Autumn Lake Healthcare At Overlea
Inspection history, citations, penalties and survey trends for this long-term care facility in Baltimore, Maryland.
- Location
- 6116 Belair Road, Baltimore, Maryland 21206
- CMS Provider Number
- 215209
- Inspections on file
- 21
- Latest survey
- April 13, 2026
- Citations (last 12 mo.)
- 5
Citation history
Health deficiencies cited at Autumn Lake Healthcare At Overlea during CMS and state inspections, most recent first.
A resident with multiple comorbidities and an existing pressure area was admitted with a Braden score indicating mild risk, but facility staff documented the sacral moisture-associated skin damage without measurements or detailed wound characteristics and care planned the area to be left open to air. Subsequent Braden assessments continued to rate the resident as low risk, and care plans did not include specific q2h turning/repositioning, while CNA documentation showed numerous shifts where the resident was not turned. Later, two new pressure wounds on the coccyx and sacrum were documented without measurements or physician notification, and a wound consultant subsequently identified an unstageable full-thickness sacral pressure injury and a Stage 3 buttock wound, both present for more than five days, with no prior documentation of skin changes by the medical providers, indicating a failure to implement and communicate appropriate pressure ulcer prevention and management.
Facility staff did not ensure that handrails on the third floor were properly repaired and safe for use, as multiple handrails were found with protruding screws and nails, gaps, holes, and loose attachments. These issues were observed in several locations, including near the elevator, outside resident rooms, and between storage areas, with some handrails shaking when touched. The Administrator acknowledged the problem after it was reported by a surveyor.
Two residents with suprapubic catheters did not receive care according to specialist recommendations, including routine flushing and timely catheter changes. Documentation was lacking for both catheter flushes and exchanges over several months, and staff interviews confirmed these lapses. Communication issues with consulting providers and inaccurate information given to a resident's representative further contributed to the deficiency.
Surveyors identified that two residents with suprapubic catheters did not have complete or consistent documentation of catheter changes in their medical records, despite orders and urology consult recommendations for routine exchanges. The DON confirmed that documentation was missing for several months, and staff interviews revealed inconsistent communication and documentation practices between the facility and consulting providers.
Staff did not ensure that two shower rooms on the third floor were properly cleaned, as evidenced by persistent stains and soiling observed over two days. The rooms are used daily by residents, and cleaning was not performed as required, with staff acknowledging challenges in cleaning due to inadequate equipment.
Facility staff did not allow residents whose funds were managed by the facility to access their money outside of normal business hours, with no access available on weekends. This affected 94 residents with open accounts, as confirmed by the Business Office Manager.
Surveyors identified multiple deficiencies in food service sanitation, including failure to achieve proper dish sanitization temperatures, excessive buildup of food debris and grease on equipment, improper placement of trashcans near ice machines, unsanitary storage of beverage dispensers, and visibly soiled portable ice chest coolers and knife holders. Maintenance staff could not verify inspection or replacement of backflow prevention devices, and cleaning schedules for certain equipment were not provided.
Staff failed to label basins and urinals in shared bathrooms, leading to potential cross contamination, and did not maintain proper separation between clean and soiled linens in the laundry area due to damaged infrastructure and improper cleaning practices.
Surveyors observed that several residents did not have their call bells within reach, with some call bells found on the floor or on the opposite side of the room. A GNA confirmed the lack of accessible call bells, and the ADON stated that staff are expected to ensure call bells are always available, though they may sometimes fall and are checked during regular rounding.
Staff failed to conduct required annual performance reviews for several GNAs, as confirmed by personnel file review and staff interviews. Three employees who had been employed for over a year did not have documented yearly evaluations.
Surveyors found expired medication and multiple instances of loose, unidentified pills in medication carts and storage areas. Staff present were unable to account for the origin of the loose pills, and expired medication was confirmed during review. These findings indicate lapses in proper medication storage and labeling practices.
Surveyors observed multiple deficiencies in the facility's environment, including broken furniture, missing privacy curtains, non-functioning bathroom fixtures, and accumulation of trash under a resident's bed on repeated occasions. Staff confirmed these issues and described a maintenance reporting process involving binders and an electronic system, but the deficiencies persisted across several rooms and days.
A resident who was totally dependent for bathing did not receive scheduled showers over several weeks, as confirmed by documentation and family interviews. The resident only received bed baths and expressed discomfort and dissatisfaction, while the GNA task records showed no showers were provided during the period in question.
Two resident rooms were found to be dirty and in disrepair, with issues such as sticky floors, brown stains on bathroom walls, broken blinds, damaged ceiling tiles, and cracked flooring. Facility staff acknowledged these environmental concerns during surveyor interviews.
Staff did not create or implement care plans for dental care in two residents with poor dentition and failed to initiate an integumentary care plan for a resident receiving twice-daily skin treatments, as confirmed by record review and DON interview.
Staff failed to clarify a physician's order for a dermatologic cream, resulting in a resident with Atopic Dermatitis not receiving the prescribed treatment due to unclear instructions and the cream being unavailable. Another resident on psychotropic medication was not monitored for extrapyramidal side effects as recommended by pharmacy review, and a third resident did not receive all required iron-related lab monitoring despite provider acceptance of the pharmacist's recommendations. These deficiencies reflect failures in order clarification, treatment administration, and laboratory monitoring by nursing and pharmacy staff.
Staff did not follow up on a pharmacist's recommendation to specify the dosage for a prescribed supplement for a resident. The pharmacy review form was left unsigned, and the supplement order lacked a strength until a dose was added much later. An LPN also documented administering the supplement twice in one day, and the DON could not explain the lack of action on the recommendation.
The facility failed to document and investigate abuse allegations for four residents, with missing or incomplete investigations attributed to previous ownership. Incidents included verbal and physical abuse allegations, inappropriate touching, and incomplete documentation of alleged abuse by a GNA. The NHA was unable to locate necessary investigation files, highlighting issues with documentation during ownership transitions.
The facility failed to maintain complete and accurate medical records for several residents, including missing documentation from medical appointments, discharge details, and wound assessments. Additionally, care conferences were not documented following MDS assessments. The DON confirmed the absence of necessary documentation, indicating a failure to adhere to professional standards.
A resident was found on the floor with low oxygen saturation and required hospital transfer. Although the physician was notified and 911 was called, the resident's representative was not informed of the hospital transfer until several hours later. The facility administrator could not provide evidence of immediate notification.
The facility failed to timely report abuse allegations for two residents. In one case, a GNA allegedly abused a resident, but the report to OHCQ was delayed. In another case, a resident alleged physical abuse by a staff member, but local law enforcement was not contacted. The NHA confirmed the reporting delays and lack of evidence for police contact.
The facility failed to accurately code MDS assessments for two residents. One resident's MDS did not reflect their Hospice care status, while another resident's MDS inaccurately documented behavioral symptoms and medication use. The MDS coordinator confirmed these discrepancies during interviews.
