Alice Byrd Tawes Nursing Home
Inspection history, citations, penalties and survey trends for this long-term care facility in Crisfield, Maryland.
- Location
- 201 Hall Highway, Crisfield, Maryland 21817
- CMS Provider Number
- 215058
- Inspections on file
- 14
- Latest survey
- November 26, 2024
- Citations (last 12 mo.)
- 0
Citation history
Health deficiencies cited at Alice Byrd Tawes Nursing Home during CMS and state inspections, most recent first.
The facility failed to transmit MDS assessments to CMS as required, affecting four residents. The MDS, crucial for care planning, was not transmitted for several residents, with assessments still in progress. The MDS director acknowledged the delay, and the facility was informed of the deficiency.
The facility failed to provide timely baseline care plan (BLCP) summaries to several residents and/or their representatives within 48 hours of admission, as required. This deficiency was identified during a survey, revealing a lack of documentation confirming that residents received their BLCPs, which include initial goals and a list of medications. The DON acknowledged the absence of necessary documentation, indicating a systemic issue in the facility's process for ensuring timely communication of care plans.
The facility failed to post required nurse staffing information on all floors during a recertification survey. Surveyors found that dry erase boards on the second and third floors lacked essential details such as the facility name, total number of staff, and actual hours worked. Interviews with the DON and a receptionist confirmed the absence of posted staffing information, with staffing binders found out of reach behind the nursing counter.
A recertification survey revealed deficiencies in food storage practices at a facility. Unlabeled and undated bags of brownies and cookies were found in the dessert freezer, and a blue rag was also discovered stored there. The Food Service Supervisor and Dietary Aide were unaware of the duration the food items had been stored and the reason for the rag's presence. The facility's policy requires all stored foods to be labeled and dated, which was not followed in this instance.
A facility failed to maintain and retrieve advance directives for a resident in their medical record. Although a living will and power of attorney were documented, the actual documents were missing from both the hard chart and electronic health record. A physician's note indicated prior counseling on advance directives, but the absence was confirmed by a social worker, who acknowledged the oversight.
A facility failed to document when the IDT determined a resident met the criteria for a Significant Change in Status Assessment (SCSA). The policy requires documentation of significant changes impacting multiple health areas, but no evidence was found in the resident's medical record. Interviews with staff confirmed the absence of documentation, indicating non-compliance with the facility's policy.
A facility failed to develop a comprehensive, person-centered care plan for a resident, as observed during a recertification survey. The resident, who preferred individual activities, was repeatedly found in bed without activity materials. The care plan intervention was incomplete, lacking specific details about the resident's preferred activities. The Activities Coordinator acknowledged the issue, confirming the resident's preferences and the incomplete care plan.
A facility failed to conduct a care plan meeting for a resident at the time of admission, as required. The resident reported not attending a care plan meeting since admission, and a review of medical records confirmed the absence of such a meeting around the time of the admission MDS assessment. The MDS Coordinator acknowledged the oversight, and no evidence of a meeting was provided to the survey team.
A facility failed to implement and monitor fall interventions for a resident with a history of falls. Despite a care plan requiring a low bed with a mat, the intervention was delayed and not consistently in place, leading to additional falls. Staff were unaware of the resident's fall precautions, and documentation inaccurately reflected the presence of the fall mat. The DON confirmed the absence of the mat, and the Administrator acknowledged the issue.
A facility failed to implement a nutrition intervention for a resident, resulting in further weight loss. The resident required assistance with eating, but observations showed they struggled to open food containers and had not consumed their meal without help. Staff interviews revealed inconsistencies in providing feeding assistance, and documentation was incomplete. The DON acknowledged the care plan did not reflect the current feeding assistance needs.
A facility failed to label oxygen tubing and humidifier bottles for a resident receiving respiratory care, as observed during a survey. The resident's oxygen equipment was not labeled with the date and time of placement, contrary to physician's orders. Interviews with staff revealed inconsistencies in understanding the protocol for changing and labeling the equipment, with one LPN unsure of the frequency of changes and another stating it should occur weekly. The TAR indicated a bi-weekly change requirement, highlighting a failure to adhere to orders.
