Autumn Lake Healthcare At Birch Manor
Inspection history, citations, penalties and survey trends for this long-term care facility in Sykesville, Maryland.
- Location
- 7309 Second Avenue, Sykesville, Maryland 21784
- CMS Provider Number
- 215136
- Inspections on file
- 19
- Latest survey
- November 20, 2025
- Citations (last 12 mo.)
- 9
Citation history
Health deficiencies cited at Autumn Lake Healthcare At Birch Manor during CMS and state inspections, most recent first.
The facility did not consistently hold or document required interdisciplinary care plan meetings for three residents following their MDS assessments. In each case, there was either no evidence of meetings occurring after admission or quarterly assessments, or documentation was missing. Staff interviews confirmed the absence of these meetings, and residents were often unaware of any care planning discussions.
The facility did not have an effective system to ensure grievances and concerns raised during Resident Council meetings were addressed and followed up on. Nursing-related concerns, such as missed medications and reports of rough staff behavior, were documented but not consistently followed up or logged as grievances. Communication between the Activity Director and DON was inconsistent, leading to unresolved issues persisting over several months.
Surveyors found that the facility did not develop or implement individualized care plans based on comprehensive assessments for several residents. For example, a resident with expressive aphasia did not have their music, TV, or religious preferences reflected in their care plan, and other residents' preferences for religious services and reading materials were omitted despite being documented as important. Additionally, one resident did not have a comprehensive care plan completed within the required timeframe, and there was insufficient documentation of interdisciplinary team involvement in care planning.
Surveyors identified deficiencies in infection prevention and control, including improper disinfection of glucometers by nursing staff using alcohol wipes instead of manufacturer-recommended sanitizing wipes, and improper handling of laundry with clean linen left uncovered near soiled items and soiled materials found on the floor. Additionally, water temperature logs for legionella prevention were incomplete and did not meet the required temperature standard, as confirmed by facility staff.
Surveyors found that several residents with complex medical and cognitive needs did not receive individualized activities as outlined in their care plans and assessments. Activity preferences such as music, religious services, and group participation were not consistently addressed or documented, and staff interviews revealed gaps in understanding and implementation of resident-centered activity planning. Documentation failed to show that planned one-on-one visits and preferred activities were provided or offered, resulting in unmet psychosocial and physical needs.
A resident with a personal funds account managed by the facility did not receive the required quarterly statement, as confirmed by both the resident and the business office manager. Review of records showed the last statement provided was for the previous quarter, and the most recent statement had not been delivered as required.
Surveyors found that the facility failed to maintain clean and functional shower areas, with cracked and discolored tiles, missing shower heads, and out-of-order showers that were still used for resident bathing. Additionally, a resident's privacy curtains remained stained for several days despite staff awareness, indicating a lack of timely response to environmental concerns.
A resident who was unable to make health care decisions was transferred to the hospital, but the responsible representative did not receive complete or accurate written notice regarding the bed hold policy and transfer. Required sections on the transfer and bed hold forms were left blank, and essential contact information for appeals and the State LTC Ombudsman was missing. Staff interviews revealed inconsistent notification practices and lack of documentation, resulting in the representative not being properly informed of the resident's rights and facility policies.
A resident's MDS assessment was inaccurately documented, indicating the presence of natural teeth despite the resident being edentulous and wearing dentures. Staff interviews and record reviews confirmed the resident had no natural teeth, and the MDS Coordinator acknowledged the error. Additionally, the MDS signature page incorrectly identified a Social Services Assistant as a Social Worker.
A resident with an anxiety disorder had a scheduled order for Lorazepam 0.5 mg three times daily. Staff documented administration of the medication for every scheduled dose, but records showed that the last available tablet was used earlier in the day and no additional supply was accessed for the evening dose. Despite this, staff documented that the evening dose was given, with no evidence from pharmacy or automated dispensing records to support this.
A resident who was fully dependent on staff was found using an air mattress without a physician order or monitoring instructions, and the mattress was set at a weight much higher than the resident's actual weight. Staff were unaware of the mattress assignment, and the DON confirmed the resident did not require an air mattress. This resulted in a failure to prevent accident hazards and provide adequate supervision.
A resident with a tracheostomy did not receive respiratory care in accordance with professional standards when a used suction catheter was left on the bedside table after suctioning by an LPN. The facility's policy required sterile technique for tracheostomy care, but this was not followed, resulting in a lapse in infection control.
A resident with severe cognitive impairment and documented dental issues did not receive routine dental services after admission. Despite regular dental provider visits to the facility and monthly tracking, there was no evidence that the resident had been seen by a dentist or dental hygienist, and only records from a prior facility were available. The DON confirmed the lack of dental care since admission.
Several residents did not receive all items listed on their meal tickets during lunch, including missing milk, margarine, butter, and a dessert, despite expressing preferences for these items. Staff confirmed the omissions at the time of service, indicating that meals were not consistently served according to the predetermined menu or resident preferences.
Surveyors found expired Jello cups stored in a unit nourishment room refrigerator. A Geriatric nurse aide identified and disposed of the expired items, which had been missed during routine checks by the unit manager. The DON was later informed of the expired food.
Surveyors found that the facility did not maintain accurate and complete medical records for several residents, including discrepancies between medication orders and administration, inaccurate documentation of tracheostomy care, and missing care planning meeting notes in the electronic medical record. These deficiencies were identified through record reviews and staff interviews.
The facility did not ensure the development and ongoing implementation of a data-driven QAPI program, as required by its own policy, and failed to have an active Performance Improvement Project (PIP) within the past year. The QAPI committee maintained meeting minutes and discussed high-risk topics, but there was no evidence of a structured process to systematically address quality issues or monitor corrective actions.
The facility did not ensure that a certified Infection Preventionist (IP) attended QAPI committee meetings, as required. Instead, the DON, who was not a certified IP, signed in as the IP for several months, and attendance records for other months also lacked evidence of a qualified IP nurse.
A resident with a tracheostomy and chronic respiratory failure was found to have their oxygen concentrator and suction machine plugged into a standard wall outlet instead of a generator-powered outlet. Staff confirmed that only red faceplate outlets were connected to the backup generator, but these were already in use for other equipment. The facility's policy directed staff to move equipment after a power outage rather than ensuring critical devices were always connected to emergency power, and documentation of required safety checks was not provided.
The facility did not follow its grievance policy for two residents who reported missing personal property and concerns about care. In both cases, staff failed to document, investigate, or communicate the outcome of the grievances as required by policy. Key staff members acknowledged that the grievance process was not followed and that there was a lack of awareness and adherence to the established procedures.
A resident with cognitive impairment and multiple medical conditions alleged being physically abused by a staff member, with documented bruising observed by both hospital and facility staff. Despite clear policy requiring immediate reporting, the DON and NHA did not report the abuse allegation to authorities until prompted by a surveyor, resulting in a delay in required notification.
