Carroll Park Healthcare
Inspection history, citations, penalties and survey trends for this long-term care facility in Baltimore, Maryland.
- Location
- 3330 Wilkens Avenue, Baltimore, Maryland 21229
- CMS Provider Number
- 215085
- Inspections on file
- 23
- Latest survey
- March 4, 2026
- Citations (last 12 mo.)
- 17
Citation history
Health deficiencies cited at Carroll Park Healthcare during CMS and state inspections, most recent first.
A resident at the nursing station became upset about delayed laundry and began yelling and cursing at a GNA after being told the dryer was down. The resident then threw an iPad and a heavy metal snack tray toward the GNA and two LPNs seated at the nurses’ station. The GNA caught the tray and slammed it down on the desk, striking the resident’s hand, which was resting on the desk, and causing a broken fingernail. This incident reflects a failure to ensure the resident was free from abuse.
Surveyors observed multiple large insects in common areas and reviewed pest control logs documenting repeated roach and mice sightings throughout the facility, including a significant number of mice on one floor. Staff interviews confirmed awareness of ongoing pest issues, but recent sightings had not been addressed, indicating a failure to maintain an effective pest control program.
The facility did not maintain or provide required investigation documentation for two reported incidents involving two residents—one alleging theft of money and another exhibiting unusual drowsiness. In both cases, only minimal or no investigation records were available when requested by surveyors, and facility leadership acknowledged that these records should have been retained and accessible.
A resident with intact cognition requested that a Geriatric Nursing Assistant stop providing care and leave the room, but the staff member continued despite the resident's wishes. Another staff member present confirmed the resident's request was ignored, resulting in a failure to protect the resident from abuse.
A resident reported an allegation of physical abuse by a staff member, and despite facility policy requiring immediate removal of the alleged perpetrator, the staff member continued to work their shift after the allegation was reported. Timecard records and HR confirmation showed the policy was not followed.
The facility did not report unusual occurrences and abuse allegations within required timeframes, including failing to notify law enforcement when a resident alleged a nurse pulled their mask, yelled, and took a video without consent. In another case, a resident was found unresponsive and the incident was not reported promptly, and a sexual assault allegation was not reported within the mandated two-hour window.
Staff did not ensure accurate nutritional assessment or documentation for a resident with quadriplegia, resulting in outdated weight records and discrepancies between reported and actual meal intake. Additionally, staff failed to follow a physician order for contracture management for another resident, with repeated lapses in the use and documentation of a prescribed palm grip device.
A resident did not receive a scheduled wound dressing change as ordered by the physician, and there was no documentation explaining the missed treatment. The last dressing change was performed outside the prescribed schedule, and the DON confirmed that staff are expected to document all wound care, including missed treatments.
A GNA was found to have an expired certification during a surveyor's review of employee files. The HR Director, responsible for tracking certification expiration dates, acknowledged the lapse as an oversight. The GNA was not on duty at the time the deficiency was identified.
Surveyors found that annual performance reviews for all GNAs reviewed were missing from employee files. Despite repeated requests, neither the HR Director nor the DON could provide the required documentation, revealing a failure to conduct and maintain annual GNA performance evaluations.
Staff documented a blood pressure reading for a resident after the individual had already been discharged and transferred to the hospital. The DON confirmed that no vital signs should be recorded post-discharge and could not explain the inaccurate entry.
The facility failed to adequately assess and supervise residents who were known smokers, leading to multiple incidents of unsafe smoking behavior. Residents were found smoking in their rooms despite being assessed as safe smokers requiring supervision. Additionally, the facility failed to ensure that residents' rooms were free from hazards, contributing to the deficiency.
The facility failed to use the QAPI process to track, review, and analyze drug overdoses, resulting in 23 SPAEs and six fatalities. Despite discussing drug use in QAPI meetings, no performance improvement plan was implemented. The facility's failure to address this issue led to multiple resident deaths.
The facility failed to provide CPR for a resident with a full code status. An LPN found the resident unresponsive and did not initiate CPR, instead calling an RN who also did not perform CPR, mistakenly believing the resident had a DNR order. The resident's chart indicated a full code status, and the facility's policy was not followed.
The facility failed to timely implement physician instructions and orders related to SUD treatment, effectively plan care for residents with SUD, and initiate a SUD care plan for residents identified with SUD. This led to multiple overdose events and placed residents at increased risk for serious harm and possible death.
The facility administration failed to provide effective oversight, resulting in immediate jeopardy for resident safety due to inadequate supervision of smoking, inconsistent monitoring of substance abuse, and poor maintenance and pest control. These failures led to repeated citations and actual harm to residents.
The facility failed to store and prepare food in accordance with professional standards, with multiple instances of improperly stored and expired food, a malfunctioning ice maker, low sanitizing solution levels, and wet nesting of kitchenware observed during a survey.
The facility failed to facilitate care plan meetings for five residents, as evidenced by interviews and medical record reviews. Residents and their representatives reported infrequent or non-existent meetings, and staff admitted to not scheduling these meetings as required.
The facility failed to inform residents of their right to formulate advanced directives, affecting five residents. The Social Service Director and Nursing Home Administrator confirmed that residents were not asked if they wanted to create advanced directives unless they specifically requested it. Additionally, one resident had no MOLST form or code status indicator in their medical record.
The facility failed to maintain appropriate temperature control for medication storage, properly waste narcotic medications, and secure medications and treatments. Observations included expired medications, an unlocked medication cart, a pill on the floor, and a medication cup left on a resident's bedside table. Staff admitted to not following proper procedures.
A facility with over 120 beds experienced a 5-month period without a qualified, full-time Social Worker overseeing social service duties. Employee records indicated a staffing gap from March to September 2022, during which individuals without the required qualifications were employed as Social Service Director. The Nursing Home Administrator confirmed the absence of a qualified Social Worker during this time.
The facility failed to maintain a sanitary environment, with food trays left in hallways and on PPE storage bins. Two residents experienced issues with room conditions: one had unpacked belongings and a non-functional closet, while another had a room with a mattress on the floor, chipped paint, a damaged A/C unit, and a clogged toilet. Staff were aware but did not promptly address these issues.
The facility failed to report allegations of abuse to the state agency within the required timeframe for three residents. One resident alleged being struck and kissed, another felt mistreated and did not want to return to the facility, and a third abuse incident was reported late. These delays in reporting violated the mandated 2-hour reporting window.
The facility staff failed to thoroughly investigate and accurately report allegations of abuse, affecting 12 out of 30 residents reviewed. Incidents involving injuries, theft accusations, and altercations were not properly documented or investigated, compromising resident safety and well-being.
A facility did not develop a care plan for a resident with chronic respiratory conditions and tobacco use, despite identifying the resident as an unsafe smoker requiring supervision. Additionally, the facility failed to involve the Power of Attorney (POA) in care plan meetings for another resident. Several residents reported not being informed about or invited to care plan meetings, and there was a lack of timely scheduling and documentation of these meetings. The Social Work Director, responsible for planning care plan meetings, could not provide sign-in sheets for some residents, indicating organizational issues in the care planning process.
A survey identified deficiencies in medication administration and documentation processes. One resident with Diabetes Mellitus lacked a sliding scale in their insulin order, potentially affecting blood sugar management. Another resident with end-stage renal disease and dialysis dependence had incomplete documentation on the Dialysis Communication Form, raising concerns about the transfer of vital health information between the facility and the dialysis clinic.
The facility staff failed to ensure residents received quality care, including timely medication administration, catheter care, and intervention for acute changes in condition. Several residents experienced delays or missed doses of critical medications, improper documentation, and lack of timely medical intervention, leading to severe health complications.
The facility staff failed to appropriately administer pain medications as ordered for three residents. One resident was given Oxycodone despite reporting a pain level of 0, another received medication outside the prescribed pain scale due to staff intimidation, and a third experienced significant delays in receiving pain medication after hospital readmission. The facility's pain management policy was not followed, and staff interviews confirmed the deficiencies.
