Autumn Lake Healthcare At Chevy Chase
Inspection history, citations, penalties and survey trends for this long-term care facility in Chevy Chase, Maryland.
- Location
- 8700 Jones Mill Road, Chevy Chase, Maryland 20815
- CMS Provider Number
- 215029
- Inspections on file
- 21
- Latest survey
- April 3, 2026
- Citations (last 12 mo.)
- 5
Citation history
Health deficiencies cited at Autumn Lake Healthcare At Chevy Chase during CMS and state inspections, most recent first.
Facility staff failed to accurately code an MDS assessment for a resident admitted for rehab after an acute hospitalization. A NP documented three pressure ulcers—Stage 1 on the right heel, Stage 3 on the left heel, and an unstageable ulcer on the coccyx—but the admission MDS in Section M recorded only one unhealed Stage 3 pressure ulcer and omitted the Stage 1 and unstageable ulcers. The RN MDS Coordinator later confirmed that the MDS did not capture all documented pressure ulcers.
Facility staff did not timely develop or implement a baseline or comprehensive care plan for a resident admitted for rehab with multiple preexisting PUs, including Stage 1, Stage 3, and unstageable ulcers on the heels and coccyx. Although the admission MDS documented PU risk and an unhealed PU, no baseline care plan was initiated within 48 hours of admission, and specific PU care plans for the left heel, right heel, and coccyx wounds were not started until more than two weeks after the admission assessment, resulting in a failure to meet required care planning timeframes.
A resident admitted with multiple pre-existing PUs on the heels and coccyx did not receive pressure ulcer care consistent with professional standards. The wound NP documented specific treatment recommendations for each ulcer and later recommended an alternating air/low air loss mattress, but these orders were not promptly entered into the medical record, resulting in delayed and incomplete implementation. For days after admission, no coccyx PU treatments were documented, a left heel treatment order was entered late, and when a new left heel order was added, the old order was not discontinued, leading to both treatments being charted on multiple days. The NP later documented that the right heel PU had progressed to a DTI and that the coccyx ulcer had significantly increased in size. The admission MDS did not capture all existing PUs, and the resident lacked a comprehensive care plan with measurable goals for PU management. Staff interviews confirmed that the process for transcribing NP orders and initiating care plans broke down, contributing to these deficiencies.
A resident with a history of stroke and intact cognition reported that a GNA was rough and rushed during incontinence care, leading the resident to call 911. Although staff and the DON became aware of the allegation in the morning, the incident was not reported to the state survey agency until several hours later, exceeding the required two-hour reporting window.
A nurse failed to perform hand hygiene between glove changes while providing wound care to a resident with an unstageable pressure ulcer and peripheral vascular disease. The nurse repeatedly changed gloves without washing hands, contrary to facility policy, during a dressing change procedure. Both the nurse and the DON confirmed that hand hygiene should have occurred between glove changes.
Surveyors found that the facility failed to maintain a homelike environment, with multiple rooms missing toilet paper holders, damaged furniture, and exposed plumbing. Common areas such as shower and utility rooms were observed to be unclean and disorganized, with trash, soiled items, and personal belongings improperly stored. Additionally, residents reported being without hot water for several days, confirmed by low water temperatures in multiple rooms, requiring alternative arrangements for bathing.
Staff did not consistently review and update care plans after comprehensive and quarterly assessments. In several cases, residents did not participate in care plan meetings, documentation of meetings and invitations was missing, and quarterly screenings for rehab services were not performed as required. After therapy discharge, recommended nursing interventions were not entered into the EMR or reflected in the care plan.
Surveyors identified multiple deficiencies, including failure to implement and document wound care orders for a resident post-amputation, lack of adherence to physician orders for TEDS application, administration of blood pressure medication outside of ordered parameters without physician notification, and incomplete documentation of ordered showers. These actions and omissions involved several residents and demonstrated lapses in following professional standards and physician instructions.
Two residents were not treated with dignity during care: one was fed by a CNA standing over them instead of sitting at eye level, and another, who required extensive ADL assistance and had significant medical conditions, reported being left on a bedside commode for two hours before receiving help. Both incidents reflect lapses in upholding resident rights to dignity and respect.
A resident's legal representative experienced a significant delay—between 19 and 40 days—in receiving requested medical records, despite having valid POA documentation on file. The facility's process required additional legal review, which was not explained as necessary, and the records were not provided within the facility's stated 2-day timeframe.
Surveyors found that the facility did not ensure resident safety after a staff member accused of abuse was not immediately escorted from the building, and also failed to conduct a thorough investigation into another resident's allegation of rough handling by a GNA. In both cases, required investigative steps and documentation were lacking.
A resident's MDS assessment was inaccurately coded to indicate a fall with injury, despite documentation showing no pain or injury after the fall. Facility records and staff interviews confirmed the error, as the resident's assessments and x-ray results did not support the presence of an injury.
