Below 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 August 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Autumn Lake Healthcare At Salem County during CMS and state inspections, most recent first.
Failure to Document and Implement Verbal Nystatin Order: A resident with encephalopathy, cachexia, and severely impaired cognition had a fungal rash to the sacrum and anus, and an NP gave a verbal order for Nystatin cream and a wound consult. The order was not transcribed to the MAR/TAR, the Order Summary did not show it, and there was no nursing documentation of the NP evaluation or implementation of the verbal order.
A resident with multiple comorbidities and incontinence was not given a complete and accurate skin assessment upon admission, resulting in missed documentation of excoriation and edema. The initial assessment failed to identify skin impairment, and wound care orders were delayed until a subsequent assessment by an LPN. Required incident reporting and documentation were not completed as per facility policy.
Kitchen sanitation and hand hygiene lapses were observed during meal service. Dust was noted on a potholder above the steam table and on ceiling vent areas over the sink and shelving, while lunch was served from the steam table beneath the dusty potholder and trays and plates were set up under the dusty vent area. A cook was also observed removing gloves and then touching the stove, handling utensils, taking dirty dishes to the dish area, wiping the sink, and later picking up a paper towel from the floor before putting on another pair of gloves without proper hand hygiene between task changes.
Improper Dumpster Maintenance and Refuse Disposal: Observation of the refuse area found two dumpsters with open lids, no plugs in the bottom holes, and used gloves and debris on the ground around the dumpsters. When the Dietary Director closed the lids, a liquid substance splashed on the Director. The Dietary Director and MD stated maintenance was responsible for cleaning and maintaining the dumpsters.
The facility did not ensure pharmaceutical services were provided to meet each resident's needs and failed to employ or obtain a licensed pharmacist as required.
Failure to Assess Resident for Self-Administration Before Leaving Medications at Bedside: A resident with COPD and a BIMS score of 15 had an inhaler and nasal spray left at the bedside without a documented assessment for self-administration. The EMR showed orders for daily Breo Elipta and fluticasone nasal spray, but the care plan had no self-medication plan. An LPN, UM, and DON all stated the medications should not have been at the bedside without an assessment.
Resident Exposed in Room Without Privacy: A resident with metabolic encephalopathy and moderate cognitive impairment was observed in bed with his backside exposed to the hallway while his room door was open and no privacy curtain was pulled. Staff and other residents passed by during the observation, and an LPN later stated the curtain needed to be pulled to provide dignity. The resident was later observed again with his buttocks exposed from the doorway while the privacy curtain remained open.
Resident-to-resident abuse was not prevented when one resident with no cognitive impairment scratched another resident with severe cognitive impairment in the face during activities in the dining room. Staff interviews and the facility’s investigation confirmed the incident occurred, and the resident later stated he did it because he believed the other resident was being disrespectful to a female staff member.
A resident with dementia and severe cognitive impairment received Risperdal for psychotic disorder, but the MAR and nurse’s notes contained no documented target behaviors or routine monitoring tied to the antipsychotic use. The UM said behaviors were counted monthly and discussed in weekly meetings, but could not explain how staff would know which specific behaviors were being tracked, and the DON stated staff were expected to monitor specific target behaviors for residents on psychotropic medications.
Failure to Timely Report Resident-to-Resident Abuse: The facility did not report an allegation of resident-to-resident abuse within the required timeframe after an LPN documented that one resident scratched another resident in the face during activities. One resident had no cognitive impairment on BIMS, while the other had severe cognitive impairment. The Administrator stated the report was delayed because the facility completed its investigation first, despite policy requiring prompt reporting of alleged abuse.
The facility failed to provide written emergency transfer and bed hold notices to residents and/or their representatives for three residents who were sent to the hospital. One resident with severe cognitive impairment had forms completed, but there was no evidence the family received them; another resident’s forms could not be located; and a third resident with severe cognitive impairment was transferred for respiratory distress, with staff describing a process that relied on sending forms with the resident and notifying family by phone. Interviews showed inconsistent handling of the transfer packet and no clear evidence that the required written notices reached the resident representatives.
Incomplete PASARR Level I Assessment: A resident admitted with major depressive disorder, bipolar disorder, PTSD, and schizophrenia had an inaccurate PASARR Level I. The record also showed the resident was physically aggressive toward another resident and was sent for a psych crisis eval, but the PASARR did not include those diagnoses or the crisis event. The SSD stated the PASARR was not completed correctly and the resident should have been referred for a Level II PASARR.
A resident admitted with PTSD was given Seroquel, but the order was entered by an LPN as being for schizophrenia even though hospital records listed PTSD/mood and did not document schizophrenia. The MDSC then carried that diagnosis into the MDS and EMR, while the resident denied having schizophrenia and the DON later confirmed the diagnosis should not have been present.
A resident with cellulitis and type 2 DM with circulatory complications did not receive ordered daily wound care to the right lower extremity. The resident stated the bandage had not been changed since the prior treatment, and an LPN confirmed the dressing was last changed on that date. The TAR showed a daily order for cleansing, absorbent dressing, cling wrap, and ace bandage, and both the Administrator and DON stated the bandage should have been changed every day until the order was discontinued.
A resident using supplemental O2 did not have clear O2 orders or a documented care plan for oxygen use, and staff observed the nasal cannula disconnected from the oxygen source at times. Another resident’s oxygen concentrator had dust-filled filters, with staff giving conflicting accounts of who was responsible for cleaning them. The DON stated O2 orders should include the rate and pulse ox checks, and the facility policy required oxygen equipment filters to be washed as needed.
A resident receiving dialysis had no documented pre- or post-dialysis assessments in the EMR, inconsistent vital sign documentation, and no order for a return-from-dialysis assessment. The facility also failed to consistently use or retain dialysis communication sheets between the facility and the dialysis center, with several forms missing from the chart and others found at the nursing desk.
