Berlin Nursing And Rehabilitation Center
Inspection history, citations, penalties and survey trends for this long-term care facility in Berlin, Maryland.
- Location
- 9715 Healthway Drive, Berlin, Maryland 21811
- CMS Provider Number
- 215126
- Inspections on file
- 14
- Latest survey
- August 14, 2025
- Citations (last 12 mo.)
- 64
Citation history
Health deficiencies cited at Berlin Nursing And Rehabilitation Center during CMS and state inspections, most recent first.
A resident was not protected from a significant medication error due to a failure in the medication administration process.
Surveyors found three opened, unlabeled bags of bread and three unlabeled containers of seasoning base in the kitchen. The Dietary Manager confirmed that the bread should have been labeled and that two containers held chicken base transferred from a larger container. This failure to properly store and label food items did not meet professional standards.
Surveyors found that the facility did not develop or implement complete care plans for three residents with complex needs, including dialysis, constipation, diabetes, depression, chronic pain, anticoagulant use, and contractures. Key health conditions and therapy recommendations were omitted from care plans, and these omissions were confirmed through interviews and record reviews. The DON acknowledged that these care needs should have been addressed in the care plans.
Surveyors identified that staff failed to document medication administration in the MAR at the time medications were given, with multiple instances of late charting for several residents. In addition, a resident's nursing note was incorrectly filed under another individual's record, resulting in incomplete documentation during a hospital transfer. The DON and NHA confirmed these documentation lapses and acknowledged that they did not meet facility policy requirements.
Surveyors identified that several residents did not receive accurate MDS assessments, including incorrect coding of hearing loss, falls, and urinary continence. For example, a resident with severe hearing impairment was assessed as having only moderate loss, and two residents who experienced falls were not properly coded for these events. Another resident with a Foley catheter was incorrectly coded as occasionally incontinent. These discrepancies were confirmed by facility staff during the survey.
Two residents experienced physical abuse by GNAs, including being pushed and sustaining injuries. In both cases, the facility substantiated the abuse through investigation and interviews, but failed to report one of the incidents to the Maryland Board of Nursing as required by policy and regulation.
A resident with an indwelling Foley catheter was observed with a visible, uncovered drainage bag attached to the bed frame, despite a physician order and facility policy requiring a privacy barrier. The DON confirmed that nursing staff were responsible for ensuring privacy covers were used, but this was not done at the time of the surveyor's observation.
A resident did not receive scheduled showers as ordered, with records showing only one shower provided over several months. The resident's POA raised concerns, and review of POC documentation confirmed the lack of showers and no evidence of refusals. The DON verified that neither refusals nor missed showers were documented, and the care plan did not address refusals.
A resident's legal representative repeatedly requested the complete medical record, but only partial records were provided on two occasions. Facility staff could not confirm that the full record was ever sent, and documentation to verify transmission was lacking.
A resident admitted with Atherosclerotic Heart Disease, Dementia, and End Stage Renal Disease, and receiving hemodialysis three times weekly, did not have a Baseline care plan developed or provided within 48 hours of admission as required. The DON confirmed the absence of the care plan in the clinical record.
Surveyors identified that two residents did not have their care plans properly reviewed or revised to reflect current interventions, including one with a wound lacking specific care plan interventions and documentation, and another whose responsible party was not properly notified or documented for a care plan meeting. The DON and social worker confirmed these deficiencies in care plan management and documentation.
Two residents did not receive care in accordance with professional standards. One resident, after an unwitnessed fall resulting in a head laceration and wrist fracture, had no documented follow-up nursing care, including missing neuro and circulation checks. Another resident was left unattended, undressed, and calling for help, with soiled items left in the room and bathroom, and without privacy measures in place. The assigned GNA reported leaving the resident after a refusal of care and combative behavior.
A resident with dementia and end stage renal disease, dependent on staff for grooming, was repeatedly observed with unshaven facial hair due to staff being unaware of the care plan requirement for shaving assistance. The lack of communication in updating the resident's profile led to the omission of necessary care.
