Adelphi Nursing And Rehabilitation Center
Inspection history, citations, penalties and survey trends for this long-term care facility in Adelphi, Maryland.
- Location
- 1801 Metzerott Road, Adelphi, Maryland 20783
- CMS Provider Number
- 215064
- Inspections on file
- 20
- Latest survey
- October 20, 2025
- Citations (last 12 mo.)
- 3
Citation history
Health deficiencies cited at Adelphi Nursing And Rehabilitation Center during CMS and state inspections, most recent first.
A resident with a history of atrial fibrillation, heart failure, and severe cognitive impairment was admitted with a pacemaker, but the care plan did not include any interventions or monitoring instructions for the device. Although staff were informed of the pacemaker through an order, the care plan lacked specific guidance on its management, as confirmed by interviews with the resident and the DON.
Licensed staff did not have or follow orders to monitor a resident's pacemaker, and the care plan lacked interventions for device monitoring. In a separate case, after a resident with mobility and cognitive issues fell, staff moved the resident without notifying a nurse or obtaining an assessment, contrary to facility policy. Both incidents involved failures to follow established protocols for medical device monitoring and fall management.
The facility did not document a behavioral incident involving a resident with psychiatric diagnoses who became aggressive with staff, nor did it ensure accurate transcription of a medication order, resulting in a medication being recorded for the wrong resident. Staff interviews confirmed that required documentation and verification procedures were not followed.
Surveyors found that several residents did not receive wound and skin care treatments as ordered by a wound NP, including missed or delayed applications of ointments, emollients, and dressings, and incomplete documentation of care. Care plans identified the need for these interventions, but the facility did not consistently implement or record them.
A review of medication records and staff interviews revealed that multiple nurses failed to document the administration of PRN narcotic medications in the MAR, despite signing them out in the controlled substance log book. This discrepancy was identified for several residents, indicating that the facility's policy requiring documentation in both the MAR and controlled substance log was not consistently followed.
Surveyors identified improper storage and labeling of food items, unsanitary conditions in kitchen and nourishment rooms, and incorrect dish handling practices. Observations included unsealed and unlabeled bulk foods, undated opened beverages, debris and insects on kitchen windowsills, and a resident-use ice machine with visible contamination.
Surveyors found that the facility did not provide adequate maintenance services, resulting in stained ceiling tiles, dirty air conditioning units, torn window screens, and patched ceiling holes in several rooms. Widespread peeling paint was also observed in many second-floor rooms and hallways, with staff confirming the issue had persisted for some time. Facility leadership acknowledged the ongoing problems and the lack of a clear timeline for repairs.
A resident assessed to need side rails for bed mobility did not have timely access to them, despite documented family preference and care plan interventions. Delays in obtaining physician orders resulted in the resident being without the required mobility device for several days after both initial assessment and readmission.
A resident with scheduled dialysis orders did not receive a required treatment because both dialysis and facility staff failed to recognize the omission, and the resident was not listed on the dialysis schedule. The missed session was only discovered after a call from the resident's representative, and by then, it was too late to provide the treatment.
Surveyors found that two residents were not provided with information about their right to formulate advance directives, as required. In both cases, documentation was either missing or incorrect, and staff confirmed that there was no evidence the residents had been offered this information.
A resident's medication was incorrectly coded as insulin instead of a hypoglycemic agent on the MDS assessment. Review of the MAR and discussion with the MDS Coordinator confirmed the error in medication classification.
Surveyors identified that two residents did not have accurate or complete care plans reflecting their current medical conditions and needs. One resident with an ileostomy and on hemodialysis was incorrectly documented as incontinent, while another resident's care plan failed to address a new pain complaint and lacked specific details. The DON and NHA confirmed the care plans were not person-centered or complete.
The facility did not consistently invite two residents to participate in their care plan meetings or conduct care plan meetings after each MDS assessment, as required. One cognitively intact resident was not documented as being invited or present at care plan meetings, and another resident had no documented care plan meetings following multiple MDS assessments, with a scheduled meeting not occurring as planned.
A resident who was dependent on staff for ADL care and cognitively intact did not consistently receive showers as ordered in their care plan. Documentation was inconsistent, with some records indicating showers were given, while others showed refusals or lacked explanation for missed showers. The resident reported only receiving bed baths and not being offered showers, and interviews with the NHA confirmed the inconsistency in providing necessary hygiene services.
Two residents with physician orders for continuous oxygen therapy were observed without their oxygen supply during and after transport to dialysis. In both cases, staff failed to ensure the oxygen concentrators accompanied the residents, resulting in periods where the nasal cannula was not connected to supplemental oxygen, despite documented orders and care plans requiring continuous administration.
Staff failed to document the administration of PRN narcotic medications in the MAR for three residents, despite signing out the medications in the controlled substance log. This resulted in multiple undocumented administrations, contrary to facility policy requiring documentation in both records.
Staff did not follow infection prevention protocols for a resident with a PEG tube, including leaving an incorrectly dated water flush bag, unlabeled tube feeding bottles, and failing to remove an old, odorous Xeroform strip from the tube site. The required daily dressing change was not completed as ordered, and the presence of the Xeroform strip was unexplained by staff.
A resident was observed being transported in a recliner chair that did not steer properly and had a faulty reclining mechanism, causing abrupt movements of the head and foot sections. A GNA reported that all similar chairs were in this condition, and a UM confirmed the malfunction.
A resident was found with a mattress that did not fit the bed frame, causing it to hang over the sides and not lay flat. Staff were aware of the issue, but maintenance procedures were unclear and documentation of required bed audits could not be provided. The Director of Maintenance could not confirm the mattress type or origin, and no records of annual bed inspections were available.
Garbage bags were left unattended in a hallway after a GNA placed them outside resident rooms following her rounds. The DON confirmed that this practice was not in accordance with facility policy, as garbage should be taken directly to the dirty utility room.
