Bedford Court Healthcare Cent.
Inspection history, citations, penalties and survey trends for this long-term care facility in Silver Spring, Maryland.
- Location
- 3701 International Drive, Silver Spring, Maryland 20906
- CMS Provider Number
- 215246
- Inspections on file
- 14
- Latest survey
- March 20, 2026
- Citations (last 12 mo.)
- 2
Citation history
Health deficiencies cited at Bedford Court Healthcare Cent. during CMS and state inspections, most recent first.
The facility failed to consistently document controlled substance counts with the required dual nurse signatures on two nursing units. During medication pass observations, surveyors found multiple missing signatures from incoming and outgoing nurses in the narcotic control records, even though facility practice requires two nurses to jointly count and then sign to verify all controlled medications are accounted for. Nursing staff and the DON confirmed that both outgoing and incoming nurses are expected to sign the narcotic records after each shift-to-shift count.
A resident was admitted from a hospital with discharge instructions for Eliquis BID, amiodarone QD, and Buspirone BID, but nursing staff used an outdated hospital discharge summary from a prior hospitalization when entering admission orders. As a result, the facility ordered and administered Eliquis QD instead of BID, amiodarone BID instead of QD, initiated Losartan that was not on the current discharge list, and delayed starting Buspirone. The DON later acknowledged that staff misread the date on the discharge summary, and the errors continued for several days until identified by the family.
The facility failed to obtain physician orders for CPAP treatment for three residents, including one who used the machine nightly. Another resident experienced significant weight loss due to lack of assistance during meals, despite care plan requirements. Additionally, a resident was left unattended after vomiting, as the RN failed to assess or intervene, leaving a gap in care.
The facility failed to secure medication carts, as observed during a survey. Three instances of unattended and unlocked carts containing medications were noted. Staff interviews confirmed awareness of the policy to lock carts when unattended, yet lapses occurred, indicating a systemic issue.
The facility failed to adhere to professional food safety standards, with numerous unlabeled and expired food items found in the kitchens. Staff were unaware of proper labeling practices, and internal temperature monitoring devices were absent, leading to incomplete temperature logs. The Dining Service Director acknowledged these issues, citing staffing problems but admitting there was no excuse for the deficiencies.
The facility failed to properly dispose of waste in the kitchen and dumpster areas, leading to potential contamination and pest attraction. Surveyors observed a pile of empty boxes blocking access to kitchen equipment and an overfilled trash can. In the dumpster area, trash was scattered, and a buildup of dried leaves was noted. The Dining Service Director acknowledged the issues and instructed staff to address them.
The facility did not ensure the presence of required staff members at monthly QA Committee meetings, as revealed by attendance records. Over a six-month period, key personnel such as the DON, IP, and MD were frequently absent, leading to a deficiency noted during a recertification survey.
The facility failed to provide access to grievance forms as required by its policy. A complaint was filed after a resident and a complainant were denied copies of grievance forms by the Social Service Director, who cited the facility's policy of keeping such documents internal. However, the facility's grievance policy stated that these forms should be accessible to residents, family, and team members. The Nursing Home Administrator confirmed the policy's requirements and the discrepancy in its implementation.
A resident did not receive scheduled showers as part of their ADL care, as confirmed by a formal complaint and medical record review. The resident was supposed to have showers on specific days, but only received a bed bath twice and a shower once over several weeks. The NHA acknowledged the error, noting that the bathing order was mistakenly marked as 'as needed.'
A resident was repeatedly observed slumped over asleep in a wheelchair at the dining table, with drool on their lap and no assistance from staff. Despite having a plate of food in front of them, the resident did not eat, and staff intervention was required to awaken them. The ADON acknowledged the situation as unacceptable.
The facility did not post the location of the most recent state survey results and plan of correction in an accessible area for residents, family members, and visitors. This was observed during a recertification survey and confirmed by the Nursing Home Administrator, who acknowledged the oversight.
The facility failed to document that advance directives were offered to two residents, despite their capacity to make such decisions. The Social Worker confirmed that while she routinely offered advance directives, she did not document these interactions in the medical records, leading to a deficiency noted during a recertification survey.
A facility failed to develop a comprehensive care plan for a resident's splint use, despite physician orders for a left upper extremity rigidity splint and a soft brace elbow. The resident, observed with left arm weakness, had no care plan formulated since the orders were issued. Interviews confirmed the absence of a care plan, highlighting a deficiency in care planning processes.