A resident with schizoaffective disorder and cognitive communication deficit was ordered to have two half side rails for repositioning, but the record showed no evidence that alternatives were explored before use and no assessment for entrapment risk. Staff interviews confirmed that alternatives were not explored prior to bed rail use and that there was no process for entrapment assessment, despite the facility policy requiring evaluation and use only after alternatives were found ineffective.
A resident with diabetes experienced a critically low blood sugar, but the LPN did not notify the physician as required by orders and facility policy. Review of records and staff interviews confirmed the lack of notification and documentation, despite clear protocols for such events.
Staff failed to consistently document ADL care provided or refused for three residents with complex medical needs, resulting in missing entries in the DSR and progress notes. Despite the use of a mobile documentation system and clear policy expectations, required ADL documentation was incomplete on multiple shifts, and supervisory checks did not ensure compliance.
A facility failed to develop a comprehensive care plan for a resident with diabetes and elongated toenails, despite the resident's severe cognitive impairment. The facility's policy required a person-centered care plan, but interviews with staff, including the UM and DON, confirmed the absence of such a plan. This oversight was identified during a survey, highlighting a deficiency in the care planning process.
A resident with diabetes and dementia did not have a care plan for their conditions, and there was a delay in podiatry care for elongated toenails. Additionally, there was a significant delay in notifying the physician of abnormal urine culture results, contrary to facility policy. These lapses in care highlight deficiencies in adhering to clinical standards.
A facility failed to provide timely podiatry care for a diabetic resident admitted with elongated toenails, who was not seen by a podiatrist for nearly nine months. Despite the facility's policy for prompt podiatry referrals, the resident's toenails were only addressed after a significant delay. Interviews revealed a breakdown in communication and procedure adherence among staff, contributing to the deficiency.
A resident with severe cognitive impairment and multiple diagnoses had an abnormal urine culture result that was not promptly communicated to the physician, contrary to facility policy. The urine culture was collected and reported in early September, but the physician was not informed until several days later, delaying necessary antibiotic treatment. Interviews with facility staff confirmed the expectation for immediate notification of abnormal lab results to prevent potential escalation of the resident's condition.
The facility failed to maintain a homelike environment for three resident rooms on the C/D unit. Observations included damaged furniture, walls, and leaking sinks. Staff confirmed that maintenance issues were reported in a log, but some entries were incomplete, and repairs were not made. The Interim Maintenance Director acknowledged the unresolved issues and the need for repairs.
The facility failed to properly handle and store potentially hazardous foods and maintain kitchen equipment and areas to prevent microbial growth and cross-contamination. Observations included undated raw chicken, wilted lettuce, undated liquids, unlabeled scalloped potatoes, damaged pork loins, a dented can, a dirty slicer, and a stained cutting board. The Dietary Director acknowledged these issues, which were not in compliance with the facility's policies.
An LPN failed to follow infection control practices and perform hand hygiene during a meal tray pass, handling food and interacting with residents without cleaning her hands. This was confirmed by multiple staff members and a review of the facility's hand hygiene policy.
The facility failed to follow professional standards by not obtaining a diagnosis for the use of an IV antibiotic for a resident admitted with cellulitis and a PICC line. The physician's order for Vancomycin did not include a diagnosis, and the resident and LPN were unaware of the infection being treated. The LPN/UM later confirmed the antibiotic was for MRSA in the blood, but acknowledged the order should have included a diagnosis. The facility's policy requires medication orders to include the clinical condition, which was not followed.
The facility failed to obtain a physician order for a skin tear treatment and did not update a resident's Care Plan with fall prevention interventions after an unwitnessed fall. The resident, who had a history of falls and was cognitively impaired, fell while trying to retrieve something from the closet, resulting in a skin tear. Despite claims in the incident report, no documentation was found in the Care Plan or Electronic Medical Record to support these actions.
The facility failed to ensure proper handling of a urinary catheter drainage bag for a resident with urinary retention. The drainage bag was observed touching the floor and not kept below the bladder level, contrary to the care plan and staff statements. The facility's Catheter Care policy did not specify that the drainage bag should be kept off the floor.
A resident receiving IV antibiotic therapy for cellulitis had an unlabeled and undated IV medication bag and tubing hanging on the IV pole. The medication was not administered due to a clogged PICC line, and the nurse failed to discard the medication as required. The facility's policies lacked specific instructions on labeling and dating IV tubing, contributing to the deficiency.
A facility failed to maintain an accurately documented and complete medical record for a resident who experienced an unwitnessed fall, resulting in a skin tear. Multiple staff members confirmed the absence of documentation in the progress notes, violating the facility's policy on charting and documentation.
Failure to Document and Implement Verbal Nystatin Order
Penalty
Summary
The facility failed to follow professional standards of practice when it did not implement a provider’s verbal wound treatment order for Nystatin and did not transcribe that order onto the resident’s Treatment Administration Record (TAR). Resident #1 had diagnoses including encephalopathy, cachexia, and hyperlipidemia, and a comprehensive MDS dated 3/19/26 showed a BIMS score of 5 out of 15, indicating severely impaired cognition. The resident was not at the facility during the survey, so the record was reviewed as a closed chart. The medical record included an NP evaluation dated 6/4/26 documenting a fungal rash to the sacrum and anus and stating that Nystatin cream and a wound consult would be added. The evaluation further listed an order for Nystatin cream to the sacrum and anus twice daily for 7 days and a wound care consult. However, the Order Summary Report did not show the Nystatin order, and the June 2026 MAR and TAR did not include it. The resident’s progress notes also did not contain nursing documentation related to the NP’s evaluation. During interview, the NP confirmed she evaluated the resident and gave a verbal order to the nurse, and the DON stated she expected nurses to document and implement verbal orders.
