Allegany Health Nursing And Rehab
Inspection history, citations, penalties and survey trends for this long-term care facility in Cumberland, Maryland.
- Location
- 730 Furnace Street, Cumberland, Maryland 21502
- CMS Provider Number
- 215230
- Inspections on file
- 16
- Latest survey
- February 4, 2025
- Citations (last 12 mo.)
- 0
Citation history
Health deficiencies cited at Allegany Health Nursing And Rehab during CMS and state inspections, most recent first.
A resident was admitted without a clear physician's order for end-of-life care, and facility staff failed to initiate CPR when the resident was found not breathing. Despite prior education on CPR and MOLST forms, an LPN and RN supervisor did not act due to the absence of a completed MOLST form, leading them to wait for EMS. The facility's policy required staff to treat residents as full code in emergencies without a completed MOLST form.
Two residents suffered injuries due to staff failing to follow care plans in a LTC facility. One resident fell out of bed during incontinence care, resulting in bilateral femoral neck fractures, as the GNA did not use the required two-person assist. Another resident sustained a fractured humerus during a manual transfer to a shower chair, contrary to the care plan requiring a lifting device. Staff did not verify care plans before performing tasks, leading to improper handling and supervision.
A resident was subjected to abuse when a staff member, GNA2, kicked them on the leg, causing a skin tear, after the resident attempted to remove food trays. The incident was witnessed by an LPN who reported it to a supervisor. GNA2 was verbally aggressive and attempted to move the resident backward before the physical altercation occurred.
The facility failed to implement its abuse policy when two staff members reported an allegation of sexual abuse between two residents. An anonymous complaint indicated that the administration required a nurse to retract documentation of the incident, and the facility did not report the abuse to the State Survey Agency. Despite the facility's policy requiring immediate reporting and investigation, no formal documentation or notification to authorities occurred.
A facility failed to report an allegation of resident-to-resident sexual abuse to the State Survey Agency. The incident involved two residents, with one observed touching the other's genitals. Despite being reported to the Director of Social Work and the facility Administrator, no proper documentation or investigation was conducted, and the incident was not reported to authorities as required by facility policy.
A facility failed to investigate an allegation of resident-to-resident sexual abuse when it was reported by staff. The incident involved two residents, with one observed touching the other's genitals. Despite being informed, the facility's leadership did not document or investigate the incident, nor did they notify the local police or State Survey Agency, contrary to their policy.
A resident was improperly restrained in a geriatric chair and wheelchair with a lap tray, preventing her from standing up, which was done for staff convenience. The facility's policy requires restraints to be used only as a last resort with proper documentation, which was not followed. The resident, who was cognitively intact, expressed anxiety due to the inability to move freely, and staff interviews revealed a lack of awareness and assessment regarding the use of these devices as restraints.
A facility failed to update a resident's care plan to include the use of a geriatric chair and lap trays, which were used as restraints. The resident, cognitively intact, was placed in these devices after a fall, but the care plan did not reflect this. Staff confirmed the oversight, and the DON and Administrator did not recognize these as restraints, leading to potential safety risks.
Failure to Initiate CPR Due to Incomplete MOLST Form
Penalty
Summary
The facility staff failed to identify a newly admitted resident who was admitted without a clear physician's order for end-of-life care and did not follow the facility policy to initiate Cardiopulmonary Resuscitation (CPR). This deficiency was evident for one resident during an annual recertification survey. The resident was admitted from the community and had been evaluated in the emergency room earlier in the day. Upon admission, the resident was assessed by a physician and deemed incapable of understanding any information, necessitating a third party to make decisions on their behalf. During the night, the resident was found on a floor mat by the bed but showed no evidence of injury and was placed back in bed. Later, a staff member noticed changes in the resident's breathing pattern and alerted an LPN, who assessed the resident and found them not breathing with eyes rolled back. The LPN notified 911/EMS and applied oxygen but did not initiate CPR. The LPN and an RN supervisor reviewed the resident's medical record and could not find a completed MOLST form, leading them to wait for emergency services to arrive. CPR was not performed, and the resident was pronounced deceased by EMS upon arrival. Interviews with staff revealed that the LPN had received prior education on CPR and MOLST forms but did not act due to the absence of a completed MOLST form. The former Social Work Director stated that newly admitted residents without a completed MOLST form should be considered full code in emergencies. However, there was no documentation of advance directives or MOLST status in the resident's progress notes. The facility's policy indicated that in the absence of appropriate DNR identification or orders, staff should respond with CPR measures and treat the resident as a full code.