A resident with polyneuropathy and kidney failure requiring dialysis experienced significant medication errors due to inaccurate transcription and administration of Gabapentin. The resident missed 74 doses over several months, as the Nursing Unit Coordinator failed to detect discrepancies in the Medication Administration Record (MAR).
The facility experienced issues with maintaining accurate resident records, leading to discrepancies in documentation. For one resident, conflicting information about dental status was found in various assessments. Additionally, incorrect room name displays caused confusion for multiple residents. Another resident faced inadequate documentation and implementation of physician orders, particularly concerning hypoglycemia management and essential care needs like nutritional monitoring and dialysis access. Discharge instructions from hospitalizations were also not promptly addressed or accurately documented, impacting the resident's care plan.
The facility staff failed to ensure that resident rooms were free from mice, as evidenced by observations and interviews with two residents. Despite pest control reports identifying mice as an issue months prior, staff were not using the designated logbooks to report sightings, opting instead for an electronic system. The Maintenance Director was unaware of the reliance on logbooks for pest management.
The facility failed to provide timely psychiatric care for two residents with mental disorders. One resident experienced a delay in receiving recommended medication, leading to aggressive behavior and hospitalization. Another resident did not receive individual therapy due to a communication error regarding insurance approval.
A resident expressed a desire to be discharged home but did not receive social work assessments or discharge planning. The Social Services Director noted the absence of an active social work department upon her arrival, with temporary assistance provided only for discharge planning, not for completing social histories or care plan meetings.
The facility failed to provide a bariatric bedside commode for a resident, despite repeated requests. The standard-sized commode was too small, and the bathroom toilet was too low for the resident to use. Staff indicated that obtaining bariatric equipment was straightforward, but the commode was only delivered shortly before the resident's discharge.
The facility's staff failed to ensure a sanitary and safe environment for a resident. Observations revealed used paper towels under the sink, a ceiling tile off the track, torn curtains, and a damaged bathroom door. Despite daily rounds, staff were unaware of these issues, which remained unaddressed upon follow-up.
The facility failed to provide written transfer notices to two residents and did not notify the Ombudsman of resident transfers in a timely manner. One resident was transferred to the hospital due to an unwitnessed fall, and another due to hypoglycemia, but neither received written notices. Additionally, the facility delayed notifying the Ombudsman of transfers and discharges.
The facility failed to ensure residents and their representatives were informed of the bed hold policy during hospital transfers. Two residents were transferred without proper documentation or communication of the policy, revealing inconsistencies among staff in implementing this procedure.
The facility failed to accurately assess two residents for antipsychotic medications and behaviors. One resident's MDS was incorrectly coded, omitting the need for an antipsychotic medication review. Another resident's MDS had dashes in sections for cognition and behavior, despite a documented history of behaviors, due to incomplete nursing documentation.
The facility failed to develop and implement a baseline care plan for a resident requiring hemodialysis and experiencing recurrent hypoglycemic episodes within 48 hours of admission. The resident was transferred to the ER due to hypoglycemia shortly after being taken to the dialysis clinic, highlighting the lack of proper care planning and coordination between the facility and the dialysis provider.
The facility did not create timely comprehensive care plans for two residents. One resident, admitted with PTSD and adjustment disorder, had a care plan for psychological services developed 10 months post-admission. Despite multiple psychiatric visits, there was a 5-month gap without documented visits, indicating a delay in addressing mental health needs.
A resident requiring assistance with mobility, transfer, dressing, and toileting was not provided the necessary ADL care by facility staff. Despite documented needs and an OT assessment confirming the required assistance, the resident was told that nobody gets up before noon, and staff did not return to provide the needed help.
The facility failed to provide ongoing personalized activities for three residents, including one with severe cognitive impairment and another who is cognitively intact. Despite care plans indicating the need for one-to-one room visitations and weekly activities, there was no documentation or evidence of these activities being provided.
The facility failed to provide appropriate oxygen therapy equipment for a resident. The resident's oxygen cart lacked a handle, and the oxygen tubing was outdated. The resident reported the tank was empty and difficult to move. An LPN confirmed the tubing should be changed nightly, and the Director of Nursing stated it should be changed every 7 days.
The facility failed to develop and implement a process to determine if residents with a history of trauma received appropriate trauma-informed care. This was evident for a resident with PTSD, as no assessment or care plan was completed. Interviews confirmed the absence of a screening process for trauma history.
The facility failed to consistently and accurately reconcile controlled medications, as evidenced by missing staff signatures and discrepancies in medication counts in two out of six narcotic log binders. These issues were identified during a recertification survey and confirmed by staff.
The facility failed to maintain the outdoor garbage storage area properly, with debris scattered around the dumpster and a garbage bin full to the top with trash items. A staff member confirmed that all trash should be contained inside the dumpster to avoid attracting rodents.
The facility failed to initiate a customized QAPI plan, as the reviewed plan contained template examples with placeholders and lacked facility-specific concerns. The Administrator acknowledged the issue, citing the absence of a dedicated QAPI person.
The facility failed to protect clean linen from contamination, maintain proper infection prevention practices for a resident with CP-CRE, and ensure isolation carts were adequately stocked with PPE. Despite being reported, the linen cabinet remained broken, staff were unclear on proper precautions, and PPE shortages were not communicated effectively.
The facility failed to ensure that an Agency Geriatric Nursing Assistant received facility training prior to working, despite a process being in place for two months. The GNA had not completed the required training, indicating a lapse in the implementation of the training process.
The facility failed to honor a resident's right to participate in family events outside the facility. The resident requested a Leave of Absence (LOA) on two occasions, but only the first request was approved. The second request was lost, and there was no documentation to support its denial, leading to the determination that the facility failed to honor the resident's right.
Failure to Protect a Resident From Abuse During Altercation With GNA
Penalty
Summary
The deficiency involves the facility’s failure to protect a resident from abuse during an altercation with a GNA. On the date of the incident, the resident was at the second-floor nursing station complaining that their laundry had not been returned. GNA #5 explained that the dryer was down, which was why the clothes were delayed. The resident then began cursing and yelling at the GNA. During this exchange, the resident picked up an iPad and a heavy metal snack tray and threw them toward GNA #5 and two LPNs who were seated at the nursing station. According to the DON and staff interviews, GNA #5 caught the metal tray and then slammed it down on the nursing station desk, striking the resident’s hand, which was resting on the desk. This action caused the resident to sustain a broken fingernail. The incident occurred at the second-floor nursing station and was witnessed by LPN staff who confirmed the sequence of events, including the resident’s verbal outburst, the throwing of the items, and the GNA’s response that resulted in injury to the resident’s hand.
Failure to Maintain Effective Pest Control Program
Penalty
Summary
The facility failed to maintain an effective pest control program, as evidenced by multiple observations and documentation of insect and rodent activity throughout the building. On several occasions, large black and brown insects were observed in the lobby, hallways, and conference room. Pest control logs revealed repeated roach sightings over several months, with treatments occurring days after the initial reports. Additionally, a bedbug sighting was reported in the lobby, and although the pest control company treated the area, no bedbugs were found during their inspection. The logs also documented a significant number of mice sightings, particularly on the 4th floor, with 24 instances recorded in one month. Interviews with facility staff indicated awareness of ongoing pest issues, specifically waterbug sightings, but staff were not aware of the most recent insect observations made by surveyors. The facility's pest control records and incident reports further confirmed the presence of pests, including both insects and rodents, in resident areas and common spaces. These findings demonstrate a failure to implement and maintain an effective pest control program, with the potential to affect all residents.
