Chapel Hill Nursing Center
Inspection history, citations, penalties and survey trends for this long-term care facility in Randallstown, Maryland.
- Location
- 4511 Robosson Road, Randallstown, Maryland 21133
- CMS Provider Number
- 215220
- Inspections on file
- 16
- Latest survey
- March 30, 2026
- Citations (last 12 mo.)
- 4
Citation history
Health deficiencies cited at Chapel Hill Nursing Center during CMS and state inspections, most recent first.
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.
Two residents’ rights were not upheld when one resident’s urinary catheter bag was repeatedly observed uncovered, with the bag cover at one point lying on the floor, and another resident was refused feeding assistance while on the phone with family despite the family’s consent to proceed. The staff member told the resident they would only be fed after ending the call, and leadership later acknowledged the resident had the right to be fed while on the phone but cited staff discomfort as the reason this did not occur.
Surveyors found that the facility failed to develop and implement comprehensive care plans for two residents. One resident used a motorized wheelchair and had a documented safety assessment and an ED note describing a leg injury that occurred while using the device, yet the care plan contained no documentation or interventions related to motorized wheelchair use. Another resident had a documented diagnosis of PTSD and a history of childhood sexual abuse, and while the care plan noted trauma as a focus, it listed no specific interventions to address PTSD or the trauma history.
Surveyors identified that the facility failed to revise person-centered care plans after significant changes in two residents’ conditions. For one resident, the MOLST and paper chart were updated from Full Code to DNR-B with No CPR and palliative/supportive care orders, but the care plan continued to list the resident as Full Code. For another resident who sustained a fall with injuries and was sent to the ER, the existing fall-prevention care plan was not updated to reflect the incident or any new interventions, and no timely review was documented. During interviews, the rehab director reported that therapy provides recommendations after falls but does not revise care plans, and the DON and regional administrator confirmed that no care plan revisions or fall investigation documentation were available.
A resident with dementia and epilepsy fell and suffered a subdural hematoma after a GNA left them unattended with the bed raised, despite a care plan requiring two-person assistance. The facility's inconsistent communication and incomplete staff training on resident assistance levels contributed to the incident.
The facility's dietary staff failed to maintain temperature logs for refrigerators and freezers, did not date or label food items with expiration dates, and handled residents' food without wearing beard covers. These deficiencies were observed during a recertification survey, with the Dietary Manager citing short staffing as a reason for incomplete logs and aides unaware of the beard cover requirement.
The facility failed to provide evidence of annual training on abuse, neglect, and exploitation for all nursing staff. A review of six staff members' records revealed no documentation for 2022 and 2024. The DON confirmed the absence of records for these years, despite providing documentation for 2023.
The facility failed to conduct background checks on certain staff members, including a GNA and an LPN, as revealed during a re-certification survey. The Director of Human Resources could not provide documentation for these checks, and the Administrator was unable to identify or provide files for staff involved in an alleged verbal abuse incident.
A facility failed to promptly report a suspected abuse incident involving a GNA and a resident. The incident, where a GNA placed a wedge pillow on a bed after becoming discouraged, was reported by the resident's family to the ombudsman. The NHA was informed the next day but did not report to OHCQ until the ombudsman raised the issue days later. Both the resident and the GNA denied any abusive intent.
The facility failed to thoroughly investigate incidents involving a resident's injury of unknown origin, an elopement, and an abuse allegation. Inadequate documentation and lack of staff interviews were noted, and training was insufficiently attended. The Nursing Home Administrator confirmed these deficiencies.
A facility failed to accurately code the MDS assessment for a resident's smoking status. The resident was found smoking in their room, but the MDS inaccurately documented no cigarette use. The MDS coordinator confirmed that smoking status should be assessed initially, quarterly, and upon any significant change, but this was not accurately reflected. The NHA validated the inaccuracy in the resident's initial MDS record.
