Autumn Lake Healthcare At Silver Spring
Inspection history, citations, penalties and survey trends for this long-term care facility in Silver Spring, Maryland.
- Location
- 2501 Musgrove Road, Silver Spring, Maryland 20904
- CMS Provider Number
- 215224
- Inspections on file
- 19
- Latest survey
- April 28, 2026
- Citations (last 12 mo.)
- 17
Citation history
Health deficiencies cited at Autumn Lake Healthcare At Silver Spring during CMS and state inspections, most recent first.
A resident reported during a grievance process and a resident council meeting that a GNA threatened to slap them if they did not go to bed, and this allegation was promptly relayed by the Activity Director to the NHA and ADON. The ADON documented the allegation on a grievance form and began an internal investigation but did not report it to the State Agency, and the GNA identified by the resident continued to work and remained assigned to the resident. The facility later reported the incident to the State Agency only after the Ombudsman notified the NHA, despite internal documentation showing the same allegation had been known and investigated earlier.
A resident reported that a GNA threatened to slap them after pressuring them to go to bed, and later clearly identified a specific GNA as the alleged perpetrator when that staff member entered the room. The ADON and an RN began an investigation and confirmed the resident’s identification of the GNA, and the Ombudsman also received the same allegation and identification from the resident. Despite this, and despite time records showing the identified GNA was working multiple evening shifts during the period in question, the facility did not remove the GNA from the resident care area while the abuse allegation was being investigated.
A resident with generalized muscle weakness, wheelchair dependence, and extensive ADL needs requested transfer to another facility during the initial care plan meeting, but the Social Services Director left the discharge planning section incomplete and did not send referrals or ensure follow-through. The Social Services Assistant, who was on leave at the time, was not directed to assist and only contacted another facility weeks later after the resident repeated the request. As insurance coverage ended, the resident and family agreed to discharge home but later expressed concern because the resident could not walk and no clear home health or in-home therapy services had been arranged. The NP, physician, and PT documented that the resident still required extensive therapy and had not met goals for safe discharge, while social services delayed initiating home health referrals until the day of the planned discharge, resulting in no secured home health or therapy services at that time.
A resident with generalized muscle weakness, mobility and ADL dysfunction had a care plan and physician/NP orders for PT/OT to improve function, but did not receive any therapy for an 11‑day period after services stopped despite an extended stay and an appeal of discharge. The resident, who required staff assistance with most ADLs and used a wheelchair, reported not receiving therapy after the appeal, while the PT confirmed the resident had not met goals and still needed to improve stair navigation before going home. The Rehab Director acknowledged awareness of the appeal, confirmed the absence of therapy during this period, and stated the resident would experience physical decline without those services, demonstrating a failure to provide rehabilitative services as care‑planned and ordered.
Wet Nesting of Serving Equipment During Meal Service: Dietary staff used serving warming plates and cloches that were still wet with standing water during lunch plating. Surveyors observed the wet equipment being placed on the warming charger, where the water began to boil with obvious bubbles. The surveyor discussed the wet nesting issue with an employee, who directed kitchen staff to run the items back through the dishwasher and air dry them.
Missing Annual GNA Performance Reviews: The facility failed to complete required annual performance reviews for GNAs. Review of employee files showed 4 of 5 GNA files lacked a current evaluation, and interviews with the ADON/Staff Educator and NHA confirmed the reviews were not consistently completed or filed in the employee records. Only 1 of the 5 GNAs reviewed had a 2025 performance review located.
Infection control practices were not consistently followed when several residents had undated oxygen tubing and humidification bottles, multiple PPE carts for residents on contact precautions or EBP were missing gloves and/or gowns, and a resident’s urinary catheter drainage bag was observed touching and then lying on the floor. Staff interviews confirmed the facility expected PPE to be stocked outside rooms and catheter drainage bags to be kept off the floor.
A resident's right to a safe, comfortable, and homelike environment was not upheld when the facility failed to inventory and safeguard the resident's personal belongings. During a complaint investigation, staff were unable to account for multiple missing items, including clothing and a phone charger, and review of both electronic and paper records showed that no personal belongings inventory had been completed or maintained for the resident, contrary to facility policy requiring such documentation at admission and updates as new items are brought in.
Facility staff did not develop complete, person-centered care plans for two residents. For one resident, ongoing dental issues and denture replacement documented by a contract dental provider were not included in the care plan despite active treatment. For another resident, a diagnosis of CKD Stage 3, identified by the primary provider and during multiple ER visits, was not addressed in either the initial or current care plan. A staff member later confirmed that these needs were missing from the residents’ care plans.
