Calvert County Nursing Ctr.
Inspection history, citations, penalties and survey trends for this long-term care facility in Prince Frederick, Maryland.
- Location
- 85 Hospital Road, Prince Frederick, Maryland 20678
- CMS Provider Number
- 215188
- Inspections on file
- 23
- Latest survey
- March 26, 2026
- Citations (last 12 mo.)
- 2
Citation history
Health deficiencies cited at Calvert County Nursing Ctr. during CMS and state inspections, most recent first.
A resident’s motorized wheelchair remained nonfunctional for an extended period despite vendor measurements and an approved authorization, limiting the resident’s mobility and independence. The PT director had a vendor assess the resident and forwarded the estimate to the Administrator during a period when there was no BOM. The BOM, who started later, learned that payer authorization had already been granted, but the facility had not tracked or followed up on the process, and the Administrator acknowledged a breakdown in follow-up and communication with the resident regarding the status of the wheelchair.
A resident reported that an agency GNA provided rough and rude care while repositioning them in bed, including being roughly pulled by the neck and arm. During the facility’s investigation of the incident, two other residents also reported that the same agency GNA was rude and provided rough care. The NHA concluded that the agency GNA had abused the resident.
A facility failed to provide a psychiatric evaluation for a resident with a history of trauma from physical abuse. The resident reported an alleged abuse incident involving an LPN, leading to a recommendation for psychiatric assessment. Despite a trauma-informed care assessment confirming the need, the evaluation was not conducted during the resident's stay, as confirmed by the facility administrator.
A resident at high risk for falls was improperly transferred by a GNA who did not use the required sit-to-stand device, resulting in a fractured arm. Despite the resident and another GNA indicating the need for the device, the transfer was done manually, causing injury. The resident was dependent on staff for transfers, as noted in their MDS assessment.
The facility did not promptly report allegations of staff-to-resident abuse and injuries of unknown origin for four residents, including incidents where an LPN was reported to have thrown medication at a resident and unexplained bruising was found on residents with cognitive impairment. These events were either not reported to the DON or state agency as required, or only discussed informally, contrary to facility policy.
Surveyors found that ice machines in both the kitchen and a unit nourishment room had visible smears, debris, and film on their surfaces. The ADM confirmed the unclean conditions, and interviews revealed unclear staff responsibilities for cleaning. The cleaning log did not specify if the entire machine was cleaned, and relevant policies were not provided.
A resident was prescribed an antibiotic for a UTI without documented signs or symptoms to justify the prescription, and there was no evidence that the facility's antibiotic stewardship program ensured compliance with McGeer Criteria. The Infection Preventionist could not confirm the presence of required clinical indicators due to lack of nursing documentation, and the DON acknowledged the oversight in the review process.
The facility did not provide or document required education and consent or declination for flu and pneumococcal vaccines for several residents, despite administering the vaccines. Residents with chronic conditions such as diabetes, COPD, asthma, heart failure, and vascular dementia were affected. Interviews with the IP and DON revealed confusion about responsibilities and errors in documentation, leading to the deficiency.
A resident with severe cognitive impairment wandered into another resident's room, leading to a confrontation where the latter was pushed and fell. The facility's interventions were insufficient to prevent the incident, despite policies ensuring residents' rights to be free from abuse.
Two residents reported incidents of inappropriate conduct by staff members, but their care plans were not updated to reflect these changes in condition. Despite facility policy requiring care plan reviews after such incidents, no updates were made, as confirmed by the DON and Administrator.
The facility failed to provide trauma-informed care for three residents. One resident disclosed past sexual abuse, but the assessment was not updated. Another resident alleged inappropriate touching, and a third reported being slapped, yet no trauma-informed assessments were conducted. The DON and Administrator confirmed assessments should occur at admission and after changes in condition.
Two residents with injuries of unknown origin did not have their cases investigated as required by facility policy. In both instances, staff observed unexplained bruising, reported the findings to supervisors and clinical staff, but no formal investigation was conducted to determine the cause. The DON and Administrator confirmed that these incidents were not investigated, despite policy requiring prompt reporting and thorough investigation of such events.