A resident who was always incontinent of bowel and bladder did not have a care plan developed to address these needs. Medical records and the MDS confirmed ongoing incontinence, and staff interviews revealed that the required care plan was not in place, resulting in a deficiency.
A resident with significant medical conditions and limited ROM did not receive ongoing contracture management as recommended by OT after discharge from therapy. The recommended nursing interventions, including daily splint application, were not entered as orders in the EMR or included in the care plan, resulting in a lapse in care.
A resident with multiple comorbidities and a worsening sacral wound did not receive a timely Infectious Disease (ID) consultation, despite repeated orders and elevated CRP levels indicating severe inflammation. The ID consult was delayed by 28 days, and there was no documentation of the consultation in the medical record prior to the resident's hospital transfer and diagnosis of sepsis.
Surveyors identified that two residents had incomplete or inaccurate medical records. One resident's shower schedule in the kardex did not match the physician's order, and another resident discharged from OT for contracture management did not have the recommended splinting orders entered into the EMR or care plan. Staff interviews confirmed these documentation lapses.
Surveyors found that multiple refrigerators and ice machines in the kitchen and main dining room were not operational, with food stored at improper temperatures and staff unaware of equipment failures. Staff reported broken ice machines to residents, and maintenance was not aware of all issues, indicating a lack of oversight and failure to keep essential equipment in safe working order.
A resident was observed with a mattress that extended about 8 inches beyond the right side of the bed frame. The surveyor and the Director of Maintenance confirmed that the mattress was too large for the bed frame, resulting in a failure to ensure the mattress properly fit the bed frame as required for safety.
A resident was found resting in bed without access to their call light, which was discovered wrapped around a chair arm and out of reach. An LPN confirmed that staff are expected to keep the call device accessible before leaving the room, and medical records included instructions to keep the call light within reach at all times.
A resident was transferred to the hospital without their comprehensive care plan goals included in the required documentation. Both an RN/Unit Supervisor and an LPN confirmed that care plan goals were not sent with residents during transfers, and this issue was reviewed with the DON.
Staff did not provide written notification to a resident and their representative upon the resident's transfer to the hospital, instead relying solely on verbal communication as confirmed by both an RN/Unit Supervisor and an LPN.
A resident who was dependent on staff for ADLs did not receive scheduled showers as ordered, receiving only one shower during the month while daily bed baths were substituted without proper documentation or explanation. The resident's preference for more frequent showers was not honored, and there was no record of refusal or justification for the missed care.
A resident with bowel and bladder incontinence and a stage 4 sacral pressure ulcer did not have documented interventions or services in place to address their incontinence. Review of medical records and staff interviews confirmed the absence of a care plan or treatment for incontinence.
A resident was prescribed Bupropion, an antidepressant, without an accompanying order for side effect monitoring for several weeks. The DON confirmed that monitoring should have been initiated when the medication was ordered, but this was not done until a later date.
During a breakfast meal service, three residents did not receive coffee as listed on their dietary meal tickets due to a delay in the arrival of the beverage cart. The unit was staffed with only two GNAs for 32 residents, and additional staff from other departments assisted with meal delivery. The omission was observed and confirmed by surveyors in the presence of the unit manager, charge nurse, and medication nurse.
Surveyors found that food served to a unit of 32 residents was not maintained at appropriate temperatures, with hot foods cooling significantly and cold beverages warming above recommended levels due to delays between tray preparation and service. The regional dietary manager acknowledged the failure to ensure proper food temperatures at the point of service.
Surveyors identified failures in food storage at appropriate temperatures, use of non-functional kitchen equipment, and improper storage of dry goods. Additionally, two residents did not receive meal trays matching their meal tickets, with missing or incorrect items. Staff acknowledged the discrepancies and were made aware of the issues.
A facility failed to provide an accurate assessment of direct care staff to resident ratios. The administrator was unable to explain the staffing plan documented in the assessment and later admitted it was incorrect, providing hand-written ratios that did not match the official documentation. This discrepancy resulted in a deficiency related to the facility's assessment process.
Staff did not keep isolation carts stocked with required PPE for residents on enhanced barrier precautions, with missing gloves and gowns noted on multiple units. An LPN confirmed the deficiencies, and medication was found improperly stored in one cart. The administrator and DON were informed of these findings.
Surveyors identified that daily nurse staffing postings were incomplete on all units, with missing information such as dates, nurse-to-resident ratios, staff titles, shift supervisors, hours worked, and unit census. The staff scheduler responsible for collecting these forms was unaware of the full requirements and depended on unit managers to complete the postings.