The facility failed to update care plans for two residents, one of whom reported feeling unsafe after an incident, and another who required Ativan for anxiety. Despite investigations and ongoing medication orders, care plans were not revised to reflect these changes, as confirmed by the DON and Activity Director.
A resident with adequate cognitive ability did not receive scheduled showers due to inadequate facility accommodations, resulting in bed baths without documented refusals or encouragement for showers. Staff interviews revealed the lack of appropriate shower facilities for residents unable to sit in a shower chair, and the resident eventually received a shower after surveyor intervention.
A resident on blood-thinner medication underwent a tooth extraction without holding the medication, leading to excessive bleeding and hospital admission. The RN was unaware of the dentist's visit and did not document informing the dentist about the medication intake. The facility ceased using the dentist due to communication issues.
A facility failed to monitor a resident's significant weight changes, resulting in a 20-pound loss over two months without physician notification. The resident, with failure to thrive and swallowing difficulties, required full meal support. Despite documented weight refusals, there was no evidence of further intervention or communication with the physician. Staff interviews revealed inconsistencies in communication and documentation processes, which were validated by the Nursing Home Administrator.
A facility failed to ensure the justified use of psychotropic medication for a resident with anxiety. The resident was prescribed Ativan without implementing or documenting non-pharmacological interventions or behavior monitoring. The facility did not monitor the resident's psychiatric symptoms, and interviews confirmed the lack of non-pharmacological interventions before administering the medication.
The facility failed to ensure GNAs received training on resident safety and care after an alleged abuse incident. One GNA had no records of training on safety and mobility, while another was involved in an incident with a resident but lacked training on customer service and timely reporting. The Nursing Home Administrator confirmed the absence of these training records.
The facility failed to ensure a safe and clean environment in two bathrooms, where floor radiator heaters had missing end caps, exposing sharp, rusted edges. In one bathroom, two unsecured metal pieces were also present, and a paper towel dispenser was missing. The Director of Maintenance acknowledged these issues, but the radiator heater in one bathroom remained uncapped, posing a risk to residents.
The facility failed to notify a resident and their representative in writing about the bed hold policy when the resident was transferred to an acute care facility. During a recertification survey, it was found that there was no written evidence of the policy being communicated. Interviews with the DON and a Social Worker confirmed the lack of documentation.
A facility failed to maintain an effective communication system for a non-English speaking resident who speaks only Russian. Staff interviews revealed reliance on basic sign language and family assistance for communication, with no consistent tools or interventions in place. The care plan noted the language barrier, but lacked specific strategies to address it. The Nursing Home Administrator mentioned tools like a picture board and Google Translate, but their use was not verified.
The facility failed to properly store medications, with two opened insulin vials not discarded within the required 28-day period and expired supplies found in the medication storage room. These issues were identified during a recertification survey and confirmed with the ADON.
The facility failed to prevent infection and protect the dignity of residents with indwelling catheters by improperly using pillowcases for Foley bags. Additionally, a resident did not receive complete TB screening, and an RN did not sanitize hands between medication administrations, breaching infection control protocols.
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 Maintain Dignity and Respect Resident Communication Rights
Penalty
Summary
The facility failed to promote resident dignity for a resident with an indwelling urinary catheter. On 3/23/2026 at 8:30 AM, a surveyor observed that this resident’s urinary catheter bag was hanging from the bed without a cover. On 3/24/2026 at 12:35 PM, the same resident was observed with a cover over the urinary catheter bag. However, on 3/26/2026 at 2:43 PM, the resident was again observed lying in bed with the urinary catheter bag uncovered, and the bag cover was seen lying on the floor next to where the catheter bag was hanging. These observations showed that the facility did not consistently ensure the catheter bag was covered, which the surveyor identified as a failure to maintain the resident’s dignity. The facility also failed to uphold a resident’s right to self-determination and communication during a mealtime. A facility-reported incident and subsequent interviews revealed that a resident was on the phone with their sister, who was also the resident representative, and their mother at lunchtime when staff arrived to assist with feeding. The staff member told the resident they would be fed after they finished their phone conversation and refused to feed the resident while they remained on the phone, despite the sister stating it was acceptable to feed the resident during the call. The staff member left, stating they would return once the resident was off the phone. During an interview, the DON acknowledged that the resident had the right to be fed while on the phone but stated that staff could not be made to do something they were uncomfortable with. The surveyor informed the DON that the resident’s rights had been denied because the resident had to end the phone call in order to receive their meal.
