Carriage Hill Bethesda
Inspection history, citations, penalties and survey trends for this long-term care facility in Bethesda, Maryland.
- Location
- 5215 Cedar Lane, Bethesda, Maryland 20814
- CMS Provider Number
- 215234
- Inspections on file
- 18
- Latest survey
- March 26, 2026
- Citations (last 12 mo.)
- 4
Citation history
Health deficiencies cited at Carriage Hill Bethesda during CMS and state inspections, most recent first.
A resident who was cognitively intact, as evidenced by a BIMS score of 14, had previously told facility staff that he/she did not want to apply for Medicaid and planned to return home. Despite this, facility leadership and the business office submitted a Medicaid application without the resident's knowledge or consent, designating the case as an applicant without a representative who lacked capacity to appoint one. This misrepresented the resident's decision-making capacity and failed to honor the resident's right to refuse services and direct his/her own personal and financial affairs.
Pharmaceutical services failed to verify correct indications for antiepileptic medications prescribed to a resident. The MAR listed Depakote for seizures and Lamotrigine for epilepsy, yet review of the medical record showed no history or current diagnosis of seizures or epilepsy. A staff member confirmed the absence of such diagnoses in the chart and could not explain how the facility or pharmacy ensured that the indications documented for these medications were accurate.
A resident’s MAR and physician orders showed that acetaminophen was administered in amounts exceeding the ordered 3 g/24 hr maximum when both scheduled and PRN doses were given on the same days. The same resident had PRN orders for oxycodone 5 mg q6h for mild to moderate pain and oxycodone 7.5 mg q6h for severe pain rated 7–10, yet received oxycodone 7.5 mg doses before the 6‑hour interval elapsed and for pain scores below the ordered severity range. Facility staff, upon review with surveyors, acknowledged these administrations as medication errors.
A resident was found to lack access to both a phone and a working TV remote in a semi-private room. Staff confirmed there was only one phone jack in the room, with the single phone line connected to the roommate’s phone, and that the resident did not have a personal or facility-provided phone. Staff reported the resident sometimes used the roommate’s phone for private communication with family. During observation, the Maintenance Director was unable to operate the TV with the resident’s remote and had to turn the TV on manually, confirming the remote was not functioning.
The facility failed to complete and transmit MDS assessments for 27 residents within the required timeframe. The delay was due to increased admissions and a reduction in staff responsible for MDS assessments. The facility prioritized Medicare assessments, leading to delays in others. The issue was acknowledged by the Lead MDS Coordinator and reported to the NHA and DON.
The facility failed to maintain safe hot water temperatures, with several resident bathroom sinks exceeding the maximum allowable limit. Despite weekly monitoring and a mixing valve set at 118 degrees Fahrenheit, temperatures were recorded as high as 128.2 degrees Fahrenheit. The Maintenance Director could not explain the discrepancy, posing a potential risk to all residents.
The facility failed to ensure a homelike environment and accommodate resident needs, as observed by surveyors. Environmental concerns such as stained ceiling tiles, missing call bell cords, and a covered smoke detector were noted. Additionally, a resident experienced discomfort due to an air mattress not ordered by a physician, which was not promptly addressed despite complaints.
The facility failed to complete MDS assessments within the required timeframe for six residents, with some assessments being over 30 days overdue. The Lead MDS Coordinator cited increased admissions and reduced staffing as reasons for the delay. The NHA and DON were informed of these findings.
The facility did not complete Quarterly MDS assessments within the required timeframe for 18 residents. The delay was due to increased admissions and a reduction in staff responsible for assessments, leaving only the Lead MDS Coordinator and an LPN to handle the workload. The NHA and DON were informed of the issue.
The facility failed to provide invitations and conduct care plan meetings for several residents, leading to deficiencies in care plan documentation and updates. A resident with moderate cognitive impairment was not invited to meetings, and another resident's care plan was not updated to reflect current dialysis access. Additionally, two residents had only one documented care plan meeting over extended periods, with the facility acknowledging the lack of documentation and late status of meetings.
