Caroline Nursing And Rehab
Inspection history, citations, penalties and survey trends for this long-term care facility in Denton, Maryland.
- Location
- 520 Kerr Avenue, Denton, Maryland 21629
- CMS Provider Number
- 215083
- Inspections on file
- 22
- Latest survey
- March 13, 2026
- Citations (last 12 mo.)
- 11
Citation history
Health deficiencies cited at Caroline Nursing And Rehab during CMS and state inspections, most recent first.
A resident reported being left on a bedside commode for 2.5 hours before staff assisted with transfer. Record review showed no documentation that the resident had been left on the commode or required additional assistance. In interviews, a staff member stated the resident had been left on the toilet by the previous shift and could not be transferred because the bariatric Hoyer lift believed to be required was not charged and used a different, often-unplugged battery. The DON was unsure about the incident and needed to verify lift weight limits, while the NHA stated that existing Hoyer lifts had a 600-pound capacity and could not explain why a specific bariatric lift was needed, and no further clarification was provided on why other lifts were not used.
Surveyors identified that the facility did not properly manage narcotic medications, including failing to document the required wasting of unused portions after splitting tablets, and did not ensure that ordered medications were administered as prescribed. Several residents did not receive their medications due to unavailability, and there was no evidence that the pharmacy or physician was notified, despite staff acknowledging this as required procedure.
A resident was transferred to an acute care hospital without documentation in the medical record of the resident's status at discharge or the reason for the transfer. Staff interviews confirmed that required forms and physician notifications were not completed or documented for this event, and the DON verified the absence of necessary documentation and orders.
Two residents experienced significant medication errors, including the administration of the wrong type and dose of insulin without proper blood sugar monitoring or physician notification, and the administration of an incorrect dose of Oxycodone after a medication order change. The DON confirmed these errors and the lack of required documentation.
Staff did not record the administration of Narcan in the MAR for a resident who was lethargic and received the medication; the event was only documented in the progress note. Both a nurse and the DON confirmed that proper documentation should have included the MAR entry.
The facility failed to conduct and document competency evaluations for six nursing staff members, including LPNs and GNAs, as required. Despite protocols for training and evaluations during onboarding, interviews revealed that competency training was not being conducted. The DON was informed of these deficiencies.
The facility failed to provide adequate food quality and diabetic snacks to residents. Residents reported poor food quality and unavailability of menu items, while staff indicated issues with the procurement process under new management. Additionally, diabetic residents did not consistently receive their prescribed snacks, with staff unaware of individualized snack needs and lacking a tracking system for snack delivery.
The facility failed to ensure proper labeling and expiration of stored food items, as observed during a kitchen tour. Items in the refrigerator, freezer, and dry storage were found unlabeled and undated, including salsa, sour cream, potatoes, liquid eggs, mixed salad, various meats, cereals, and rice. The Food Service Director acknowledged the issue, and the DON was informed.
The facility failed to conduct required competency evaluations for its Geriatric Nursing staff. Three GNAs were found without up-to-date competency evaluations, with one having no evaluation since hiring. Interviews revealed that competency training was not being conducted, and the DON was informed of these issues.
The facility failed to thoroughly investigate multiple abuse allegations, including sexual and verbal abuse, involving several residents. Investigations lacked documentation of interviews with victims, witnesses, and staff, and incidents were not reported to law enforcement or relevant boards. The Nursing Home Administrator and Director of Nursing acknowledged the incomplete investigations.
The facility failed to update care plans to reflect residents' current conditions and did not conduct timely care plan meetings with residents or their representatives. A resident at high risk for falls had an outdated care plan, and another resident's care plan did not reflect multiple falls requiring hospital evaluation. Additionally, several residents were not included in care planning meetings as required, and documentation was lacking. The DON and staff acknowledged these issues, indicating systemic problems with care plan management.
Facility staff failed to notify a resident's representative of a medication change involving Mirtazapine, despite the facility's policy requiring such notification. The resident, with a history of major depressive disorder and Alzheimer's, was administered the medication without the representative's knowledge. Documentation and interviews confirmed the lack of notification, highlighting a deficiency in communication protocols.
A GNA verbally abused a resident by threatening to leave them in a chair all night if they yelled again. The incident was reported by another resident's family member. The resident initially did not recall the event but later vaguely remembered it. The facility terminated the GNA after confirming the inappropriate comment was made.
A facility failed to timely report a verbal abuse incident involving a resident. The incident was witnessed by a family member and reported to a supervisor, but the facility delayed reporting it to the Office of Health Care Quality until the next day. This did not comply with the facility's policy, which requires immediate reporting within 2 hours.
A resident in an LTC facility expressed a desire to participate in activities but was not involved in any due to being bed-bound. The Activities Director admitted that the facility had not initiated activities for the resident and that current programs favored more mobile residents. The resident's activity log showed personal activities, not facilitated by staff, and there was no care plan in place for in-room activities. The DON was unaware of the lack of a care plan, confirming the resident's non-participation.
A facility failed to provide appropriate care for a resident with dysphagia, lacking supervision during meals and a care plan for the condition. Additionally, two residents experienced issues with medication administration times, with one receiving insulin late and another receiving medications earlier than scheduled. Staff interviews and medical records confirmed these deficiencies.
A facility failed to prevent new pressure ulcers and document weekly skin assessments for a resident. The resident, unable to leave bed due to wound vac treatment, did not receive regular showers. Weekly skin assessments were missing for three weeks, and wound vac dressing changes were inconsistently managed, leading to delays. The resident was not seen weekly by a wound care practitioner, resulting in a new unstageable pressure ulcer. The DON acknowledged limited staff proficiency in wound vac care.
A resident experienced a significant weight loss of 24.9% within 13 days, dropping from 258.8 to 194.3 pounds. Despite a dietitian's note indicating possible significant weight loss and recommending a reweigh, there was no documentation of follow-up actions or communication with the resident's provider and family. Interviews with staff revealed that the facility's protocol for addressing significant weight changes was not followed, as confirmed by the DON.
The facility failed to develop and implement comprehensive care plans for three residents. One resident expressed a desire to participate in activities but lacked a care plan for such engagement. Another resident with PTSD did not have a care plan with appropriate interventions, and a third resident's care plan lacked interventions for hemodialysis care. The Director of Nursing acknowledged these deficiencies.