Failure to Develop Comprehensive Care Plans for Motorized Wheelchair Use and PTSD
Penalty
Summary
Surveyors identified a failure to develop and implement comprehensive care plans for two residents. For one resident who used a motorized wheelchair, interviews with the DON, Administrator, and Occupational Therapist confirmed that the resident had a power mobility device and that a safety assessment for its use had been completed by therapy. The resident’s medical record included an Emergency Department physician note documenting the resident’s report that they were in their motorized wheelchair when they sustained a leg skin tear or laceration after running into their bed. The facility’s matrix and records showed the resident had been admitted and later discharged, and a power mobility indoor driving assessment dated several months prior was provided. Despite this information and the confirmed use of a motorized wheelchair, review of the resident’s care plan showed no documentation addressing the resident’s use of a motorized wheelchair. For another resident, record review showed documentation in the facility matrix and in a Quarterly MDS that the resident had a medical diagnosis of post-traumatic stress disorder (PTSD) and a history of trauma related to childhood sexual abuse. The resident’s care plan focus reflected this trauma history; however, the only listed intervention for that focus was the word “trauma,” with no specific interventions identified to address the PTSD diagnosis or trauma history. During an interview, the Nursing Home Administrator was informed that the resident had a PTSD diagnosis, but the surveyor could not locate any detailed interventions in the care plan beyond the generic trauma notation.
Failure to Revise Care Plans After Code Status Change and Resident Fall
Penalty
Summary
The deficiency involves the facility’s failure to ensure person-centered care plans were timely updated and revised by the interdisciplinary team following significant changes in residents’ status and events. For one resident, a social services note documented that the Maryland MOLST was reviewed and changed from Full Code to DNR-B on a specified date, and the paper chart contained a MOLST form with orders for No CPR, Option B, Palliative and Supportive Care. However, the resident’s care plan still contained a focus stating that the resident’s Full Code MOLST would remain in place through the review date, and this care plan was not revised to reflect the updated code status. During record review with the Nursing Home Administrator, it was confirmed that the MOLST had been updated but the care plan had not been revised accordingly. The deficiency also includes the facility’s failure to revise a resident’s care plan after a fall event. A progress note by an LPN documented that another resident experienced a fall, sustained several injuries, and was transferred to the emergency room. Review of this resident’s care plan showed that no revisions were made to the existing fall interventions in response to the fall, and the care plan was not documented as reviewed and revised until a later date. During interviews, the Director of Rehabilitation stated that therapy makes recommendations and sees residents after falls but does not revise the care plan and was unsure if nursing was responsible for care plan revisions. The DON and Regional Administrator confirmed that no care plan revisions had been made in response to the fall and that there was no recollection or documentation of a fall investigation.