The facility did not consistently notify residents' legal representatives or responsible parties of changes to the plan of care, as required. In several cases, residents with guardians or responsible parties had changes in care or important notices provided without proper documentation that their representatives were informed or had acknowledged these changes, leading to inconsistencies in records and communication.
Surveyors identified that the facility did not maintain accurate and complete medical records for two residents. One resident's care plan and clinical notes inaccurately documented incontinence status despite a history of ileostomy and hemodialysis. In another case, a resident's complaint of wrist pain led to orders for Tylenol and a STAT X-ray, but the MAR did not show Tylenol administration and the X-ray results were missing from the chart until later requested by the DON.
Surveyors observed bugs in a resident's room, an elevator, and dead insects and debris on kitchen windowsills, indicating a failure to maintain an effective pest control program. Pest management records showed repeated treatments for roaches and fruit flies in resident rooms, but no evidence of preventative measures in new resident locations or adequate kitchen cleanliness.
Failure to Address Pacemaker Care in Resident's Care Plan
Penalty
Summary
The facility failed to develop and implement a care plan that addressed the monitoring and care of a resident's pacemaker. Despite the resident having a documented medical history of atrial fibrillation, heart failure, and severe cognitive impairment, the care plan did not include any focus area or interventions related to the presence or management of a pacemaker. The resident's admission records and Minimum Data Set assessment confirmed these diagnoses and cognitive status, and the care plan only addressed risks for cardiac complications without specifying the pacemaker. Further review of the resident's order summary revealed an order indicating the presence of a pacemaker, with instructions for staff to be aware of this every shift. However, there were no corresponding interventions or guidance in the care plan for staff on how to monitor the pacemaker for proper functioning. Interviews with the resident and the Director of Nursing confirmed the existence of the pacemaker and the expectation that it should be addressed in the care plan, but this was not done.
Failure to Monitor Pacemaker and Inadequate Response to Resident Fall
Penalty
Summary
Licensed nursing staff failed to obtain and follow orders for monitoring a resident's pacemaker for proper functioning. The resident, who had a history of cardiomyopathy, heart assist device, and congestive heart failure, was admitted with a pacemaker, but the care plan did not include interventions for pacemaker monitoring. The only order present was an informational note about the presence of a pacemaker, with no directive for staff to monitor its function. Interviews confirmed that the resident could not recall the last time their pacemaker was checked, and facility leadership acknowledged that no monitoring was being performed by staff. In a separate incident, staff failed to follow facility policy regarding the management of resident falls. A resident with muscle weakness, difficulty walking, and moderate cognitive impairment fell out of bed. The assigned Geriatric Nursing Assistant (GNA) enlisted the help of a housekeeper to lift the resident back into bed without notifying a licensed nurse or having the resident assessed prior to being moved, as required by policy. The fall was not reported to nursing staff until the following day, after the resident complained of leg pain. Both deficiencies were identified through interviews, record reviews, and policy review, which revealed that staff did not follow established protocols for monitoring medical devices and responding to resident falls. The lack of appropriate orders and failure to report and assess a fall before moving the resident directly contributed to the deficiencies cited.
Failure to Document Behavioral Incident and Medication Order Transcription Error
Penalty
Summary
The facility failed to document a behavioral incident involving a resident with a history of bipolar and delusional disorders. The incident occurred when the resident became agitated, was verbally aggressive, and struck the Human Resources Director, prompting law enforcement involvement. Multiple staff interviews confirmed that the event was not recorded in the resident's medical record, progress notes, or risk management forms, despite facility policy requiring documentation of significant changes in condition and behavioral incidents. The lack of documentation was acknowledged by the Assistant Director of Nursing, Director of Nursing, Unit Manager, and Administrator, all of whom stated that such incidents should be recorded to ensure proper monitoring and follow-up. Additionally, the facility failed to ensure accurate transcription of medication orders for another resident. A nurse transcribed a medication order for tranexamic acid onto a resident's Medication Administration Record (MAR) without verifying that the order was actually prescribed to that resident. The error occurred because the nurse did not check the name on the hospital discharge paperwork, resulting in a one-time dose of medication being recorded for the wrong individual. The Director of Nursing and Administrator confirmed that the transcription error was due to a failure to match the resident's name with the correct medication order from the hospital discharge summary.
Failure to Provide Ordered Skin and Wound Care Treatments
Penalty
Summary
The facility failed to provide treatments and care according to the orders and recommendations of a wound Nurse Practitioner (NP) for multiple residents with skin care needs. In several cases, the prescribed wound care treatments, including cleansing, application of ointments, and use of emollients, were either not performed as frequently as ordered or were not documented as completed. For example, one resident with chronic wounds and severe dryness was supposed to receive wound care twice daily, but records showed it was only done once per day, and there was a delay in initiating recommended emollient therapy. Another resident with multiple scabbed areas and dry, flaky skin was observed without the recommended dressings, and the treatment administration record indicated that while a topical corticosteroid was applied, other aspects of the care plan, such as Vaseline application and leg wrapping, were not documented as completed. Additional residents with dry, cracked, or flaky skin had recommendations for daily emollient use and other preventive measures, but there was no documentation that these treatments were provided as ordered. Throughout the review, the surveyor noted that the care plans for these residents identified their risk for skin breakdown and the need for specific interventions, yet the facility did not consistently implement or document the recommended treatments. Interviews with the Nursing Home Administrator confirmed that the concerns regarding the lack of adherence to the wound NP's recommendations were reviewed during the survey.
Failure to Document PRN Narcotic Administration in MAR
Penalty
Summary
Surveyors determined that the facility failed to ensure nursing staff were competent in medication administration, specifically regarding the documentation of PRN narcotic medications. During the recertification survey, a review of records and staff interviews revealed that 21 out of 59 licensed nursing staff did not properly document the administration of PRN narcotic medications in the Medication Administration Record (MAR), despite these medications being signed out in the controlled substance log book. This discrepancy was observed during a review of the controlled substance log book on the first floor medication cart, where PRN narcotic medications were signed out but not recorded in the MAR for several residents. The facility's policy requires that after administering medication, staff must document the administration in the MAR or Treatment Administration Record (TAR) and, if necessary, in the controlled substance sign out record. However, surveyors found that this policy was not consistently followed by the nursing staff. The Director of Nursing confirmed that the expectation is for all administered medications to be documented in the MAR, and a list of staff who failed to do so was provided. The Quality Assurance/Staff Development RN also acknowledged the issue during interviews, noting that medication administration competencies are observed monthly or more frequently if needed, but the documentation lapses persisted among the identified staff.