The facility failed to maintain accurate medical records and documentation for several residents, including discrepancies in activity participation records, medication administration, and Medical Orders for Life-Sustaining Treatment (MOLST) forms. A resident did not receive prescribed medication for ten days, and another was observed without the ordered air mattress. Additionally, MOLST forms inaccurately reflected residents' cognitive statuses.
A resident was neglected during an entire shift, resulting in soaked bed linens and significant distress. The resident's call light was on, and they expressed a need to be cleaned. The night shift staff found the resident in this condition, indicating neglect during the evening shift. An LPN documented the incident, and the Director of Nursing acknowledged awareness of the situation.
A facility failed to thoroughly investigate an abuse allegation involving a resident who was reportedly hit by a GNA. Despite interviews with the resident, staff, and other residents, the facility did not obtain a statement from the alleged perpetrator, which was a critical oversight in the investigation process.
The facility failed to uphold resident dignity and staff identification protocols. A GNA entered a resident's room without knocking, and another GNA was observed without a visible name badge. Both staff members acknowledged the expectations and their lapses. These incidents were reported to the NHA and DON.
A facility failed to accurately code a resident's discharge status on the MDS assessment. The resident was discharged to another nursing home, but the MDS incorrectly recorded the discharge as to a short-term general hospital. This error was confirmed by the Social Worker Director, an LPN, and the Lead MDS Coordinator, who acknowledged the need for correction. The NHA was informed of the inaccuracy.
The facility failed to develop comprehensive care plans for three residents, leading to deficiencies in addressing their specific health needs. A resident experienced unmanaged constipation, another had no care plan for IV hydration despite IBS-related diarrhea, and a third lacked a care plan for ADL support despite being dependent on staff. These oversights were confirmed by facility staff.
A resident with documented preferences for various activities was frequently observed sitting inactive in a hallway, indicating a failure by facility staff to provide a personalized and ongoing activities program. Despite the resident's care plan requiring participation in activities 3-5 times weekly, minimal engagement was documented, and staff interviews confirmed limited activity involvement.
A facility failed to schedule a neurology consultation for a resident with New Onset Seizure, despite hospital discharge instructions and progress notes from physicians and nurse practitioners indicating the need for follow-up. Staff interviews revealed a lack of clarity in the appointment scheduling process, and the Medical Director acknowledged the oversight, noting the resident's stability on medication.
A facility failed to adhere to its respiratory care protocols for a resident requiring oxygen therapy. The surveyor observed that the oxygen humidifier bottle and tubing were not dated, and there was no oxygen usage sign on the resident's door. The facility's policy required these measures, and the DON acknowledged the oversight.
A facility failed to discontinue a medication in a timely manner for a resident with cognitive and psychiatric diagnoses. Despite a pharmacist's recommendation and a physician's order to discontinue Oxycodone PRN due to non-use, the medication was not discontinued until two months later. The DON confirmed the oversight during an interview, highlighting a lapse in following the process for pharmacy recommendations.
A resident with severe malnutrition and encephalopathy reported a painful dental issue upon admission, but the facility failed to provide prompt dental care. An initial assessment identified a broken tooth, but it was later altered to indicate no issues, and the resident was not referred for dental services. The administrator acknowledged the oversight.
The facility failed to provide meals according to the dietary preferences and needs of three residents, leading to deficiencies in food service. A resident received incorrect breakfast trays missing items like biscuits and coffee, while another resident on a gluten-free diet received unsuitable food. A third resident experienced issues with incorrect meal trays, resulting in missed meals. The Dietary Manager cited understaffing as a reason for delayed updates to dietary preferences.