Failure to Maintain Investigation Documentation for Reported Incidents
Penalty
Summary
The facility failed to maintain and provide complete records of investigation documentation for reported incidents involving two residents. In the first case, a resident alleged that $70 was stolen from their possession. Upon review, the investigation file contained only the initial and follow-up self-reports submitted to the Office of Health Care Quality, with no additional documentation such as statements, interviews, in-services, or education. The Director of Nursing confirmed that no further documentation was available beyond what was provided. In the second case, another resident was found to be high, drowsy, and sleeping in a walkway, which was reported as unusual behavior. When surveyors requested the investigation documentation for this incident, facility leadership was unable to locate or provide the investigation packet. Both the Director of Nursing and the Nursing Home Administrator acknowledged that such documents should be retained for five years and made available upon request, but the required investigation records were missing.
Failure to Honor Resident's Refusal of Care
Penalty
Summary
A resident with intact cognition, as indicated by a Brief Interview for Mental Status (BIMS) score of 15, alleged that a Geriatric Nursing Assistant continued to provide care after the resident explicitly requested the care to stop and asked the staff member to leave the room. Another staff member present during the incident confirmed in a written statement that the resident told the assistant to stop and leave, but the care was continued despite the resident's request. Facility documentation and staff interviews corroborated that the staff member did not honor the resident's wishes, resulting in a failure to protect the resident from abuse as required.
Failure to Remove Staff After Abuse Allegation
Penalty
Summary
The facility failed to implement its abuse policy when an allegation of physical abuse was made against a staff member towards a resident. The incident occurred during a night shift, and the resident reported the alleged abuse and contacted the police. Despite the facility's policy requiring immediate removal of the alleged perpetrator from the facility and away from other residents following an abuse allegation, the staff member in question continued to work their shift after the allegation was reported. This was confirmed through timecard records and an interview with the Human Resource Director. The facility's abuse policy was reviewed and found to clearly state the requirement for immediate removal of the alleged perpetrator, which was not followed in this case.
Failure to Timely Report Abuse Allegations and Notify Law Enforcement
Penalty
Summary
The facility failed to report unusual occurrences and allegations of abuse in a timely manner, as well as to notify law enforcement as required. In one instance, a resident was found lethargic and difficult to arouse, requiring oxygen and Narcan administration before being sent to the ER. The incident, which occurred in the morning, was not reported to the Office of Health Care Quality (OHCQ) until four days later, and the facility leadership was unaware of the 24-hour reporting requirement for non-abuse incidents. In another case, a resident alleged sexual assault by another resident, but the incident was not reported to the appropriate agency within the required two-hour timeframe. Additionally, an allegation involving a nurse pulling a resident's mask, yelling, and taking a video without consent was reported to the state agency but not to law enforcement. The DON confirmed that the absence of a police investigation number indicated that law enforcement had not been notified, as required.
Failure to Meet Professional Standards in Nutrition Assessment and Physician Order Compliance
Penalty
Summary
Facility staff failed to ensure that services provided met professional standards of quality for two residents. For one resident with quadriplegia and complete dependence on staff, the facility did not accurately assess, document, or update the resident's nutritional status in accordance with healthcare standards. The resident appeared malnourished, and family members reported significant weight loss and missed meals. Review of the electronic medical record showed that the last documented weight was several months old, and meal intake records indicated the resident was consuming only about 50% of meals, despite documentation stating the resident was meeting more than 75% of nutritional needs. The registered dietitian admitted that some assessments were not documented in the EMR and that calculations of intake were based on meal orders rather than actual consumption, with no documentation explaining changes in nutritional supplements. For another resident, staff failed to follow a written physician order for contracture management. The order required the use of a left palm grip, to be removed only during daily hand hygiene. Multiple observations by the surveyor found the resident was not wearing the palm grip, and there was no documentation in the medical record regarding its use, contraindications, or resident refusal. Nursing staff were unable to locate documentation of palm grip usage and only after surveyor inquiry was the device observed in use. No explanation was provided by staff for the lack of compliance with the physician order during previous observations.
Missed Wound Care Treatment and Documentation Failure
Penalty
Summary
Facility staff failed to complete wound care treatment as ordered by the physician for one resident. The resident reported that wound dressing changes were scheduled for every Tuesday, Thursday, and Saturday, but the dressing change scheduled for Thursday was not performed. Observation confirmed that the last dressing change occurred on Tuesday, which was outside the prescribed schedule. Review of the treatment administration records showed an order for wound care every other evening shift, with the last documented dressing change on Tuesday and no documentation explaining the missed treatment on Thursday. The Director of Nursing confirmed that staff are expected to document all wound care, including when a dressing change is not completed, but there was no such documentation for the missed treatment.
Expired GNA Certification Not Detected by Facility
Penalty
Summary
Facility staff failed to ensure that a geriatric nursing assistant (GNA) maintained an active certification, as evidenced by a review of employee files during the annual survey. The surveyor requested the employment file for the GNA and found that the certification had expired. The Human Resource Director stated that certification and license expiration dates are tracked on a spreadsheet and reviewed monthly, but acknowledged that the expired certification was an oversight. The Administrator confirmed that the GNA's certification was expired, and the GNA was not working at the time of the survey.
Failure to Conduct and Document Annual GNA Performance Reviews
Penalty
Summary
Facility staff failed to ensure that annual performance reviews were conducted for all geriatric nursing assistants (GNAs). During the annual survey, the surveyor requested complete employee files for several GNAs, specifically requesting the inclusion of annual performance reviews. Upon review, it was found that the annual performance reviews were missing from all the requested files. The HR Director and the Director of Nursing (DON) both acknowledged the process for conducting and tracking annual reviews, but were unable to provide the required documentation during the survey period. Despite multiple requests over several days, the facility was unable to produce the annual performance reviews for any of the GNAs whose files were reviewed. Both the Administrator and DON were informed of the missing documentation, and the surveyor ceased further requests after the files were not provided. The deficiency was evident in all seven GNA files reviewed, indicating a systemic failure to maintain required annual performance evaluations.
Inaccurate Documentation of Vital Signs After Resident Discharge
Penalty
Summary
Facility staff documented inaccurate data in a resident's medical record, as evidenced by a blood pressure reading recorded after the resident had already been discharged and transferred to the hospital. Specifically, a progress note indicated the resident was sent to the emergency room at the family's request, and another note confirmed the resident was out of the facility. Despite this, a blood pressure measurement was documented in the resident's chart after the discharge date. During an interview, the DON was unable to explain how or why this documentation occurred and confirmed that no vital signs should be recorded after a resident has been discharged.
Failure to Assess and Supervise Smokers
Penalty
Summary
The facility failed to adequately assess and supervise residents who were known smokers, leading to multiple incidents of unsafe smoking behavior. Resident #78 was repeatedly found smoking in their room despite being assessed as a safe smoker requiring supervision. The care plan for Resident #78 was updated multiple times to reflect these incidents, yet the resident continued to smoke unsafely. Similarly, Resident #41 was found smoking in their room on several occasions, including smoking marijuana, despite being assessed as a safe smoker requiring supervision. The facility's failure to reassess these residents after repeated incidents of unsafe smoking behavior contributed to the deficiency. Resident #90, who had physical limitations affecting their ability to smoke safely, was found smoking in a room with another resident who was on oxygen, posing a significant fire hazard. Despite being assessed as an unsafe smoker needing supervision, Resident #90 continued to smoke unsafely. Additionally, Resident #63, who had behavior issues and was non-compliant with smoking rules, was placed in a room with Resident #10, who was on oxygen. Resident #63 was also found smoking in the room with friends, further exacerbating the risk. The facility's failure to reassess and adequately supervise these residents contributed to the ongoing unsafe smoking behavior. The facility also failed to ensure that residents' rooms were free from hazards. Resident #368 was found smoking in their room, which was filled with smoke and had cigarette butts in cups of water. Despite being assessed as an unsafe smoker with poor vision and a roommate on oxygen, the resident continued to smoke unsafely. Additionally, a power strip hanging off the wall in Resident #63's room was identified as a safety hazard, yet it remained in place. The facility's failure to remove these hazards and adequately supervise residents contributed to the deficiency.
