Autumn Lake Healthcare At Bradford Oaks
Inspection history, citations, penalties and survey trends for this long-term care facility in Clinton, Maryland.
- Location
- 7520 Surratts Road, Clinton, Maryland 20735
- CMS Provider Number
- 215165
- Inspections on file
- 19
- Latest survey
- April 10, 2026
- Citations (last 12 mo.)
- 8
Citation history
Health deficiencies cited at Autumn Lake Healthcare At Bradford Oaks during CMS and state inspections, most recent first.
The facility failed to consistently conduct and document care plan meetings and to revise care plans after changes in condition. Several residents reported either not having care plan meetings or not knowing about them, and record reviews showed only single, outdated care plan meeting entries with no subsequent documentation despite multiple MDS assessments that should have prompted quarterly IDT reviews. In addition, a resident who had been discharged from hospice services continued to have an active hospice physician order and an active hospice-related care plan, indicating that the care plan was not revised to reflect the resident’s discontinued hospice status.
A resident’s total program of care was not accurately reviewed and documented by the primary medical provider, resulting in conflicting information about catheter type, medication route, and cognitive status. The NP documented that the resident had a suprapubic catheter and received meds and hydration via PEG tube, while active orders included flushing a suprapubic catheter, enhanced barrier precautions for a Foley catheter, and administration of all meds orally. The UM confirmed the resident actually had a Foley catheter and received meds through the PEG tube, and the NP later acknowledged errors in documenting the catheter type, medication route, and the resident’s cognitive status, creating discrepancies between assessments, progress notes, and physician orders.
Surveyors identified that two residents did not have accessible call light cords in their room, as the cords were found tied and curled on the floor against the wall, despite both residents being alert and ambulatory. In a separate case, a resident reported intermittent problems with a call light that, when tested by the resident, a GNA, and later the NHA, failed to illuminate in the room or hallway on two separate occasions, with staff attributing the issue to a loose wall adapter.
Facility staff failed to notify a resident’s responsible party when the resident’s sacral pressure ulcer worsened from Stage 3 to Stage 4. The resident, admitted with multiple skin injuries and serious comorbidities, initially had an unstageable sacral ulcer that resolved and later reopened, at which time the responsible party was documented as notified and the wound was assessed as Stage 3. After a hospital transfer and return, the wound consultant documented the sacral ulcer as a worsening Stage 4 and new treatments were ordered, but there was no documentation that the responsible party was informed of this change in condition, contrary to the DON’s stated expectations.
A resident was admitted without having a baseline care plan completed and signed within the required 48 hours. Review of the medical record showed that the baseline care plan, which is intended to outline how to provide care for a new resident and is required to be created within 48 hours of admission, was not finalized until more than two weeks after the admission date. The resident’s representative confirmed this delay, and the DON acknowledged that facility policy and requirements call for baseline care plans to be completed, signed, and provided to the resident or representative within 48 hours of admission.
The facility failed to conduct and document required IDT care plan meetings with a resident and their responsible party following quarterly MDS assessments, despite multiple completed assessments and the responsible party reporting they were never invited to such meetings. For another resident with a Stage 3 sacral pressure ulcer, a suprapubic skin tear, and bilateral heel calluses present on admission, the facility initiated a care plan that only noted risk for impaired skin integrity and did not specifically address these existing wounds. When this resident later developed a new wound, the care plan and interventions were not revised to reflect the change in condition, even though the DON stated that care plans are to be updated upon changes in condition.
A resident developed swelling of the left lower lip, and nursing progress notes repeatedly documented that a physician or on-call physician was notified and gave a new order to apply a warm compress, followed later by an order for a cold compress, routine mouth care, and Vaseline. However, review of the physician orders showed that the warm compress order was never entered into the medical record, a fact confirmed by the DON. This failure occurred despite facility policy and an LPN’s statement that telephone orders received after a change in condition must be documented on the physician order form and properly verified and transcribed.
Surveyors found that two residents received multiple scheduled medications late, with delays of several hours, and an LPN left pre-poured medications unattended in a resident's room during administration. The DON confirmed that these practices did not meet professional standards, as medications were not administered or documented at the correct times and were improperly handled during administration.
The facility failed to maintain a sanitary environment, with litter observed in the parking lot and unsanitary conditions in the East hallway. Masks, gloves, and other debris were repeatedly found outside, while inside, stained ceiling tiles, torn flooring, and unclean handrails were noted. Maintenance and Environmental Services staff acknowledged the issues but cited access problems and ongoing renovations as contributing factors.
