Average — CMS composite of the measures below.
A standard survey is most likely before around November 2026
Estimate from public CMS data, current as of July 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Autumn Lake Healthcare At Spa Creek during CMS and state inspections, most recent first.
A deficiency was identified when the door alarm system for a stairwell exit failed to sound an audible alert at the nursing station after the door was opened without entering a code. Although a panel light illuminated, four staff members present did not recognize this as an alert, and the Maintenance Director confirmed the alarm should have sounded. The issue was traced to a wiring problem, resulting in the alarm not functioning as intended.
Surveyors identified multiple failures by nursing staff to follow professional standards, including not administering medications as documented, improper medication administration via PEG tube, and lack of communication or documentation when a resident requested a different dose of anxiety medication. These deficiencies involved several residents and resulted in inaccurate records and unmet care needs.
Failure to Develop Complete Care Plans for Multiple Residents: The facility did not have complete care plans for several residents with documented needs. A resident with dementia and schizophrenia, a resident with dermatitis and topical treatment, a resident receiving psychotropic meds with side-effect monitoring, a resident needing assistance with bathing, and a resident with DM on insulin all lacked corresponding care plan interventions or had incomplete plans when reviewed by surveyors.
Medication administration errors exceeded the allowed threshold when an LPN documented medications as given that were not observed during the pass, including topical, oral, and PEG-tube medications. Observations also found a duplicate Lidocaine order issue, improper crushing of an enteric-coated medication, undissolved meds left in cups, and failure to follow ordered PEG-tube flush instructions. MAR review confirmed additional missed doses, and the DON stated the missed and incomplete medications would be reported to the physician.
Improper Storage and Labeling of Medications: The facility failed to keep the medication refrigerator limited to medications when a cup of half and half creamers was found inside. Surveyors also found multiple insulin pens on medication carts that were unopened but undated, one unopened pen that was dated, and opened pens that were undated; one opened pen remained for a resident who no longer lived in the facility. The DON stated he would provide in-services on insulin pen storage, medication refrigerator use, and discarding medications for discharged residents.
Improper food storage and labeling were observed in the kitchen and on unit pantry refrigerators. Surveyors found cardboard boxes on the floor, staff personal items and beverages stored with food, unlabeled food in the freezer, and a dented can not stored in the designated area. On the units, a broken nourishment refrigerator, unlabeled resident food and drinks, and staff items stored in the nourishment refrigerator were observed; additional staff beverages and personal items were later found in the tray line area.
Immunization education was not documented for several residents after vaccines were given or refused, including PCV20, TB testing, influenza vaccine, and a COVID-19 vaccine refusal. In addition, one resident was overdue for the pneumococcal vaccine, and the ICP confirmed the vaccine had not been offered since it was due.
Two residents with urinary drainage devices were observed with urine visible in uncovered drainage bags. One resident had a Foley catheter bag hanging on the bed frame without a privacy cover, and the bag was visible from the hallway. Another resident was seen in a wheelchair with a leg bag secured to the leg and urine visible, without a sheet covering the legs as expected by the DON. Both residents had physician orders for Foley catheter care and regular emptying of the drainage bags.
Resident Funds Not Accessible Outside Posted Banking Hours: A resident reported that residents could not access personal funds on weekends. The BOM stated money was available only during posted banking hours, and although she said a nurse supervisor could access the safe after hours, the Unit Manager was unsure of that access and the Administrator confirmed residents usually did not have access to funds outside regular hours or when key leaders were not present. A sign at the front desk listed resident banking hours as Monday through Friday, 9:00 AM to 4:00 PM.
Resident rooms had multiple items in poor repair, including marred or chipped bedside tables, dressers, closets, bed headboards, bathroom doors, and doorframes in 5 of 5 rooms reviewed. The Maintenance Director acknowledged the condition of the furniture and doors/doorframes on the 1st floor and stated the plan was to replace them with a later renovation.
A resident was transferred to a hospital ER and later admitted, but the record did not show that the resident representative received the required bed hold notice or transfer summary. The Ombudsman weekly discharge list also did not include the transfer, and the DON stated the representative was not notified in writing and that the facility had not been documenting when transfer summaries were sent or to whom.
A resident who was alert and oriented and receiving insulin for diabetes had an admission MDS incorrectly coded to show no use of a hypoglycemic drug under N0415. Record review confirmed an active insulin order, and the MDS Coordinator acknowledged the inaccurate coding.
Delayed Care Plan Meetings: A resident did not routinely recall attending care plan meetings, and record review showed the meetings were not held in a timely manner after MDS assessments. Social Service staff acknowledged the delay, stated she was not initially aware of the MDS calendar, and could not explain why the meetings continued to be delayed.
Failure to provide ADL assistance to two residents was identified during survey observations and record review. One resident was found uncleaned, in a soiled diaper, with an odor of urine after reporting no morning care, while another cognitively intact resident with ROM limitations and a care plan for ADL self-care deficit still had visible facial hair after asking for a razor.
Failure to Follow Ordered Bowel Management Protocol: A resident with intact cognition reported a week of constipation and abdominal discomfort, and staff observed the resident grimacing and feeling terrible. The physician ordered a stepwise bowel regimen using MOM, Dulcolax suppository, and Fleet enema, but the MAR showed MOM and Dulcolax were not given before the enema was administered. LPNs stated the bowel protocol was expected to be followed and documented, while the DON reported a claim that the resident refused treatment, with no record evidence of refusal.