A resident with cognitive impairment and multiple medical conditions alleged being punched and kicked by a staff member, with physical bruising documented by both hospital and facility staff. The allegation was recorded in a physician's note, but the clinical team failed to identify and investigate it as required by facility policy. Leadership confirmed that the abuse allegation was missed during routine review, and no investigation was conducted or documented.
The facility failed to protect residents' personal property by not adhering to its policy requiring an inventory and tracking process for belongings upon admission and discharge. Two residents were affected, with one discharged without a documented inventory, resulting in missing items, and another discharged with another resident's clothing. Staff interviews revealed inconsistent application of the inventory process, indicating a systemic issue. An Ombudsman interview suggested a pattern of issues related to managing residents' belongings, raising concerns about the facility's ability to safeguard property.
The facility failed to report injuries of unknown origin for two residents to the state survey agency within the required timeframe. One resident with cognitive impairment had a hand fracture that was reported two days late, while another resident with severe cognitive impairment had facial bruising that was not reported at all. The clinical team did not believe the latter injury met reporting criteria due to the resident's care plan behaviors.
Failure to Hold and Document Required Interdisciplinary Care Plan Meetings
Penalty
Summary
The facility failed to hold and document required interdisciplinary care plan meetings for three residents following their comprehensive and quarterly MDS assessments. For one resident with a history of traumatic brain injury, anxiety, depression, seizure disorder, and cognitive impairment, the only documented care plan meeting occurred at admission, with no evidence of subsequent meetings despite multiple MDS assessments. Staff interviews confirmed that no further interdisciplinary care plan meetings had taken place, and a note provided as evidence was unrelated to care planning and not part of the medical record. Another resident, who had resided in the facility for several years, had an MDS assessment completed, but there was no documentation of a care plan meeting following this assessment. Staff responsible for scheduling care plan meetings reported leaving messages for the resident's family but did not document these contacts, and acknowledged that no care plan meeting had occurred since the previous year. The lack of documentation persisted through the time of the survey, with no additional evidence provided to show that a meeting had taken place. A third resident, who had been in the facility since the beginning of the year, also had an MDS assessment completed, but there was no indication that a care plan meeting was held afterward. The resident was unaware of any care plan meetings, and staff interviews confirmed that while meetings were supposed to be scheduled based on MDS schedules, there was no documentation to support that a meeting had occurred. These findings demonstrate that the facility did not consistently conduct or document care plan meetings as required for residents following their MDS assessments.
Failure to Address and Follow Up on Resident Council Grievances
Penalty
Summary
The facility failed to maintain an effective system to ensure that grievances and concerns raised during Resident Council meetings were addressed and followed up on. Review of Resident Council meeting minutes from October 2024 through May 2025 revealed that the documentation did not consistently include sections for follow-up on previously raised issues, particularly for nursing-related concerns. Specific concerns, such as residents not receiving pain medication when supplies ran out and reports of nursing staff being mean or rough, were documented in the minutes but lacked evidence of follow-up or resolution in subsequent meeting notes or grievance logs. In several instances, concerns raised in one meeting were not addressed in the following meetings or documented in the facility's grievance logs, and there was no indication that department heads, including the DON, were consistently made aware of these issues. Interviews with the Activity Director and DON revealed inconsistent communication practices regarding how concerns from Resident Council were relayed to department heads. The Activity Director reported emailing department heads and discussing concerns, but documentation of responses was inconsistent, and the DON was unaware of several concerns raised. Additionally, some concerns that could be interpreted as allegations of abuse were not escalated or documented as such. The lack of a structured process for tracking and addressing grievances resulted in unresolved issues persisting across multiple months, with no clear documentation of investigation or resolution.
Failure to Develop and Implement Resident-Centered Care Plans
Penalty
Summary
Surveyors identified that the facility failed to develop and implement comprehensive, resident-centered care plans that accurately reflected the assessed needs and preferences of multiple residents. For one resident with expressive aphasia and total dependence on staff for activities of daily living, the care plan did not include specific information about the resident's music preferences, television programs, or religious denomination, despite these being documented as important in assessments. The care plan also lacked documentation of certain activities, such as hand massages, that were reportedly provided. The Activity Director acknowledged that care plans did not always reflect assessment findings and that staff often relied on assumptions rather than resident input. Another resident with a history of traumatic brain injury, anxiety, depression, and cognitive impairment reported not participating in activities due to a lack of interest and was unaware of care planning meetings. The care plan for this resident did not address their stated preferences for religious services and access to reading materials, which were documented as very important in the MDS assessment. Similarly, a resident with a history of stroke and cognitive deficits stated that they used personal devices for entertainment and required assistance to attend activities, but their care plan did not specify their preferences for church attendance or reading materials, despite these being identified during assessments and interviews. Additionally, a resident admitted to the facility had only a baseline care plan documented, with no comprehensive care plan completed within the required timeframe following the comprehensive assessment. There was also a lack of documentation indicating that the interdisciplinary team regularly attended care plan meetings. Staff interviews confirmed these deficiencies, and facility leadership acknowledged the concerns raised by surveyors regarding the lack of individualized, assessment-based care planning.
Infection Control and Environmental Sanitation Deficiencies
Penalty
Summary
The facility failed to maintain safe and sanitary conditions to prevent the spread of infection, as evidenced by improper disinfection of blood glucose meters and inadequate laundry handling practices. Nursing staff were observed using alcohol wipes to disinfect glucometers, despite the manufacturer's instructions and facility policy requiring the use of Super Sani-cloth sanitizing wipes. Interviews with nursing staff confirmed the use of alcohol wipes, and the infection preventionist acknowledged that alcohol wipes were not recommended. Additionally, clean linen was observed uncovered and stored in close proximity to dirty laundry, with soiled items found on the floor in the laundry area. The environmental services supervisor confirmed that clean linen should be covered when moved and that the observed practices did not meet facility expectations. Black marks were also noted on the plastic door flaps separating clean and dirty laundry areas, indicating a lack of proper cleaning. The facility also failed to consistently monitor and maintain water temperatures as part of its legionella prevention measures. The maintenance director reported that water temperatures were recorded at the boiler, but documentation showed that temperatures were only recorded for 16 out of 31 days in May, and none of the recorded temperatures reached the required 116 degrees Fahrenheit. The administrator confirmed that the facility aimed to follow CDC guidelines by maintaining the boiler at 116 degrees, but the logs did not support that this standard was met.
