Autumn Lake Healthcare at Glade Valley

Inspectors wroteBased on observation, interview and review of pertinent documentation it was determined that the facility failed to prepare, distribute and serve food in accordance with professional standards for food service safety. This deficient practice has the potential to affect all residents.

Inspectors wroteBased on observations and interviews, it was determined that the facility failed to ensure linens were processed in a manner that prevents cross contamination. This deficient practice had the potential to affect all residents of the facility.

Inspectors wroteBased on record review and interviews, it was determined that the facility failed to ensure that Minimum Data Set (MDS) assessments were accurately documented. This was evident for 3 (Residents #106, #5, #54) out of 6 Residents reviewed for Resident assessment. The Minimum Data Set (MDS) is an assessment of the Resident that provides the facility with the necessary information to develop a care plan, deliver appropriate care and services to the Resident, and modify the care plan based on the Resident's status. 1) A review of Resident #106's medical record on 5/27/26 at 1:57 PM included an occupational therapy (OT) evaluation and plan of treatment dated 2/24/26, noting that the Resident had a limited range of motion (ROM) in all extremities. However, further review of Resident #106's MDS assessment dated [DATE] showed one-sided impairment in the resident's upper- and lower-extremity ROM. [...]

Inspectors wroteBased on observations, record reviews, and interviews, it was determined that the facility failed to ensure a physician documented the resident's current health status and failed to write, sign, and date new orders during physician visits. This was evident for 1 (Resident #59) of 1 resident reviewed for transmission-based precaution and 1 (Resident #123) of 2 residents reviewed for respiratory care.

Inspectors wroteBased on interviews and observations, it was determined that the facility failed to treat residents with respect and dignity, as evidenced by failing to knock and request permission before entering a resident's room. This was evident for one (Resident #85) of one Resident reviewed for dignity.

Inspectors wroteBased on record review and interview, it was determined that the facility failed to notify residents' representatives when a resident's status changed. This was evident for 2 related complaints (#2737149, and #2735716) for one resident (Resident #125), of 5 complaints reviewed during the annual survey.

Inspectors wroteBased on record review and interview it was determined that the facility failed to provide a notice of transfer to a resident's representative when the resident transferred to the hospital. This was evident for two related complaints (#2737149 and #2745057 regarding a fall for Resident #125) of 5 complaints reviewed for hospitalization.

Inspectors wroteBased on record review and staff interviews, it was determined that the facility failed to complete comprehensive Minimum Data Set (MDS) assessments within regulatory time frames to maintain current and accurate assessment records. This was evident for 3 (Residents #42, #5, #26) of 6 residents reviewed for Resident Assessment.

Inspectors wroteBased on record review and staff interview, it was determined that the facility failed to complete a Significant Change in Status Minimum Data Set (MDS) assessment within 14 days of a resident's admission to hospice care. This was evident in one (Resident #8) of six residents reviewed for Resident assessment.

Inspectors wroteBased on medical record review and interview it was determined the facility failed to ensure nursing staff maintained professional standards in regard to documention of assessments. This was found to be evident for one (Resident #39) out of one resident reviewed for side rail usage.

Inspectors wroteBased on observations, interviews, and a review of records, it was determined that the facility failed to ensure that residents who required assistance with Activities of Daily Living (ADLs) received showers. This was evident for 2 (Residents #85, #8) of 6 Residents reviewed for ADLs.

Inspectors wroteBased on medical record review and interviews, it was determined that the facility failed to 1.) identify and follow up on a resident's significant abnormal laboratory value and 2.) ensure orders for psychiatric medications were kept active in the absence of a plan to reduce the dosage. This was evident in 1 complaint (#2735716 related to Resident #126) of 5 complaints reviewed during the annual survey, and 1 (Resident #3) of 5 residents reviewed for unnecessary medication.

Inspectors wroteBased on observations, record review, and interviews, it was determined that the facility failed to ensure that residents with a limited range of motion received treatment and services to prevent further decline in the range of motion. This was evident for one (Resident #106) out of one resident reviewed for position and mobility.

Inspectors wroteBased on medical record review, interview and observation it was determined that the facility failed to ensure informed consent was obtained prior to the initiation of side rails. This was found to be evident for one (Resident #39) out of one resident reviewed for side rail usage.

