Chesapeake Shores Nursing Center
Inspection history, citations, penalties and survey trends for this long-term care facility in Lexington Park, Maryland.
- Location
- 21412 Great Mills Road, Lexington Park, Maryland 20653
- CMS Provider Number
- 215142
- Inspections on file
- 17
- Latest survey
- January 9, 2026
- Citations (last 12 mo.)
- 13
Citation history
Health deficiencies cited at Chesapeake Shores Nursing Center during CMS and state inspections, most recent first.
The facility failed to employ a full-time clinically qualified nutrition professional to oversee food preparation and daily kitchen operations. The Dietary Director, in charge for a year, was not a Certified Dietary Manager, holding only a State Food Safety Food Protection Manager Certification. The contracted district manager also lacked the necessary qualifications, possessing only a CPFS certificate. This deficiency was communicated to the nursing home administrator.
The facility failed to ensure proper operation of the dishwashing machine and adequate monitoring of food temperatures. The dishwashing machine did not reach the required temperature, and expired test strips were used for sanitation checks. Additionally, food items did not have final internal temperatures recorded, and the tray line was not paused for temperature checks. The district manager and nursing home administrator were involved in discussions about these deficiencies.
A facility was found deficient for not ensuring call devices were accessible to residents. A resident's call device was out of reach, requiring them to yell for help. Additionally, shared bathrooms had call devices without pull cords, making them inaccessible if a resident fell. The Maintenance Director confirmed this was the case throughout the facility.
The facility failed to properly investigate allegations of abuse and medication issues, and did not document statements from residents or staff involved in incidents. A resident's allegation of abuse was not fully investigated, and another resident's report of abuse lacked a personal statement despite their ability to provide one. Additionally, a controlled medication was mishandled by a former employee, and training to prevent similar incidents was not attended by all staff. A rectal probe incident also highlighted inadequate staff education.
The facility failed to provide appropriate pain management for three residents. One resident received Oxycodone despite a documented pain level of zero, with no pain scale guiding medication administration. Another resident had chronic pain but lacked pain scale parameters for their medications. A third resident, with intact cognitive function, called 911 due to unmanaged pain, leading to a hospital transfer. The facility's staff acknowledged the absence of necessary pain management protocols.
The facility failed to maintain food at a palatable temperature, leading to resident complaints about cold and unappetizing meals. Observations revealed that kitchen staff did not perform real-time temperature checks, and the cooking log lacked final temperature recordings. A test tray showed significant temperature drops, and the kitchen ran out of food items, causing service delays.
A facility failed to monitor a resident's known sexually inappropriate behavior, resulting in an incident of inappropriate contact with another resident. Despite staff awareness and clinical notes describing the behavior, there was no documentation of monitoring in June, and the order for monitoring was only placed in July.
A resident was left without a meal during lunch service while their tablemates were served and began eating. The delay occurred as staff were occupied assisting other residents, and the resident's meal was only served after a 20-minute wait, highlighting a failure to ensure dignified treatment.
The facility failed to ensure that residents were offered the opportunity to develop an advance directive, as evidenced by two cases during a survey. One resident's record lacked documentation of an advance directive offer, while another's advance directive was missing from the records despite being noted in the initial assessment. Interviews confirmed these deficiencies, highlighting a gap in the facility's adherence to its policy.
The facility failed to maintain a safe and homelike environment, as evidenced by a resident's room with a damaged nightstand and spackled walls, and a shared bathroom with missing floor tiles exposing the subfloor. The maintenance director acknowledged these issues, but repairs had not been made. The NHA was informed but did not provide an explanation.
A facility failed to properly document and prepare a resident for a hospital transfer following a fall. The medical records lacked details on interventions, resident communication, and understanding of the transfer. The unit manager acknowledged poor documentation by a new nurse and was unaware of the regulatory requirements.
A facility failed to accurately code a resident's discharge status on the MDS assessment. The resident, who was discharged home with family, was incorrectly coded as discharged to a short-term general hospital. This error was identified during an annual survey through a review of electronic medical records and confirmed by the NHA.
A facility failed to provide a baseline care plan to a resident within 48 hours of admission. The resident's record lacked documentation of the care plan, and staff could not provide evidence that it was given to the resident. Although a care plan meeting was held, there was no confirmation that the resident or their representative received the necessary information.
The facility failed to update and evaluate care plans for two residents, one with dehydration and diarrhea issues and another with dementia. The care plans were not revised to reflect changes in the residents' conditions, leading to potential confusion for staff. Interviews revealed a lack of documentation and clarity on assessing care plan effectiveness.
A resident with a stage IV sacral wound was not provided with a pressure-relieving mattress, despite the facility's awareness of the condition prior to admission. The care plan lacked an intervention for such a device, and interviews with staff confirmed the oversight. Observations during the survey showed the resident remained on a regular mattress.
The facility failed to conduct and document yearly performance reviews for its GNAs, as required. Three GNAs, including one with over thirty years of service, did not have evaluations documented for 2020, 2021, and 2022. Despite claims of annual evaluations, only one performance review was recorded for each in 2023. Interviews confirmed the absence of documented evaluations, highlighting a deficiency in the facility's record-keeping practices.
A resident expressed dissatisfaction with the food, noting a lack of seasoning and the presence of disliked items. The facility failed to document the resident's food preferences and did not provide prescribed supplemental sandwiches for dysphagia. Despite having a form for food preferences, it was not uploaded into the resident's medical records. The oversight in providing sandwiches was only addressed after surveyor intervention.
The facility failed to follow proper infection control procedures when a resident's pillows were placed on a clean bed after being on the floor without changing the pillowcases. Additionally, clean items were improperly stored in the dirty laundry room due to lack of space, as confirmed by staff.
A healthcare facility was found to have deficiencies in managing vaccine records and obtaining consent for flu and pneumococcal vaccines. Two residents were reviewed, revealing missing documentation for vaccine consent and administration. One resident had no record of consent for vaccines given in previous years, while another had no documentation of being offered or declining current year vaccines. The infection preventionist and Nursing Home Administrator were informed but could not provide current records, highlighting concerns over the facility's record-keeping and consent processes.
A facility failed to maintain safe bed rails for a resident, as observed during a survey. The resident's bed had quarter side rails that were easily pulled away, creating a gap between the rails, mattress, and bed frame. The Maintenance Director, who conducts daily visual inspections, acknowledged the issue but admitted to only performing spot checks without keeping a log. The Nursing Home Administrator was informed, but no inspection documentation was provided.
The facility failed to develop comprehensive care plans for two residents, leading to deficiencies. One resident's care plan inaccurately reflected their code status, listing them as Full Code instead of DNR/DNI as indicated in their MOLST. Another resident, admitted with a high fall risk, did not have a fall risk care plan until after experiencing a fall. Staff interviews confirmed these discrepancies, highlighting a lack of resident-centered care planning.