A facility failed to revise a care plan for a resident with a history of banging their arm on the side rail, leading to skin tears. Despite placing padding on the side rail to prevent further injury, the intervention was not included in the care plan. The Director of Nursing confirmed the omission during an interview.
A facility failed to provide complete discharge documentation for a resident who was discharged to an assisted living facility. The medical record lacked a physician's discharge summary, medication instructions, and a summary for the receiving facility. Additionally, there was no nursing documentation regarding the resident's condition at discharge or the items and documentation provided to them and the receiving facility.
A resident with dementia, requiring assistance for bathing, did not receive the expected two showers per week over several months. Despite a care plan indicating the need for staff assistance, documentation showed inadequate showering frequency, with no recorded refusals by the resident. The DON confirmed the deficiency in meeting the showering schedule.
A resident with existing pressure ulcers developed new open areas on the sacrum and right buttocks, which were not assessed by the wound care physician for 24 days despite being documented by nursing staff. The delay in evaluation and treatment was confirmed by the DON, highlighting a deficiency in the care provided.
Two residents in the facility were administered Metoprolol outside of the physician-ordered parameters for blood pressure and heart rate. One resident received the medication twice when their heart rate and blood pressure were below the specified limits, while another resident was given the medication despite a low blood pressure reading. These actions were confirmed by the DON.
A resident with hydronephrosis did not receive a scheduled follow-up urology appointment due to insurance network issues, and no further attempts were made to reschedule. The resident's discharge plan included a urology follow-up and a voiding trial, neither of which were completed during their stay. The DON confirmed these findings.
Failure to Implement Pressure Ulcer Prevention and Timely Wound Management
Penalty
Summary
The deficiency involves the facility’s failure to implement appropriate pressure ulcer prevention and management for a resident who was admitted with multiple serious medical conditions and an existing pressure area. The resident was admitted from the hospital with septic shock, UTI, severe cognitive-communication deficits, diabetes, anorectal cancer with prior radiation and chemotherapy, an indwelling Foley catheter, and a gluteal cleft/coccyx pressure area being treated with Santyl. The hospital documented a Braden score of 15 (mild risk). On admission, the facility physician determined the resident could understand medical information and make decisions, and the BIMS score was 12/15, indicating moderate cognitive impairment. The facility’s pressure injury policy required a systematic approach including prompt assessment, treatment, and modification of interventions as appropriate. On admission, nursing notes documented the resident as cognitively impaired, requiring two-person assistance for transfers and toileting, and having an indwelling Foley catheter. That same night, nursing staff identified an open area on the sacral region attributed to moisture-associated skin damage (MASD), but there were no documented measurements, nor any description of odor, drainage, or wound depth. The baseline care plan intervention for this sacral MASD was to leave the area open to air, and subsequent Braden assessments on three dates in November classified the resident as low risk for pressure injury, despite the existing skin breakdown and functional limitations. The care plans and nursing interventions did not include specific preventative measures such as scheduled turning and repositioning every two hours. Later in November, weekly skin evaluations documented two new pressure wounds on the coccyx and sacrum, but again without measurements or documentation of odor, drainage, or depth, and without evidence that the physician was notified at the time of discovery. A Braden assessment on the same date showed a score of 10, indicating high risk for pressure wound development. The wound consultant’s assessment the following day identified an unstageable full-thickness sacral pressure wound measuring 6 cm by 3 cm with unknown depth and moderate serous drainage, and a Stage 3 full-thickness pressure wound on the left buttock, both described as being greater than five days in duration. Review of physician and nurse practitioner notes showed no documentation of skin changes during this period, and both the nurse practitioner and attending physician reported they had not been alerted to skin issues in November. CNA documentation showed that on multiple shifts over a 20–21 day period, staff recorded that the resident was not turned and repositioned, with numerous day, evening, and night shifts indicating “no” for turning and repositioning, demonstrating a lack of consistent implementation of pressure-relief interventions.
Handrails Not Properly Secured and Maintained on Third Floor
Penalty
Summary
Facility staff failed to ensure that handrails on the third floor were properly repaired and safe for resident use. Multiple handrails were observed with screws and nails that were not flush with the surface, creating a potential for injury to residents' hands. Specific observations included handrails with protruding screws, a gap near the elevator, a nail sticking out, a hole in the handrail, and several areas where the handrails were loose or not secured to the wall. The handrail between the Storage Room and EVS Room was noted to shake with minimal pressure, and the handrail near the Central Supply Room was also loose with an unflushed screw. These deficiencies were widespread on the third floor and were confirmed through both observation and staff interview. The Administrator acknowledged the issue when informed by the surveyor, stating that attempts were being made to secure the handrails with screws, but the surveyor pointed out that the screws were not flush and posed a risk of injury.
Failure to Provide Proper Suprapubic Catheter Care and Documentation
Penalty
Summary
The facility failed to provide proper care and treatment for residents with suprapubic catheters, as evidenced by the lack of adherence to physician and specialist recommendations for catheter flushing and routine catheter changes. For one resident with a history of benign prostatic hyperplasia and urinary retention, medical records showed that urology and pelvic medicine specialists repeatedly recommended flushing the suprapubic catheter twice daily and exchanging the catheter every 4-6 weeks. However, documentation revealed significant lapses, including no record of catheter changes for several months and a prolonged period without ordered or documented flushes following a hospitalization. The care plan also indicated a need for monthly catheter changes, but there was no evidence these were performed as required. Interviews with the DON confirmed that there was no documentation of catheter flushes or changes during the specified periods, and that communication issues with multiple consulting providers contributed to the lack of consistent care. The DON acknowledged that catheter changes were expected to be performed by facility staff unless otherwise specified by the consulting provider, but could not provide records to support that these tasks were completed. The consulting provider also clarified that unless specifically documented, catheter changes were not performed by their team and were the responsibility of the facility per the resident's care plan. A second resident with a history of obstructive and reflux uropathy and overactive bladder also did not receive routine suprapubic catheter changes as ordered. The resident's medical record showed an order for catheter changes every four weeks, but this was discontinued and changed to 'as needed,' with no documentation of changes for several months. Urology consultation notes continued to recommend routine exchanges every 4-6 weeks, but there was no evidence these were carried out. Staff communication with the resident's representative incorrectly indicated that monthly changes were being performed by urology staff, despite a lack of supporting documentation.
