Autumn Lake Healthcare At Spa Creek
Inspection history, citations, penalties and survey trends for this long-term care facility in Annapolis, Maryland.
- Location
- 35 Milkshake Lane, Annapolis, Maryland 21403
- CMS Provider Number
- 215258
- Inspections on file
- 18
- Latest survey
- September 10, 2025
- Citations (last 12 mo.)
- 41
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.
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 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.
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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Every citation, penalty and Plan of Correction is sourced from public CMS records (latest release May 27, 2026) and official state health department websites — never guesswork.
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