The facility failed to properly assess a resident with a rectal probe and did not consistently monitor another resident's blood sugar levels despite insulin administration. Staff did not document or recognize the probe during initial assessments, and blood sugar monitoring orders were not re-entered upon readmission, leading to lapses in care.
The facility failed to provide appropriate care for residents with urinary catheters, as evidenced by inconsistent and incomplete orders in the Treatment Administration Record (TAR) for a resident with a urinary catheter and a lack of documentation for catheter output for another resident with a suprapubic catheter. Interviews with staff revealed a lack of clarity in documenting and following catheter care orders, leading to inadequate care and management of urinary catheters.
A resident admitted for respite care with a history of nutritional deficiency and blindness did not have a physician-ordered diet, and the nursing staff failed to notify the physician of the resident's low meal intake. Despite documentation showing the resident often consumed 0-25% of meals, the staff did not initiate a nutritional care plan to address the resident's history of choking. The facility administrator was informed of these deficiencies.
The facility failed to ensure proper documentation of narcotic administration for two residents, leading to discrepancies between the narcotic sign-out sheets and the MAR. Staff interviews confirmed that the required process of documenting narcotic medications on both records was not consistently followed, and the Nursing Home Administrator validated these concerns.
A facility failed to properly store a resident's Alprazolam medication, which was taken by a former RN without authorization. Staff expressed discomfort with the medication being in the cart without a narcotic count sheet, leading to its transfer to the RN for return to the family. The medication was later found in the RN's belongings after her termination, and all pills were accounted for.
The facility failed to provide access to electronic medical records and maintain accurate documentation for residents. Issues included inaccessible records due to ownership changes, undocumented Narcan administration via an incorrect route, inaccurate mattress documentation, missing narcotic sign-out sheets, and incorrect transfer details. These deficiencies highlight significant lapses in record-keeping and verification processes.
Lack of Qualified Dietary Management in Facility
Penalty
Summary
The facility failed to employ a full-time clinically qualified nutrition professional to oversee food preparation and daily kitchen operations, affecting all residents. During an interview, the Dietary Director, who has been in charge of the kitchen for a year, was found not to be a Certified Dietary Manager. Instead, she held a State Food Safety Food Protection Manager Certification, which does not meet the required qualifications for her role. Additionally, the facility contracts with Health Care Services Group for kitchen and dining services. The district manager from this group, who supervises multiple facilities, also lacks the Certified Dietary Manager qualification, holding only a CPFS certificate. This deficiency was communicated to the nursing home administrator, highlighting the lack of appropriately qualified personnel in the dietary department.
Deficiencies in Dishwashing and Food Temperature Monitoring
Penalty
Summary
The facility staff failed to ensure the dishwashing machine was operating at the appropriate water temperature and sanitation levels. During an observation, it was noted that the Ecolab model ES-2000 dishwashing machine was not reaching the required minimum wash and rinse temperature of 120 degrees Fahrenheit. The temperature gauge on the machine was difficult to read and appeared foggy, and the dietary director acknowledged that the county inspector had previously indicated that the gauge needed to be fixed. Additionally, the dietary aide responsible for recording the water temperature and sanitation levels admitted to simply writing 120 on the log without actually checking the temperature gauge. The test strips used to check the chemical sanitation level were expired, and the dietary director was unsure of the proper procedure for testing the sanitation level. The facility also failed to ensure that food reached proper final internal cooking temperatures and that all hot foods were held at 135 degrees Fahrenheit or higher on the steam table. During a kitchen inspection, it was observed that the cooking temperature logbook did not have final internal temperatures recorded for several food items. The tray line was not paused to perform temperature checks, and the dietary director admitted to not being accustomed to working on the steam table side. On another occasion, the cook did not have time to record food temperatures because he was busy starting the tray line. The cooking temperature log showed overlapping cooking times with the active tray line, indicating that the cook was not taking food temperatures at the times documented. The district manager was involved in discussions regarding the deficiencies, but there was a lack of real-time documentation of food temperatures. The cooking temperature logs were incomplete, and there were no recorded temperatures for alternative menu items. The nursing home administrator was interviewed to review the identified kitchen concerns, highlighting the facility's failure to maintain proper food safety protocols.
Inaccessible Call Devices in Resident Rooms and Bathrooms
Penalty
Summary
The facility failed to ensure that call devices were accessible to residents, as observed during a recertification survey. In one instance, a resident was found sitting in a recliner with the call device plugged into the wall but not within reach. The resident confirmed that they sometimes had to yell for help when the call device was out of reach. An activity director who entered the room found the call device twisted under the bed and placed it within the resident's reach. A Geriatric Nursing Assistant confirmed that call bells are expected to be within residents' reach and answered promptly. Additionally, the surveyor observed that the shared bathroom between two rooms had a call device on the wall next to the toilet, but it lacked a pull cord, making it inaccessible if a resident fell. The Maintenance Director confirmed that all call devices in the facility were the same, without pull cords, and was unable to explain how a resident could reach the alarm in such a situation. The Nursing Home Administrator was informed of these deficiencies.
Investigation and Documentation Deficiencies in LTC Facility
Penalty
Summary
The facility failed to thoroughly investigate allegations of abuse and medication storage issues, as well as unusual incidents, involving several residents. In one case, a resident alleged that a black male GNA had hit them, but the investigation did not include statements from the days prior to the discovery of the bruise, despite the allegation indicating the incident occurred earlier. The GNA in question was no longer employed at the facility, and the resident's care documentation, which showed the GNA had provided care on specific dates, was not reviewed during the investigation. Another incident involved a resident who reported physical and verbal abuse by staff. The facility conducted assessments and interviews with other residents and staff, including the alleged perpetrator, but failed to obtain a statement from the resident themselves, despite their cognitive status being intact and them being able to provide a statement. The Nursing Home Administrator confirmed that the resident was alert and oriented, yet no separate statement was documented. Additionally, there was an issue with the handling of a controlled medication, Alprazolam, which was taken by a former employee. The facility's investigation lacked a written statement from the involved RN, and the in-service training provided to prevent similar incidents was not attended by all nursing staff. Another incident involved a rectal probe found on a resident, and the facility's in-service training to prevent such occurrences was not adequately communicated to all staff, as evidenced by a GNA's lack of understanding of the training's relevance to the incident.