A resident with multiple medical conditions did not receive prescribed medications as ordered because the medications were not available from the pharmacy. The LPN documented the medications as on hold and did not check facility stock or notify the physician, as confirmed by the DON.
A registered nurse left a medication cart unlocked and unattended with an insulin pen on top while conducting a blood sugar check for a resident. The cart and medication were out of the nurse's sight as she went into the resident's bathroom, contrary to facility policy requiring medication carts to be locked and medications secured when not in direct view.
Staff failed to protect resident-identifiable information by leaving computers with electronic medical records unlocked and unattended during care tasks. Both a registered nurse and a unit manager left computers open on medication carts, exposing resident information, and later acknowledged this was improper. The DON confirmed this practice was unacceptable.
Staff did not consistently use required PPE when caring for a resident on contact precautions for MSSA infection, and failed to properly handle medications after they were dropped during administration. A nurse provided care without donning PPE, and other staff attempted to administer medications that had been dropped onto unclean surfaces, contrary to facility policy and infection control standards.
The facility failed to update its facility-wide assessment, crucial for resource allocation during emergencies, as identified in a complaint survey. The assessment lacked plans for emerging infections, and interviews revealed that the water management program was outdated and not reviewed by current staff, contributing to the deficiency.
The facility failed to inform residents and families of respiratory illness outbreaks and did not monitor water temperatures effectively, leading to potential infection risks. Despite a meeting to address the respiratory illness, documentation was lacking, and water temperatures in several rooms were below the required level.
Failure to Provide Timely Motorized Wheelchair to Support Resident Independence
Penalty
Summary
The deficiency involves the facility’s failure to ensure a resident’s right to self-determination and freedom of movement by not providing a functional motorized wheelchair in a timely manner. A resident reported during the complaint investigation that their motorized wheelchair had been nonfunctional since 2025. The resident stated that a vendor had come to complete measurements for repair or replacement, but there had been no follow-up or communication regarding the status of the equipment. The resident reported that the lack of a functioning motorized wheelchair limited their mobility within the facility and affected their independence. Record review and staff interviews showed that the Physical Therapy Director had the resident measured for a motorized wheelchair by Freedom Mobility on 08/18/2025 and forwarded the vendor’s estimate to the Administrator because there was no Business Office Manager (BOM) in place at that time. The BOM, who started in December 2025, stated she became aware of the wheelchair issue on 01/16/2026 and learned from Freedom Mobility that authorization from Telligen had been received on 10/10/2025. The Administrator confirmed that from July 2025 through December 2025 there was no BOM and she had assumed Business Office responsibilities, which led to a breakdown in follow-up and tracking of the authorization process. She acknowledged that the facility did not follow up on the approved request and did not update the resident on the status, resulting in a delay in providing the necessary mobility equipment.
Agency GNA Provided Rough and Rude Care During Repositioning
Penalty
Summary
The facility failed to protect a resident from abuse when an agency GNA provided rough and rude care during repositioning in bed. During an interview, Resident #6 reported that Agency GNA #16 roughly pulled the resident by the neck and arm and was very rude while assisting with repositioning. A review of Facility Reported Incident (FRI) #2736958 showed that, following investigation, the Nursing Home Administrator determined that Agency GNA #16 had abused Resident #6. During the same investigation, two other residents also reported that Agency GNA #16 was rude and provided rough care, supporting the finding that the resident was not kept free from abuse.
Failure to Provide Psychiatric Evaluation for Resident with Trauma History
Penalty
Summary
The facility failed to provide a psychiatric evaluation for a resident who had a history of trauma from physical abuse. During a complaint survey, it was found that the resident reported an allegation of abuse by an LPN, who allegedly threw a cup filled with medication at the resident. Although the facility's investigation could not substantiate the abuse, it recommended a psychiatric assessment for the resident following the incident. A trauma-informed care assessment confirmed the resident's history of physical abuse and the need for psychiatric evaluation. However, a review of the resident's medical records revealed no evidence that the recommended psychiatric assessment was conducted during the resident's stay. The facility administrator confirmed this oversight during an interview.