Pharmacy DRR recommendations were not reviewed and implemented in a timely manner for two residents. One resident’s rivaroxaban dose was recommended for reassessment based on CrCl, but the physician response was delayed and the MAR later showed a different administration time. Another resident had delayed action on DRR findings involving fludrocortisone dosing and Voltaren Gel directions/indication. The DON stated pharmacy recommendations should be completed within a week, while the facility policy required action on medication regimen review irregularities.
Failure to Monitor Anticoagulant Therapy: A resident receiving Xarelto for DVT prophylaxis had visible bruising and was noted to be on newly initiated anticoagulation therapy, with a provider note directing monitoring for bleeding. However, review of the MAR and TAR showed no anticoagulant monitoring task in place, and the UM confirmed the expected monitoring for bleeding, bruising, and black tarry stool was absent from the record.
An LPN failed to sanitize shared BP equipment after use and did not perform hand hygiene before preparing and administering a resident's medication. The ICP confirmed that shared medical equipment must be sanitized after each use and that hand hygiene is required during direct care, including medication administration.
Activities program was not directed by a qualified professional. The Activities Director said she had worked in the role for 3 years, but the only credential provided was a BS degree, which did not show the required federal qualifications. The Admin stated an NCCAP application had been submitted for ADC credentialing, but no other education, training, or documentation was available to verify the Activities Director met the required standards.
Surveyors found that the facility failed to maintain a safe, clean, and comfortable environment, with multiple rooms having damaged furniture, missing or loose molding, exposed drywall, and unsanitary conditions. A resident reported prolonged disrepair of a wheelchair and dirty privacy curtains, with surveyors confirming these issues during their inspection.
Facility staff did not accurately code MDS assessments for four residents, failing to document opioid use, scheduled pain medications, anticonvulsant administration, antibiotic use, topical treatments, and a fall event. These omissions were confirmed by the MDS Coordinator as oversights during the survey.
Staff failed to follow infection control protocols, including not performing hand hygiene between resident contacts and after handling soiled items. Multiple resident bathrooms contained uncovered, unlabeled, and improperly stored basins and urinals, with some containing soiled materials or stacked together without protection. The Infection Control Nurse confirmed these practices did not align with facility policy.
The facility did not maintain an effective pest control program, as evidenced by repeated reports and observations of roach and ant activity in resident rooms, pantries, kitchen, and nurses stations. Pest control logs and vendor reports documented ongoing infestations and contributing factors such as poor sanitation and standing water, while direct observations and interviews confirmed persistent pest presence throughout the facility.
A GNA was observed standing while feeding two residents and speaking in a harsh, loud tone to another resident to wake them for breakfast. These actions, including quickly shoveling food and failing to sanitize hands between resident contacts, did not honor residents' rights to dignity and respectful communication.
A resident was found at a nursing station with a bed sheet tied in a knot around their back, and the incident was reported by housekeeping staff to a GNA after initially being unable to find staff on the first floor. Although the charge nurse was promptly informed, the required report to OHCQ was not submitted within the mandated 2-hour period, as confirmed by the DON.
Facility staff did not complete neuro checks at the required intervals or with current vital signs for two residents following unwitnessed falls, despite provider instructions and facility protocol. Nursing leadership confirmed that neuro checks were missed or performed inaccurately.
Facility staff failed to administer prescribed pressure ulcer treatments for two residents, including missing several days of ordered wound care and delaying the initiation of treatment for a deep tissue injury. Staff also did not complete required weekly wound assessments and measurements on multiple occasions, as confirmed by nursing leadership.
A resident admitted with multiple fractures and pain management needs did not receive prescribed controlled medications in a timely manner due to delays in order processing and pharmacy authorization. Despite requests from the resident and family, the medications were not administered, leading the spouse to sign the resident out against medical advice to seek care elsewhere. Nursing documentation showed alternative pain medications were offered and refused, but pain levels were not recorded. Facility investigation confirmed the medications were not made available as required.
Facility staff did not timely arrange required outside specialist appointments for two residents, including neurology, urology, pulmonology, and orthopedics, as directed by hospital discharge instructions. One resident did not have a neurology follow-up scheduled, and another experienced significant delays and lack of evidence of visits to pulmonology and orthopedics, as confirmed by facility leadership.
A resident with a history of bladder neck obstruction had a physician order for a cystoscopy, but the results of this procedure were not present in the medical record. This was confirmed by the Administrator during a survey, indicating incomplete and inaccurate documentation.
Failure to Maintain Operational Door Alarm System
Penalty
Summary
During a recertification survey, a deficiency was identified regarding the facility's failure to ensure that essential equipment, specifically the door alarm operating system, was functioning as intended. The surveyor and the Maintenance Director (MD) tested the exit door alarm system in the first-floor stairwell following concerns related to a recent elopement. The MD explained the system's operation, stating that an audible alarm should sound at the first-floor nursing station if the door is opened without entering a code. However, when the door was opened without the code, the alarm did not sound, although the number 36 illuminated on the panel. Four staff members present at the nursing station were unaware that the illuminated number indicated the door had been opened, as there was no audible alert. The MD confirmed that an audible alarm should have been triggered and subsequently discovered that connecting two wires in the wall panel caused the alarm to sound. This sequence of events demonstrated that the door alarm system was not operational as required, and staff were not alerted to the door being opened, constituting a failure to maintain essential safety equipment.