Inadequate Pain Management for Residents
Penalty
Summary
The facility failed to provide appropriate pain management for three residents during a recertification survey. Resident #74 was administered Oxycodone, a controlled pain medication, on multiple occasions when their pain level was documented as zero, indicating no pain. The facility's staff, including a Registered Nurse and a Licensed Practical Nurse, stated that pain medications should not be given if the pain level is zero, and there should be a pain scale associated with medication orders. However, the review revealed that there was no pain scale to determine at what pain level each medication should be given. Resident #43's care plan indicated a problem with chronic pain, and the resident had orders for both non-narcotic and narcotic pain medications on an as-needed basis. However, neither medication order included pain scale parameters to guide administration. Interviews with nursing staff revealed that they typically use a pain scale to assess severity and decide on medication administration, but in the absence of parameters, they would contact the doctor. The facility's Nurse Practitioner confirmed that there should have been parameters for all pain medication orders. Resident #89 experienced a lack of pain management, as evidenced by missing documentation in the Medication Administration Records for several days. The resident, who had a perfect BIMS score indicating intact cognitive function, called 911 for medical assistance due to pain, but the facility canceled the call. The resident was later observed crying in pain and was transferred to the hospital. A progress note indicated the resident complained of stomach pain, but there was no further evaluation or documentation of the pain. The Nursing Home Administrator acknowledged the concern regarding the lack of pain management for this resident.
Deficiency in Food Temperature and Quality
Penalty
Summary
The facility failed to serve food at a palatable temperature, as evidenced by multiple resident complaints and observations during a survey. Residents reported that the food was often cold, bland, and unappetizing, with some unaware of alternative menu options. Specific complaints included food being dry, lacking seasoning, and not being served with expected items like milk. The resident council also expressed concerns about the food being cold and not tasting good. During a lunch meal service observation, it was noted that the kitchen staff did not perform real-time temperature checks on the food items. The cooking temperature logbook lacked final internal temperature recordings for several items, and the tray line was not paused to check temperatures. A test tray revealed significant temperature drops from the kitchen to the resident, with food items being served at temperatures well below the initial cooking temperatures. Additionally, the kitchen ran out of certain food items, causing delays in meal service.
Failure to Monitor Resident's Behavioral Health
Penalty
Summary
The facility failed to provide necessary behavioral health monitoring for a resident, leading to a deficiency. During a recertification survey, it was found that a resident with a known history of sexually inappropriate behavior was not monitored for such behavior in June 2023, despite staff awareness of the issue. An incident occurred on June 7, 2023, where the resident was witnessed engaging in inappropriate physical contact with another resident. Although clinical notes described the resident's behavior, there was no documentation of behavior monitoring for June 2023. The order to monitor the resident's sexually inappropriate behavior was only placed in July 2023, after the incident had occurred. The deficiency was confirmed through interviews and record reviews, highlighting a lapse in the facility's behavioral health care services.
Resident Meal Service Delay
Penalty
Summary
The facility failed to treat residents in a dignified manner during a lunch meal service in the Potomac dining room. On the observed date, a resident was left without a meal while their tablemates were served and began eating. The lunch cart was present in the dining room, and staff members, including a social worker and a unit manager, were distributing meals. However, the resident in question was not served until 20 minutes after the meal service began. The unit manager was occupied assisting another resident at the same table, and it was only after a request from the unit manager that the social worker retrieved and served the meal to the resident, resulting in a delay and a lack of dignity in the meal service process.
Failure to Ensure Advance Directives Offered and Documented
Penalty
Summary
The facility failed to ensure that residents were offered the opportunity to develop an advance directive, as evidenced by the cases of two residents during a recertification survey. For one resident, the clinical record review revealed that while a MOLST form was present, there was no documented evidence that the resident or their representative was given the opportunity to formulate an advance directive. Interviews with the Director of Nursing and a Social Worker confirmed that the resident did not have an advance directive on file, and the facility's policy required that such documents be placed on the chart upon admission if available. In the case of another resident, the initial assessment form indicated that an advance directive was offered and that the resident had one, but the document could not be found in the medical records. The Social Worker confirmed that the process involved offering advance directives upon admission and revisiting them during quarterly assessments. Despite this, only the MOLST form and physician certification were located, and the advance directive was not present in the records. The Director of Nursing was informed of the issue and noted that the resident's relatives had the advance directive.
Facility Fails to Maintain Safe and Homelike Environment
Penalty
Summary
The facility failed to maintain a safe, clean, and homelike environment for its residents, as evidenced by the condition of a resident's bedroom and a shared bathroom. In the resident's room, a nightstand was observed to be in disrepair, with the plastic veneer peeling off and the bottom drawer hanging out. Additionally, the wall at the head of the resident's bed had spackled areas due to staff moving the bed during care provision. The resident confirmed that the nightstand had been in this condition for some time, and the maintenance director acknowledged the issue but had not yet addressed it. In the shared bathroom between two rooms, a section of the floor tile was missing, exposing the concrete subflooring. This condition had persisted for six months following a pipe repair, with no subsequent repair of the flooring. The maintenance director was aware of the issue but did not provide an explanation for the delay in repairs. The nursing home administrator was informed of both the disrepair in the resident's room and the missing flooring in the shared bathroom but did not offer any information or explanation for these deficiencies.
Failure to Document and Prepare Resident for Hospital Transfer
Penalty
Summary
The facility failed to properly orient, prepare, and document a resident's transfer to the hospital. This deficiency was identified for one resident who had experienced a fall. The medical record review revealed an einteract SBAR Summary note indicating a recommendation for hospital transfer following the fall. However, the documentation lacked details on interventions implemented before the transfer, what the resident was informed about, and whether the resident understood the transfer and its reasons. An interview with the unit manager confirmed that the nursing progress notes did not specify if the fall was observed or the location of the fall. The unit manager acknowledged the poor documentation by a new nurse and was unaware of the regulatory requirements for documenting a facility-initiated resident transfer to the hospital.
Inaccurate MDS Discharge Coding
Penalty
Summary
The facility failed to accurately code the discharge status of a resident on the Minimum Data Set (MDS) assessment. During an annual survey, it was discovered that the discharge status for a resident, who was discharged home with family, was incorrectly coded as a discharge to a short-term general hospital. This discrepancy was identified through a review of the resident's electronic medical records and a progress note written by a registered nurse, which clearly stated that the resident was discharged home with family. The Nursing Home Administrator confirmed the error during an interview, acknowledging that the MDS coordinator might have mistakenly coded the discharge status.
Failure to Provide Baseline Care Plan
Penalty
Summary
The facility failed to provide a baseline care plan for a resident within 48 hours of admission, as required. During a clinical record review, it was found that the resident's record lacked documentation of a baseline care plan. When the surveyor requested a copy of the baseline care plan, the Business Office Manager and the MDS nurse were unable to provide evidence that the care plan was given to the resident within the specified timeframe. Although a care plan meeting was held, the documentation did not include confirmation that the resident or their representative received the baseline care plan and medication list.