A resident’s monthly Medication Regimen Reviews (MRRs) were not timely addressed by providers, and pharmacist recommendations were not acted upon as required by facility policy. The ADON reported that the pharmacist emails MRRs, which are printed and given to an NP to review and mark agree/disagree/other, with changes then entered into the EMR by the NP or unit managers before the next month’s review. For this resident, one MRR contained a recommendation to discontinue melatonin that was not signed and agreed to by the provider until nearly two months later, and the subsequent MRR repeated the same recommendation but had no provider signature, date, or response documented. The ADON acknowledged both MRRs were missed.
A resident’s MDS assessment was not transmitted within the required timeframe. The MDS Coordinator later provided a Final Validation Report showing the assessment was submitted late, and the RMDS confirmed the late submission during interview.
Failure to follow a provider order for a midline IV dressing change was identified for a resident with a midline in the L arm. The dressing remained dated with an earlier date despite the TAR showing the dressing change was completed, and the RN supervisor confirmed the mismatch between the observed dressing and the documented TAR entries.
Pest control program failure was identified when a surveyor observed a large number of gnats flying in the first-floor hallway and a higher concentration in a resident room. More than 20 gnats were seen resting on the resident’s bed and privacy curtain, and the resident stated the flies are always in the room. The DSES later confirmed the gnats were present.
A resident did not have quarterly care plan meetings as required, and neither the resident nor their representative were included in such meetings for nearly ten months. Although the social worker maintained regular communication with the family, no official care plan meeting was documented during this period, as confirmed by facility leadership.
Surveyors observed that the exit doors on the Arcadia unit had damaged plastic kick plates with cracks, chips, and jagged edges, some of which were covered with tape. A resident was seen picking at the broken area, highlighting the unsafe and uncomfortable condition of the doors. Facility leadership was notified of these findings.
The facility failed to employ sufficient qualified staff in the food and nutrition department, affecting all residents. The RD had not been onsite since July 2024 and worked remotely, while the FSD was unqualified per job description and federal requirements. This led to failures in providing palatable food, food choices, snacks, timely meals, and nutritional interventions. Interviews confirmed the RD's absence and the FSD's lack of qualifications.
The facility failed to maintain sanitary kitchen operations, risking foodborne illness for 126 residents. Observations revealed that the dishwasher did not meet required temperature specifications, and dietary staff did not follow proper hand hygiene and glove use when handling ready-to-eat foods. Despite policies in place, these deficiencies persisted, posing a health risk to residents.
The facility failed to maintain a sanitary garbage area over three days, with surveyors observing significant amounts of garbage around the compactor. Items included plastic, paper, and food waste, posing a potential sanitation concern. The Regional CDM, HM, and FSD acknowledged the issue, and the Administrator expected housekeeping to maintain cleanliness.
Two residents in an LTC facility experienced significant weight loss due to inadequate nutritional interventions. One resident with Alzheimer's and dysphagia was not weighed weekly and did not receive prescribed supplements, while another with breast cancer and malnutrition had inaccessible supplements. Staff failed to offer meal alternatives and inaccurately documented intake, with the RD working remotely and not visiting the facility since July.
The facility failed to provide meals that were palatable, attractive, and served at safe temperatures, as reported by multiple residents. Observations revealed deviations from recipes and inappropriate food temperatures. Despite awareness of these issues, they persisted, affecting resident satisfaction and potentially their nutritional intake.
The facility failed to honor residents' food preferences and provide alternatives, leading to dissatisfaction and potential weight loss. Residents reported not being consulted about their preferences and faced difficulties in ordering from the Always Available menu. Observations showed that some residents refused meals without being offered alternatives, and staff did not consistently follow the facility's policy to provide options.
The facility failed to meet the nutritional needs of residents by not providing meals and snacks according to their needs and preferences. Observations revealed that the time span between dinner and breakfast exceeded 15 hours, and residents reported not being offered snacks. Interviews confirmed the lack of snack offerings and extended meal times, with the Resident Council not reviewing or approving the longer time span. The facility's failure could lead to health issues due to nutrient deficiencies.
An LPN failed to follow infection control practices by picking up a dropped Oxycontin tablet with bare fingers and placing it in a medication cup for a resident. The LPN did not sanitize her hands after handling other blister packs and cart drawers. Facility policy requires medications to be handled without bare hands.