Two residents experienced deficiencies: one did not receive a physician order for splint use despite OT recommendations for contracture management, and another was transferred to the hospital without proper assessment or documentation of vital signs and without addressing a complaint of trouble breathing. The DON confirmed the lack of necessary orders and documentation.
A resident with documented bilateral hearing loss and moderate hearing difficulty, as assessed in the MDS, did not receive an audiology consultation or hearing aids since admission. The facility's only intervention was the use of a whiteboard for communication, and the Clinical Service Director confirmed that no audiology referral had been made.
Two residents requiring dialysis care did not receive proper monitoring and documentation as required by physician orders and facility policy. For one resident, vital signs and weights were often not recorded before and after dialysis, and communication sheets from the dialysis center were frequently missing or incomplete. For another resident, the clinical record lacked documentation of the type and location of the dialysis shunt, physician orders for shunt monitoring, and evidence of nursing assessment of the shunt site, despite policy requiring regular inspection.
A required annual performance review was not completed for a Geriatric Nursing Assistant, despite facility policy mandating yearly evaluations. The DON confirmed the omission after a review of personnel files.
A resident's monthly drug regimen reviews identified that physician orders for PRN pain medications lacked pain scale guidance and that a narcotic pain medication had not been used for 60 days, with recommendations for clarification and discontinuation made by the pharmacist. These recommendations were not addressed by the physician, and no documentation of response was found in the medical record.
Surveyors found that a CMA administered medication from a bottle of Senna Plus that was not labeled with the date it was opened, contrary to facility practice. Additionally, a medication cart was observed unlocked and unattended in a hallway, with staff later confirming it should have been secured according to policy.
Two residents with indwelling medical devices did not receive proper infection control measures as required by facility policy. One resident with multiple wounds and a dialysis catheter was not placed on Enhanced Barrier Precautions, and there were no signs or supplies for EBP at the room entry. Another resident with a urinary catheter had the drainage bag lying on the floor, contrary to infection control standards.
Significant Medication Error Occurred
Penalty
Summary
Residents were not ensured to be free from significant medication errors. The report identifies that there was at least one instance where a resident experienced a significant medication error, indicating a failure in the medication administration process. Specific details regarding the actions or omissions that led to the error, as well as information about the resident's medical history or condition at the time, are not provided in the report.
Failure to Properly Store and Label Food Items
Penalty
Summary
During an initial kitchen tour, surveyors observed three opened, unlabeled bags of bread stored on a steel cart in the kitchen, as well as three 14-ounce containers of beef flavored base that were also unlabeled and stored with other seasonings. The Dietary Manager confirmed that the bread bags were expected to be labeled and that two of the containers actually contained chicken flavored base, which had been transferred from a larger container in the cooler. These observations indicated that the facility failed to properly store and label food items to maintain their integrity, as required by professional standards.
Failure to Develop and Implement Comprehensive Care Plans
Penalty
Summary
Surveyors identified that the facility failed to develop and implement comprehensive care plans for several residents, as required. For one resident with a history of constipation and undergoing dialysis three times a week, neither condition was included in the care plan despite documented complaints of constipation and ongoing dialysis treatments. The omission was confirmed through interviews and record reviews, which showed that the care plan was only updated after the issue was identified by surveyors. Another resident reported ongoing constipation and chronic pain, with a medical history including Type II Diabetes, Major Depressive Disorder, and use of anticoagulant medication. Despite these significant health concerns and active medication orders for each, the care plan did not address constipation, anticoagulant use, depression, diabetes, or chronic pain. The DON acknowledged that these issues should have been included in the care plan, but review of the updated care plan showed that only constipation was added, leaving other conditions unaddressed. A third resident was observed with contractures of the left elbow and both hands, and medical records confirmed these diagnoses along with recommendations from occupational therapy for splinting and positioning. However, there was no evidence that a care plan had been formulated to address the contractures since admission, despite documentation of therapy recommendations and care plan meeting notes referencing therapy involvement. The DON confirmed the absence of a care plan for contractures and stated that therapy recommendations were expected to be discussed in meetings.