Failure to Update and Evaluate Resident Care Plans
Penalty
Summary
The facility failed to review and revise resident care plans after each assessment or as resident care needs changed over time. This deficiency was identified during a recertification survey for two residents. Resident #82, who was initially assessed for dehydration and diarrhea related to antibiotic use, had a care plan that included administering IV fluids. However, the resident was no longer receiving IV fluids or antibiotics, and the care plan had not been updated to reflect these changes. The MDS nurse acknowledged that the care plan contained inactive problems and had not been revised, which could lead to confusion for nurses unfamiliar with the resident's current care needs. Similarly, Resident #76, diagnosed with unspecified dementia, had a care plan that had not been evaluated or updated since its initiation. The care plan included goals for the resident to communicate basic needs and develop coping skills for cognitive decline, but there was no documentation of progress or new interventions. Interviews with staff revealed a lack of clarity on how care plan effectiveness was assessed and documented, with no evidence of evaluations or revisions being made. The MDS assessor confirmed that the revision date on the care plan was merely a change of the quarterly target date, with no additional documentation of care plan evaluations.
Failure to Provide Pressure-Relieving Mattress for Resident with Pressure Ulcers
Penalty
Summary
The facility failed to provide appropriate care for a resident with pressure ulcers, as observed during a recertification survey. The resident, identified as having a stage IV sacral wound, was found to be on a regular mattress without any pressure-relieving device. Despite the resident's care plan indicating the presence of multiple pressure ulcers, it did not include an intervention for a pressure-relieving mattress. Interviews with the Licensed Practical Nurse (LPN) and the Unit Manager confirmed the absence of a pressure-relieving mattress, even though the facility was aware of the resident's condition prior to admission. Further interviews with the facility's wound care nurse and the Unit Manager reiterated that a pressure-relieving mattress should have been provided to the resident. However, no such device was observed on the resident's bed during subsequent observations. The Nursing Home Administrator was informed of the issue, but no additional information was provided by the end of the survey.
Failure to Conduct and Document Yearly GNA Performance Reviews
Penalty
Summary
The facility failed to conduct and document yearly performance reviews for its Geriatric Nursing Assistants (GNAs) as required. During a survey, it was found that three GNAs, who were randomly selected for review, did not have performance evaluations documented for the years 2020, 2021, and 2022. GNA #38 and #39 were hired in July 2020, and GNA #40 had been employed for over thirty years. Despite the facility's claim that evaluations were conducted annually, only one performance evaluation was recorded for each of these GNAs in 2023. Interviews with the Nursing Home Administrator (NHA) and a registered nurse (RN #6) revealed that the facility's practice was to evaluate GNAs' skills annually through observation and feedback from nurses. However, the business office manager, who was responsible for assessing data from the previous system, confirmed that no yearly performance reviews were available for the years in question. The NHA acknowledged the surveyor's concerns about the lack of documented evaluations, validating the deficiency in the facility's record-keeping practices.
Failure to Document Food Preferences and Provide Prescribed Dietary Supplements
Penalty
Summary
The facility failed to document a resident's food preferences and provide supplemental dietary sandwiches as per the resident's dietary order. During an interview, a resident expressed dissatisfaction with the food, noting a lack of seasoning and the presence of disliked items such as green peas. The resident was unaware of alternative diet options. A review of the resident's meal ticket and medical records revealed no documentation of food likes or dislikes, despite sections designated for this information on dietary profile assessments. Interviews with staff indicated that while a food preference form exists, it is not uploaded into the resident's medical records. Additionally, the facility did not adhere to a dietary order for supplemental sandwiches due to dysphagia, as documented by a previous dietitian and signed by the attending physician. The resident reported not receiving the prescribed sandwiches, and the unit manager confirmed there was no documentation in the chart to indicate the sandwiches were being provided. This oversight was only addressed after surveyor intervention, with new orders being written to ensure the resident received the necessary nutritional supplements.
Infection Control Deficiencies in Pillow and Laundry Handling
Penalty
Summary
The facility failed to utilize appropriate infection control processes in two specific instances. Firstly, a surveyor observed a resident's personal pillows lying on the bare floor in their room. A Geriatric Nursing Assistant (GNA) then picked up the pillows from the floor and placed them on the clean bed without changing the pillowcases, despite acknowledging that the floor was dirty and could be contaminated. Interviews with other GNAs confirmed that the correct procedure would have been to replace the pillowcases before placing the pillows back on the bed, as the floor is considered dirty and could harbor germs. Secondly, during a tour of the facility's laundry room, it was observed that clean items, such as waffle boots, were stored in the same room as dirty laundry. A laundry technician explained that there was no other place to store the clean items, despite the room being designated for dirty laundry. The environmental supervisor confirmed the process of handling dirty laundry and acknowledged the concern about storing clean items in the dirty laundry room.
Deficiency in Vaccine Record and Consent Management
Penalty
Summary
The report identifies a deficiency in the management of vaccine records and consent at a healthcare facility. Two residents were reviewed for their immunization status and it was found that there was a lack of documentation for both the consent and administration of flu and pneumococcal vaccines. One resident had their last flu and pneumococcal vaccines administered in 2022 and 2021, respectively, but there was no record of consent for these vaccines. Another resident refused the flu vaccine but consented to and received the pneumococcal vaccine, yet there was no documentation showing that they were offered or declined both vaccines in the current year. The infection preventionist was informed of the missing consent forms and vaccine administration records for both residents, but was unable to provide current documentation. This issue was escalated to the Nursing Home Administrator, indicating a concern over the facility's record-keeping and consent processes for vaccinations. The lack of proper documentation and consent forms constitutes a deficiency in the facility's ability to ensure that residents are fully informed and protected through vaccination, as required by health regulations.
Failure to Maintain Safe Bed Rails
Penalty
Summary
The facility failed to ensure the safe maintenance of bed rails for a resident during a recertification survey. An observation revealed that the resident's bed had quarter side rails that could be easily pulled away from the bed, allowing space between the rails, mattress, and bed frame. The resident's clinical record indicated an order for 1/4 top bilateral side rails as enablers. The Maintenance Director, responsible for daily visual inspections, acknowledged the looseness of the side rails and admitted to only performing spot checks without maintaining a log of inspections. The Nursing Home Administrator was informed of the issue, but no documentation of bed rail inspections was provided by the end of the survey.