A resident's care plan was not updated after the completion of IV antibiotic treatment and removal of a PICC line. Despite the PICC line being removed, the care plan continued to include interventions for PICC line care, which were no longer necessary. This oversight was confirmed through interviews and medical record reviews, highlighting a failure to revise the care plan to reflect the resident's current needs.
The facility failed to maintain oxygen therapy equipment according to professional standards for two residents, as their oxygen tubing and humidification bottles were not labeled. Observations and interviews revealed that the equipment was not labeled as required by physician orders, and staff were unaware of when the equipment was last changed. The ADON confirmed the expectation for staff to change and label the equipment weekly.
The facility failed to maintain accurate medical records for two residents, leading to medication administration errors and inadequate monitoring. One resident received Ibuprofen for pain instead of fever, while another's medication orders for monitoring were not transmitted to the TAR, resulting in a lack of side effect monitoring. Additionally, a wound care plan was not documented in the TAR, indicating lapses in record-keeping.
The facility was found deficient in maintaining a sanitary environment and ensuring functional equipment. The laundry room had dirty floors and damaged walls, while a resident's room had a broken toilet paper holder. The NHA acknowledged the issues and entered a work order for the broken holder after it was pointed out.
Failure to Consistently Document Dual Nurse Signatures for Narcotic Counts
Penalty
Summary
The deficiency involves the facility’s failure to consistently document controlled substance counts with the required dual nurse signatures during shift-to-shift narcotic counts on two of three units. On the Choice unit, during a medication pass observation with an LPN, review of the narcotic control book showed a missing incoming nurse signature for the 3:00 PM to 11:00 PM shift and a missing outgoing nurse signature for the 11:00 PM to 7:00 AM shift on a specific date. The assisting nurse from another unit who helped complete the narcotic count during a family emergency for the scheduled incoming nurse did not sign the narcotic book, despite the expectation that both outgoing and incoming nurses sign after jointly counting narcotics. On the Independence unit, during another medication pass observation with an LPN, review of the narcotic binder revealed three missing signatures: an incoming nurse signature for the 3:00 PM to 11:00 PM shift, an outgoing nurse signature for the 11:00 PM to 7:00 AM shift on the same date, and an incoming nurse signature for the 11:00 PM to 7:00 AM shift on a different date. The LPN on that unit confirmed the missing signatures and stated that both outgoing and incoming nurses are required to sign to verify that narcotics were counted. The DON also confirmed that facility expectations require two nurse signatures after a joint count to document that all controlled medications are accounted for, and acknowledged the missing signatures when informed of the findings.
Failure to Verify Hospital Discharge Orders Resulting in Medication Errors
Penalty
Summary
The facility failed to ensure that a newly admitted resident was free from significant medication errors by not verifying the accuracy of hospital discharge paperwork before entering admission medication orders. The resident was admitted from the hospital with discharge paperwork dated 02/20/2026 that listed Eliquis 5 mg by mouth twice daily, amiodarone 200 mg by mouth once daily, and Buspirone 5 mg by mouth twice daily. Facility records showed that orders were instead entered for Eliquis 5 mg by mouth once daily and amiodarone 200 mg by mouth twice daily, both starting on 02/21/2026 and discontinued on 02/25/2026, and these medications were administered as ordered. Additionally, Losartan Potassium 50 mg by mouth once daily was ordered and administered from 02/21/2026 through 02/27/2026, even though this medication was not listed on the hospital discharge medication list. Buspirone was not started until 02/27/2026, despite being included on the hospital discharge medication list. During interviews, the Medical Director confirmed that a medication error had occurred involving these medications for the resident and stated that the errors were present when he evaluated the resident. The DON reported that the facility had received a hospital discharge summary from a prior hospitalization dated 07/18/2025 and that nursing staff misread the date and did not identify that it was from an earlier admission. As a result, the resident received incorrect medications for the first four days of their stay until the error was identified by a family member. The surveyor reviewed the 07/18/2025 hospital discharge paperwork and confirmed that the wrong discharge summary had been used, leading to the inaccurate medication orders and administration.