Failure to Complete Timely and Accurate Skin Assessment on Admission
Penalty
Summary
The facility failed to perform an initial full body skin assessment and implement timely interventions for a resident upon admission, as required by its Skin Assessment Policy. Upon review, the admission screening indicated the resident's skin was intact, but a subsequent body check performed within 24 hours identified edema in both lower extremities and excoriation to both buttocks. The initial assessment did not document these findings, and the discrepancy was acknowledged by the Director of Nursing, who stated that the excoriation may have been missed during the first assessment. The resident in question had significant medical conditions, including aphasia, hemiplegia, hemiparesis following a stroke, diabetes, and major depressive disorder. The resident required one-person assistance for transfers and was incontinent of urine and frequently incontinent of bowel. Despite these risk factors, the initial skin assessment failed to identify the presence of skin impairment, and the need for wound care with Zinc Oxide was not recognized until the second assessment was completed by another nurse. Interviews with facility staff revealed that if skin issues were identified, an incident report should have been initiated and documented in the electronic medical record, but this was not done. The Treatment Administration Record indicated that a previous skin impairment was present, but there was no corresponding documentation in the progress notes or incident reporting. The delay in identifying and treating the skin impairment resulted in a delay in the administration of prescribed wound care.
Kitchen sanitation and hand hygiene lapses during meal service
Penalty
Summary
The facility failed to ensure the kitchen was clean and that staff performed handwashing between glove use and task changes during meal service. During observation of the kitchen, dust was noted on the potholder above the steam table where meals were served and on the ceiling around the vent areas above the sink and shelving. Lunch was later served from the steam table directly beneath the dust-covered potholder, and staff were observed using tongs that had been hanging on that potholder. Trays and plates were also set up under the vent area where dust was hanging from the ceiling. During meal service, Cook1 was observed removing gloves and then touching the stove knob, moving utensils from above the sink to the steam table, taking dirty dishes to the dish area and returning to the main kitchen with the same gloves on, and wiping down the sink. Cook1 later removed gloves and washed hands, but there were no paper towels in the dispenser, and she left the kitchen with wet hands to get napkins from the storeroom. She also picked up a paper towel from the floor and placed it in the trash, then adjusted stove knobs and put on another pair of gloves. In interview, Cook1 agreed her hands should have been washed after glove removal and after picking up the paper towel. The DM confirmed the dust and grease over the food service area and stated handwashing should have occurred after glove removal and after picking up the paper towel. The MD stated cleaning the kitchen ceilings was maintenance responsibility.
Improper Dumpster Maintenance and Refuse Disposal
Penalty
Summary
The facility failed to ensure the dumpsters' lids were closed, the plugs were in place, and used gloves and debris were picked up off the ground. On 08/04/25 at 10:10 AM, observation of the dumpster area revealed two refuse dumpsters with both lids open, and when the Dietary Director shut the lids, a liquid substance splashed on the Dietary Director. Gloves and other debris were observed lying on the ground around the dumpsters, and neither dumpster had plugs in the holes at the bottom of the container. During interviews on 08/04/25 and 08/07/25, the Dietary Director and Maintenance Director stated that maintenance was responsible for cleaning up the area and maintaining the dumpsters. Review of the facility policy titled, Preventive Maintenance Program dated 12/28/22, stated that a preventive maintenance program shall be developed and implemented to ensure a safe, functional, sanitary, and comfortable environment for residents, staff, and the public.
Failure to Provide Required Pharmaceutical Services
Penalty
Summary
The facility failed to provide pharmaceutical services to meet the needs of each resident and did not employ or obtain the services of a licensed pharmacist. This deficiency was identified during the survey process, indicating that the required pharmaceutical oversight and services were not in place for residents as mandated by regulations. No additional details regarding specific residents, their medical history, or their condition at the time of the deficiency are provided in the report.
Failure to Assess Resident for Self-Administration Before Leaving Medications at Bedside
Penalty
Summary
The facility failed to assess one resident for self-administration of medications before leaving medications at the bedside. During an observation, an inhaler and a bottle of nose spray were found sitting on the resident’s bedside table, and the resident stated, “I need to use them.” The resident had been admitted with diagnoses of COPD and shortness of breath, and the quarterly MDS showed a BIMS score of 15 out of 15, indicating the resident was cognitively intact. Physician orders in the EMR included Breo Elipta inhalation powder one puff daily for COPD and Fluticasone Propionate nasal spray two sprays in both nostrils daily for rhinitis and congestion. Review of the resident’s comprehensive care plan showed no care plan related to self-administration of medication. During interview, an LPN stated the medications should not have been there. The UM stated residents should be assessed and verified that this resident had not been assessed. The DON stated medications should not be at the bedside without an assessment. The facility policy stated residents may self-administer medications only if it is determined they are capable, and that the interdisciplinary team will assess the resident’s mental and physical abilities to determine whether the resident is capable of self-administering medication.
Resident Exposed in Room Without Privacy
Penalty
Summary
The facility failed to maintain a resident’s dignity when R102 was observed lying in bed with his backside exposed to the hallway outside his room. R102 was admitted with diagnoses including metabolic encephalopathy and had a BIMS score of 12 out of 15 on 07/25/25, indicating moderate cognitive impairment. During an observation on 08/05/25 at 8:30 AM, his room door was fully open, he was lying on his side facing away from the door, and he wore a gown tied at the neck and open in the back with his back and upper buttocks exposed. He also wore an incontinent brief that covered the lower half of his buttocks but not the upper buttocks, and no privacy curtain was pulled around the bed. During constant hallway observation from 8:30 AM to 9:30 AM, four staff members and three residents passed the doorway while R102 remained exposed. When an LPN was asked to look at him at 9:30 AM, she stated the privacy curtain needed to be pulled to provide dignity, pulled the curtain around the bed, and asked the resident if he wanted to get up. On 08/07/25 at 3:10 PM, R102 was again observed in bed facing away from the door with the door partially closed and the privacy curtain not pulled; his pants were pulled down, exposing most of his buttocks from the doorway. When asked if he wanted others to see his bottom, he shook his head no but did not answer further questions. The DON stated staff were expected to maintain residents’ dignity and close doors or pull privacy curtains as needed.