A facility failed to report an abuse allegation to the state agency within the required timeframe. An LPN reported a resident's abuse allegation to the RN supervisor, but the RN did not document notifying the DON and NHA. The NHA was informed the next day, leading to a delay in reporting to the SA, resulting in a deficiency.
A facility failed to suspend a GNA accused of abuse, allowing her to continue working with vulnerable residents. The investigation was inadequate, lacking documentation and interviews with other staff or residents. The NHA and HR Director could not explain discrepancies in the handling of the allegation, revealing lapses in adherence to abuse policies.
A facility failed to provide a baseline care plan to a resident's representative, which is necessary for proper care upon admission. The representative was not given a copy of the care plan or informed about the resident's medications. This deficiency was confirmed through a review of records and acknowledged by the Regional DON.
The facility staff failed to maintain complete and accurate medical records for two residents. One resident's records showed discrepancies between GNA and nurse documentation regarding turning and repositioning, while another resident's records lacked signatures for bowel, bladder, and personal hygiene care. The Regional DON confirmed these issues, but no rationale was provided for the inconsistencies.
The facility failed to discard expired food items in the dry storage area, including Med Plus 2.0 vanilla nutritional supplements and Thickened Dairy Drink. The Dietary Manager admitted that the items were not in rotation, posing a potential risk to residents consuming these products. The facility's policy mandates proper food storage to prevent deterioration or contamination.
A resident with RSV was not properly isolated due to staff failing to follow droplet precautions. Despite clear signage and available PPE, an LPN and the Activities Director entered the resident's room without the necessary protective equipment, risking cross-contamination. The facility's infection control policies were not adhered to, as confirmed by staff interviews.
Failure to Conduct, Document, and Revise Resident Care Plans
Penalty
Summary
The deficiency involves the facility’s failure to conduct and document timely, regular care plan meetings and to revise care plans following changes in residents’ conditions. One resident reported not having had a care plan meeting in a while, and record review showed the last documented care plan meeting occurred in May 2025, despite multiple subsequent MDS assessments, including an annual and several quarterly assessments. The DON confirmed that care plan meetings were missed following these MDS assessments. Another resident stated that they did not have care plan meetings, and the Social Services Director (SSD) confirmed that this resident had no documented care plan meeting since July 2025, despite multiple MDS assessments that should have triggered additional meetings. A third resident reported being unaware of care plan meetings, and record review showed only one documented care plan meeting in June 2025 with no further documentation of care plan meetings over the following year. Similarly, a fourth resident stated not knowing about care plans or care plan meetings, and the medical record showed a single documented care plan meeting in April 2025 with no additional care plan meeting documentation over the subsequent year. The facility also failed to revise a care plan after a significant change in a resident’s condition related to hospice services. One resident had been admitted to hospice services in March 2024 and discharged from hospice in July 2025 at the request of the resident’s daughter. However, record review revealed that the resident still had an active physician order for hospice and an active care plan for unavoidable decline due to hospice status and hospice care, even though hospice services had been discontinued. The DON acknowledged that the care plan had not been updated to reflect the resident’s change in status when hospice services ended.
Inaccurate Provider Documentation and Conflicting Orders for Catheter and Medication Administration
Penalty
Summary
The deficiency involves the primary medical provider’s failure to accurately review and document a resident’s total program of care, resulting in conflicting and inaccurate clinical information in the medical record. Record review showed that a nurse practitioner documented in a progress note that the resident had a neurogenic bladder with a suprapubic catheter (SPC) and a PEG tube used for medications and hydration, and also described the resident as a poor historian due to cognitive/psychiatric impairment. However, active orders directed that all medications be given orally rather than via PEG tube, there were orders to flush an SPC every shift, and there were separate orders for enhanced barrier precautions related to a Foley catheter, indicating simultaneous orders for two different types of urinary catheters. During interviews, the unit manager confirmed that the resident currently had a Foley catheter, not an SPC, and reported having recently changed the Foley catheter. The unit manager also stated that the resident actually received medications through the PEG tube, despite the orders specifying oral administration, and could not explain why the orders did not match the provider’s note. In a subsequent interview, the nurse practitioner acknowledged documenting the SPC in error, stated that the resident had advanced in diet and could take medications orally, and admitted that her notes did not reflect this change. She also reported that, upon reevaluation, the resident was capable of making his or her own decisions and that the previously documented cognitive impairment was not accurate, further highlighting discrepancies between the resident’s assessment, the documentation, and the written orders.