Deficiencies in Resident Care and Documentation
Penalty
Summary
The facility failed to obtain physician orders for CPAP treatment for three residents, including Resident #17. During a survey, it was observed that Resident #17 had a CPAP machine on their bedside table and used it nightly for sleep issues. However, a review of the resident's clinical record revealed no physician's order for the CPAP treatment until the surveyor's inquiry prompted the Director of Nursing to obtain one. This oversight indicates a lapse in ensuring that all medical treatments are properly documented and authorized by a physician. Resident #8 was observed multiple times in a state of neglect, slumped over in a wheelchair or bed, with food trays untouched and no staff assistance provided. The resident experienced significant weight loss, and their care plan indicated a need for supervision or assistance while eating. Despite this, the resident was left unattended during meals, leading to further weight loss and signs of malnutrition. Additionally, the resident's care plan required the use of an abduction pillow post-surgery, but observations showed the pillow was not consistently in place, and staff falsely documented its use. Resident #292 experienced vomiting and pain, but the RN on duty failed to assess or intervene, leaving the resident unattended. The RN left the facility before being relieved by the incoming nurse, resulting in a gap in care. The resident's daughter reported that no nurse attended to her mother for about an hour after the vomiting incident. This lack of timely response and communication among staff members highlights a deficiency in maintaining quality care and ensuring residents' immediate needs are addressed.
Medication Cart Security Lapses
Penalty
Summary
The facility failed to maintain a secure system for medication storage, as evidenced by three separate observations of unattended and unlocked medication carts during a re-certification survey. On the first occasion, a medication cart was found unlocked and unattended, with drawers containing both prescribed and over-the-counter medications accessible. Additionally, a laptop displaying resident names was left open. This incident occurred when an RN left the cart to attend to a resident, acknowledging the oversight and citing a rough night as the reason for the lapse. Subsequent observations revealed similar deficiencies, with two more instances of unlocked and unattended medication carts. In both cases, the carts contained medications labeled with resident names and room numbers. The facility's policy requires that medication carts be locked when unattended, a policy that was not adhered to by the staff involved. Interviews with the staff confirmed awareness of the policy, yet the lapses continued, indicating a systemic issue in securing medication carts as per the facility's guidelines.
Food Safety and Labeling Deficiencies
Penalty
Summary
The facility failed to store and prepare food in accordance with professional standards of food service safety, as observed during a survey. In the Dining Room Kitchen, several food items were found improperly labeled or not labeled at all, including cooked ham, cheese, Rice Krispies, and peanut butter. The Lead Dietary Aide admitted to not knowing the correct expiration dates for these items and acknowledged the presence of expired Old Bay seasoning. This lack of proper labeling and disposal of expired items was confirmed during interviews with facility staff. In the Main Kitchen, numerous food items were found opened without labels or expiration dates, including roasted peppers, muffins, cookie dough, tomato sauce, and various dressings. Additionally, expired items such as bananas and lingonberries were discovered. The Lead Cook confirmed these items were expired and should have been disposed of. The surveyors also noted a sign instructing staff to label all open items, which was not being followed. Furthermore, the facility lacked internal temperature monitoring devices in refrigerators and freezers, and temperature logs were incomplete. The Lead Cook was unaware of the need for internal temperature devices, relying instead on external thermometers. The Dining Service Director acknowledged the issues with labeling, expired items, and temperature monitoring, attributing some of the problems to staffing issues but recognizing there was no excuse for the deficiencies.
Improper Waste Disposal in Kitchen and Dumpster Areas
Penalty
Summary
The facility failed to properly dispose of waste in the kitchen area, leading to potential contamination and pest attraction. During an initial tour of the main kitchen, surveyors observed a pile of 14 empty boxes blocking the doors of the refrigerator, freezer, and holding warmer. Additionally, a trash can beside the door was overfilled, preventing the lid from closing completely, with several cans visible on top of the trash. Interviews with the lead staff and the Dining Service Director confirmed that the trash should not have been there and acknowledged the issue without providing an excuse. Further observations in the dumpster area revealed improper waste disposal, with trash scattered over several areas, including disposable cups, papers, and carry-out trays. There was also a heavy buildup of dried leaves around the dumpster area. A cart with two bags of trash and a stack of boxes were noted beside the dumpster, waiting to be thrown out. The Dining Service Director acknowledged the situation and instructed a dietary employee to ensure the trash is disposed of properly to prevent rodent attraction.
QA Committee Meetings Lacked Required Staff Attendance
Penalty
Summary
The facility failed to ensure the required staff members were present for each of the monthly Quality Assurance (QA) Committee meetings, as revealed during a review of the Quality Assurance and Performance Improvement (QAPI) program during the recertification survey. Specifically, attendance sheets for the past six months showed that in May, the Director of Nursing (DON), Infection Preventionist (IP), and Medical Director (MD) were absent. In June, the DON and IP were not present, and in July, the DON, IP, and MD were again absent. This deficiency was identified during an interview with the Nursing Home Administrator (NHA) and a subsequent review of the attendance records.