The facility failed to properly date, label, and maintain oxygen equipment for two residents, leading to potential infection risks. One resident's oxygen tubing and humidifier bottle were not dated, and the care plan lacked focus on oxygen therapy. Another resident's oxygen tubing and nebulizer mask were stored unsanitarily, despite intermittent oxygen use. The DON acknowledged the policy non-compliance and the need for staff re-education.
The facility failed to conduct annual performance reviews for GNAs and LPNs, as required. During a survey, it was found that several staff members, hired between 2013 and 2023, lacked documented evaluations. The DON acknowledged the issue, which will be addressed in their QAPI program.
During a survey, expired medications and supplies were found in multiple units of the facility. Expired items included Derma lotion, Basaglar insulin, Stomahesive powder, Midazolam, Senna Syrup, Ondansetron, and Acidophilus Probiotic. Unit Managers confirmed the findings, and the DON was informed.
A facility failed to implement proper infection control measures for a COVID-19 positive resident, who was not isolated as per physician's orders and was placed with a roommate. The facility also did not conduct required follow-up tests for the exposed roommate, contrary to its policy. The DON acknowledged these oversights, including incorrect door signage and lack of documentation for the roommate's request.
Failure to Provide Timely Toileting Assistance Due to Unavailable Lift Equipment
Penalty
Summary
The deficiency involves the facility’s failure to provide timely assistance with toileting as part of activities of daily living (ADL) care for one resident. The resident reported to the local health department that on the morning of 10/30/25, they were left on a bedside commode for 2.5 hours before staff responded to transfer them back. Review of the electronic medical record showed that the assigned staff member for that morning, Staff #20, had documented care but there were no entries in the treatment record or progress notes indicating that the resident had been left on the commode or required additional assistance. During a subsequent interview, Staff #20 stated that the resident had been left on the toilet by the previous shift and that staff were unable to transfer the resident off the toilet because the bariatric Hoyer lift required for the resident was not charged. Staff #20 explained that this bariatric lift used a different battery than the other lifts in the facility and staff often failed to plug it in, and that a compatible charged battery could not be obtained from the charger. The DON reported being unsure about the incident and needing to verify the weight limits and usage of the facility’s Hoyer lifts. The NHA stated that the Hoyer lifts in the building had a weight limit of up to 600 pounds and could not explain why this resident required a specific bariatric Hoyer lift, and the surveyor confirmed that the resident did not exceed the weight limit of the other lifts. By the end of the survey, the facility had no additional information clarifying why alternative equipment could not be used to assist the resident off the toilet.
Failure to Manage Narcotic Medications and Administer Physician-Ordered Medications
Penalty
Summary
The facility failed to appropriately manage narcotic medications and ensure medications were administered as ordered by a physician. In one instance, a resident with a prescription for Oxycodone had their dose changed from 15mg to 7.5mg every 8 hours. The medication administration record showed that half-tablet doses were given, but there was no documentation of the required wasting of the unused half-tablets, as mandated by facility policy and federal regulations. Staff interviews confirmed that narcotics should not be split unless immediately wasted with two nurses' signatures, and the facility's own policy required documentation of both the administered and destroyed portions of controlled substances. Additionally, the facility failed to provide ordered medications to several residents due to unavailability. Multiple medications, including Calcium Citrate, Listerine Mouthwash, Potassium Chloride, Trelegy Ellipta, and Fish Oil, were not administered as ordered over several days. Documentation in the medical records indicated that these medications were unavailable, but there was no evidence that the pharmacy or the prescribing physician was notified about the missing medications, as required by standard practice. Staff interviews revealed that when medications were unavailable, the process was to document the issue and inform the nurse, who was then responsible for contacting the pharmacy and physician. However, in these cases, there was no documentation that such notifications occurred. The Director of Nursing confirmed the expectation that the pharmacy and physician should be contacted when medications are unavailable, but this was not reflected in the records reviewed during the survey.
Failure to Document Resident Status and Reason for Hospital Transfer
Penalty
Summary
A deficiency was identified when a resident was transferred or discharged to an acute care hospital, and the facility failed to document the resident's status at the time of discharge and the reason for the transfer in the medical record. Medical record review showed a Transfer/Discharge Report with admission and discharge dates, but lacked information regarding the resident's condition or the rationale for the transfer. Staff interviews confirmed that standard procedure involves completing an EInteract Change in Condition form, notifying the physician, and documenting all actions in the progress notes, but in this case, there was no documentation or physician order related to the resident's change in condition that led to the hospital transfer. The Director of Nursing verified the absence of required documentation and physician order for the event.
Failure to Prevent Significant Medication Errors and Ensure Proper Physician Notification
Penalty
Summary
The facility failed to ensure residents were free from significant medication errors, as evidenced by multiple incidents involving two residents. In one case, a nurse administered 10 units of fast-acting insulin instead of the scheduled long-acting insulin to a resident. Following this error, blood sugar monitoring was not performed at the 15-minute intervals as ordered, and there was no physician order documented for this monitoring in the medical record. The Assistant Director of Nursing acknowledged the failure to document the order and confirmed that blood sugars were not monitored as frequently as required. Additionally, on a separate occasion, the same resident had their scheduled long-acting insulin withheld due to low blood sugar without evidence of physician notification or an order to hold the medication, contrary to facility expectations. In another incident, a resident with a prescription for Oxycodone 15mg every 8 hours had their order changed to Oxycodone 5mg every 6 hours as needed. Despite this change, the resident was administered the higher 15mg dose on two occasions after the new order was in effect. The medication administration record did not support the administration of the 5mg dose, and the controlled drug record confirmed the dispensing of the 15mg tablets. The Director of Nursing verified that the resident received the incorrect dose, indicating a failure to administer medications as ordered.
Failure to Document Narcan Administration in MAR
Penalty
Summary
Facility staff failed to document the administration of Narcan (naloxone) in the Medication Administration Record (MAR) for a resident who was found to be lethargic and subsequently received the medication. The administration of Narcan was only recorded in the resident's progress note by a registered nurse, with no corresponding entry in the MAR. During interviews, both a registered nurse and the Director of Nursing confirmed that such medication administration should be documented in both the MAR and the progress note, and acknowledged the omission.
