Blue Point Healthcare Center
Inspection history, citations, penalties and survey trends for this long-term care facility in Baltimore, Maryland.
- Location
- 2525 West Belvedere Avenue, Baltimore, Maryland 21215
- CMS Provider Number
- 215340
- Inspections on file
- 19
- Latest survey
- July 7, 2025
- Citations (last 12 mo.)
- 11 (2 serious)
Citation history
Health deficiencies cited at Blue Point Healthcare Center during CMS and state inspections, most recent first.
The facility did not provide necessary behavioral health care and services to residents who required them, as evidenced by a lack of appropriate assessment, planning, or delivery of behavioral health interventions.
The facility did not set up an ongoing quality assessment and assurance group to review quality deficiencies and develop corrective plans of action, resulting in a lack of systematic review and response to quality issues.
Surveyors found that two residents had medication cups with multiple pills left at their bedsides without documented assessments for self-administration. Both residents were cognitively intact and able to make their own medical decisions, but there was no evaluation in their records confirming their ability to self-administer medication without nursing supervision. LPNs reported that medications were given and residents were watched, but the required assessments were missing.
Facility staff did not inform the attending physician when a resident, admitted for IV antibiotics and substance use disorder treatment, repeatedly refused Suboxone doses. Despite documentation of multiple refusals and a physician note indicating the resident appeared high, neither the physician nor mental health services were notified prior to the resident experiencing a suspected overdose requiring Narcan.
A resident reported theft of personal funds after being transferred to a new room without being provided a lock box to secure valuables. The resident kept money unsecured in a drawer, and the DON confirmed that the lock box was not present in the new room, leading to the loss.
Facility staff failed to provide written notice and required documentation to two residents and their representatives during transfers to a hospital, including missing information about the transfer, lack of communication to the receiving institution, and absence of discharge and bed-hold policy notifications. The DON confirmed that only minimal documentation existed for these transfers.
The facility did not develop individualized care plans for residents with SUD, as evidenced by three cases where residents experienced unresponsiveness and required Narcan administration. Care plans lacked documentation of SUD-specific interventions such as group meetings, 1:1 support, and mental health services, despite residents' participation in these activities. Facility leadership did not provide explanations for these omissions.
The facility failed to intervene when a resident with a history of substance use disorder showed signs of relapse, including refusing Suboxone and being found unresponsive, without notifying mental health or the physician. Additionally, another resident admitted with multiple injuries did not have hospital wound care instructions implemented or documented, and the care plan did not address surgical wounds. These deficiencies were confirmed through record review and staff interviews.
The facility failed to consistently document and administer pain medications as ordered, did not provide adequate parameters for PRN pain medications, and did not ensure pain assessments or non-pharmacological interventions were completed prior to administering narcotics. Several residents with significant pain were affected, with missing documentation of pain levels, medication effectiveness, and appropriate interventions.
A deficiency occurred when a radiology report indicating a femoral neck fracture was not promptly reviewed or acted upon by the attending physician after being received by the facility. The delay in physician follow-up extended from the evening the report was received until midday the next day, despite recommendations for further imaging.
Facility staff did not ensure that a resident's court-appointed guardian was contacted, educated, or given the opportunity to consent or decline a COVID-19 vaccine booster, as required. Documentation only reflected the resident's refusal, despite the resident being unable to make decisions, and did not indicate guardian involvement.
Failure to Provide Necessary Behavioral Health Services
Penalty
Summary
The facility failed to ensure that each resident received necessary behavioral health care and services. This deficiency was identified based on observations and records indicating that the required behavioral health interventions and supports were not provided to residents who needed them. The lack of appropriate behavioral health care and services was directly related to the facility's inaction in assessing, planning, or delivering the necessary interventions for residents with behavioral health needs.
Failure to Establish Ongoing Quality Assessment and Assurance Group
Penalty
Summary
The facility failed to establish an ongoing quality assessment and assurance group to review quality deficiencies and develop corrective plans of action. This inaction resulted in the absence of a systematic process to identify, review, and address quality issues within the facility. As a result, there was no documented evidence that quality deficiencies were being regularly reviewed or that corrective plans were being developed and implemented to address identified issues.
