrator confirmed that the RD was expected to work 24 hours a week remotely but was not providing the necessary onsite presence. The Regional Certified Dietary Manager and the FSD both acknowledged the lack of qualified personnel and the absence of the RD from the facility. The deficiencies were cross-referenced with tags related to food palatability, food substitutes, mealtimes, kitchen sanitation, and nutritional parameters.
Sanitation and Hygiene Deficiencies in Kitchen Operations
Penalty
Summary
The facility failed to maintain the kitchen in a sanitary manner, which could potentially spread foodborne illness to 126 out of 129 residents. The deficiency was identified through observations, interviews, document reviews, and policy reviews. The facility's dishwasher was not operating according to the manufacturer's specifications, with wash and rinse temperatures consistently below the required levels. Despite the facility's policy stating that the wash temperature should be between 150-165 degrees Fahrenheit and the rinse temperature should be 180 degrees or above, observations over three days revealed that the dishwasher's temperatures were frequently below these thresholds. The Regional Certified Dietary Manager (CDM) and the Maintenance Director acknowledged the issue, noting that the heating element was not functioning properly. Additionally, dietary staff did not adhere to proper hand hygiene and glove use when handling ready-to-eat foods, creating a risk of cross-contamination. Observations showed that staff members were using the same gloves to handle food and touch various surfaces and utensils without washing their hands or changing gloves between tasks. For instance, a cook was observed using gloved hands to handle bread and other items without changing gloves or washing hands, and another staff member was seen using gloved hands to handle hamburger buns and other items without proper hygiene practices. The Regional CDM was present during some of these observations and instructed staff on proper procedures, but the issues persisted. The facility's policies on dishwasher temperature and dietary employee personal hygiene were not followed, contributing to the deficiencies observed. The dishwasher temperature logs from previous months showed discrepancies, with recorded temperatures meeting the required levels despite observations to the contrary. The facility's failure to adhere to its own policies and ensure proper sanitation practices in the kitchen posed a risk to the residents' health and safety.
Failure to Maintain Sanitary Garbage Area
Penalty
Summary
The facility failed to maintain the outdoor garbage area in a sanitary manner over a period of three days, as observed by surveyors. On the first day, a significant amount of garbage was found strewn around the garbage compactor area, extending approximately fifteen feet away. The garbage included various items such as plastic, drink cartons, condiment packets, paper refuse, silverware, pieces of cardboard, garbage bags with trash, scrambled eggs, and disposable gloves. Both the Regional Certified Dietary Manager (CDM) and the Housekeeping Manager (HM) confirmed that the area was not sanitary and required cleaning. On the subsequent days, similar observations were made, with garbage extending approximately ten feet away from the compactor. Items observed included pieces of plastic, paper, disposable gloves, tin foil, plastic bottles, and cardboard. The Food Service Director (FSD) acknowledged that the presence of food in the garbage could pose a sanitation concern due to potential rodent access. The Regional CDM and HM reiterated the need for cleanup, and the HM stated that housekeeping was responsible for maintaining the cleanliness of the area. The facility's Administrator also expressed the expectation that housekeeping staff should keep the garbage area clean and free of accumulated garbage.
Failure to Provide Adequate Nutritional Interventions
Penalty
Summary
The facility failed to provide adequate nutritional interventions for two residents, R184 and R19, who experienced significant weight loss. R184, diagnosed with Alzheimer's disease and dysphagia, was not weighed weekly as required by physician orders and facility policy, despite a 24% weight loss over six months. Observations revealed that R184 was not served prescribed nutritional supplements like Magic Cups and house shakes during meals, and staff failed to offer meal alternatives when R184 refused to eat. Documentation inaccurately recorded R184's meal intake and supplement consumption, indicating a lack of adherence to prescribed dietary interventions. R19, with diagnoses including breast cancer and protein malnutrition, also experienced a significant weight loss of 13.30%. Observations showed that R19's prescribed nutritional supplements were not made accessible, as they were left unopened and out of reach without necessary utensils. The facility's dietary management was inadequate, with the Registered Dietitian working remotely and not visiting the facility since July 2024, which contributed to the lack of proper nutritional assessments and interventions for R19. Interviews with staff revealed a lack of understanding and implementation of procedures for offering meal alternatives and ensuring accurate documentation of residents' nutritional intake. The facility's failure to provide necessary nutritional support and accurate documentation for these residents highlights significant deficiencies in the care provided, contributing to their unplanned weight loss and nutritional risk.