Failure to Maintain Complete Medical Records for Suprapubic Catheter Care
Penalty
Summary
The facility failed to maintain complete and accurate medical records in accordance with accepted professional standards for two residents with suprapubic catheters (SPC). For one resident with a history of benign prostatic hyperplasia and urinary retention, the facility was unable to provide medical health information to the hospital emergency room staff upon transfer. Review of the resident's records showed inconsistent documentation of SPC changes, with the last recorded change in December, and no documentation of changes from January through May, despite care plan and urology consult recommendations for routine exchanges every 4-6 weeks. The Director of Nursing (DON) confirmed that there was no documentation available to support that the SPC was changed during this period and indicated that different urology providers had varying communication methods, which contributed to the lack of documentation. For another resident with obstructive and reflux uropathy and an overactive bladder, the facility's records also lacked documentation of SPC changes as ordered. The resident had an order for SPC changes every four weeks, which was later changed to 'as needed.' However, there was no documentation in the Treatment Administration Records (TARs) of any SPC changes from January through July, despite ongoing urology consult notes recommending routine exchanges every 4-6 weeks. The DON was unable to provide documentation to confirm that the SPC was changed as recommended during this time frame. Interviews with facility staff and urology consultants revealed that while providers may have performed SPC changes during consultation visits, these were not consistently documented in the residents' medical records. The lack of documentation meant that the facility could not demonstrate compliance with physician orders or care plan interventions regarding SPC management for the affected residents.
Failure to Maintain Cleanliness in Shower Rooms
Penalty
Summary
Facility staff failed to ensure that the third-floor shower rooms were cleaned for resident use, as evidenced by observations and interviews during a complaint survey. On two consecutive days, surveyors observed large stains under the sink, water and stains around the commode in one shower room, and multiple round brown stains on the floor in front of the sink and in the shower stall of another shower room. The stains remained present on the second day, and a surveyor was able to remove one of the brown spots with a wet paper towel, indicating the area had not been properly cleaned. Geriatric Nursing Assistant (GNA) stated that the shower rooms are used daily by residents, and the Environmental Services (EVS) Director confirmed that showers should be cleaned daily, with deep cleaning on weekends, but noted difficulties in cleaning due to the condition of mop heads.
Residents Denied Access to Managed Funds Outside Business Hours
Penalty
Summary
Facility staff failed to ensure that residents whose funds were managed by the facility had access to their money at any time. During an interview, the Business Office Manager stated that residents could only access their funds during normal business hours, which are 8:30 AM to 5:00 PM, Monday through Friday, and that no one could access funds on weekends. Prior to the COVID-19 pandemic, the Receptionist would provide residents with money, including on weekends if present, but this practice had ceased. At the time of the survey, there were 94 open resident accounts with balances being managed by the facility, and none of these residents could access their funds outside of business hours.
Multiple Food Service Sanitation and Equipment Deficiencies Identified
Penalty
Summary
Facility staff failed to ensure that the high temperature dishwasher reached the required final rinse temperature of 180°F for proper sanitization, as observed during multiple cycles where temperatures only reached 162°F and 163°F. The dishwasher was also found to have excessive food debris and grease buildup both inside and outside the unit. Additionally, clean dish warming carts were observed to be visibly soiled, and the 3-compartment sink's sanitizing solution was found to be too strong, exceeding 400 ppm. The grease trap interceptor was unable to handle the flowrate of greywater discharge, resulting in overflow onto the kitchen floor. A trashcan was placed less than five inches from the ice machine and in front of a cracked wall-mounted ice scoop holder, and a beverage dispenser was stored in unsanitary conditions near a food prep area. The maintenance director was unable to verify that backflow prevention devices on various waterlines had been replaced or inspected by a licensed plumber. Surveyors also observed a visibly soiled, broken non-commercial portable ice chest cooler used for resident ice storage, placed on an unclean rolling cart, and noted that cleaning schedules for this equipment were not provided. Excessive buildup of dirt, dust, debris, and food spills was found on a wall-mounted knife holder. These findings were evident for all food service and kitchen equipment observed during the survey, indicating a failure to store, prepare, distribute, and serve food in accordance with professional standards for food service safety procedures.
Failure to Prevent Cross Contamination in Shared Bathrooms and Laundry Areas
Penalty
Summary
Facility staff failed to properly label residents' basins and urinals in shared bathrooms on the second floor, resulting in the potential for cross contamination of bodily fluids. During observation rounds, multiple unlabeled basins and a urinal were found in shared bathrooms between resident rooms. When questioned, a Geriatric Nursing Assistant stated that staff typically write room numbers on basins to identify ownership, but this was not done at the time of observation. The Assistant Director of Nursing/Infection Preventionist acknowledged the issue and indicated that it had been previously addressed with staff. Additionally, the facility did not ensure that clean linens were kept separate from contaminated linens in the laundry area. The dividing wall between the dirty and clean laundry rooms was damaged, with exposed wall frames and a gap caused by water damage. Grey water was observed splashing onto the drywall, saturating it and extending moisture to the ceiling. The washing machine drain line was improperly supported, and the washing machines themselves had significant residue buildup on both interior and exterior surfaces. Staff acknowledged the accumulation and the need for cleaning.
Failure to Ensure Call Bells Accessible to Residents
Penalty
Summary
Facility staff failed to ensure that residents had their call bells within reach to notify staff when assistance was needed. During observation rounds, five residents were found without accessible call bells: some had their call bells on the floor, while others had them placed out of reach on the opposite side of the room. These findings were confirmed by a Geriatric Nursing Assistant present during the observations. The Assistant Director of Nursing acknowledged that all residents should have their call bells accessible at all times, but noted that call bells can occasionally fall and that staff are expected to check on residents and their call bells during regular two-hour rounding.
Failure to Complete Annual Performance Reviews for GNAs
Penalty
Summary
Facility staff failed to conduct yearly performance reviews for Geriatric Nursing Assistants (GNAs) as required. During a review of five nursing assistant personnel files, it was found that three employees who had been employed for over a year did not have annual performance evaluations documented in their files. Interviews with the Assistant Director of Nursing, who was responsible for staff development, and the Nursing Home Administrator confirmed that annual evaluations for GNAs were not being completed. These findings were based on direct review of personnel files and staff interviews, with no evidence provided that the required yearly performance reviews had been performed for the identified staff members.
Medication Storage and Labeling Deficiencies Identified
Penalty
Summary
Surveyors identified that the facility failed to comply with professional standards for medication storage and labeling. On the 2nd floor, a blister pack of Famotidine 20 mg tablets was found to be expired, and this was confirmed by the LPN present. Additionally, on the 3rd floor, 11 loose pills were discovered in a medication cart, with the RN unable to specify their origin, only stating that they might have fallen out of packets. On the ground floor, 4 loose pills were also found in a medication cart, and the LPN present could not determine their source. In both instances of loose pills, staff indicated that such findings would be reported to the unit manager. These observations were made during reviews of medication storage areas and carts, and the deficiencies were confirmed through staff interviews and direct observation. No information about the medical history or condition of any residents was provided in the report.