Failure to Provide Adequate Staff Support Leads to Resident Injury
Penalty
Summary
The facility failed to provide the specified number of staff support needed when providing care for residents, resulting in a serious accident. A resident with a history of dementia, epilepsy, and seizure disorder, who was dependent on activities of daily living, fell out of bed and suffered a left acute frontal subdural hematoma requiring surgery. The incident occurred when a Geriatric Nursing Assistant (GNA) left the resident unattended with the bed raised to her waist level, contrary to the care plan that required two-person assistance. The investigation revealed that the GNA admitted to leaving the resident unattended while she went to the bathroom to wet a towel, during which time the resident fell. The facility's investigation also showed that the GNA was aware of the resident's squirming behavior but failed to ensure the resident's safety by not lowering the bed or securing the resident. The care plan clearly indicated the need for two-person assistance, which was not followed, leading to the resident's fall and subsequent injury. Interviews with other staff members indicated inconsistencies in how they were informed about the required assistance levels for residents. Some staff relied on information from the rehabilitation team, while others referred to notes on the resident's bed or electronic health records. The facility's documentation and training records were incomplete, as not all staff received the necessary in-service education on resident safety and transfer mobility, contributing to the deficiency.
Deficiencies in Food Safety and Hygiene Practices
Penalty
Summary
The dietary staff at the facility failed to maintain proper temperature logs for the refrigerators and freezers from January 4 to January 6, 2025. During an initial tour of the kitchen, it was observed that the temperature logs were not completed, and the Dietary Manager attributed this to being short-staffed during those days. However, during a follow-up visit, the missing temperature logs were found to be completed, but the Dietary Manager could not provide a reason for this discrepancy. Additionally, the dietary staff did not date or label food items stored in the refrigerator and freezer with expiration dates. Items such as a large bowl of beefaroni meal, tomatoes, carrots, cheese, sour cream, frozen vegetables, and French fries were found without proper labeling. Furthermore, a dietary aide was observed handling residents' food without wearing a beard cover, and during a follow-up visit, two dietary aides were seen without beard covers despite having beards. The aides mentioned that they were unaware of the requirement and that beard covers were being ordered.
Deficiency in Annual Abuse, Neglect, and Exploitation Training
Penalty
Summary
The facility failed to provide evidence that all nursing staff received annual training on abuse, neglect, and exploitation, as required. During a recertification and complaint survey, the surveyor reviewed the training records of six randomly selected nursing staff members, including registered nurses and geriatric nurse aides, and found no documentation of the required training for the years 2022 and 2024. The Director of Nursing stated that the facility offered annual abuse training and provided documentation for 2023, but confirmed the absence of records for the other years. This deficiency was identified for all six staff members whose records were reviewed.
Failure to Conduct Background Checks on Staff
Penalty
Summary
The facility administration failed to ensure that background checks were conducted for certain employees, which is a critical measure to protect residents from abuse, neglect, and theft. During a re-certification survey, it was found that four out of nine employees reviewed did not have documented background checks. Specifically, the Director of Human Resources was unable to provide a background check for GNA #26, despite reviewing both paper and electronic employee records. Additionally, the Administrator could not identify or provide employee files for GNA #46, LPN #47, and GNA #48, whose initials were listed in a facility reported incident for alleged verbal abuse. This lack of documentation and identification indicates a significant oversight in the facility's hiring and record-keeping processes.
Delayed Reporting of Suspected Abuse Incident
Penalty
Summary
The facility staff failed to immediately report an allegation of suspected resident abuse involving a Geriatric Nursing Assistant (GNA) and a resident. The incident allegedly occurred when the GNA was attempting to position a wedge pillow under the resident's feet but became discouraged and placed the wedge on the bed, stating she would return later. The resident did not perceive this action as abusive, nor did the roommate, but the family reported the incident to the ombudsman during a care plan meeting. The Nursing Home Administrator (NHA) was informed of the incident the day after it occurred but did not report it to the Office of Healthcare Quality (OHCQ) until it was brought up by the ombudsman four days later. The NHA conducted interviews with the resident and the GNA, both of whom denied any abusive intent. Despite this, the facility's delay in reporting the incident to the OHCQ was noted as a deficiency during the recertification survey.