Inspectors wroteBased on medical record review and interview it was determined that the facility failed to ensure pain medications were administered within the ordered parameters. This was found to be evident for one (Resident #3) out of five residents reviewed for unnecessary medications.

Inspectors wroteBased on observation, record review, and staff interview, the facility failed to ensure medication refrigerator temperatures were consistently monitored and documented to verify that medications requiring refrigeration were stored within appropriate temperature ranges. This deficient practice was observed in 1 (Sugarloaf Unit) of 2 medication storage refrigerators reviewed.

Inspectors wroteBased on interview and review of facility documentation it was determined that the facility failed to have a qualified food service director. This was found to be evident for the one out of one food service director at the facility.

Inspectors wroteBased on interview, observation and review of menus it was determined that the facility failed to ensure menus were followed as posted. This was found to be evident for one (Resident #76) out of one resident included in the sample for review of food.

Inspectors wroteBased on medical record review and interview it was determined that the facility failed to ensure the psychiatric providers notes were accurately documented. This was found to be evident for one (Resident #3) out of five residents reviewed for unnecessary medications.

Inspectors wroteBased on administrative record review and staff interviews, it was determined that the facility staff failed to ensure that a resident was free of verbal abuse while in the care of a Geriatric Nursing Assistant (GNA). This was evident for 1 (#7) of 4 residents reviewed for abuse.

Inspectors wroteBased on administrative record review and staff interviews, it was determined that the facility staff failed to immediately report allegations of abuse to the facility administration and the state agency. This was evident for 1 (#7) of 4 residents reviewed for abuse.

Inspectors wroteBased on record review and resident and staff interviews it was determined the facility staff failed to conduct a thorough investigation of an allegation of abuse. This was evident for 1 (#5) of 5 residents reviewed for Abuse.

Inspectors wroteBased on medical record review, review of pertinent documents, and staff interviews, it was determined that the facility failed to provide the appropriate care for activities of daily living to residents for a resident who was dependent on staff for showers and bathing. This was evident for 1 (#) of 5 residents reviewed for quality of care.

Inspectors wroteBased on observations, record review, and interviews, it was determined that the facility staff failed to implement the use of a gait belt resulting in avoidable falls. This was evident for 1 (#14) of 6 residents reviewed for a complaint.

Inspectors wroteBased on record reviews and staff interviews, it was determined that the facility failed to conduct thorough investigations of an allegation of abuse. This was evident for 4 (Resident #9, #71, #77, #33) of 10 residents reviewed for abuse.

Inspectors wroteBased on observation and interview, it was determined that the facility failed to provide privacy to a resident during a dressing change. This was evident for 1 (Resident #108) of 4 residents observed for pressure ulcer care.

Inspectors wroteBased on observation, pertinent document review and interviews, it was determined that the facility failed to have an effective process in place to ensure that the residents receive their choices from the alternative menu. This was evident for 1(Resident #69) in a random dining observation.

Inspectors wroteBased on record review and interviews, it was determined that the facility failed to ensure that Beneficiary Protection Notifications were issued to residents discharged from Medicare Part A services but had benefit days remaining and intended to remain at the nursing facility receiving non-skilled care. This was evident for 2 (Resident #5, #39) of 3 residents reviewed for Skilled Nursing Facility Beneficiary Protection Notification.

Inspectors wroteBased on interviews and observation it was determined that the facility failed to maintain a clean home-like environment. This was evident for 1 shower room out of 2 shower rooms observed during a survey.

Inspectors wroteBased on record review and interviews, it was determined that the facility failed to identify a Grievance Official in the facility's grievance policy, and failed to ensure that grievances were followed up with a written response. This was evident for 5 of 5 grievance investigations reviewed during the recertification survey.

Inspectors wroteBased on a record review and interview it was determined that the facility failed to report a resident's allegation of missing money. This was evident for 1 (Resident #263) and was discovered during the investigation of the facility reported incident #MD00212599. During the survey 15 facility reported incidents were investigated.

