Coffman Nursing Home
Inspection history, citations, penalties and survey trends for this long-term care facility in Hagerstown, Maryland.
- Location
- 1304 Pennsylvania Avenue, Hagerstown, Maryland 21742
- CMS Provider Number
- 215352
- Inspections on file
- 15
- Latest survey
- August 12, 2025
- Citations (last 12 mo.)
- 28
Citation history
Health deficiencies cited at Coffman Nursing Home during CMS and state inspections, most recent first.
The facility did not consistently serve meals at appropriate temperatures, as evidenced by missing temperature logs, resident complaints about cold food, and direct observation of food items being out of the safe temperature range. Residents also reported that warming liners were rarely used, and staff had not been trained on their use, contributing to the deficiency.
Surveyors found multiple instances of expired and improperly labeled food items in facility refrigerators and freezers, including spoiled produce, expired juice, and prepared foods lacking use-by dates. Staff confirmed that dietary personnel were responsible for managing these items, but failed to consistently follow professional standards for food storage and preparation.
Surveyors found that several residents did not receive all items listed on their meal tickets, with missing foods such as ice cream, milk, yogurt, and fruit. Residents and staff confirmed that meal trays often lacked items based on which dietary staff prepared them, and concerns were raised during food committee meetings. The dietary manager acknowledged the issue during the survey.
Surveyors identified multiple environmental deficiencies, including cracked and discolored tiles, a detached trim guard, and a rusted P-trap in several hallways and rooms. These issues were confirmed by the Maintenance Director and indicate a failure to maintain a safe, clean, and homelike environment for residents.
Staff failed to consistently use required gowns and gloves during high-contact care for residents with wounds or pressure ulcers, and a nurse did not wear gloves while handling IV equipment. Multiple staff were unaware of or did not follow EBP protocols, and infection control policies had not been reviewed or updated to reflect current standards or the facility's resident population.
A resident who required special eating utensils and adaptive equipment due to decreased fine motor strength and coordination was not provided with the necessary assistive devices during a meal. Instead, regular utensils were given because the required items were not supplied by dietary staff, as confirmed by staff and an occupational therapist.
Two residents had inaccurate MDS assessments: one received an antipsychotic for dementia with behavioral disturbance, but the MDS listed dementia without behavioral disturbance; another had psychotic disorder documented on the MDS without supporting provider documentation or recent treatment.
A resident did not have an interdisciplinary team (IDT) care plan meeting conducted within 7 days of their comprehensive MDS assessment. The care plan meeting was missed due to a scheduling oversight after the MDS date was changed, and the resident was not aware of any care plan meeting.
A resident was prescribed and administered levofloxacin for 10 days to treat a respiratory condition, despite the physician's intention for a 7-day course and a chest x-ray showing no active disease. The extended duration was due to a misunderstanding, resulting in unnecessary antibiotic use.
Surveyors found that clean utility rooms on two halls, containing OTC medications and biologicals, were left unlocked and accessible. A nurse confirmed that these rooms did not remain locked, and a handwritten sign on one door did not prevent access. The DON acknowledged the issue.
The facility did not maintain daily posted nurse staffing information in a readily accessible format. Staffing details, including hours worked by RNs, LPNs, and CNAs, were only available on a wipe board and not included on the saved assignment sheets, which are required to be kept for 18 months. The DON confirmed that hours worked were stored on other reports, not with the posted assignment sheets.
A resident who was unsteady and on anticoagulant medication fell and sustained injuries. The facility staff failed to immediately notify the resident's physician and family, delaying necessary medical assessment and intervention.
Failure to Serve Meals at Safe and Palatable Temperatures
Penalty
Summary
The facility failed to ensure that meals were delivered to residents at appropriate and palatable temperatures. Multiple sources, including a complaint, food committee meeting notes, and resident interviews, indicated ongoing concerns about food being served cold, half-cooked, and lacking in presentation and taste. Review of food service temperature logs revealed numerous instances where required temperature records were missing for various meals, and some logs were undated or incomplete. The facility's own policy required foods to be served at proper temperatures for safety, but documentation did not show that this was consistently achieved before serving residents. During direct observation, residents reported that food was always cold and that liners intended to keep food warm were rarely used. A test tray obtained during a dinner tray line observation showed that milk was served at 57 degrees, above the acceptable maximum of 41 degrees, confirming the temperature concern. The dietary manager acknowledged the issue and noted that staff had not yet been trained to use the food warming liners. The administrator was informed of these concerns during the survey.