The facility failed to meet the dietary needs of two residents. One resident did not receive the prescribed low-fat, low-residue diet, and the facility could not verify the initial diet order. Another resident was not provided with a lunch meal on dialysis days, despite leaving the facility after breakfast and returning in the afternoon. The facility did not ensure the resident had a meal during dialysis, and the meal tray was left on the food delivery cart.
Resident Rights Violated by Unauthorized Medicaid Application Submission
Penalty
Summary
The facility failed to honor a resident's right to make his/her own decisions regarding personal and financial affairs, including the right to refuse services, by submitting a Medicaid application without the resident's knowledge or consent. During an interview, the resident and the resident's daughter reported that the resident had previously informed the social worker that he/she did not want to apply for Medicaid and intended to return home. Despite this expressed wish, the facility proceeded to submit a Medicaid application on the resident's behalf, and the resident stated not knowing how the facility could do that without his/her information and permission. The Administrator confirmed in an interview that a Medicaid application had been submitted for the resident and stated it was done to help him/her. The Business Office Manager reported she had been advised by the facility that it was acceptable to submit the Medicaid application on the resident's behalf. Review of the Medicaid application showed it was completed under the designation "applicant without representative who lacks capacity to appoint a representative." However, review of the medical record revealed the resident had a BIMS score of 14, indicating he/she was cognitively intact and capable of making his/her own decisions. These findings show the facility inaccurately represented the resident's decision-making capacity while submitting the application without consent.
Incorrect Medication Indications Not Verified for Antiepileptic Drugs
Penalty
Summary
Surveyors identified that pharmaceutical services failed to ensure accurate indications for medications prescribed and administered to a resident. Review of the resident’s March 2026 MAR showed physician orders for Depakote 250 mg twice daily for seizures and Lamotrigine 25 mg, four tablets once daily, for epilepsy. Further review of the resident’s medical record revealed no history or current diagnosis of seizures or epilepsy to support these indications. In an interview, a staff member confirmed that the resident did not have epilepsy or seizures and that there was nothing in the medical file indicating any history of these conditions, and was unable to explain how the facility or pharmacy verified that the indications listed for these medications were correct.
Medication Administration Errors With Acetaminophen and Oxycodone
Penalty
Summary
Surveyors identified a deficiency in medication administration for one resident when review of the medical record and MARs showed that acetaminophen was given in excess of the ordered maximum daily dose. The physician had ordered acetaminophen 500 mg, two tablets by mouth every 8 hours as needed for moderate pain, with a directive not to exceed 3 g in 24 hours, and a separate order for Tylenol Extra Strength 500 mg, two tablets by mouth three times a day for pain. Review of the March MAR showed that on two dates the resident received both the scheduled three-times-daily acetaminophen and additional PRN acetaminophen, totaling 4,000 mg in 24 hours, which exceeded the 3,000 mg limit specified in the order. During interview, facility staff reviewed the MAR with the surveyor and acknowledged that the resident received more than 3 g of acetaminophen on those dates. Further review of the same resident’s record showed physician orders for oxycodone 5 mg by mouth every 6 hours as needed for mild to moderate pain, and oxycodone 7.5 mg by mouth every 6 hours as needed for severe pain rated 7 to 10. The March MAR documented that on one date the resident received oxycodone 5 mg at 7:47 a.m. for pain level 5 and then oxycodone 7.5 mg at 9:37 a.m. for pain level 4, which was before the 6‑hour interval had elapsed. Additional MAR review showed that the resident received oxycodone 7.5 mg on multiple dates for pain levels of 3, 4, and 6, which did not meet the order requirement that this dose be used only for severe pain rated 7 to 10. In interviews, staff confirmed that the 7.5 mg oxycodone was administered both before the 6‑hour interval and for pain levels outside the ordered severity range, and that these administrations were in error.