Failure to Maintain Clean, Comfortable, and Home-like Environment
Penalty
Summary
Facility staff failed to consistently maintain a clean, comfortable, and home-like environment for residents, as evidenced by multiple observations during a recertification survey. Specific deficiencies included a clothing armoire door hanging off in a resident room, accumulation of trash such as empty bottles, snack packs, and tissues under a resident's bed on multiple days, a broken toilet paper dispenser, and a non-functioning light bulb in a shared bathroom. Additional issues noted were the absence of privacy curtains in a resident room, a loose faucet that could not be turned off, a missing drawer in a resident's dresser, and stains on the wall behind a commode. These conditions were confirmed by a GNA during the surveyor's rounds. Interviews with facility staff revealed that maintenance concerns are reported via binders on each unit, with urgent issues communicated directly to the Maintenance Director. However, staff do not determine what constitutes an urgent issue and simply document all concerns in the binder. The Maintenance Director stated that room audits are conducted based on identified issues, with a goal of auditing one room daily and every resident's room quarterly. Maintenance issues are addressed by the maintenance assistant, and staff use both binders and an electronic system (TELS) to report problems. Despite these processes, the observed deficiencies indicate lapses in maintaining a safe and comfortable environment.
Failure to Provide Scheduled Showers to Dependent Resident
Penalty
Summary
Facility staff failed to provide adequate personal hygiene care to a dependent resident by not offering or providing scheduled showers. The resident, who is totally dependent for bathing and requires extensive assistance for all activities of daily living as documented in the Minimum Data Set (MDS), did not receive any showers between 3/25/2025 and 4/18/2025, despite being scheduled for showers every Tuesday and Friday. This was confirmed through review of the Geriatric Nursing Assistant (GNA) task documentation on the Task Administration Record (TAR), which showed no showers were documented during this period. Interviews with the resident's family revealed that the resident expressed dissatisfaction with only receiving bed baths and desired a shower. The resident's son reported that the resident's spouse, who is physically unable to assist with showers, provided a sponge bath instead, during which the water and washcloth became black with dirt. The resident also reported feeling itchy due to lack of proper washing. The Director of Nursing (DON) confirmed the absence of shower documentation for the resident during the specified timeframe.
Failure to Maintain Clean and Homelike Resident Rooms
Penalty
Summary
Surveyors observed that two out of eleven ground floor rooms reviewed were not maintained in a clean, comfortable, and homelike condition. Specifically, one room was found to have a dirty and sticky floor, brown stains smeared on the bathroom wall, broken window blinds, ceiling tiles coming apart, a toilet pipe not fixed in the wall with surrounding wall cracks, and a cracked and broken floor at the bathroom entry. These environmental deficiencies were confirmed during interviews and observations with the Administrator, Maintenance Director, and Account Manager of the Healthcare Services Group, who acknowledged the concerns raised by the surveyors. No information was provided regarding the medical history or condition of the residents occupying the affected rooms at the time of the deficiency.
Failure to Develop and Implement Care Plans for Dental and Integumentary Needs
Penalty
Summary
Facility staff failed to develop and implement individualized care plans addressing dental and integumentary needs for three out of five residents reviewed during the recertification survey. Specifically, two residents with poor dentition did not have care plans for dental care documented in their electronic medical records, and another resident receiving physician-ordered skin treatments twice daily did not have an integumentary care plan initiated. These omissions were confirmed through medical record reviews and an interview with the DON, who acknowledged that care plans should have been in place for each of the affected residents.
Failure to Clarify Orders, Provide Treatments, and Complete Monitoring
Penalty
Summary
Facility staff failed to clarify a physician's order for a dermatologic cream for a resident diagnosed with Atopic Dermatitis, resulting in unclear instructions regarding the application site. During observations, the prescribed cream was not available on the treatment or medication carts, and staff were unable to locate it. The resident's skin was observed to be extremely dry and scaly, with ashen arms and a dry face, indicating the treatment was not administered as ordered. The lack of clarity in the order and failure to reorder the cream contributed to the resident not receiving the prescribed therapeutic treatment. Additionally, staff did not monitor a resident prescribed psychotropic medication for extrapyramidal side effects (EPS), despite a pharmacy recommendation to do so. There was no documentation of EPS monitoring in the medication administration records for several months. In another case, a pharmacist recommended specific laboratory monitoring for a resident on iron supplementation, which was accepted by the provider. However, the required iron-related labs (ferritin, TIBC, TSAT) were not ordered, and only a CBC, CMP, and lipid panel were completed. These failures demonstrate lapses in following through on medication regimen review recommendations and ensuring appropriate monitoring and treatment according to physician orders.
Failure to Act on Pharmacy Recommendation for Supplement Dosage
Penalty
Summary
Facility staff failed to act upon a pharmacist's recommendation to specify the dosage for a prescribed supplement, Cyanocobalamin, for one resident. The pharmacist's recommendation, dated 02/19/25, was not addressed by nursing staff, and the pharmacy review form remained unsigned. The process described by the DON involved receiving recommendations via email, printing and forwarding them to physicians, and then checking for new orders before filing the signed form, but this process was not followed in this instance. The supplement order lacked a specified strength, and a dose was not added until over two months later. Additionally, an LPN signed off that the supplement was administered twice on the same day, and the DON was unable to explain why the recommendation was not addressed.
Failure to Document and Investigate Abuse Allegations
Penalty
Summary
The facility failed to provide documentation that allegations of abuse were thoroughly investigated for four residents during a complaint survey. In the case of one resident, an allegation of verbal and physical abuse was reported by a hospital social worker, but the facility's documentation only included an initial and 5-day email confirmation without the actual investigation. The Nursing Home Administrator (NHA) could not locate the investigative file, attributing the issue to previous ownership. Another incident involved a resident alleging inappropriate touching by another resident, which led to a physical altercation. The NHA was unable to find the investigation report, again citing previous ownership as a reason. In another case, a resident alleged abuse by a geriatric nursing assistant, but the investigation was incomplete, lacking comprehensive interviews and documentation. The NHA confirmed the investigation's incompleteness and noted that he was not employed at the facility during that time. Additionally, the facility could not locate the investigation for another resident's abuse allegation, with the NHA indicating that it occurred under prior ownership. Despite reaching out to the previous administration, the investigation could not be found. These deficiencies highlight a lack of thorough documentation and investigation of abuse allegations, particularly during transitions of facility ownership.
Deficiencies in Medical Record Documentation
Penalty
Summary
The facility failed to maintain complete and accurate medical records for several residents, as evidenced by the findings during a complaint survey. For one resident, there was no documentation from a neurology appointment, despite notes indicating the resident left and returned to the facility on the day of the appointment. The Director of Nursing confirmed the absence of this documentation. Another resident's medical record lacked nursing documentation of their discharge to an assisted living facility, including details about the resident's condition, how they left, and what documentation was provided. The Nursing Home Administrator later provided a discharge summary but confirmed the absence of nursing notes regarding the discharge. A third resident had a physician's order for a CT scan of the chest, but the medical record did not contain the results or documentation explaining why the scan was not performed as scheduled. The Director of Nursing and medical records staff could not find documentation to explain the delay, although a later CT scan was documented. Additionally, a fourth resident's medical record showed inconsistencies and lack of documentation regarding the monitoring and assessment of pressure wounds. The record failed to provide clear ongoing documentation of the progress or lack of progress related to the resident's wounds. Furthermore, the facility did not document care conferences to update a resident's plan of care following MDS assessments. The Director of Nursing, who was not employed at the facility during the time of these deficiencies, confirmed the absence of documentation after reviewing the medical records. These deficiencies highlight the facility's failure to adhere to professional standards for maintaining accurate and complete medical records.