Deficiencies in Resident Care Plans and Risk Management
Penalty
Summary
The facility staff failed to develop and initiate comprehensive person-centered care plans for residents, as evidenced by deficiencies found during a recertification survey. For one resident, the care plan did not accurately reflect the resident's current code status. The resident's Medical Orders for Life-Sustaining Treatment (MOLST) and face sheet indicated a Do Not Resuscitate/Do Not Intubate (DNR/DNI) status, but the care plan incorrectly listed the resident as Full Code. This discrepancy was confirmed by the Director of Nursing (DON) and Nursing Home Administrator (NHA), who acknowledged that the care plan was not comprehensive or resident-centered. Another resident was admitted with a high fall risk score, but the care plan did not address this risk until after the resident experienced a fall. The resident's medical records showed a consistent high fall risk score, yet the care plan lacked goals and interventions for fall prevention. The DON confirmed that the admitting nurse failed to initiate a fall risk care plan upon admission, and the oversight was not corrected until after the fall occurred. Interviews with facility staff, including registered nurses and the social worker, revealed inconsistencies in the documentation and understanding of residents' care plans and code statuses. The staff acknowledged the discrepancies and confirmed that the care plans were not adequately addressing the residents' needs, leading to the deficiencies identified during the survey.
Deficiencies in Resident Assessment and Blood Sugar Monitoring
Penalty
Summary
The facility failed to properly assess and monitor two residents, leading to deficiencies in care. For Resident #347, a rectal probe wire was found attached to the sacral dressing, which was not documented or identified during the initial assessment upon readmission. Staff members, including a Geriatric Nursing Aide and a wound nurse, did not recognize or document the presence of the probe, and the Nursing Home Administrator was unable to explain why the probe was not detected earlier. For Resident #24, the facility did not consistently monitor blood sugar levels despite the resident receiving long-acting insulin at bedtime. The medical records showed that blood sugar levels were not documented routinely, and there were no active orders for blood sugar monitoring. Interviews with staff, including an LPN and the Director of Nursing, confirmed that blood sugars were not checked as expected before insulin administration, and the Medical Director noted that blood sugars should be monitored in the morning. The surveyor's review revealed that previous orders for blood sugar monitoring and related lab tests had been discontinued without new orders being placed upon the resident's readmission. A Nurse Practitioner acknowledged the oversight in re-entering orders and indicated that new orders would be placed, highlighting a lapse in the continuity of care for Resident #24.
Deficiencies in Urinary Catheter Care and Documentation
Penalty
Summary
The facility failed to provide appropriate treatment and care for residents with urinary catheters, as evidenced by deficiencies found during a recertification survey. Resident #19, who had a urinary catheter for 1-2 years, did not have comprehensive orders for catheter care in their Treatment Administration Record (TAR) for several months. The orders were inconsistent and lacked specific instructions for catheter management, which is crucial for preventing urinary tract infections (UTIs). Interviews with staff revealed a lack of clarity and consistency in documenting and following catheter care orders. Resident #93, who had a suprapubic catheter due to obstructive uropathy, also experienced deficiencies in care. The resident's medical records showed orders for catheter care, including cleaning and flushing the catheter, but there was a lack of documentation for catheter output for significant periods in March and April 2022. Despite low catheter output being reported by nurse aides, there was no documentation or intervention recorded by the nursing staff to address the issue, as confirmed by interviews with registered nurses and the Nursing Home Administration. The deficiencies highlight a failure in the facility's processes for managing and documenting catheter care, leading to inadequate care for residents with urinary catheters. The lack of comprehensive orders and documentation for catheter management poses a risk for complications such as UTIs, as evidenced by the survey findings for Residents #19 and #93.
Failure to Obtain Physician's Diet Order and Notify Physician of Resident's Nutritional Intake
Penalty
Summary
The nursing staff at the facility failed to obtain a physician's order for a specific diet for a resident who was admitted for respite care with a diagnosis of nutritional deficiency. The resident, who had a history of malignant neoplasm of the prostate and blindness, was previously receiving hospice services and had been sent to the hospital following a choking episode and UTI. Upon admission, the resident's orders included meal consumption tasks for breakfast, lunch, and dinner, but there was no specific diet ordered by a physician. The nursing staff documented meal intake percentages, revealing that the resident often consumed 0-25% of meals or did not eat at all, yet failed to notify the resident's physician of these findings. Additionally, the nursing staff did not initiate a nutritional care plan to address the resident's history of choking. The care plan for nutritional status noted that the resident was at nutritional risk, consuming less than 75% of food and/or fluids at most meals, with a goal for the resident to remain comfortable. However, the nursing staff did not report signs of dehydration or follow the physician's order to not obtain any weights on the resident. The facility administrator was informed of these findings during the survey process, but no questions were raised regarding the deficiencies identified.
Narcotic Documentation Discrepancies
Penalty
Summary
The facility staff failed to ensure that narcotics removed from the residents' supply were properly documented as administered to the residents. This deficiency was identified during the annual survey for two residents who were reviewed for pain management. For one resident, discrepancies were found between the narcotic sign-out sheet and the Medication Administration Record (MAR), with instances where the narcotic medication was documented on one record but not the other. Interviews with staff revealed that the facility's process required narcotic medications to be documented on both the narcotic sign-out sheets and the MAR simultaneously, which was not consistently followed. In another case, a resident's MAR indicated that scheduled doses of acetaminophen-codeine were administered, but these doses were not recorded on the controlled drug record. Additionally, there was a discrepancy on a specific date where the medication was removed for administration in the morning, but the MAR documented it as given in the evening, with no corresponding record on the controlled drug record. Interviews with nursing staff confirmed that controlled medication administration should be documented on both the MAR and the controlled drug records. The Nursing Home Administrator validated these concerns when they were shared by the surveyor.
Improper Storage and Handling of Resident's Medication
Penalty
Summary
The facility failed to properly store a resident's medication, specifically Alprazolam, which is a psychotropic medication used for anxiety and panic. This deficiency was identified during an annual survey when it was discovered that the medication, brought from home upon the resident's admission, was taken by a former employee, RN #46. The issue came to light when staff members expressed discomfort with the medication being in the cart without a narcotic count sheet. Staff #47 and #48 provided written statements indicating that the medication was given to RN #46 to return to the family upon the resident's discharge. However, the medication was later found in RN #46's belongings after her termination. During interviews, it was confirmed that the facility staff could not locate the Alprazolam and had to contact RN #46, who admitted to accidentally taking the medication but assured that all pills were accounted for. The Nursing Home Administrator validated the surveyor's concerns about the unauthorized removal of the medication by RN #46, highlighting a lapse in the facility's medication storage and handling procedures.