Failure to Provide Resident-Centered Activities Program
Penalty
Summary
Surveyors identified that the facility failed to provide an ongoing, resident-centered activities program that met the physical, mental, and psychosocial well-being and individual interests of residents. Multiple residents with varying medical conditions, including expressive aphasia, traumatic brain injury, stroke, and cognitive impairment, were not provided with activities tailored to their preferences as documented in their assessments and care plans. For example, one resident who was totally dependent on staff and unable to communicate verbally had care plans that did not specify preferred activities, such as music type, TV programs, or religious denomination, despite these being identified as important in assessments. Documentation did not support that planned one-on-one visits or preferred activities were consistently provided. Another resident, who had a high cognitive function score and expressed little interest or pleasure in activities, reported never being offered activities and was unaware of the Resident Council or key staff. The care plan indicated daily visits and encouragement to join group activities, but activity records showed that on most days, no activities were documented, and there was no evidence of offers or refusals. Similarly, a resident with a traumatic brain injury and cognitive impairment had a care plan emphasizing the importance of religious services, but there was no documentation of attendance, offers, or refusals for such activities. Additionally, a resident with a history of stroke who required assistance to attend activities reported not participating due to lack of staff support. The care plan included specific interventions such as providing daily puzzles and twice-weekly one-on-one visits, but records did not show these were provided. Staff interviews revealed a lack of understanding of documentation requirements and inconsistent consideration of resident preferences when planning activities. The facility's documentation practices did not reflect the provision of individualized activities as outlined in care plans, nor did they consistently record resident participation, refusals, or unavailability.
Failure to Provide Quarterly Personal Funds Statements
Penalty
Summary
The facility failed to provide quarterly personal funds statements to a resident whose funds were managed by the facility. The resident, who was cognitively intact and acted as their own responsible party, reported not receiving a new statement since January, despite being entitled to quarterly updates. Review of the resident's records confirmed that the last signed statement was for the period ending December 31, and no statement had been provided for the subsequent quarter. The business office manager acknowledged being behind in distributing the required statements and confirmed that the resident had not yet received the most recent quarterly statement. The process for delivering statements involved hand delivery and obtaining the resident's signature, with copies kept in a binder. The deficiency was further confirmed during interviews and a review of the facility's records, which showed the lapse in providing timely statements to the resident.
Failure to Maintain Clean and Functional Resident Shower Areas and Privacy Curtains
Penalty
Summary
Surveyors identified deficiencies related to the facility's failure to maintain a clean, comfortable, and homelike environment for residents. On multiple occasions, surveyors observed cracked and discolored tiles, missing shower heads, and out-of-order showers in spa rooms on the first, second, and third floors. Despite staff being aware of these maintenance issues, there was a lack of timely repair and incomplete documentation in the maintenance logs. Some showers in disrepair were still being used for resident bathing, and dirty washcloths were found in the shower stalls during observations. Additionally, a resident's privacy curtains were noted to have dark brown stains during the initial and subsequent observations over several days. Although the environmental services department was reportedly responsible for changing stained curtains, the stained curtains in the resident's room remained unaddressed until after surveyor intervention. Staff interviews confirmed awareness of the issue, but there was a lack of follow-through to resolve it in a timely manner.
Failure to Provide Complete Bed Hold and Transfer Notices to Resident Representative
Penalty
Summary
The facility failed to provide complete and accurate written notice of the bed hold policy and transfer to a resident's responsible representative during a hospitalization event. The resident in question was not capable of making health care decisions, and a responsible representative had been identified. When the resident was transferred to the hospital, documentation indicated that the bed hold policy and reason for transfer/discharge were sent to the representative, but the method of delivery was unclear, and the actual forms lacked required information. Review of the Notification of Resident Hospital Transfer form revealed that critical sections, such as the reason for transfer and the location of transfer, were left blank. The form also failed to include necessary contact information for appealing the transfer, such as the name, address, or telephone number of the entity handling appeals, and the contact information for the State Long-Term Care Ombudsman. The bed hold notice form was also incomplete, missing essential details such as the reason for the notice, whether a bed hold was requested, the per diem rate, and the actual bed hold policy attachment. Additionally, the bed hold policy referenced outdated information, stating that the state pays for 14 days of bed hold, which has not been the case since 2012. Interviews with staff revealed inconsistent practices regarding notification. The social worker reported only sending the bed hold notice if specifically requested by the representative and did not document phone calls to the family. There was also a lack of clarity and documentation regarding whether the required notifications had actually been sent, and staff were unable to provide current per diem rates when asked. These actions and omissions resulted in the failure to ensure that the resident's representative received all required information regarding transfer, appeal rights, and bed hold policies.
Inaccurate MDS Assessment Documentation for Dental Status
Penalty
Summary
The facility failed to ensure that Minimum Data Set (MDS) assessments were accurately documented for a resident reviewed for dental care. Observations showed that the resident was edentulous and wore complete dentures, which were not present at the time of observation. The nursing admission assessment confirmed the absence of natural teeth. However, the MDS assessment incorrectly indicated that the resident had natural teeth, contradicting both the resident's statement and the nursing assessment. Interviews with staff further confirmed that the resident had no natural teeth, and the MDS Coordinator acknowledged the documentation error in the MDS assessment. Additionally, the MDS assessment's signature page listed sections as being completed by a staff member identified as a Social Worker, when in fact this individual was a Social Services Assistant. This misidentification was confirmed by both the Social Services Director and the MDS Coordinator, who recognized the inaccurate information on the MDS assessment's signature page.
Failure to Administer and Document Scheduled Medication as Ordered
Penalty
Summary
Staff failed to provide medication as ordered for a resident with an anxiety disorder who had a physician's order for Lorazepam 0.5 mg three times daily. Medical record review showed that the medication was documented as administered every day in April, but the controlled drug administration record indicated that the last tablet from a 30-tablet supply was removed at 2:00 PM on 4/28, with no tablets left for the 8:00 PM dose that same day. A new supply was not received until the following morning, and there was no documentation that the interim supply was accessed for the missed dose. Despite the lack of available medication, staff documented that the 8:00 PM dose on 4/28 was administered as ordered. Review of pharmacy and automated dispensing records did not show that the interim supply was accessed for this dose, and the pharmacy was unable to provide documentation to account for the administration. The deficiency was identified through interviews and record reviews, which confirmed that the medication was not re-ordered in a timely manner and that staff failed to obtain it from the interim supply, yet still documented its administration.
Failure to Ensure Proper Use and Monitoring of Air Mattress
Penalty
Summary
A deficiency was identified when a resident, who was totally dependent on staff for activities of daily living and had no current or recent pressure ulcers, was found in bed with an air mattress that was unplugged and not inflated. The air mattress was later plugged in by a nurse and observed to be set at 240 lbs, despite the resident's most recent recorded weight being 115.8 lbs. The medical record only contained an order for a pressure reducing mattress, not specifically for an air mattress, and there was no order or documentation for monitoring the use of the air mattress. Further review revealed that staff were unaware of how the air mattress was assigned to the resident, and the unit nurse manager was not informed that the bed had an air mattress. The air mattress was used without an appropriate physician order, without monitoring instructions, and was set at an incorrect weight setting. The DON confirmed that air mattresses were typically reserved for residents with Stage 3 or 4 pressure ulcers and that this resident did not require one. The lack of an order and monitoring for the air mattress, as well as improper setup, constituted a failure to ensure the area was free from accident hazards and that adequate supervision was provided to prevent accidents.