Improper Transfer Leads to Resident Injury
Penalty
Summary
The facility staff failed to transfer Resident #417 using a sit-to-stand transfer device, resulting in the resident sustaining a fracture to their right arm. The resident was at high risk for falls, as indicated in their fall prevention care plan. The Minimum Data Set (MDS) assessment showed that the resident depended on staff for transfers and required the support of two or more individuals. On the day of the incident, the resident was preparing to attend an activity when GNA 2 and GNA 3 entered the room to assist with the transfer. Despite the resident and GNA 3 indicating that a sit-to-stand device should be used, GNA 2 opted to manually lift the resident, leading to the injury. The incident report revealed that the resident informed the Director of Nursing that the aide did not transfer her correctly, and the resident experienced pain and heard a snap in her arm during the transfer. GNA 3 confirmed that the resident was a sit-to-stand transfer and offered to retrieve the device, but GNA 2 proceeded with the manual lift due to being in a hurry. The Director of Nursing confirmed that the sit-to-stand lift transfer had been in place since 2022, and GNA 2 did not follow the proper protocol. The resident was subsequently sent to the emergency room for treatment of the fractured arm.
Failure to Timely Report Alleged Abuse and Injuries of Unknown Origin
Penalty
Summary
The facility failed to promptly report allegations of staff-to-resident abuse and injuries of unknown origin for four residents, as required by its own policy and regulatory expectations. In one instance, a cognitively intact resident reported that an LPN was rude and tossed a medication cup onto her roommate's bed, and that a GNA was similarly rude and dismissive when she requested assistance. The resident reported the incident to the Unit Manager, who acknowledged that the incident should have been reported to the Director of Nursing (DON) but was only mentioned informally and not through official channels. Another resident, also cognitively intact, reported to the Unit Manager that an LPN threw her medication cup onto her bed and told her to take what she wanted, which was corroborated by her roommate. The DON admitted that she had not reported the incident because she did not realize it required investigation. In both cases, the facility's policy requiring prompt reporting to authorities was not followed, and the incidents were not officially documented or reported as potential abuse. For two other residents with severe cognitive impairment, staff discovered unexplained bruising and injuries. In one case, a large bruise was found on a resident's left flank, and in another, a bruise was noted on the right eye socket. Staff reported these findings to supervisors and discussed them in clinical meetings, but there was no evidence that the injuries were reported to the state agency as required. Similarly, another resident with severe cognitive impairment was found to have bruising and swelling on the inner thigh, which was reported internally but not to the state agency. Interviews with staff and administration confirmed that these injuries of unknown origin were not reported within the required timeframe, and in some cases, not reported at all.
Ice Machines Not Maintained in Clean Condition
Penalty
Summary
Surveyors observed that the facility failed to maintain cleanliness of the ice machines located in both the kitchen and the Southern Shore unit nourishment room. The kitchen ice machine was found with clear and brownish colored smears, debris on the exterior, and an orangish film on the interior front surface. Similarly, the ice machine in the Southern Shore unit nourishment room had clear and brownish colored smears with debris. The Assistant Dietary Manager confirmed the presence of these smears and debris on both machines. The Maintenance Director stated that maintenance staff cleaned the inside of the machines while kitchen staff cleaned the exterior, but the cleaning log only documented quarterly clean-outs and filter changes without specifying if the entire machine was cleaned inside and out. The DON was unsure who was responsible for cleaning the ice machines, noting that it had been a group effort involving maintenance, kitchen, and housekeeping staff. Requested policies regarding ice machine cleaning were not provided before the end of the survey. This deficiency had the potential to affect 97 of 98 residents in the facility, as noted by the surveyors.