Failure to Immediately Inform Resident Representative of Hospital Transfer
Penalty
Summary
The facility staff failed to immediately inform the resident representative of a resident's transfer to the hospital. The incident involved a resident who was found lying on the floor with no apparent injuries but had an oxygen saturation level of 75%, which is below the normal range of 95%-100%. A respiratory assessment revealed diminished lung sounds and grunting-like breathing. The physician was notified and ordered oxygen administration, with instructions to send the resident to the emergency room if there was no improvement. Although the resident's oxygen saturation improved to 85%, 911 was called for ER evaluation. The progress notes did not indicate that the resident's representative was updated about the hospital transfer until 6:00 AM, several hours after the initial incident. The facility administrator could not provide additional evidence that the representative was informed immediately of the hospital transfer.
Failure to Timely Report Abuse Allegations
Penalty
Summary
The facility failed to provide timely documentation of abuse allegations to the appropriate agencies for two residents during a complaint survey. For one resident, an incident was reported where a geriatric nursing assistant allegedly abused the resident during care. The initial report to the Office of Healthcare Quality (OHCQ) was not filed within the required two-hour window, as it was submitted at 5:25 PM, despite the incident occurring early in the morning. The Nursing Home Administrator (NHA) confirmed the delay in reporting and noted that he was not employed at the facility at the time of the incident. In another case, a resident alleged that a staff member scratched, grabbed, and shoved them after requesting to be sent to the hospital. Although the facility submitted the initial and final reports to OHCQ, they failed to contact local law enforcement as required. The Administrator was unable to provide additional evidence to confirm that the police were contacted, indicating a lapse in the facility's reporting protocol.
Inaccurate MDS Assessments for Two Residents
Penalty
Summary
The facility staff failed to ensure that Minimum Data Set (MDS) assessments were accurately coded for two residents during a complaint survey. For one resident, the quarterly MDS assessment did not capture that the resident was receiving Hospice services, despite being admitted to Hospice on a previous date. This oversight was confirmed by the MDS coordinator during an interview. For another resident, there were discrepancies in the MDS coding related to behavioral symptoms and medication administration. The resident exhibited verbal aggression towards staff, which was documented in progress notes, but the MDS assessment inaccurately indicated no such behaviors. Additionally, the MDS documented the use of a hypnotic medication, but the Medication Administration Record did not reflect this. The MDS coordinator clarified that the medication Lorazepam, which the resident was receiving, was intended for anxiety, not as a hypnotic, according to the physician's order. These errors were confirmed by the MDS coordinator.
Failure to Revise Care Plan for Resident with History of Injury
Penalty
Summary
The facility staff failed to revise a resident's care plan, which was evident during a complaint survey for one of the residents. The incident involved a resident who alleged that a GNA hurt their arm. The facility's investigation revealed that the resident had a history of banging their arm on the side rail, and padding had been placed on the side rail to prevent further injury. However, the care plan did not include the intervention of padding the side rail, despite the resident's history of skin tears and behavior problems related to banging their arm on the side rails. An interview with the Director of Nursing confirmed that the padding was not added to the care plan.
Incomplete Discharge Documentation for Resident
Penalty
Summary
The facility failed to ensure a complete recapitulation of a resident's stay was conducted following their discharge. This deficiency was identified during a complaint survey for a resident who was admitted in July 2017 for physical and occupational therapy after an above-the-knee amputation. The resident was discharged to an assisted living facility, but the medical record lacked a physician's discharge summary and documentation of medications to be taken post-discharge. Additionally, there was no summary provided to the receiving facility. Further investigation revealed that the last documented note in the resident's medical record was dated after the discharge date, and there was no nursing documentation regarding the resident's condition at discharge, how they left the facility, or what items and documentation were provided to them and the receiving facility. The Director of Nursing confirmed the absence of a discharge summary, and the Nursing Home Administrator later provided a discharge summary but acknowledged the lack of nursing notes and a physician's discharge summary.
Failure to Provide Adequate Showering for a Resident with Dementia
Penalty
Summary
The facility staff failed to provide showers twice weekly to a resident diagnosed with dementia, who was admitted to the facility with a need for supervision and/or touching assistance for showering and bathing. The resident's care plan, initiated shortly after admission, specified the requirement of one staff member's participation in bathing. However, documentation revealed that the resident received no showers for the last five days of October 2023, only one shower in November 2023, two showers in December 2023, and four showers in January 2024. There was no documentation of the resident refusing showers during this period. The Director of Nursing confirmed that the resident did not receive the expected two showers per week from October 2023 until January 2024.
Failure to Timely Assess and Treat Pressure Ulcers
Penalty
Summary
The facility staff failed to provide adequate treatment and services to prevent and heal pressure ulcers for a resident. The resident was admitted with pressure ulcers on both heels and was under the care of a wound care physician who conducted weekly assessments. However, on 8/19/24, a nurse's note documented new open areas on the resident's sacrum and right buttocks. Despite notifying the doctor and receiving recommendations for treatment, the wounds were not assessed by the wound care physician until 9/12/24, 24 days after they were first noted. The delay in assessment and treatment of the sacral and right buttock wounds was confirmed by the Director of Nursing during an interview. The lack of timely evaluation and documentation of the wounds' status by the wound care physician contributed to the deficiency in care provided to the resident, as the wounds were not properly monitored or managed for nearly a month after their discovery.
Failure to Adhere to Medication Parameters for Two Residents
Penalty
Summary
The facility failed to ensure that the drug regimens for two residents were free from unnecessary drugs, as evidenced by the administration of Metoprolol outside of the physician-ordered parameters. Resident #15, who was admitted with a diagnosis of hypertension, was ordered Metoprolol 25 mg daily with instructions to hold the medication if the blood pressure was less than 110 or the heart rate was less than 60. However, the resident was administered Metoprolol on two occasions, on 4/8/24 and 4/13/24, when the heart rate and blood pressure were below the specified parameters, respectively. This was confirmed by the Director of Nursing during an interview. Similarly, Resident #6, also diagnosed with hypertension, was ordered Metoprolol 50 mg daily with the same parameters to hold the medication. On 2/16/25, the resident received Metoprolol despite having a blood pressure reading of 107/73, which was below the ordered threshold. This administration was also confirmed by the Director of Nursing. These instances indicate a failure to adhere to physician orders, resulting in the administration of medication outside of the prescribed parameters.