Deficiencies in Medical Record Accessibility and Documentation
Penalty
Summary
The facility failed to provide access to electronic medical records and maintain complete and accurate medical records for several residents. During a review of a complaint, the surveyor was initially able to access a resident's closed medical records but later encountered an error message preventing further access. The business office manager was unable to locate any paper records for the resident, and it was revealed that access issues were due to a change in facility ownership. Eventually, a new username and password were provided to the surveyor, but the delay highlighted deficiencies in record accessibility. In another instance, the facility did not document the administration of Narcan to a resident who was found unresponsive. The medication was administered via a nasal route, contrary to the intramuscular route specified in the resident's orders. The medication administration record (MAR) lacked documentation of the Narcan administration, and the unit manager confirmed that the order was not updated to reflect the actual route used. Additionally, the resident's treatment administration record (TAR) inaccurately indicated the use of an air mattress, despite the resident being on a regular mattress, which was confirmed by multiple staff members. Further deficiencies were noted in the documentation of narcotic sign-out sheets and transfer forms. A portion of a narcotic sign-out sheet was missing from the medical records, and the director of nursing confirmed that no audits were conducted on these sheets. Additionally, a progress note inaccurately documented a resident's status while they were not in the facility, and a transfer form contained incorrect transfer details. These inaccuracies were acknowledged by the nursing home administrator, indicating a lack of proper record-keeping and verification processes.
Latest citations in Maryland
The facility did not ensure that its Infection Preventionist (IP) met required qualifications for managing the Infection Prevention and Control Program. The DON reported serving as the IP but acknowledged lacking the specialized infection control training required for the role, and confirmed that no other staff member was currently qualified. Records showed that the previously qualified IP left several months earlier, and the Administrator and DON confirmed they were still seeking a replacement, leaving the infection control program without a properly trained leader.
Staff failed to consistently secure medications and medical supplies across three units, including an oxygen tank left on the floor behind a resident’s bed without a supporting device, a treatment cart with Collagenase Santyl cream left on top while two residents in power wheelchairs passed by, an unattended and unlocked treatment cart at a nursing station, and another treatment cart with Diclofenac gel and dressings left on top, indicating repeated lapses in maintaining locked and secure storage for drugs, biologicals, and related supplies.
The facility failed to provide sufficient dietitian coverage and timely nutritional assessments for several residents with significant dietary needs. A resident admitted for diabetic management with a high A1C was placed on a regular diet instead of the recommended carb-controlled diet and had only one weight taken in the first two weeks, with no dietitian review of the record. Another resident with prior significant weight loss had no documented dietitian follow-up despite continued weight loss, and a resident admitted with severe protein-calorie malnutrition experienced further significant weight loss without any dietitian assessment. The dietitian reported working limited hours and prioritizing certain high-risk cases, resulting in delayed or missed evaluations for new admissions and residents with ongoing nutritional concerns.
The facility failed to maintain adequate linen and incontinence supplies and did not keep resident care areas in good repair, resulting in delays and alterations in incontinence care and substandard environmental conditions. Staff reported that towels and washcloths were used instead of wipes and then discarded due to heavy soiling, and that linen deliveries to units were late, leaving residents waiting for care. Observations showed very limited numbers of clean washcloths and other linens on units and in the laundry, with no stock of disposable wipes or backup washcloth supply despite repeated reports to housekeeping. Additional observations revealed recliner chairs blocking a dining-area handwashing sink and kitchenette, multiple resident and shared bathrooms with unfinished spackle, chipped paint, musty odors, black substances near showers, missing threshold molding, exposed cracks and nails, and eroded, rusted baseboard heaters. Hallway handrails on both units were worn, chipped, and splintered, and a shower room contained fecal odors, dried brown stains on the toilet, and deteriorated fixtures, all contributing to a failure to provide a safe, clean, and homelike environment.
Facility staff did not thoroughly investigate two separate abuse allegations involving a resident and an injury of unknown origin involving another resident. In both cases, investigations focused on the directly affected resident and included staff interviews, but there were no interviews of other residents on the unit or documented assessments of those residents for signs of abuse or injuries of unknown origin, including residents unable to communicate due to cognitive status.
Two residents who were dependent on staff for oral care, including one with a tracheostomy, were observed with thick, white or milky substances coating their mouths and teeth, indicating inadequate oral hygiene. One resident communicated that staff did not brush their teeth and that staff "need to." In another case, despite oral care supplies being present in the room, the resident’s mouth and teeth remained unclean on multiple observations, with a thick milky substance caking the teeth and stringing between them when the resident tried to open their mouth. These findings showed that staff did not consistently provide oral care to residents who relied on them for this ADL.
Staff failed to maintain complete and accurate medical records for multiple residents, including missing and inconsistent documentation of wound care, delayed pain assessment after discovery of an injury of unknown origin in a cognitively impaired resident, and inaccurate recording of a PPD test result that was documented as negative despite no evidence the injection was administered and no supporting nurse’s note. Residents reported not receiving certain treatments, while MAR entries either lacked signatures for completion or contained conflicting information about whether care was provided.
Surveyors found that the facility failed to consistently implement and communicate correct transmission-based precautions and PPE use. One resident with a Foley catheter related to wounds had no precaution signage posted, while another resident in a double room had a contact precautions sign at the door, yet the NP entered without PPE and the GNA provided high-contact care wearing only gloves. Staff in that room stated the resident was not on contact precautions and later reversed the sign to show no PPE requirement. Therapy staff reported they rely solely on posted signs to determine PPE, and surveyors identified broader issues with inaccurate signage and staff awareness of which residents required contact precautions.
Surveyors found that MDS assessments were inaccurately coded for two residents. In one case, a resident sustained a femoral neck fracture after a fall, but the subsequent significant change MDS did not code the fall as a major injury and failed to capture prn Tylenol use documented on the MAR within the look-back period. In the other case, a quarterly MDS indicated opioid use for a resident, but the MAR for the same period showed no prescribed opioid, indicating incorrect coding of high-risk drug classes.
A resident who had recently been admitted and experienced a fall received multiple doses of the narcotic analgesic Tramadol, but the facility failed to accurately document all administered doses on the Medication Administration Record (MAR). Review showed only one Tramadol dose recorded on the MAR, while the Controlled Drug Receipt/Record/Disposition Form on the med cart reflected three doses given over two days. In interview, the DON stated staff are expected to document narcotic administration on the MAR and confirmed that two administered doses were not recorded there, resulting in an incomplete and inaccurate medical record.
Unqualified Infection Preventionist Overseeing Infection Control Program
Penalty
Summary
The facility failed to ensure that its designated Infection Preventionist (IP) met the mandatory qualifications for overseeing the Infection Prevention and Control Program. During an interview on 3/24/26 at 10:00 AM, the DON confirmed that she/he was serving as the facility’s IP but had not completed the specialized training in infection control required for the position. The DON further stated that no other staff member currently met the qualifications to serve as IP. Record review showed that the previously qualified IP left the facility in October 2025, and as of the survey date, the position remained unfilled by a qualified individual. At 1:30 PM on the same day, the Administrator and DON confirmed they were still in the process of finding a qualified IP for the facility, leaving the Infection Prevention and Control Program without a properly trained and qualified leader. No specific residents, medical histories, or clinical conditions were described in relation to this deficiency.