Failure to Implement Functional Antibiotic Stewardship Program
Penalty
Summary
The facility failed to maintain a functional Antibiotic Stewardship Program in accordance with its own policy and the McGeer Criteria for antibiotic prescribing. Specifically, a resident with diagnoses including diabetes mellitus and morbid obesity was prescribed Ciprofloxacin for a urinary tract infection (UTI) without documented evidence of signs or symptoms that would warrant the collection of a urine specimen or the initiation of antibiotic therapy. The resident's electronic medical record showed a urine specimen was collected, but there was no prior documentation of a change in condition or physician order for the specimen collection. Interviews with the Infection Preventionist (IP) and the Director of Nursing (DON) revealed that the required review of the resident's chart to ensure compliance with McGeer's criteria was not performed. The IP was unable to confirm whether the resident met the necessary clinical criteria for a UTI, as the nurse had not documented any relevant signs or symptoms. The DON acknowledged that it is the IP nurse's responsibility to review each antibiotic order for compliance, indicating a lapse in the facility's antibiotic stewardship process.
Failure to Provide Vaccine Education and Obtain Consent for Flu and Pneumococcal Vaccinations
Penalty
Summary
The facility failed to provide required education and obtain consent or declination for influenza and pneumococcal vaccinations for four out of five sampled residents, as identified through record review, interviews, and facility document review. According to the facility's own policies and CDC guidelines, residents or their representatives should receive education about these vaccines, and documentation of education, consent, or refusal must be maintained in the medical record. However, for the residents reviewed, there was no documented evidence that education was provided or that consent or declination was obtained for either the flu or pneumococcal vaccines. Specifically, one resident with diabetes mellitus and chronic obstructive pulmonary disease received a flu vaccine and previously refused a pneumococcal vaccine, but there was no documentation of education or offer of the pneumococcal vaccine since a prior date. Another resident with asthma and myocardial infarction received a flu vaccine, but there was no evidence of education or offer of the pneumococcal vaccine. A third resident with atrial fibrillation, a stage four pressure ulcer, and hypertension received both vaccines at different times, but again, there was no documentation of education or offer of the pneumococcal vaccine since admission. The fourth resident, with heart failure, atrial fibrillation, and vascular dementia, also received both vaccines, but lacked documentation of education or offer of the pneumococcal vaccine since admission. Interviews with the Infection Preventionist (IP) and the Director of Nursing (DON) revealed confusion regarding responsibilities for providing education, obtaining consent, and documenting these actions. The IP stated that education and consents were provided but admitted to erroneously marking forms in a way that indicated education or offers were not made. This lack of proper documentation and process adherence resulted in the identified deficiency.
Failure to Protect Resident from Abuse by Another Resident
Penalty
Summary
The facility failed to protect a resident's right to be free from physical abuse by another resident. Resident 57, who was severely cognitively impaired with a BIMS score of zero, wandered into Resident 58's room. Resident 58, who was not cognitively impaired with a BIMS score of 12, became startled and yelled at Resident 57 to leave. Due to limited impulse control from dementia, Resident 57 shoved Resident 58, causing her to fall. The incident was witnessed by staff, and Resident 58 reported pain in the back of her head but was stable and able to walk with a cane after being assisted up. The facility's policy on abuse and neglect states that residents have the right to be free from abuse by anyone, including other residents. However, the facility's interventions for Resident 57, who was known to wander and become confused about room locations, were insufficient to prevent the incident. Staff had to redirect Resident 57 frequently, and a sign was put up after the incident to help him identify his room. The Director of Nursing at the time of the report was not aware of the incident, as she was not in the position when it occurred.
Failure to Update Care Plans After Allegations of Abuse
Penalty
Summary
The facility failed to update the care plans of two residents following allegations of inappropriate conduct by staff members. Resident #406 reported being touched inappropriately by a male GNA, as documented by a hospice volunteer. Despite the allegation, a review of the resident's medical record revealed no evidence of any changes made to the care plan to address this change in condition. Interviews with the Social Work Director and nursing staff confirmed that the facility's policy requires a review and update of the care plan following such incidents, but this was not done in this case. Similarly, Resident #407 alleged being slapped in the face by a staff member, as reported to the resident's spouse. A review of the medical record showed no updates to the care plan following this allegation. The Director of Nursing and the Administrator acknowledged that the care plan should have been reviewed and updated in response to the change in condition, but confirmed that no such changes were made. These findings were identified during a complaint survey conducted by the State of Maryland's Office of Health Care Quality.