Resident Lacked Access to Phone and Working TV Remote
Penalty
Summary
Surveyors identified a deficiency in which a resident did not have access to a personal or facility-provided phone and had a non-functioning TV remote control in their room. During review of an intake alleging multiple concerns, staff confirmed that there was only one phone jack in the semi-private room, and that the single phone line was connected to the roommate’s phone. The resident therefore did not have a phone of their own in the room. When asked how the resident communicated privately with family, a GNA and an RN stated that the resident sometimes used the roommate’s phone, and the RN confirmed that the resident did not have a personal or facility phone. Further observation in the resident’s room with the Administrator and Maintenance Director showed that there was only one phone jack available in the room, consistent with prior staff statements. During the same observation, the surveyor asked whether the resident’s TV remote control worked. The Maintenance Director attempted multiple times to turn on the TV using the remote and was unable to do so, ultimately turning the TV on manually. These observations confirmed that the resident lacked direct access to a working phone and a functioning TV remote control in their room.
Failure to Timely Complete and Transmit MDS Assessments
Penalty
Summary
The facility failed to complete and transmit the Minimum Data Set (MDS) assessments for 27 out of 33 residents reviewed during the annual survey. The MDS is a critical component for assessing the needs of residents in nursing homes, and timely submission is required to ensure proper care. The assessments were not completed and transmitted within the required 14-day period following the Assessment Reference Date (ARD) for various types of assessments, including annual, quarterly, and discharge assessments. The Lead MDS Coordinator acknowledged the delay in completing the assessments, attributing it to an increased number of facility admissions and a reduction in the number of nurses responsible for completing the MDS assessments from three to two. The facility prioritized Medicare assessments over Medicaid and private ones, which contributed to the delay. The Nursing Home Administrator and the Director of Nursing were informed of the issue, highlighting the facility's awareness of the deficiency.
Facility Fails to Maintain Safe Hot Water Temperatures
Penalty
Summary
The facility failed to ensure a safe environment by not maintaining acceptable hot water temperatures in resident bathroom sinks. During a recertification survey, surveyors observed that the hot water temperatures in several resident rooms exceeded the maximum allowable limit of 120 degrees Fahrenheit, with temperatures recorded as high as 128.2 degrees Fahrenheit. The Maintenance Director (MD) stated that weekly water temperature monitoring was conducted and documented in TELS, but no recent concerns had been noted. Despite the mixing valve being set at 118 degrees Fahrenheit, the observed temperatures were significantly higher. The MD was unable to explain the discrepancy between the mixing valve setting and the actual water temperatures. An observation of the water system showed the mixing valve temperature at 114 degrees Fahrenheit, yet the water temperatures in resident rooms remained elevated. The MD suggested that the temperature variations could be due to the continued use of water, but no definitive explanation was provided. This deficiency has the potential to affect all residents in the facility.
Failure to Ensure Homelike Environment and Accommodate Resident Needs
Penalty
Summary
The facility failed to provide a homelike environment and accommodate the needs of residents, as observed during a survey. Multiple environmental concerns were noted in resident rooms, including stained ceiling tiles, missing bathroom call bell pull cords, holes in walls, and a plastic bag covering a smoke detector. These issues were acknowledged by the Nursing Home Administrator during a tour of the facility. The lack of a homelike environment was evident for several residents, as these deficiencies were observed in multiple rooms. Additionally, a resident expressed discomfort due to an air mattress that was not ordered by a physician and caused difficulty sleeping. Despite informing the nursing staff about the discomfort, the issue was not addressed promptly, taking three days to resolve. The resident's discomfort and inability to sleep were communicated to the Unit Manager and the Assistant Director of Nursing, highlighting a failure to accommodate the resident's needs in a timely manner.
Failure to Complete MDS Assessments Timely Due to Staffing Issues
Penalty
Summary
The facility failed to complete comprehensive Minimum Data Set (MDS) assessments within the required timeframe for six residents during the annual survey. The MDS assessments, which are crucial for ensuring residents receive appropriate care, were not completed within the 14-day period following the Assessment Reference Date (ARD) as mandated by CMS guidelines. Specifically, the assessments for five residents were more than 30 days overdue, and the initial comprehensive assessment for another resident was not completed within 14 days of admission. The Lead MDS Coordinator acknowledged the delay in completing the assessments, attributing it to an increased number of facility admissions and a reduction in the number of nurses responsible for MDS assessments from three to two. The Nursing Home Administrator and the Director of Nursing were informed of these findings, which highlight the facility's inability to adhere to the required timelines for MDS assessments due to staffing issues.