Deficient Food Storage and Sanitation Practices Identified
Penalty
Summary
Surveyors observed multiple deficiencies in the facility's kitchen and nourishment rooms related to improper storage and sanitation of food items and utensils. Specifically, nine large cans of green peas lacked clear delivery and expiration dates, and several bulk food items such as cornstarch, parboiled rice, and orzo pasta were found opened, unsealed, or without labels. Cleaned red cereal bowls were stacked face up, contrary to proper procedure, which could allow water to collect. Additionally, debris, dark spots, and dead insects were found on kitchen windowsills near critical food preparation and storage areas. Further inspection of nourishment rooms revealed the absence of a thermometer in a refrigerator, and several food and beverage items were either undated or had unclear labeling. In the freezer, multiple Styrofoam cups with frozen liquid were also missing date labels. The ice machine used by residents was found to have a black substance on the dispensing flap and rust around the storage bin. These findings indicate failures in maintaining sanitary conditions and proper food storage practices as required by professional standards.
Failure to Maintain Clean and Homelike Environment Due to Maintenance Deficiencies
Penalty
Summary
Surveyors identified that the facility failed to maintain a safe, clean, comfortable, and homelike environment for residents. Observations revealed multiple deficiencies in resident rooms, including stained ceiling tiles, dirty and debris-filled air conditioning units, open windows with torn screens, and patched ceiling holes with surrounding stains. These issues were noted in several specific rooms, and not all were included in the facility's maintenance report. The Maintenance Director acknowledged ongoing problems with building leaks and broken window screens, and the Nursing Home Administrator confirmed that staff are expected to report such maintenance concerns. Additionally, surveyors observed widespread peeling paint in 19 rooms and hallways on the second floor, particularly behind beds and chairs. Staff interviews confirmed that the peeling paint had been an ongoing issue, with multiple requests for repairs submitted. The Maintenance Director recognized that paint debris could pose a health hazard but was unable to provide a timeline for completion of the repainting project. The Administrator agreed that the persistent environmental issues were a concern.
Failure to Provide Timely Access to Mobility Device
Penalty
Summary
Facility staff failed to ensure that a resident assessed to need a mobility device, specifically side rails, had timely access to the device. The resident's care plan, initiated on 1/14/25, documented the family's and guardian's preference for side rails, and a bed side rail tool completed on 1/21/25 confirmed consent for their use as an enabler for mobility. Despite these assessments and documented preferences, there was a delay in obtaining a physician's order for the side rails, with the first order not written until 1/29/25. This order was discontinued shortly after due to the resident's transfer out of the facility on 1/30/25. Upon the resident's readmission, the care plan continued to indicate the need for side rails, but no new order was written until 2/7/25, several days after the resident's return. Observations during this period showed the resident in bed without side rails present, despite the documented need and care plan interventions. The deficiency centers on the facility's failure to promptly provide the mobility device as assessed and care planned, resulting in the resident not having access to the required side rails for an extended period.
Missed Dialysis Treatment Due to Scheduling Oversight
Penalty
Summary
A deficiency was identified when a resident with a provider order for dialysis on Tuesdays, Thursdays, and Saturdays did not receive the required dialysis treatment on one scheduled day. Record review showed no treatment notes for the missed session, and interviews revealed that both dialysis and facility staff failed to recognize the missed treatment. The Dialysis Clinical Manager confirmed the missed session and stated that by the time the issue was discovered, it was too late to provide the treatment, and the dialysis center was subsequently closed due to weather. The Director of Nurses reported that the facility only became aware of the missed treatment after a phone call from the resident's representative, and that the resident was not on the dialysis schedule, which led to staff not realizing the omission. The resident was monitored for symptoms, but no issues were reported as a result of the missed treatment.
Failure to Inform Residents of Right to Formulate Advance Directives
Penalty
Summary
The facility failed to inform residents of their right to formulate advance directives, as evidenced by the review of two residents' records. For one resident, a psychosocial assessment documented that the resident did not have advance directives, but there was no documentation indicating that information about initiating advance directives was offered. For another resident, conflicting documentation was found regarding the presence of advance directives, and it was later clarified by staff that the resident did not have any. In both cases, interviews with facility staff and administration confirmed that there was no documentation to show that these residents were offered information about formulating advance directives. These findings were based on record reviews and staff interviews, which revealed a lack of proper documentation and communication regarding residents' rights to be informed about and to formulate advance directives.
Inaccurate MDS Medication Coding
Penalty
Summary
The facility failed to accurately code a resident's medication on the Minimum Data Set (MDS) assessment. During a review of one resident's medical record, surveyors found that the quarterly MDS indicated the resident received an injection of insulin for one day. However, examination of the Medication Administration Record (MAR) for the same period showed that the resident was administered Trulicity by injection, which is a hypoglycemic agent, not insulin. Upon review with the MDS Coordinator, it was confirmed that Trulicity had been incorrectly coded as insulin on the MDS assessment.
Failure to Develop Comprehensive, Person-Centered Care Plans
Penalty
Summary
The facility failed to develop comprehensive, person-centered care plans for two residents. For one resident, the medical record showed a history of ileostomy and hemodialysis, with no urine output, following a recent hospital readmission. However, the care plan inaccurately documented the resident as incontinent of bladder and/or bowels due to medication use and impaired mobility. This discrepancy was confirmed by the DON during an interview, acknowledging the care plan did not reflect the resident's actual condition. For another resident, after reporting new pain in the left foot following a treatment, the care plan was found to be incomplete and not resident-centered. The care plan only noted a risk for pain and constipation, without specifying causes or addressing the new complaint. The NHA confirmed during an interview that the care plan lacked completeness and person-centered details.