Failure to Track and Analyze Drug Overdoses
Penalty
Summary
The facility failed to use the Quality Assurance Performance Improvement (QAPI) process to track, review, and analyze serious preventable adverse events (SPAE) related to drug overdoses. The first identified occurrence was a drug overdose resulting in the death of a resident. Despite this, the facility did not implement effective QAPI interventions, leading to 22 additional drug overdose SPAEs, including six fatalities. The Maryland Office of Health Care Quality (OHCQ) determined that this concern met the Federal definition of Immediate Jeopardy. The surveyors found that the facility did not have a systematic approach to track and analyze drug overdoses. The Medical Director confirmed that drug overdoses were discussed in QAPI meetings but were not tracked or tallied. The facility's QAPI plan indicated the use of various tools for root cause analysis and performance improvement projects (PIP), but there was no evidence that drug overdoses were prioritized or addressed. The facility admitted residents with Substance Use Disorder (SUD) but failed to implement a performance improvement plan for drug overdoses. Interviews with the Medical Director and other staff revealed that while drug use was a significant concern, the facility had not conducted a performance improvement plan on drug overdoses. The Wellness Director confirmed that tracking of overdoses had only started recently, and no PIP was in place. The facility's failure to initiate an effective QAPI response after multiple SPAEs over 16 months resulted in six resident deaths. The facility provided a plan to remove the immediacy, which was accepted by OHCQ after multiple submissions.
Failure to Provide CPR for Resident with Full Code Status
Penalty
Summary
The facility failed to provide Cardiopulmonary Resuscitation (CPR) for a resident with a full code status. During a random observation, a Licensed Practical Nurse (LPN) discovered the resident unresponsive and did not initiate CPR. Instead, the LPN attempted to contact the Director of Nursing (DON) and the Administrator but was unsuccessful. The LPN then called a Registered Nurse (RN) from another floor, who also did not immediately perform CPR upon arrival, mistakenly believing the resident had a Do Not Resuscitate (DNR) order. The RN later confirmed the resident's death without initiating CPR. Upon reviewing the resident's physical chart, it was found that the resident had a Maryland Order for Life Sustaining Treatment (MOLST) form indicating a full code status, meaning CPR should have been performed. The LPN admitted to learning about the resident's full code status only when Emergency Medical Services (EMS) arrived. The facility's policy and procedures for calling a code and performing CPR were not followed, as the staff failed to initiate CPR immediately upon finding the resident unresponsive. The facility's policy mandates that staff provide basic life support, including CPR, in accordance with the resident's advance directives. The policy also requires staff to maintain current CPR certification and follow American Heart Association (AHA) guidelines. The failure to adhere to these policies and procedures resulted in the facility being cited for Immediate Jeopardy by the Maryland Office of Health Care Quality (OHCQ).
Failure to Implement SUD Treatment and Care Plans
Penalty
Summary
The facility failed to timely implement physician instructions and orders related to Substance Use Disorder (SUD) treatment, effectively plan care for residents with SUD, and initiate a SUD care plan for residents identified with SUD. This was evident for five residents reviewed during the survey. These failures contributed to resident overdoses and placed residents at increased risk for serious harm and possible death. For Resident #147, the facility did not verify and restart Suboxone as recommended by the physician, leading to a medical emergency where the resident was found unresponsive and required Narcan administration. The care plan for this resident was created five months after the first overdose and lacked individualized interventions to monitor for triggers or withdrawal symptoms. Similarly, Resident #90 experienced two overdose events before Suboxone was ordered, and the care plan did not include interventions for monitoring individualized triggers or signs of withdrawal. Resident #101 had inconsistent documentation regarding the administration of Buprenorphine and experienced two potential overdose events. The care plan was not revised to monitor for individualized triggers and withdrawal symptoms. Resident #149, with a history of psychoactive substance dependence, experienced multiple overdose events, and no care plan was implemented for managing the resident's substance abuse disorder. Resident #154 suffered three overdose events, and no care plan was ever opened to manage the resident's needs related to substance abuse disorder.
Facility Administration Fails to Ensure Resident Safety and Compliance
Penalty
Summary
The facility administration failed to provide effective oversight activities to ensure that resources were used effectively to meet the health and safety needs of each resident. This was evidenced by the failure to ensure substantial compliance with regulations identified as deficient, failure to implement plans of correction resulting in immediate jeopardy for the safety of residents who required supervision while smoking, and failure to implement plans of correction related to residents' behavioral health. Specifically, the facility failed to identify, monitor, and prevent additional occurrences of substance abuse, and failed to provide oversight and monitoring of the maintenance and pest control plan of correction for the facility and the kitchen, resulting in repeated citations of a non-homelike environment and unsanitary kitchen and food preparation area. These failures had the potential to adversely affect the health and safety of all residents in the facility and resulted in immediate jeopardy for the third consecutive survey regarding smoking safety and actual harm regarding substance abuse prevention in a resident with an identified substance abuse disorder. The facility's Substance Use Tracking tool was found to be incomplete and inconsistent. Resident #63, who was hospitalized twice for an overdose and reported suicidal ideations, was not included in the tracking tool. Additionally, a K-9 search identified multiple resident rooms with drug paraphernalia, but these residents were not initially included in the tracking tool. Orders related to ongoing monitoring for substance use prevention were also inconsistent, with some residents having orders in place while others did not. The facility lacked a policy and procedure for this process, leading to confusion among staff about their responsibilities. The facility also failed to address unsafe smoking practices, resulting in repeated immediate jeopardy citations. Despite corrective measures being indicated, the facility did not consistently implement safety measures for residents who required supervision while smoking. Furthermore, the facility failed to maintain a safe, clean, and homelike environment. Issues such as mice and mice feces throughout the facility, including the kitchen, and concerns related to bed bugs and lice were identified. The facility did not adequately implement pest control recommendations, leaving open holes throughout the facility. These environmental concerns were not reported to the Office of Health Care Quality in a timely manner, further exacerbating the issues.
Failure to Maintain Professional Standards of Food Service Safety
Penalty
Summary
The facility failed to store and prepare food in accordance with professional standards of food service safety. During an initial tour of the kitchen, the surveyor and a cook observed multiple instances of improperly stored food, including opened and undated bags of bread, sausage, personal beverages, and a personal pan pizza in the walk-in freezer. Additionally, a black substance was found inside the ice maker machine, which had stopped working a week prior. The dishwashing area was also found to have a low sanitizing solution level, gnats flying around, food particles in the sink drain, and wet nesting of kitchenware. The dry food storage area contained an undated and unlabeled bag of coconut flakes. Expired containers of dried herbs and seasonings were also found in the food preparation area during a follow-up tour. Interviews with facility staff confirmed that the observed practices were against the facility's food storage policy, which requires securely closing packages and labeling them with open and use-by dates. The cook and dietary manager acknowledged the issues, including the low sanitizing solution level and the presence of gnats, and stated that the maintenance staff was responsible for checking and cleaning the ice machine weekly. The dietary manager also confirmed that all unopened bulk food should be labeled with an expiration date once removed from its original container. The expired food items were identified and acknowledged by the dietary manager during the follow-up tour.