Unsecured Medications, Treatment Carts, and Oxygen Equipment
Penalty
Summary
Facility staff failed to ensure that drugs, biologicals, and related medical supplies were securely stored and properly maintained on multiple units. On one unit, an oxygen tank assigned to a resident was observed sitting on the floor behind the resident’s bed without any supporting device. On another unit, a treatment cart was observed with a tube of Collagenase Santyl cream labeled for a specific resident left on top of the cart, while residents in power wheelchairs passed by and staff were present at the nursing station. These observations showed that medications and oxygen equipment were not consistently secured as required. Further observations on additional units revealed an unattended and unlocked treatment cart at a nursing station, and on a separate occasion, a treatment cart with Diclofenac gel labeled for a resident left on top along with multiple packs of dressings. These incidents occurred across three units and on more than one date, demonstrating repeated failures to keep medications and treatment supplies in locked compartments or otherwise secured from unauthorized access.
Insufficient Dietitian Coverage and Delayed Nutritional Assessments
Penalty
Summary
The deficiency involves the facility’s failure to employ sufficient food and nutrition staff, including adequate dietitian coverage, to ensure timely assessment and appropriate diets for residents with significant nutritional and diabetic needs. A resident admitted over two weeks earlier with multiple comorbidities and an A1C of 11.5% had a hospital discharge recommendation for a carbohydrate-controlled diet, but was placed on a regular diet at admission with no acknowledgment of the recommended diet until one week later, when the resident requested larger portions. As of the survey date, the dietitian had not yet seen or reviewed this resident’s medical record, and the resident reported not having seen a dietitian and being very frustrated with the meals. During the first two weeks after admission, only one weight was obtained for this resident, despite physician notes stating the resident’s weight was “stable.” Further review of other residents showed additional failures in timely dietitian assessment and follow-up. One resident, readmitted in January and previously seen by the dietitian in September for a 6.4 lb weight loss over 30 days, had no documented follow-up despite continued weight loss totaling 22 lbs since the last dietitian review. Another resident admitted at the end of February with severe protein-calorie malnutrition had not been seen by the dietitian after about a month in the facility, despite a documented 14 lb (7%) weight loss over two weeks. The dietitian reported working only 12 hours per week at the facility and stated that she must prioritize which residents to see, focusing first on residents with tube feedings and those identified in risk meetings, resulting in delayed or absent assessments for new admissions and residents with ongoing weight loss and malnutrition diagnoses.
Linen Shortages and Poor Environmental Maintenance Compromise Resident Care and Comfort
Penalty
Summary
The deficiency involves the facility’s failure to maintain an adequate supply of clean linens and appropriate incontinence wipes, resulting in delays and alterations in residents’ incontinence care, as well as the use of towels and washcloths in place of disposable wipes. During the initial tour, the surveyor observed that the linen supply on one nursing unit hallway was low. Complaint reviews included concerns about delays in incontinence care and bed linens not being changed regularly, with residents left without clean bedding. A complainant reported that there was not enough clean linen available for residents. Staff interviews confirmed that towels, sheets, and washcloths were being used to wipe residents for incontinence care due to the absence of wipes, and that many of these linens were being thrown away when soiled. Staff also reported a shortage of linen, that linen deliveries to the units were late, and that residents who preferred to get up before breakfast had to wait for care when linen was delayed. Further observations showed that the clean supply room contained no disposable wipes or cloths for incontinence care, and a resident reported that staff did not use wipes, that the resident had to purchase their own, and that heavily soiled towels or washcloths were discarded. A tour of all nursing unit linen carts and closets revealed only six clean washcloths and limited supplies of towels, gowns, and bed linens. In the laundry room, only three washcloths were present, and the laundry assistant stated that there were only three washcloths available for each nursing unit that morning, that the facility was short on linen supply, and that these concerns had been repeatedly reported to the Director of Housekeeping over the preceding month and again that morning. The laundry assistant confirmed there was no additional laundry in process. The DON stated that wipe squares should be used for incontinence care, but no such wipes were found in the clean medical supply room, and no backup supply of washcloths was present in the emergency linen supply. The Director of Housekeeping confirmed there was no backup supply of washcloths. The deficiency also includes environmental and maintenance issues affecting resident bathrooms, handrails, and common areas. In the main dining area, a recliner chair was observed positioned directly in front of the handwashing sink, and two recliner chairs were stored in front of the nutrition area kitchenette. Multiple resident bathrooms and shared bathrooms were repeatedly observed over several days with unfinished spackle on walls that needed resurfacing and painting, chipped paint around sinks, uneven boards nailed to walls under sinks that appeared to partially cover holes, musty odors, black substances between shower bases and walls, missing threshold transition molding exposing cracks, missing tiles, and a nail, as well as eroded and chipped paint on baseboard heaters with exposed dark brown metal and rust-like material. Hallway handrails on both nursing units were observed to be worn, with chips, splintering, holes, and areas where the wood finish had worn off. A shower room was observed with a foul fecal odor, dried brown stains on the back of the toilet seat and in the toilet bowl, and a baseboard heater with eroded, chipped paint and rust-like material, along with chipped paint on the handrail. These conditions were acknowledged by the Director of Maintenance and other leadership, and some areas were noted to be in the process of renovation, but the observed deficiencies remained present during the survey period. Overall, the facility did not maintain a safe, clean, comfortable, and homelike environment in good repair across both nursing units and the dining area. The lack of adequate linen and incontinence supplies, combined with the poor condition of resident bathrooms, handrails, and certain common areas, constituted the basis for the cited deficiency. The observations and staff and resident reports consistently described shortages of essential hygiene supplies, delayed care related to linen availability, and multiple unresolved environmental and maintenance issues in resident care areas and shared spaces.
Failure to Thoroughly Investigate Abuse Allegations and Injuries of Unknown Origin
Penalty
Summary
Facility staff failed to thoroughly investigate allegations of potential abuse involving one resident and an injury of unknown origin involving another resident. For one resident, there were two separate allegations of abuse occurring on different days in early February. The facility’s investigation packets included interviews with staff who cared for or were scheduled to work with this resident on the days of the alleged incidents, and the investigations focused solely on this resident. However, there were no interviews conducted with other residents on the unit to inquire about abusive or neglectful treatment by the staff who were working during the times of the allegations. The surveyors noted that, although the allegations were not validated, there was no documentation that other residents were interviewed, if able, or assessed for signs or symptoms of injury. In a separate incident, another resident was identified on March 4 with a new bruise on the right eye, documented as a change in condition at 4:09 AM. This resident had a BIMS score of 99, indicating the resident was unable to complete an interview and therefore could not report how the injury occurred. The facility’s investigation identified a potential cause of the injury but did not reach a definitive resolution. Additionally, there were no interviews of other residents on the unit regarding possible abuse, nor were there documented assessments of other residents for injuries of unknown origin, particularly for those unable to speak for themselves, as in this resident’s case.