Failure to Invite Residents and Conduct Timely Care Plan Meetings
Penalty
Summary
The facility failed to ensure that residents were invited to participate in their care plan meetings and that care plan meetings were conducted after each Minimum Data Set (MDS) assessment, as required. In the case of one resident, who was cognitively intact as indicated by a BIMS score of 15, there was no documentation that the resident was invited to or attended care plan meetings following admission. The only invitation on record was sent to the resident's guardian, and there was no note in the medical record indicating that the resident was invited or declined to attend. The Social Work Coordinator acknowledged that she did not document the resident's invitation or declination, and there was no explanation for the resident's absence from subsequent care plan meetings. For another resident, there was no documentation of care plan meetings being conducted after multiple MDS assessments throughout the year. Although a care plan meeting was scheduled, the resident was not present at the scheduled time, and there was no record of who attended the meeting or if it was conducted. The lack of documentation persisted until a care plan meeting was finally documented at a later date. These findings were confirmed through interviews with facility staff and review of medical records.
Failure to Provide Ordered Showers and Maintain Hygiene for Dependent Resident
Penalty
Summary
A deficiency was identified when a cognitively intact resident, who was dependent on staff for activities of daily living, reported only receiving bed baths and not being offered showers as per their care plan. The resident's medical record included an order for showers twice weekly on specific days and shifts. Documentation reviewed by the surveyor showed inconsistencies: only three showers were documented in the point of care system, while shower sheets indicated refusals on some dates and a lack of explanation for missed showers on others. Additionally, the Treatment Administration Record (TAR) showed showers marked as given on multiple dates, but corresponding shower sheets were missing or indicated refusals, creating discrepancies in the records. Interviews with the resident and the Nursing Home Administrator (NHA) confirmed that the resident was not consistently offered or provided showers as ordered. The lack of consistent and accurate documentation, as well as the resident's own report, demonstrated that necessary services to maintain good personal hygiene were not reliably provided to the dependent resident, resulting in a failure to meet the resident's care needs as outlined in their plan of care.
Failure to Provide Continuous Oxygen Therapy During Resident Transport
Penalty
Summary
The facility failed to provide respiratory care consistent with professional standards for oxygen administration for two residents who required continuous supplemental oxygen. In one instance, a resident with an order for continuous oxygen at 2 liters per minute via nasal cannula was observed being transported to dialysis without the oxygen concentrator, despite having a nasal cannula in place. The staff member responsible for the transport confirmed that the resident required oxygen and returned later to retrieve the concentrator. The resident's medical record included orders and care plan interventions specifying the need for continuous oxygen and monitoring, as well as documentation of ongoing shortness of breath and a goal to maintain oxygen saturation above 92%. In another case, a resident with a diagnosis of COPD and an order for continuous oxygen at 2 liters per minute via nasal cannula was found in bed with the nasal cannula not connected to any oxygen source. The resident stated that the concentrator had likely been left in dialysis, and a staff member subsequently retrieved and reconnected the device. The facility's policy on respiratory care and oxygen equipment required that oxygen support not be initiated or adjusted without a provider's order and described the need for continuous therapy as ordered. The Nursing Home Administrator acknowledged that residents with continuous oxygen orders should not be taken off oxygen for transport convenience.
Failure to Document PRN Narcotic Administration in MAR
Penalty
Summary
Facility staff failed to appropriately document the administration of PRN (as needed) narcotic medications in the Medication Administration Record (MAR) for three residents who were prescribed controlled substances for pain management. Record reviews revealed that, although staff signed out PRN narcotics in the controlled substance log book, they did not consistently record these administrations in the MAR. For one resident, this discrepancy occurred 30 times in a single month. Interviews with nursing staff confirmed that the facility's expectation is for all administered medications to be documented in the MAR, but staff did not notice discrepancies between the narcotic log and the MAR. Further review of the controlled substance sign out logs and MARs for two additional residents showed similar failures to document PRN narcotic administration in the MAR, despite proper sign-out in the controlled substance log. The facility's medication administration policy requires documentation in both the MAR and the controlled substance log after administration. The DON confirmed that several nurses administered PRN narcotics without documenting them in the MAR, as required by facility policy.
Failure to Maintain Infection Control in Enteral Feeding Tube Care
Penalty
Summary
Facility staff failed to maintain proper infection prevention and control practices in the care of a resident with a percutaneous endoscopic gastrostomy (PEG) tube. During observation, the resident's tube feeding water flush bag was found hanging with an incorrect date, and two unopened Jevity bottles were left unlabeled on a draw table. Record review confirmed that the resident's orders required tube feeding via pump and daily cleansing and dressing of the PEG tube site with split gauze, which was to be dated each shift. Further bedside observation of a PEG tube site dressing change revealed that there was no split gauze covering the insertion site from the previous day, and an old Xeroform strip, which was not part of the resident's care order, was discovered under the external fixation plate. The Xeroform strip was discolored and emitted an odor, and nursing staff could not explain its presence or duration. The unit manager confirmed that staff had omitted to remove the old Xeroform strip, and both the administrator and infection preventionist acknowledged that these findings did not meet infection prevention standards or the facility's standard of care.
Failure to Maintain Safe Patient Care Equipment
Penalty
Summary
The facility failed to maintain patient care equipment in safe operating condition, as evidenced by observations of a resident being transported in a malfunctioning recliner chair on two separate occasions. During both observations, the chair did not steer straight, and the reclining mechanism failed to maintain its position, causing the head and foot of the chair to abruptly move. A Geriatric Nursing Assistant (GNA) was seen struggling with the chair, and when questioned by the Unit Manager (UM), the GNA indicated that all the chairs were in similar condition. The UM acknowledged that the chair was not functioning correctly. These findings were based solely on direct observations and staff interviews.