Failure to Schedule Follow-Up Urology Appointment
Penalty
Summary
The facility staff failed to schedule a follow-up appointment with a urology consultant for Resident #15, who was admitted with a diagnosis of hydronephrosis. The resident's hospital discharge summary indicated the need for an outpatient urology follow-up for moderate right hydronephrosis and a voiding trial, with a referral for a urology appointment already made. A nurse's note documented that a follow-up urology appointment was initially scheduled but later canceled due to out-of-network insurance issues. No further attempts were made to reschedule the appointment during the resident's stay, and there was no evidence of a voiding trial or completed follow-up with a urologist. The Director of Nursing confirmed these findings during an interview with the surveyor.
Latest citations in Maryland
Facility staff did not ensure that 2nd floor residents who could not use stairs were able to receive visitors when the only elevator was out of service for an extended period. Complaints indicated that some family members, who were themselves unable to ambulate stairs, could not visit their relatives on the 2nd floor during this time. The emergency plan directed non-ambulatory 2nd floor residents to remain on that floor unless there was an emergency and did not address how visitation would be maintained when the elevator was inoperable. The Administrator reported that visitors could use the stairs and that an emergency chair system could be used to move residents, but also stated that the chair system was not used for visitation and was unaware of any complaints, despite two having been filed.
Facility staff did not complete required quarterly smoking safety assessments for several residents identified as smokers, including some who had not been reassessed for many months and one who had never been assessed during their stay. This issue was discovered during a complaint survey after the facility’s only elevator was out of service for an extended period, affecting a group of residents on an upper floor who needed to reach a designated smoking area on a lower floor. Review of records and staff interviews, including with the DON and a unit manager, confirmed that the facility’s own practice of quarterly smoking safety assessments for smokers was not followed for half of the affected residents.
Facility staff failed to accurately code multiple MDS assessments for several residents, leading to discrepancies between MDS entries and MARs for pain management, falls, and high-risk drug classes. In several cases, scheduled pain management was coded as provided when MARs did not show daily pain medications, often because an LPN counted low-dose Aspirin ordered for cardiovascular prophylaxis or heart failure as pain medication, contrary to RAI guidance. One resident’s falls were underreported on the MDS despite two documented falls, and daily use of a topical analgesic and an antiplatelet (Aspirin) was not correctly captured. Other residents had MDS entries indicating use of hypnotic or antianxiety medications when MARs showed none, while actual antidepressant and hypoglycemic medications administered daily were omitted from Section N0415. These errors were confirmed by the involved LPNs during surveyor interviews.
Staff failed to conduct complete investigations into two residents’ abuse allegations. In one case, a resident reported that an employee poked their face and made an obscene gesture, but the investigation lacked a statement from the corporate representative who was first notified of the allegation. In another case, a resident reported that someone in blue clothing put a hand by their face and over their mouth, with a specific GNA identified as the alleged perpetrator; however, the investigation did not include statements from two GNAs who were on duty on the unit at the time of the alleged incident, despite leadership having the opportunity to ensure all relevant documents were present.
Staff failed to create person-centered care plans for two residents, one with mobility limitations and one receiving peritoneal dialysis. For the resident with mobility issues, the care plan did not address the resident’s refusal to use a Hoyer lift and preference for pivot transfers, despite therapy prohibiting pivot transfers and staff awareness of the resident’s resistance. For the resident on peritoneal dialysis, the care plan did not specify that the treatment was peritoneal dialysis, nor did it include the treatment schedule or cycle time frames; an LPN Unit Manager acknowledged using a generalized renal care plan without incorporating the specific dialysis prescription.
A resident’s medical record lacked documentation confirming that scheduled showers or bed baths were provided on multiple dates, and there was also no record of any refusals of care on those days. The DON and an LPN unit manager reported that showers were scheduled on specific shifts and that completed showers and refusals should be documented on shower/skin sheets and in the care plan, but the surveyor found gaps where no such entries existed. This resulted in incomplete ADL documentation and failure to maintain medical records according to accepted professional standards.
A resident with multiple fractures and chronic pain was receiving an opioid-based pain regimen, including PRN hydromorphone. The resident was later found unresponsive and "out of it" by an LPN, who located an order for Narcan and administered it, with the resident responding to the medication. A physician note documented an opioid overdose treated with Narcan. Review of the medical record showed no documentation that the resident’s representative was notified of this significant change in condition and emergency intervention, and staff interviews confirmed that notification likely did not occur, despite the DON’s expectation that the responsible party should have been informed.
Staff failed to follow updated wound care orders and to document an opioid overdose event and Narcan use for two residents. One resident with venous and arterial lower extremity wounds did not receive the prescribed change from oil emulsion to daily skin prep on one foot wound, and did not receive ordered skin prep on a new plantar wound for several days after the wound physician revised the treatment plan. Another resident with multiple fractures and chronic pain, receiving multiple opioid and adjunct analgesics, reportedly experienced an opioid overdose; an LPN found the resident unresponsive, located an existing Narcan order, administered Narcan, and observed the resident return to baseline, but did not complete or document a change-in-condition assessment, vital signs, or the Narcan administration in the medical record.
Surveyors substantiated a deficiency when disinfectant wipes, labeled for storage in areas inaccessible to children and not for personal cleansing, were observed sitting openly on a wire shelf in the dining room of a locked dementia unit while cognitively impaired residents waited for breakfast. A GNA and an LPN present on the unit stated that staff used the wipes to clean tables and that residents were never left alone in the dining room and had not been seen using the wipes. The ICP reported being unaware that the wipes’ placement in the dining room was a concern, and the NHA and DON stated they had not previously been informed about the issue, though the DON acknowledged understanding the concern.
A resident’s medical record showed multiple instances where Hydromorphone, a controlled narcotic, was documented as signed out and given on the Controlled Drug Administration Record but was not documented on the MAR on the same dates and times. An LPN reported signing only the narcotic sheet and not the MAR, while the DON acknowledged awareness that nurses were signing the narcotic sheet without completing the MAR, and a unit manager stated they were unaware this was occurring and that both records should be completed. The NHA and DON agreed with the surveyor’s findings after the issue was identified.
Failure to Ensure Visitation Rights During Elevator Outage
Penalty
Summary
Facility staff failed to ensure that residents residing on the 2nd floor who could not safely ambulate using stairs were able to exercise their right to have visitors when the facility’s only elevator malfunctioned. Complaint reviews showed that family members were unable to visit their relatives on the 2nd floor when the elevator was inoperative, and these family members themselves were unable to use the stairs. An incident report documented that the facility’s only elevator was malfunctioning for an extended period, from 3/28/26 to 4/23/26. During this time, residents who could not use the stairs remained on the 2nd floor, and some of their family members could not access them due to the lack of elevator service. Review of the facility’s emergency plan revealed that it instructed that 2nd floor residents who could not safely use the stairs should remain on the 2nd floor unless there was an emergency, and it did not include any provisions for maintaining visitation when the elevator was inoperable. In an interview, the Administrator stated that visitors could use the stairs to visit 2nd floor residents and that residents could be transported using an emergency chair system to meet visitors who could not use the stairs. However, the Administrator acknowledged that the emergency chair system was not used for visitation purposes during the elevator outage and reported being unaware of any complaints about the inoperative elevator, despite two complaints having been received by OHCQ. No additional documentation was provided to show a plan to support visitation for 2nd floor residents during the elevator malfunction.