Failure to Follow Care Plans Leads to Resident Injuries
Penalty
Summary
The facility staff failed to provide adequate supervision and follow the resident's plan of care, resulting in harm to two residents. In the first incident, a resident with cognitive impairment and total dependence on staff for care fell out of bed during incontinence care, leading to bilateral femoral neck fractures. The GNA responsible for the resident's care did not adhere to the care plan, which required two staff members for bed mobility. The GNA turned the resident onto their side and left them unattended while seeking additional supplies, resulting in the resident rolling out of bed. In the second incident, another resident with a history of a fractured hip, dementia, and metabolic encephalopathy suffered a fractured humerus during a transfer to a shower chair. Two GNAs attempted to transfer the resident manually, contrary to the care plan that required the use of a lifting device. During the transfer, they heard a popping sound and lowered the resident to the floor. The GNAs had not reviewed the resident's updated care plan, which specified the use of a Hoyer lift for transfers. Both incidents highlight a failure to adhere to established care plans and protocols, resulting in significant injuries to the residents. The staff involved did not verify the residents' care plans before performing tasks, leading to improper handling and supervision. These deficiencies were identified during a survey, and the facility was found to have past noncompliance with a compliance date established after corrective measures were implemented.
Resident Abuse Incident Involving Staff Member
Penalty
Summary
The facility failed to ensure that a resident remained free of abuse, as evidenced by an incident involving a staff member, GNA2, who was witnessed kicking a resident on the right lower leg. This incident occurred when the resident attempted to remove food and meal trays from a food cart. GNA2, who was verbally aggressive, attempted to move the resident backward by holding the wheelchair handles and subsequently kicked the resident, resulting in a skin tear. The resident expressed distress by screaming and wheeling themselves down the hall, where they were later found crying by another staff member, LPN5, who observed the injury and reported the incident to a supervisor. The incident was substantiated through witness statements, including that of LPN5, who detailed the sequence of events leading to the abuse. The resident was initially told by GNA2 to return to their room after being informed they had already eaten. Despite the resident's request to be left alone, GNA2 persisted in trying to move the resident, leading to the physical altercation. The facility's investigation confirmed the abuse, and GNA2 was immediately suspended and subsequently terminated following the incident.
Failure to Implement Abuse Policy and Procedures
Penalty
Summary
The facility failed to implement its existing abuse policy and procedures when an allegation of sexual abuse was reported by two staff members. An anonymous complaint revealed that a resident was observed sexually assaulting another resident, and the facility administration allegedly required a licensed nurse to retract their documentation of the incident. Furthermore, the facility did not report the allegation of resident-to-resident sexual abuse to the State Survey Agency. Interviews with the Director of Social Work and the facility Administrator confirmed that an investigation was initiated, but there were no administrative documents or investigative records regarding the alleged abuse. Additionally, the local police and the State Survey Agency were not notified. The facility's leadership did not adhere to its policy, which mandates immediate reporting of alleged violations involving abuse, neglect, exploitation, or mistreatment. The policy requires reporting to the State Survey Agency within two hours of receiving an allegation and conducting a prompt investigation. However, the facility failed to document the incident properly, did not collect witness statements, and did not notify the appropriate authorities. The staff were aware of the resident's history of intrusive behaviors, yet no formal investigation or documentation was completed, leading to a deficiency in handling the reported abuse incident.