Failure to Facilitate Care Plan Meetings
Penalty
Summary
The facility failed to facilitate care plan meetings for residents, as evidenced by the lack of such meetings for five residents reviewed for care planning. Interviews with residents and their personal representatives revealed that care plan meetings were either infrequent or non-existent. For instance, Resident #59's Personal Representative reported only two care plan meetings since admission, and Resident #463 stated they were unaware of any care plan meetings. Medical record reviews for these residents confirmed the absence of documented care plan meetings. Further interviews with facility staff, including a social worker, indicated that care plan meetings were supposed to be scheduled 7 days after admission, quarterly, and upon significant changes. However, the social worker admitted to not scheduling these meetings for the residents in question. The Regional Director also confirmed the lack of care plan meeting notes in the medical records. This deficiency highlights a systemic issue in the facility's process for involving residents and their representatives in care planning.
Failure to Inform Residents of Advanced Directives
Penalty
Summary
The facility failed to inform residents of their right to formulate advanced directives, as evidenced by the cases of five residents. Resident #55, admitted initially in January 2022 and most recently in April 2023, had no advanced directive in their medical record and no documentation that they were offered to create one. The Social Service Director confirmed that residents were not asked if they wanted to formulate an advanced directive unless they specifically requested it. The Nursing Home Administrator acknowledged that residents were not given the opportunity to formulate advanced directives upon admission. Similarly, Resident #22, admitted in early 2023, had no documentation of an advanced directive or an offer to create one. Resident #15 and Resident #67 were also admitted without advanced directives and were not offered the opportunity to create them. Additionally, Resident #27 had no Maryland Order for Life Sustaining Treatment (MOLST) form in their chart, and there was no current order or code status indicator in the electronic medical record. Staff confirmed the absence of the MOLST form and acknowledged the issue. The Nursing Home Administrator recognized the problem but did not take immediate corrective action as per the report.
Medication Storage and Security Deficiencies
Penalty
Summary
The facility failed to maintain appropriate temperature control for medication storage, as observed in the 4th floor medication storage room where the refrigerator's temperature was recorded at 52 degrees Fahrenheit, exceeding the acceptable range of 36 to 46 degrees Fahrenheit. Additionally, expired medications were found in the refrigerator, including bags of normal saline with added antibiotics labeled with discard dates that had already passed. The interim DON confirmed the findings and acknowledged the need for education on proper medication storage practices. The facility also failed to properly waste narcotic medications. A bottle of an opioid for a resident was found double locked in the medication cart, despite the resident being out of the facility and the medication needing to be wasted. Staff admitted that the wellness coordinator and physician should have been notified, and the medication should have been wasted with two nurses signing off on it. This issue was discussed with the interim DON, RDCO, and the Administrator. Furthermore, the facility did not maintain a safe and effective system for securing medications and treatments. Observations included an unlocked and unattended medication cart on the 4th floor, a large white pill found on the floor behind the nurses' station, and a medication cup with pills left on a resident's bedside table. Staff admitted to failing to lock medication carts and leaving medications unattended, which is against the facility's policy. These deficiencies were observed and confirmed through interviews with the nursing staff.
Qualified Social Worker Staffing Gap Identified
Penalty
Summary
The facility with more than 120 beds failed to have a qualified, full-time Social Worker employed to oversee social service duties for a period of 5 months in 2022. The review of employee records revealed that there was a gap in qualified Social Worker staffing from 3/5/22 to 9/5/22, during which no qualified social worker was employed. The facility had employed individuals without the required qualifications for the role of Social Service Director during this period, leading to the deficiency identified by surveyors. The Nursing Home Administrator acknowledged the months without a qualified Social Worker during an interview conducted by the surveyor.
Sanitary and Environmental Deficiencies
Penalty
Summary
The facility failed to maintain a sanitary environment, as evidenced by multiple observations of food trays left in hallways and on top of PPE storage bins. On several occasions, surveyors observed partially-eaten food trays labeled breakfast, supper, and other meals left unattended in the hallways and on storage bins. Staff members, including a GNA and an LPN, acknowledged that the trays should not be there and removed them upon being questioned by the surveyor. Despite these removals, the issue persisted over multiple days and was not adequately addressed by the facility's administration or staff. The facility also failed to provide a functional and comfortable environment for residents. Resident #84 reported that after switching rooms, their belongings were not unpacked, and the closet in the new room lacked a rod for hanging clothes, resulting in clothes being placed on the floor. Staff interviews confirmed that the closet should have a rod and that the resident's belongings should have been properly stored. Despite a note in the resident's medical record indicating the room change, the issue remained unresolved for several days. Additionally, Resident #59's room was found to be in poor condition, with a mattress on the floor, chipped paint, a damaged A/C unit, and a bathroom with a strong smell of urine and sewage. The toilet was clogged and filled with brown water. Housekeeping staff were aware of the issue but reported that it had not been addressed by maintenance. The Maintenance Director was new to the role and unfamiliar with the facility's work order system, resulting in a lack of timely repairs. The resident was eventually moved to a new room, but the initial conditions were substandard and not promptly rectified.
Failure to Timely Report Allegations of Abuse
Penalty
Summary
The facility staff failed to ensure allegations of abuse were reported to the state agency in a timely manner for three residents. Resident #150 alleged being struck in the face and later kissed on the cheek on 1/31/23. The nurse informed the unit manager the same day, but the incident was not reported to the state agency until 2/5/23. The Administrator confirmed the delay in reporting during an interview on 10/20/23. Resident #22, admitted in early 2023, expressed to an outside provider on 6/1/23 that they felt mistreated at the facility and did not want to return. The Nursing Home Administrator admitted to not reporting this allegation during an interview on 10/3/23. On 9/14/23, facility staff on the 3rd floor were informed of an abuse incident involving Resident #90 around 5 PM. However, the state agency was not notified until 9:39 PM, exceeding the required 2-hour reporting window. These incidents highlight the facility's failure to report allegations of abuse to the state agency within the mandated timeframe, as evidenced by the delayed reporting for all three residents.
Inadequate Investigation and Reporting of Abuse Allegations
Penalty
Summary
The facility staff failed to ensure allegations of abuse were thoroughly investigated and accurately reported, affecting 12 out of 30 residents reviewed for abuse. For Resident #119, the facility reported an incident to the state survey agency but failed to include that the resident suffered an injury. The Administrator acknowledged this omission during an interview. Similarly, investigations for Resident #161's allegations of physical and sexual abuse lacked witness statements, which the Administrator admitted was an oversight. Resident #165 experienced an incident involving the roommate's daughter, who was also an employee. The daughter accused the resident of theft, leading to a confrontation. Although the daughter was suspended and later terminated, there was no evidence that she was prevented from entering Resident #165's room during visits. The Administrator could not provide proof that the resident was protected throughout the investigation. Additionally, the facility failed to produce investigation reports for several other residents, including Resident #365, Resident #42, and Resident #369, among others. In another case, Resident #22 reported feeling mistreated and did not want to return to the facility after an outside appointment. The facility did not follow up or investigate the resident's concerns upon their return. Furthermore, an altercation between two residents on the smoking patio was not adequately investigated, as the facility failed to interview the staff responsible for supervising the area. These deficiencies highlight a pattern of inadequate investigation and reporting of abuse allegations, compromising resident safety and well-being.
Care Plan Development and Review Deficiencies Identified
Penalty
Summary
The facility failed to ensure the development of a care plan for a resident who was an active smoker upon admission and did not review or revise the care plan after a quarterly assessment. Specifically, for Resident #109, who had diagnoses including chronic respiratory failure, COPD, traumatic brain injury, and tobacco use, there was no care plan initiated for smoking despite being identified as an unsafe smoker requiring supervision. The facility also did not invite the Power of Attorney (POA) to a care plan meeting for Resident #371, leading to a lack of involvement of the POA in the resident's care decisions. Additionally, care plan meetings were not scheduled in a timely manner for several residents, including Resident #10 who reported not being informed about the last care plan meeting and Resident #33 whose care plan meetings had not been held for a year. Resident #39 mentioned not attending meetings as residents were no longer being invited, and Resident #67 expressed unawareness of care plan meetings, indicating a lack of resident involvement and communication regarding care planning. The Social Work Director was responsible for planning care plan meetings but could not provide sign-in sheets for some residents, indicating a lack of documentation and organization in the care planning process.