Failure to Meet Professional Standards in Medication Administration and Documentation
Penalty
Summary
The facility failed to ensure that nursing staff provided services in accordance with professional standards of practice, as evidenced by multiple medication administration errors and documentation discrepancies observed during a recertification survey. In several instances, LPNs documented the administration of medications that were not actually given to residents. For example, one LPN recorded that a topical medication was applied to a resident's foot, but this was not observed during the medication pass. Similarly, another LPN signed off on the administration of an oral antiviral medication that was not given, and a blood thinner that was not administered to another resident. There were also issues with the administration of medications via PEG tube, where an LPN crushed and attempted to administer an enteric-coated medication that was labeled 'do not crush,' and failed to ensure that all medications were fully dissolved and delivered. The LPN did not follow physician orders regarding the required water flushes before and after medication administration, and signed off on the administration of a medication that was not observed to be given. Additionally, there were two active and potentially conflicting orders for a lidocaine patch for one resident, leading to the application of a patch for an extended period without proper clarification until after the surveyor's intervention. Another deficiency involved a resident who reported anxiety and requested a specific dose of lorazepam that had previously been effective. The LPN did not administer the medication, did not document the resident's refusal or request for a different dose, and did not notify the physician as required by facility policy. Review of the medication administration record and narcotic log confirmed that the medication was not given and was instead wasted, with no documentation of communication with the physician or follow-up regarding the resident's request.
Failure to Develop Complete Care Plans for Multiple Residents
Penalty
Summary
The facility failed to develop and implement complete care plans for multiple residents whose records and observations showed ongoing care needs. During the recertification survey, 5 of 25 residents reviewed for care plans were found to have missing or incomplete care plans related to their diagnoses, treatments, or daily care needs. Resident #16 had diagnoses of Dementia and Schizophrenia, but the care plan reviewed did not include either condition. Resident #8 was observed with multiple scabs and redness on the face and reported treatment for dermatitis; the medical record showed a diagnosis of Dermatitis and an order for Ketoconazole Hydrocortisone for seborrheic dermatitis, but the care plan did not include Dermatitis. Resident #60 had orders for psychotropic medications, including Mirtazapine for depression and Clonazepam for anxiety, along with an order for every-shift monitoring for potential side effects of psychotropic medications, but the care plan did not reveal a plan for psychotropic medications. Resident #107 stated that he/she had not been washed up or received a shower for approximately 12 days, and the posted shower schedule in the room showed showers on Tuesday and Friday. The MDS indicated the resident required partial/moderate assistance with showering and setup/clean-up help with tub/shower transfer, yet the care plan did not show a specific plan for assistance with ADLs for showering and bathing. Resident #82 had a diagnosis of Diabetes Mellitus and physician orders for insulin in the morning and at bedtime, but the record did not contain a comprehensive care plan for diabetes mellitus or insulin at the time of review.
Medication Administration Error Rate Exceeded Allowed Threshold
Penalty
Summary
The facility failed to ensure medications were administered with a 5% or less error rate, with survey observations identifying 12 errors out of 31 medication administration opportunities for an error rate of 38.71%. During medication pass observations, an LPN documented administration of medications that were not actually observed being given to residents, including Biofreeze topical to a resident’s right foot, Entecavir oral tablet to another resident, and Brilinta oral tablet to a third resident. In each of these instances, the surveyor reviewed the MAR and found the medications had been signed off as administered even though they were not observed during the medication pass. One resident had two active Lidocaine patch orders at the same time, including a 4% patch and a 5% patch with different directions. During the observation, the LPN removed a previously applied patch and placed another Lidocaine patch on the resident after the resident stated a patch had already been applied earlier by night shift. The LPN later acknowledged that the orders had to be clarified and that the 5% Lidoderm order was discontinued. The surveyor also noted that the LPN believed she had administered Entecavir even though it had not been included in the medications reviewed before administration. For another resident with a PEG tube, an LPN crushed multiple medications individually and placed them in separate cups, including Senna enteric coated 5 mg, which the bottle labeled as do not crush. The surveyor observed undissolved medication remaining in each cup after administration, and the LPN agreed it was impossible to dissolve the medications. The same resident also had an order to flush the tube with 15 ml of water before each medication pass and after the final medication, but the LPN did not follow the ordered pre-medication flush. MAR review confirmed additional missed administrations, including Omeprazole oral tablet release, and the LPN later acknowledged that Brilinta and Omeprazole had not been administered and that the flushing order had not been followed.
Improper Storage and Labeling of Medications
Penalty
Summary
The facility failed to ensure that drugs and biologicals were stored in accordance with accepted professional principles when the first-floor medication refrigerator contained a 16-ounce cup of half and half creamers instead of only medications. During the same survey, multiple medication carts were observed with insulin pens that were not properly stored or labeled. On the Prospect Bay 1 PO medication cart, Resident #77’s Glargine insulin pen was dated 07/20/25 but was unopened and kept in a pharmacy bag labeled to refrigerate until opened, and Resident #123’s Lantus Solostar insulin pen was found unopened, undated, and also in a pharmacy bag labeled to refrigerate until opened. On the 2nd floor Lighthouse medication cart, Resident #58’s Basaglar Kwik insulin pen was unopened, undated, and in a pharmacy bag labeled refrigerate until opened. In another 2nd floor medication cart, Resident #113 had an opened, undated Tresiba FlexTouch insulin pen, and Resident #111 had an opened, undated Basaglar Kwikpen insulin pen that the Unit Manager stated should have been removed and destroyed because the resident no longer resided in the facility. During interview, the DON stated he would provide in-services on insulin pen storage, proper use of medication refrigerators, and discarding medications for discharged residents.