Inaccessible and Malfunctioning Resident Call Systems
Penalty
Summary
The deficiency involves the facility’s failure to ensure that resident call systems were accessible and functioning properly in resident rooms and bathrooms. During a tour of the North Nursing Unit, the surveyor observed that two alert and ambulatory residents did not have accessible call lights in their room. The call light cords for both residents were found on the floor next to the wall, curled up and tied together, rather than positioned so the residents could use them. When notified, the North Unit Nurse Manager observed the same condition in the room. In a separate incident, another resident reported that his/her call light did not always work. When the surveyor asked the resident to activate the call light, neither the light in the room nor the hallway door light illuminated. A GNA then attempted to use the call light and confirmed it was not working, stating that sometimes the wall adapters can get loose; after adjusting the adapter, the call light became functional. Later, when the NHA was asked to evaluate the same resident’s call light, activation again failed to produce any illumination, marking the second time the call light did not function properly.
Failure to Notify Responsible Party of Worsening Pressure Ulcer
Penalty
Summary
Facility staff failed to notify the responsible party when a resident’s sacral pressure ulcer worsened. The resident was admitted from the hospital with multiple skin injuries, including an unstageable sacral pressure ulcer, and had diagnoses such as COPD, peripheral vascular disease, and pressure-induced deep tissue damage to the right heel and another site. The sacral pressure ulcer was documented as resolved and later reopened, at which time a Change in Condition form indicated that the responsible party was notified in person, and the wound consultant assessed the reopened ulcer as a Stage 3 pressure ulcer. The wound consultant continued weekly evaluations, and the resident was later transferred to the hospital for a change in condition and then returned to the facility. Following the resident’s return, the wound consultant evaluated the sacral ulcer again and documented that it had worsened to a Stage 4 pressure ulcer, and a new treatment order for Santyl and calcium alginate dressing was implemented. However, review of the clinical record did not show any documentation that the responsible party was informed of this worsening of the sacral pressure ulcer. In an interview, the DON stated that her expectation was that nursing staff notify the responsible party of any change in condition, and that worsening of a pressure ulcer to Stage 4 was considered a change in condition for which the responsible party should have been notified. After further review of the record, the DON confirmed there was no documentation that the responsible party had been notified of the worsening pressure ulcer.
Failure to Complete Baseline Care Plan Within 48 Hours of Admission
Penalty
Summary
The facility failed to develop and implement a baseline care plan within 48 hours of admission for one resident. Record review on 1/8/26 at 11:30 AM showed that this resident was admitted on 10/13/25, but the baseline care plan was not completed and signed until 10/28/25, which exceeded the required 48-hour timeframe. The baseline care plan is described in the report as a document that outlines how to provide care for a new nursing home resident, created within 48 hours of admission to reduce the risk of adverse events and ensure the resident receives quality care. This delay in completing the baseline care plan was confirmed by the resident’s representative. During an interview on 1/8/25 at 12:23 PM, the DON acknowledged that baseline care plans are required to be completed and signed within 48 hours of admission and that a copy must be provided to the resident or their representative, thereby confirming that the facility did not meet this requirement for the identified resident.
Failure to Conduct IDT Care Plan Meetings and Update Wound Care Plans
Penalty
Summary
The facility failed to hold and document required care plan meetings with the Interdisciplinary Team (IDT) and the resident or responsible party (RP) within 7 days of quarterly MDS assessments for one resident, and failed to review and revise care plans to address identified skin conditions and new wounds for another resident. For Resident #2, who had diagnoses including COPD, peripheral vascular disease, and multiple pressure-related injuries (sacral pressure ulcer, deep tissue damage of the right heel and another site) and later expired, quarterly MDS assessments were completed on three separate dates. However, there was no evidence in the clinical record that care conferences were held with the resident/RP and the IDT around the time of these assessments. The RP reported not being invited to participate in care plan meetings, the Social Services Director could not find documentation of care conferences or invitations to the RP, and the Administrator, despite stating he believed conferences were held and that attempts had been made to contact the RP, did not provide any supporting documentation by the time of survey exit. The facility also failed to ensure that a resident’s care plan was specific to existing wounds and revised when a new wound developed. For Resident #5, a family member submitted a complaint regarding wound care, and review of wound progress notes showed that on admission the resident had a Stage 3 pressure ulcer to the sacrum, a suprapubic skin tear, and calluses on both heels. The care plan initiated after admission only identified the resident as being at risk for alteration in skin integrity and did not specify or address these ongoing skin conditions. Further review of wound progress notes showed that the resident acquired a new wound on a later date, yet the care plan and its interventions were not revised to reflect this change in condition. During interview, the DON stated that care plans were initiated on admission by the admitting nurse and updated by the Unit Manager or designated staff when there was a change in condition or as needed, and was informed of the failure to include and update the resident’s wound conditions in the care plan.