Deficiencies in Medication Administration and Documentation Processes
Penalty
Summary
The survey conducted at the nursing facility identified several deficiencies related to medication administration and documentation processes. In one instance, it was noted that a resident with Diabetes Mellitus did not have a sliding scale included in their insulin order, leading to potential issues in managing blood sugar levels effectively. The lack of a sliding scale for insulin administration was highlighted during the survey, prompting the need for corrective action to align with professional standards of care for residents requiring insulin therapy. Another deficiency involved a resident with end-stage renal disease and dependence on dialysis, where incomplete documentation on the Dialysis Communication Form raised concerns about the transfer of vital health information between the facility and the dialysis clinic. The incomplete form failed to provide essential details about the resident's health status, potentially impacting the continuity of care and treatment coordination for the resident receiving dialysis services.
Multiple Deficiencies in Medication Administration and Resident Care
Penalty
Summary
The facility staff failed to ensure residents received quality care in several areas, including medication administration, catheter care, and timely intervention for acute changes in residents' conditions. For instance, Resident #121 missed a follow-up angiogram appointment due to a broken Hoyer lift and had multiple medications administered outside the prescribed times. Similarly, Resident #161's medications were administered 2-4 hours past the ordered time, and some were not administered at all. Resident #364 also experienced delays in medication administration, with some medications not given until the following day. Additionally, Resident #381 missed 107 out of 870 medication doses in June 2021, with no documentation of refusal in the progress notes. Resident #63 received an extra dose of Methadone due to a failure in documenting the medication administration properly. The nurse administering the medication did not sign out the medication on the chain of custody form, leading to a double dose. Resident #16 had no active orders for Foley catheter care/maintenance, resulting in a urinary tract infection that led to septic shock. Resident #517, who had multiple health conditions, was visibly unstable and hypoglycemic but was sent to the dialysis clinic without proper assessment or intervention. The resident's condition worsened, requiring emergency transfer to the hospital. Resident #162 did not receive several critical medications until days after admission, and the staff failed to order Narcan despite the resident's history of substance abuse. Resident #131, who required Midodrine for orthostatic hypotension, did not receive a single dose over several months, and staff failed to monitor blood pressure as required. Finally, Resident #108 experienced a significant drop in blood sugar, and the staff failed to provide timely emergency medication, leading to an emergency transfer to the hospital. These deficiencies highlight significant lapses in medication administration, documentation, and timely medical intervention across multiple residents.
Failure to Administer Pain Medication as Ordered
Penalty
Summary
The facility staff failed to appropriately administer pain medications as ordered for three residents. Resident #15 was given Oxycodone despite reporting a pain level of 0 on multiple occasions across July, August, and September 2023. The Director of Nursing (DON) confirmed that medication should not be administered if the pain is rated as 0 and that the nurse should have called the physician for clarification if the pain scale was not included in the order. The DON reviewed the cases to identify the responsible nurses. Resident #63 had an order for Oxycodone to be administered for pain levels between 7-10. However, the medication was administered multiple times in August and September 2023 for pain scores below 7. Staff interviews revealed that the medication might have been given outside the prescribed parameters due to the resident intimidating the staff. The facility's pain management policy states that opioids should be dosed according to professional standards and manufacturers' guidelines, which was not followed in this case. Resident #517 experienced significant delays in receiving pain medication after being readmitted from the hospital. Despite reporting high pain levels, the resident did not receive pain medication from 10/4/2023 to 10/6/2023, and even after the medication was ordered on 10/6/2023, it was not administered until 10/9/2023. The resident's pain assessments consistently showed high pain scores, and the care plan included interventions to administer analgesics as ordered. The interim DON and the physician confirmed the delays and the failure to provide timely pain relief to the resident. The facility staff did not provide additional documentation regarding the missed opportunities for pain relief during the survey.
Significant Medication Errors Due to Inaccurate Transcription and Administration
Penalty
Summary
The facility staff failed to ensure that prescribed medications were correctly transcribed and administered, leading to significant medication errors for a resident diagnosed with polyneuropathy, nerve pain, and kidney failure requiring dialysis. The resident had an admission order for Gabapentin to be administered three times a week after dialysis. However, a review of the Medication Administration Record (MAR) revealed that the resident received Gabapentin only three out of seven days per week, resulting in 74 missed doses from June 24, 2023, through November 3, 2023. This discrepancy was not detected by the Nursing Unit Coordinator, who was responsible for overseeing physicians' order management and ensuring accurate transcription and administration of medications. Interviews with the resident's physician and the Nursing Unit Coordinator confirmed that the admission orders and MAR transcriptions were inaccurate and should have been reviewed and verified by both the physician and nursing staff. The Nursing Unit Coordinator acknowledged that the continuous medication errors were due to undetected inaccurate orders and MARs, which were not properly reviewed. Despite daily reviews and reporting discrepancies, the Nursing Unit Coordinator failed to identify the issues with the resident's medication orders, leading to the significant medication errors observed during the survey.
Inaccurate Resident Records and Documentation Discrepancies
Penalty
Summary
The facility failed to maintain accurate resident records in accordance with professional standards, as evidenced by multiple instances of discrepancies in documentation and record-keeping. For Resident #22, conflicting information was found regarding the presence of teeth in various assessments, highlighting inconsistencies in the medical records. Additionally, the failure to display residents' names outside their rooms accurately led to confusion and potential risks, as observed with Residents #8, #79, #64, and others. Furthermore, inadequate documentation and implementation of physician orders were noted in the case of Resident #517, who experienced issues related to hypoglycemia and other complex medical conditions. The lack of active orders addressing essential care needs, such as nutritional monitoring and dialysis access, raised concerns about the quality of care provided to the resident. The failure to promptly address and accurately document discharge instructions from hospitalizations further compounded the deficiencies in the resident's care plan.
Failure to Maintain Pest-Free Environment
Penalty
Summary
The facility staff failed to ensure that resident rooms were free from mice, as evidenced by observations and interviews with two residents. Resident #23 reported seeing two mice every night and sometimes during the day. Additionally, a mouse was observed running across the floor in Resident #16's room, and the resident mentioned that the mouse would climb up cords near the head of the bed. These findings were brought to the attention of the Nursing Home Administrator. A review of service reports from Orkin, the pest control company, revealed that mice had been identified as an issue months before the survey. Despite this, the logbooks at the nurses' stations, which were intended for reporting pest sightings, were not being used by facility staff. Interviews with staff members indicated that they were aware of the mice problem but were not using the logbooks to report sightings, instead opting to use the electronic communication program, TELS. The Maintenance Director also acknowledged the issue and mentioned that he was unaware of the reliance on logbooks for pest management treatments.
Failure to Provide Timely Psychiatric Care
Penalty
Summary
The facility failed to appropriately treat two residents diagnosed with mental disorders. Resident #115, who had a history of schizophrenia, was recommended by a psychiatrist to start on Prolixin due to agitation and depression. However, the primary provider delayed the medication pending an EKG, which was completed, but the medication was not started until after the resident was hospitalized following aggressive behavior. This delay in administering the recommended psychological medication contributed to the resident's escalating behavior and subsequent hospitalization. Resident #78, diagnosed with post-traumatic stress disorder and adjustment disorder with mixed anxiety and depressed mood, had multiple orders for psychiatric consultations and individual therapy. Despite these orders, the resident did not receive the recommended individual psychotherapy due to a communication error regarding insurance approval. The facility's process for ensuring psychiatric services was found to be inadequate, as the resident's needs were not met in a timely manner, leading to unmanaged anxiety and other symptoms. Interviews with staff and review of medical records revealed that the facility's system for managing psychiatric services was flawed. The facility relied on an external service for psychiatric consultations, but failed to ensure that all recommended services were provided. This resulted in significant lapses in care for residents with mental health needs, as evidenced by the cases of Resident #115 and Resident #78.