Investigation and Documentation Deficiencies in Resident Incidents
Penalty
Summary
The facility failed to thoroughly investigate a resident's injury of unknown origin, as evidenced by the lack of documentation for interviews with other residents. Resident #30 was found with a bruise on the left flank and coccyx, and while the facility conducted staff interviews and hospital follow-ups, they did not interview other residents to verify their safety. The Nursing Home Administrator confirmed the absence of these interviews during a review with the surveyor. Additionally, the facility did not adequately address an elopement incident involving Resident #23, who left the building unnoticed by staff. The investigation lacked an interview with the staff member who initially observed the resident leaving via camera. Although in-service training was provided on the day of the incident, only nine nursing staff members attended, despite the facility having more staff. The Nursing Home Administrator acknowledged these shortcomings. Furthermore, the facility's investigation into an allegation of abuse involving Resident #19 was incomplete, as there was no documentation of witness statements, skin assessments, or abuse training following the incident.
Inaccurate MDS Assessment for Resident's Smoking Status
Penalty
Summary
The facility staff failed to ensure that Minimum Data Set (MDS) assessments were accurately coded for a resident reviewed for smoking during the recertification/complaint survey. The investigation revealed that the resident was found smoking in their room, and although an initial smoking assessment was completed upon admission, the MDS assessment inaccurately documented no cigarette use. This discrepancy was identified during a review of the resident's medical records, which showed that the resident was admitted in October 2022, and the incident of smoking occurred in November 2022. The MDS coordinator confirmed that smoking status should be assessed initially, quarterly, and upon any significant change, but this was not accurately reflected in the resident's MDS assessment. The Nursing Home Administrator validated the inaccuracy in the resident's initial MDS record.
Failure to Revise Care Plans for Residents
Penalty
Summary
The facility staff failed to revise the interdisciplinary care plans to meet the needs of two residents, leading to deficiencies in care. For one resident, an incident was reported where the resident did not feel safe due to being touched by someone. Despite the facility's investigation, which concluded that the resident was confused about their roommate's gender, the care plan was not updated to reflect this incident. The Director of Nursing confirmed that the care plan should have been revised following the incident, but it was not. For another resident, the care plan did not reflect changes in behavior that required the administration of Ativan for anxiety. The initial order for Ativan was placed and renewed multiple times, but the care plan goals and interventions were not updated to address these behavior changes. Additionally, the activity care plan goals and interventions were not revised to reflect the resident's current needs, as confirmed by the Activity Director and other staff members. This lack of revision in care plans indicates a failure to provide appropriate and individualized care for the residents.
Failure to Provide Scheduled Showers for Resident
Penalty
Summary
The facility staff failed to ensure that a dependent resident's personal hygiene needs were adequately met by not providing showers as scheduled. This deficiency was identified during a recertification/complaint survey for a resident who expressed dissatisfaction with not receiving showers. The resident, who had a Brief Interview for Mental Status (BIMS) score indicating adequate cognitive ability, confirmed during an interview that he had not been receiving showers and expressed a desire to have them. The facility's records showed that the resident was scheduled for showers twice a week, but instead, he was given bed baths without documentation of refusal or encouragement to take showers. Interviews with facility staff, including a Geriatric Nurse Aide (GNA) and the Director of Nursing (DON), revealed that the resident had been receiving bed baths due to the facility's shower room not having appropriate accommodations for his condition. The GNA stated that refusals were documented, but there was no record of the resident refusing showers or being encouraged to take them. The DON and Nursing Home Administrator (NHA) acknowledged the lack of appropriate shower accommodations for residents who could not sit in a shower chair, but did not provide a solution. The resident eventually received a shower after the surveyor's inquiry.