Inspectors wroteBased on record review, interviews, and observation, it was determined that the facility failed to ensure that Minimum Data Set (MDS) assessments were accurately recorded. This was evident for 2 (Resident #39, #48) of 4 residents reviewed for limited range of motion (ROM), 1 (Resident #40) of 7 residents reviewed for unnecessary medications, and 1 (Resident #110) of 3 closed record reviews.

Inspectors wroteBased on pertinent document review and interviews, it was determined that the facility failed to perform a Pre-admission Screening and Resident Review (PASSAR) screen within 40 days of the resident admission. This was evident for 1 (Resident #69) out of 4 residents reviewed for PASSAR screening during a survey.

Inspectors wroteBased on record reviews and interviews, it was determined that the facility failed to develop and implement a baseline care plan. This was evident for 1 (Resident #369) of 4 residents reviewed for pressure ulcers and injuries.

Inspectors wroteBased on record reviews and interviews, it was determined that the facility failed to develop and implement a comprehensive care plan. This was evident for 1 (Resident #369) out of 4 residents reviewed for pressure ulcers and injuries.

Inspectors wroteBased on record review and interviews, it was determined that the facility failed to ensure that care plans were reviewed and revised after a change in a resident's condition. This was evident for 1 (Resident #48) of 2 residents reviewed for care planning.

Inspectors wroteBased on record reviews, interviews and observations, it was determined that the facility failed to ensure that residents who required assistance with Activities of Daily Living (ADL) were provided with showers and incontinence care. This was evident for 3 (Resident #57, #366, #365) of 3 residents reviewed for ADL.

Inspectors wroteBased on record review, and interviews, it was determined that the facility failed to ensure that medications and treatments were administered per physician orders. This was evident in 1 (Resident #363) of 53 residents reviewed during the survey.

Inspectors wroteBased on pertinent document review and interviews, it was determined that the facility failed to provide treatment for a pressure injury. This was evident for 3 (Residents # 364, #369 and #108) out of 4 Resident reviewed for Pressure injury during a survey.

Inspectors wroteBased on Interview and record review, it was determined that the facility failed to have an effective process in place to ensure that recommendations from therapy are communicated to the nursing staff, failed to provide treatment to maintain a resident's range of motion (ROM), and failed to provide necessary adaptive equipment during meals. This was evident for 2 (Residents #50, #48) out of 4 reviewed for position and mobility and 1 (Resident #108) of 4 residents reviewed for pressure ulcers during a survey.

Inspectors wroteBased on observation, interview, and record review, it was determined that the facility failed to provide proper urinary catheter care. This was evident for 1 (Resident #108) reviewed during the initial screening of the 32 residents of the Catoctin unit during the recertification survey.

Inspectors wroteBased on observations, record reviews and interviews, it was determined that the facility failed to have an order in place for oxygen administration and failed to follow an attending physician's order to administer oxygen to a resident. This was evident for 2 Resident (Resident #74, #315) of 3 residents reviewed for Respiratory Care during the survey.

Inspectors wroteBased on review of employee files and staff interviews, it was determined that the facility failed to conduct annual nursing staff performance reviews ensuring competencies in their skills. This was evident for 5 out of 5 employee files (#3, #15, #26, #36 and #39) reviewed for skill competencies during the recertification survey.

Inspectors wroteBased on review of Geriatric Nursing Assistant (GNA) personnel files and staff interview, it was determined that the facility staff failed to conduct yearly performance reviews and ensure twelve (12) hours of annual in-service education was provided. This was evident for 2 (GNA #15 and GNA #36) of 2 personnel files reviewed during the recertification survey.

Inspectors wroteBased on record reviews and interviews, it was determined that the facility failed to ensure that a controlled substance logbook was signed by 2 licensed staff at change of shifts. This was evident for 1 of 4 controlled substance logbooks inspected during the survey.

Inspectors wroteBased on medical record review and interviews, it was determined that the facility failed to ensure that the attending physician reviewed irregularities identified by the pharmacist, acted upon them in a timely manner, and documented them in the Resident's medical record. This was evident for 1 (Resident #40) of 7 residents reviewed for unnecessary medications.

Inspectors wroteBased on records review and interviews, it was determined that the facility failed to ensure non-pharmacological interventions were provided or attempted prior to administering a psychotropic medication. This was evident for 1 (Resident #371) of 7 residents reviewed for unnecessary medications.