Lack of Social Work Assistance for Resident Requesting Discharge
Penalty
Summary
The facility failed to ensure social work assistance for Resident #385, who expressed a desire to be discharged home. Despite the resident's request and the absence of social work notes or evaluations, no social worker assessments or discharge planning were provided. The Social Services Director mentioned the lack of an active social work department upon her arrival, with temporary assistance brought in for discharge planning but not for completing social histories or care plan meetings.
Failure to Provide Bariatric Bedside Commode
Penalty
Summary
The facility failed to provide a bariatric bedside commode for a resident's use, despite the resident's repeated requests. On 09/28/23, the resident stated that the standard-sized bedside commode provided was not big enough to fit their body, making it impossible to use the bathroom. The resident also mentioned that the toilet in the bathroom was too low, preventing them from getting back up. Interviews with staff revealed that obtaining bariatric equipment involved requesting it from the Rehab department, and it was not considered difficult to obtain. However, the bariatric bedside commode was only delivered to the therapy room shortly before the resident was discharged, indicating a delay in meeting the resident's needs.
Failure to Maintain Sanitary and Safe Environment
Penalty
Summary
The facility's staff failed to ensure a sanitary and safe interior environment for one resident. On 09/28/23, a surveyor observed a pile of used paper towels under the sink, a ceiling tile off the ceiling track, torn curtains between two beds, and a damaged bathroom door in the resident's room. Despite daily rounds by the Maintenance Director and Housekeeping staff, they were unaware of these issues. A follow-up observation on 10/03/23 confirmed that the deficiencies remained unaddressed, and the Maintenance Director was notified again of the unacceptable conditions.
Failure to Provide Written Transfer Notices and Timely Ombudsman Notification
Penalty
Summary
The facility failed to provide written notice with the reason for transfer to two residents and failed to notify the Ombudsman of resident transfers in a timely manner. Resident #22 was transferred to a hospital due to an unwitnessed fall, but there was no documentation that a written notice was given to the resident informing them of the reason for the transfer. The Nursing Home Administrator (NHA) was only aware of the transfer summary completed by staff and did not provide a written notice to the surveyor by the exit date. Additionally, the NHA admitted that the August transfers and discharges were not sent to the Ombudsman, and the notices from May were sent several months late, with no subsequent notifications sent after August 7th, 2023. Resident #517 was observed in a distressed state and was later transferred to the hospital due to hypoglycemia. The resident's medical records confirmed the transfer, but there was no written notice provided to the resident or their representative. The interim Director of Nursing (DON) was unsure of the facility's transfer/discharge policy, and the Unit Coordinator confirmed that no written notice was sent. The failure to provide written transfer notices for Resident #517's hospitalizations was reviewed with the Regional Director of Clinical Operations (RDCO) and the Administrator.
Failure to Provide Bed Hold Policy During Hospital Transfers
Penalty
Summary
The facility failed to implement a process to ensure that residents and their representatives were made aware of the bed hold policy upon transfer to the hospital. This deficiency was identified for two residents during the survey. Resident #517, who had multiple medical conditions including end-stage renal disease and hypoglycemia, was transferred to the hospital twice without being provided with the bed hold policy. The interim Director of Nursing and other staff members were either unaware of the policy or failed to document it properly, resulting in incomplete records and lack of communication with the resident or their representative. Resident #517 was first transferred to the hospital due to hypoglycemia, and no bed hold policy was noted in the transfer summary. Upon readmission and a subsequent transfer, the bed hold policy documentation was incomplete, lacking the resident's signature. Interviews with staff revealed inconsistencies in the understanding and implementation of the bed hold policy, with some staff members being unaware of the policy altogether. The surveyors were unable to obtain documentation indicating that the bed hold policy was provided to the resident or their representative during both transfers. Similarly, Resident #22, who was transferred to the hospital following an unwitnessed fall, did not receive written notice of the bed hold policy. The Nursing Home Administrator acknowledged that there was inconsistency among the nursing staff in providing the bed hold policy and was unable to locate the documentation for Resident #22. This lack of consistent communication and documentation regarding the bed hold policy highlights a significant deficiency in the facility's process for informing residents and their representatives about their rights and the facility's policies during hospital transfers.
Inaccurate MDS Assessments for Antipsychotic Medications and Behaviors
Penalty
Summary
The facility failed to accurately assess two residents for antipsychotic medications and to document their assessments correctly. For one resident, the Quarterly Minimum Data Set (MDS) was incorrectly coded, failing to indicate the need for an antipsychotic medication review despite the resident being on such medication. This error was acknowledged by the Resource MDS Coordinator and the Director of Nursing, who confirmed that the MDS had been amended after the surveyor's notification. For another resident, the MDS assessment had dashes through sections related to cognition patterns and behavior, despite the resident having a documented history of behaviors and a care plan addressing these issues. The Regional MDS Coordinator explained that the dashes were used because nursing staff did not specify the types of behaviors in their documentation, which prevented the resident from being coded correctly for behaviors on the MDS. The omission of a narrative explanation led to the inaccurate assessment.
Failure to Develop Adequate Baseline Care Plan for Resident
Penalty
Summary
The facility failed to develop and implement a baseline care plan for a resident requiring hemodialysis treatments and experiencing recurrent hypoglycemic episodes within 48 hours of admission. This deficiency was identified during a survey when Resident #517, who had been admitted with multiple diagnoses including ESRD, hypoglycemia, and heart failure, was found to have an inadequate baseline care plan that did not address his dialysis needs or hypoglycemic care. The resident was transferred to the ER due to hypoglycemia shortly after being taken to the dialysis clinic within the facility, highlighting the lack of proper care planning and coordination between the facility and the dialysis provider. Further review of the resident's electronic medical record and hospital discharge summary confirmed the need for dialysis three times a week and recurrent hypoglycemic episodes requiring dextrose infusions. Despite these critical care needs, the baseline care plan developed on the day of admission did not include an adequate plan for dialysis or hypoglycemia management. The interim DON confirmed the inadequacy of the care plan during an interview with surveyors. The resident was subsequently rehospitalized due to low blood sugar levels and has not been able to receive dialysis at the facility since the incident.
Delayed Development of Comprehensive Care Plans for Residents with Mental Health Needs
Penalty
Summary
The facility failed to create comprehensive care plans for two residents during an annual and complaint survey. For Resident #78, admitted with a history of post-traumatic stress disorder and adjustment disorder with mixed anxiety and depressed mood, the care plan addressing psychological/psychiatry services was not developed until 10 months after admission. Despite multiple visits to psych between February and November, there was a gap of 5 months without documented visits. The care plan finally created on 10/7/23 highlighted the need for consultation with psych, indicating a significant delay in addressing the resident's mental health needs.
Failure to Provide Necessary ADL Care
Penalty
Summary
The facility staff failed to provide necessary activities of daily living (ADL) care based on the resident's level of daily living needs. This was evident for one resident who required assistance with mobility, transfer, dressing, and toileting. On the specified date, the resident requested assistance to get up and perform ADLs but was told by two Geriatric Nursing Assistants (GNAs) that nobody gets up before noon. The surveyor observed that the staff did not return to provide the needed assistance for at least 22 minutes after the initial request. A record review confirmed that the resident's assessment indicated a need for two-person assistance for mobility and transfers, and one-person assistance for dressing and toileting. An interview with the Occupational Therapist corroborated the resident's need for this level of assistance. Despite these documented needs, the staff failed to provide the necessary care, resulting in a deficiency in the resident's ADL care.