Failure to Ensure Proper Mattress Fit and Document Bed Inspections
Penalty
Summary
A deficiency was identified when a resident's mattress was observed to be too large for the bed frame, causing the mattress to hang over both sides and preventing it from lying flat. The issue was initially reported by the resident, who used the call light to request assistance after previously notifying staff that the bed was not working. Upon investigation, a Geriatric Nursing Assistant responded and indicated that the nurse was already aware of the problem. The Registered Nurse confirmed that maintenance had been contacted, but also revealed unfamiliarity with the facility's computerized repair request system, relying instead on phone calls to notify maintenance. Further inspection by maintenance staff confirmed that the mattress did not fit the bed frame. The Director of Maintenance was unable to identify the origin of the mattress and stated that it was not appropriate for either regular or bariatric beds used in the facility. When asked about regular annual inspections of beds, the Director referenced a computer system for scheduling preventive maintenance but could not provide documentation of completed bed audits. The Nursing Home Administrator also could not produce records of bed audits performed, and no documentation was provided to the surveyor by the time of exit.
Improper Disposal of Garbage in Hallway
Penalty
Summary
The facility failed to maintain a sanitary environment in the common hallway of the East Wing. During an early morning observation, three garbage bags full of waste were found left in the hallway with no staff present. A Geriatric Nursing Assistant (GNA) was observed exiting a resident's room with a garbage bag and explained that she placed garbage outside the door after completing her rounds. Shortly after, two staff members collected the garbage bags and took them to the dirty utility room. The Director of Nursing (DON) confirmed during an interview that garbage should not be left outside resident rooms and should be taken directly to the dirty utility room when emptied.
Failure to Notify Resident Representatives of Care Plan Changes
Penalty
Summary
The facility failed to properly notify residents' legal representatives or responsible parties of changes to the residents' plans of care, as required. In one case, a resident with a court-appointed guardian was given Medicare non-coverage and liability notices without documented notification or acknowledgment from the guardian, despite the guardian being the legal decision-maker. The social services staff stated they had contacted the guardian, but there was no documentation to confirm the guardian was aware of or had acknowledged the notices. In another instance, a resident who was determined unable to make decisions and had a temporary guardian had documentation inconsistencies regarding who was acting as the responsible party. Some records indicated the resident was his or her own decision-maker, while others referenced the guardian, and there was a lack of clarity and documentation about who was notified of care plan changes. A third resident with established guardianship had inconsistent documentation about whether the responsible party was informed of changes to the plan of care, with some notes indicating communication with family members and others lacking evidence that the legal representative was updated.
Failure to Maintain Accurate and Complete Medical Records
Penalty
Summary
The facility failed to maintain accurate and complete medical records for two residents, resulting in documentation that did not align with accepted professional standards. For one resident who was readmitted after a hospital stay and had a history of ileostomy and hemodialysis, the care plan and multiple clinical notes inaccurately described the resident as incontinent of urine and stool, despite the resident no longer producing urine. The Director of Nursing confirmed these inaccuracies during an interview, acknowledging that the documentation regarding incontinence was not correct. In another case, a resident admitted for rehabilitation and colostomy care reported right wrist pain to an LPN, who documented the complaint, obtained a physician's order for Tylenol and a STAT X-ray, and noted that Tylenol was administered. However, the medication administration record did not reflect any Tylenol given for the relevant period, and the X-ray results were not present in the resident's medical chart at the time of review. The Director of Nursing later confirmed that the X-ray results were not in the chart and had to be requested from the imaging facility, and also confirmed the lack of documentation for the administered medication.
Deficient Pest Control Program and Insect Activity Observed
Penalty
Summary
The facility failed to maintain an effective pest control program, as evidenced by multiple observations of insect activity in resident rooms, common areas, and the kitchen. During an interview with a resident who reported feeling things crawling on them, surveyors observed bugs crawling on the floor and wall of the resident's room. Pest management records showed that the room had been treated for roaches and general insects, and that another room had a history of fruit flies and roaches, with recommendations for additional interventions that were not documented as completed. After the resident was transferred to a new room, there was no evidence of preventative pest control measures or evaluation in the new location, where bugs were also observed. Additionally, a bug was observed by surveyors in an elevator, and the DON confirmed the presence of the insect, which was similar to those seen in the resident's room. During a kitchen tour, surveyors and the kitchen manager observed debris, dark spots, and dead insects on multiple kitchen windowsills near food preparation and storage areas. The kitchen manager confirmed the need for cleaning, and the NHA stated that housekeeping was responsible for monthly cleaning of the kitchen, but evidence of pest presence and debris was still found during the survey.
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The facility did not ensure that its Infection Preventionist (IP) met required qualifications for managing the Infection Prevention and Control Program. The DON reported serving as the IP but acknowledged lacking the specialized infection control training required for the role, and confirmed that no other staff member was currently qualified. Records showed that the previously qualified IP left several months earlier, and the Administrator and DON confirmed they were still seeking a replacement, leaving the infection control program without a properly trained leader.
Staff failed to consistently secure medications and medical supplies across three units, including an oxygen tank left on the floor behind a resident’s bed without a supporting device, a treatment cart with Collagenase Santyl cream left on top while two residents in power wheelchairs passed by, an unattended and unlocked treatment cart at a nursing station, and another treatment cart with Diclofenac gel and dressings left on top, indicating repeated lapses in maintaining locked and secure storage for drugs, biologicals, and related supplies.
The facility failed to provide sufficient dietitian coverage and timely nutritional assessments for several residents with significant dietary needs. A resident admitted for diabetic management with a high A1C was placed on a regular diet instead of the recommended carb-controlled diet and had only one weight taken in the first two weeks, with no dietitian review of the record. Another resident with prior significant weight loss had no documented dietitian follow-up despite continued weight loss, and a resident admitted with severe protein-calorie malnutrition experienced further significant weight loss without any dietitian assessment. The dietitian reported working limited hours and prioritizing certain high-risk cases, resulting in delayed or missed evaluations for new admissions and residents with ongoing nutritional concerns.