Failure to Communicate Medication Concerns Leads to Complications
Penalty
Summary
The facility staff failed to communicate and document a concern regarding a resident's medication regimen prior to a dental procedure, which led to complications. The resident, who was on blood-thinner medication, underwent a tooth extraction without the necessary precaution of holding the medication, resulting in excessive gum bleeding. The electronic health record indicated that the resident had been receiving Eliquis and Aspirin as prescribed, and these medications were administered on the day of the procedure. The Registered Nurse (RN) responsible for administering the medications was unaware of the dentist's visit and did not document informing the dentist about the resident's medication intake. The situation escalated when the resident experienced substantial bleeding post-extraction, necessitating a trip to the emergency department. Despite attempts to manage the bleeding with gauze and communication with the on-call physician, the resident's condition required hospital admission. The Nursing Home Administrator acknowledged the communication issues with the contracted dentist, who did not inform the facility of her visits, leading to the decision to cease using the vendor. The dentist was no longer reachable for further clarification as she no longer worked with the facility.
Failure to Monitor Significant Weight Changes in Resident
Penalty
Summary
The facility failed to adequately monitor a resident's significant weight changes, as evidenced by a 20-pound weight loss over a period from April to June 2024. The resident, who was identified as having failure to thrive, swallowing difficulties, and requiring 100% support with meals, had a documented weight of 187.2 pounds in April 2024, which decreased to 166.5 pounds by June 2024. Despite these significant changes, there was no documentation indicating that a physician was made aware of the resident's weight loss or nutritional status. The dietician noted the resident's refusal to be weighed and the need for encouragement, but there was no evidence of further intervention or communication with the physician regarding the resident's condition. Interviews with facility staff revealed inconsistencies in the communication and documentation processes related to the resident's weight management. The dietician and the Assistant Director of Nursing (ADON) described procedures for handling weight refusals and the importance of notifying the physician, yet these steps were not reflected in the resident's records. Additionally, after the resident's readmission to the facility, there was a lack of documented weights or refusals, and no communication with the provider was recorded. The deficiency was validated by the Nursing Home Administrator upon review of the surveyor's findings.
Failure to Implement Non-Pharmacological Interventions Before Psychotropic Use
Penalty
Summary
The facility failed to ensure the necessary and justified use of high-risk psychotropic medication for a resident diagnosed with anxiety. The resident was prescribed Ativan, an anxiolytic medication, on an as-needed basis, with the order being renewed multiple times over a period of months. However, the facility did not implement or document any non-pharmacological interventions prior to administering the medication. Additionally, there was a lack of behavior monitoring documentation to justify the administration of the anxiolytic medication. During the recertification survey, it was found that the facility did not have any tasks ordered for monitoring the resident's psychiatric symptoms, including anxiety. Interviews with the Director of Nursing and the Facility Administrator confirmed that the facility did not monitor the resident's behaviors when receiving anxiolytics and did not perform non-pharmacological interventions before administering psychotropics. This deficiency was evident for one of the two residents reviewed for the utilization of unnecessary medication.
Deficiency in GNA Training on Resident Safety and Abuse Prevention
Penalty
Summary
The facility failed to ensure that Geriatric Nursing Assistants (GNAs) received necessary training on resident safety and care, particularly after an alleged abuse incident. This deficiency was identified during a recertification/complaint survey, where it was found that GNA #10, hired in July 2023, had no training records for resident safety and transfer mobility. Despite the Director of Nursing's explanation of the training process, there was no evidence of completed training in these areas for GNA #10. The Nursing Home Administrator confirmed the absence of such training in the employee's records. Additionally, the facility's investigation into a self-reported incident revealed that GNA #37 was involved in an incident where a resident reported being hurt and having a dirty brief placed in their face. Although the facility conducted assessments and interviews, and GNA #37 was removed from the assignment, there was no record of the GNA receiving training on customer service or timely reporting related to the incident. The Nursing Home Administrator confirmed the lack of training records for GNA #37 concerning the incident.