Resident-to-Resident Abuse Not Prevented
Penalty
Summary
The facility failed to ensure residents were free from resident-to-resident abuse involving two residents reviewed for abuse. R8 was admitted with diagnoses including major depressive disorder, bipolar disorder, post-traumatic stress disorder, and schizophrenia, and his annual MDS showed a BIMS score of 13 out of 15, indicating no cognitive impairment. R55 was admitted with diagnoses including major depressive disorder and anxiety disorder, and his quarterly MDS showed a BIMS score of 3 out of 15, indicating severe cognitive impairment. A nurse’s note documented that R8 scratched R55 in the face while both residents were in the dining room during activities, and an incident report was required. The facility’s self-report confirmed the incident occurred and that R8 intentionally scratched R55 in the face. Staff interviews stated that R8 later said he scratched R55 because he did not like the way R55 spoke to a female and believed R55 was being disrespectful. The Activities Aide reported that R8 reached across and scratched R55 after getting a lollipop, and the Administrator stated the investigation concluded the incident did occur and was seen on security cameras.
Failure to Monitor Target Behaviors for Antipsychotic Use
Penalty
Summary
The facility failed to monitor target behaviors for the use of Risperdal for one resident with dementia and severe cognitive impairment. The resident’s record showed an admission diagnosis of dementia, a quarterly MDS with a BIMS score of 6 out of 15, and documentation that the resident was not exhibiting behavioral symptoms during the assessment period while still receiving an antipsychotic medication. The physician order directed Risperdal 1 mg by mouth twice daily for psychotic disorder. Review of the MAR for June, July, and August 2025 found no documented evidence identifying which specific behaviors were associated with the antipsychotic administration or showing routine monitoring of those behaviors. Review of the nurse’s notes for the same period also found no documented behaviors related to the psychotic disorder diagnosis. During interview, the UM stated behaviors would be documented in progress notes and counted monthly, but could not explain how staff would know what specific behaviors were being tracked if they were only listed on monthly psych evaluations. The DON stated staff were expected to monitor specific target behaviors for residents receiving psychotropic medications.
Failure to Timely Report Resident-to-Resident Abuse
Penalty
Summary
The facility failed to report an allegation of resident-to-resident abuse involving two residents. R8 was admitted with diagnoses including major depressive disorder, bipolar disorder, post-traumatic stress disorder, and other schizophrenia, and his annual MDS showed a BIMS score of 13 out of 15, indicating no cognitive impairment. R55 was admitted with diagnoses including major depressive disorder and anxiety disorder, and his quarterly MDS showed a BIMS score of 3 out of 15, indicating severe cognitive impairment. A nurse's note documented that R8 scratched R55 in the face while both residents were in the dining room during activities, and the residents were separated immediately. The facility's self-report form showed the incident occurred at 11:40 AM, and an LPN stated she reported it to the corporate nurse and Administrator immediately after it happened. During interview, the Administrator stated the incident was not reported within two hours of becoming aware of it because the facility needed to complete its investigation first. The facility policy titled Abuse, Neglect and Exploitation required reporting of alleged violations to the Administrator, state agency, adult protective services, and other required agencies within specified timeframes, including immediately but not later than 2 hours after the allegation is made if the events involve abuse or result in serious bodily injury. The report identified that the facility did not report the allegation of abuse within the required timeframe.
Failure to Provide Written Transfer and Bed Hold Notices
Penalty
Summary
The facility failed to ensure written notice of emergency transfer to the hospital and the bed hold policy were provided to residents and their representatives for three residents reviewed for hospitalization. The report identified that the facility used triplicate transfer and bed hold forms, but in practice the written notices were not consistently provided to the resident or the resident’s representative, and in one case the facility could not locate the forms at all. For one resident with stroke and prostate cancer and severely impaired cognition, the resident was sent to the ED after a non-responsive episode and the family member was informed by phone. The facility had a Notice of Emergency Transfer to a Hospital and/or Therapeutic Leave and a Notice A Bed Hold Form, but the transfer form was addressed to the resident and there was no evidence it was provided to the family member. The bed hold form stated it was sent with the transfer documentation, but there was no evidence it was provided to the family member, who reported receiving only a phone call and no verbal or written bed hold information. For another resident with stroke and diabetes and intact cognition, the facility was unable to locate either the emergency transfer notice or the bed hold form for the hospitalization that occurred after an appointment. The resident reported not recalling any written notice or bed hold policy. Staff interviews showed differing descriptions of where the forms were sent and who notified the family, but the SSD stated she could not locate the forms and was unaware that anyone followed up with the responsible party. For a third resident with metabolic encephalopathy and multiple sclerosis and severe cognitive impairment, the resident was transferred to the hospital for respiratory distress, and staff again described a process of sending the bed hold and transfer forms with the resident and notifying family by phone, while the SW stated she was not aware of the family receiving the bed hold or transfer notice.
Incomplete PASARR Level I Assessment
Penalty
Summary
The facility failed to ensure that an accurate Preadmission Screening and Resident Review (PASARR) Level I assessment was completed after admission for one resident. The resident was admitted with diagnoses including major depressive disorder, bipolar disorder, post-traumatic stress disorder, and schizophrenia. Review of the resident’s annual MDS showed a BIMS score of 13 out of 15, indicating no cognitive impairment. The record also showed that the resident was physically aggressive toward another resident and was sent out for a psychiatric crisis evaluation. However, the PASARR Level I dated 06/25/25 did not include the resident’s bipolar disorder, post-traumatic stress disorder, or schizophrenia diagnoses, and it did not reflect the psychiatric crisis evaluation. During interview, the Social Services Director stated the PASARR Level I was not completed correctly and that, based on the resident’s diagnoses and crisis intervention, the resident should have been referred for a Level II PASARR.