The facility failed to maintain adequate linen and incontinence supplies and did not keep resident care areas in good repair, resulting in delays and alterations in incontinence care and substandard environmental conditions. Staff reported that towels and washcloths were used instead of wipes and then discarded due to heavy soiling, and that linen deliveries to units were late, leaving residents waiting for care. Observations showed very limited numbers of clean washcloths and other linens on units and in the laundry, with no stock of disposable wipes or backup washcloth supply despite repeated reports to housekeeping. Additional observations revealed recliner chairs blocking a dining-area handwashing sink and kitchenette, multiple resident and shared bathrooms with unfinished spackle, chipped paint, musty odors, black substances near showers, missing threshold molding, exposed cracks and nails, and eroded, rusted baseboard heaters. Hallway handrails on both units were worn, chipped, and splintered, and a shower room contained fecal odors, dried brown stains on the toilet, and deteriorated fixtures, all contributing to a failure to provide a safe, clean, and homelike environment.
Facility staff did not thoroughly investigate two separate abuse allegations involving a resident and an injury of unknown origin involving another resident. In both cases, investigations focused on the directly affected resident and included staff interviews, but there were no interviews of other residents on the unit or documented assessments of those residents for signs of abuse or injuries of unknown origin, including residents unable to communicate due to cognitive status.
Two residents who were dependent on staff for oral care, including one with a tracheostomy, were observed with thick, white or milky substances coating their mouths and teeth, indicating inadequate oral hygiene. One resident communicated that staff did not brush their teeth and that staff "need to." In another case, despite oral care supplies being present in the room, the resident’s mouth and teeth remained unclean on multiple observations, with a thick milky substance caking the teeth and stringing between them when the resident tried to open their mouth. These findings showed that staff did not consistently provide oral care to residents who relied on them for this ADL.
Staff failed to maintain complete and accurate medical records for multiple residents, including missing and inconsistent documentation of wound care, delayed pain assessment after discovery of an injury of unknown origin in a cognitively impaired resident, and inaccurate recording of a PPD test result that was documented as negative despite no evidence the injection was administered and no supporting nurse’s note. Residents reported not receiving certain treatments, while MAR entries either lacked signatures for completion or contained conflicting information about whether care was provided.
Surveyors found that the facility failed to consistently implement and communicate correct transmission-based precautions and PPE use. One resident with a Foley catheter related to wounds had no precaution signage posted, while another resident in a double room had a contact precautions sign at the door, yet the NP entered without PPE and the GNA provided high-contact care wearing only gloves. Staff in that room stated the resident was not on contact precautions and later reversed the sign to show no PPE requirement. Therapy staff reported they rely solely on posted signs to determine PPE, and surveyors identified broader issues with inaccurate signage and staff awareness of which residents required contact precautions.
Surveyors found that MDS assessments were inaccurately coded for two residents. In one case, a resident sustained a femoral neck fracture after a fall, but the subsequent significant change MDS did not code the fall as a major injury and failed to capture prn Tylenol use documented on the MAR within the look-back period. In the other case, a quarterly MDS indicated opioid use for a resident, but the MAR for the same period showed no prescribed opioid, indicating incorrect coding of high-risk drug classes.
A resident who had recently been admitted and experienced a fall received multiple doses of the narcotic analgesic Tramadol, but the facility failed to accurately document all administered doses on the Medication Administration Record (MAR). Review showed only one Tramadol dose recorded on the MAR, while the Controlled Drug Receipt/Record/Disposition Form on the med cart reflected three doses given over two days. In interview, the DON stated staff are expected to document narcotic administration on the MAR and confirmed that two administered doses were not recorded there, resulting in an incomplete and inaccurate medical record.
Unqualified Infection Preventionist Overseeing Infection Control Program
Penalty
Summary
The facility failed to ensure that its designated Infection Preventionist (IP) met the mandatory qualifications for overseeing the Infection Prevention and Control Program. During an interview on 3/24/26 at 10:00 AM, the DON confirmed that she/he was serving as the facility’s IP but had not completed the specialized training in infection control required for the position. The DON further stated that no other staff member currently met the qualifications to serve as IP. Record review showed that the previously qualified IP left the facility in October 2025, and as of the survey date, the position remained unfilled by a qualified individual. At 1:30 PM on the same day, the Administrator and DON confirmed they were still in the process of finding a qualified IP for the facility, leaving the Infection Prevention and Control Program without a properly trained and qualified leader. No specific residents, medical histories, or clinical conditions were described in relation to this deficiency.
Unsecured Medications, Treatment Carts, and Oxygen Equipment
Penalty
Summary
Facility staff failed to ensure that drugs, biologicals, and related medical supplies were securely stored and properly maintained on multiple units. On one unit, an oxygen tank assigned to a resident was observed sitting on the floor behind the resident’s bed without any supporting device. On another unit, a treatment cart was observed with a tube of Collagenase Santyl cream labeled for a specific resident left on top of the cart, while residents in power wheelchairs passed by and staff were present at the nursing station. These observations showed that medications and oxygen equipment were not consistently secured as required. Further observations on additional units revealed an unattended and unlocked treatment cart at a nursing station, and on a separate occasion, a treatment cart with Diclofenac gel labeled for a resident left on top along with multiple packs of dressings. These incidents occurred across three units and on more than one date, demonstrating repeated failures to keep medications and treatment supplies in locked compartments or otherwise secured from unauthorized access.