Inspectors wroteBased on observations and record reviews, it was determined that the facility failed to ensure medications were stored and labeled properly as evidenced by failing to discard expired medications and failing to date medications when they were opened. This was evident in 1 of 2 medication storage rooms and 3 of 4 medication carts inspected during the survey.

Inspectors wroteBased on interview, observation and pertinent document review, it was determined that the facility failed to have a process in place to ensure that Residents receive their meal in a timely manner and at a palatable temperature. This was evident for 1 of 1 food test tray reviewed during a survey.

Inspectors wroteBased on record review, observation, and staff interview, it was determined that the facility failed to ensure care documentation was accurate. This was evident for 1 (Resident #108) of 4 residents reviewed for pressure ulcer care.

Inspectors wroteBased on observation, interview and record review, it was determined that the facility failed to ensure infection prevention and control practices were followed when 1) an unlabeled, uncovered bedpan was left on the handrail in a resident's bathroom, and 2) hand hygiene was not performed during a dressing change of a pressure ulcer. This was evident for 1) 1 (Resident #109) of 6 residents in the initial screening pool, and 2) 1 (Resident #108) of 4 residents reviewed for pressure ulcer care.

Inspectors wroteBased on interview and observation it was determined that the facility failed to maintain a Residents shower rooms in good repair. This was evident for 1 out of 2 resident shower rooms observed during a survey.

Inspectors wroteBased on record reviews of employee files and staff interviews, it was determined that the facility failed to develop a system that provides and tracks the required training for dementia management, abuse, neglect, exploitation, and misappropriation of resident property. This was evident for 5 of 5 random employee files (Staff #3, #15, #26, #36 and #39) and 1 employee reviewed for an allegation of abuse during the survey.

Inspectors wroteBased on a record review of a facility reported incident, employees' file and staff interviews, it was determined that the facility failed to ensure Geriatric Nurse Assistants (GNA's) received training that included dementia management, abuse, neglect, exploitation, and misappropriation of resident property. This was evident for 4 of 4 GNA's employee files (#15, #21, #29 and #36) reviewed during the recertification survey.

Inspectors wroteBased on medical record review and interview, it was determined that the facility failed to ensure that residents were safe from accidents during mechanical lift transfers which resulted in harm to resident #16. This was evident for 1 (#16) of 1 resident reviewed for accidents.

Inspectors wroteBased on record review and interview, it was determined that the facility failed to ensure that their residents were free of misappropriation of property as evidenced by a staff member taking a resident's personal property from the facility without their permission. This was evidenced by 1 (#13) of 12 residents reviewed for abuse.

Inspectors wroteBased on record review and interview, it was determined that the facility failed to employ a qualified Activity Director. This was evident for 1 of 1 Activity Director.

Inspectors wroteBased on record review and interview, it was determined that the facility failed to provide a resident quality care based on standards of professional practice for a pressure ulcer/injury. This was evident for 1 (#14) of 3 resident reviewed for pressure ulcer/injury.

Inspectors wroteBased on record review and staff interview, it was determined that the facility failed to have a process in place to ensure that nurse aides were receiving performance evaluations annually and that in-services training was provided to the nurse aide based on the outcome of the performance evaluation. This was evident for 2 of 2 staff reviewed for annual performance evaluations.

Inspectors wroteBased on record review and staff interview, it was determined that the facility failed to provide training to staff related to mental and psychosocial disorders that affected residents with trauma and a history of post-traumatic stress disorders as evidenced by those residents being identified in Facility Assessment Tool, however, there was no documentation that such training was provided to staff. This was evident for 4 (#60, #61, #62, and #63) of 4 facility staff reviewed.

Inspectors wroteBased on surveyor observation and resident interview, it was determined that the facility failed to provide a safe, clean, comfortable and homelike environment. This deficient practice had the potential to affect multiple residents.

Inspectors wroteBased on clinical record and policy reviews, and staff interview, it was determined that the facility failed to implement a thorough investigation according to the abuse policy for 9 (#200, #204, #209, #210, #11, #69, #83, #35, #88) of 32 residents reviewed for abuse during an annual survey.