Failure to Ensure Timely and Accurate Medical Record Documentation
Penalty
Summary
The facility failed to ensure timely and accurate documentation of medical records for several residents, as evidenced by interviews and record reviews. Multiple instances were identified where medications were administered but not documented in the Medication Administration Record (MAR) at the time of administration. For one resident, medications scheduled for 9 PM were consistently signed off as complete well after 11 PM, with notes indicating that charting was done late but medications were administered on time. The Director of Nursing confirmed that medications are expected to be administered and documented within a specific timeframe, and acknowledged that the documentation was not completed as required. Further review of other residents' MARs revealed similar patterns of late documentation. For another resident, both afternoon and evening medications, including insulin and other critical medications, were signed off several hours after the scheduled administration times, again with notes stating that charting was late. Another resident's MAR showed delayed documentation for antibiotics, with charting occurring hours after the scheduled dose. These findings were corroborated by the facility's own Medication Management Program Policy, which requires immediate documentation after medication administration. Additionally, a review of medical records for a resident who was admitted and then discharged to the hospital revealed a lack of appropriate nursing documentation. Only one progress note was found for the period in question, and a relevant nursing note was incorrectly filed under the record of the resident's spouse rather than the correct resident. Both the Nursing Home Administrator and the Director of Nursing confirmed the absence of proper documentation and acknowledged the error in record-keeping.
Failure to Ensure Accurate Resident Assessments
Penalty
Summary
The facility failed to ensure that residents received accurate and comprehensive assessments, as evidenced by multiple discrepancies found during interviews and record reviews. One resident with severe bilateral hearing loss, who could only communicate via a whiteboard, was incorrectly assessed on the Minimum Data Set (MDS) as having moderate hearing loss, despite documentation and staff interviews confirming a higher level of impairment. Another resident who experienced a fall was not accurately coded for this event on the quarterly MDS assessment, even though progress notes and care plans documented the fall. A third resident with an indwelling Foley catheter was discharged to the hospital, but the discharge MDS assessment inaccurately coded urinary continence as "occasionally incontinent" instead of "Not rated," which is the correct coding when a catheter is present. Additionally, a fourth resident who had a fall and was sent to the hospital was not coded for the fall on the subsequent quarterly MDS assessment, despite clinical records confirming the incident. In each case, the discrepancies were confirmed by facility staff, including the Director of Nursing and the MDS Coordinator, during interviews with surveyors. These findings demonstrate that the facility did not consistently ensure the accuracy of MDS assessments for residents, particularly in areas related to hearing loss, falls, and urinary continence. The inaccuracies were identified through direct review of medical records, care plans, and staff interviews, highlighting a pattern of incomplete or incorrect documentation in resident assessments.
Failure to Protect Residents from Abuse and Report to Licensing Board
Penalty
Summary
The facility failed to protect residents from abuse, as evidenced by two separate incidents involving geriatric nursing assistants (GNAs) and residents. In the first incident, a resident reported being pushed by a GNA by the back of the neck, shoved onto the bed, and sustaining an arm injury. The investigation conducted by the acting DON confirmed the presence of a bruise consistent with the resident's account, and the GNA was found to have abused the resident. In the second incident, another resident accused a GNA of hitting their finger after the resident pointed at a meal tray and put their hand in the GNA's face. The facility's investigation substantiated that there was direct physical contact between the GNA and the resident, and the GNA admitted to pushing the resident's hand away. The incident was reported to local law enforcement, and the resident confirmed being physically abused. However, the facility did not file a required complaint with the Maryland Board of Nursing regarding the substantiated abuse by the GNA, as was mandated by facility policy and state regulations.
Failure to Maintain Resident Dignity by Not Covering Foley Catheter Drainage Bag
Penalty
Summary
Facility staff failed to ensure the dignity of a resident with an indwelling Foley catheter. During the initial facility tour, a surveyor observed that the resident's Foley catheter drainage bag was attached to the bed frame and was not covered with a privacy barrier, making the urine visible. The resident's electronic medical record indicated a physician order for both the indwelling Foley catheter and a privacy bag to be in place every shift. In an interview, the DON confirmed that the facility provided privacy barrier covers for Foley catheter drainage bags and that it was the nursing staff's responsibility to ensure these were used upon resident admission. The deficiency was identified when the resident was found without the required privacy barrier, despite facility policy and physician orders mandating its use.