Failure to Timely Report Resident Abuse Allegation to State Agency
Penalty
Summary
The deficiency involves the facility’s failure to timely report an allegation of abuse to the State Agency (SA) within the required timeframe. A grievance form showed that a resident reported on 4/15/26 that, on the prior evening, an assigned GNA entered the room to assist with going to bed. When the resident stated they were not ready, the GNA continued to urge them and threatened to slap the resident if they did not go to bed. This allegation was documented on a grievance form signed by an RN. During a resident council meeting on 4/15/26, the resident again reported to the Activity Director that a staff member had threatened to slap them if they did not go to bed, and the Activity Director immediately reported this verbally to the NHA and informed the ADON. The facility’s investigation file for incident #298941, reported to the SA on 4/27/26, stated that the facility was not aware of the abuse allegation until 4/17/26, when the Ombudsman reported it to the NHA, and characterized the allegation as the resident being hit by a GNA. However, a witness statement completed by the RN and ADON showed that the allegation was the same as what the resident had reported on 4/15/26. The ADON confirmed that she was informed of the allegation on 4/15/26, that the NHA instructed her to place it on a grievance form and start an investigation, and that she did not report it to the SA at that time because they were still investigating. She also acknowledged that the resident reported an incorrect date for the incident, and that the GNA identified by the resident continued to work and was assigned to the resident on 4/15/26. The ADON was unable to explain why the allegation was not reported as abuse on 4/15/26 but was only reported after the Ombudsman contacted the NHA.
Failure to Remove Alleged Perpetrator From Resident Care Area After Abuse Allegation
Penalty
Summary
The deficiency involves the facility’s failure to remove an identified staff member from the resident care area after an allegation of abuse was made, pending completion of an investigation. A grievance form received on 4/15/26 documented that Resident #2 reported an incident that allegedly occurred on 4/14/26 around 8:30 PM, in which the assigned GNA attempted to assist the resident to bed, continued to urge the resident to go to bed after the resident stated they were not ready, and then threatened to slap the resident if they did not comply. The grievance form was signed by RN #7. The ADON reported that on 4/15/26 the Activity Director approached her about the allegation, and that she and the evening shift supervisor, RN #7, began an investigation that evening and into the next day. They asked the GNA assigned to the resident on the evening of 4/14/26 to come to the facility on 4/15/26, and when Resident #2 saw this GNA, the resident stated it was not her and instead identified GNA #8 as the staff member who had threatened them. The ADON stated she did not ask GNA #8 to leave the resident care area because she believed GNA #8 had not been working on the date the resident alleged the incident occurred. However, she acknowledged she had not noticed during the investigation that, although GNA #8 had not worked on 4/14/26, she had worked on 4/13/26, and that the resident may have had the wrong date but had clearly identified GNA #8 as the alleged perpetrator. The Ombudsman reported that during a visit with Resident #2 on 4/16/26, the resident again reported the allegation of abuse, and when GNA #8 entered the room, the resident identified her as the staff member who had threatened them. A witness statement dated 4/17/26 from RN #7 also documented that Resident #2 pointed out GNA #8 as the alleged perpetrator. Time records showed that GNA #8 worked evening shifts from 4/15/26 through 4/24/26, and despite the allegation being reported a second time to the NHA by the Ombudsman, GNA #8 was not removed from the resident care area while the investigation was ongoing.
Failure to Provide Medically Related Social Services and Adequate Discharge Planning
Penalty
Summary
The deficiency involves the failure of the social services department to provide medically related social services and adequate discharge planning for a resident admitted with generalized muscle weakness, mobility and ADL dysfunction, and wheelchair dependence. The admission MDS documented no cognitive or communication impairment, but a need for staff assistance with most ADLs. During the initial care plan meeting, attended by a family member and documented by the Social Services Director, the discharge planning section was left incomplete, and the resident’s expressed request to transfer to another facility was not documented in the discharge planning section. The resident and family later reported that the resident had asked to be transferred on the day of admission because the resident felt the facility could not meet their needs, and that nothing was done in response at that time. The Social Services Director stated he did not complete the discharge planning section because the resident wanted to transfer and claimed he asked the Social Services Assistant to handle the transfer. However, he acknowledged that he did not send any referrals to other facilities, and the Social Services Assistant reported she had not been asked to assist with the transfer and was on leave at the time of the initial care plan meeting. The assistant stated she knew the resident had asked to be transferred but was not involved until the resident personally approached her in the hallway weeks later, at which point she arranged to meet the next day and then contacted another facility. This contact occurred 18 days after the resident’s initial transfer request and only after the resident had to repeat the request. As the resident’s insurance coverage was ending, the resident agreed to go home and then later appealed the decision, while the NP and attending physician documented that the resident remained in extensive need of therapy and was not ready for discharge home. The resident and family expressed concern about going home due to the resident’s inability to walk and the home’s physical layout, and both reported they were unaware of any in-home services arranged by the facility. The record showed the resident refused discharge unless home health services were set up and was charged private pay while remaining at the facility. The PT confirmed the resident had not met therapy goals and could not safely discharge home without continued PT. The Social Services Director admitted he had not set up home health or therapy services and had not ensured everything was in place before the planned discharge, while the Social Services Assistant acknowledged she did not request home health services until the day of the planned discharge and was unaware she could arrange them earlier, resulting in no secured home health or therapy services at the time of the attempted discharge, as also confirmed by the Ombudsman.