Failure to Conduct Nursing Staff Competency Evaluations
Penalty
Summary
The facility failed to ensure that all nursing staff had competency evaluations, as evidenced by the lack of documented evaluations for six randomly selected nursing staff members. These included three Licensed Practical Nurses (LPNs) and three Geriatric Nursing Assistants (GNAs). Specifically, LPN #19, hired in May 2023, and LPN #40, hired in October 2023, had no competency evaluations on record for 2023. LPN #41, hired in August 2022, also lacked a competency evaluation for 2023. Similarly, GNA #42, hired in December 2017, had documented competencies for 2021 and 2022 but none for 2023. GNA #43, hired in January 2013, had evaluations for 2020, 2021, and 2022, but not for 2023. GNA #44, hired in January 2023, had no competency evaluation on record. Interviews with facility staff revealed a lack of adherence to competency evaluation protocols. The Staffing Coordinator indicated that training and competencies were supposed to be conducted by the Assistant Director of Nursing (ADON) or the Director of Nursing (DON) during onboarding. However, the ADON admitted that competency training was not being conducted. The DON was informed of these concerns, highlighting a systemic issue in ensuring nursing staff competencies were evaluated and documented as required.
Deficiencies in Food Quality and Diabetic Snack Provision
Penalty
Summary
The facility failed to provide sufficient food of adequate quality to meet residents' dietary needs and preferences, as well as ensure diabetic residents received necessary snacks. Multiple residents reported dissatisfaction with the food quality and availability, noting that meals did not match the menu and that certain food items were often unavailable. Staff interviews revealed that the new management's procurement process limited food options, leading to substitutions and shortages. This resulted in residents receiving poor-quality food, such as tough bread and moldy cheese, and missing condiments like mayo and ketchup. Additionally, the facility did not consistently provide diabetic snacks as ordered for residents with diabetes. An anonymous resident reported not receiving scheduled diabetic snacks, and a review of medical records confirmed missing documentation of snack delivery on several occasions. Interviews with staff indicated a lack of awareness and tracking of diabetic snack distribution, with no system in place to ensure snacks were delivered to the unit. The dietitian acknowledged the issue and noted the absence of a tracking tool to monitor snack delivery.
Deficient Food Storage Practices
Penalty
Summary
The facility failed to ensure that stored food items were properly labeled and not expired, as observed during a kitchen tour. In the walk-in refrigerator, there was a large open container of salsa with conflicting dates, a large open container of sour cream past its best-by date, a 5lb bag of cubed potatoes without a label, 2lbs of open pasteurized liquid eggs undated, and a bag of mixed salad open and undated. In the walk-in freezer, several items lacked labels and dates, including bags of frozen pork patty, rib steaks, Salisbury steak, meatballs, hot dogs, unknown meat, potato tots, corn dogs, unknown red meat, frozen soup, frozen pork, and open bags of frozen vegetables stored in a large container. Additionally, the dry storage room contained a large open undated bag of rice crispy treat cereal, a large undated open bag of cornflakes cereal, a large undated open bag of cheerios cereal, a 20-liter plastic jar of rice unlabeled and undated, an open 3lb bag of potato granules, and an unlabeled bag of croissants. The Food Service Director acknowledged that all items should be labeled and not expired and removed the items of concern during the tour. The Director of Nursing was informed of these findings, indicating a systemic issue in food storage practices that could potentially affect all residents in the facility.
Failure to Conduct Competency Evaluations for Geriatric Nursing Staff
Penalty
Summary
The facility failed to ensure that all Geriatric Nursing staff had competency evaluations, as required by the Center for Medicare and Medicaid Services. This deficiency was identified for three Geriatric Nursing Aides (GNAs) who were randomly selected for review. GNA #42, hired in December 2017, had documented competencies for 2021 and 2022 but none for 2023. GNA #43, hired in January 2013, had competency evaluations for 2020, 2021, and 2022, but none for 2023. GNA #44, hired in January 2023, had no competency evaluation documented at all. Interviews with the Staffing Coordinator and the Assistant Director of Nursing (ADON) revealed that competency training was not being conducted, and the Director of Nursing (DON) was made aware of these concerns.
Inadequate Investigation of Abuse Allegations
Penalty
Summary
The facility failed to thoroughly investigate multiple allegations of abuse involving several residents. In one case, a resident reported a sexual assault by a staff member, but the facility's investigation lacked documentation of interviews with the resident and other potential witnesses. The Nursing Home Administrator confirmed that no formal documentation of the resident's statement was made, and no interviews with other residents were conducted. In another incident, a resident reported being verbally abused by a Geriatric Nurse Aide, but the facility did not document interviews with the alleged victim, other residents, or staff members. Additionally, the facility did not report the incident to law enforcement or the Maryland Board of Nursing Licensing Board. The Nursing Home Administrator admitted that the facility did not notify the police, believing the incident did not warrant such action, and was unsure if the resident's family was informed. Further deficiencies were noted in the investigation of a verbal abuse allegation where a resident claimed a staff member spoke inappropriately. The investigation lacked a witness statement and documentation of required training for the staff involved. The Nursing Home Administrator, who was not in position at the time of the incident, could not provide missing documentation, and the Director of Nursing acknowledged the incomplete investigation.
Deficiencies in Care Plan Management and Resident Involvement
Penalty
Summary
The facility staff failed to revise and update resident care plans to reflect accurate and current interventions, and did not conduct timely care plan meetings with residents or their representatives. This was evident for six residents during a recertification/complaint survey. For instance, Resident #38, who was at high risk for falls, had a care plan that was not updated to reflect this risk or the actual falls that occurred. The care plan did not include interventions such as fall mats or bed in low position, which were observed in the resident's room. Despite multiple falls, the care plan remained unchanged, and the Director of Nursing (DON) acknowledged that the care plan should have been revised. Resident #241 experienced multiple falls and was sent to the hospital for evaluation, yet the care plan was not updated to reflect these incidents. The care plan was revised on a date following one of the falls, but it still did not capture the actual falls. Staff interviews revealed that the responsibility for updating care plans lay with the DON or Assistant Director of Nursing (ADON), and it was acknowledged that the care plans should have been updated to reflect the actual falls. Additionally, residents #63, #68, #19, and #37 were not included in care planning meetings as required. Resident #63's care plan meetings were not conducted within seven days after the MDS assessments, and there was no documentation to support timely meetings. Resident #68 and their representative were not present for several care plan meetings, and the facility could not provide documentation of their participation. Similarly, Resident #19's care conferences were held earlier than the MDS dates, and there was a lack of documentation for a care conference following an MDS assessment for Resident #37. The DON and staff acknowledged these issues, indicating a systemic problem with care plan management and documentation within the facility.