Improper Food Storage and Labeling in Kitchen and Pantry Refrigerators
Penalty
Summary
Proper sanitation was not maintained for food storage in the kitchen and on the nursing units. During the initial kitchen tour, several cardboard boxes were observed directly on the floor in the dry storage room, employee personal items were stored on the top shelf in the dry storage room, an angel food cake in the walk-in freezer had no label, two half-full water bottles were stored in a staff-labeled metal container in the walk-in refrigerator, and a can of beef stew with a dented lid was not stored on the designated shelf for dented food items. The Food Services Director acknowledged these sanitation concerns during the tour. On the nursing units, the 1st floor nourishment refrigerator was broken and marked do not use, and a half-full jar of applesauce in the small freezer had no date when opened. In the 2nd floor pantry room, the nourishment refrigerator contained multiple food items that were not labeled and dated with resident names, three half-full water bottles, a take-out entree, a plastic cup half full of red-colored liquid, and several food items stored in a brown leather bag, all without labels or dates. During a later kitchen observation, additional staff beverages and personal items were found stored above the sinks in the tray line area, and the DFSM acknowledged those sanitation concerns.
Immunization Education Not Documented and Pneumococcal Vaccine Not Offered
Penalty
Summary
The facility failed to ensure that immunization education was provided to residents or their resident representatives when vaccines or related immunizations were given or refused. Record review showed that Resident #33 received PCV20, Resident #14 received TB step Mantoux Skin Test - Step 1 & 2, Resident #16 received PCV20, Resident #10’s family refused the SARS-COV-2 (COVID-19) Spikevax (Moderna) Fall 2024 vaccine, and Resident #58 received the influenza vaccine, but education was not documented as provided for any of these residents or their representatives. During interview, the Infection Control Preventionist reviewed the immunization records for Residents #33, #14, #16, and #10 and confirmed that immunization education had not been provided. The record review also showed that Resident #58 was due for the pneumococcal vaccine on 11/19/24 and was overdue. The Infection Control Preventionist reviewed Resident #58’s immunization record and confirmed that the resident had not received the pneumococcal vaccine since that due date. During interview, the Infection Control Preventionist confirmed that Resident #58 was overdue for the facility to offer the pneumococcal vaccine.
Failure to Protect Dignity with Visible Urinary Drainage Bags
Penalty
Summary
The facility failed to ensure the dignity of two residents with urinary drainage devices. Resident #143 was observed in bed with a Foley catheter drainage bag attached to the bed frame, and the bag was not covered with a privacy barrier; urine was visible in the bag. The resident was later observed again in bed with the Foley catheter drainage bag hanging on the bed frame without a privacy covering, and urine in the bag was visible from the hallway. The resident had a physician order for a Foley catheter and for the drainage bag to be emptied at least every eight hours. Resident #99 was observed sitting in a wheelchair in the vending machine room near the lobby and later at the first-floor nursing station with a urinary drainage leg bag secured to the right leg, with urine visible in the bag. The resident had physician orders for a Foley catheter, for the drainage bag to be emptied at least every eight hours, and that a leg bag may be used when out of bed. The DON stated the facility did not have a protective barrier for leg bags and that the expectation was for residents with leg bags to have a sheet covering their legs when out of bed; however, Resident #99 was not observed with a sheet covering at either observation.
Resident Funds Not Accessible Outside Posted Banking Hours
Penalty
Summary
The facility failed to provide access to a resident’s personal funds during non-banking hours. During an interview, the resident reported that residents were not able to access their personal funds on weekends. The Business Office Manager stated that residents can obtain money during Monday through Friday banking hours from 9:00 AM to 4:00 PM, and that after those hours the nurse supervisor can access the safe, although she also stated this had never occurred because residents typically receive their money for the weekends on Fridays. She confirmed that the solution would be to provide the night supervisors with the code if access were needed. During interviews, the Unit Manager, who was confirmed to be the same role as the nurse supervisor, stated she was not sure whether she could access the safe outside of banking hours and did not believe that was the case. The Administrator stated that the facility does not typically give money to residents on weekends and confirmed that residents usually do not have access to their funds at those times. She further confirmed that the facility did not have a designated person who could access the safe outside of regular hours, and that residents would not be able to access their funds when the Administrator, DON, BOM, and front desk attendant were not in the building. A posted sign at the front desk listed resident banking hours as Monday through Friday, 9:00 AM to 4:00 PM.
Resident Rooms Had Marred and Chipped Furniture and Doors
Penalty
Summary
The facility failed to provide a safe, clean, comfortable, homelike environment for residents when surveyors observed multiple items in resident rooms that were not in good repair. During the initial tour, surveyors noted marred or chipped bedside tables, dressers, closets, bathroom doors, bathroom doorframes, and bed headboards in five resident rooms, including rooms assigned to Residents #5, #9, #99, #119, and #141. The observations showed that all 5 of the 5 resident rooms reviewed had items that were not in good repair. During an interview, the Maintenance Director acknowledged awareness that the furniture and doors/doorframes in the resident rooms on the 1st floor were not in good repair. He stated that the plan was to replace the furniture in the resident rooms on the 1st floor with the renovation of the 1st floor of the facility in September. No additional information was provided by the facility at the time of survey exit.