Failure to Complete Quarterly MDS Assessments on Time
Penalty
Summary
The facility failed to complete the Quarterly Minimum Data Set (MDS) assessments within the required timeframe for 18 out of 33 residents reviewed during the annual survey. The MDS is a core set of data elements that form the foundation of a comprehensive assessment for all residents of nursing homes certified to participate in Medicare or Medicaid. According to CMS guidelines, an MDS Quarterly assessment must be completed within 14 days of the Assessment Reference Date (ARD). However, the review revealed that the assessments for the identified residents were still in progress and not completed within the specified timeframe. The Lead MDS Coordinator confirmed the delay in completing the assessments, attributing it to an increased number of facility admissions and a reduction in the number of nurses available to complete the MDS assessments, from three to two. Currently, only the Lead MDS Coordinator and an LPN are responsible for completing these assessments. The Nursing Home Administrator and the Director of Nursing were notified of this concern.
Deficiencies in Care Plan Meetings and Documentation
Penalty
Summary
The facility failed to provide invitations to residents for care plan meetings, did not conduct care plan meetings as required, and did not revise care plans for several residents. This deficiency was identified in five out of ten residents reviewed. For instance, Resident #1, who had moderate cognitive impairment, was not invited to care plan meetings, and there were no conference notes or invitations documented. The social worker responsible could not explain the lack of invitations, and the administrator acknowledged the deficient practice. Resident #62 reported not recalling recent care plan meetings, and the medical record review showed only one documented meeting in the past year. The Nursing Home Administrator confirmed the lack of additional documentation for care plan meetings for this resident. Similarly, Resident #58 stated they had never been invited to a care plan meeting, and the records showed only two documented meetings in the past year, with no invitation for the August 2024 meeting. Additionally, there was a discrepancy in Resident #58's care plan regarding dialysis access, which was not updated to reflect the current AV Fistula. Residents #158 and #164 also experienced deficiencies in care plan meetings. Resident #158 had only one documented care plan meeting since May 2022, and Resident #164 had only one documented meeting during their stay from December 2022 to January 2024. The social service designee confirmed that care plan meetings were not up to date, and the Nursing Home Administrator acknowledged the lack of documentation and the late status of care plan meetings for these residents.
Deficiencies in Medical Record Accuracy and Documentation
Penalty
Summary
The facility failed to maintain accurate and complete medical records for several residents, as evidenced by discrepancies in documentation and missing records. For instance, Resident #94's activity participation was not accurately documented in the electronic health record (PCC) for December 2024 and January 2025, and there was no evidence to support the resident's attendance in activities according to their care plan. Similarly, Resident #256's activity participation was not documented in PCC, and there was no evidence of the resident's newspaper reading activities or refusals to attend activities. Additionally, the facility did not ensure the accuracy of medication administration records. Resident #166 did not receive Atorvastatin Calcium for ten days, as confirmed by a review of the Medication Administration Record (MAR) and an interview with the Assistant Director of Nursing. Furthermore, Resident #455 was observed lying on a standard mattress instead of the ordered air mattress, despite the Task Administration Record (TAR) indicating that the air mattress was monitored and functioning correctly. The facility also failed to maintain accurate Medical Orders for Life-Sustaining Treatment (MOLST) forms. Resident #1, who had moderate cognitive impairment, was incorrectly marked as a cognitive intact consent party on the MOLST form. Similarly, Resident #10, with a history of cognitive impairment, had a MOLST order form that did not accurately reflect their cognitive status. These deficiencies highlight the facility's failure to ensure accurate documentation and adherence to professional standards in maintaining medical records and orders.