Failure to Assess Residents for Self-Administration of Medication
Penalty
Summary
Surveyors observed that the facility failed to assess residents for their ability to self-administer medications. During a tour of one unit, surveyors found medication cups containing multiple pills left at the bedsides of two residents. In one instance, a medication cup with seven pills was found on a bedside table, and the resident explained that the nurse left the medication there because the resident needed to use the bathroom. The resident then took the medication in the presence of the LPN. In another instance, a resident was found with a medication cup containing six pills at the bedside and stated they had been distracted and would take the medication now. Interviews with LPNs revealed that medications were given to residents and they were supposed to be watched while taking them, but no narcotics were left at the bedside. Review of the medical records for both residents showed they were cognitively intact and able to make their own medical decisions, but there was no documented assessment or evaluation in the records to determine their ability to self-administer medication without nursing supervision.
Failure to Notify Physician of Medication Refusals in Resident with Substance Use Disorder
Penalty
Summary
Facility staff failed to notify the attending physician when a resident was refusing prescribed Suboxone, a medication used as part of substance use disorder treatment. The resident, who was admitted for a minimum six-week course of intravenous antibiotics due to septic wounds and endocarditis suspected to be related to drug use, refused nine doses of Suboxone in January and five of eight doses in February. Despite these refusals, there was no documentation that the physician was informed of the missed doses. Additionally, after a note was made by a physician indicating the resident appeared high, there was no report to mental health services or a multidisciplinary meeting prior to the resident experiencing a suspected overdose that required Narcan administration. Interviews with facility staff confirmed that neither the physician nor mental health services were notified of the medication refusals or the concerning behavior prior to the overdose incident.
Failure to Provide Secure Storage for Resident Valuables After Room Transfer
Penalty
Summary
A deficiency was identified when a resident reported that $110.00 was stolen from their room. The facility's records indicated that the resident had previously been provided with a lock box to secure valuables. However, after being transferred to a new room, the resident did not have access to a lock box and was keeping valuables unsecured in a drawer. During an interview, the resident confirmed the absence of a lock box in the new room, and the DON acknowledged that the lock box had not been provided following the room transfer. This failure to provide a means for the resident to secure their valuables resulted in the misappropriation of the resident's personal funds.
Failure to Provide Required Transfer Documentation and Notifications
Penalty
Summary
Facility staff failed to provide written notice to a resident and their representative regarding a transfer to a local hospital for evaluation. Medical record review showed that the resident was treated for abnormal laboratory results by their primary provider, and nursing staff documented the resident's hospitalization the following day. However, there was no evidence in the medical record of documentation regarding the resident's change of condition or the transfer for treatment prior to the hospitalization. The Director of Nursing confirmed that nursing staff did not create or provide the required transfer documentation to the resident or their representative before the transfer occurred. Additionally, another resident's medical record indicated that the resident called 911 and was transported to the emergency room, but the record lacked documentation of the transfer location, reason for transfer, and required information provided to the receiving health care institution. There was also no evidence that the resident received a written discharge notice or information about the facility's bed hold and return policy. The record did not document the resident's orientation or physician notification. The Director of Nursing confirmed that the only documentation related to this hospital transfer was a nurse's note indicating the resident called 911, with no additional documentation available.
Failure to Individualize Care Plans for Residents with Substance Use Disorder
Penalty
Summary
The facility failed to develop and implement individualized care plans for residents with substance use disorder (SUD), as evidenced by medical record reviews of three residents. One resident with intact cognition and a diagnosis of SUD was found unresponsive and required emergency interventions including CPR, multiple doses of Narcan, and use of an AED. The care plan for this resident only included general monitoring and medication administration, omitting specific interventions such as participation in SUD group meetings, 1:1 support, and mental health or recovery services, despite the resident's involvement in these activities. There were also no documented notes from the social worker or evidence of interdisciplinary discussion regarding interventions in the quality assurance records. Another resident with SUD was found unresponsive in the courtyard and required Narcan administration before regaining consciousness. The care plan for this resident lacked documentation of SUD-specific interventions, such as group meetings or mental health services, even though the resident was receiving these services. A third resident with a history of opioid use and recent Narcan administration did not have an updated care plan reflecting behavioral health involvement, behavioral contracts, or references to SUD nurse practitioner visits or group participation. In all cases, interviews with facility leadership yielded no responses regarding the deficiencies in care planning.