Unsafe and Unclean Bathroom Conditions in Facility
Penalty
Summary
The facility failed to maintain a safe, clean, and comfortable environment for residents, as evidenced by the condition of the floor radiator heaters in two of the five bathrooms observed during the recertification survey. In the bathrooms shared by rooms 36/38 and 35/37, the floor radiator heaters were found with significant damage, including missing end caps, which exposed sharp, rusted edges. These conditions posed a potential risk of injury to residents using the bathrooms. Additionally, in the bathroom for rooms 36/38, two unsecured long flat metal pieces were leaning against the wall, and the paper towel dispenser was missing. The Director of Maintenance, identified as Staff #8, was shown these deficiencies during the survey. Staff #8 acknowledged the issues, agreeing that the sharp, rusted edges should not be exposed and that the metal pieces should not be present in the bathroom. Despite some corrective actions being taken, such as the removal of the metal pieces and the installation of a paper towel dispenser, the floor radiator heater in the bathroom for rooms 36/38 remained without a cap, leaving sharp edges exposed. This ongoing issue was observed even after initial corrective measures were implemented, with a resident continuing to use the affected bathroom daily.
Failure to Provide Written Bed Hold Policy Notification
Penalty
Summary
The facility failed to notify a resident and their representative in writing about the bed hold policy when the resident was transferred to an acute care facility. This deficiency was identified during a recertification survey for a resident who was admitted to the facility and later sent to an acute care facility due to a change in their medical condition. A review of the medical record revealed no written evidence that the resident or their representative received notice of the bed hold policy. The Director of Nursing and the Social Worker were unable to provide documentation that the policy was communicated in writing, as confirmed during their interviews.
Failure to Maintain Effective Communication for Non-English Speaking Resident
Penalty
Summary
The facility failed to maintain an effective communication system for a non-English speaking resident, identified as Resident #51, who speaks only Russian. During the recertification survey, it was observed that the resident was unable to communicate effectively with staff, as they primarily spoke English and relied on basic sign language and gestures for communication. Interviews with staff revealed that during business hours, an employee from another department assisted with communication, but during off hours and weekends, the staff had to call the resident's family for assistance. This indicates a lack of a consistent and reliable communication method for the resident. A review of Resident #51's medical records showed that the resident was admitted with Russian as their native language, yet there was no evidence of any intervention or tools in place to assist with communication. The care plan noted the language barrier, but no specific strategies were documented to address it. The Nursing Home Administrator mentioned the use of a picture board and Google Translate, but there was no verification that these tools were effectively utilized by the staff. This deficiency highlights the facility's failure to ensure that the resident's communication needs were adequately met, potentially impacting their ability to perform activities of daily living and receive appropriate care.
Medication Storage and Labeling Deficiency
Penalty
Summary
The facility failed to properly store medications, as evidenced by improper labeling and dating of medication vials and expired supplies. During the recertification survey, two opened resident-specific insulin vials were found in the refrigerator of Units 1 A and B. Vial one and vial two were opened on different dates, but neither was discarded within the 28-day period as required by the facility's medication labeling and storage policy. Additionally, in the medication storage room of Unit 2 A and B, an expired spill kit and three expired condom catheter packs were found. These findings were confirmed during a review with the Assistant Director of Nursing.
Infection Control and Dignity Deficiencies in LTC Facility
Penalty
Summary
The facility failed to prevent infection in residents with indwelling catheters and did not protect their dignity. During an initial tour, it was observed that two residents had their Foley bags placed on the floor inside pillowcases, which is not the appropriate method for handling such medical equipment. The LPNs acknowledged the improper use of pillowcases and removed them, but were unsure of the correct alternative. The Director of Nursing admitted to improvising with pillowcases due to a lack of proper dignity bags, which had been ordered but not yet received. Additionally, the facility did not perform complete Tuberculosis screening for a resident, as evidenced by the absence of documentation for the second step of the PPD skin test. Furthermore, during medication administration, an RN failed to sanitize hands between residents, increasing the risk of contamination. The RN also used a medication container lid to measure medication, which was identified as a breach of infection control principles by the Assistant Director of Nursing. These deficiencies were brought to the attention of the Director of Nursing.
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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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