A facility failed to ensure monthly Medication Regimen Reviews were completed by a pharmacist and did not respond to pharmacy recommendations in a timely manner. A resident's medication adjustment was not formally documented or addressed, and a recommendation to increase Symbicort was delayed by 82 days. The facility lacked a system to track pharmacy recommendations, contributing to the deficiency.
The facility failed to ensure all employees' immunizations and screenings were up to date, affecting infection prevention and control. A GNA lacked a TB screening, and an LPN lacked a Tdap immunization. The LNHA admitted the facility's policy did not require Tdap for all employees, only for the pediatric unit, and missing documentation was unavailable.
Failure to Transmit MDS Assessments Timely
Penalty
Summary
The facility staff failed to ensure that assessments were sent to the Centers for Medicare and Medicaid Services as required, which was evident for four out of seven residents reviewed for late reporting. The Minimum Data Set (MDS), a federally mandated assessment tool, was not transmitted for several residents, impacting the accuracy of care planning. During a review of clinical records, it was found that the discharge MDS for Residents #11, #51, #56, and #69 were still in progress and not transmitted. The MDS director acknowledged that most of these assessments were late, and the facility administrative staff were informed of this deficiency at the exit conference.
Failure to Provide Timely Baseline Care Plans
Penalty
Summary
The facility failed to provide a baseline care plan (BLCP) summary to residents and/or their representatives within 48 hours of admission, as required. This deficiency was identified during a recertification survey for six out of twelve residents reviewed. The BLCP is essential for ensuring continuity of care and includes initial goals based on admission orders, physician orders, dietary orders, therapy services, and social services. It also includes a list of the resident's current medications. The absence of documentation confirming that residents or their representatives received a written copy of the BLCP within the stipulated time frame was a common issue across multiple cases. In several instances, the Director of Nursing (DON) acknowledged the lack of documentation verifying that residents or their representatives were presented with their BLCPs. For example, Resident #36's BLCP was completed after the required 48-hour window, and there were no signatures to confirm receipt by the resident or representative. Similarly, Resident #57's BLCP lacked documentation of receipt, and the field for the resident's signature was blank. These oversights indicate a systemic issue in the facility's process for ensuring timely communication of care plans to residents and their representatives.
Failure to Post Required Nurse Staffing Information
Penalty
Summary
The facility failed to post required nurse staffing information during a recertification survey. Upon entering the building, surveyors observed that no staffing information was posted on the first floor. During a tour of the second floor nursing unit, a dry erase board was found lacking the facility name, the total number of staff, and actual hours worked for 7 out of 11 nursing staff. Similarly, on the third floor, the dry erase board did not display the facility name, total number of staff, or actual hours worked for 10 out of 13 nursing staff. No other postings of staffing information were observed on these units. Interviews with the Director of Nursing (DON) and Front Desk Receptionist confirmed the absence of posted staffing information. The DON mentioned that a staffing binder was supposed to be available on the second floor nursing station counter, but it was found out of reach behind the nursing counter in the office area. The DON acknowledged that no paper copies were posted, only the boards and binders were used. The facility Administrator was informed of the concern, and the issue was reiterated during the exit conference.
Deficiency in Food Storage Practices
Penalty
Summary
During a recertification survey, a deficiency was identified in the facility's food storage practices. The surveyor, along with the Food Service Supervisor (FSS), conducted an inspection of the kitchen's refrigerator and freezers. In the dessert freezer, they found a large bag of brownies and a large bag of cookies stored in clear Ziplock bags without any labels or dates. When questioned, the FSS was unsure of how long these items had been stored. Dietary Aide, responsible for desserts, stated that the items were from the previous day and proceeded to label and date them only after being prompted by the surveyor. Additionally, a blue rag in a clear Ziplock bag was discovered on the middle shelf of the dessert freezer. The FSS and Dietary Aide were both unaware of why the rag was stored there. The facility's policy, as provided by the Food Service Director, mandates that all foods stored in the refrigerator or freezer must be covered, labeled, and dated with a use-by date. The presence of unlabeled food items and a non-food item in the freezer indicates a failure to adhere to this policy, potentially compromising food safety and increasing the risk of cross-contamination.