Failure to Intervene for Substance Use and Address Hospital Wound Care Instructions
Penalty
Summary
The facility failed to provide appropriate interventions and care for two residents with significant medical needs. In the first case, a resident with a known history of substance use disorder was admitted following hospitalization for septic wounds and endocarditis related to suspected drug use. The resident had a central catheter and was prescribed Suboxone for opioid withdrawal, but repeatedly refused the medication. Staff documented that the resident appeared to be under the influence and was unavailable for medications and wound care on multiple occasions. Despite these observations and the resident later being found unresponsive and requiring Narcan administration, there was no evidence that mental health services were notified or that a multidisciplinary meeting occurred to address the relapse concerns. The physician was also not informed of the repeated Suboxone refusals. In the second case, another resident was admitted with multiple traumatic injuries and surgical wounds following a motor vehicle accident. The hospital discharge summary included specific instructions for wound care and follow-up appointments. However, the facility's admission assessment did not identify the presence or location of the surgical wounds, and there were no physician orders or documentation on the Treatment Administration Record (TAR) for wound care as outlined in the hospital instructions. The care plan addressed only the prevention of pressure ulcers and did not include the resident's surgical wounds or their care. The Director of Nursing confirmed that wound care orders should have been present upon admission, but no additional documentation was found. These deficiencies were identified through interviews, medical record reviews, and discussions with facility leadership, demonstrating failures to intervene appropriately for substance use concerns and to ensure continuity of care for surgical wounds as directed by hospital discharge instructions.
Failure to Provide Consistent and Documented Pain Management
Penalty
Summary
The facility failed to provide safe and appropriate pain management for multiple residents, as evidenced by inconsistent documentation and administration of pain medications, lack of adequate medication parameters, and insufficient assessment and monitoring of pain. For one resident, Dilaudid (Hydromorphone) was ordered as needed for pain, but records showed that the medication was removed from the controlled lock box on several occasions without corresponding documentation in the Medication Administration Record (MAR) or evidence that the resident's pain level and the effectiveness of the medication were monitored. The Director of Nursing confirmed that staff did not ensure the medication was administered as ordered. Another resident with a history of dementia, chronic pain, and a previous hip fracture had orders for both Acetaminophen and Tramadol for pain, but the orders lacked clear parameters for when each medication should be used. Documentation showed that pain medications were administered without recording the location or source of pain, and there was no evidence that non-pharmacological interventions were attempted prior to giving narcotic pain medication. Pain assessments before and after medication administration were inconsistently documented, and the effectiveness of interventions was not always evaluated as required. A third resident experienced a right humeral fracture and was described as being in excruciating pain, but the MAR did not show that scheduled or as-needed pain medication was administered during the period of severe pain, except for a single dose. There was no documentation of further pain interventions prior to the resident's transfer to the emergency room, despite orders allowing for additional pain medication. These findings were confirmed through record review and interviews with facility leadership.
Delay in Physician Review of Radiology Report Following Resident Injury
Penalty
Summary
A deficiency was identified when the facility failed to ensure timely accessibility of a radiology report to the attending physician for a resident who sustained an injury of unknown origin. Medical record review showed that an x-ray was ordered and completed for the resident, revealing a right femoral neck fracture with a recommendation for further imaging. Although the radiology report was received by the facility in the evening, there was no documented response or follow-up by the attending physician until the following day at midday. The Director of Nursing was informed of these findings during the survey, and no additional information was provided regarding the delay in reviewing the x-ray report.
Failure to Obtain Guardian Consent for COVID-19 Vaccination
Penalty
Summary
Facility staff failed to ensure that the court-appointed guardian of a resident who was incapable of making decisions was provided with education and the opportunity to consent to or decline a COVID-19 vaccine booster on the resident's behalf. The resident's medical record confirmed the presence of a court-appointed guardian since 2017, yet the immunization record only showed electronic consent forms indicating that education was provided and the resident refused the vaccine. There was no documentation that the guardian was contacted, educated, or given the opportunity to provide or withhold consent for the vaccine. Interviews with facility staff, including the current and former Infection Preventionists (IPs), revealed that the established process required contacting the guardian, providing education, and obtaining consent or declination, either verbally or in writing. The electronic documentation system allowed for specifying whether the resident or guardian provided consent, but in this case, the records only reflected the resident's refusal, not the guardian's involvement. The Director of Nursing acknowledged that the electronic documentation did not reflect the required guardian contact.
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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