Failure to Notify Representative and Ombudsman of Hospital Transfer
Penalty
Summary
The facility failed to ensure that required notifications and documentation were completed for a resident who was transferred to a local hospital emergency room and later admitted. Review of the resident’s medical record showed a change in condition/concurrent form, but the form did not indicate that the resident representative received a bed hold notice or a transfer summary. During the survey, the Nursing Home Administrator provided a bed hold notice dated 07/10/25, a list sent to the ombudsman, and the change in condition/current form, but the record still did not show that the resident representative had been given the transfer summary. The Ombudsman weekly discharge notification list did not include the resident’s transfer to the hospital, and the Nursing Home Administrator confirmed the resident’s name was not listed. The DON stated that the resident’s representative was not notified in writing of the transfer summary and reported that the facility’s usual practice was for the BOM or nurse to mail the transfer summary. The DON also stated that the facility had not recorded when a transfer summary had been sent out, and that the facility’s process did not capture when or to whom the transfer summary was sent.
Inaccurate MDS Coding for Insulin Use
Penalty
Summary
The facility failed to accurately complete the Minimum Data Set (MDS) assessment for Resident #82. During the initial tour, the resident was observed alert and oriented x4, in no distress, and lying in bed, and stated that he/she was diabetic and received insulin injections. Record review showed the resident had a physician order for insulin in the morning and at bedtime for diabetes, with insulin ordered on admission to the facility in May 2025. Review of the admission MDS dated [DATE] showed section N0415 High-Risk Drug Classes: Use and Indication was coded "no" for taking a hypoglycemic drug, including insulin, despite the resident having an active insulin order. During interview, the Lead MDS Coordinator reviewed the assessment and acknowledged the incorrect coding on the admission MDS.
Delayed Care Plan Meetings
Penalty
Summary
The facility failed to ensure care plan meetings were held in a timely manner for Resident #3. The report states that a comprehensive care plan meeting should be held within seven days of completing the MDS assessment and reviewed and revised after each subsequent assessment, but Resident #3’s care plan meetings were documented only on 1/31/24, 06/04/24, 10/31/24, and 03/03/25. During an interview on 07/30/2025, Resident #3 stated that he/she did not recall attending care plan meetings routinely. A Social Service note dated 08/05/25 stated that a care plan meeting was scheduled for Monday, August 18th at 12 PM, and that a detailed voicemail had been left for the family requesting a call back. During an interview on 08/06/2025, the second floor Social Service staff member acknowledged the delay in providing Resident #3’s care plan meetings and stated she was not initially aware that MDS had a calendar, but later began using it. The staff member stated that MDS was not behind with Resident assessments and that the continued delay in holding care plan meetings was on her end, but she was unable to provide a reason for the delay.
Failure to Provide ADL Assistance
Penalty
Summary
Activities of daily living were not provided for two residents who were dependent on assistance. One resident was observed uncleaned, with disheveled hair, wearing a night gown, and having an odor of urine. The resident stated that he or she had not been cleaned all morning and that a diaper had been soiled since early that morning. The Unit Manager stated that the staffing agency had cancelled all scheduled GNAs for that morning, leaving the facility short staffed, and the Nursing Home Administrator confirmed that all assigned GNAs had been cancelled by the staffing agency. Another resident was observed lying in bed with noticeable facial hair on the chin and upper lip and stated that aides had been informed and asked for a razor. The resident’s record showed a BIMS score of 15 out of 15, indicating cognitive intactness, and the MDS identified functional limitation in range of motion and a need for assistance with personal hygiene. The care plan also identified an ADL self-care performance deficit, yet the resident still had visible facial hair during the follow-up observation.
Failure to Follow Ordered Bowel Management Protocol
Penalty
Summary
The facility failed to follow the physician-ordered bowel management protocol for Resident #33, a cognitively intact resident with a BIMS score of 15 out of 15, who reported constipation for about a week and abdominal discomfort. On 7/30/2025, the resident was observed grimacing and stated that he/she felt terrible and had not slept during the night because of the discomfort. The resident said staff had been informed about the constipation but that only Milk of Magnesia had been received. At that time, an LPN informed the resident that an enema had been ordered. The active physician orders required a stepwise regimen for constipation: Milk of Magnesia if no bowel movement in 3 days, Dulcolax suppository if there was no result from MOM or Miralax by the next shift, and Fleet enema if there was no result from Dulcolax within 2 hours, with the provider to be called if all measures failed. Review of the July MAR showed the resident did not receive MOM or Dulcolax suppository from July 2 through July 31, 2025, before receiving a Fleet enema on 7/30/25 at 1:00 PM. LPNs stated that nurses were expected to follow the bowel protocol as ordered and document the results, while the DON later reported that LPN #10 said the resident refused MOM and Dulcolax, although there was no evidence in the record that the resident complained of constipation and declined the bowel protocol.