Failure to Implement Trauma-Informed Care
Penalty
Summary
The facility failed to develop and implement a process to ensure that residents with a history of trauma received appropriate trauma-informed care. This deficiency was identified for three residents. Resident #421 felt uncomfortable during a bath by a Geriatric Nursing Assistant, and later disclosed a history of sexual abuse, which was not updated in the trauma-informed care assessment. The Director of Social Work acknowledged the oversight in updating the assessment after the resident revealed the trauma. Resident #406 alleged inappropriate touching by a male staff member, but no trauma-informed care assessment was conducted following the allegation. Similarly, Resident #407 reported being slapped by a staff member, yet there was no evidence of a trauma-informed care assessment after the incident. Interviews with the Director of Nursing and Administrator confirmed that trauma-informed assessments should be conducted at admission and after any change in condition, but these were not completed for the residents involved.
Failure to Investigate Injuries of Unknown Origin
Penalty
Summary
The facility failed to investigate injuries of unknown origin for two residents who were reviewed for abuse. For one resident with severe cognitive impairment, a nurse discovered swelling and bruising on the right inner thigh during medication administration. The incident was reported to the on-call advanced practice nurse, the resident's daughter, and the supervisor, but no investigation was conducted to determine the cause of the injury. Both the DON and the Administrator confirmed during interviews that the incident was not investigated, despite acknowledging that it should have been. For another resident, who had no cognitive impairment, staff observed a bruise on the left flank during routine care, and the resident exhibited discomfort. The bruise was reported to the unit manager and discussed in clinical meetings, but staff were unable to determine the cause. Additionally, a bruise to the right eye socket was noted, which the unit manager did not report immediately, believing it was not severe. The DON and Administrator both confirmed that these injuries were not investigated, and documentation regarding the determination of the cause was not provided. The facility's policy requires all injuries of unknown origin to be promptly reported and thoroughly investigated, which was not followed in these cases.
Failure to Provide Ordered Medications Due to Unavailability
Penalty
Summary
The facility failed to ensure that a resident's prescribed medications were available and administered according to the physician's orders. The resident, who was admitted with diagnoses including complete intestinal obstruction, surgical aftercare, and hypertension, had orders for Pramipexole Dihydrochloride ER for restless leg syndrome and carvedilol for hypertension. Review of the Medication Administration Record showed that Pramipexole was marked as on hold for several consecutive days, and carvedilol was also marked as on hold on one occasion. Documentation indicated that the medications were not available from the pharmacy during these times. During interviews, the LPN responsible for administering the medications stated uncertainty about why the medications were documented as on hold, but suggested it was likely due to the medications not being received from the pharmacy. The LPN also indicated that they did not check the facility's stock for available medications. The Director of Nursing confirmed that if the medications were not present, the nurse should have notified the physician, but there was no confirmation that this occurred.
Medication Cart Left Unlocked and Unattended During Medication Pass
Penalty
Summary
A deficiency occurred when a registered nurse (RN) failed to secure a medication cart during a medication pass. The RN left the medication cart unlocked and unattended outside a resident's room, with an insulin pen placed on top of the cart. While the RN was inside the resident's bathroom, both the cart and the medication were out of her sight. This action was observed during a blood sugar check for the resident. Facility policies require that medication carts be locked at all times when not in the nurse's view and that all drugs and biologicals be stored securely. The RN confirmed during an interview that she had left the cart unlocked with the insulin pen on top, acknowledging that she should have secured the medication. The Director of Nursing also stated that the expectation is for medications to be securely stored and carts to be locked when not within staff sight.
Failure to Safeguard Electronic Medical Records
Penalty
Summary
Facility staff failed to safeguard resident-identifiable information in accordance with their policy on electronic medical records. During a blood sugar check, a registered nurse left a computer unlocked and unattended on top of the medication cart, exposing resident information while washing hands in a resident's bathroom. The nurse confirmed the computer was left open and acknowledged this was improper. In a separate incident during a medication pass, a unit manager left the computer open with resident information visible on the medication cart while leaving to obtain cups, with the computer out of reach and sight. The unit manager also acknowledged the failure to lock the computer. The Director of Nursing confirmed that exposing protected health information was unacceptable.