Inaccurate MDS Coding of Resident Pressure Ulcers
Penalty
Summary
Facility staff failed to ensure an accurate Minimum Data Set (MDS) assessment for a resident with multiple pressure ulcers. The resident was admitted for rehabilitation following an acute hospitalization in early January 2026, and a Nurse Practitioner skin and wound note dated 1/9/26 documented three pressure ulcers: a Stage 1 pressure ulcer on the right heel, a Stage 3 pressure ulcer on the left heel, and an unstageable pressure ulcer on the coccyx. However, review of the admission MDS with an assessment reference date of 1/14/26 showed that Section M, Skin Conditions, captured only one unhealed pressure ulcer, coded as a Stage 3, and did not include the Stage 1 right heel ulcer or the unstageable coccyx ulcer. During an interview, the RN MDS Coordinator confirmed that the MDS failed to capture all of the resident’s documented pressure ulcers.
Failure to Timely Develop and Implement Care Plan for Preexisting Pressure Ulcers
Penalty
Summary
Facility staff failed to timely develop and implement a comprehensive, resident-centered care plan for a resident admitted with preexisting pressure ulcers. The resident was admitted in early January 2026 for rehabilitation following an acute hospitalization, with documented preexisting pressure ulcers on the left heel and sacrum. A Skin and Wound Note dated 1/9/26 by the wound NP identified three pressure ulcers: a Stage 1 pressure ulcer on the right heel, a Stage 3 pressure ulcer on the left heel, and an unstageable pressure ulcer on the coccyx. An admission MDS with an ARD of 1/14/26 documented that the resident was at risk for pressure ulcers and had an unhealed pressure ulcer. Despite these findings, review on 4/2/26 showed that no baseline care plan had been implemented within 48 hours of admission to address the resident’s preexisting pressure ulcers. Further review of the resident’s care plans revealed that specific care plans for the left heel wound, right heel wound, and coccyx wound were not initiated until 1/30/26, which was 16 days after completion of the admission assessment and admission. This delay meant that a timely comprehensive care plan addressing care and management of the resident’s preexisting pressure ulcers was not developed or implemented as required. The NHA and DON were informed of these concerns and acknowledged them without further comment.
Failure to Timely Implement and Document NP-Ordered Pressure Ulcer Treatments
Penalty
Summary
The deficiency involves the facility’s failure to provide pressure ulcer care consistent with professional standards, resulting in delayed and incomplete treatment orders, missing interventions, and inaccurate documentation for a resident admitted with multiple pre-existing pressure ulcers. The resident was admitted following an acute hospitalization with multiple diagnoses and existing pressure ulcers, including a right heel Stage 1 pressure ulcer, a left heel Stage 3 pressure ulcer, and an unstageable coccyx pressure ulcer. On the initial wound NP visit, specific treatment recommendations were documented for each wound, but there was no evidence that these treatment orders were entered into the medical record at that time. As a result, the recommended treatments were not promptly implemented. Subsequent NP visits documented that the resident continued to have multiple wounds and that the NP discussed with the wound nurse the need to continue treatments as ordered on the earlier visit. However, the medical record and January Treatment Administration Record (TAR) showed delays and omissions in entering and implementing these orders. The left heel treatment order consistent with NP recommendations was not entered until several days after the NP visit, and there were no coccyx pressure ulcer treatments documented for the period following admission until a later NP visit. When new treatment orders for the left heel were entered, the previous order was not discontinued, and the TAR showed that both the old and new treatments were documented as being performed on multiple days. The NP also recommended an alternating air/low air loss mattress for pressure redistribution on two separate wound visits, but the order for an air mattress was not entered until after the second recommendation, and there was no evidence that the specialized mattress had been implemented in the interim. The NP later documented that the right heel pressure ulcer had progressed from Stage 1 to a deep tissue injury and that the coccyx ulcer had worsened significantly in size. Additionally, the admission MDS failed to capture all of the resident’s existing pressure ulcers, omitting the Stage 1 right heel ulcer and the unstageable coccyx ulcer, and the resident’s care plan did not include a comprehensive plan with measurable goals to address the pressure ulcers present on admission. Staff interviews confirmed that the wound NP made recommendations, that the wound nurse was responsible for entering treatment orders, and that there were delays and omissions in entering those orders and in developing an appropriate care plan. Interviews with nursing leadership and supervisory staff further clarified the process and the gaps. The evening supervisor RN reported following the NP on wound rounds and transcribing NP orders into the medical record and recalled that the resident had multiple wounds, including sacral and heel pressure ulcers. The RN initially stated being unaware of concerns with the resident’s treatment orders and later attributed delays in wound treatment to the resident’s frequent refusal of care, but was informed by the surveyor that the primary concern was the failure to enter NP-recommended treatment orders into the record in a timely manner. The RN also acknowledged not knowing why the treatment orders were not entered and was made aware of the lack of a pressure ulcer care plan and the delay in implementing the recommended pressure-redistribution mattress. The Nursing Home Administrator and DON acknowledged these concerns when they were discussed with them. Overall, the facility did not ensure timely transcription and implementation of NP wound treatment recommendations, did not provide consistent and accurate wound treatment orders, failed to implement recommended pressure redistribution equipment promptly, and did not accurately document all existing pressure ulcers on the MDS or in a comprehensive care plan. These actions and inactions led to a failure to provide pressure ulcer care and prevention consistent with professional standards of practice for this resident.