Delayed and inaccurate completion of pharmacy DRR recommendations
Penalty
Summary
The facility failed to ensure pharmacy recommendations from the monthly drug regimen review were reviewed in a timely manner and implemented accurately for 2 of 5 residents reviewed. For one resident, Omnicare issued a clinical priority recommendation that the resident’s rivaroxaban dose be evaluated because the resident’s creatinine clearance was 48 mL/min and the manufacturer recommended 15 mg once daily with the evening meal for nonvalvular atrial fibrillation when CrCl was 50 mL/min or less. The physician did not sign the recommendation until 34 days later, and the resident’s MAR later showed rivaroxaban 15 mg ordered at bedtime for Afib. For another resident, the pharmacist’s DRR report dated 5/19/2025 identified that fludrocortisone 0.3 mg daily was above the usual maximum maintenance dose of 0.2 mg daily for orthostatic hypotension. The physician did not act on that recommendation until 6/23/2025. A second pharmacist DRR report dated 6/16/2025 identified that Voltaren Gel was ordered without a specific quantity in the directions and that the indication was documented as edema rather than pain; the physician did not act on that recommendation until 6/24/2025, and the order/start date on the drug regimen was not until 6/28/2025. The facility policy stated that it shall act upon all recommendations according to procedures for addressing medication regimen review irregularities, and that written communications from the pharmacist become a permanent part of the resident’s medical record. During interview, the DON stated the expectation was that pharmacist DRR recommendations should be completed by physicians within a week of receiving the reports. The LNHA stated the concern was being addressed in a PIP, and the facility’s PIP identified decreased and delayed completion of pharmacy recommendations by the attending physician as the problem.
Failure to Monitor Anticoagulant Therapy
Penalty
Summary
The facility failed to provide adequate monitoring for a resident receiving anticoagulant therapy. Resident #33 was observed with bruising on both posterior hands and arms and stated that the bruising was caused by the blood thinner being taken. The resident’s active physician orders showed Xarelto (rivaroxaban) 10 mg by mouth daily for DVT prophylaxis, and a progress note from the APN stated that the resident was on newly initiated anticoagulation therapy and should be monitored for bleeding related to anticoagulation therapy. Review of the resident’s July and August MAR and TAR showed no evidence that anticoagulant monitoring had been entered or implemented. The Unit Manager confirmed that nurses were expected to enter monitoring interventions in the electronic medical record for residents receiving anticoagulants, including monitoring for bleeding, bruising, and black tarry stool, and verified that the task was absent from the resident’s MAR and TAR. The resident’s record later showed that an anticoagulant monitoring order was written after surveyor intervention.
Infection Control Lapses During Medication Administration
Penalty
Summary
The facility failed to ensure staff practiced infection control during medication administration and resident care. During an observation on 07/31/25 at 7:31 AM, LPN #4 obtained Resident #55's blood pressure, then failed to sanitize the blood pressure equipment and cuff after use. The LPN returned to the medication cart and prepared the resident's medication without performing hand hygiene, then entered the resident's room and administered the medication again without first practicing hand hygiene. During an interview on 07/31/25 at 7:37 AM, LPN #4 stated the facility's expectation was to always practice infection control, including sanitizing shared medical equipment and performing hand hygiene when delivering direct care. During an interview with the Infection Control Preventionist on 08/05/25 at 11:50 AM, the ICP confirmed that shared medical equipment was to be sanitized after each use and hand hygiene is required when delivering direct care, including medication administration.
Activities Program Not Directed by Qualified Professional
Penalty
Summary
The facility failed to ensure that the activities program was directed by a qualified professional. During the survey, the Activities Director stated she had been employed in that role at the facility for three years. When the Administrator provided the requested credential records, the documentation consisted only of proof of a Bachelor of Science degree and did not include the credentials required for an Activities Director per federal guidelines. The Administrator later stated that a form had been submitted to the National Certification Council for Activity Professionals (NCCAP) for the Activities Director to receive the Activity Director Certified (ADC) credential, but confirmed there was no other education, training, or documentation available to show the Activities Director met the required qualifications. On a subsequent interview, the Administrator again confirmed that no additional credentials could be provided, and the surveyor informed the Administrator that this was a concern, which the Administrator acknowledged.
Failure to Maintain Safe and Homelike Environment Due to Poor Maintenance
Penalty
Summary
Surveyors observed multiple deficiencies in the facility's maintenance of a safe, clean, and comfortable environment for residents. On three of four hallways on the second-floor nursing unit, several resident rooms had furniture with missing or peeling laminate, exposed particle board, cracked vinyl on wheelchair armrests, missing or damaged drawer handles, and rusted toilet riser frames. Additional issues included loose or missing baseboard molding, holes in ceilings and molding, exposed drywall above heaters, dirty fans, broken bathroom sink drains, and plastic pipes left on the floor. These conditions were confirmed by the Maintenance Director during an environmental tour. A resident reported that their wheelchair had been in disrepair since September 2023, with unsecured arms and sharp metal corners, requiring the use of a seat pad for protection. The same resident also noted a dirty privacy curtain with a brown spot and a worn footboard with missing material and baseboard molding. These observations were confirmed by the surveyor during interviews and room inspections. The facility staff were aware of these issues, as acknowledged by the Nursing Home Administrator, but the necessary maintenance and repairs had not been completed at the time of the survey.