Failure to Document Telephone Order for Warm Compress
Penalty
Summary
The deficiency involves the facility’s failure to document a physician’s order for a warm compress in accordance with professional standards and facility policy. A resident was noted on multiple occasions to have swelling of the left lower lip with skin intact, no pain observed, and no tongue swelling or airway compromise. Progress notes dated over several days documented that the physician or on-call physician was notified of the change in condition and that new orders were received to apply a warm compress to the affected area. A subsequent note indicated that the physician was again notified and a new order was received to apply a cold compress, provide routine mouth care, and apply Vaseline to moisten the mouth. On review of the physician orders, surveyors found no evidence that the warm compress order was ever written in the medical record, despite repeated nursing documentation that such an order had been received. The DON confirmed that the warm compress order was not documented for this resident. Facility policy for consulting physician/practitioner orders required that telephone orders be documented on the physician order form with time, date, name and title of the person providing the order, and the signature and title of the person receiving the order, as well as verification by the attending physician and appropriate transcription. An LPN stated that when a change in condition occurs and a telephone order is received, nurses are expected to record the order in the medical record, which did not occur for the warm compress order in this case.
Failure to Adhere to Professional Standards in Medication Administration
Penalty
Summary
Surveyors identified that the facility failed to adhere to professional standards of practice in medication administration for multiple residents. One resident reported ongoing concerns about medications being administered late, which was confirmed by a review of the medical record showing that several scheduled morning medications, including those for hypertension, COPD, atrial fibrillation, and bowel regimen, were documented as given over two hours past the scheduled time. Another resident's medication administration audit revealed that numerous morning medications, including those for pain management, nerve pain, hypertension, asthma, GERD, and wound support, were also administered significantly later than scheduled, with some medications given several hours late. The Director of Nursing acknowledged these delays and attributed some of the issues to agency nurses not documenting medication administration at the time it occurred, despite the facility's standard practice requiring real-time documentation. Additionally, during a medication administration observation, an LPN was seen preparing and bringing scheduled medications into a resident's room while the resident was receiving morning care. During this process, one pill was dropped onto the bed, and the nurse left the room to retrieve a replacement, leaving the cup with the prepared medications unattended on the bedside table. The nurse admitted that leaving pre-poured medications unattended was not the accepted standard of practice. The DON confirmed that medications should never be left unattended and that the standard is to sign off medications at the time of administration. These findings were based on resident interviews, direct observation, and medical record reviews, and were discussed with the facility's administration team. The deficiencies involved both the timing of medication administration and the improper handling of medications during administration, affecting residents with complex medical needs such as hypertension, COPD, atrial fibrillation, pain management, and wound care.
Facility Fails to Maintain Sanitary Environment
Penalty
Summary
The facility failed to maintain a safe and sanitary environment for residents, visitors, and staff, as evidenced by multiple observations of litter and debris in the parking lot and unsanitary conditions in the East hallway. Over several days, surveyors observed masks, gloves, and various paper packaging littering the parking lot, with additional trash such as a pile of nonsterile gloves and a piece of cardboard. Interviews with the Maintenance Director revealed that the parking lot was supposed to be cleaned daily, but the issue persisted despite staff being informed. Inside the facility, the East hallway exhibited several maintenance and cleanliness issues, including a ceiling vent with a gap and black spots, stained ceiling tiles, and a torn flooring tile. Boxes of medical supplies were left piled up near a dummy waiter, and the hallway walls and handrails were stained with a reddish-brown substance. Environmental Services staff were supposed to clean these areas daily, but the Director of Environmental Services noted issues with access due to equipment blocking the way. The Director of Maintenance acknowledged the need for vent cleaning but did not provide a reason for the neglect. The Nursing Home Administrator was aware of the trash issue but did not offer a rationale for the ongoing housekeeping concerns.
Failure to Timely Report Abuse Allegation
Penalty
Summary
The facility failed to ensure timely reporting of an abuse allegation to the state agency (SA) within the required timeframe. A Licensed Practical Nurse (LPN) became aware of a resident's allegation of abuse against a Geriatric Nursing Assistant (GNA) during the evening shift. The LPN reported the allegation to the Registered Nurse (RN) on duty, who was the supervisor for that shift. However, the RN did not document the date, time, and manner of notifying the Director of Nursing (DON) and the Nursing Home Administrator (NHA) about the incident. The facility's documentation indicated that the abuse allegation was reported to the SA the following day, outside the required 2-hour timeframe. The Nursing Home Administrator stated that he was informed of the allegation by the previous DON the day after the incident and denied being notified by the RN on the day of the incident. He acknowledged awareness of the regulatory requirement to report such allegations within two hours but noted that staff often do not report incidents to him immediately if he is not in the building. This lack of immediate reporting and documentation led to a delay in notifying the SA, resulting in a deficiency in the facility's process for handling abuse allegations.