Failure to Provide Scheduled Showers and Support Resident Self-Determination
Penalty
Summary
A deficiency was identified when a resident did not receive scheduled showers as ordered by their physician, with documentation showing only one shower provided over a period of more than three months. The resident's Power of Attorney reported concerns about the lack of routine showers. Review of the resident's physician orders confirmed a standing order for showers twice weekly on the day shift. Examination of the Point of Care (POC) documentation revealed that showers were not provided as scheduled, and there was no documentation indicating that the resident refused care or showers during this period. The Director of Nursing confirmed the lack of both shower provision and refusal documentation, and the resident's care plan did not address refusals of care or showers.
Failure to Provide Complete Medical Records Upon Request
Penalty
Summary
The facility failed to provide a complete set of medical records to a complainant who had requested them multiple times for a specific resident. Record reviews confirmed that only partial records were sent on two separate occasions, with 9 pages (including a cover page) faxed on one date and 14 pages (including a cover page) faxed on another. Despite repeated requests, including a formal letter requesting all medical records from the patient chart, there was no documentation or fax confirmation that the full medical record had ever been provided to the complainant. Interviews with facility staff revealed uncertainty regarding whether the complete medical record packet was ever sent. The medical records staff member was unable to confirm the transmission of the full records and needed IT assistance to retrieve email records, which were not immediately available. The DON later confirmed that only incoming emails had been retrieved, and there was no confirmation of outgoing emails to verify that the complete records were sent. As a result, the surveyor determined that the facility did not ensure timely and complete access to the resident's medical records as required.
Failure to Complete Baseline Care Plan for Hemodialysis Resident
Penalty
Summary
The facility failed to develop and implement a Baseline care plan within 48 hours of admission for a resident requiring hemodialysis treatments. Record review showed that the resident, admitted with diagnoses including Atherosclerotic Heart Disease, Dementia, and End Stage Renal Disease, did not have a Baseline care plan completed or provided to them or their responsible party, as required. The resident was receiving hemodialysis three times a week. During an interview, the DON confirmed that the Baseline care plan was missing from the clinical record and could not provide a reason for the omission.
Failure to Review and Revise Care Plans and Inadequate Documentation of Care Plan Meetings
Penalty
Summary
The facility failed to review and revise interdisciplinary care plans to accurately reflect interventions for residents, as evidenced by two cases. In the first case, a resident with a wound on the right thigh had been receiving daily dressing changes per physician order, but the care plan did not include specific interventions or approaches to manage the skin impairment. Additionally, the clinical record lacked a description or measurements of the wound, despite documentation by a nurse noting its presence and treatment. The Director of Nursing confirmed that the care plan was not updated to include the resident's actual skin impairment and that the clinical record did not contain a description of the affected area. In the second case, a resident's significant other reported not being invited to a care plan meeting following the resident's admission. The social worker confirmed that no care plan meeting had been scheduled and that invitations were typically sent within two weeks of admission, but there was no documentation indicating that the responsible party declined the invitation or that a meeting had occurred. The deficiency was identified when the surveyor found a lack of documentation in the medical record regarding the care plan meeting process for this resident.
Failure to Meet Professional Standards of Care and Ensure Resident Dignity
Penalty
Summary
The facility failed to ensure that care provided to two residents met professional standards of practice. For one resident, after an unwitnessed fall resulting in a forehead laceration and a left wrist fracture, there was no documented evidence of follow-up nursing care. The resident's medical record lacked documentation of neurological checks for the head injury, circulation checks for the fractured arm, and progress notes regarding the resident's condition following the fall and injuries. The Director of Nursing confirmed the absence of this required documentation during the surveyor's review. In a separate incident, another resident was observed unattended, lying naked in a high bed, calling for help, and holding onto the bed rail. A soiled disposable brief was found on the floor, and a feces-soiled washcloth was left in the bathroom sink with water running. The privacy curtain was not drawn, and no staff were present in the room for at least ten minutes. The assigned GNA later stated that the resident had refused care and become combative, so the GNA left the resident in that condition. The Unit Manager and Regional Clinical Services Director subsequently provided education to the GNA regarding safety, privacy, dignity, infection control, and handling of residents who refuse care.