Failure to Timely Report Alleged Abuse to State Agency
Penalty
Summary
The facility failed to timely report an allegation of abuse to the state survey agency as required by its own policy and federal regulations. According to facility policy, all alleged violations involving abuse or resulting in serious bodily injury must be reported immediately, but not later than two hours after the allegation is made. In this case, a resident with a history of stroke and intact cognition, as indicated by a BIMS score of 15, reported that a geriatric nursing assistant (GNA) was rough and rushed during incontinence care. The resident called 911 to report the incident, prompting police officers to visit the facility. The incident occurred during the overnight shift, and staff became aware of the allegation in the morning when police arrived and the resident was interviewed by the DON and Unit Manager. Despite the facility's policy and staff acknowledgment that abuse allegations should be reported within two hours, the incident was not reported to the state survey agency until several hours after staff became aware of it. The Administrator, who serves as the facility's abuse coordinator, confirmed that the report to the state agency was not made until the afternoon, well beyond the required two-hour timeframe. Documentation and interviews confirm that the delay in reporting constituted a failure to follow established procedures for timely reporting of abuse allegations.
Failure to Perform Hand Hygiene Between Glove Changes During Wound Care
Penalty
Summary
The facility failed to adhere to its infection prevention and control policy during wound care for a resident with a history of peripheral vascular disease and an unstageable pressure ulcer. During an observed dressing change, the registered nurse did not perform hand hygiene between glove changes at multiple points in the procedure, despite the facility's policy requiring hand washing after glove removal and before donning new gloves. The nurse removed gloves and immediately put on new gloves several times without washing hands, including after removing soiled dressings and before handling clean supplies and applying new dressings. The resident involved had moderate cognitive impairment and a large, deep unstageable wound on the sacrum. The nurse's actions were observed and later confirmed in interviews, where both the nurse and the Director of Nursing acknowledged that hand hygiene should have been performed between glove changes. The facility's policy, which was reviewed, clearly outlined the steps for hand hygiene during wound care, but these were not followed during the observed incident.
Failure to Maintain Safe, Clean, and Homelike Environment; Lack of Hot Water for Residents
Penalty
Summary
Surveyors identified multiple deficiencies related to the facility's failure to maintain a safe, clean, and homelike environment for residents. Observations revealed that in several resident rooms, toilet paper rolls were hung using trash bags tied to handrails or towel holders due to missing or broken toilet paper holders. Additional issues included nightstand drawers that did not fit properly or lacked knobs, missing door knobs on bathroom doors, and exposed holes. Several rooms had warped or cracked linoleum, missing or scratched paint, missing guest chairs, and exposed water shutoff valves. These maintenance concerns were observed over multiple days and confirmed by staff interviews, with staff reporting that maintenance issues were to be reported via an online platform, but the Director of Maintenance was unaware of the problems until the survey walkthrough. Further deficiencies were noted in the cleanliness and organization of common areas, including the resident shower room, clean utility room, and soiled utility room. The shower room contained a basin on a trash can, wheelchair pedals, a mop and broom, trash on the floor, a brown substance on the toilet seat, and various personal items and towels scattered in the tub and on the floor. The clean utility room had a used glove on a bin, incomplete paint, missing floor tiles, and staff personal items stored inappropriately. The soiled utility room had a sink full of dirty water, soiled shelves, and miscellaneous items. The Housekeeping Director acknowledged the challenges in monitoring and maintaining cleanliness in these areas. Additionally, residents reported being without hot water for three days, confirmed by surveyors who found water temperatures in several rooms to be significantly below acceptable levels. Residents stated they had to bathe with cold water, and staff confirmed the administration was aware of the issue. Temperature logs showed a drop in water temperature, and the facility was in the process of addressing the problem. During this period, residents were transferred to other units for showers, and water was warmed for bed baths as needed.
Failure to Review and Revise Care Plans After Assessments
Penalty
Summary
Facility staff failed to ensure that resident care plans were reviewed and revised by the interdisciplinary team after each assessment, including both comprehensive and quarterly review assessments. For one resident, there was no documentation verifying participation in care plan meetings, and the Director of Social Work was unable to provide proof that required meetings were conducted or that invitations were consistently sent. Another resident reported concerns about not having quarterly care plan meetings, and documentation could only be provided for a single meeting within the required timeframe. Additionally, quarterly screenings for rehabilitation services were not consistently performed as expected. For a third resident, after discharge from physical and occupational therapy for contracture management, the recommended nursing interventions were not entered into the electronic medical record, and the care plan was not updated to reflect these recommendations. The Director of Rehabilitation and the occupational therapist were unable to confirm when the last quarterly evaluation was conducted, and orders for nursing to follow the discharge recommendations were never placed. These findings demonstrate a pattern of incomplete care plan reviews, lack of interdisciplinary team involvement, and insufficient documentation following assessments and therapy discharges.