Inspectors wroteBased on medical record review, facility policy reviews, and staff interview, it was determined that the facility failed to 1) ensure all allegations of abuse were timely reported to the appropriate state regulatory authority within the required time period and 2)ensure the procedures included in the document that was being utilized as their policy were implemented as evidenced by the failure to report allegations of abuse in a timely manner. This was evident for 11 (#95, #98, #99, #195, #197, #200, #202, #216, #35, #88, #69) of 32 residents reviewed for abuse during the annual survey.

Inspectors wroteBased on medical record review, facility policy reviews, and staff interview, it was determined that the facility failed to timely report allegations of abuse and the results of the investigations within the regulatory timeframes. This was evident for 10 (#95, #98, #99, #195, #197, #200, #202, #216, #35, #88) of 32 residents reviewed for abuse during the annual survey.

Inspectors wroteBased on clinical record and policy reviews, and staff interview, it was determined that the facility failed to thoroughly investigation allegations of abuse for 11 (#200, #204, #209, #210, #11, #69, #83, #35, #88, #69, #83)) of 32 residents reviewed for abuse during an annual survey.

Inspectors wroteBased on medical record review and staff interview, it was determined the facility staff failed to ensure that Minimum Data Set (MDS) assessments were accurately coded. This was evident for 1(#196) of 14 residents reviewed for falls, 2 (195, #206) of 32 residents reviewed for abuse and 1 (#95) of 3 residents reviewed for hospitalization during the annual survey.

Inspectors wroteBased on record reviews and staff interview, it was determined that the facility failed to develop and implement comprehensive person centered care that were resident specific with measurable objectives and goals. This was evident for 4 (#196, #36, #62, #40) of 92 residents reviewed during the annual survey.

Inspectors wroteBased on medical record review and staff interview, it was determined the facility staff failed to review and revise the interdisciplinary care plans to reveal up to date interventions for residents who requested for certain staff not to care for them. This was evident for 6 (#95, #96, #210, #97, #24, #84) of 92 residents reviewed during the annual survey.

Inspectors wroteBased on review of medical records and other pertinent documentation, and interview, it was determined that the facility failed to ensure that nursing staff did not erroneously document the administration of medications that were not available for administration. This was found to be evident for 1 (Resident #295) out of the 4 residents whose medical records were reviewed as part of the medication administration task.

Inspectors wroteBased on observation, resident and staff interview, and medical record review , it was determined the facility failed to ensure the physician addressed the resident's need for and use of oxygen in his assessment, failed to include orders for the use and monitoring of oxygen therapy, and failed to develop a care plan that included goals and interventions for respiratory care for a resident with a known history of respiratory issues. This was evident for 2 (#296, #84) of 4 residents reviewed for respiratory care during the annual survey.

Inspectors wroteBased on observation, interview and review of documentation, it was determined that the facility failed to 1) ensure that expired medications and supplies were removed from medication storage areas and to ensure regular monitoring of the medication refrigerator temperature, 2) to keep medication carts locked and secured when unattended to prevent access from residents and unauthorized individuals and 3) to document administration of a controlled substance after signing out the medication on the controlled substance log . This was evident for 1 of 3 nursing units observed during an annual survey. This was found to be evident for two out of the two medication storage rooms, 1 of 3 nursing units and 1 (#62) of 5 residents reviewed for pain, respectively.

Inspectors wroteBased on observation, record review and staff interview, it was determined that facility staff failed to 1) implement infection control policies as evidenced by facility staff failing to date and initial oxygen tubing to ensure it was changed as needed and failed to change the normal saline by the expiration date written on the container and 2) failing to wear appropriate Personal Protective Equipment (PPE) prior to entering an identified isolation room [ROOM NUMBER] of a resident on contact precautions. This was evident for 2 of 92 residents (#84, #296) and one Geriatric Nursing Assistant (GNA#5) observed during the survey.

Inspectors wroteBased on observations and interviews with staff, it was determined that the facility failed to ensure that residents had a means of directly contacting staff. This was evident for 2 showers in the Sugarloaf Units shower room.

Inspectors wroteBased on observations and interviews, it was determined that the facility failed to ensure that residents received their meals in a timely manner. This was found to be evident for 2 (resident # 349 & #367) out of 6 resident observed during the survey.