Insufficient Dietitian Coverage and Delayed Nutritional Assessments
Penalty
Summary
The deficiency involves the facility’s failure to employ sufficient food and nutrition staff, including adequate dietitian coverage, to ensure timely assessment and appropriate diets for residents with significant nutritional and diabetic needs. A resident admitted over two weeks earlier with multiple comorbidities and an A1C of 11.5% had a hospital discharge recommendation for a carbohydrate-controlled diet, but was placed on a regular diet at admission with no acknowledgment of the recommended diet until one week later, when the resident requested larger portions. As of the survey date, the dietitian had not yet seen or reviewed this resident’s medical record, and the resident reported not having seen a dietitian and being very frustrated with the meals. During the first two weeks after admission, only one weight was obtained for this resident, despite physician notes stating the resident’s weight was “stable.” Further review of other residents showed additional failures in timely dietitian assessment and follow-up. One resident, readmitted in January and previously seen by the dietitian in September for a 6.4 lb weight loss over 30 days, had no documented follow-up despite continued weight loss totaling 22 lbs since the last dietitian review. Another resident admitted at the end of February with severe protein-calorie malnutrition had not been seen by the dietitian after about a month in the facility, despite a documented 14 lb (7%) weight loss over two weeks. The dietitian reported working only 12 hours per week at the facility and stated that she must prioritize which residents to see, focusing first on residents with tube feedings and those identified in risk meetings, resulting in delayed or absent assessments for new admissions and residents with ongoing weight loss and malnutrition diagnoses.
Linen Shortages and Poor Environmental Maintenance Compromise Resident Care and Comfort
Penalty
Summary
The deficiency involves the facility’s failure to maintain an adequate supply of clean linens and appropriate incontinence wipes, resulting in delays and alterations in residents’ incontinence care, as well as the use of towels and washcloths in place of disposable wipes. During the initial tour, the surveyor observed that the linen supply on one nursing unit hallway was low. Complaint reviews included concerns about delays in incontinence care and bed linens not being changed regularly, with residents left without clean bedding. A complainant reported that there was not enough clean linen available for residents. Staff interviews confirmed that towels, sheets, and washcloths were being used to wipe residents for incontinence care due to the absence of wipes, and that many of these linens were being thrown away when soiled. Staff also reported a shortage of linen, that linen deliveries to the units were late, and that residents who preferred to get up before breakfast had to wait for care when linen was delayed. Further observations showed that the clean supply room contained no disposable wipes or cloths for incontinence care, and a resident reported that staff did not use wipes, that the resident had to purchase their own, and that heavily soiled towels or washcloths were discarded. A tour of all nursing unit linen carts and closets revealed only six clean washcloths and limited supplies of towels, gowns, and bed linens. In the laundry room, only three washcloths were present, and the laundry assistant stated that there were only three washcloths available for each nursing unit that morning, that the facility was short on linen supply, and that these concerns had been repeatedly reported to the Director of Housekeeping over the preceding month and again that morning. The laundry assistant confirmed there was no additional laundry in process. The DON stated that wipe squares should be used for incontinence care, but no such wipes were found in the clean medical supply room, and no backup supply of washcloths was present in the emergency linen supply. The Director of Housekeeping confirmed there was no backup supply of washcloths. The deficiency also includes environmental and maintenance issues affecting resident bathrooms, handrails, and common areas. In the main dining area, a recliner chair was observed positioned directly in front of the handwashing sink, and two recliner chairs were stored in front of the nutrition area kitchenette. Multiple resident bathrooms and shared bathrooms were repeatedly observed over several days with unfinished spackle on walls that needed resurfacing and painting, chipped paint around sinks, uneven boards nailed to walls under sinks that appeared to partially cover holes, musty odors, black substances between shower bases and walls, missing threshold transition molding exposing cracks, missing tiles, and a nail, as well as eroded and chipped paint on baseboard heaters with exposed dark brown metal and rust-like material. Hallway handrails on both nursing units were observed to be worn, with chips, splintering, holes, and areas where the wood finish had worn off. A shower room was observed with a foul fecal odor, dried brown stains on the back of the toilet seat and in the toilet bowl, and a baseboard heater with eroded, chipped paint and rust-like material, along with chipped paint on the handrail. These conditions were acknowledged by the Director of Maintenance and other leadership, and some areas were noted to be in the process of renovation, but the observed deficiencies remained present during the survey period. Overall, the facility did not maintain a safe, clean, comfortable, and homelike environment in good repair across both nursing units and the dining area. The lack of adequate linen and incontinence supplies, combined with the poor condition of resident bathrooms, handrails, and certain common areas, constituted the basis for the cited deficiency. The observations and staff and resident reports consistently described shortages of essential hygiene supplies, delayed care related to linen availability, and multiple unresolved environmental and maintenance issues in resident care areas and shared spaces.
Failure to Thoroughly Investigate Abuse Allegations and Injuries of Unknown Origin
Penalty
Summary
Facility staff failed to thoroughly investigate allegations of potential abuse involving one resident and an injury of unknown origin involving another resident. For one resident, there were two separate allegations of abuse occurring on different days in early February. The facility’s investigation packets included interviews with staff who cared for or were scheduled to work with this resident on the days of the alleged incidents, and the investigations focused solely on this resident. However, there were no interviews conducted with other residents on the unit to inquire about abusive or neglectful treatment by the staff who were working during the times of the allegations. The surveyors noted that, although the allegations were not validated, there was no documentation that other residents were interviewed, if able, or assessed for signs or symptoms of injury. In a separate incident, another resident was identified on March 4 with a new bruise on the right eye, documented as a change in condition at 4:09 AM. This resident had a BIMS score of 99, indicating the resident was unable to complete an interview and therefore could not report how the injury occurred. The facility’s investigation identified a potential cause of the injury but did not reach a definitive resolution. Additionally, there were no interviews of other residents on the unit regarding possible abuse, nor were there documented assessments of other residents for injuries of unknown origin, particularly for those unable to speak for themselves, as in this resident’s case.