Failure to Notify Resident's Representative of Medication Change
Penalty
Summary
Facility staff failed to notify a resident's representative when a medication change occurred, as identified during a Recertification/Complaint survey. This deficiency was evident for one resident who was started on Mirtazapine, a medication used to treat depression, insomnia, and to increase appetite. The resident's representative was not informed of this medication change, despite the facility's policy requiring notification of family or representatives for any medication changes. The review of the resident's clinical records and interviews with the resident's representative confirmed the lack of notification. The resident, who had a history of major depressive disorder, Alzheimer's disease, and other medical conditions, was given Mirtazapine starting in early May 2023. Documentation revealed that the medication was administered without notifying the resident's representative, and there was no change in condition form or family notification documented. Interviews with the Director of Nursing confirmed the expectation that families should be notified of all medication changes, but no evidence was provided to show that this occurred in this instance.
Verbal Abuse Incident Involving GNA and Resident
Penalty
Summary
The facility failed to ensure that residents were free from verbal abuse, as evidenced by an incident involving a geriatric nurse aide (GNA) and a resident. On the evening of the incident, the GNA reportedly threatened the resident by stating that if the resident yelled again, they would be made to sit in a chair all night. This incident was reported to the facility by another resident's family member who overheard the exchange. The resident involved initially did not recall the incident but later vaguely remembered the threat when prompted by the surveyor. The facility's initial response included the termination of the GNA involved, as confirmed by the employee status change form. The Nursing Home Administrator (NHA) indicated that the facility's abuse reporting process involves removing residents from the situation and suspending the accused staff pending investigation. The NHA confirmed that the GNA admitted to making the inappropriate comment, and no other residents or staff witnessed the incident. The facility's documentation included a witness note and a statement from the NHA, which supported the decision to terminate the GNA based on the reliability of the witness report.
Failure to Timely Report Verbal Abuse Incident
Penalty
Summary
The facility failed to timely report an incident of verbal abuse involving a resident. The incident was witnessed by another resident's family member, who reported it to a supervisor. The alleged verbal abuse occurred when a Geriatric Nurse Aide (GNA) verbally abused a resident. The incident was reported to the facility on the evening of 8/21/2024, but the facility did not submit a self-report to the Office of Health Care Quality (OHCQ) until the following day, 8/22/2024, at 4:09 PM. This delay in reporting did not comply with the facility's abuse policy, which requires immediate reporting to the Administrator, other officials, and the State Survey agency. The Nursing Home Administrator confirmed the verbal abuse and stated that the required agency is notified within 24 hours for any issues, but the facility's policy mandates a 2-hour reporting window after an allegation is reported to the facility.
Failure to Provide Activities Program for Bed-Bound Resident
Penalty
Summary
The facility staff failed to provide an activities program that met the needs and preferences of residents, specifically for one resident reviewed during the Medicare/Medicaid Recertification survey. The resident expressed a desire to participate in activities but reported not being involved in any. The Activities Director acknowledged that the facility had not initiated any activities with the resident, who was bed-bound, and that the current activities favored residents who could move about independently. The resident's activity log showed entries of personal activities like reading and watching television, but these were not facilitated by the staff. The Activities Director admitted that the documentation reflected what the resident was doing independently rather than activities provided by the staff. She also confirmed that there was no care plan in place for the resident to receive in-room activities. The Director of Nursing was unaware of the lack of a care plan and confirmed the resident's non-participation in activities. The deficiency was identified as a failure to provide a structured activities program tailored to the resident's needs and preferences.
Deficiencies in Dysphagia Care and Medication Administration
Penalty
Summary
The facility failed to provide appropriate care for a resident with dysphagia, as evidenced by the lack of supervision and assistance during meals, and the absence of a care plan addressing the condition. The resident was observed with partially chewed food on their lap and in their mouth, indicating inadequate supervision. Despite recommendations from a speech therapy consultation for supervision or assistance during meals, the resident's care plan did not include any measures for managing dysphagia. Interviews with staff confirmed that the resident's eating was not properly supervised, and the Director of Nursing acknowledged the oversight in care planning. Additionally, the facility did not adhere to prescribed medication administration times for two residents. One resident reported grievances about delayed blood sugar checks and insulin administration, which were confirmed by medical record reviews and staff interviews. Another resident stated that their evening and night medications were administered earlier than scheduled, affecting their sleep. The medication administration records corroborated these claims, showing that medications were given significantly earlier than prescribed. Interviews with nursing staff revealed inconsistencies in medication administration timing, contributing to the deficiencies identified during the survey.
Failure in Pressure Ulcer Prevention and Documentation
Penalty
Summary
The facility failed to prevent new pressure ulcers and document weekly skin and wound assessments for a resident with pressure ulcers. A resident was unable to get out of bed due to wound vac treatment and had not received a shower since admission, although they could wash their upper body. Weekly skin assessments were not documented for three weeks, and the resident had physician orders for wound vac dressing changes that were not consistently followed. The wound vac dressing frequently came off, and only selective staff could assist with its reapplication, leading to delays in care. The unit manager confirmed that the wound vac dressing often came off, and staff resorted to using wet-to-dry dressings when issues arose during evenings and weekends. The resident was not seen by the wound care practitioner weekly, and a new unstageable pressure ulcer developed, which was only noticed three weeks after the last visit by the wound care provider. The Director of Nursing acknowledged that few staff were proficient in managing wound vac care, contributing to the deficiency in pressure ulcer prevention and treatment.