Neglect of Resident's ADL Care Leads to Distress
Penalty
Summary
The facility failed to ensure that a resident was free from neglect, as evidenced by the case of a resident who did not receive necessary Activities of Daily Living (ADL) care during an entire shift. The resident was found with a soaked gown and bed linen, which caused significant distress. The complaint, submitted to the Office of Health Care Quality, highlighted that the resident's call light was on, and the resident expressed a need to be cleaned and have their wet bed linens changed. The night shift staff discovered the resident in this condition, indicating that the neglect occurred during the evening shift. A health status note from an LPN documented that the resident's diaper and bed had been wet throughout the evening shift, leading to bed soreness. The resident was in distress and screaming due to the lack of care. The LPN and an aide eventually attended to the resident's needs. During an interview, the Director of Nursing acknowledged awareness of the incident and mentioned providing in-service training to the LPN involved for proper documentation and reporting of patient concerns.
Failure to Obtain Statement from Alleged Perpetrator in Abuse Investigation
Penalty
Summary
The facility failed to thoroughly investigate an allegation of abuse involving a resident. A family member reported that the resident's Geriatric Nurse Assistant (GNA) allegedly hit the resident in the back of the head five times. The incident was reported approximately two weeks after it allegedly occurred. The resident, who had a BIMS score indicating moderate cognitive impairment, denied being hit when interviewed. Other staff and residents also denied knowledge or witnessing any abuse. Despite these interviews, the facility did not obtain a statement from the alleged perpetrator, which was a critical step missing in the investigation process. The Director of Nursing (DON) and the Nursing Home Administrator (NHA) were involved in the investigation. They followed several protocols, such as removing the alleged staff from the schedule, conducting a head-to-toe assessment of the resident, notifying the doctor and family, involving the Social Worker, and reporting the incident to law enforcement. However, the failure to obtain a statement from the alleged perpetrator was a significant oversight in the investigation, as acknowledged by the NHA when made aware of the deficiency.
Failure to Ensure Resident Dignity and Staff Identification
Penalty
Summary
The facility failed to ensure the dignity of its residents, as evidenced by two specific incidents involving nursing staff. In the first incident, a Geriatric Nursing Assistant (GNA) entered a resident's room without knocking, which was confirmed during an interview with the resident and the GNA. The GNA acknowledged the expectation to knock before entering and admitted to not doing so. In the second incident, another GNA was observed without a visible name badge while delivering food outside a resident's room. Upon inquiry, the GNA confirmed that all staff were expected to wear name tags, and she was later seen with a makeshift name tag made from tape. These actions were reported to the Nursing Home Administrator and the Director of Nursing at the time of the surveyor's exit.
Inaccurate MDS Discharge Coding
Penalty
Summary
The facility failed to accurately code a resident's discharge status on the Minimum Data Set (MDS) assessment. This deficiency was identified for one resident who was reviewed for hospitalizations during the survey. The resident was discharged to another nursing home, as indicated in the discharge summary dated October 8, 2024. However, the MDS Discharge Return Not Anticipated assessment incorrectly recorded the discharge status as a short-term general hospital (acute hospital). This discrepancy was confirmed through interviews with the Social Worker Director, a Licensed Practical Nurse, and the Lead MDS Coordinator, who acknowledged the error and indicated that the assessment should reflect the discharge to another facility. The Nursing Home Administrator was informed of the MDS inaccuracy.