Failure to Complete Required Quarterly Smoking Safety Assessments
Penalty
Summary
Facility staff failed to update smoking safety assessments at least once every three months for multiple residents identified as smokers. During a complaint survey focused on smoking safety, surveyors reviewed an incident involving the facility’s only elevator being inoperative for nearly a month, which affected residents who lived on the 2nd floor and needed to access the 1st-floor smoking area. The facility’s investigation identified a group of 10 residents on the 2nd floor who smoked and required additional accommodations to safely ambulate to the designated smoking area. Review of these residents’ medical records showed that 5 of the 10 did not receive quarterly smoking safety assessments as required by the facility’s practice. Specifically, four residents had not received a smoking assessment since May 2025, and one resident had no documented smoking assessment at any time during their stay. During interviews, the Unit Manager stated that residents identified as smokers are to be assessed quarterly for smoking safety. When the surveyor pointed out the missing assessments, the DON reviewed the records and confirmed that these residents had not received the required quarterly smoking assessments. This lack of timely reassessment occurred in the context of an extended elevator outage that necessitated special consideration for safe smoking access for residents residing on the 2nd floor.
Inaccurate MDS Coding for Pain Management, Falls, and High-Risk Drug Classes
Penalty
Summary
Facility staff failed to ensure that Minimum Data Set (MDS) assessments were accurately coded for multiple residents, based on medical record review and staff interviews. For one resident with cerebrovascular disease, an MDS with an Assessment Reference Date (ARD) of 3/2/26 coded Section J0100A (scheduled pain management) as "yes," but the March Medication Administration Record (MAR) did not show daily pain medication administration. An LPN stated she coded it that way because the resident received Aspirin 81 mg daily, although the physician’s order showed the Aspirin was prescribed as prophylaxis for cardiovascular events, and the RAI Manual specifies that medications not primarily intended for pain relief should not be coded as pain management. Another resident with cerebral infarction, congestive heart failure, and vascular dementia had two documented falls in progress notes between the prior assessment and the ARD of 2/4/26, but Section J1900 (number of falls since admission or prior assessment) captured only one fall. The same MDS coded Section J0100A (scheduled pain management) as "no" despite the February MAR documenting daily use of Diclofenac topical gel for pain. The MAR also showed daily Aspirin 81 mg for coronary artery disease, but Section N0415 (high-risk drug classes) did not capture the use of an antiplatelet medication. The responsible LPN confirmed missing the second fall and the Aspirin coding error. Additional residents had similar discrepancies: one resident’s MDS repeatedly coded use of hypnotic medications in Section N0415 when MARs showed no hypnotics administered, and failed to capture an antidepressant (Sertraline) that was given; the LPN reported coding Clonazepam as a hypnotic based on dual use, though reference guidelines did not classify it as such. Further inaccuracies were identified for other residents in pain management and high-risk drug class coding. One resident’s MDS with an ARD of 1/8/26 coded receipt of PRN pain medication in Section J0100A, but the January MAR showed no PRN pain medications given; a later MDS for the same resident coded use of an antianxiety medication in Section N0415, while the April MAR showed no such medication administered. Another resident with traumatic subarachnoid hemorrhage, type 2 diabetes with neuropathy, atrial fibrillation, and atherosclerotic heart disease had an MDS with an ARD of 2/3/26 that coded scheduled pain medication as "yes" and PRN pain medication as "no," although the MAR showed intermittent PRN Tylenol for pain and no daily pain medication, and also documented daily Aspirin 81 mg for heart failure and daily Rybelus for diabetes; the MDS failed to capture PRN pain use, incorrectly coded daily pain medication, and did not code hypoglycemic medication in Section N0415. Another resident with a history of stroke and right-sided hemiplegia/hemiparesis had two MDS assessments in February coded as receiving scheduled pain medication, but the February MAR did not show daily pain medication; the LPN reported coding based on daily prophylactic Aspirin 81 mg, which was not ordered for pain.
Incomplete Investigations of Resident Abuse Allegations
Penalty
Summary
Facility staff failed to complete thorough investigations of two separate resident allegations that were reported to the state agency. For the first incident, a resident alleged that on a specific date and time an employee poked two fingers into their face and showed them their middle finger. The five-day follow-up documented the allegation, but the investigation file did not clearly identify who was the first point of contact for the report. During interview, the Administrator stated that a corporate representative was initially made aware of the alleged incident, but there was no statement from this corporate representative included in the investigation file. The Administrator described their usual investigation process as interviewing involved parties, identifying and interviewing witnesses, reviewing staffing for the date of the alleged incident, and interviewing the resident’s roommate and other nearby residents if there were no direct witnesses. In the second incident, a resident reported that during a specific shift someone wearing blue put a hand by their face and over their mouth, and a particular GNA was identified as the alleged perpetrator. Review of the staffing sheet for the time of the alleged incident showed that two GNAs were working on the unit where the incident was reported to have occurred. However, the investigation file contained no statements or interviews from these two GNAs. Prior to the surveyor’s review of the investigation, the DON and a regional nurse were given the opportunity to review the investigation to ensure all necessary documents were available, yet the statements from the two GNAs remained absent. These omissions demonstrated that the facility did not conduct complete investigations into the reported allegations.
Failure to Develop Person-Centered Care Plans for Mobility and Peritoneal Dialysis Needs
Penalty
Summary
Facility staff failed to develop and implement person-centered care plans that addressed all identified needs for two residents, one with mobility limitations and one receiving peritoneal dialysis. For the resident with mobility limitations, the care plan included interventions for resistance to care and adjustment issues, but did not address the resident’s specific resistance to use of a Hoyer lift and the resident’s insistence on pivot transfers from bed to wheelchair. The Unit Manager confirmed that the resident was resistant to care, did not like the Hoyer lift, and preferred pivot transfers, but also stated that physical therapy had prohibited pivot transfers. Despite this known conflict between the resident’s preferences and therapy restrictions, the care plan lacked individualized interventions related to the resident’s resistance to the Hoyer lift and continued request for pivot transfers. For the resident receiving peritoneal dialysis, review of the electronic health record showed an order for peritoneal dialysis, but the resident’s care plans did not include a person-centered care plan specific to this treatment. The existing dialysis care plan did not specify the type of dialysis treatment being provided, did not document when the resident was scheduled to receive the treatment, and did not include time frames for the dialysis cycles. During an interview, the LPN Unit Manager stated that they do not place the dialysis prescription details into the care plan and instead use a generalized renal care plan by selecting standard items, confirming that the care plan was not individualized to the resident’s ordered peritoneal dialysis regimen.