Incorrect schizophrenia diagnosis used to support antipsychotic order
Penalty
Summary
The facility failed to ensure the medical staff documented the correct indication for an antipsychotic medication for one resident, R6. R6 was admitted with diagnoses including PTSD, and the care plan identified psychotropic medication use related to a mood disorder, but it did not reflect schizophrenia. Hospital discharge documentation faxed to the facility continued quetiapine (Seroquel) under PTSD/mood and did not document schizophrenia. Despite this, an order for Seroquel entered by an LPN was indicated for schizophrenia and was later signed by a nurse practitioner. R6’s quarterly MDS, completed with a BIMS score of 15 indicating intact cognition, also identified schizophrenia. The MDS Coordinator stated she entered schizophrenia into the EMR while completing the assessment after seeing the Seroquel order for schizophrenia and then used that diagnosis for the MDS and the Med Diag tab. The Regional Nurse later stated the schizophrenia diagnosis was an error on admission, and the DON reviewed the documentation and verified R6 should not have had a schizophrenia diagnosis. The LPN stated she had glanced through the records, saw behavioral episodes, and used her clinical judgment to obtain Seroquel from the pharmacy.
Failure to Provide Ordered Daily Wound Care
Penalty
Summary
The facility failed to provide wound treatments as ordered by the physician for one resident with diagnoses including cellulitis of other sites and type 2 diabetes mellitus with other circulatory complications. The physician ordered the right lower extremity to be cleansed with normal sterile saline, covered with an absorbent dressing, then cling wrap and an ace bandage every day shift for weeping. During observation, the resident had an ace bandage on the lower right leg and stated the bandage had not been changed since 08/01/25 and was supposed to be changed daily. An LPN observed during interview confirmed there was a white bandage under the ace bandage dated 08/01 with her initials and stated she had performed wound care on the resident's lower right leg on 08/01/25. She also stated the wound care was supposed to be done daily. The TAR reflected the daily wound care order, and the Administrator and DON both stated the bandage should have been changed every day until the order was discontinued.
Missing Oxygen Orders and Dirty Oxygen Concentrator Filters
Penalty
Summary
The facility failed to ensure safe and appropriate respiratory care for a resident using supplemental oxygen because the resident did not have clear oxygen orders or a documented plan of care for oxygen use. R65 was admitted with diagnoses including acute respiratory failure with hypoxia, acute pulmonary edema, pleural effusion, and heart failure. The hospital discharge summary stated the resident had been weaned from 4 liters to 1 liter, baseline was room air, and she would be discharged with oxygen and weaned as tolerated. However, the baseline care plan did not identify oxygen therapy, the care plan remained unfinished without documentation of oxygen use, and the order record contained no oxygen order specifying the amount of oxygen or oxygen saturation monitoring. The record also showed limited oxygen saturation documentation and no progress note documentation regarding oxygen use. During observation, R65 had a nasal cannula in place but the tubing was not connected to an oxygen source and was lying on the floor; later the tubing was again observed not connected to the concentrator or tank. The oxygen concentrator in the room was turned on and set at 1 liter. Staff interviews reflected differing understanding of the resident’s oxygen needs and responsibility for documenting or ordering oxygen. An LPN stated the resident sometimes did not use oxygen in bed and that her saturations were fine, while the DOR stated the resident needed oxygen during therapy and that therapists checked saturations before and during therapy. The DON stated that if a resident used oxygen, orders should be present in the EMR with the rate and pulse oximetry every shift, and oxygen use should be documented in the baseline care plan. The facility also failed to ensure oxygen concentrator filters were clean for another resident, R31, who had diagnoses of acute and chronic respiratory failure with hypoxia and acute respiratory failure with hypoxia and an order for oxygen inhalation via nasal cannula at 2 lpm every shift with checks every shift. During observation, the resident’s oxygen concentrator had two dust-filled filters. Staff interviews showed conflicting responsibility for cleaning the filters: RN supervision stated an RN or LPN was responsible, an LPN stated maintenance was responsible, the Maintenance Director stated CNAs were responsible, and the DON stated nurses were responsible and that the filters should be cleaned weekly. The facility policy stated filters from oxygen concentrators should be washed as needed with soap and water, rinsed, and squeezed dry.
Dialysis Assessment and Communication Documentation Missing
Penalty
Summary
The facility failed to ensure documentation of assessment prior to and upon return from dialysis for a resident with end stage renal disease and dependence on renal dialysis. The resident’s record showed orders for dialysis transportation on Monday, Wednesday, and Friday, monitoring of the fistula on the left upper extremity every shift, and removal of the pressure dressing on dialysis days. The quarterly MDS indicated the resident received dialysis and had a BIMS score of 15 out of 15. However, the EMR contained no pre- and post-dialysis evaluations, and the MAR and progress notes showed inconsistent documentation of pre- and post-dialysis assessments, including vital signs. There were also no orders for an assessment upon the resident’s return from dialysis. The facility also failed to ensure communication forms were used between the facility and the dialysis center for this resident. Review of the EMR revealed no scanned communication forms between dialysis and the facility, although paper charts at the nursing desk contained some dialysis communication sheets with pre- and post-dialysis weight, blood pressure, and heart rate. Several dates were missing from the paper chart, and additional forms were found at the desk that were not in the chart. During interviews, nursing staff reported that dialysis sent papers back with the resident and that notes were entered into the EMR, while the DON stated she expected communication sheets to be used but did not think the facility did that. The facility policy stated that communication sheets should be initiated and kept on the unit and/or in the resident medical record.
Side Rail Use Without Alternative Measures or Entrapment Assessment
Penalty
Summary
The facility failed to ensure that alternative measures were explored before side rails were installed and failed to complete an assessment for the risk of entrapment for one of four residents reviewed for side rails, Resident R59. R59 was admitted with diagnoses including schizoaffective disorder and cognitive communication deficit. His annual MDS showed a BIMS score of 14 out of 15, indicating no cognitive impairment. His care plan dated 06/25/24 contained no intervention related to side rail use, while a physician order dated 06/27/24 stated that he may have two half side rails while in bed for repositioning. The resident’s Bedrail Assist Device evaluation dated 06/25/25 showed no evidence that alternatives were explored and no assessment for risk of entrapment. During interviews, the Unit Manager stated staff determine on admission whether residents need side rails for repositioning, obtain a consent form, and do not explore alternatives prior to bed rail use. The Maintenance Director stated there was not a process to assess for risk of entrapment for bedrail use. The DON stated she was unsure whether the facility was assessing for entrapment risk or exploring alternatives prior to use. The facility policy stated siderails are to be applied after alternative methods have been found ineffective and that all residents are to be evaluated for side rail use on admission.