Failure to Provide Grooming Assistance per Care Plan
Penalty
Summary
A deficiency was identified when a resident with diagnoses including atherosclerotic heart disease, dementia, and end stage renal disease, who was dependent on staff for grooming, was repeatedly observed with unshaven facial hair over several days. The resident stated that assistance was needed with shaving due to inability to perform the task independently. The resident's care plan, initiated months prior, documented limited ability to maintain grooming and specified that staff should provide assistance or full performance for facial hair care. Despite this care plan, a Geriatric Nursing Assistant (GNA) was unaware of the resident's need for shaving assistance and believed the resident was independent, only providing help upon request. This lack of awareness was traced to a failure to transfer the care plan intervention to the resident's profile, resulting in staff not being informed of the resident's grooming needs. The deficiency was confirmed through interviews and record review, as well as direct observation of the resident's unshaven condition.
Failure to Obtain Splint Orders and Inadequate Assessment Prior to Hospital Transfer
Penalty
Summary
The facility failed to obtain a physician order for the use of a splint and did not properly assess or address a resident's condition prior to hospital transfer. For one resident with contractures of the left elbow and both hands, observations revealed the absence of splints or braces despite occupational therapy recommendations for orthotic support and the use of towel rolls. The occupational therapist confirmed that recommendations were made and communicated verbally to staff, but no formal physician order was documented, and the Director of Nursing acknowledged the lack of orders to address the contractures. In a separate incident, another resident was transferred to the hospital after experiencing pain and trouble breathing. Documentation showed that only one progress note was written in the relevant timeframe, and there was no record of vital signs being obtained or documented prior to the transfer, despite facility expectations. While pain medication was administered, there was no documentation indicating that the complaint of trouble breathing was addressed. The Director of Nursing confirmed the absence of vital sign documentation and the lack of follow-up on the respiratory complaint.
Failure to Provide Audiology Services for Resident with Hearing Loss
Penalty
Summary
A resident with a diagnosis of unspecified bilateral hearing loss was observed to have significant difficulty hearing, requiring the use of a whiteboard for communication with staff. During interviews, the resident confirmed not having hearing aids and reported not having seen an audiologist since admission to the facility. Review of the resident's medical records and care plan confirmed the presence of hearing loss, with interventions limited to the use of a whiteboard for communication. Further review of the resident's Minimum Data Set (MDS) assessment indicated moderate hearing difficulty, yet there was no documentation of an audiology consultation since the resident's admission. The Clinical Service Director acknowledged that the facility had not ordered an audiology consult to assess the resident's hearing. This lack of referral and assessment resulted in the resident not receiving appropriate audiology services to address their hearing loss.
Failure to Ensure Proper Dialysis Care and Documentation
Penalty
Summary
The facility failed to provide safe and appropriate dialysis care and services for two residents requiring such care. For one resident receiving hemodialysis three times a week, there were multiple deficiencies in following physician orders and facility protocols. Orders required documentation of pre- and post-dialysis vital signs and weights, as well as the return and scanning of Dialysis Communication Sheets into the electronic medical record. However, vital signs and weights were frequently not documented, with staff often citing the resident's condition or absence for dialysis as reasons. Additionally, many Dialysis Communication Sheets were missing or not scanned into the system, and those that were available often lacked required information such as pre- and post-dialysis weights and blood pressures. For another resident with end stage renal disease and a dialysis shunt, the clinical record lacked essential information, including the type and location of the shunt, a physician's order to monitor the shunt site for infection, and documentation of nursing staff monitoring the site. The care plan also did not include interventions or approaches related to shunt care, despite facility policy requiring shunt site inspection every shift for signs of infection. Staff interviews confirmed the absence of these critical elements in the resident's record, and the infection preventionist was unable to identify the shunt location or find relevant orders in the chart. These deficiencies were identified through record reviews and staff interviews, which revealed that the facility did not consistently follow its own policies or physician orders regarding dialysis care and monitoring. The lack of documentation and incomplete communication between the dialysis center and facility staff contributed to the failure to ensure proper care for residents undergoing dialysis.