Failure to Provide Personalized Activities for Residents
Penalty
Summary
The facility failed to provide ongoing personalized activities for three residents, as observed and documented by surveyors. Resident #4, who has a low cognitive baseline due to a stroke and chronic diseases, was observed lying in bed and later sitting in a wheelchair without any engagement in personalized activities. Despite the care plan indicating the need for one-to-one room visitations involving music and reading, there was no documentation of such activities from March to September 2023. Interviews with the Activity Director and Activity Assistant revealed that while one-to-one activities were supposed to be offered, they were not documented, and no evidence of these activities was provided for Resident #4. Resident #59, with a BIMS score of 00 indicating severe cognitive impairment, had a care plan that required participation in weekly activities 3-5 times a week. However, there was no documentation to support that Resident #59 was engaged in any ongoing and individualized activities program. The Personal Representative of Resident #59 confirmed that there had been no follow-up on the activities plan since the resident's admission two years ago. The Activity Director admitted to not conducting any activities for the 4th floor residents, including Resident #59, since his employment began in August 2023. Resident #23, who is cognitively intact, was observed lying awake in bed without engagement in activities. The resident confirmed that facility staff did not bring activities or engage in one-to-one activities as preferred. The activities assessment completed in July 2023 indicated a preference for one-to-one room visits, but there was no evidence that these were provided. The Activity Director acknowledged that while staff engaged residents in one-to-one activities, they were not recording them, and no evidence was provided for Resident #23's engagement in such activities.
Failure to Provide Appropriate Oxygen Therapy Equipment
Penalty
Summary
The facility failed to provide appropriate oxygen therapy equipment for Resident #416. During observations, the surveyor noted that the resident's oxygen cart lacked a handle, and the oxygen tubing was outdated. The resident reported that the oxygen tank was empty and difficult to move without a handle. An LPN confirmed that the tubing should be changed nightly and that the resident uses oxygen as needed. The LPN also acknowledged the empty tank and the missing handle on the oxygen cart. The Director of Nursing stated that oxygen tubing should be changed every 7 days and that staff would be educated on this policy. A review of the facility's Oxygen Administration Policy indicated that oxygen delivery devices should be changed every 72 hours or as needed. The Treatment Administration Record confirmed orders for oxygen use as needed and tubing changes every 7 days. The surveyor later observed that the resident had received a new oxygen concentrator and tubing covered in a plastic bag.
Failure to Provide Trauma-Informed Care
Penalty
Summary
The facility failed to develop and implement a process to determine if residents with a history of trauma received appropriate trauma-informed care. This deficiency was evident for one resident who had a documented history of post-traumatic stress disorder (PTSD). A medical record review revealed that no assessment or care plan had been completed to ensure the resident received trauma-informed care. Interviews with Social Services Staff and the Director of Nursing confirmed that the facility had no process in place to screen residents for a history of trauma to develop and implement a corresponding plan of care.
Failure to Accurately Reconcile Controlled Medications
Penalty
Summary
The facility failed to implement a system to consistently and accurately reconcile controlled medications, as evidenced by the review of two out of six narcotic log binders during the recertification survey. In the first binder, a missing staff signature was identified for the administration of a 5 mg tablet of a controlled medication to a resident on 10/7/2023 at 1:00 AM. In the second binder, a discrepancy was found in the medication count for another resident, where the on-hand amount and the remaining amount did not match after the administration of two 5 mg tablets on 10/10/2023 at 6:30 PM. This miscount was documented by an agency nurse. Additionally, a missing signature was noted for a medication administered to another resident on 10/5/2023 at 9:30 AM. Staff #25 confirmed that incorrect documentation on any resident's medication monitoring/control records should be identified at shift change between the off-going nurse and the incoming nurse, requiring signatures from both nurses. The Unit Manager is responsible for the daily review of the narcotic binders on the unit. These concerns were communicated to the interim Director of Nursing, the Regional Director of Clinical Operations, and the Administrator throughout the survey and at the survey exit.
Improper Garbage Disposal
Penalty
Summary
The facility failed to maintain the outdoor garbage storage area in a manner to prevent the harborage and feeding of pests. During an outside tour of the facility, debris was observed scattered around the dumpster area, including a peanut butter and jelly sandwich, disposable cups, and food containers. Additionally, the garbage bin close to the basement exit door was full to the top with trash items. In an interview, the staff member confirmed that the expectation was for all trash to be contained inside the dumpster to avoid attracting rodents and stated that the scattered debris and other trash would be disposed of immediately.
Failure to Initiate a Customized QAPI Plan
Penalty
Summary
The facility failed to initiate a Quality Assurance and Performance Improvement (QAPI) plan, as evidenced by the review of the 2023 QAPI Plan during the annual survey. The plan contained template examples with placeholders for dates and goals, indicating that it had not been customized to address facility-specific concerns. The Administrator confirmed that the current QAPI plan was a template and acknowledged the lack of updates due to the absence of a dedicated QAPI person. The plan had only been altered to include the facility's name on the title page, with revision dates listed but no substantive changes made to the content.
Infection Control Deficiencies
Penalty
Summary
The facility failed to ensure that clean linen was protected from contamination, as observed on the 3rd floor where the linen cabinet was missing a door, leaving clean linen exposed. Despite the issue being reported to the Unit Manager and the Director of Nursing, the problem persisted for several days. Staff interviews confirmed that the linen was at risk of contamination due to the broken door, and the Nursing Home Administrator acknowledged the issue but stated that a new cabinet had been ordered, which had not yet arrived by the time of the final observation. The facility also failed to maintain proper infection prevention practices for a resident identified with Carbapenemase-producing Carbapenem-resistant Enterobacterales (CP-CRE). The resident was placed on contact precautions, but there was confusion among staff regarding the appropriate signage and precautions. Observations revealed that a Licensed Practical Nurse (LPN) did not follow proper protocol by wearing a gown and gloves outside the resident's room and placing a contaminated food tray on an isolation supply storage bin. Staff interviews indicated a lack of clarity and education on the correct precautions to be taken. Additionally, the facility did not ensure that isolation carts were adequately stocked with Personal Protective Equipment (PPE). Observations showed that several isolation carts were missing PPE gowns, and staff admitted to performing wound care without proper PPE due to the shortage. The central supply person responsible for stocking PPE carts claimed to have filled them, but no calls were received from staff about the shortages. A follow-up revealed that the facility had sufficient PPE supplies in storage but failed to distribute them properly to the isolation carts.
Failure to Train Agency Staff Prior to Working
Penalty
Summary
The facility failed to ensure that Agency Staff received facility training prior to working. This was evident when an Agency Geriatric Nursing Assistant (GNA) stated that she had not received training by the facility despite it being her second day there. The Regional Director of Clinical Operations confirmed that all staff should be trained prior to working on the floor. The HR Director explained that a process for agency training had been in place for two months, involving a training binder that agency staff are supposed to review upon arrival. However, the interviewed Agency GNA had not completed this training, indicating a lapse in the implementation of the training process.
Failure to Honor Resident's Right to Participate in Family Events
Penalty
Summary
The facility failed to honor a resident's right to participate in family events outside the facility. Resident #46 requested a Leave of Absence (LOA) on two occasions, 8/25/23 and 9/5/23, but only the first request was approved. The resident followed the facility policy by submitting both requests four days in advance. The Unit Manager confirmed receiving both requests and stated that LOA requests were typically approved by him unless there was a medical risk, in which case they were forwarded to the physician. The Business Office Manager also reviewed the requests due to the facility's policy on therapeutic Bed Hold Days. However, the second request was lost, and there was no documentation to support its denial. The Primary Physician indicated that LOA requests for family or community activities were generally approved by unit managers, while other requests required her review. She had no recollection of the 9/5/23 LOA request and planned to provide information later. Despite the surveyor's request for documentation of the 9/5/23 LOA, none was provided, leading to the determination that the facility failed to honor the resident's right to participate in family events outside the facility.
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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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