Failure to Provide Ordered Rehabilitation Services During Extended Stay
Penalty
Summary
The facility failed to provide specialized rehabilitative services according to the resident’s care plan and clinical assessments. The care plan initiated on 3/25/26 identified a focus for rehabilitation services with a goal to improve the resident’s current level of function, and included an intervention to provide therapy services per physician orders. The admission MDS documented that the resident had no cognitive or communication impairment but required staff assistance with most ADLs and was wheelchair bound. On 4/16/26, an NP documented that the resident had generalized muscle weakness, mobility and ADL dysfunction, and was at risk for functional impairment without pain control and PT/OT services. The attending physician also documented on 4/16/26 that the resident was in extensive need of therapy and not ready for discharge home. Despite these assessments and the active care plan for rehabilitation, therapy notes showed that the resident did not receive any therapy services after 4/16/26. The record and interviews showed that the resident’s insurance coverage was initially ending, the resident agreed to go home, then appealed the decision and was granted additional days of coverage and an extended stay. The Social Services Director confirmed that the resident’s stay was extended and that the resident appealed and was granted to remain until 4/22/26. The resident reported being granted an extended stay and stated they had not received therapy since 4/16/26, despite feeling they needed more therapy to be safe at home. The PT stated the resident had not met therapy goals and needed to improve stair navigation before going home, and acknowledged that although services were approved until 4/23/26, insurance sometimes stopped services. The Rehab Director confirmed that the resident had not received therapy since 4/16/26, was aware of the appeal, and stated that the resident would experience physical decline without therapy services for 11 days, confirming a gap in providing ordered and care-planned rehabilitative services during the appeal and extended-stay period.
Wet Nesting of Serving Equipment During Meal Service
Penalty
Summary
Dietary staff failed to maintain proper infection control procedures during lunch plating by using serving warming plates and cloches that had been wet nested and were still wet with standing water when residents' plates of food were placed in them. During the survey observation, the warming plates and cloches being used were very wet, and the warming plates had standing water in them. When the warming plates were set on the warming charger, the water began to boil with obvious bubbles. The surveyor discussed the wet nesting situation with Employee #31, who directed kitchen staff to run the warming plates and cloches back through the dishwasher and allow them to air dry.
Missing Annual GNA Performance Reviews
Penalty
Summary
The facility failed to conduct required annual performance reviews for Geriatric Nursing Assistants (GNAs) at least once every 12 months. During review of employee files for GNA #17, GNA #18, GNA #19, GNA #20, and GNA #5, surveyors found that 4 of the 5 files did not contain a 2025 performance review. The Human Resources Director confirmed the files reviewed were complete employee files, excluding health files, and the missing reviews were noted in the records for GNAs hired in 2018, 2016, 2025, 2024, and 2015. In interviews, the Assistant Director of Nursing/Staff Educator stated that performance reviews were supposed to be completed every year by supervisors, managers, or the DON, but she was unsure where they were stored and later said the facility was in the process of putting the evaluations together. She later acknowledged that if the reviews were not in the employee file, they were not completed, and stated the facility had "dropped the ball" because of changes and ownership transitions. When the Nursing Home Administrator later provided additional performance reviews, only 1 of the 5 GNAs reviewed for staffing had a 2025 evaluation, and the remaining reviews located were from 2024. The Administrator stated some paperwork had been stacked rather than filed and should have been in the employees' files.