Failure to Notify Physician of Critically Low Blood Sugar
Penalty
Summary
A deficiency was identified when a nurse failed to notify a resident's physician of a critically low blood sugar result, as required by both physician orders and facility policy. The resident, who had intact cognition and a history of diabetes, hypertension, and chronic pain syndrome, had a blood sugar reading of 52, which was below the threshold specified in the physician's orders for mandatory physician notification. Review of the medical record and progress notes revealed no documentation that the physician was informed of this low blood sugar event. Interviews with nursing staff and the Director of Nursing confirmed that the physician should have been notified immediately and that documentation of this notification was required. The facility's policy on Notification of Changes also mandates prompt communication with the physician and the resident's representative when significant changes occur. The incident report further confirmed that the responsible nurse did not notify the physician as required.
Failure to Consistently Document ADL Care in Resident Records
Penalty
Summary
Facility staff failed to consistently document Activities of Daily Living (ADL) care in the Documentation Survey Report (DSR) for multiple residents, as required by facility policy. For three out of four residents reviewed, there were missing entries in the DSR and progress notes regarding whether ADL care was provided or refused on specific dates and shifts. The residents involved had significant medical conditions, including quadriplegia, acute respiratory failure, dysphagia, bipolar disorder, dementia, hyperlipidemia, diabetes, hypertension, and chronic pain syndrome. Their cognitive statuses ranged from intact to severely impaired, as indicated by their Brief Interview of Mental Status (BIMS) scores. Interviews with staff revealed that Certified Nursing Assistants (CNAs) were responsible for documenting ADLs using a mobile app, and documentation was expected to be completed by the end of each shift. The Director of Nursing (DON) and Unit Manager (UM) confirmed that blank documentation fields did not necessarily mean care was not provided, but acknowledged that documentation should not be left incomplete. The facility's ADL Documentation Policy required all nursing staff and caregivers to document ADLs as part of their daily routines, with supervisors responsible for regular compliance checks. Despite these requirements, the review found multiple instances where ADL documentation was missing, indicating a failure to follow established policy and professional standards.
Failure to Develop Comprehensive Care Plan for Resident
Penalty
Summary
The facility failed to develop a comprehensive care plan for a resident diagnosed with diabetes and admitted with elongated toenails. The resident, who had severe cognitive impairment as indicated by a BIMS score of 5 out of 15, did not have a care plan addressing these specific needs. The facility's policy required a comprehensive, person-centered care plan to be developed and implemented for each resident, which was not followed in this case. Interviews with staff, including an LPN, the Unit Manager (UM), and the Director of Nursing (DON), confirmed the absence of a care plan for the resident's diabetes and toenails, highlighting a lapse in the facility's adherence to its care plan policy. The UM was responsible for updating the resident's care plan, typically every quarter and as needed, and acknowledged the oversight in not addressing the resident's toenails. The DON confirmed that the care plan should have included interventions for the resident's diabetes and toenails, as per the facility's policy. The failure to develop and implement a care plan for the resident's specific needs was identified during a survey, revealing a deficiency in the facility's care planning process.
Failure to Follow Clinical Standards for Resident Care
Penalty
Summary
The facility failed to adhere to professional standards of clinical practice in several areas concerning Resident #2. The resident, who was admitted with diagnoses including Diabetes, Major Depressive Disorder, and Unspecified Dementia, did not have a care plan developed to address their diabetes and elongated toenails. Despite the resident's severely impaired cognition, as indicated by a BIMS score of 5 out of 15, the facility did not create a care plan to manage these conditions, which is a requirement under the facility's care plan policy. Additionally, there was a delay in the resident being seen by a podiatrist. The resident was admitted with elongated toenails, a condition noted in the admission screener, but was not seen by a podiatrist until several months later. The podiatry consult revealed that the resident was at risk for complications without treatment of the toenails, indicating a lapse in timely care. The Unit Manager and Director of Nursing acknowledged that the process for scheduling podiatry visits was not followed, as the nurse should have notified the physician to get a treatment order in place. Furthermore, there was a significant delay in notifying the physician of abnormal urine culture results. The urine culture, collected on September 5, 2024, showed abnormal results reported on September 7, 2024, but the physician was not informed until September 14, 2024. This delay in communication and subsequent treatment initiation was contrary to the facility's policy, which requires immediate notification of abnormal results to the physician. The Director of Nursing confirmed that the facility's procedures for laboratory notifications and care plan initiation were not followed, contributing to the deficiency.
Failure to Provide Timely Podiatry Care for Diabetic Resident
Penalty
Summary
The facility failed to provide timely foot care for a resident with diabetes, who was admitted with elongated toenails and was not seen by a podiatrist until nearly nine months later. The resident, who had severe cognitive impairment, was admitted to the facility with elongated toenails, as noted in the admission records. Despite the facility's policy requiring prompt referral to podiatry for residents with identified foot issues, the resident's toenails were not addressed until a podiatry consult in October, where the toenails were debrided. The delay in podiatric care was noted as a deficiency, particularly given the resident's diabetic condition, which increases the risk of complications. Interviews with facility staff revealed a breakdown in communication and procedure adherence. The LPN responsible for the resident's care did not ensure timely podiatric intervention, and the Unit Manager and Director of Nursing acknowledged the delay in treatment. The facility's policy required nurses to notify the Unit Clerk to schedule podiatry appointments, but this process was not effectively followed. The Director of Nursing confirmed that the delay constituted a lapse in care, especially for a diabetic resident, highlighting a failure to adhere to the facility's podiatry services policy.