Failure to Follow Physician Orders and Maintain Professional Documentation Standards
Penalty
Summary
The facility failed to implement and document physician-ordered wound and skin care for a resident admitted after a surgical amputation and with an identified pressure ulcer. The resident was admitted with 22 staples to the amputated toe site and a heel wound, but no wound care orders were entered for either site during the resident's month-long stay. Although the wound care nurse documented weekly measurements and care for the heel, there was no formal order or documentation system in place for staff to consistently sign off on completed treatments. The Director of Nursing was unaware of these omissions until notified by surveyors. Another resident with a history of cerebrovascular disease had a physician's order for daily application and removal of Thrombo-Embolic Deterrent Stockings (TEDS), but was repeatedly observed not wearing them. There was no documentation of refusal or physician notification regarding the lack of TEDS application, and staff could not provide supporting documentation for these omissions. Additionally, a resident with an order for clonidine to be administered via PEG tube with specific blood pressure and heart rate parameters received the medication multiple times when their systolic blood pressure was below the ordered threshold, without documentation that the physician was notified of these out-of-range readings. The facility also failed to maintain professional standards in documenting showers for a resident with an order for showers on specific days. On several occasions, the treatment administration record indicated that the shower was not given, but no reason was documented for the omission. There were also days when the shower order was not documented at all. The Director of Nursing confirmed that staff were expected to document the reason for missed showers and to document all care provided according to orders.
Failure to Maintain Resident Dignity During Care Activities
Penalty
Summary
The facility failed to ensure that residents were treated with dignity during daily care activities. In one instance, a CNA was observed feeding a resident while standing over them at the bedside, rather than sitting at the resident's level. The CNA stated that the chair available was too wide to fit in the area and was unaware that standing while feeding was a dignity issue. Despite being informed of the concern, the CNA continued to stand while feeding the resident. In another case, a resident with a history of muscle spasm, congestive heart failure, fluid overload, and a left leg below-the-knee amputation reported being left on a bedside commode for two hours during the night before receiving assistance back to bed. The resident expressed feeling disrespected and described the treatment as inhuman. The incident was not previously known to the facility's administration or DON until brought up during the survey.
Delay in Providing Medical Records to Resident's Legal Representative
Penalty
Summary
The facility failed to provide timely access to a resident's medical records to the resident's established legal representative, as required. A request for medical records was made by the resident's Power of Attorney (POA), with all necessary authorization paperwork already on file and accepted by the facility. Despite this, the process for releasing records involved additional review by the legal department, which was not explained as necessary given the existing POA documentation. The business office manager could not provide a clear turnaround time for record requests and acknowledged that the process could cause delays. Documentation showed that the request for records was made on 6/11/24, but the records were not provided to the POA until sometime in July 2024, resulting in a delay of at least 19 days and possibly up to 40 days. The facility's own policy stated that records should be available within 2 days after receipt of payment, but in this case, there was no financial liability attached to the request. Both staff and the complainant confirmed the significant delay, and no further documentation was provided to clarify the exact date the records were delivered.
Failure to Ensure Resident Safety and Thorough Abuse Investigations
Penalty
Summary
The facility failed to ensure resident safety and proper investigation procedures in response to allegations of staff abuse involving two residents. In the first instance, a nurse was directed to leave the facility immediately following an abuse allegation made by a resident. However, the nurse remained in the building for nearly two hours after being instructed to leave, citing the need to complete a narcotic count and hand over keys. The nurse was not escorted out, and the facility's administration acknowledged that the staff member should have been escorted to ensure resident safety. The abuse allegation was ultimately unsubstantiated, but the staff member was later terminated for insubordination. In the second instance, the facility did not conduct a thorough investigation after a resident reported to their representative that a Geriatric Nursing Assistant was rough during repositioning and turned the resident onto a side they did not want to be on. Facility documentation did not show that the specific allegation was addressed, nor did it indicate that the staff member involved was interviewed or provided a statement regarding the incident. When asked for further documentation, the facility administrator was unable to provide any additional evidence that the allegation was investigated as required.