Infection Control Practices Not Followed
Penalty
Summary
Provide and implement an infection prevention and control program was deficient when surveyors observed multiple infection control practices not being followed for several residents. On 03/23/2026, oxygen tubing and humidification bottles for Residents #157, #22, #9, and #116 were observed without dates, and the facility later provided a policy stating humidification bottles are to be changed every 72 hours. The absence of dates prevented verification that the equipment had been changed according to facility policy. Surveyors also observed that contact precaution and enhanced barrier precaution PPE carts outside several resident rooms were not stocked with gloves and/or gowns, and one room had no PPE cart or PPE inside the room. RN #12 stated PPE should be located outside resident rooms in carts for residents on contact precautions or EBP, and the ADON stated it was the facility's expectation that PPE carts be stocked and placed outside resident rooms. In addition, Resident #3's urinary catheter drainage bag was observed hanging from the bed but touching the floor, and later was observed laying directly on the floor; the ADON stated the facility expected the drainage bag not to be on the floor and to be hung properly from the bed frame.
Failure to Inventory and Safeguard Resident Personal Belongings
Penalty
Summary
The facility failed to honor a resident's right to a safe, clean, comfortable, and homelike environment by not securing and accounting for the resident's personal belongings. During a complaint investigation, it was discovered that the facility could not account for several of the resident's items, including a phone charger, three white tee shirts, three ball caps, and a pair of sweatpants. Review of the resident's medical record and paper chart revealed that there was no personal belongings inventory sheet on file, despite the facility's policy requiring that all resident personal items be inventoried at admission and that documentation be retained in the medical record, with additional possessions added over time. In an interview, the Administrator confirmed that a search of both the electronic and paper medical records found no inventory sheet for this resident. This deficiency arose from the facility's failure to complete and maintain the required personal belongings inventory for the resident, which resulted in the inability to verify or locate the resident's missing items when the complaint was investigated.
Failure to Incorporate Dental and CKD Needs Into Comprehensive Care Plans
Penalty
Summary
Facility staff failed to develop and initiate comprehensive person-centered care plans that addressed all identified needs for two residents. For one resident, medical record review on 03/26/2026 showed that although contract dental services had been actively treating the resident, identifying dental issues, and working to replace the resident’s dentures, these dental problems and related interventions were not included in the resident’s care plan. The dental provider had documented completed and pending dental work, but this information was not reflected in the care planning documentation. For another resident, medical record review on 03/27/2026 revealed that a diagnosis of Chronic Kidney Disease (CKD), Stage 3, made by the primary provider and also identified during two emergency room visits at an acute care hospital within the prior eight months, was not incorporated into either the initial or current care plan. During an interview on 03/27/2026 at 2:20 PM, Employee #8 confirmed that the care plans for both residents were missing these identified elements.
Failure to Timely Address Pharmacist Medication Regimen Review Recommendations
Penalty
Summary
The deficiency involves the facility’s failure to ensure timely completion and follow-up of monthly Medication Regimen Reviews (MRRs) by a provider, and failure to respond to consulting pharmacist recommendations as required by facility policy. For one resident reviewed for unnecessary medications, the medical record showed MRR entries for two consecutive months documented only as “See [pharmacist’s] report,” without the actual reports initially available. The ADON described the facility’s MRR process, stating that the pharmacist emails the MRRs, she prints the recommendations, and then gives them to the NP to address, with the expectation that the provider will check agree/disagree/other, sign, and date the form. She further stated that some recommendations are implemented in the EMR by the NP, while others are passed to unit managers to enter, and that MRRs are to be completed before the next month’s review. When the surveyor requested the resident’s MRRs, the 1/8 MRR was not provided until the following day, and the 2/9 MRR was initially unavailable. Review of the 1/8 MRR showed a pharmacist recommendation to discontinue melatonin, with the provider marking “agree” and signing on 3/3, nearly two months after the recommendation. The 2/9 MRR, when later produced, contained the same recommendation to discontinue melatonin, but had no provider signature, date, or box checked, and the ADON acknowledged that both MRRs had been missed, noting she had been on vacation. The facility’s policy states that MRR irregularities must be reported to the attending physician, medical director, and DON, must be acted upon, and that non-urgent recommendations must be addressed and documented prior to the next scheduled review, which did not occur in this case.