Failure to Provide Access to Grievance Forms
Penalty
Summary
The facility failed to ensure that grievance forms were accessible to residents, family, and team members, as required by their own grievance policy. This deficiency was identified during a review of a formal complaint filed with the Office of Healthcare Quality. The complaint involved verbal grievances filed by the Social Service Director on behalf of a resident and a complainant. The complainant requested copies of the written grievances, but the request was denied based on the facility's policy, which considered grievance forms as internal documents not for public view. Upon reviewing the facility's grievance policy, it was found that the policy explicitly stated that grievance reports should be readily accessible to residents, family, and team members. However, the Social Service Director's actions were contrary to this policy, as she denied the complainant's request for access to the grievance forms. The Nursing Home Administrator confirmed the policy's requirements and acknowledged the discrepancy between the policy and the actions taken by the Social Service Director.
Failure to Provide Scheduled ADL Care for a Resident
Penalty
Summary
The facility failed to provide adequate Activities of Daily Living (ADL) care for Resident #244, as evidenced by the lack of scheduled showers. A formal complaint was filed with the Office of Healthcare Quality, indicating that the resident did not receive showers as scheduled during their stay. A review of the resident's medical records confirmed that showers were scheduled for Tuesday and Friday evenings. However, the records showed that the resident only received a bed bath on two occasions and a shower on one occasion over a period of several weeks. During an interview, the Nursing Home Administrator (NHA) acknowledged that the resident did not receive the scheduled bed baths and showers due to an error in the bathing order, which was incorrectly marked as 'as needed.'
Failure to Respect Resident's Dignity
Penalty
Summary
The facility failed to respect a resident's dignity, as observed in the case of Resident #8. During multiple observations, the resident was found slumped forward asleep in a wheelchair at the dining room table, with drool draining from their mouth onto their lap. On one occasion, a plate of food was placed in front of the resident, but no food had been eaten, and no assistance was provided by the staff. Attempts by a Geriatric Nursing Assistant to awaken the resident required loud calling and physical shaking, after which the resident appeared groggy and unable to hold their head up. On a subsequent day, the resident was again observed slumped over asleep in their wheelchair at lunch, with wet spots on their shirt from drool, and no food had been delivered. Despite the presence of a plate of food later, the resident remained asleep and unattended. The Assistant Director of Nursing was informed of the situation and upon returning to the dining room, found the resident still asleep with untouched food. The ADON had to wake the resident by calling their name loudly and shaking their shoulders, noting the situation as unacceptable.
Failure to Post Survey Results Location
Penalty
Summary
The facility failed to ensure that the location of the most recent state survey results and plan of correction were posted in a place readily accessible to residents, family members, and visitors. During the recertification survey, observations made by the surveyor on two separate occasions did not reveal any posted notification indicating where these documents were located. This deficiency was confirmed in an interview with the Nursing Home Administrator, who acknowledged the oversight and stated an intention to address the issue immediately.
Failure to Document Offer of Advance Directives
Penalty
Summary
The facility failed to provide evidence that advance directives were offered to two residents during a recertification survey. Specifically, for two of the four residents reviewed, there was no documentation in their medical records indicating that they were offered the opportunity to formulate an advance directive. Both residents were determined to have the capacity to make such decisions, as indicated by completed capacity forms. However, the facility's records lacked any evidence of discussions or offers regarding advance directives prior to the surveyors' intervention. During an interview, the Social Worker confirmed that while she routinely checked for advance directives and offered residents the opportunity to formulate one, she did not document these interactions in the medical records. This lack of documentation was evident in the cases of the two residents reviewed, as their records did not reflect any offer or discussion of advance directives until after the surveyors intervened. The deficiency was brought to the facility's attention during the exit meeting of the survey.
Failure to Develop Comprehensive Care Plan for Splint Use
Penalty
Summary
The facility failed to develop and implement a comprehensive care plan for the use of a splint for Resident #37. This deficiency was identified during a recertification survey, where it was observed that the resident, who had left arm weakness, was using a half lap board arm rest attached to the wheelchair, and a plastic splint was noted on the windowsill. Despite physician orders dated 11/18/2024 for the use of a left upper extremity rigidity splint during the day shift and a soft brace elbow at bedtime, there was no evidence of a care plan for the splint use in the resident's medical record. Interviews with the Nursing Home Administrator and the acting Director of Nursing confirmed the absence of a care plan for the splint. The acting DON explained the process for formulating care plans, which involves the nurse completing the admission assessment and updating the care plan with input from the DON, NHA, Social Worker, and Resident Assessment Coordinator when changes are needed. However, despite being notified of the splint order on 11/18/2024, the care plan was never formulated, leading to the deficiency.