Failure to Provide Oral Care to Dependent Residents
Penalty
Summary
The deficiency involves the facility’s failure to provide oral care to residents who were dependent on staff for activities of daily living, specifically oral hygiene. One resident with a tracheostomy was observed with a thick, sticky white substance in the mouth and was noted to intermittently chew on nearby bedding. This resident made good eye contact and, when asked if staff brushed their teeth, shook their head no and mouthed that staff “need to.” According to the resident’s Minimum Data Set (MDS) dated 2/11/26, the resident was dependent on staff for oral care. Another resident, also dependent on staff for oral care per the 3/11/26 MDS, was observed sitting propped up in bed and able to respond with smiles. During the initial observation, the inside of this resident’s lips and upper and lower teeth had a thick, clear, white milky substance visible when the resident tried to open their mouth to smile. Oral care supplies were present in the nightstand, but the resident’s mouth and teeth were not clean. On a subsequent observation with the DON, NHA, and Corporate VP of clinical services, the same resident again had a thick, clear, milky substance between the lips and caking the teeth, which would string between the teeth when the resident attempted to open their mouth, demonstrating a lack of consistent oral care for residents dependent on staff for this ADL.
Incomplete and Inaccurate Medical Record Documentation for Treatments and Assessments
Penalty
Summary
Facility staff failed to maintain complete and accurate medical records and documentation for multiple residents. For one resident with wound care needs, review of the MAR showed that wound care and related treatments were signed as completed on the dates initially reported, despite the resident’s ongoing complaints that wound dressings were not being changed. When additional dates were reviewed, there were missing staff signatures for wound care on two specific dates, as well as three instances where application of A&D ointment to the resident’s feet was not signed off out of 24 days reviewed. Another resident with severe cognitive impairment, as evidenced by a BIMS score of 00, was found to have an injury of unknown origin (a bruise on the left hand). Documentation showed that a change in condition was initiated late in the morning, but a formal pain evaluation was not initiated and completed until that night, and the resident was unable to explain how the injury occurred or verbalize pain using a standard pain scale. For a third resident, documentation related to the admission PPD test was inconsistent and incomplete. The MAR contained an entry indicating “9” for the administration date, meaning “see nurse’s note,” but there was no corresponding nurse’s note. Despite the absence of a signed administration of the PPD injection, staff documented the PPD result as “negative” on the scheduled read date. The resident reported never receiving the PPD injection, and the DON confirmed that the facility had been out of PPD solution at the time, so the test would not have been administered. These findings demonstrate failures in accurate documentation of treatments and assessments, including wound care, pain assessment, and TB screening, as well as missing or incomplete supporting notes in the medical record.
Failure to Implement and Communicate Correct Transmission-Based Precautions
Penalty
Summary
Surveyors identified a deficiency in the facility’s infection prevention and control program related to inconsistent and incorrect implementation of transmission-based precautions and PPE use. During a complaint investigation focused on residents on transmission-based precautions, one resident with a visible Foley catheter was observed in the room with physical therapy, but there were no signs posted indicating any need for PPE, despite the resident being a new admission with a Foley catheter placed related to wounds. In another double-occupancy room, a contact precautions sign was posted at the doorway, but the nurse practitioner was in the room on a personal phone with no PPE, and the assigned GNA was repositioning the resident in bed while wearing only gloves. When questioned, the NP, RN, and GNA all stated that the resident in the room was not on contact precautions, and the GNA reported that signs were hanging at all doors and that this particular resident’s sign was “just wrong.” The surveyor observed the GNA later return to the room and turn the sign around to indicate no PPE requirement. Subsequent interviews revealed that therapy staff relied on posted signage to determine PPE use and that if the sign was wrong, the PPE used would be wrong. Overall, surveyors found problems with signage accuracy and staff awareness of which residents required contact precautions, as well as observed failures to follow appropriate PPE use for residents who should have been on contact precautions.
Inaccurate MDS Coding for Falls, Pain Management, and High-Risk Medications
Penalty
Summary
Facility staff failed to ensure Minimum Data Set (MDS) assessments were accurately coded for two residents reviewed during a complaint survey. For one resident, a facility-reported incident showed that the resident was found seated on the floor beside the bed and was diagnosed with a non-displaced femoral neck impaction fracture of the left hip following an x-ray. Despite this fall with a major injury, the subsequent significant change MDS dated 11/4/25 did not code the fall with major injury in Section J1900C. Review of the resident’s Medication Administration Records for October and November 2025 showed administration of Tylenol on 10/31/25 at 9:30 PM, which fell within the 5-day look-back period for the MDS, but Section J0100 (prn pain) of the same significant change MDS did not capture the use of Tylenol. For another resident, review of a quarterly MDS with an assessment reference date of 10/15/25 showed that Section N0415 (High-Risk Drug Classes) documented the use of an opioid medication. However, review of the resident’s October 2025 Medication Administration Record did not show that the resident had been prescribed an opioid during that period. In both cases, MDS staff later confirmed that these were errors in MDS coding, demonstrating that the assessments did not accurately reflect the residents’ clinical status and medication use as documented in their medical records.
Incomplete Documentation of Narcotic Administration on MAR
Penalty
Summary
The facility failed to maintain complete and accurate medical records in accordance with accepted professional standards for one resident receiving narcotic medication. The resident, admitted in March 2026, had a fall on 3/6/26 and was sent to the hospital on 3/9/26. Review of the March 2026 Medication Administration Record (MAR) showed documentation of a single 25 mg dose of Tramadol administered on 3/8/26 at 9:23 AM. However, review of the resident’s Controlled Drug Receipt/Record/Disposition Form, kept on the nurse’s medication cart and not in the medical record, showed that Tramadol 25 mg was administered three times between 3/8/26 and 3/9/26: at 11:00 AM and 9:00 PM on 3/8/26, and at 9:00 AM on 3/9/26. In interview, the DON stated that staff are expected to document narcotic administration on the MAR and confirmed that only one of the three Tramadol doses reflected on the controlled drug record was documented on the resident’s MAR. This discrepancy between the controlled substance record and the MAR, with missing documentation of two administered doses of Tramadol on the official medical record, constituted the failure to maintain a complete and accurate medical record for the resident.
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Every citation, penalty and Plan of Correction is sourced from public CMS records (latest release May 27, 2026) and official state health department websites — never guesswork.
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