Failure to Address Significant Weight Loss in Resident
Penalty
Summary
The facility failed to address a significant weight loss for a resident, identified as Resident #238, who experienced a 24.9% weight loss within 13 days. The resident's weight dropped from 258.8 pounds to 194.3 pounds, as recorded on two separate occasions. A subsequent weight recorded showed a slight increase to 198.3 pounds. Despite the dietitian's progress note indicating possible significant weight loss and recommending a reweigh, there was no documentation of follow-up actions or communication with the resident's provider and family members regarding the weight loss. Interviews with facility staff, including a dietitian, an LPN, and the Director of Nursing, revealed that the facility's protocol for addressing significant weight changes was not followed. The dietitian stated that any weight difference of more than 5 pounds should be noted and reweighed within 24 hours, and significant weight loss should be reported to the provider and family. The LPN confirmed that weight issues should be documented in a progress note and discussed with the provider. The DON acknowledged the significant weight loss and the lack of timely follow-up and documentation, validating the surveyor's concerns.
Failure to Develop Comprehensive Care Plans
Penalty
Summary
The facility failed to develop and implement comprehensive care plans for three residents, as identified during a Medicaid/Medicare recertification survey. Resident #11 expressed a desire to participate in activities within the facility but was not provided with a care plan that included focus, goals, or interventions for activities. The Activities Director admitted that the resident had not been engaged in any activities except for receiving daily activity schedules, which did not cater to bed-bound residents. The Director of Nursing confirmed the absence of a care plan for Resident #11's activities. Resident #57, who had an active diagnosis of PTSD, did not have a care plan with appropriate interventions to address this condition. The care plan was initiated and revised but failed to include necessary interventions for PTSD. The Director of Nursing acknowledged the missing care plan for PTSD. Additionally, Resident #247's care plan lacked interventions for hemodialysis care, as confirmed by a registered nurse and the Director of Nursing. The nursing leadership was responsible for initiating and updating care plans, but the necessary interventions for hemodialysis were not included.
Failure to Maintain and Label Oxygen Equipment
Penalty
Summary
The facility staff failed to properly date and label oxygen administration equipment and maintain a nasal cannula in a sanitary manner for two residents. For Resident #39, the surveyor observed that the oxygen tubing, nasal cannula, and humidifier bottle were not dated, and the resident could not recall when the equipment was last changed. The Assistant Director of Nursing and the E-Wing Unit Manager confirmed the lack of labeling, and the Unit Manager stated that night shift nurses were responsible for changing the equipment. A review of the resident's medical record showed active physician orders to change and label the equipment as needed, but the Treatment Administration Record did not document these changes. Additionally, the resident's care plan did not address oxygen therapy. For Resident #74, the surveyor observed an opened oxygen tubing set and nebulizer mask that were not labeled and were stored in an unsanitary manner. The resident was reportedly weaned off oxygen, but the equipment was still in use intermittently. The oxygen tubing was found laying on the floor, and the nebulizer mask was not stored in a clean environment. The resident's physician orders indicated a need for continuous oxygen, but the resident was being weaned off. The Registered Nurse and Licensed Practical Nurse acknowledged the improper storage and labeling of the equipment. The Director of Nursing was informed of the findings and confirmed that the facility's policy required oxygen tubes to be changed weekly on the night shift. The DON acknowledged the lack of compliance with the policy and the need for re-education of the nursing staff. The report highlights the facility's failure to maintain proper respiratory care equipment management and documentation, leading to potential infection risks for the residents.
Failure to Conduct Annual Performance Reviews for Nursing Staff
Penalty
Summary
The facility staff failed to conduct performance reviews of Geriatric Nursing Assistants (GNAs) and Licensed Practical Nurses (LPNs) at least once every 12 months, as required. This deficiency was identified during a recertification/complaint survey, where records of six randomly selected nursing staff were reviewed for annual training requirements. Specifically, GNAs hired in 2013, 2017, and January 2023, as well as LPNs hired in May 2023, August 2022, and October 2023, did not have documented annual performance evaluations. The Director of Nursing acknowledged the absence of these evaluations and indicated that this issue would be addressed in their Quality Assurance and Performance Improvement (QAPI) program.
Expired Medications and Supplies Found During Survey
Penalty
Summary
During a recertification and complaint survey, facility staff failed to remove expired medications and patient supplies across multiple units. On the B/C-Wing, expired Derma Daily Moisturizing lotion was found in the med room, and expired Basaglar Kwik Pen insulin was discovered in the OMNICELL room refrigerator. The Unit Manager confirmed these findings and acknowledged that the insulin pens were from an old pharmacy. Additionally, expired Stomahesive Protective powder was found in the Central Supply room. On the D/E Wing, expired medications were found in the med room and CMA med cart. These included Midazolam vials for a resident, Senna Syrup floor stock, and Ondansetron tablets for another resident. An unopened bottle of Acidophilus lactobacilli Probiotic was also expired. The Unit Manager verified these findings. The Director of Nursing was informed of these issues during an interview with the surveyor.
Failure in COVID-19 Isolation and Testing Protocols
Penalty
Summary
The facility failed to implement appropriate infection prevention and control measures for a resident who tested positive for COVID-19. Specifically, the facility did not adhere to the physician's order for strict isolation, which required the COVID-19 positive resident to remain alone in a room without a roommate. Instead, the resident was readmitted to their original room with a roommate who had been exposed but was not positive for COVID-19. Additionally, the facility did not change the door signage to reflect the correct contact and droplet precautions as per the physician's order, leaving an enhanced barrier precaution sign instead. Furthermore, the facility did not conduct the required follow-up COVID-19 tests for the exposed roommate. The facility's policy mandates a series of three viral tests for residents exposed to COVID-19, but the exposed resident was only tested on the first day of exposure and not on the subsequent days as required. The Director of Nursing acknowledged these oversights, including the lack of documentation for the roommate's request to remain with the COVID-19 positive resident, which was not in line with the facility's standard practice of separating positive and exposed residents.
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The facility did not ensure that its Infection Preventionist (IP) met required qualifications for managing the Infection Prevention and Control Program. The DON reported serving as the IP but acknowledged lacking the specialized infection control training required for the role, and confirmed that no other staff member was currently qualified. Records showed that the previously qualified IP left several months earlier, and the Administrator and DON confirmed they were still seeking a replacement, leaving the infection control program without a properly trained leader.