Inaccurate MDS Coding for Resident Fall Event
Penalty
Summary
The facility failed to ensure the accuracy of the Minimum Data Set (MDS) assessment for one resident reviewed for accidents. Specifically, the MDS Quarterly Assessment coded the resident as having experienced a fall with injury, despite documentation in nurse notes and pain assessments indicating that the resident had no pain and no physical injury following the fall. The facility's matrix also incorrectly indicated a fall with injury for this resident. Further review of the care plan and progress notes confirmed that the resident did not report pain and had no injury on multiple assessments following the incident. An x-ray ordered after the resident reported arm pain was negative for fracture. Interviews with the Nursing Home Administrator and the MDS Coordinator confirmed that the MDS was coded incorrectly, as the resident did not have a fall with injury. The MDS Coordinator acknowledged that the assessment was inaccurate, as pain and injury were not present according to the documentation. The deficiency was discussed with the administration team during the exit conference.
Failure to Develop Care Plan for Bowel and Bladder Incontinence
Penalty
Summary
A review of medical records for a resident revealed that the individual was incontinent of both bowel and bladder. Despite this, there was no evidence that a care plan had been developed to address the resident's bowel and bladder incontinence. The Minimum Data Set (MDS) confirmed that the resident was always incontinent of both bowel and bladder, and this condition had been present since admission. Interviews with facility staff indicated that the interdisciplinary team is responsible for reviewing each resident's plan of care quarterly and annually, with the nurse unit manager specifically tasked with ensuring the nursing portion is current. However, upon review, both the surveyor and the nurse unit manager acknowledged that a care plan for incontinence was missing for this resident, confirming the deficiency.
Failure to Implement Contracture Management Orders for Resident with Limited ROM
Penalty
Summary
A deficiency was identified when a resident with a history of morbid obesity, protein-calorie malnutrition, and a PEG tube, who was bed-bound and had limited range of motion (ROM) in all extremities, did not receive appropriate ongoing contracture management. The resident had previously received Physical Therapy (PT) and Occupational Therapy (OT) services for contracture management, with OT goals to prevent further contractures. Upon discharge from therapy, recommendations were made for nursing staff to apply splints daily and remove them at night. However, there was no evidence that these recommendations were entered as orders in the electronic medical record (EMR), nor were they reflected in the resident's care plan. During the survey, staff interviews revealed that neither the Director of Rehab nor the Occupational Therapist could confirm when the last quarterly evaluation was completed for the resident, and they were initially unable to clarify who was responsible for entering therapy discharge orders into the EMR. It was later confirmed that the orders for nursing to implement the OT discharge recommendations were never placed, resulting in a lack of follow-through on the prescribed contracture management interventions for the resident.
Delayed Infectious Disease Consultation and Documentation Failure for Resident with Worsening Wound
Penalty
Summary
The facility failed to ensure the timely scheduling of an Infectious Disease (ID) consultation for a resident admitted with multiple comorbidities, including an infection following a fasciotomy and a urinary tract infection. Upon admission, the resident had a wound vac at the surgical site, and over the first two months, the sacral wound worsened, with increasing size and persistent infection despite ongoing IV antibiotics. Elevated C-reactive protein (CRP) levels were documented, indicating severe inflammation, and the need for an ID consult was repeatedly noted in both physician and nursing progress notes. The resident's responsible party was kept informed of the need for the consult, and the wound continued to be monitored and cultured as infection persisted. Despite multiple documented requests and orders for an ID consultation starting on 8/19, the consult was not completed until 28 days later. There was no documentation of the actual ID consultation report in the resident's electronic health record, and the Director of Nursing (DON) was unable to provide this documentation when requested. The delay in obtaining the required specialist consultation and the lack of documentation occurred prior to the resident's hospital transfer and subsequent admission with a diagnosis of sepsis.
Incomplete and Inaccurate Medical Record Documentation
Penalty
Summary
The facility failed to ensure that medical records were complete and accurately documented for two residents. For one resident, there was a discrepancy between the active physician order for showers, which specified Tuesdays and Fridays, and the kardex task, which indicated Mondays and Thursdays. The Director of Nursing confirmed that the kardex should reflect the physician's order, but this was not the case. For another resident who was bed-bound with limited range of motion and had received PT and OT services for contracture management, the discharge recommendations from OT included daily application and nightly removal of splints by nursing staff. However, there were no orders placed in the medical record for nursing to carry out these recommendations, nor were the recommendations reflected in the care plan. Interviews with the Director of Rehab and OT staff revealed that the orders were never entered into the EMR, and there was confusion regarding responsibility for entering such orders.