Failure to Maintain Sterile Technique in Tracheostomy Care
Penalty
Summary
A deficiency was identified when a resident with a tracheostomy did not receive respiratory care consistent with professional standards of practice. The resident, who required oxygen via tracheostomy and was observed to have shortness of breath with audible breath sounds, was under the care of staff trained in tracheostomy care and suctioning. Documentation showed that suctioning was performed by a licensed practical nurse during the night shift, and the facility's policy required the use of sterile technique for this procedure. However, a used suction catheter was observed left on the resident's bedside table, indicating a lapse in infection control and sterile technique. The nurse responsible for the care acknowledged providing suctioning and confirmed that the procedure should be sterile, as outlined in facility policy. The presence of the dirty catheter at the bedside and its subsequent removal only after being noticed by surveyors demonstrated a failure to maintain proper infection control practices during respiratory care for the resident.
Failure to Provide Routine Dental Services to Resident with Dental Concerns
Penalty
Summary
The facility failed to provide routine dental services to a Medicaid-funded resident with severe cognitive impairment. The resident was admitted in early 2023 and had documented dental concerns, including obvious or likely cavities, broken natural teeth, and mouth or facial pain, discomfort, or difficulty with chewing, as noted in a comprehensive assessment. The responsible party reported ongoing concerns about dental care and stated that they had not received updates regarding dental services or a dental visit for the resident. Despite the facility's process of having a dentist or dental hygienist visit 1 to 2 times per month and maintaining monthly reports of residents seen, there was no evidence in the medical record or dental service reports that the resident had received dental care since admission. The only dental documentation available pertained to services provided at a previous facility, not the current one. The DON confirmed that the resident had not been seen by a dentist or dental hygienist since admission.
Failure to Serve Meals According to Prescribed Menus and Resident Preferences
Penalty
Summary
The facility failed to ensure that residents were served meals according to predetermined menus that incorporated their preferences and met their nutritional needs. During lunch observations, multiple residents did not receive all items listed on their meal tickets. One resident's tray was missing milk and margarine, while another did not receive milk and butter, despite expressing a desire for these items. A third resident's tray was missing whole milk, margarine, and a dessert item called magic cup, all of which were specified on the meal ticket. These discrepancies were confirmed by staff present during the meal service. The observations were corroborated by both the residents and staff, who acknowledged the missing food items at the time of service. The failure to provide the correct menu items as ordered and preferred by the residents demonstrates a lack of adherence to the planned menu and dietary requirements. This practice has the potential to affect all residents receiving meals in the facility.
Expired Food Items Found in Unit Refrigerator
Penalty
Summary
A deficiency was identified when four cups of Jello with an expiration date of 4/24/25 were found stored in the nourishment room refrigerator on the 2nd-floor unit during an observation with a Geriatric nurse aide. The staff member acknowledged that the Jello was expired and appeared watery before disposing of it. The unit manager reported that she checks the refrigerator every morning but missed the expired Jello. The Director of Nursing was later informed of the issue by staff. This deficiency was observed in one out of three units during the recertification survey, and the findings were based on direct observation and staff interviews.
Failure to Maintain Accurate and Complete Medical Records
Penalty
Summary
The facility failed to ensure that resident records were accurate, complete, and maintained in accordance with accepted professional standards and practices. For one resident with dementia, mood disorder, chronic pain, and kidney disease, discrepancies were found between physician and nurse practitioner notes and the actual medication orders and administration records. Specifically, the physician's note referenced a PRN order for Lorazepam, but the resident was receiving it on a scheduled basis, and the medication administration record did not reflect a PRN order. Additionally, the nurse practitioner's notes indicated that certain lab tests were to be performed, but there was no documentation that these labs were ordered or completed as stated. Another nurse practitioner's note referenced a medication (Lidocaine) that was not actually ordered or administered, and the practitioner acknowledged this was likely a documentation error due to not updating the note template. For a resident with a tracheostomy, documentation in the Treatment Administration Record (TAR) inaccurately reflected that a registered nurse had performed tracheostomy care, when in fact the care was provided by a respiratory therapist. The nurse confirmed that she documented the care as completed, even though she had not performed it, resulting in the TAR not accurately reflecting the resident's care experience. The Director of Nursing and Regional Director of Nursing also acknowledged that the documentation did not match the actual care provided. In another case, a resident who had been readmitted from the hospital did not have care planning meeting notes documented in the electronic medical record. When the surveyor was unable to locate the documentation, the Social Services Director provided a handwritten note as evidence of a care planning meeting, but confirmed that this note was not considered part of the official medical record. The Director of Nursing confirmed that care planning meeting notes are expected to be documented in the resident's medical record, but this was not done in this instance.
Failure to Implement Facility-Wide QAPI Program with Active PIP
Penalty
Summary
The facility failed to develop and implement an ongoing, facility-wide, data-driven Quality Assurance and Performance Improvement (QAPI) program that included at least one current Performance Improvement Project (PIP) within the past 12 months. Upon review, the facility provided its QAPI policy, which outlined the process for identifying areas for improvement, including high-risk, high-volume, and problem-prone areas, and emphasized the importance of considering the incidence, prevalence, and severity of problems affecting resident outcomes. However, during an interview, the Nursing Home Administrator (NHA) confirmed that no PIP had been identified or implemented in the last year. Further review of the QAPI committee's documentation revealed that while meeting minutes and highlights of high-risk topics such as falls, wounds, and maintenance concerns were maintained, there was no evidence of a structured approach to systematically identify and address quality issues. The NHA stated that QAPI meetings primarily served as notification forums, and daily clinical meetings were used to review clinical concerns and interventions. No documentation was provided to demonstrate that the facility was systematically investigating root causes, implementing interventions, or monitoring the effectiveness of corrective actions as required by their own policy.
Failure to Ensure Qualified Infection Preventionist Attended QAPI Meetings
Penalty
Summary
The facility failed to ensure that a qualified Infection Preventionist (IP) attended the Quality Assurance and Performance Improvement (QAPI) committee meetings as required. Review of QAPI meeting attendance records for the period from December 2024 through May 2025 showed that the Director of Nursing (DON) signed as the IP for the months of December 2024, January 2025, and February 2025. However, the Nursing Home Administrator (NHA) confirmed that the DON was not a certified IP nurse during those months. Further review of attendance records for October 2024 also revealed the absence of a qualified IP nurse at the QAPI meeting. These findings were based on interviews and record reviews conducted by surveyors.