Staff failed to consistently secure medications and medical supplies across three units, including an oxygen tank left on the floor behind a resident’s bed without a supporting device, a treatment cart with Collagenase Santyl cream left on top while two residents in power wheelchairs passed by, an unattended and unlocked treatment cart at a nursing station, and another treatment cart with Diclofenac gel and dressings left on top, indicating repeated lapses in maintaining locked and secure storage for drugs, biologicals, and related supplies.
The facility failed to provide sufficient dietitian coverage and timely nutritional assessments for several residents with significant dietary needs. A resident admitted for diabetic management with a high A1C was placed on a regular diet instead of the recommended carb-controlled diet and had only one weight taken in the first two weeks, with no dietitian review of the record. Another resident with prior significant weight loss had no documented dietitian follow-up despite continued weight loss, and a resident admitted with severe protein-calorie malnutrition experienced further significant weight loss without any dietitian assessment. The dietitian reported working limited hours and prioritizing certain high-risk cases, resulting in delayed or missed evaluations for new admissions and residents with ongoing nutritional concerns.
The facility failed to maintain adequate linen and incontinence supplies and did not keep resident care areas in good repair, resulting in delays and alterations in incontinence care and substandard environmental conditions. Staff reported that towels and washcloths were used instead of wipes and then discarded due to heavy soiling, and that linen deliveries to units were late, leaving residents waiting for care. Observations showed very limited numbers of clean washcloths and other linens on units and in the laundry, with no stock of disposable wipes or backup washcloth supply despite repeated reports to housekeeping. Additional observations revealed recliner chairs blocking a dining-area handwashing sink and kitchenette, multiple resident and shared bathrooms with unfinished spackle, chipped paint, musty odors, black substances near showers, missing threshold molding, exposed cracks and nails, and eroded, rusted baseboard heaters. Hallway handrails on both units were worn, chipped, and splintered, and a shower room contained fecal odors, dried brown stains on the toilet, and deteriorated fixtures, all contributing to a failure to provide a safe, clean, and homelike environment.
Facility staff did not thoroughly investigate two separate abuse allegations involving a resident and an injury of unknown origin involving another resident. In both cases, investigations focused on the directly affected resident and included staff interviews, but there were no interviews of other residents on the unit or documented assessments of those residents for signs of abuse or injuries of unknown origin, including residents unable to communicate due to cognitive status.
Two residents who were dependent on staff for oral care, including one with a tracheostomy, were observed with thick, white or milky substances coating their mouths and teeth, indicating inadequate oral hygiene. One resident communicated that staff did not brush their teeth and that staff "need to." In another case, despite oral care supplies being present in the room, the resident’s mouth and teeth remained unclean on multiple observations, with a thick milky substance caking the teeth and stringing between them when the resident tried to open their mouth. These findings showed that staff did not consistently provide oral care to residents who relied on them for this ADL.
Staff failed to maintain complete and accurate medical records for multiple residents, including missing and inconsistent documentation of wound care, delayed pain assessment after discovery of an injury of unknown origin in a cognitively impaired resident, and inaccurate recording of a PPD test result that was documented as negative despite no evidence the injection was administered and no supporting nurse’s note. Residents reported not receiving certain treatments, while MAR entries either lacked signatures for completion or contained conflicting information about whether care was provided.
Surveyors found that the facility failed to consistently implement and communicate correct transmission-based precautions and PPE use. One resident with a Foley catheter related to wounds had no precaution signage posted, while another resident in a double room had a contact precautions sign at the door, yet the NP entered without PPE and the GNA provided high-contact care wearing only gloves. Staff in that room stated the resident was not on contact precautions and later reversed the sign to show no PPE requirement. Therapy staff reported they rely solely on posted signs to determine PPE, and surveyors identified broader issues with inaccurate signage and staff awareness of which residents required contact precautions.
Surveyors found that MDS assessments were inaccurately coded for two residents. In one case, a resident sustained a femoral neck fracture after a fall, but the subsequent significant change MDS did not code the fall as a major injury and failed to capture prn Tylenol use documented on the MAR within the look-back period. In the other case, a quarterly MDS indicated opioid use for a resident, but the MAR for the same period showed no prescribed opioid, indicating incorrect coding of high-risk drug classes.
A resident who had recently been admitted and experienced a fall received multiple doses of the narcotic analgesic Tramadol, but the facility failed to accurately document all administered doses on the Medication Administration Record (MAR). Review showed only one Tramadol dose recorded on the MAR, while the Controlled Drug Receipt/Record/Disposition Form on the med cart reflected three doses given over two days. In interview, the DON stated staff are expected to document narcotic administration on the MAR and confirmed that two administered doses were not recorded there, resulting in an incomplete and inaccurate medical record.
Unqualified Infection Preventionist Overseeing Infection Control Program
Penalty
Summary
The facility failed to ensure that its designated Infection Preventionist (IP) met the mandatory qualifications for overseeing the Infection Prevention and Control Program. During an interview on 3/24/26 at 10:00 AM, the DON confirmed that she/he was serving as the facility’s IP but had not completed the specialized training in infection control required for the position. The DON further stated that no other staff member currently met the qualifications to serve as IP. Record review showed that the previously qualified IP left the facility in October 2025, and as of the survey date, the position remained unfilled by a qualified individual. At 1:30 PM on the same day, the Administrator and DON confirmed they were still in the process of finding a qualified IP for the facility, leaving the Infection Prevention and Control Program without a properly trained and qualified leader. No specific residents, medical histories, or clinical conditions were described in relation to this deficiency.
Unsecured Medications, Treatment Carts, and Oxygen Equipment
Penalty
Summary
Facility staff failed to ensure that drugs, biologicals, and related medical supplies were securely stored and properly maintained on multiple units. On one unit, an oxygen tank assigned to a resident was observed sitting on the floor behind the resident’s bed without any supporting device. On another unit, a treatment cart was observed with a tube of Collagenase Santyl cream labeled for a specific resident left on top of the cart, while residents in power wheelchairs passed by and staff were present at the nursing station. These observations showed that medications and oxygen equipment were not consistently secured as required. Further observations on additional units revealed an unattended and unlocked treatment cart at a nursing station, and on a separate occasion, a treatment cart with Diclofenac gel labeled for a resident left on top along with multiple packs of dressings. These incidents occurred across three units and on more than one date, demonstrating repeated failures to keep medications and treatment supplies in locked compartments or otherwise secured from unauthorized access.