Inspectors wroteBased on review of medical records, facility documentation and interviews, it was determined that the facility failed to ensure residents were free from misappropriation of property as evidenced by the removal of narcotic medication from residents' supply without administering the medication to the resident. This was found to be evident for two (Resident #145 and #146) out of the 32 residents reviewed for abuse during the survey.

Inspectors wroteBased on medical record review and staff interview, it was determined that the facility failed to have an effective system in place to ensure that baseline care plans addressed all of the residents needs as evidenced by failure 1) to address pain management for a resident with pain related to a recent procedure; and 2) failed to address a residents respiratory interventions and goals for a resident with chronic lung disease. This was evident for 2(resident # 296 and # 298) of 2 residents reviewed for base line care plans during the annual survey.

Inspectors wroteBased on medical record review and interviews, it was determined that the facility failed to provide evidence of the implementation of an ongoing program of activities that met the needs of Residents # 16, and #45 that was based on their abilities, interests and treatment . This was evident for 2 of 6 residents reviewed for activity needs during this annual survey.

Inspectors wroteBased on observation, record reviews and interviews, it was determined the facility failed to ensure the safety of the resident by not implementing fall precautions. This was found to be evident for 1 (resident # 92) out 3 residents reviewed for falls.

Inspectors wroteBased on medical record review and interview with facility staff, it was determined that a facility physician failed to include treatment orders and documentation about the continued appropriateness of the resident's current treatment regimen. This was evident for 1 (Resident # 296) of 4 residents reviewed for respiratory care during the annual survey.

Inspectors wroteBased on observation, interview and review of records and policies, it was determined that the facility failed to 1) ensure that counts of controlled substances were completed by two nurses at the change of shifts 2) that the narcotic counts were accurate for all controlled medications, 3) ensure that narcotics removed from the supply were administered to the residents as evidenced by failure to document the need for, request of, or administration to the resident, and 4) have an effective system in place to ensure regularly scheduled medications were re-ordered in a timely manner to ensure residents did not miss doses. [...]

Inspectors wroteBased on record review and interview, it was determined that the facility staff failed to ensure that residents were not prescribed unnecessary medication as evidenced by a physician's order for pain medication for Resident #62 that had not been administered for 4 months. This was evident for 1 (#62) of 5 Residents reviewed for pain management.

Inspectors wroteBased on medical record review and staff interview, it was determined that facility staff failed to ensure that a resident's medication regimen was free of unnecessary psychotropic medications as evidenced by the failure to monitor behaviors that attributed to the need for the psychotropic medication. This was evident for 1 (#40) of 12 resident reviewed for unnecessary medications.

Inspectors wroteBased on observation and medical record review, it was determined that the facility failed to ensure a medication error rate of less than 5% as evidenced by the identification of 3 errors out of 31 opportunities for error observed during a medication pass observation. The errors were identified related to one (Resident #295) out of the four residents whose medication administrations were observed during the survey.

Inspectors wroteBased on medical record review and interview, it was determined that the facility staff failed to maintain medical records in the most complete and accurate form. This was evident for 2 (#97, #84) of 92 residents selected for review during the annual survey process.

Inspectors wroteBased on record review and staff interview, it had been determined that the facility failed to ensure that Geriatric Nursing Assistants (GNA) had the required 12 hours of in-service training based on needs identified through performance evaluation and the required training subjects. This was evident for 2 (#62, and #63) of 2 staff reviewed for training requirements.

Inspectors wroteBased on observation, record review, and staff interview, it was determined that the facility staff failed to document and calculate nurse staffing information daily basis, therefore had not retained these records for 18 months and failed to post nurse staffing information on a daily basis at the beginning of each shift. This was evident for 22 of 25 days reviewed for required posting information and 22 of 22 days reviewed for the posting.

Inspectors wroteBased on review of facility records and interview with staff, it was determined that the facility failed to conduct and document an accurate facility-wide assessment as evidenced by the failure to provide a quantitative date regarding the amount of staff needed each shift to care for the residents, failure to include that a Registered Nurse was required 24 hours and 7 days a week, and the need for education for staff regarding Behavioral Health needs of the residents. This was evident during the review of staffing and had potential to affect all residents in the facility.