Failure to Maintain Advance Directives in Resident's Medical Record
Penalty
Summary
The facility failed to ensure that advance directives for a resident were maintained and readily retrievable in their medical record. During the recertification survey, it was observed that the medical record for a resident included documentation of a living will and power of attorney, but the actual documents were not present in either the hard chart or electronic health record. The Maryland Medical Orders for Life Sustaining Treatment form indicated the resident had a healthcare agent, yet no advance directives were found in the medical record. A physician's note from earlier in the year documented that advanced directives counseling had occurred, but the absence of the actual documents was confirmed during an interview with a social worker. The social worker acknowledged the oversight and confirmed that the resident's advance directives were not in the medical record. This issue was highlighted during the exit conference with the surveyor.
Failure to Document Significant Change in Status Assessment
Penalty
Summary
The facility failed to document in the medical record when the Interdisciplinary Team (IDT) determined that a resident met the criteria for a Significant Change in Status Assessment (SCSA). This deficiency was identified during a recertification survey for one resident out of 33 reviewed. The facility's policy requires that a significant change in a resident's condition, which impacts more than one area of health status and requires interdisciplinary review, be documented in the medical record. However, for Resident #24, there was no evidence in the medical record indicating when the IDT determined the resident met the criteria for a significant change. Interviews with facility staff, including the MDS Coordinator and the Director of Nursing, revealed that there was no documentation available to show that the resident met the criteria for a significant change on the specified date. The MDS Coordinator was unable to find any documentation related to the significant change assessment for the resident, and the Director of Nursing confirmed the absence of such documentation. This lack of documentation indicates a failure to adhere to the facility's policy on recording changes in a resident's condition.
Incomplete Care Plan for Resident Activities
Penalty
Summary
The facility failed to ensure a resident's care plan was comprehensively developed and person-centered, as observed during a recertification survey. The deficiency was identified for a resident who was reviewed for activities. On multiple occasions, the resident was observed in bed without any activity materials within reach, despite their preference for specific individual activities over group activities. The resident's care plan intervention, initiated in March, was incomplete and did not specify the independent activities the resident enjoyed. The Activities Coordinator confirmed the resident's preferences and acknowledged the incomplete care plan intervention, indicating an understanding of the concern.
Failure to Conduct Timely Care Plan Meeting
Penalty
Summary
The facility failed to hold care plan meetings for residents and/or their representatives at the time of their admission, as required. This deficiency was identified during a recertification survey, specifically for one resident out of 33 reviewed. The care plan is a critical tool used to address the unique needs of each resident, and it is essential for planning, assessing, and evaluating the effectiveness of the resident's care. In this case, the resident, identified as Resident #18, reported not having attended a care plan meeting since her admission to the facility. Upon review of Resident #18's medical records, it was found that the resident was admitted earlier in the year, and an admission MDS assessment was completed in February. However, there was no documentation of a care plan meeting held around the time of this assessment. The MDS Coordinator, responsible for scheduling these meetings, confirmed that a care plan meeting was not held in February and acknowledged that it was missed. Despite requests from the survey team, no evidence was provided to show that a care plan meeting had taken place for the resident around the time of the admission MDS assessment.
Failure to Implement and Monitor Fall Interventions
Penalty
Summary
The facility failed to ensure and monitor the implementation of fall interventions for a resident with an extensive fall history. The resident, who was at high risk for falls, had experienced multiple falls in October 2024. Despite a care plan intervention requiring a low bed with a mat to be in place after falls on 10/15/24 and 10/18/24, this intervention was not implemented until 10/24/24. Even after implementation, the resident sustained two additional falls on 10/31/24, and during a surveyor's observation on 11/19/24, no fall mat was found in the resident's room. The surveyor's investigation revealed that the nursing staff, including an RN and LPN, were unaware of the current fall precautions for the resident. The RN assigned to the resident's care was unfamiliar with the resident and had to confirm their assignment. The DON confirmed the absence of the fall mat, which should have been present in the room. Additionally, documentation inaccurately indicated that the fall mat had been in place, despite its absence. The facility's Administrator acknowledged the surveyor's concerns during the exit conference.