Late Transmission of MDS Assessment
Penalty
Summary
The facility failed to transmit an MDS assessment within the required timeframe for one resident, Resident #53. The report states that each resident assessment must be encoded within 7 days and transmitted to CMS within 14 days of completion, but the February 2026 MDS for Resident #53 was not submitted within that period. A document provided by the MDS Coordinator showed the message, "Record Submitted Late: The submission date is more than 14 days after Z0500B on this new (A0050 equals 1) assessment," confirming the assessment was late. During interviews, the MDS Coordinator initially said she would check whether any data had been transmitted for Resident #53 in the last 120 days, then later provided the Final Validation Report showing a Target Date of 2/13/26 and a Submission Date/Time of 3/19/26 11:54 AM. When asked why it was submitted late, she stated her supervisor submits the MDSs. The Regional MDS later verified and confirmed that the assessment was submitted late and said she could not remember what happened.
Failure to Follow Midline IV Dressing Change Order
Penalty
Summary
The facility failed to follow provider orders for Resident #3’s midline IV dressing changes. On 3/23/2026, the resident was observed with a midline IV in the left arm, and the dressing was dated 3/17/2026. On 3/26/2026, the dressing was again observed with the same 3/17/2026 date. The resident’s medical record showed an active order dated 3/18/2026 directing that the midline insertion site dressing be changed every evening shift every Thursday and as needed, with initials, date, and time documented. On 3/27/2026, the Treatment Administration Record documented that the dressing change was performed on 3/19/2026 and 3/26/2026 by facility staff, but the midline dressing was observed that same day and was still dated 3/17/2026. The RN Supervisor reviewed the dressing with the surveyor and confirmed it was dated 3/17/2026, and also confirmed the TAR showed dressing changes documented as completed on 3/19/2026 and 3/26/2026. The RN Supervisor stated it was the facility’s expectation that orders checked off as performed in the TAR are completed.
Pest Control Program Failure with Gnats Observed on First Floor
Penalty
Summary
Failure to ensure an effective pest control program was identified when flying gnats were observed throughout the first floor of the building. During an environmental tour of the first floor unit, the surveyor observed a plethora of gnats flying in the hallway and a more concentrated amount of flies upon entrance into room [ROOM NUMBER]. While interviewing a resident in that room, the surveyor observed more than 20 gnats resting on the resident's right side of the bed and on the resident's privacy curtain. The resident stated that the flies are always in the room, but did not confirm or deny reporting the issue to facility staff. When the Director of Environmental Services toured the hallway and room with the surveyor, he confirmed the presence of the gnats.
Failure to Hold Timely Care Plan Meetings with Resident and Representative
Penalty
Summary
The facility failed to ensure that care plan meetings were scheduled quarterly and that both the resident and their representative were included in these meetings. Medical record review for one resident showed that the last official care plan meeting occurred nearly ten months prior, with the most recent documentation being a 'social determinants of health' note, which did not constitute a full care plan meeting. Interviews with the facility social worker confirmed regular communication with the family but no recent official care plan meeting. This deficiency was identified during a complaint investigation, and both the DON and Nursing Home Administrator acknowledged the lack of recent care plan meetings with the family.
Damaged Exit Door Kick Plates Create Unsafe Environment
Penalty
Summary
The facility failed to maintain the doors exiting the Arcadia unit in good repair, resulting in an environment that was not safe or comfortable for residents. Observations revealed that the double doors had plastic kick plates attached with multiple screws, and the right door had black tape covering the top and right side of the kick plate where it was coming loose. There were numerous cracks, chips, and jagged edges where the plastic had broken around the screws. At one point, a resident was observed standing at the door and picking at the jagged edges of the broken plastic kick plate. Facility leadership, including the NHA and DON, were notified of these concerns and observations.
Deficiency in Food and Nutrition Services Due to Lack of Qualified Staff
Penalty
Summary
The facility failed to employ sufficient staff with the appropriate competencies and skills to carry out the functions of the food and nutrition department, potentially affecting all residents. The Registered Dietitian (RD), who was supposed to provide oversight, had not been to the facility since July 2024 and worked part-time remotely. The Food Service Director (FSD) was also found to be unqualified for the position, as their ServSafe Certification did not meet the facility's job description or federal requirements. This lack of qualified personnel resulted in failures to provide palatable food, food alternates, snacks, and meals without extended timeframes between dinner and breakfast, as well as nutritional interventions to prevent unplanned weight loss. Interviews and document reviews revealed that the RD completed all work offsite and was not available for the survey conducted from December 3 to December 6, 2024. The Administrator confirmed that the RD was expected to work 24 hours a week remotely but was not providing the necessary onsite presence. The Regional Certified Dietary Manager and the FSD both acknowledged the lack of qualified personnel and the absence of the RD from the facility. The deficiencies were cross-referenced with tags related to food palatability, food substitutes, mealtimes, kitchen sanitation, and nutritional parameters.