Insufficient Dietitian Coverage and Delayed Nutritional Assessments
Penalty
Summary
The deficiency involves the facility’s failure to employ sufficient food and nutrition staff, including adequate dietitian coverage, to ensure timely assessment and appropriate diets for residents with significant nutritional and diabetic needs. A resident admitted over two weeks earlier with multiple comorbidities and an A1C of 11.5% had a hospital discharge recommendation for a carbohydrate-controlled diet, but was placed on a regular diet at admission with no acknowledgment of the recommended diet until one week later, when the resident requested larger portions. As of the survey date, the dietitian had not yet seen or reviewed this resident’s medical record, and the resident reported not having seen a dietitian and being very frustrated with the meals. During the first two weeks after admission, only one weight was obtained for this resident, despite physician notes stating the resident’s weight was “stable.” Further review of other residents showed additional failures in timely dietitian assessment and follow-up. One resident, readmitted in January and previously seen by the dietitian in September for a 6.4 lb weight loss over 30 days, had no documented follow-up despite continued weight loss totaling 22 lbs since the last dietitian review. Another resident admitted at the end of February with severe protein-calorie malnutrition had not been seen by the dietitian after about a month in the facility, despite a documented 14 lb (7%) weight loss over two weeks. The dietitian reported working only 12 hours per week at the facility and stated that she must prioritize which residents to see, focusing first on residents with tube feedings and those identified in risk meetings, resulting in delayed or absent assessments for new admissions and residents with ongoing weight loss and malnutrition diagnoses.
Linen Shortages and Poor Environmental Maintenance Compromise Resident Care and Comfort
Penalty
Summary
The deficiency involves the facility’s failure to maintain an adequate supply of clean linens and appropriate incontinence wipes, resulting in delays and alterations in residents’ incontinence care, as well as the use of towels and washcloths in place of disposable wipes. During the initial tour, the surveyor observed that the linen supply on one nursing unit hallway was low. Complaint reviews included concerns about delays in incontinence care and bed linens not being changed regularly, with residents left without clean bedding. A complainant reported that there was not enough clean linen available for residents. Staff interviews confirmed that towels, sheets, and washcloths were being used to wipe residents for incontinence care due to the absence of wipes, and that many of these linens were being thrown away when soiled. Staff also reported a shortage of linen, that linen deliveries to the units were late, and that residents who preferred to get up before breakfast had to wait for care when linen was delayed. Further observations showed that the clean supply room contained no disposable wipes or cloths for incontinence care, and a resident reported that staff did not use wipes, that the resident had to purchase their own, and that heavily soiled towels or washcloths were discarded. A tour of all nursing unit linen carts and closets revealed only six clean washcloths and limited supplies of towels, gowns, and bed linens. In the laundry room, only three washcloths were present, and the laundry assistant stated that there were only three washcloths available for each nursing unit that morning, that the facility was short on linen supply, and that these concerns had been repeatedly reported to the Director of Housekeeping over the preceding month and again that morning. The laundry assistant confirmed there was no additional laundry in process. The DON stated that wipe squares should be used for incontinence care, but no such wipes were found in the clean medical supply room, and no backup supply of washcloths was present in the emergency linen supply. The Director of Housekeeping confirmed there was no backup supply of washcloths. The deficiency also includes environmental and maintenance issues affecting resident bathrooms, handrails, and common areas. In the main dining area, a recliner chair was observed positioned directly in front of the handwashing sink, and two recliner chairs were stored in front of the nutrition area kitchenette. Multiple resident bathrooms and shared bathrooms were repeatedly observed over several days with unfinished spackle on walls that needed resurfacing and painting, chipped paint around sinks, uneven boards nailed to walls under sinks that appeared to partially cover holes, musty odors, black substances between shower bases and walls, missing threshold transition molding exposing cracks, missing tiles, and a nail, as well as eroded and chipped paint on baseboard heaters with exposed dark brown metal and rust-like material. Hallway handrails on both nursing units were observed to be worn, with chips, splintering, holes, and areas where the wood finish had worn off. A shower room was observed with a foul fecal odor, dried brown stains on the back of the toilet seat and in the toilet bowl, and a baseboard heater with eroded, chipped paint and rust-like material, along with chipped paint on the handrail. These conditions were acknowledged by the Director of Maintenance and other leadership, and some areas were noted to be in the process of renovation, but the observed deficiencies remained present during the survey period. Overall, the facility did not maintain a safe, clean, comfortable, and homelike environment in good repair across both nursing units and the dining area. The lack of adequate linen and incontinence supplies, combined with the poor condition of resident bathrooms, handrails, and certain common areas, constituted the basis for the cited deficiency. The observations and staff and resident reports consistently described shortages of essential hygiene supplies, delayed care related to linen availability, and multiple unresolved environmental and maintenance issues in resident care areas and shared spaces.
Failure to Thoroughly Investigate Abuse Allegations and Injuries of Unknown Origin
Penalty
Summary
Facility staff failed to thoroughly investigate allegations of potential abuse involving one resident and an injury of unknown origin involving another resident. For one resident, there were two separate allegations of abuse occurring on different days in early February. The facility’s investigation packets included interviews with staff who cared for or were scheduled to work with this resident on the days of the alleged incidents, and the investigations focused solely on this resident. However, there were no interviews conducted with other residents on the unit to inquire about abusive or neglectful treatment by the staff who were working during the times of the allegations. The surveyors noted that, although the allegations were not validated, there was no documentation that other residents were interviewed, if able, or assessed for signs or symptoms of injury. In a separate incident, another resident was identified on March 4 with a new bruise on the right eye, documented as a change in condition at 4:09 AM. This resident had a BIMS score of 99, indicating the resident was unable to complete an interview and therefore could not report how the injury occurred. The facility’s investigation identified a potential cause of the injury but did not reach a definitive resolution. Additionally, there were no interviews of other residents on the unit regarding possible abuse, nor were there documented assessments of other residents for injuries of unknown origin, particularly for those unable to speak for themselves, as in this resident’s case.