Failure to Implement Nutrition Intervention for Resident
Penalty
Summary
The facility failed to implement a nutrition intervention for a resident, leading to further weight loss. Upon admission, the resident weighed 114.2 lbs and later weighed 103.9 lbs, indicating weight loss. The resident was documented as needing partial/moderate assistance for eating, and a nutrition note indicated that the resident ate 100% when fed by staff. However, observations revealed that the resident was unable to feed themselves and required assistance, which was not consistently provided. The resident was observed struggling to open food containers and had not consumed any food items on their tray without assistance. Staff interviews revealed inconsistencies in the process of ensuring residents received feeding assistance. A registered nurse acknowledged the need for assistance but noted that staff often had to figure out feeding arrangements among themselves. Documentation of the resident's meal consumption and assistance level was not completed as expected. The Director of Nursing acknowledged that the care plan did not reflect the most current feeding assistance requirements and stated that it should be updated at the time of any change.
Failure to Label Oxygen Equipment
Penalty
Summary
The facility failed to properly label oxygen tubing and humidifier bottles for a resident receiving respiratory care, as observed during a recertification survey. On two separate occasions, a surveyor noted that the oxygen tubing and humidifier bottle for a resident using a nasal cannula with 2 liters of oxygen were not labeled with the date and time they were placed. This deficiency was identified for one resident reviewed for respiratory care. Interviews with staff revealed inconsistencies in the understanding and execution of the facility's protocol for changing and labeling oxygen equipment. One LPN was unsure of the frequency of tubing changes, while another LPN stated that the tubing and humidifier should be changed every Sunday night by the night shift nurse, with the changes documented on the Medication Administration Record (MAR) or Treatment Administration Record (TAR). However, a review of the TAR showed an order to change the equipment every two weeks and as needed, with labeling required. The lack of labeling indicated a failure to follow the physician's orders and facility protocol.
Failure to Complete and Respond to Medication Regimen Reviews
Penalty
Summary
The facility failed to ensure that monthly Medication Regimen Reviews (MRR) were completed by the pharmacist and did not respond to recommendations made by consulting pharmacists in a timely manner. This deficiency was identified during a recertification survey for a resident who was reviewed for unnecessary medications. The pharmacist documented a recommendation to decrease levothyroxine due to a low TSH level in the resident's medical record, but there was no formal recommendation sent to the facility for August 2024. The Licensed Nursing Home Administrator (LNHA) and Director of Nursing (DON) were unaware of this recommendation, and the pharmacist confirmed that no entry was made for the resident in August 2024. Additionally, the facility did not address a pharmacy recommendation made in September 2024 to increase the dose of Symbicort for the resident. The recommendation was not acted upon within the facility's expected timeline of 7-14 days. The LNHA acknowledged that the recommendation was not addressed until surveyor intervention, 82 days after it was made. The physician eventually disagreed with the recommendation, providing a rationale and signing the document only after the surveyor's involvement. The lack of a system to ensure all pharmacy recommendations were received and addressed contributed to the deficiency. The LNHA admitted that there was no current system in place to track which pharmacy recommendations should be received monthly. This oversight led to a delay in addressing the pharmacist's recommendations, impacting the resident's medication management and potentially their health outcomes.
Deficiency in Employee Immunization and Screening Documentation
Penalty
Summary
The facility failed to ensure that all employees' required immunizations and screenings were up to date, as part of their infection prevention and control program. During a recertification survey, it was found that two out of five employees reviewed did not have the necessary documentation on file. Specifically, a Geriatric Nursing Assistant (GNA) did not have a documented TB screening, and a Licensed Practical Nurse (LPN) did not have a documented Tdap immunization. In an interview, the Licensed Nursing Home Administrator acknowledged that the facility's employee health procedures did not require Tdap immunizations for all employees, only for those in the pediatric unit, and admitted that any missing documentation was not available. The facility's policy requires two-step TB testing for all new team members and annual TB assessments, as well as a single dose of Adult Tdap for new team members and those in high-risk areas, which includes the nursing home.
Latest citations in Maryland
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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