Sanitation and Hygiene Deficiencies in Kitchen Operations
Penalty
Summary
The facility failed to maintain the kitchen in a sanitary manner, which could potentially spread foodborne illness to 126 out of 129 residents. The deficiency was identified through observations, interviews, document reviews, and policy reviews. The facility's dishwasher was not operating according to the manufacturer's specifications, with wash and rinse temperatures consistently below the required levels. Despite the facility's policy stating that the wash temperature should be between 150-165 degrees Fahrenheit and the rinse temperature should be 180 degrees or above, observations over three days revealed that the dishwasher's temperatures were frequently below these thresholds. The Regional Certified Dietary Manager (CDM) and the Maintenance Director acknowledged the issue, noting that the heating element was not functioning properly. Additionally, dietary staff did not adhere to proper hand hygiene and glove use when handling ready-to-eat foods, creating a risk of cross-contamination. Observations showed that staff members were using the same gloves to handle food and touch various surfaces and utensils without washing their hands or changing gloves between tasks. For instance, a cook was observed using gloved hands to handle bread and other items without changing gloves or washing hands, and another staff member was seen using gloved hands to handle hamburger buns and other items without proper hygiene practices. The Regional CDM was present during some of these observations and instructed staff on proper procedures, but the issues persisted. The facility's policies on dishwasher temperature and dietary employee personal hygiene were not followed, contributing to the deficiencies observed. The dishwasher temperature logs from previous months showed discrepancies, with recorded temperatures meeting the required levels despite observations to the contrary. The facility's failure to adhere to its own policies and ensure proper sanitation practices in the kitchen posed a risk to the residents' health and safety.
Failure to Maintain Sanitary Garbage Area
Penalty
Summary
The facility failed to maintain the outdoor garbage area in a sanitary manner over a period of three days, as observed by surveyors. On the first day, a significant amount of garbage was found strewn around the garbage compactor area, extending approximately fifteen feet away. The garbage included various items such as plastic, drink cartons, condiment packets, paper refuse, silverware, pieces of cardboard, garbage bags with trash, scrambled eggs, and disposable gloves. Both the Regional Certified Dietary Manager (CDM) and the Housekeeping Manager (HM) confirmed that the area was not sanitary and required cleaning. On the subsequent days, similar observations were made, with garbage extending approximately ten feet away from the compactor. Items observed included pieces of plastic, paper, disposable gloves, tin foil, plastic bottles, and cardboard. The Food Service Director (FSD) acknowledged that the presence of food in the garbage could pose a sanitation concern due to potential rodent access. The Regional CDM and HM reiterated the need for cleanup, and the HM stated that housekeeping was responsible for maintaining the cleanliness of the area. The facility's Administrator also expressed the expectation that housekeeping staff should keep the garbage area clean and free of accumulated garbage.
Failure to Provide Adequate Nutritional Interventions
Penalty
Summary
The facility failed to provide adequate nutritional interventions for two residents, R184 and R19, who experienced significant weight loss. R184, diagnosed with Alzheimer's disease and dysphagia, was not weighed weekly as required by physician orders and facility policy, despite a 24% weight loss over six months. Observations revealed that R184 was not served prescribed nutritional supplements like Magic Cups and house shakes during meals, and staff failed to offer meal alternatives when R184 refused to eat. Documentation inaccurately recorded R184's meal intake and supplement consumption, indicating a lack of adherence to prescribed dietary interventions. R19, with diagnoses including breast cancer and protein malnutrition, also experienced a significant weight loss of 13.30%. Observations showed that R19's prescribed nutritional supplements were not made accessible, as they were left unopened and out of reach without necessary utensils. The facility's dietary management was inadequate, with the Registered Dietitian working remotely and not visiting the facility since July 2024, which contributed to the lack of proper nutritional assessments and interventions for R19. Interviews with staff revealed a lack of understanding and implementation of procedures for offering meal alternatives and ensuring accurate documentation of residents' nutritional intake. The facility's failure to provide necessary nutritional support and accurate documentation for these residents highlights significant deficiencies in the care provided, contributing to their unplanned weight loss and nutritional risk.