Failure to Provide Oral Care to Dependent Residents
Penalty
Summary
The deficiency involves the facility’s failure to provide oral care to residents who were dependent on staff for activities of daily living, specifically oral hygiene. One resident with a tracheostomy was observed with a thick, sticky white substance in the mouth and was noted to intermittently chew on nearby bedding. This resident made good eye contact and, when asked if staff brushed their teeth, shook their head no and mouthed that staff “need to.” According to the resident’s Minimum Data Set (MDS) dated 2/11/26, the resident was dependent on staff for oral care. Another resident, also dependent on staff for oral care per the 3/11/26 MDS, was observed sitting propped up in bed and able to respond with smiles. During the initial observation, the inside of this resident’s lips and upper and lower teeth had a thick, clear, white milky substance visible when the resident tried to open their mouth to smile. Oral care supplies were present in the nightstand, but the resident’s mouth and teeth were not clean. On a subsequent observation with the DON, NHA, and Corporate VP of clinical services, the same resident again had a thick, clear, milky substance between the lips and caking the teeth, which would string between the teeth when the resident attempted to open their mouth, demonstrating a lack of consistent oral care for residents dependent on staff for this ADL.
Incomplete and Inaccurate Medical Record Documentation for Treatments and Assessments
Penalty
Summary
Facility staff failed to maintain complete and accurate medical records and documentation for multiple residents. For one resident with wound care needs, review of the MAR showed that wound care and related treatments were signed as completed on the dates initially reported, despite the resident’s ongoing complaints that wound dressings were not being changed. When additional dates were reviewed, there were missing staff signatures for wound care on two specific dates, as well as three instances where application of A&D ointment to the resident’s feet was not signed off out of 24 days reviewed. Another resident with severe cognitive impairment, as evidenced by a BIMS score of 00, was found to have an injury of unknown origin (a bruise on the left hand). Documentation showed that a change in condition was initiated late in the morning, but a formal pain evaluation was not initiated and completed until that night, and the resident was unable to explain how the injury occurred or verbalize pain using a standard pain scale. For a third resident, documentation related to the admission PPD test was inconsistent and incomplete. The MAR contained an entry indicating “9” for the administration date, meaning “see nurse’s note,” but there was no corresponding nurse’s note. Despite the absence of a signed administration of the PPD injection, staff documented the PPD result as “negative” on the scheduled read date. The resident reported never receiving the PPD injection, and the DON confirmed that the facility had been out of PPD solution at the time, so the test would not have been administered. These findings demonstrate failures in accurate documentation of treatments and assessments, including wound care, pain assessment, and TB screening, as well as missing or incomplete supporting notes in the medical record.
Failure to Implement and Communicate Correct Transmission-Based Precautions
Penalty
Summary
Surveyors identified a deficiency in the facility’s infection prevention and control program related to inconsistent and incorrect implementation of transmission-based precautions and PPE use. During a complaint investigation focused on residents on transmission-based precautions, one resident with a visible Foley catheter was observed in the room with physical therapy, but there were no signs posted indicating any need for PPE, despite the resident being a new admission with a Foley catheter placed related to wounds. In another double-occupancy room, a contact precautions sign was posted at the doorway, but the nurse practitioner was in the room on a personal phone with no PPE, and the assigned GNA was repositioning the resident in bed while wearing only gloves. When questioned, the NP, RN, and GNA all stated that the resident in the room was not on contact precautions, and the GNA reported that signs were hanging at all doors and that this particular resident’s sign was “just wrong.” The surveyor observed the GNA later return to the room and turn the sign around to indicate no PPE requirement. Subsequent interviews revealed that therapy staff relied on posted signage to determine PPE use and that if the sign was wrong, the PPE used would be wrong. Overall, surveyors found problems with signage accuracy and staff awareness of which residents required contact precautions, as well as observed failures to follow appropriate PPE use for residents who should have been on contact precautions.
Inaccurate MDS Coding for Falls, Pain Management, and High-Risk Medications
Penalty
Summary
Facility staff failed to ensure Minimum Data Set (MDS) assessments were accurately coded for two residents reviewed during a complaint survey. For one resident, a facility-reported incident showed that the resident was found seated on the floor beside the bed and was diagnosed with a non-displaced femoral neck impaction fracture of the left hip following an x-ray. Despite this fall with a major injury, the subsequent significant change MDS dated 11/4/25 did not code the fall with major injury in Section J1900C. Review of the resident’s Medication Administration Records for October and November 2025 showed administration of Tylenol on 10/31/25 at 9:30 PM, which fell within the 5-day look-back period for the MDS, but Section J0100 (prn pain) of the same significant change MDS did not capture the use of Tylenol. For another resident, review of a quarterly MDS with an assessment reference date of 10/15/25 showed that Section N0415 (High-Risk Drug Classes) documented the use of an opioid medication. However, review of the resident’s October 2025 Medication Administration Record did not show that the resident had been prescribed an opioid during that period. In both cases, MDS staff later confirmed that these were errors in MDS coding, demonstrating that the assessments did not accurately reflect the residents’ clinical status and medication use as documented in their medical records.
Incomplete Documentation of Narcotic Administration on MAR
Penalty
Summary
The facility failed to maintain complete and accurate medical records in accordance with accepted professional standards for one resident receiving narcotic medication. The resident, admitted in March 2026, had a fall on 3/6/26 and was sent to the hospital on 3/9/26. Review of the March 2026 Medication Administration Record (MAR) showed documentation of a single 25 mg dose of Tramadol administered on 3/8/26 at 9:23 AM. However, review of the resident’s Controlled Drug Receipt/Record/Disposition Form, kept on the nurse’s medication cart and not in the medical record, showed that Tramadol 25 mg was administered three times between 3/8/26 and 3/9/26: at 11:00 AM and 9:00 PM on 3/8/26, and at 9:00 AM on 3/9/26. In interview, the DON stated that staff are expected to document narcotic administration on the MAR and confirmed that only one of the three Tramadol doses reflected on the controlled drug record was documented on the resident’s MAR. This discrepancy between the controlled substance record and the MAR, with missing documentation of two administered doses of Tramadol on the official medical record, constituted the failure to maintain a complete and accurate medical record for the resident.
Trusted data from CMS and state health departments
Every citation, penalty and Plan of Correction is sourced from public CMS records (latest release May 27, 2026) and official state health department websites — never guesswork.
Trusted by long-term care providers and associations.