Improper Food Storage and Labeling Practices Identified
Penalty
Summary
Surveyors observed multiple instances of improper food storage and preparation within the facility. In the walk-in refrigerator, nine cabbages were found with a grayish substance growing on them, indicating spoilage, and a bag of broccoli was present past its labeled 'best if used by' date. Additionally, a bag of shredded cheese was found with an open date but no use-by date, and an opened container of buttermilk ranch dressing was labeled only with a received date, lacking both an open and use-by date. In the walk-in freezer, a container of prepared spaghetti sauce was found with a preparation date but no use-by date, and it had been stored beyond the time frame staff indicated was appropriate for use. Further inspection of the nutrition room refrigerator on the nursing unit revealed a carton of thickened orange juice with a use-by date that had already passed. Staff confirmed that expired and improperly labeled food items were present and acknowledged that dietary staff were responsible for managing these items. These findings demonstrate that the facility failed to consistently follow professional standards for labeling, dating, rotating, and disposing of perishable food items.
Failure to Serve Meals According to Residents' Menu Preferences
Penalty
Summary
Surveyors identified that the facility failed to serve meals according to predetermined menus that reflected residents' preferences, as evidenced by multiple dining observations and record reviews. Residents' meal trays were missing items listed on their meal tickets, such as vanilla ice cream, salt, pepper, milk, low-fat yogurt, cottage cheese, and bananas. These omissions were confirmed through direct observation, resident statements, and interviews with dietary staff. Residents also voiced concerns and grievances during food committee meetings about not consistently receiving meals as ordered. Staff interviews revealed that the occurrence of missing food items depended on which dietary staff member loaded the meal cart. The dietary manager and a dietary aide both acknowledged the issue of missing items on residents' trays. The deficiency was observed across several meals and residents, indicating a pattern of not following the established menu and residents' documented preferences.
Environmental Deficiencies Compromise Homelike Setting
Penalty
Summary
Surveyors observed that the facility failed to maintain a safe, clean, and homelike environment for residents, as evidenced by multiple environmental deficiencies across three hallways. Specifically, cracked tiles were found in the 200, 300, and 400 hallways, with six cracked tiles between a resident room and the nurses' station in the 200 hallway, and eight cracked tiles in a resident room in the 300 hallway. Additional issues in the 300 hallway included two tiles with bubbles under the head of the first bed, six tiles with black discoloration, a detached trim guard from a bathroom door post, and a rusted P-trap under a bathroom sink. In the 400 hallway, four broken tiles were observed between resident rooms, and two cracked tiles were found behind the door in the unit shower room. These findings were confirmed by the Maintenance Director during an environmental tour. No information was provided regarding the medical history or condition of the residents at the time of the deficiency.
Failure to Maintain Enhanced Barrier Precautions and Update Infection Control Policies
Penalty
Summary
The facility failed to ensure staff consistently maintained standard and enhanced barrier precautions (EBP) during resident care and did not review or revise infection prevention and control policies annually. Observations revealed that staff provided high-contact care to a resident with a wound without donning required gowns, despite posted EBP signage and a care plan specifying this requirement. Staff involved were unaware of the resident's wound status and the necessity for gowns, even though the infection preventionist later confirmed the resident did have a wound requiring such precautions. In another instance, a nurse performed a dressing change for a resident with a stage 3 pressure ulcer without wearing a gown, despite EBP signage and the infection preventionist's confirmation that gown and glove use was required for such cases. The nurse admitted uncertainty about EBP requirements during the surveyor's inquiry. Additionally, a nurse was observed preparing and priming an intravenous line and pump for another resident without wearing gloves, failing to adhere to standard infection control precautions. The facility's Director of Nursing acknowledged that infection prevention and control policies had not been reviewed or updated in the past year, and no documentation was available to demonstrate that policies had been evaluated or revised based on the current facility assessment or resident population. The policies provided were outdated, generic, and lacked facility-specific information.