Failure to Maintain Safe and Functional Kitchen Equipment
Penalty
Summary
Surveyors identified that essential kitchen equipment was not maintained in safe working order. During multiple observations, refrigerator #3 in the back room was found to be operating at 51°F, with food items inside that were warm to the touch, indicating improper cold storage. Refrigerator #4 was unplugged and being used to store dry goods, despite being labeled as a refrigerator. The facility dietary manager was unaware of the malfunctioning refrigerator, and temperature logs did not reflect the actual temperature observed. Additionally, the kitchen's ice machine was not operational, and staff relied on other units to provide ice to residents. Work orders for repairs were pending at the time of the survey. Further investigation revealed that the main dining room ice machine was also not functioning. An anonymous complaint indicated that staff often told residents the ice machine was broken when they requested ice water. The Director of Maintenance was unaware of the issue with the main dining room ice machine, and direct observation confirmed it was not dispensing ice. These findings demonstrate a failure to ensure that essential kitchen equipment was kept in safe and functional condition, as required.
Improper Mattress Fit on Bed Frame
Penalty
Summary
During a random observation on the Annapolis Unit, a resident was found in bed with a mattress that extended approximately 8 inches beyond the right side of the bed frame. This observation was confirmed by both the surveyor and the Director of Maintenance, who noted that the mattress was too large for the bed frame. The report documents that the facility failed to ensure the mattress properly fit the bed frame, as required for resident safety. No additional information about the resident's medical history or condition at the time of the deficiency was provided in the report.
Failure to Ensure Resident Access to Call Light
Penalty
Summary
Facility staff failed to ensure that a resident had access to their call light, as observed during a survey. On 04/16/25, a surveyor found the resident resting in bed without the call light within reach; the device was discovered wrapped around the arm of a chair near the bed, out of the resident's reach. When questioned, an LPN confirmed that staff are expected to keep the call device accessible to residents before leaving the room. Review of the resident's medical records showed explicit instructions to keep the call light within reach at all times. The deficiency was reported to the facility administrator.
Failure to Send Comprehensive Care Plan Goals During Resident Transfer
Penalty
Summary
The facility failed to include the resident's comprehensive care plan goals in the required documentation during a transfer to the hospital. Record review showed that one resident was hospitalized, and interviews with both a Registered Nurse/Unit Supervisor and a Licensed Practical Nurse confirmed that the care plan goals were not sent with the resident upon transfer. The surveyor discussed this concern with the Director of Nursing.
Failure to Provide Written Notification of Resident Transfer
Penalty
Summary
Facility staff failed to provide written notification of transfer to a resident and their responsible representative when the resident was hospitalized. Record review showed that the resident was transferred to the hospital, and interviews with both a Registered Nurse/Unit Supervisor and a Licensed Practical Nurse confirmed that only verbal notification was given to the resident's representative regarding the transfer and its reasoning. There was no evidence that written notification was provided as required.
Failure to Provide Scheduled Showers and Proper Documentation for Dependent Resident
Penalty
Summary
Facility staff failed to provide scheduled showers to a resident who was dependent on staff for activities of daily living (ADLs), specifically bathing. The resident reported receiving only one shower during the month of April, despite a documented preference and physician order for showers twice weekly. Instead, the resident received daily bed baths, with no documentation explaining the substitution of bed baths for showers or any record of resident refusal. Review of the treatment administration record and geriatric nursing assistant documentation confirmed the lack of scheduled showers and absence of required documentation for missed or substituted care.
Failure to Provide Incontinence Care and Services
Penalty
Summary
Facility staff failed to provide appropriate treatment and services for a resident who was incontinent of bowel and bladder and had a stage 4 sacral pressure ulcer. Review of the resident's medical records, including treatment administration records, physician orders, and the care plan, revealed no documentation of interventions or services to address the resident's incontinence. Interviews with the Director of Social Work and the Nurse Unit Manager confirmed that there was no plan in place to manage the resident's incontinence, and both acknowledged that such a plan should have existed. The deficiency was identified during a review of the resident's chart and confirmed through staff interviews.
Failure to Ensure Timely Monitoring for Antidepressant Medication
Penalty
Summary
A review of the medical record for Resident #16 revealed an active order for Bupropion, an antidepressant, to be administered once daily starting on 3/24/2025. Despite the known need for monitoring due to potential side effects associated with antidepressant use, there was no order for antidepressant monitoring documented in the resident's medical record until 4/16/2025. An interview with the Director of Nursing confirmed that the facility's expectation is for side effect monitoring to be ordered when an antipsychotic is prescribed. This lapse resulted in a period during which the resident was receiving Bupropion without the required monitoring for side effects.
Failure to Serve Preferred Hot Beverage at Breakfast
Penalty
Summary
Surveyors determined that the facility failed to provide residents with their preferred hot beverage, specifically coffee, during breakfast as indicated on their dietary meal tickets. On the morning of the observation, the dietary food carts were delivered to the unit, but the cart containing coffee, tea, and condiments arrived later than the food trays. As a result, three residents who had coffee listed on their meal tickets did not receive coffee with their breakfast meal. The unit was staffed with only two GNAs for 32 residents, and additional staff from other departments were brought in to assist with meal delivery. The deficiency was observed during a breakfast meal service in the Arcadia unit, where seven residents required maximum assistance with feeding. Despite the presence of the unit manager, charge nurse, and medication nurse, the delay in the arrival of the beverage cart led to the omission of serving coffee to the affected residents. These findings were reviewed with the DON and the administrator later that morning.