Failure to Follow Infection Control Protocols and Safe Medication Handling
Penalty
Summary
Staff failed to follow appropriate infection prevention and control protocols for a resident on contact precautions due to a methicillin-susceptible Staphylococcus aureus (MSSA) infection. The resident, who was cognitively intact and had a history of MSSA bacteremia, pneumonia, and congestive heart failure, was placed on contact isolation as indicated by physician orders and facility policy. Despite clear signage and policy requirements for the use of gowns and gloves upon entering the resident's room, a registered nurse entered the room and connected intravenous antibiotics to the resident's PICC line without donning any personal protective equipment (PPE). When questioned, the nurse stated a belief that PPE was unnecessary because the resident's infection was limited to the lungs, which contradicted both the facility's policy and the infection control preventionist's instructions. Additionally, staff did not adhere to infection control procedures during medication administration. During medication passes, a medication technician dropped a pill onto the medication cart, picked it up with bare hands, and intended to administer it to a resident. In a separate incident, a unit manager dropped a pill onto a piece of paper on the medication cart and then scooped it up with a medication cup, expressing uncertainty about the cleanliness of the paper. Both staff members acknowledged during interviews that these actions were not in line with proper infection control practices, and the director of nursing confirmed that dropped medications should be disposed of and not administered. These observations demonstrate a failure to consistently implement the facility's infection prevention and control policies, specifically regarding the use of PPE for residents on contact precautions and the handling of medications to prevent contamination. The deficiencies were identified through direct observation, interviews with staff, and review of facility policies and resident records.
Deficiency in Facility-Wide Assessment and Water Management Program
Penalty
Summary
The facility failed to revise and document an accurate, up-to-date facility-wide assessment, which is crucial for determining the necessary resources to care for residents during both regular operations and emergencies. This deficiency was identified during a complaint survey, which included a review of the facility's emergency preparedness plan. The assessment did not account for potential emerging infections and illnesses, nor did it include a plan for identifying, treating, and preventing the spread of organisms within the facility. This oversight has the potential to affect all residents in the facility. Interviews with facility staff revealed further issues with the facility's water management program. The Infection Control Preventionist (ICP) confirmed the existence of a water management program but noted a lack of meetings or discussions regarding water-based infections or risk assessments. The director of maintenance acknowledged that the water management plan was developed under a previous administrator but admitted that the current staff has not reviewed the plan since its creation. These inactions contributed to the facility's failure to maintain an effective and updated facility-wide assessment.
Infection Control Deficiencies in Respiratory Illness Notification and Water Temperature Monitoring
Penalty
Summary
The facility failed to maintain an effective infection control program by not informing residents, their representatives, and families of the occurrence of three or more residents or staff with new onset of respiratory symptoms within 72 hours of each other. This was evident on three different occasions in June 2024. Despite the facility administrator meeting with staff and residents on June 21, 2024, to discuss precautions for a respiratory illness, there was no documentation of resident and staff attendance at this meeting. The health department was first informed of the pneumonia outbreak on June 6, 2024, after two cases were identified on June 5, 2024, and the facility remained on outbreak status as of June 26, 2024. Additionally, the facility did not ensure consistent infection prevention monitoring for waterborne infections, as evidenced by low resident hand sink water temperatures. During a walking tour, it was found that seven rooms on the East Wing had hot water temperatures below the required minimum of 100 degrees Fahrenheit. The maintenance department's records showed that the hot water temperatures were consistently below the required level on several days in June 2024. The assistant director of maintenance confirmed that individual resident room temperatures were not measured, and the recorded temperatures were taken from the facility boiler room.
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.
Trusted data from CMS and state health departments
Every citation, penalty and Plan of Correction is sourced from public CMS records (latest release May 27, 2026) and official state health department websites — never guesswork.
Trusted by long-term care providers and associations.