Deficiency in Meal Quality and Temperature
Penalty
Summary
The facility failed to ensure that meals provided to residents were palatable, attractive, and served at safe and appetizing temperatures. Multiple residents reported dissatisfaction with the taste, temperature, and presentation of the food. Specific complaints included food being cold, bland, and not prepared according to the menu or recipes. Residents also noted that meals were sometimes delivered late, and condiments or necessary accompaniments were missing. These issues were consistently raised in resident council meetings over several months, indicating a persistent problem. Observations during meal service revealed deviations from standardized recipes, such as the addition of cinnamon and brown sugar to creamed corn, which was not part of the recipe. Test trays evaluated by the Regional Certified Dietary Manager (CDM) showed that hot foods were not reaching the desired temperature of at least 140 degrees Fahrenheit, and cold foods were not sufficiently chilled. The CDM confirmed the bland flavor and inappropriate temperatures of the meals served. The facility's policy on providing nourishing and palatable meals was not adhered to, as evidenced by the repeated complaints and observations. The residents' cognitive assessments indicated that most were cognitively intact, suggesting that their complaints were credible and reflective of their experiences. Despite awareness of these issues by the facility's administration and dietary management, the problems persisted, affecting the residents' satisfaction and potentially their nutritional intake.
Failure to Honor Resident Food Preferences and Provide Alternatives
Penalty
Summary
The facility failed to ensure that residents' food preferences and dislikes were assessed and honored, and that alternatives were available and offered to residents who did not eat what was served. This deficiency was observed in 10 out of 37 sampled residents, leading to potential weight loss and dissatisfaction among residents. The facility's policy required reasonable efforts to assess individual needs and preferences, and to provide alternative menus if the primary menu was not to a resident's liking. However, several residents reported that their food preferences were not considered, and they were not offered alternatives when they refused their meals. Multiple residents expressed dissatisfaction with the food service. One resident stated they were served the same breakfast every day and had not been consulted about their food preferences since admission. Another resident reported being served foods they could not eat, such as potatoes and oranges, and showed an unopened cup of orange juice as evidence. During a group meeting, residents shared experiences of requesting alternatives and being denied by staff, who claimed it was not their responsibility. Additionally, residents reported difficulties in contacting the kitchen to order from the Always Available menu, with calls going unanswered or being redirected. Observations during meal times revealed that some residents refused their meals and were not offered alternatives. For instance, one resident was served a meal they did not eat, and their tray was removed without any offer of an alternative. The facility's Regional Certified Dietary Manager acknowledged issues with recording food preferences on tray cards and stated that alternatives should be available. Despite the facility's policy, staff did not consistently offer alternatives, and the Resident Council Minutes indicated ongoing concerns with food preferences and the availability of alternatives.
Failure to Provide Adequate Snacks and Meal Timing
Penalty
Summary
The facility failed to meet the nutritional needs of four residents by not providing meals and snacks in accordance with their needs, preferences, and requests. The facility's policy stated that there should be no more than 14 hours between the evening meal and breakfast unless a nourishing snack is provided at bedtime. However, observations revealed that the time span between dinner and breakfast exceeded 15 hours for several meal carts, and residents reported not being offered snacks, with some staff consuming them instead. Interviews with residents and staff confirmed the lack of snack offerings and the extended time between meals. Residents expressed concerns about not receiving snacks, especially on weekends, and the absence of general snacks in the kitchenettes on various floors was noted. The Food Service Director and other staff were unaware of the extended meal times, and the Resident Council had not reviewed or approved the longer time span between meals. The Resident Council Minutes from December 2023 to October 2024 showed ongoing concerns about snack availability and meal timeframes, but there was no documentation of approval for the extended meal times. The facility's failure to provide adequate snacks and adhere to the policy on meal timing could potentially lead to health issues for the residents due to deficiencies in essential nutrients.
Infection Control Breach During Medication Administration
Penalty
Summary
The facility failed to ensure proper infection control practices were followed by an LPN during medication administration. During an observation, the LPN was seen retrieving a blister pack of Oxycontin for a resident. When attempting to dispense the medication, the tablet fell onto the top of the medication cart. The LPN then picked up the tablet with bare fingers and placed it into the medication cup with the resident's other medications. The LPN did not sanitize her hands after handling other medication blister packs and the medication cart drawers before touching the dropped medication. During an interview, the LPN stated she sanitized the cart in the morning and her hands before preparing the resident's medications, and she believed it was unnecessary to dispose of the pill. The facility's policy on medication administration indicated that medications should be removed from their source without touching them with bare hands.
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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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