Failure to Ensure Critical Respiratory Equipment Connected to Emergency Power
Penalty
Summary
The facility failed to ensure that critical medical equipment for a resident requiring continuous respiratory support was plugged into generator-powered outlets. Specifically, a resident with a history of traumatic brain injury and chronic respiratory failure, who had a tracheostomy and required continuous oxygen, was found to have their oxygen concentrator and suction machine plugged into a standard wall outlet via a power strip, rather than into the generator-supplied (red) outlets. The generator-powered outlets in the room were already in use for other medical equipment, leaving no available emergency outlet for the resident's life-sustaining devices. During interviews and observations, staff, including a respiratory therapist and the maintenance assistant, confirmed that only outlets with red faceplates were connected to the backup generator and should be used for critical equipment during a power outage. The Director of Nursing (DON) initially stated that it was not an issue since there was no current power outage and that equipment would be moved to generator outlets if needed. However, when asked to demonstrate this process, staff realized that moving the equipment would require additional steps, such as obtaining a portable oxygen tank, and that the generator outlets were already at capacity. The facility's policy instructed staff to move equipment to generator-powered outlets after a power outage, rather than requiring proactive connection of critical equipment. The Nursing Home Administrator (NHA) stated that safety checks were performed every shift to ensure life-sustaining equipment was plugged into emergency outlets, but was unaware that the resident's equipment had been found plugged into a standard outlet. Requested documentation of these safety checks was not provided to the surveyor by the time of survey exit.
Failure to Implement Grievance Policy for Resident Complaints
Penalty
Summary
The facility failed to implement its grievance policy for two residents who reported concerns regarding personal property and care. In the first instance, a long-term resident reported missing clothing to the Environmental Services Supervisor (EVS) and the resident's family also raised the issue. The EVS Supervisor acknowledged the concern but did not complete a grievance form or escalate the issue to the Director of Nursing or the Nursing Home Administrator, as required by facility policy. The Social Service Director confirmed that no grievance form was filed for this incident, and the most recent grievance form related to clothing was from several months prior, indicating the current concern was not documented or processed according to policy. In the second case, a newly admitted resident's family member reported that the resident was found in soiled clothing and an unkempt state two days after admission, despite having notified staff and meeting with several facility personnel about the issue. The family described the meeting as confrontational and did not receive any follow-up communication from the facility regarding their complaint. The Social Service Director and the designated Grievance Official both confirmed that no grievance was logged or investigated for this incident, and the Grievance Log contained no entries for the relevant period. Staff interviews revealed a lack of awareness and adherence to the grievance policy, with some staff admitting they had never read the policy. Facility policy requires that all grievances, whether verbal or written, be documented, investigated, and tracked, with written notice of the outcome provided to the complainant. In both cases, the facility did not follow these procedures, as grievances were not formally recorded, investigated, or communicated to the residents or their families. The Director of Nursing and the Nursing Home Administrator acknowledged that the grievance process was not followed and needed improvement.
Failure to Timely Report Alleged Abuse
Penalty
Summary
The facility failed to report an allegation of abuse involving a resident with a history of traumatic brain injury, anxiety, depression, seizure disorder, and cognitive impairment. The resident was taken to a hospital emergency room after becoming combative and reported to hospital staff that they had been hit and punched by staff at the facility. Hospital staff documented two small bruises on the resident. Upon readmission, facility staff also noted bruising during a head-to-toe skin check. A physician's note documented the resident's allegation that a black male staff member had punched and kicked them after the resident requested medication for a migraine. Despite these documented allegations and physical findings, the Nursing Home Administrator and Director of Nursing were unaware of the abuse report and had not reported the incident to the state agency or other required authorities as per facility policy. The policy required immediate reporting, but the allegation was not reported until prompted by the surveyor, several days after the initial incident and documentation. The failure to report was confirmed through interviews and record reviews.
Failure to Investigate Resident Abuse Allegation
Penalty
Summary
The facility failed to investigate an allegation of abuse involving a resident with a history of traumatic brain injury, anxiety, depression, seizure disorder, and cognitive impairment. The resident was sent to the hospital after a combative episode, where they reported to hospital staff that they had been hit and punched by facility staff. Hospital staff documented two small bruises on the resident, one under the left eye and one on the back. Upon readmission, a nurse and wound nurse noted a healing bruise near the left eye and another on the chest. A physician's progress note documented that during a telehealth visit, the resident alleged being punched and kicked by a black male staff member after requesting medication for a migraine. The facility's policy requires immediate investigation of any abuse allegations, including those reported by residents or documented as physical marks. However, the DON and NHA were unaware of the abuse allegation until the surveyor brought it to their attention, despite the allegation being documented in the physician's note. The DON acknowledged that the clinical team is responsible for reviewing physician notes and that the note containing the allegation was missed during the 24-hour look-back review process. Interviews with facility leadership revealed that no investigation was initiated because the team did not recognize the abuse allegation in the physician's documentation. The resident confirmed to the surveyor that they had not been followed up with regarding the abuse allegation. At the time of the survey exit, the facility had not produced any evidence of an investigation into the reported abuse, despite the requirement to do so per facility policy.
Failure to Protect Residents' Personal Property
Penalty
Summary
The facility failed to protect residents' personal property, as evidenced by the lack of adherence to its policy requiring an inventory and tracking process for resident belongings upon admission and discharge. Specifically, two residents were affected by this deficiency. One resident was discharged without a documented inventory or signed acknowledgment of their belongings, resulting in missing items such as a phone, prescription glasses, and clothing. The facility did not provide any resolution or communication regarding these missing items, and the Director of Social Services was unaware of the policy requiring an inventory to be completed and signed upon discharge. Additionally, there was no documentation of a grievance related to the missing items. Another resident was discharged with another resident's clothing, and similarly, there was no documented inventory or signed acknowledgment verifying that belongings were returned. Staff interviews revealed inconsistent application of the inventory process, indicating a systemic issue within the facility's procedures. An interview with the Ombudsman suggested a pattern of issues related to the management of residents' personal belongings, further raising concerns about the facility's ability to safeguard resident property. These findings collectively indicate a failure to comply with regulatory expectations under F584, which mandates a secure, clean, and homelike environment, including reasonable measures to protect resident belongings from loss or theft.
Failure to Timely Report Injuries of Unknown Origin
Penalty
Summary
The facility failed to report alleged violations involving abuse, neglect, exploitation, or mistreatment, including injuries of unknown source, to the state survey agency within the required timeframe for two residents. Resident #33 was observed with a swelling and pain in their left hand, which was later identified as a minimally displaced acute fracture. This injury of unknown origin was not reported to the state survey agency until two days after it was observed. Resident #33 had a history of unspecified dementia with behavioral disturbances and major depression with psychotic symptoms, indicating cognitive impairment. Resident #5, who had severe cognitive impairment due to dementia and Alzheimer's disease, was found with bruising on their forehead, nose, and below the right eye. Despite the visible injuries and the resident's inability to explain the cause due to cognitive impairment, the facility did not report the incident to the state survey agency. The Regional Director of Nursing and the Nursing Home Administrator stated that the clinical team did not believe the injury met the criteria for reporting, as it was considered consistent with the resident's care plan behaviors.