Failure to Develop Comprehensive Care Plans for Residents
Penalty
Summary
The facility failed to develop and implement comprehensive care plans for three residents, leading to deficiencies in addressing their specific health needs. Resident #355 experienced constipation from late December 2024, but no bowel regimen was initiated until January 2025. Despite receiving various medications for constipation starting January 2, 2025, there was no evidence of a care plan to address this issue. The resident reported that the medication led to diarrhea and vomiting, indicating a lack of effective management and planning for the resident's condition. Resident #356, diagnosed with irritable bowel syndrome (IBS), experienced non-stop diarrhea and was seen by a Nurse Practitioner on January 8, 2025, for nausea, vomiting, and diarrhea. The NP ordered IV hydration and other treatments, but there was no care plan developed for the use of IV fluids for hydration. The Unit Manager and Assistant Director of Nursing confirmed the absence of a care plan for this resident's hydration needs, highlighting a gap in the facility's care planning process. Resident #12, who was dependent on staff for activities of daily living (ADLs) due to conditions such as schizophrenia, muscle weakness, and intellectual disabilities, did not have a care plan addressing their dependence on staff for personal hygiene, bathing, dressing, and toileting. Despite being aware of the resident's needs, the staff failed to initiate and implement a care plan to ensure adequate support for ADLs. This oversight was acknowledged by the Director of Nursing, who was informed of the findings.
Failure to Provide Individualized Activities Program
Penalty
Summary
The facility staff failed to provide an ongoing activities program tailored to meet the needs and preferences of a resident, identified as Resident #94. Observations made during the survey revealed that the resident was frequently found sitting in a wheelchair in the hallway across from the nurses' station, not participating in any activities. The resident's Minimum Data Set (MDS) assessment indicated a strong preference for activities such as reading, listening to music, keeping up with the news, participating in group activities, and engaging in religious services. Despite these documented preferences, the resident's activity care plan, which required participation in activities of choice 3-5 times weekly, was not effectively implemented. Interviews with facility staff, including the Assistant Director of Nursing and the Activities Director, confirmed that while the resident was sometimes taken to group activities, they often did not stay long due to yelling out. The Activities Director acknowledged familiarity with the resident's preferences and health conditions but admitted to having limited documentation of the resident's participation in activities. A review of the resident's activity participation records showed minimal engagement, with only two days of documented activities in November 2024 and no records for December 2024 and January 2025. This lack of documentation and observed inactivity indicates a failure to provide a personalized and consistent activities program for the resident.
Failure to Schedule Neurology Consultation for Resident
Penalty
Summary
The facility failed to follow up on a recommendation for a neurology consultation for a resident who was readmitted with a primary diagnosis of New Onset Seizure. The resident's discharge summary from the hospital requested an appointment with a Neurologist within four weeks of discharge. Despite multiple progress notes from physicians and nurse practitioners indicating the need for a follow-up with neurology, there was no documentation in the resident's clinical record to confirm that an appointment was scheduled or attended. Interviews with facility staff revealed a lack of clarity and follow-through in the process of scheduling the necessary consultation. Staff members, including the Nurse Manager, Nurse Supervisor, or Charge Nurse, were responsible for making appointments based on physician orders and hospital recommendations. However, they were unable to confirm whether the neurology appointment was scheduled. The Medical Director acknowledged the oversight and noted that the resident was stable on medication, suggesting that a consultation was not deemed necessary after two months.
Failure to Follow Respiratory Care Protocols
Penalty
Summary
The facility failed to provide appropriate respiratory care and services for a resident, as observed during a survey. The surveyor noted that the oxygen humidifier bottle and tubing attached to the oxygen concentrator in the resident's room were not dated, and there was no oxygen usage sign on the resident's room door or doorframe. The resident had physician orders for oxygen therapy and a care plan related to respiratory illness, which included changing the oxygen tubing and humidifier bottle weekly on the night shift. The facility's policy required an oxygen sign on the resident's door and specified that the tubing and humidifier bottle should be changed weekly and every seventy-two hours, respectively. During an interview, the Director of Nursing acknowledged that the expected procedures for oxygen signage and equipment changes were not followed for this resident, indicating an oversight in adhering to the facility's policy.