Failure to Provide Oral Care to Dependent Residents
Penalty
Summary
The deficiency involves the facility’s failure to provide oral care to residents who were dependent on staff for activities of daily living, specifically oral hygiene. One resident with a tracheostomy was observed with a thick, sticky white substance in the mouth and was noted to intermittently chew on nearby bedding. This resident made good eye contact and, when asked if staff brushed their teeth, shook their head no and mouthed that staff “need to.” According to the resident’s Minimum Data Set (MDS) dated 2/11/26, the resident was dependent on staff for oral care. Another resident, also dependent on staff for oral care per the 3/11/26 MDS, was observed sitting propped up in bed and able to respond with smiles. During the initial observation, the inside of this resident’s lips and upper and lower teeth had a thick, clear, white milky substance visible when the resident tried to open their mouth to smile. Oral care supplies were present in the nightstand, but the resident’s mouth and teeth were not clean. On a subsequent observation with the DON, NHA, and Corporate VP of clinical services, the same resident again had a thick, clear, milky substance between the lips and caking the teeth, which would string between the teeth when the resident attempted to open their mouth, demonstrating a lack of consistent oral care for residents dependent on staff for this ADL.
Incomplete and Inaccurate Medical Record Documentation for Treatments and Assessments
Penalty
Summary
Facility staff failed to maintain complete and accurate medical records and documentation for multiple residents. For one resident with wound care needs, review of the MAR showed that wound care and related treatments were signed as completed on the dates initially reported, despite the resident’s ongoing complaints that wound dressings were not being changed. When additional dates were reviewed, there were missing staff signatures for wound care on two specific dates, as well as three instances where application of A&D ointment to the resident’s feet was not signed off out of 24 days reviewed. Another resident with severe cognitive impairment, as evidenced by a BIMS score of 00, was found to have an injury of unknown origin (a bruise on the left hand). Documentation showed that a change in condition was initiated late in the morning, but a formal pain evaluation was not initiated and completed until that night, and the resident was unable to explain how the injury occurred or verbalize pain using a standard pain scale. For a third resident, documentation related to the admission PPD test was inconsistent and incomplete. The MAR contained an entry indicating “9” for the administration date, meaning “see nurse’s note,” but there was no corresponding nurse’s note. Despite the absence of a signed administration of the PPD injection, staff documented the PPD result as “negative” on the scheduled read date. The resident reported never receiving the PPD injection, and the DON confirmed that the facility had been out of PPD solution at the time, so the test would not have been administered. These findings demonstrate failures in accurate documentation of treatments and assessments, including wound care, pain assessment, and TB screening, as well as missing or incomplete supporting notes in the medical record.
Failure to Implement and Communicate Correct Transmission-Based Precautions
Penalty
Summary
Surveyors identified a deficiency in the facility’s infection prevention and control program related to inconsistent and incorrect implementation of transmission-based precautions and PPE use. During a complaint investigation focused on residents on transmission-based precautions, one resident with a visible Foley catheter was observed in the room with physical therapy, but there were no signs posted indicating any need for PPE, despite the resident being a new admission with a Foley catheter placed related to wounds. In another double-occupancy room, a contact precautions sign was posted at the doorway, but the nurse practitioner was in the room on a personal phone with no PPE, and the assigned GNA was repositioning the resident in bed while wearing only gloves. When questioned, the NP, RN, and GNA all stated that the resident in the room was not on contact precautions, and the GNA reported that signs were hanging at all doors and that this particular resident’s sign was “just wrong.” The surveyor observed the GNA later return to the room and turn the sign around to indicate no PPE requirement. Subsequent interviews revealed that therapy staff relied on posted signage to determine PPE use and that if the sign was wrong, the PPE used would be wrong. Overall, surveyors found problems with signage accuracy and staff awareness of which residents required contact precautions, as well as observed failures to follow appropriate PPE use for residents who should have been on contact precautions.
Inaccurate MDS Coding for Falls, Pain Management, and High-Risk Medications
Penalty
Summary
Facility staff failed to ensure Minimum Data Set (MDS) assessments were accurately coded for two residents reviewed during a complaint survey. For one resident, a facility-reported incident showed that the resident was found seated on the floor beside the bed and was diagnosed with a non-displaced femoral neck impaction fracture of the left hip following an x-ray. Despite this fall with a major injury, the subsequent significant change MDS dated 11/4/25 did not code the fall with major injury in Section J1900C. Review of the resident’s Medication Administration Records for October and November 2025 showed administration of Tylenol on 10/31/25 at 9:30 PM, which fell within the 5-day look-back period for the MDS, but Section J0100 (prn pain) of the same significant change MDS did not capture the use of Tylenol. For another resident, review of a quarterly MDS with an assessment reference date of 10/15/25 showed that Section N0415 (High-Risk Drug Classes) documented the use of an opioid medication. However, review of the resident’s October 2025 Medication Administration Record did not show that the resident had been prescribed an opioid during that period. In both cases, MDS staff later confirmed that these were errors in MDS coding, demonstrating that the assessments did not accurately reflect the residents’ clinical status and medication use as documented in their medical records.
Incomplete Documentation of Narcotic Administration on MAR
Penalty
Summary
The facility failed to maintain complete and accurate medical records in accordance with accepted professional standards for one resident receiving narcotic medication. The resident, admitted in March 2026, had a fall on 3/6/26 and was sent to the hospital on 3/9/26. Review of the March 2026 Medication Administration Record (MAR) showed documentation of a single 25 mg dose of Tramadol administered on 3/8/26 at 9:23 AM. However, review of the resident’s Controlled Drug Receipt/Record/Disposition Form, kept on the nurse’s medication cart and not in the medical record, showed that Tramadol 25 mg was administered three times between 3/8/26 and 3/9/26: at 11:00 AM and 9:00 PM on 3/8/26, and at 9:00 AM on 3/9/26. In interview, the DON stated that staff are expected to document narcotic administration on the MAR and confirmed that only one of the three Tramadol doses reflected on the controlled drug record was documented on the resident’s MAR. This discrepancy between the controlled substance record and the MAR, with missing documentation of two administered doses of Tramadol on the official medical record, constituted the failure to maintain a complete and accurate medical record for the resident.
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