Delayed Notification of Abnormal Urine Culture Result
Penalty
Summary
The facility failed to promptly notify the physician of an abnormal urine culture result for a resident, which was a violation of their policy on laboratory services and reporting. The resident, who had severe cognitive impairment and was diagnosed with conditions including diabetes, major depressive disorder, and unspecified dementia, had a urine culture collected on September 5, 2024. The results, which were abnormal, were reported on September 7, 2024, but were not reviewed by the Unit Manager until September 11, 2024. The physician was not informed of these results until September 14, 2024, at which point an antibiotic therapy order was obtained. Interviews with facility staff, including an LPN, the Unit Manager, and the Director of Nursing, revealed that the facility's policy required immediate notification of the physician upon receiving abnormal lab results. The delay in notifying the physician was acknowledged by the staff as a significant lapse, with the Director of Nursing confirming that the expectation was for immediate communication to prevent potential escalation of the resident's condition. The physician also confirmed that they rely on the nursing staff to inform them of any abnormal results, as they do not see long-term care residents frequently.
Failure to Maintain a Homelike Environment
Penalty
Summary
The facility failed to maintain a comfortable and homelike environment for three resident rooms on the C/D unit. During the initial tour, the surveyor observed various deficiencies in room 211, including a missing drawer handle, gouged walls, scratched and missing paint, and a leaking sink with water on the floor. Similar issues were found in room 212, where the window blind was broken, and the walls and furniture were damaged. In room 213, the window blind was also broken, and the CNA acknowledged that the room's condition was not homelike. The surveyor interviewed multiple staff members, including a CNA, an LPN, the LPN Unit Manager, the Director of Nursing (DON), and the Interim Maintenance Director (IMD). The staff members confirmed that the process for reporting maintenance issues involved recording them in a maintenance log. However, the log revealed incomplete entries, indicating that some issues, such as the leaking sink in room 211, were not addressed. The LPN and DON acknowledged that the rooms were not homelike and that the maintenance requests had been overlooked. The IMD admitted that he and one other maintenance man were responsible for the facility's repairs and that the maintenance book was checked daily. Despite this, the IMD acknowledged that the issues in the resident rooms had not been resolved and that the maintenance log had blank spots for some entries. The facility's policies on reporting maintenance concerns and repairs were reviewed, revealing that the maintenance book should be checked daily and signed as work is completed. The IMD admitted that the leaking sink in room 211 had not been fixed and that the maintenance issues in the rooms needed to be resolved.
Deficiencies in Food Handling and Kitchen Maintenance
Penalty
Summary
The facility failed to properly handle and store potentially hazardous foods and maintain kitchen equipment and areas to prevent microbial growth and cross-contamination. During a kitchen tour, the surveyor observed several deficiencies, including undated raw chicken drumsticks, wilted and blackened lettuce, undated lidded cups of liquids, and an unlabeled bag of scalloped potatoes. Additionally, there were pork loins with unreadable dates and damaged packaging, a dented can of sweetened applesauce, and a slicer with tan debris despite being covered with a plastic bag. A stained cutting board was also found in the dry pots and pans area. The Dietary Director (DD) acknowledged these issues, stating that the food items should have been labeled with pull and use-by dates, and that the equipment should have been cleaned and sanitized to prevent cross-contamination. The facility's policies on food receiving and storage, sanitation, and food preparation and service were reviewed, revealing that the observed practices were not in compliance with the established guidelines. The administrative team was made aware of these concerns during the survey.
Failure to Perform Hand Hygiene During Meal Tray Pass
Penalty
Summary
The facility failed to follow appropriate infection control practices and perform hand hygiene during a meal tray pass in the Main Dining area. An LPN was observed handling food and interacting with residents without performing hand hygiene. Specifically, the LPN opened a packet of powder, mixed it into a cup, touched her phone, and continued to handle food items without cleaning her hands. She also touched her nose and various inanimate objects before feeding a resident, all without performing hand hygiene. This was confirmed through interviews with the LPN, the LPN Unit Manager, the LPN Infection Preventionist, and the Director of Nursing, all of whom acknowledged the failure to perform hand hygiene correctly during the meal tray pass. The LPN stated that hand hygiene should be performed between resident contact and when trays were passed, but admitted she did not remember if she had done so during the observation period. The LPN Unit Manager and the LPN Infection Preventionist both confirmed that hand hygiene should have been performed after touching the phone, nose, and before feeding the resident. The Director of Nursing also acknowledged that hand hygiene was not performed correctly and emphasized its importance in preventing the spread of germs. A review of the facility's hand hygiene policy and the Charge Nurse/Staff Nurse job description revealed that all personnel are required to follow handwashing procedures to prevent the spread of infections. The policy specifically states that hand hygiene should be performed after contact with objects in the immediate vicinity of the resident and before and after assisting a resident with meals. The administrative team was made aware of the observation, and the deficiency was documented as a failure to adhere to these established infection control practices.
Failure to Obtain Diagnosis for IV Antibiotic Use
Penalty
Summary
The facility failed to follow professional standards of clinical practice by not obtaining a diagnosis for the use of an antibiotic intravenous medication for a resident. The resident was admitted with IV antibiotic therapy and a PICC line for cellulitis, but the physician's order for Vancomycin did not include a diagnosis. The resident was unaware of the reason for the medication, and the LPN, who was employed through an agency, also did not know the type of infection being treated as it was not documented on the physician's order. The LPN/UM later confirmed that the IV antibiotic was for MRSA in the blood, but acknowledged that the order should have included a diagnosis. The DON explained the policy for residents with a PICC line, emphasizing the need for physician orders to include diagnoses for the IV antibiotic, which was not followed in this case. The LNHA also confirmed that the physician's order should have had a diagnosis associated with the medication use. The surveyor observed that the resident's room had a sign indicating transmission-based precautions/contact isolation, and an IV medication bag labeled with the resident's name was hanging on the IV pole. The resident mentioned that they did not receive the medication the previous night. The facility's policy on medication and treatment orders stated that orders must include the clinical condition or symptoms for which the medication is prescribed, which was not adhered to in this instance. This deficiency was identified through observation, interviews, and review of the resident's medical records and facility documentation.