Latest citations in Maryland
Facility staff did not ensure that 2nd floor residents who could not use stairs were able to receive visitors when the only elevator was out of service for an extended period. Complaints indicated that some family members, who were themselves unable to ambulate stairs, could not visit their relatives on the 2nd floor during this time. The emergency plan directed non-ambulatory 2nd floor residents to remain on that floor unless there was an emergency and did not address how visitation would be maintained when the elevator was inoperable. The Administrator reported that visitors could use the stairs and that an emergency chair system could be used to move residents, but also stated that the chair system was not used for visitation and was unaware of any complaints, despite two having been filed.
Facility staff did not complete required quarterly smoking safety assessments for several residents identified as smokers, including some who had not been reassessed for many months and one who had never been assessed during their stay. This issue was discovered during a complaint survey after the facility’s only elevator was out of service for an extended period, affecting a group of residents on an upper floor who needed to reach a designated smoking area on a lower floor. Review of records and staff interviews, including with the DON and a unit manager, confirmed that the facility’s own practice of quarterly smoking safety assessments for smokers was not followed for half of the affected residents.
Facility staff failed to accurately code multiple MDS assessments for several residents, leading to discrepancies between MDS entries and MARs for pain management, falls, and high-risk drug classes. In several cases, scheduled pain management was coded as provided when MARs did not show daily pain medications, often because an LPN counted low-dose Aspirin ordered for cardiovascular prophylaxis or heart failure as pain medication, contrary to RAI guidance. One resident’s falls were underreported on the MDS despite two documented falls, and daily use of a topical analgesic and an antiplatelet (Aspirin) was not correctly captured. Other residents had MDS entries indicating use of hypnotic or antianxiety medications when MARs showed none, while actual antidepressant and hypoglycemic medications administered daily were omitted from Section N0415. These errors were confirmed by the involved LPNs during surveyor interviews.
Staff failed to conduct complete investigations into two residents’ abuse allegations. In one case, a resident reported that an employee poked their face and made an obscene gesture, but the investigation lacked a statement from the corporate representative who was first notified of the allegation. In another case, a resident reported that someone in blue clothing put a hand by their face and over their mouth, with a specific GNA identified as the alleged perpetrator; however, the investigation did not include statements from two GNAs who were on duty on the unit at the time of the alleged incident, despite leadership having the opportunity to ensure all relevant documents were present.
Staff failed to create person-centered care plans for two residents, one with mobility limitations and one receiving peritoneal dialysis. For the resident with mobility issues, the care plan did not address the resident’s refusal to use a Hoyer lift and preference for pivot transfers, despite therapy prohibiting pivot transfers and staff awareness of the resident’s resistance. For the resident on peritoneal dialysis, the care plan did not specify that the treatment was peritoneal dialysis, nor did it include the treatment schedule or cycle time frames; an LPN Unit Manager acknowledged using a generalized renal care plan without incorporating the specific dialysis prescription.
A resident’s medical record lacked documentation confirming that scheduled showers or bed baths were provided on multiple dates, and there was also no record of any refusals of care on those days. The DON and an LPN unit manager reported that showers were scheduled on specific shifts and that completed showers and refusals should be documented on shower/skin sheets and in the care plan, but the surveyor found gaps where no such entries existed. This resulted in incomplete ADL documentation and failure to maintain medical records according to accepted professional standards.
A resident with multiple fractures and chronic pain was receiving an opioid-based pain regimen, including PRN hydromorphone. The resident was later found unresponsive and "out of it" by an LPN, who located an order for Narcan and administered it, with the resident responding to the medication. A physician note documented an opioid overdose treated with Narcan. Review of the medical record showed no documentation that the resident’s representative was notified of this significant change in condition and emergency intervention, and staff interviews confirmed that notification likely did not occur, despite the DON’s expectation that the responsible party should have been informed.
Staff failed to follow updated wound care orders and to document an opioid overdose event and Narcan use for two residents. One resident with venous and arterial lower extremity wounds did not receive the prescribed change from oil emulsion to daily skin prep on one foot wound, and did not receive ordered skin prep on a new plantar wound for several days after the wound physician revised the treatment plan. Another resident with multiple fractures and chronic pain, receiving multiple opioid and adjunct analgesics, reportedly experienced an opioid overdose; an LPN found the resident unresponsive, located an existing Narcan order, administered Narcan, and observed the resident return to baseline, but did not complete or document a change-in-condition assessment, vital signs, or the Narcan administration in the medical record.
Surveyors substantiated a deficiency when disinfectant wipes, labeled for storage in areas inaccessible to children and not for personal cleansing, were observed sitting openly on a wire shelf in the dining room of a locked dementia unit while cognitively impaired residents waited for breakfast. A GNA and an LPN present on the unit stated that staff used the wipes to clean tables and that residents were never left alone in the dining room and had not been seen using the wipes. The ICP reported being unaware that the wipes’ placement in the dining room was a concern, and the NHA and DON stated they had not previously been informed about the issue, though the DON acknowledged understanding the concern.
A resident’s medical record showed multiple instances where Hydromorphone, a controlled narcotic, was documented as signed out and given on the Controlled Drug Administration Record but was not documented on the MAR on the same dates and times. An LPN reported signing only the narcotic sheet and not the MAR, while the DON acknowledged awareness that nurses were signing the narcotic sheet without completing the MAR, and a unit manager stated they were unaware this was occurring and that both records should be completed. The NHA and DON agreed with the surveyor’s findings after the issue was identified.
Failure to Ensure Visitation Rights During Elevator Outage
Penalty
Summary
Facility staff failed to ensure that residents residing on the 2nd floor who could not safely ambulate using stairs were able to exercise their right to have visitors when the facility’s only elevator malfunctioned. Complaint reviews showed that family members were unable to visit their relatives on the 2nd floor when the elevator was inoperative, and these family members themselves were unable to use the stairs. An incident report documented that the facility’s only elevator was malfunctioning for an extended period, from 3/28/26 to 4/23/26. During this time, residents who could not use the stairs remained on the 2nd floor, and some of their family members could not access them due to the lack of elevator service. Review of the facility’s emergency plan revealed that it instructed that 2nd floor residents who could not safely use the stairs should remain on the 2nd floor unless there was an emergency, and it did not include any provisions for maintaining visitation when the elevator was inoperable. In an interview, the Administrator stated that visitors could use the stairs to visit 2nd floor residents and that residents could be transported using an emergency chair system to meet visitors who could not use the stairs. However, the Administrator acknowledged that the emergency chair system was not used for visitation purposes during the elevator outage and reported being unaware of any complaints about the inoperative elevator, despite two complaints having been received by OHCQ. No additional documentation was provided to show a plan to support visitation for 2nd floor residents during the elevator malfunction.