Missed Annual Performance Review for Geriatric Nursing Assistant
Penalty
Summary
Facility staff failed to conduct a required annual performance review for one Geriatric Nursing Assistant who had been employed for over eight years. A review of five Geriatric Nursing Assistants' personnel files revealed that the performance review for the calendar year 2023 was not completed for this staff member. The Director of Nursing confirmed that, despite facility policy requiring annual reviews, the documentation for the required review was missing for the specified period. This deficiency was identified during a surveyor's review of personnel files and was confirmed through an interview with the Director of Nursing, who acknowledged the absence of the annual performance review for the affected staff member.
Failure to Address Pharmacist Drug Regimen Review Recommendations
Penalty
Summary
The facility failed to act on recommendations made by the pharmacist during monthly drug regimen reviews for a resident reviewed for unnecessary medication use. Specifically, the pharmacist identified that the resident had physician orders for two PRN pain medications, Tylenol and Tramadol, but the orders did not specify the pain scale rating to guide nursing staff on when to administer each medication. The pharmacist recommended that the physician clarify the orders to include the pain scale rating, but this recommendation was not addressed by the physician. Additionally, a subsequent pharmacist review noted that Tramadol PRN had not been used in the past 60 days and recommended discontinuing the medication to reduce unnecessary drug storage and associated risks. This recommendation was also not acted upon by the physician. Interviews with the DON confirmed that both pharmacist recommendations were not addressed, and there was no documentation or physician response to the pharmacist's reports in the resident's medical record.
Failure to Properly Label and Secure Medications
Penalty
Summary
Surveyor observations and staff interviews revealed that the facility failed to ensure proper labeling and storage of drugs and biologicals, as well as secure medication storage. During medication administration on the 300 unit, a Certified Medication Aide (CMA) was observed using a bottle of Senna Plus (sennosides-docusate sodium) that was not labeled with the date it was opened, despite the facility's practice requiring such labeling. The bottle was already opened and approximately half empty at the time of observation. The CMA confirmed that bottles should be dated when opened and proceeded to label the bottle after the surveyor's inquiry. The Regional Nurse Consultant, Licensed Nursing Home Administrator, and Director of Nursing were all notified of this finding. Additionally, a medication cart was found unlocked and unattended in a hallway, with all drawers accessible and no staff present nearby. A Geriatric Nursing Assistant (GNA) later locked the cart, stating the responsible nurse was assessing a patient elsewhere. The nurse later confirmed she had left the cart unlocked because she intended to return shortly, and the Director of Nursing acknowledged that the cart should have been locked when not in the nurse's view. Review of facility policy confirmed that medication carts are required to be locked when not in use and in direct line of sight.
Failure to Implement and Follow Infection Control Procedures for Residents with Indwelling Devices
Penalty
Summary
The facility failed to follow its own infection prevention and control policies and procedures, resulting in lapses in infection control for two residents. One resident with multiple wounds on the right foot, including a recent diagnosis of cellulitis and a dialysis catheter in the chest, was not placed on Enhanced Barrier Precautions (EBP) as required by facility policy. There were no EBP signs or infection control supplies at the entryway to the resident's room, and no order for EBP was present in the medical record at the time of observation and review. The infection control preventionist confirmed that residents with wounds and indwelling medical devices, such as central lines, should be on EBP, and the Director of Nursing agreed that EBP should have been implemented for this resident. Another resident with an indwelling urinary catheter and a history of urinary tract infections was observed with the catheter drainage bag lying flat and face down on the floor, rather than being properly hung on the bed. The Director of Nursing acknowledged that the drainage bag should not be on the floor, as this practice is inconsistent with infection control standards and increases the risk of contamination. Review of the facility's reference materials confirmed that catheter drainage bags should not be placed on the floor to prevent infection.
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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