Failure to Document Resident Showers and Refusals
Penalty
Summary
Facility staff failed to maintain complete and accurate documentation of bathing care for a resident, specifically regarding showers and refusals of showers. During a complaint survey, the surveyor requested verification that Resident #5 was receiving scheduled showers. The DON stated that the resident was scheduled for showers on the 3 pm–11 pm shift on Tuesdays and Fridays, and provided shower sheets for several dates in October and early November. However, there was no documentation to verify that the resident received a shower or bed bath on 10/17/25, 10/21/25, and 10/24/25. The DON explained that when a resident receives a shower it is documented on a skin sheet, and that refusals of showers should be documented both in the plan of care and on the shower sheet. Despite this, the surveyor did not receive any documentation indicating that the resident either received bathing care or refused showers on the missing dates. This lack of documentation showed that the facility did not safeguard resident-identifiable information and maintain medical records in accordance with accepted professional standards, as there was no record confirming whether the resident’s scheduled showers or refusals occurred on the identified dates.
Failure to Notify Responsible Party After Narcan Administration for Suspected Opioid Overdose
Penalty
Summary
The deficiency involves the facility’s failure to notify a resident’s responsible party when there was a significant change in the resident’s medical status requiring emergency medication. A complaint alleged that there was no communication with the responsible party when Narcan (naloxone) was administered to a resident for an alleged opioid overdose. Medical record review showed the resident was admitted in March 2026 with multiple fractures, including a nondisplaced zone 1 sacral fracture, a nondisplaced fracture of the posterior column of the right acetabulum, a fracture of the right pubis, and other chronic pain. The resident’s pain regimen included multiple opioids and other pain medications, including Hydromorphone 6 mg every 4 hours PRN, Hydromorphone 4 mg every 4 hours PRN, Tylenol, Lidocaine cream, Methocarbamol, Celebrex, and Gabapentin. A physician’s note dated 4/8/26 documented that the resident reportedly had an opioid overdose earlier that morning and responded well to Narcan administration by nursing, with the note listing chronic pain and opioid overdose status post Narcan. Further review of the resident’s medical record did not show any documentation that the resident’s representative was notified of this overdose event and Narcan administration. During interviews, an agency LPN stated that the resident was “out of it and not responding” during rounds, prompting the LPN to check for and then administer Narcan, after which the resident responded. Another LPN reported that Narcan was given because the resident appeared to be having an overdose and that the physician saw the resident afterward, but stated, “I don’t think anyone was notified, but should have been.” The DON also stated that she would have expected the responsible party to be notified. These findings confirmed that the facility failed to notify the resident’s responsible party of a significant change in condition and emergency treatment.
Failure to Follow Wound Care Orders and Document Narcan Administration
Penalty
Summary
Facility staff failed to provide treatment and care in accordance with professional standards and physician orders for two residents. For one resident admitted after hospitalization with acute systolic heart failure and peripheral edema, a wound physician initially ordered daily oil emulsion dressings for venous wounds on the right shin, left medial foot, and left second toe. At a follow-up assessment, the wound physician changed the treatment for the left medial foot from oil emulsion to daily skin prep and ordered daily skin prep for a newly identified arterial wound on the left plantar foot. Review of the March 2026 medication and treatment administration records showed staff did not discontinue the oil emulsion or initiate the ordered skin prep to the left medial foot, and did not administer skin prep to the left plantar foot wound from the date of the new orders until the resident was sent to the hospital. The DON confirmed that treatments were not administered per the updated wound care orders during this period. For another resident admitted with multiple pelvic and sacral fractures and chronic pain, the record showed extensive opioid and adjunct pain medication orders, and a physician note documented that the resident reportedly experienced an opioid overdose and responded well to Narcan administration by nursing. However, the medical record contained no nursing assessment of the resident at the time of the event, no documentation of the resident’s condition or vital signs, and no record of Narcan administration or the resident’s response afterward. An agency LPN reported finding the resident unresponsive or "out of it" during rounds, knowing the resident was on significant pain medications, and, after checking for an existing order, administering Narcan, after which the resident returned to baseline. The LPN acknowledged not completing or documenting a change-in-condition assessment, and both the DON and unit manager stated they would have expected an assessment and vital signs to be documented in this situation.
Disinfectant Wipes Left Accessible in Dementia Unit Dining Room
Penalty
Summary
The deficiency involves the facility’s failure to keep the environment free from accident hazards on one locked dementia unit. During a complaint survey regarding unsecured cleaning supplies and the potential for residents to use cleaning wipes for personal use, a surveyor observed disinfectant wipes stored openly on a wire shelf in the dining room of the Seagull Unit, a locked dementia unit. The product labeling on the container directed that it be stored in areas inaccessible to children and specifically stated it was not to be used as a diaper wipe or for personal cleansing and that it was not a baby wipe. At the time of the observation, residents with cognitive impairment were present in the dining room awaiting breakfast. A GNA was in the dining room with the residents during the observation, and the unit manager, an LPN, accompanied the surveyor. The surveyor expressed concern about the wipes being accessible in a public area where cognitively impaired residents were present. The LPN reported she had never seen residents use or attempt to use the wipes and stated staff used them to wipe down tables before and after meals. The GNA stated she was always present when residents were in the dining room, that residents were never left alone there, and that she had never seen a resident use a wipe. The Infection Control Nurse stated she was not aware the disinfectant wipes in the dining room were a concern because no residents had gone near them and confirmed they were intended for staff use to clean tables. The NHA and DON reported they had not been made aware of the concern with the wipes, though the DON stated she understood the concern.
Incomplete Documentation of Narcotic Administration on MAR
Penalty
Summary
The deficiency involves the facility’s failure to maintain complete and accurate medical records in accordance with accepted professional standards for one resident. Review of the resident’s April 2026 Medication Administration Record (MAR) and the Controlled Drug Administration Record showed multiple discrepancies for Hydromorphone, a narcotic medication. On several specific dates in April, the Controlled Drug Administration Record documented that Hydromorphone doses were signed out and given by licensed nursing staff at various times, but the corresponding MAR entries for those same dates and times were left blank, indicating no documentation of administration on the MAR. During interviews, an LPN stated that they sign out the medication on the narcotic sheet but do not document it on the MAR. The DON acknowledged awareness that nurses were signing off on the narcotic sheet but not on the MAR, and a unit manager reported not being aware that nurses were failing to sign the MAR when also signing the narcotic sheet, stating that documentation should occur on both records. The NHA and DON later stated they were not aware of the concern until it was identified by the surveyor and agreed with the findings. These observations and interviews demonstrate that the facility did not ensure that all medication administrations were consistently and accurately documented on the MAR for this resident.
Trusted data from CMS and state health departments
Every citation, penalty and Plan of Correction is sourced from public CMS records (latest release June 24, 2026) and official state health department websites — never guesswork.
Trusted by long-term care providers and associations.