Failure to Complete Required Quarterly Smoking Safety Assessments
Penalty
Summary
Facility staff failed to update smoking safety assessments at least once every three months for multiple residents identified as smokers. During a complaint survey focused on smoking safety, surveyors reviewed an incident involving the facility’s only elevator being inoperative for nearly a month, which affected residents who lived on the 2nd floor and needed to access the 1st-floor smoking area. The facility’s investigation identified a group of 10 residents on the 2nd floor who smoked and required additional accommodations to safely ambulate to the designated smoking area. Review of these residents’ medical records showed that 5 of the 10 did not receive quarterly smoking safety assessments as required by the facility’s practice. Specifically, four residents had not received a smoking assessment since May 2025, and one resident had no documented smoking assessment at any time during their stay. During interviews, the Unit Manager stated that residents identified as smokers are to be assessed quarterly for smoking safety. When the surveyor pointed out the missing assessments, the DON reviewed the records and confirmed that these residents had not received the required quarterly smoking assessments. This lack of timely reassessment occurred in the context of an extended elevator outage that necessitated special consideration for safe smoking access for residents residing on the 2nd floor.
Inaccurate MDS Coding for Pain Management, Falls, and High-Risk Drug Classes
Penalty
Summary
Facility staff failed to ensure that Minimum Data Set (MDS) assessments were accurately coded for multiple residents, based on medical record review and staff interviews. For one resident with cerebrovascular disease, an MDS with an Assessment Reference Date (ARD) of 3/2/26 coded Section J0100A (scheduled pain management) as "yes," but the March Medication Administration Record (MAR) did not show daily pain medication administration. An LPN stated she coded it that way because the resident received Aspirin 81 mg daily, although the physician’s order showed the Aspirin was prescribed as prophylaxis for cardiovascular events, and the RAI Manual specifies that medications not primarily intended for pain relief should not be coded as pain management. Another resident with cerebral infarction, congestive heart failure, and vascular dementia had two documented falls in progress notes between the prior assessment and the ARD of 2/4/26, but Section J1900 (number of falls since admission or prior assessment) captured only one fall. The same MDS coded Section J0100A (scheduled pain management) as "no" despite the February MAR documenting daily use of Diclofenac topical gel for pain. The MAR also showed daily Aspirin 81 mg for coronary artery disease, but Section N0415 (high-risk drug classes) did not capture the use of an antiplatelet medication. The responsible LPN confirmed missing the second fall and the Aspirin coding error. Additional residents had similar discrepancies: one resident’s MDS repeatedly coded use of hypnotic medications in Section N0415 when MARs showed no hypnotics administered, and failed to capture an antidepressant (Sertraline) that was given; the LPN reported coding Clonazepam as a hypnotic based on dual use, though reference guidelines did not classify it as such. Further inaccuracies were identified for other residents in pain management and high-risk drug class coding. One resident’s MDS with an ARD of 1/8/26 coded receipt of PRN pain medication in Section J0100A, but the January MAR showed no PRN pain medications given; a later MDS for the same resident coded use of an antianxiety medication in Section N0415, while the April MAR showed no such medication administered. Another resident with traumatic subarachnoid hemorrhage, type 2 diabetes with neuropathy, atrial fibrillation, and atherosclerotic heart disease had an MDS with an ARD of 2/3/26 that coded scheduled pain medication as "yes" and PRN pain medication as "no," although the MAR showed intermittent PRN Tylenol for pain and no daily pain medication, and also documented daily Aspirin 81 mg for heart failure and daily Rybelus for diabetes; the MDS failed to capture PRN pain use, incorrectly coded daily pain medication, and did not code hypoglycemic medication in Section N0415. Another resident with a history of stroke and right-sided hemiplegia/hemiparesis had two MDS assessments in February coded as receiving scheduled pain medication, but the February MAR did not show daily pain medication; the LPN reported coding based on daily prophylactic Aspirin 81 mg, which was not ordered for pain.
Incomplete Investigations of Resident Abuse Allegations
Penalty
Summary
Facility staff failed to complete thorough investigations of two separate resident allegations that were reported to the state agency. For the first incident, a resident alleged that on a specific date and time an employee poked two fingers into their face and showed them their middle finger. The five-day follow-up documented the allegation, but the investigation file did not clearly identify who was the first point of contact for the report. During interview, the Administrator stated that a corporate representative was initially made aware of the alleged incident, but there was no statement from this corporate representative included in the investigation file. The Administrator described their usual investigation process as interviewing involved parties, identifying and interviewing witnesses, reviewing staffing for the date of the alleged incident, and interviewing the resident’s roommate and other nearby residents if there were no direct witnesses. In the second incident, a resident reported that during a specific shift someone wearing blue put a hand by their face and over their mouth, and a particular GNA was identified as the alleged perpetrator. Review of the staffing sheet for the time of the alleged incident showed that two GNAs were working on the unit where the incident was reported to have occurred. However, the investigation file contained no statements or interviews from these two GNAs. Prior to the surveyor’s review of the investigation, the DON and a regional nurse were given the opportunity to review the investigation to ensure all necessary documents were available, yet the statements from the two GNAs remained absent. These omissions demonstrated that the facility did not conduct complete investigations into the reported allegations.
Failure to Develop Person-Centered Care Plans for Mobility and Peritoneal Dialysis Needs
Penalty
Summary
Facility staff failed to develop and implement person-centered care plans that addressed all identified needs for two residents, one with mobility limitations and one receiving peritoneal dialysis. For the resident with mobility limitations, the care plan included interventions for resistance to care and adjustment issues, but did not address the resident’s specific resistance to use of a Hoyer lift and the resident’s insistence on pivot transfers from bed to wheelchair. The Unit Manager confirmed that the resident was resistant to care, did not like the Hoyer lift, and preferred pivot transfers, but also stated that physical therapy had prohibited pivot transfers. Despite this known conflict between the resident’s preferences and therapy restrictions, the care plan lacked individualized interventions related to the resident’s resistance to the Hoyer lift and continued request for pivot transfers. For the resident receiving peritoneal dialysis, review of the electronic health record showed an order for peritoneal dialysis, but the resident’s care plans did not include a person-centered care plan specific to this treatment. The existing dialysis care plan did not specify the type of dialysis treatment being provided, did not document when the resident was scheduled to receive the treatment, and did not include time frames for the dialysis cycles. During an interview, the LPN Unit Manager stated that they do not place the dialysis prescription details into the care plan and instead use a generalized renal care plan by selecting standard items, confirming that the care plan was not individualized to the resident’s ordered peritoneal dialysis regimen.