Failure to Suspend Staff Accused of Abuse
Penalty
Summary
The facility staff failed to ensure that an alleged perpetrator, GNA12, had no further access to vulnerable residents during an investigation of an abuse allegation. On 7/13/24, LPN5 became aware of an allegation of abuse involving GNA12 and resident R40. Although LPN5 reassigned GNA12 to prevent her from caring for R40, she continued to work her shift and had access to other vulnerable residents. This was contrary to the facility's policy, which requires immediate suspension of staff accused of abuse. The investigation into the allegation was inadequate. While LPN5 reported the incident to RN6, the evening shift supervisor, there was no documentation of RN6's actions following the report. RN6 claimed to have informed the DON and NHA and instructed GNA12 to go home, but she did not document these actions. Furthermore, the investigation did not include interviews with other staff or residents to determine if GNA12 had abused other residents, nor was there a thorough review of the type of care she provided. The NHA and Director of Human Resources were unable to provide a clear rationale for the discrepancies in the investigation and the handling of the alleged abuse. The NHA stated that staff accused of abuse should be suspended immediately, but GNA12 continued to work her shift after the allegation was reported. The Director of Human Resources confirmed that GNA12's time punches indicated she worked on the day of the allegation, contradicting the NHA's assertion that she was suspended immediately. These failures highlight significant lapses in the facility's adherence to its abuse policies and procedures.
Failure to Provide Baseline Care Plan to Resident's Representative
Penalty
Summary
The facility failed to provide a baseline care plan to a resident's representative, which is a requirement to ensure proper care upon admission. This deficiency was identified for one resident who was reviewed for care to prevent pressure ulcers. The complaint revealed that the resident's representative was not given a copy of the baseline care plan or informed about the medications the resident was taking. A review of the closed record and the electronic medical record confirmed the absence of documentation showing that the baseline care plan or medication list was provided to the resident or their representative. The Regional Director of Nursing confirmed these findings during the review process.
Incomplete and Inaccurate Medical Records for Residents
Penalty
Summary
The facility staff failed to ensure the completeness and accuracy of medical records for two residents. For one resident, there was a discrepancy between the documentation by geriatric nursing assistants (GNAs) and nurses regarding the turning and repositioning of the resident to prevent skin breakdown. The GNAs documented that the resident was not turned and repositioned on several specific dates, while the nurses documented on the Treatment Administration Record (TAR) that the resident was being turned and repositioned on those same dates. The Regional Director of Nursing (DON) acknowledged the inconsistency but could not provide a rationale for the conflicting information. For another resident, the medical record review revealed that tasks related to bowel and bladder care and personal hygiene were not signed off as completed on multiple occasions. The resident, who required assistance with activities of daily living, had family concerns about not being changed regularly. The Regional DON and the administrator confirmed that the lack of signatures meant it could not be verified whether the care was provided or if the nurse failed to document it.
Expired Food Items Found in Storage
Penalty
Summary
The facility failed to ensure that food items in the dry storage area were discarded upon reaching their use-by dates, as observed during a survey. Specifically, two cases of Med Plus 2.0 vanilla nutritional supplements and one case of Thickened Dairy Drink were found with expired use-by dates. The Dietary Manager acknowledged the oversight and indicated that the items were not in rotation, which could potentially make residents who consume these products sick. The facility's policy on food safety requires that food be stored in a manner that prevents deterioration or contamination, including from the growth of microorganisms.
Failure to Follow Droplet Precautions for Resident with RSV
Penalty
Summary
The facility failed to adhere to infection control procedures related to droplet precautions for a resident diagnosed with respiratory syncytial virus (RSV). The resident, who was cognitively intact and dependent on staff for daily activities, had a physician's order for droplet precautions. Despite clear signage on the resident's door and the availability of personal protective equipment (PPE) outside the room, staff members did not consistently follow the required precautions. Specifically, an LPN entered the resident's room to assist with a meal without wearing a gown or eye protection, and the Activities Director also entered the room without the necessary PPE. Interviews with the Director of Nursing and the involved staff confirmed the lapses in following the facility's infection control policies. The facility's policy on transmission-based precautions required staff to wear a gown, mask, gloves, and eye protection when entering the room of a resident on droplet precautions. The failure to comply with these procedures had the potential to cause cross-contamination with other residents and staff, as the facility's policies were not adequately followed by the staff members involved.
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.
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