Failure to Timely Discontinue Medication as Ordered
Penalty
Summary
The facility failed to discontinue a medication in a timely manner as ordered by the attending physician for a resident with diagnoses including Cognitive Communication Deficit, Major Depressive Disorder, and Psychosis. The resident was admitted to the facility, and on September 11, 2024, the Licensed Pharmacist recommended discontinuing Oxycodone PRN as it was not utilized by the resident. The physician reviewed this recommendation and ordered the discontinuation of the medication on September 17, 2024. However, the facility did not follow up on this order, and the medication was not discontinued until November 15, 2024, after a second recommendation from the pharmacist on November 12, 2024. The Director of Nursing confirmed the findings during an interview, explaining the process for handling pharmacy recommendations and the failure to implement the physician's order.
Failure to Provide Prompt Dental Care
Penalty
Summary
The facility staff failed to promptly provide or obtain dental services for a resident, leading to a deficiency. During a floor rounding, the resident reported a dental issue involving a cap that had fallen out, causing pain. The resident had informed the staff about this issue upon admission. A review of the resident's records revealed that an initial dental assessment was conducted by a social worker, identifying a broken or loose-fitting tooth. However, the assessment was later altered to indicate no dental issues, and the resident was not referred to the on-site dental service. The resident was admitted with severe protein-calorie malnutrition and encephalopathy, which could have been exacerbated by the dental issue. Despite the initial identification of a dental problem, the facility did not ensure the resident received the necessary dental care. The administrator acknowledged the failure to provide or schedule a dental visit, confirming the deficiency in the facility's response to the resident's dental needs.
Deficiencies in Meal Service and Dietary Adherence
Penalty
Summary
The facility failed to provide meals that adhered to the dietary preferences and needs of three residents, leading to deficiencies in food service. Resident #455 received breakfast trays that did not match the meal tickets, missing items such as biscuits, gravy, coffee, and milk. The resident expressed concerns about inadequate food supplies, as syrup was provided instead of butter and jelly. The Nursing Home Administrator confirmed that the kitchen did not prepare the menu items as indicated, such as French toast. Resident #255, who follows a gluten-free diet, repeatedly received meals that did not align with this dietary restriction. The resident's meal tray included items like muffins and sausage patties that were not suitable for a gluten-free diet. The Dietary Manager acknowledged the oversight and attributed it to being understaffed, which delayed the updating of the resident's dietary preferences. Resident #357 experienced issues with receiving incorrect meal trays, resulting in missed meals. The resident reported that the staff removed incorrect trays but did not replace them, leading to missed breakfasts. The Registered Dietitian and Certified Dietary Manager were aware of the resident's specific preferences, but these were not documented in the electronic charting system, contributing to the discrepancies in meal service.
Failure to Meet Dietary Needs and Provide Meals for Dialysis
Penalty
Summary
The facility failed to ensure that a resident's dietary needs were met and did not provide a lunch meal for a resident attending outpatient dialysis. For Resident #169, the facility did not adhere to the prescribed low-fat, low-residue diet as required by the resident's medical condition. The hospital discharge summary indicated a need for a low fiber, low insoluble residue diet, avoiding coffee and dairy. However, the resident was placed on a regular diet with mechanical soft texture upon admission. The Registered Dietician and Dietary Manager were unable to verify the initial diet order sent to the kitchen due to the absence of a copy of the diet card. The Dietary Manager noted that the resident's family had expressed dissatisfaction with the diet provided and had requested a low-fat diet, but there was no documentation of when these changes were made. For Resident #58, the facility did not provide a lunch meal to accompany the resident on scheduled dialysis days, despite the resident leaving the facility after breakfast and returning around 4:00 PM. The resident reported not receiving lunch at the dialysis center, and the meal tray was observed left on the food delivery cart. The assigned RN confirmed that the facility did not provide a lunch for the resident on dialysis days. The Nursing Home Administrator and Director of Nursing were informed of the issue, but no additional information was provided regarding the provision of lunch for the resident.
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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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