Failure to Document Resident Showers and Refusals
Penalty
Summary
Facility staff failed to maintain complete and accurate documentation of bathing care for a resident, specifically regarding showers and refusals of showers. During a complaint survey, the surveyor requested verification that Resident #5 was receiving scheduled showers. The DON stated that the resident was scheduled for showers on the 3 pm–11 pm shift on Tuesdays and Fridays, and provided shower sheets for several dates in October and early November. However, there was no documentation to verify that the resident received a shower or bed bath on 10/17/25, 10/21/25, and 10/24/25. The DON explained that when a resident receives a shower it is documented on a skin sheet, and that refusals of showers should be documented both in the plan of care and on the shower sheet. Despite this, the surveyor did not receive any documentation indicating that the resident either received bathing care or refused showers on the missing dates. This lack of documentation showed that the facility did not safeguard resident-identifiable information and maintain medical records in accordance with accepted professional standards, as there was no record confirming whether the resident’s scheduled showers or refusals occurred on the identified dates.
Failure to Notify Responsible Party After Narcan Administration for Suspected Opioid Overdose
Penalty
Summary
The deficiency involves the facility’s failure to notify a resident’s responsible party when there was a significant change in the resident’s medical status requiring emergency medication. A complaint alleged that there was no communication with the responsible party when Narcan (naloxone) was administered to a resident for an alleged opioid overdose. Medical record review showed the resident was admitted in March 2026 with multiple fractures, including a nondisplaced zone 1 sacral fracture, a nondisplaced fracture of the posterior column of the right acetabulum, a fracture of the right pubis, and other chronic pain. The resident’s pain regimen included multiple opioids and other pain medications, including Hydromorphone 6 mg every 4 hours PRN, Hydromorphone 4 mg every 4 hours PRN, Tylenol, Lidocaine cream, Methocarbamol, Celebrex, and Gabapentin. A physician’s note dated 4/8/26 documented that the resident reportedly had an opioid overdose earlier that morning and responded well to Narcan administration by nursing, with the note listing chronic pain and opioid overdose status post Narcan. Further review of the resident’s medical record did not show any documentation that the resident’s representative was notified of this overdose event and Narcan administration. During interviews, an agency LPN stated that the resident was “out of it and not responding” during rounds, prompting the LPN to check for and then administer Narcan, after which the resident responded. Another LPN reported that Narcan was given because the resident appeared to be having an overdose and that the physician saw the resident afterward, but stated, “I don’t think anyone was notified, but should have been.” The DON also stated that she would have expected the responsible party to be notified. These findings confirmed that the facility failed to notify the resident’s responsible party of a significant change in condition and emergency treatment.
Failure to Follow Wound Care Orders and Document Narcan Administration
Penalty
Summary
Facility staff failed to provide treatment and care in accordance with professional standards and physician orders for two residents. For one resident admitted after hospitalization with acute systolic heart failure and peripheral edema, a wound physician initially ordered daily oil emulsion dressings for venous wounds on the right shin, left medial foot, and left second toe. At a follow-up assessment, the wound physician changed the treatment for the left medial foot from oil emulsion to daily skin prep and ordered daily skin prep for a newly identified arterial wound on the left plantar foot. Review of the March 2026 medication and treatment administration records showed staff did not discontinue the oil emulsion or initiate the ordered skin prep to the left medial foot, and did not administer skin prep to the left plantar foot wound from the date of the new orders until the resident was sent to the hospital. The DON confirmed that treatments were not administered per the updated wound care orders during this period. For another resident admitted with multiple pelvic and sacral fractures and chronic pain, the record showed extensive opioid and adjunct pain medication orders, and a physician note documented that the resident reportedly experienced an opioid overdose and responded well to Narcan administration by nursing. However, the medical record contained no nursing assessment of the resident at the time of the event, no documentation of the resident’s condition or vital signs, and no record of Narcan administration or the resident’s response afterward. An agency LPN reported finding the resident unresponsive or "out of it" during rounds, knowing the resident was on significant pain medications, and, after checking for an existing order, administering Narcan, after which the resident returned to baseline. The LPN acknowledged not completing or documenting a change-in-condition assessment, and both the DON and unit manager stated they would have expected an assessment and vital signs to be documented in this situation.
Disinfectant Wipes Left Accessible in Dementia Unit Dining Room
Penalty
Summary
The deficiency involves the facility’s failure to keep the environment free from accident hazards on one locked dementia unit. During a complaint survey regarding unsecured cleaning supplies and the potential for residents to use cleaning wipes for personal use, a surveyor observed disinfectant wipes stored openly on a wire shelf in the dining room of the Seagull Unit, a locked dementia unit. The product labeling on the container directed that it be stored in areas inaccessible to children and specifically stated it was not to be used as a diaper wipe or for personal cleansing and that it was not a baby wipe. At the time of the observation, residents with cognitive impairment were present in the dining room awaiting breakfast. A GNA was in the dining room with the residents during the observation, and the unit manager, an LPN, accompanied the surveyor. The surveyor expressed concern about the wipes being accessible in a public area where cognitively impaired residents were present. The LPN reported she had never seen residents use or attempt to use the wipes and stated staff used them to wipe down tables before and after meals. The GNA stated she was always present when residents were in the dining room, that residents were never left alone there, and that she had never seen a resident use a wipe. The Infection Control Nurse stated she was not aware the disinfectant wipes in the dining room were a concern because no residents had gone near them and confirmed they were intended for staff use to clean tables. The NHA and DON reported they had not been made aware of the concern with the wipes, though the DON stated she understood the concern.
Incomplete Documentation of Narcotic Administration on MAR
Penalty
Summary
The deficiency involves the facility’s failure to maintain complete and accurate medical records in accordance with accepted professional standards for one resident. Review of the resident’s April 2026 Medication Administration Record (MAR) and the Controlled Drug Administration Record showed multiple discrepancies for Hydromorphone, a narcotic medication. On several specific dates in April, the Controlled Drug Administration Record documented that Hydromorphone doses were signed out and given by licensed nursing staff at various times, but the corresponding MAR entries for those same dates and times were left blank, indicating no documentation of administration on the MAR. During interviews, an LPN stated that they sign out the medication on the narcotic sheet but do not document it on the MAR. The DON acknowledged awareness that nurses were signing off on the narcotic sheet but not on the MAR, and a unit manager reported not being aware that nurses were failing to sign the MAR when also signing the narcotic sheet, stating that documentation should occur on both records. The NHA and DON later stated they were not aware of the concern until it was identified by the surveyor and agreed with the findings. These observations and interviews demonstrate that the facility did not ensure that all medication administrations were consistently and accurately documented on the MAR for this resident.
Trusted data from CMS and state health departments
Every citation, penalty and Plan of Correction is sourced from public CMS records (latest release June 24, 2026) and official state health department websites — never guesswork.
Trusted by long-term care providers and associations.