Failure to Update Care Plan After PICC Line Removal
Penalty
Summary
The facility staff failed to review and revise the interdisciplinary care plans to accurately reflect the current needs of the residents. This deficiency was identified during a survey process, specifically for one resident who was admitted with physician orders for intravenous antibiotic treatment via a peripherally inserted central catheter (PICC) line for Osteomyelitis. The resident's antibiotic treatment ended, and the PICC line was removed, but the care plan continued to include interventions related to the PICC line, which were no longer applicable. The deficiency was confirmed through interviews and medical record reviews. The resident informed the surveyor that the antibiotic treatment had ended, and the PICC line was removed approximately two weeks prior. However, the care plan still included interventions for PICC line care, such as changing the site dressing and flushing the line, even after its removal. The Director of Nursing confirmed that these interventions should have been discontinued once the PICC line was removed, indicating a failure to update the care plan in a timely manner.
Failure to Label Oxygen Therapy Equipment
Penalty
Summary
The facility failed to maintain oxygen therapy equipment according to professional standards of practice for two residents during the annual survey. Observations revealed that the oxygen tubing and humidification bottles for both residents were not labeled, which is contrary to the physician's orders. Resident #24's oxygen equipment was observed without labels on two separate occasions, and the Licensed Practical Nurse (LPN) confirmed the lack of labeling and was unaware of when the equipment was last changed. Similarly, Resident #11's oxygen equipment was also found unlabeled during observations, and the LPN again confirmed the absence of labeling and the uncertainty regarding the last change. Interviews with the LPN and the Assistant Director of Nursing (ADON) highlighted that the facility's protocol requires oxygen tubing and humidification bottles to be changed weekly and labeled accordingly. However, the LPN admitted to assuming the equipment was changed based on the date written on the humidification bottle, which was not present. The ADON reiterated the expectation for staff to follow physician orders and label the equipment. The Nursing Home Administrator and Regional Director of Clinical Care were informed of these concerns during the survey.
Deficiencies in Medication Administration and Record-Keeping
Penalty
Summary
The facility failed to maintain complete and accurate medical records for two residents, leading to deficiencies in medication administration and monitoring. For one resident, Ibuprofen was administered for pain instead of fever, despite the absence of any recorded fever episodes. The Licensed Practical Nurse (LPN) was aware of the resident's pain but did not follow the correct medication order, which was later clarified by the Director of Nursing (DON) to be for breakthrough pain. This discrepancy in medication administration was not documented properly in the resident's medical records. Another resident's medical records revealed that physician's orders for monitoring various medications, including an antipsychotic, antidepressant, anticoagulant, and behavior monitoring, were not transmitted to the Treatment Administration Record (TAR). This oversight resulted in the resident not being monitored for potential side effects of these medications. Additionally, there was a discrepancy in the indication for Mirtazapine, which was incorrectly documented as being for bipolar disorder instead of an appetite stimulant. The Assistant Director of Nursing (ADON) confirmed these errors and acknowledged the failure to monitor the resident's medication side effects. Furthermore, the resident's wound care plan, which included the use of pressure-relieving boots for a deep tissue injury, was not documented in the TAR. The ADON confirmed that the order for the boots was not listed, indicating a lapse in ensuring that the resident's care plan was accurately reflected in their medical records. These deficiencies highlight significant gaps in the facility's documentation and medication management processes.
Sanitation and Equipment Deficiencies in Facility
Penalty
Summary
The facility failed to maintain a sanitary environment and ensure functional equipment, as observed during a recertification survey. In the laundry room, the floor tiles were visibly dirty with dark residue and dirt accumulation between washing machines. The wall below the shelf housing washing machine chemicals was peeled and damaged, and a brown substance was noted on the wall above the eye wash station. These findings were confirmed by Staff #15 and the Housekeeping Supervisor, Staff #16, who attributed the wall damage to leakage from the chemical unit. Additionally, in one resident room, the toilet paper holder wall mount was broken, with one arm mount missing and the roll holder absent. The Nursing Home Administrator (NHA) was shown the broken dispenser and acknowledged that it had not been reported in their electronic maintenance system, TELS. The NHA later entered the work order request into the system, confirming the deficiency in addressing maintenance concerns promptly.
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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