Failure to Obtain Physician Order and Update Care Plan After Resident Fall
Penalty
Summary
The facility failed to obtain a physician order for the treatment of a skin tear that occurred during a fall and did not update a resident's Care Plan (CP) with fall prevention interventions after the resident fell. This deficiency was identified for one resident who was admitted with diagnoses including osteomyelitis, sepsis, and malignant neoplasm of the brain. The resident was cognitively impaired and had a history of falls prior to admission. On the date of the incident, the resident had an unwitnessed fall while trying to retrieve something from the closet, resulting in a skin tear on the right elbow. The incident report indicated that the resident was not using a walker and was not wearing shoes or socks at the time of the fall. Although the incident report stated that the resident's CP was updated and the physician was notified, the surveyor found no documentation in the CP or the Electronic Medical Record (EMR) to support these claims. Additionally, there was no treatment order for the skin tear in the Physician Order Summary Report (POSR) or the Treatment Administration Record (TAR). Interviews with facility staff, including the Licensed Practical Nurse (LPN), Certified Nursing Assistant (CNA), Licensed Practical Nurse Unit Manager (LPN/UM), Registered Nurse (RN), Director of Nursing (DON), and Regional Clinical Director (RCD), confirmed that the required documentation and updates to the CP were not completed. The facility's policies on incidents and accidents, wound treatment and management, and comprehensive care plans were not followed, leading to the deficiency.
Improper Handling of Urinary Catheter Drainage Bag
Penalty
Summary
The facility failed to ensure proper handling of a urinary catheter drainage bag for a resident with urinary retention. The surveyor observed the resident's drainage bag touching the floor and not being kept below the level of the bladder on multiple occasions. The resident's care plan specifically included an intervention to keep the drainage bag below the bladder, but this was not followed. The CNA and LPN/UM acknowledged the improper positioning of the drainage bag and corrected it during the surveyor's visit. The facility's Catheter Care policy did not specify that the drainage bag should be kept off the floor, although staff interviews confirmed this practice for infection control reasons. The resident had an intact cognition as indicated by a Brief Interview for Mental Status score of 15 on the admission MDS. The resident's physician had ordered weekly changes of the urinary catheter drainage bag. Despite these orders and the care plan, the CNA initially secured the drainage bag to the resident's waistband, which was level with the bladder, and later left it touching the floor. The LPN/UM and DON confirmed that the drainage bag should be secured below the bladder and not touch the floor to prevent infection and ensure proper urinary flow.
Failure to Label and Dispose of Medications Properly
Penalty
Summary
The facility failed to label and dispose of medications in accordance with accepted professional principles for a resident receiving antibiotic therapy. The resident, admitted in March 2024, was on IV antibiotic therapy for cellulitis and had a PICC line in the right upper arm. During a tour, the surveyor observed an IV medication bag and vial hanging on the IV pole without proper labeling or dating. The resident was unaware of the reason for the medication and mentioned that the nurse had hung the IV the previous night but did not think any medication was administered. The physician's order and Medication Administration Record indicated that the IV Vancomycin was to be administered every 12 hours, but the dose scheduled for the previous night was not given due to a clogged PICC line. The LPN, who was employed through an agency, confirmed that the resident was on IV antibiotics but was unsure of the specific infection being treated. She stated that the previous nurse had reported the clogged PICC line and that the medication should have been discarded when it could not be administered. The LPN/UM confirmed that the IV medication was for MRSA in the blood and that the medication should have been discarded when the nurse realized the PICC line was clogged. The LPN/UM also noted that the IV medication and tubing were not dated or timed, making it unclear how long they had been hanging. The DON explained the facility's policy for residents with a PICC line, including assessing the line for patency and obtaining physician orders for flushing. The DON confirmed that the IV medication should have been labeled and discarded if not administered. The LNHA also confirmed that the medication should have been disposed of after the nurse realized the PICC line was not functional. The facility's policies on discarding medications and intravenous therapy did not include specific instructions on labeling and dating IV tubing, which contributed to the deficiency.
Failure to Document Resident Fall Incident
Penalty
Summary
The facility failed to maintain an accurately documented and complete medical record for a resident who experienced an unwitnessed fall. The resident, who had diagnoses including osteomyelitis, sepsis, and malignant neoplasm of the brain, was found lying on the floor at the foot of the bed. The incident report indicated that the resident was not using a walker and was not wearing shoes or socks at the time of the fall, resulting in a skin tear on the right elbow. However, there was no corresponding documentation in the Nursing Progress Notes (NPN) in the Electronic Medical Record (EMR) regarding the fall and subsequent assessment and care provided to the resident on that date. Multiple staff members, including the LPN, CNA, LPN/UM, RN, and RCD, confirmed the absence of documentation in the progress notes for the fall incident. The facility's policy on charting and documentation requires that all services provided, progress notes, and any changes in the resident's condition be documented in the medical record to facilitate communication between the interdisciplinary team. The lack of documentation in this case represents a failure to adhere to these standards, resulting in an incomplete and inaccurate medical record for the resident. The deficiency was confirmed by the Director of Nursing (DON) and the Regional Clinical Director (RCD), who acknowledged the importance of accurate and complete documentation in the progress notes for legal and communication purposes.
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What surveyors actually found near you
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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
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Nursing homes near Salem
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Autumn Lake Healthcare At Southgate | 6.7 mi | ★★★★★ | 1 | 0 |
| Autumn Lake Healthcare At Memorial Bridge | 10.1 mi | ★★★★★ | 2 | 0 |
| New Castle Health And Rehabilitation Center | 10.9 mi | ★★★★★ | 13 | 1 |
| Kutz Rehabilitation And Nursing | 11.9 mi | ★★★★★ | 5 | 0 |
| Complete Care At Hillside Llc | 12.2 mi | ★★★★★ | 4 | 0 |
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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 August 2026) and official state health department websites.