Failure to Report Resident-to-Resident Sexual Abuse
Penalty
Summary
The facility administrative staff failed to report an allegation of resident-to-resident sexual abuse to the State Survey Agency. This incident involved two residents, where one was observed with their hands inside the other's brief, touching their genitals. The incident was initially reported by a GNA to the Director of Social Work, who then informed the facility Administrator and the Director of Nurses. However, the facility did not document or investigate the incident properly, and no report was made to the State Survey Agency or local police. The facility's policy requires immediate reporting of such allegations, but this was not adhered to. The nurse who documented the incident in the alleged perpetrator's medical record found that the progress note was later marked as invalid, and no formal witness statements were collected. The facility Administrator admitted that there were no administrative documents or investigative records regarding the alleged abuse, and the staff were aware of the resident's intrusive behaviors but failed to take appropriate action.
Failure to Investigate Resident-to-Resident Sexual Abuse Allegation
Penalty
Summary
The facility administrative staff failed to investigate an allegation of resident-to-resident sexual abuse when it was reported by staff members. This incident involved two residents, where one was observed with their hands inside the other's brief, touching their genitals. The Director of Social Work was informed of the incident and reported it to the facility Administrator and the Director of Nurses. However, there were no administrative documents or investigative records regarding the alleged abuse, and the local police and State Survey Agency were not notified. The facility's policy requires immediate reporting and investigation of any allegations of abuse, but this was not followed. A staff nurse documented the incident in the alleged perpetrator's medical record, but the progress note was later marked as invalid without explanation. The nurse who reported the incident was not asked to provide a formal witness statement or interviewed by administrative staff. The facility's leadership failed to conduct a prompt investigation or implement immediate actions to safeguard the residents involved.
Failure to Ensure Resident Freedom from Physical Restraints
Penalty
Summary
The facility failed to ensure that a resident was free from the use of physical restraints, as observed with one resident who was placed in a geriatric chair and a wheelchair with a lap tray. These devices prevented the resident from standing up, which was done for staff convenience rather than medical necessity. The facility's policy clearly states that restraints should only be used as a last resort and must be documented with a physician's order reflecting a qualifying medical symptom, which was not done in this case. The resident, who was cognitively intact with a Brief Interview for Mental Status (BIMS) score of 14 out of 15, was observed multiple times in a geriatric chair and a wheelchair with a lap tray, unable to stand or move freely. The resident's care plan did not include any interventions or assessments for the use of these restrictive devices. Staff interviews revealed a lack of awareness and assessment regarding the use of these devices as restraints, and the resident expressed feelings of anxiety and nervousness due to the inability to move freely. Interviews with the Director of Nursing (DON) and the Administrator indicated that they did not consider the geriatric chair with an overbed table or the wheelchair with a lap tray as restraints, and no assessments or care planning were completed to ensure the resident's safety. The resident was often placed in these devices without attempts to allow her to sleep in her bed, further indicating the use of these devices for staff convenience rather than the resident's best interest.
Failure to Revise Care Plan for Restraint Use
Penalty
Summary
The facility failed to revise the care plan for a resident to include the use of a geriatric chair and lap trays, which were considered restraints. The resident, who was cognitively intact with a BIMS score of 14 out of 15, was admitted to the facility and later placed in a geriatric chair after a fall. However, the care plan did not reflect the use of these devices, which were intended to prevent falls. Observations revealed the resident was often placed in a geriatric chair or a wheelchair with a lap tray, and staff intervened to keep the resident seated, indicating the devices were used as restraints. Interviews with nursing staff, including LPNs and RNs, confirmed that the care plan had not been updated to include the use of these restrictive devices. The MDS nurses were unaware of the resident's placement in a geriatric chair and the use of a lap tray, and the Director of Nursing and Administrator did not consider these devices as restraints. This oversight placed the resident at risk for unmet care needs and safety risks, as there was no assessment or care planning to ensure the resident's safety with these devices.
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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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