Deficiency in Meal Quality and Temperature
Penalty
Summary
The facility failed to ensure that meals provided to residents were palatable, attractive, and served at safe and appetizing temperatures. Multiple residents reported dissatisfaction with the taste, temperature, and presentation of the food. Specific complaints included food being cold, bland, and not prepared according to the menu or recipes. Residents also noted that meals were sometimes delivered late, and condiments or necessary accompaniments were missing. These issues were consistently raised in resident council meetings over several months, indicating a persistent problem. Observations during meal service revealed deviations from standardized recipes, such as the addition of cinnamon and brown sugar to creamed corn, which was not part of the recipe. Test trays evaluated by the Regional Certified Dietary Manager (CDM) showed that hot foods were not reaching the desired temperature of at least 140 degrees Fahrenheit, and cold foods were not sufficiently chilled. The CDM confirmed the bland flavor and inappropriate temperatures of the meals served. The facility's policy on providing nourishing and palatable meals was not adhered to, as evidenced by the repeated complaints and observations. The residents' cognitive assessments indicated that most were cognitively intact, suggesting that their complaints were credible and reflective of their experiences. Despite awareness of these issues by the facility's administration and dietary management, the problems persisted, affecting the residents' satisfaction and potentially their nutritional intake.
Failure to Honor Resident Food Preferences and Provide Alternatives
Penalty
Summary
The facility failed to ensure that residents' food preferences and dislikes were assessed and honored, and that alternatives were available and offered to residents who did not eat what was served. This deficiency was observed in 10 out of 37 sampled residents, leading to potential weight loss and dissatisfaction among residents. The facility's policy required reasonable efforts to assess individual needs and preferences, and to provide alternative menus if the primary menu was not to a resident's liking. However, several residents reported that their food preferences were not considered, and they were not offered alternatives when they refused their meals. Multiple residents expressed dissatisfaction with the food service. One resident stated they were served the same breakfast every day and had not been consulted about their food preferences since admission. Another resident reported being served foods they could not eat, such as potatoes and oranges, and showed an unopened cup of orange juice as evidence. During a group meeting, residents shared experiences of requesting alternatives and being denied by staff, who claimed it was not their responsibility. Additionally, residents reported difficulties in contacting the kitchen to order from the Always Available menu, with calls going unanswered or being redirected. Observations during meal times revealed that some residents refused their meals and were not offered alternatives. For instance, one resident was served a meal they did not eat, and their tray was removed without any offer of an alternative. The facility's Regional Certified Dietary Manager acknowledged issues with recording food preferences on tray cards and stated that alternatives should be available. Despite the facility's policy, staff did not consistently offer alternatives, and the Resident Council Minutes indicated ongoing concerns with food preferences and the availability of alternatives.
Failure to Provide Adequate Snacks and Meal Timing
Penalty
Summary
The facility failed to meet the nutritional needs of four residents by not providing meals and snacks in accordance with their needs, preferences, and requests. The facility's policy stated that there should be no more than 14 hours between the evening meal and breakfast unless a nourishing snack is provided at bedtime. However, observations revealed that the time span between dinner and breakfast exceeded 15 hours for several meal carts, and residents reported not being offered snacks, with some staff consuming them instead. Interviews with residents and staff confirmed the lack of snack offerings and the extended time between meals. Residents expressed concerns about not receiving snacks, especially on weekends, and the absence of general snacks in the kitchenettes on various floors was noted. The Food Service Director and other staff were unaware of the extended meal times, and the Resident Council had not reviewed or approved the longer time span between meals. The Resident Council Minutes from December 2023 to October 2024 showed ongoing concerns about snack availability and meal timeframes, but there was no documentation of approval for the extended meal times. The facility's failure to provide adequate snacks and adhere to the policy on meal timing could potentially lead to health issues for the residents due to deficiencies in essential nutrients.
Infection Control Breach During Medication Administration
Penalty
Summary
The facility failed to ensure proper infection control practices were followed by an LPN during medication administration. During an observation, the LPN was seen retrieving a blister pack of Oxycontin for a resident. When attempting to dispense the medication, the tablet fell onto the top of the medication cart. The LPN then picked up the tablet with bare fingers and placed it into the medication cup with the resident's other medications. The LPN did not sanitize her hands after handling other medication blister packs and the medication cart drawers before touching the dropped medication. During an interview, the LPN stated she sanitized the cart in the morning and her hands before preparing the resident's medications, and she believed it was unnecessary to dispose of the pill. The facility's policy on medication administration indicated that medications should be removed from their source without touching them with bare hands.
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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