Inaccurate Coding of MDS Assessments for Multiple Residents
Penalty
Summary
Facility staff failed to ensure that Minimum Data Set (MDS) assessments were accurately coded for four residents during a complaint survey. In one case, a resident received Oxycodone for pain, but the MDS assessment did not capture the use of an opioid. Another resident was administered scheduled pain medications, including Lidocaine patches, Voltaren gel, and Gabapentin for osteoarthritis, but the MDS failed to document the use of scheduled pain medications and anticonvulsants. The MDS Coordinator confirmed these omissions during interviews, attributing them to oversight. Additionally, a resident who was administered Amoxicillin for a urinary tract infection and received Zinc Oxide cream for skin treatment was not accurately coded for antibiotic use or topical medication application on the MDS. Another resident with a history of falls experienced a fall during their stay, but both the quarterly and discharge MDS assessments failed to document this event. The MDS Coordinator acknowledged these errors, confirming that the assessments did not accurately reflect the residents' conditions and treatments.
Failure to Follow Infection Control Practices and Proper Storage of Resident Care Items
Penalty
Summary
Facility staff failed to adhere to infection control practices as observed during a complaint survey on one of two nursing units. Specifically, a Geriatric Nursing Assistant (GNA) was seen feeding one resident, then setting up another resident's breakfast tray, and returning to the first resident without sanitizing her hands between resident contacts. The same GNA was later observed feeding another resident, handling soiled breakfast trays, and entering another room without performing hand hygiene after contact with residents and contaminated items. Additionally, multiple resident bathrooms on the second-floor nursing unit were found to have uncovered, unlabeled, and improperly stored basins and urinals. Some basins contained used paper towels, soiled utensils, or were stacked inside each other without protective plastic. Dirty containers and soiled washcloths were also observed in several bathrooms. The Infection Control Nurse confirmed that basins should be cleaned, dried, labeled, and stored in plastic bags, but acknowledged that current practices did not meet these standards and that the only available policy addressed cleaning and returning bath basins to storage.
Failure to Maintain Effective Pest Control Program
Penalty
Summary
The facility failed to maintain an effective pest control program, as evidenced by multiple documented instances of pest activity, including roaches and ants, in various areas such as the kitchen, nurses stations, pantries, and 26 out of 70 resident rooms. Review of the facility's and vendor's pest control logs from January through May revealed repeated reports and observations of roach and ant activity in resident rooms, common areas, and service areas. Specific entries noted heavy and moderate pest activity, with some areas showing persistent problems over several months. Vendor pest control logs corroborated these findings, documenting frequent inspections and treatments for roach and ant activity in resident rooms, pantries, kitchen, dish room, and nurses stations. The vendor also observed poor sanitation and standing water in the dish room, which were identified as contributing factors to ongoing pest issues. Despite regular treatments, pest activity was repeatedly observed on monitors and during service visits, indicating that the measures in place were not sufficient to control the infestation. Direct observations by surveyors and staff interviews further confirmed the presence of pests, including live sightings of ants and roaches in resident rooms, pantries, and vending areas. One resident reported seeing a bed bug and stated that staff had not followed up on the concern. These findings collectively demonstrate that the facility did not have an effective pest control program in place to prevent or address infestations, resulting in ongoing pest activity in both resident and common areas.
Failure to Maintain Resident Dignity During Feeding and Communication
Penalty
Summary
Facility staff failed to treat residents in a dignified manner during mealtime assistance. A Geriatric Nursing Assistant (GNA) from a staffing agency was observed standing while feeding a resident and quickly shoveling food into the resident's mouth. In the same room, another resident was found sleeping in bed with their breakfast tray left covered on the bedside table. The GNA then approached the sleeping resident and repeatedly spoke in a harsh and loud tone, instructing the resident to wake up for breakfast. These actions were directly observed by the surveyor. Additionally, the same GNA was later seen standing while feeding another resident in the dining room, with another resident present at the same table. The Director of Nursing (DON) was informed of these observations, including the GNA's failure to sanitize hands between resident contacts. The DON acknowledged that the GNA's behavior was inappropriate and not in accordance with facility expectations.
Failure to Timely Report Alleged Abuse to Regulatory Agency
Penalty
Summary
The facility failed to report an allegation of abuse to the regulatory agency, the Office of Health Care Quality (OHCQ), within the required 2-hour timeframe. On the morning of 9/27/23, a housekeeping staff member observed a resident at the first-floor nursing station in a wheelchair with a bed sheet tied in a knot around their back. Unable to find anyone to report the incident to on the first floor, the housekeeper went to the second-floor nursing unit and informed a GNA. The charge nurse on the second floor overheard this and immediately notified the first-floor charge nurse. Despite these actions, facility documentation shows that the initial report to OHCQ was not made until later that afternoon, well beyond the mandated 2-hour window. The DON confirmed during an interview that the report was not submitted within the required timeframe.
Failure to Perform Timely and Accurate Neuro Checks After Falls
Penalty
Summary
Facility staff failed to properly perform neurological checks after falls for two residents, as required by facility protocol. One resident, admitted with a history of falls, experienced an unwitnessed fall in the bathroom. Although the provider was notified and recommended monitoring per protocol, staff did not complete neuro checks at the required intervals and, in some instances, used outdated vital signs. Several scheduled neuro checks were missed, and the night shift did not complete the required assessments. Another resident, admitted with weakness, had an unwitnessed fall and was found sitting between the bed and wall. The provider instructed staff to follow the facility's neuro check protocol, but staff again failed to perform neuro checks at the correct intervals, omitted some checks, and used vital signs from several hours prior. Interviews with nursing leadership confirmed that neuro checks were not completed accurately or according to the established schedule for both residents.