Failure to Serve Food at Safe and Palatable Temperatures
Penalty
Summary
Surveyors observed that the facility failed to ensure food was delivered to residents at appropriate and palatable temperatures. During a kitchen tour and tray line observation, surveyors, along with the food service manager, regional food service director, and registered dietician, measured the temperatures of various food items prepared for the Garden View unit. While food items in the kitchen were within acceptable temperature ranges, delays occurred between tray preparation and service. The food cart was followed to the unit, and there was a gap between the arrival of the food and the start of tray service. When the test tray was finally served, the temperatures of hot food items had dropped significantly below the required levels, and cold beverages were above the recommended cold temperature. The regional dietary manager acknowledged that the facility did not ensure proper food temperatures at the point of service. The deficiency was identified for one out of four units, affecting a unit with 32 residents. The administrator confirmed awareness of the issue, and the findings were discussed during the exit interview. No specific resident medical history or conditions were mentioned in relation to the deficiency.
Deficient Food Storage, Equipment Maintenance, and Meal Tray Accuracy
Penalty
Summary
The facility failed to properly store food items at appropriate temperatures, maintain functional kitchen equipment, and ensure dry food items were stored in suitable containers. During a kitchen tour, a walk-in refrigerator was found at 42°F, while another refrigerator used for juice and milk was within acceptable range. However, a third refrigerator labeled 'Back Room' was found at 51°F, with its contents, including applesauce, grape jelly, soy sauce, mayonnaise, and iced tea, warm to the touch and not in compliance with food safety storage procedures. A fourth refrigerator was unplugged and used to store dry goods, such as pasta and bread, at 65°F, indicating it was not operational. Additionally, the kitchen's ice machine was not working, and the facility was relying on other units to provide ice for residents' meals. The dietary manager was unaware of the non-functional refrigerator, and temperature logs did not match actual readings. The facility also failed to ensure that residents' meal trays matched the items listed on their meal tickets. During meal service, two residents did not receive the correct items as specified: one resident was missing coffee, sugar packets, milk, and condiments, while another received skim milk instead of whole milk and was missing coffee. A geriatric nursing assistant acknowledged the discrepancies after being shown the trays and stated that it was their responsibility to verify tray accuracy. Both the administrator and director of nursing were made aware of these observations.
Inaccurate Facility Assessment for Direct Care Staffing Ratios
Penalty
Summary
The facility failed to provide an accurate and comprehensive facility-wide assessment regarding direct care staff to resident ratios. During the survey, the administrator provided a copy of the facility assessment, which was found to have been completed and reviewed by the quality assurance committee. Upon review, the assessment included a staffing template for both licensed nurses and direct care staff, separated by skilled rehab and long-term care units. When questioned, the administrator was unable to explain the staffing plan as described in the assessment and later admitted that the staffing plan documented was incorrect. The administrator then provided a hand-written staffing to resident ratio for all units, but this information did not match the ratios documented in the facility's assessment. This discrepancy between the documented staffing plan and the actual staffing ratios, as well as the administrator's inability to explain or reconcile the information, led to the determination that the facility failed to provide an accurate facility assessment for direct care staff to resident ratios.
Failure to Maintain Isolation Carts with Required PPE for EBP Residents
Penalty
Summary
Facility staff failed to maintain isolation carts with the required personal protective equipment (PPE) for residents on enhanced barrier precautions (EBP) across two of five units observed. During initial observations, EBP signs were posted on several room doors, but some rooms lacked an isolation cart entirely, while others had carts missing essential PPE such as gloves. In one instance, a resident's medication was found stored inside an isolation cart, which is not appropriate for PPE storage. These deficiencies were confirmed by an LPN during interviews, who acknowledged the missing PPE and the presence of medication in the cart. Follow-up observations revealed that isolation gowns were also missing from the carts outside certain rooms, and this issue persisted over multiple checks on the same day. The LPN again confirmed the absence of gowns when asked to review the cart. Both the administrator and the director of nursing were made aware of these observations at the time they occurred.
Incomplete Daily Nurse Staffing Postings
Penalty
Summary
Facility staff failed to ensure that daily nurse staffing postings were complete and accurate across all five units, as observed and confirmed during a survey. The surveyor found that several daily staffing sheets were missing critical information, including dates, nurse-to-resident ratios, staff titles, current dates, shift supervisor names, actual hours worked, and unit census. The staff scheduler, responsible for collecting and storing these forms, stated she was unaware that this information was required and relied on unit managers to complete the postings. These omissions were identified through record reviews and staff interviews, demonstrating a lack of compliance with daily staffing posting requirements.
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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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