Failure to Provide Timely Pressure Ulcer Care and Assessment
Penalty
Summary
Facility staff failed to provide appropriate treatment and services to prevent and heal pressure ulcers for two residents. One resident, admitted with a history of cerebral infarction, was documented by the Wound Nurse Practitioner (WNP) to have an unstageable sacral pressure ulcer. The prescribed treatment regimen included cleansing with dakins and applying santyl with dakins wet to dry dressing daily. However, medical record review showed that staff did not administer the ordered treatment on three consecutive days, as confirmed by the Director of Nursing. Another resident, who was readmitted from the hospital, was assessed by the WNP to have a Stage 3 sacral pressure ulcer. Facility staff failed to complete weekly wound assessments, including measurements, on three separate occasions. Additionally, although a left heel wound was identified, treatment for a deep tissue injury (DTI) was not initiated until nearly two weeks after the wound was first documented. The Assistant Director of Nursing confirmed these lapses in wound assessment and delayed initiation of treatment.
Failure to Provide Timely Access to Prescribed Medications After Admission
Penalty
Summary
The facility failed to provide timely access to prescribed medications for a resident admitted from an acute care hospital with multiple fractures and pain management needs. Upon admission, the resident had orders for several controlled substances, including hydromorphone for pain, alprazolam and lorazepam for anxiety, and pregabalin for nerve pain. Despite these orders, the medications were not administered on the day of admission, as documented in the Medication Administration Record. The resident and family requested pain medication within two hours of arrival, but were informed that the orders needed to be cleared by the physician due to their controlled status. After six hours without receiving the prescribed medications, the resident's spouse signed the patient out against medical advice to seek medication at a hospital. Nursing notes indicated that the resident was assessed and offered alternative pain medications, which were refused, but did not document the resident's pain level. Interviews with staff revealed that the process for obtaining controlled substances required physician review and pharmacy authorization, even though some of the medications were available in the facility's Omnicell system. The facility's own investigation confirmed that the medications were not available as required and that orders should have been processed within four hours of admission. The deficiency was identified as an isolated incident involving a failure to ensure timely pharmaceutical services to meet the resident's needs.
Failure to Timely Obtain Outside Professional Services for Residents
Penalty
Summary
Facility staff failed to obtain necessary outside professional services for two residents as required. For one resident admitted with a diagnosis of cerebral infarction, the hospital discharge summary included instructions for a neurology follow-up. However, review of the medical record showed that no order was placed and no neurologist appointment was scheduled from admission through discharge. The DON confirmed that the neurology appointment was not scheduled. For another resident admitted with diagnoses including bladder neck obstruction, solitary pulmonary nodule, and low back pain, the hospital discharge summary required follow-up appointments with urology, pulmonology, and orthopedics. The urology appointment was not ordered until several months after admission, and although the resident was eventually seen by the urologist, the pulmonology and orthopedic appointments were not ordered until even later, with no evidence that the resident was seen by those specialists. The Administrator confirmed that these appointments were not ordered in a timely manner and that there was no evidence of visits to pulmonology or orthopedics.
Missing Diagnostic Test Results in Medical Record
Penalty
Summary
The facility failed to maintain complete and accurate medical records in accordance with accepted professional standards for one resident reviewed during a complaint survey. Specifically, a resident admitted with a diagnosis including bladder neck obstruction had a physician order for a cystoscopy. Upon review of both electronic and paper medical records, the results of the cystoscopy were not found. This omission was confirmed during an interview with the Administrator, who acknowledged that the medical record did not contain the required cystoscopy results. The deficiency was identified through medical record review and staff interview, demonstrating that the facility did not ensure all relevant diagnostic results were included in the resident's official medical record.
What surveyors are citing around you — mapped
All 10 risk areas, ranked with evidence
Repeat citations, what's rising near you, and quality measures — ranked so department heads know exactly where to look first.
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What surveyors actually found near you
We read the 880 citations issued within 25 miles in the last 12 months — including the 4 immediate-jeopardy cases — and tell you exactly what happened, in plain English, matched to your record.
Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
Walk-in cooler logs missing for 12 days; expired supplements in the medication room fridge.
Illustrative
A prioritized, do-first checklist
Every risk area becomes concrete audit steps drawn from real citations at facilities like yours — run them this week, before your window opens.
Illustrative
Risk indicators are statistical estimates from public CMS data — not predictions, findings, or compliance advice.
Nursing homes near Annapolis
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Complete Care At Annapolis | 0.7 mi | ★★★★★ | 11 | 0 |
| Baywoods Of Annapolis | 1.6 mi | — | 0 | 0 |
| Ginger Cove | 3 mi | ★★★★★ | 12 | 0 |
| South River Rehabilitation And Wellness Center | 3.5 mi | ★★★★★ | 22 | 0 |
| Future Care Annapolis | 4.6 mi | — | 0 | 0 |
Every risk area ranked, a do-first checklist, and your local survey patterns
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Trusted data, never guesswork. Every citation, penalty, rating and Plan of Correction on this page is sourced from public CMS records (latest release July 2026) and official state health department websites.