Failure to Provide Required Assistive Eating Devices
Penalty
Summary
A deficiency was identified when a resident who required special eating utensils, specifically a weighted fork and spoon with built-up handles, an anti-spill cup, and a yellow-lipped plate due to decreased fine motor strength and coordination, was not provided with these assistive devices during a meal. Record review indicated that these items were required for every meal. However, during a dinner observation, the resident was given regular utensils instead of the prescribed weighted utensils because the dietary staff had not supplied them. Staff present at the time confirmed the omission, and the occupational therapist later verified that the specialized utensils were necessary to help the resident manage eating tasks and limit spillage.
Inaccurate MDS Assessments for Diagnoses and Medication Use
Penalty
Summary
The facility failed to ensure that Minimum Data Set (MDS) assessments were accurately recorded for two residents. For one resident, the medical record showed an attending provider's order for an antipsychotic medication with a diagnosis of dementia with behavioral disturbance. However, the MDS assessments documented the diagnosis as dementia without behavioral disturbance, which did not reflect the updated diagnosis in the resident's record. This discrepancy was confirmed by the MDS Coordinator, who acknowledged missing the update in the resident's diagnosis. For another resident, MDS assessments documented a diagnosis of psychotic disorder, but there was no supporting documentation in the medical record. Specifically, there was no evidence of treatment for psychotic disorder in the seven days prior to the assessment, nor was there an attending provider's note documenting the diagnosis in the previous sixty days. The MDS Coordinator confirmed that these MDS assessments were recorded inaccurately.
Failure to Conduct Timely IDT Care Plan Meeting After MDS Assessment
Penalty
Summary
The facility failed to ensure that an interdisciplinary team (IDT) care plan meeting was conducted for a resident following the completion of the comprehensive Minimum Data Set (MDS) assessment. The resident had been admitted in June 2025, and the admission MDS assessment was completed on July 1, 2025. However, there was no documentation or evidence that a care plan meeting took place within the required 7 days after the MDS assessment, as mandated by federal regulations. During interviews, the resident stated they were not aware of any care plan meeting, and the Social Services Director (SSD) confirmed that the meeting had not been scheduled due to a change in the MDS assessment date. The SSD acknowledged missing the scheduling of the care plan meeting for this resident, which resulted in the care plan not being developed and reviewed by the required interdisciplinary team within the specified timeframe.
Unnecessary Prolonged Antibiotic Administration
Penalty
Summary
A deficiency was identified when a resident, who had resided in the facility for over a year, was prescribed and administered levofloxacin (Levaquin) for 10 days to treat a cough with phlegm, which was initially assessed as bronchitis and possible pneumonia. The physician's progress note indicated that the antibiotic was to be started for 7 days, pending chest x-ray results to determine if a change in antibiotics was necessary. The chest x-ray, performed the same day, showed no active cardiopulmonary disease. Despite this, the resident received the antibiotic for 10 days, as documented in the Medication Administration Record. During an interview, the physician clarified that the antibiotic should have been prescribed for only 7 days and attributed the 10-day administration to a misunderstanding. The facility's antibiotic stewardship policies, last revised in December 2016, were reviewed in relation to this incident. The failure to ensure the resident was free from unnecessary antibiotics, specifically the administration of an antibiotic for longer than intended, constituted the deficiency.
Medications and Biologicals Not Securely Stored in Utility Rooms
Penalty
Summary
Surveyors observed that the facility failed to ensure drugs and biologicals were stored securely in accordance with professional standards. Specifically, the clean utility supply rooms on both the 200 and 300 halls, which contained over-the-counter medications and biologicals such as vitamin A&D ointment, saline enemas, iodoform packing strips, hydrogel wound dressing, calcium alginate dressings, Silvasorb, and COVID-19 test kits, were found to be unlocked and accessible. The 300 hall clean utility room was observed to be unlocked and accessible at 11:08 AM, and the 200 hall clean utility room was also found to be freely accessible without a lock or keypad. During interviews, a nurse confirmed that the clean utility rooms did not remain locked and demonstrated that the 200 hall room could be opened without restriction. A handwritten sign on the 300 hall room door instructed staff to see the nurse for the key, but the room remained accessible. The Director of Nursing was informed of these observations and acknowledged the deficiency. No information was provided regarding any residents' medical history or condition at the time of the deficiency.
Failure to Maintain Readily Accessible Daily Nurse Staffing Information
Penalty
Summary
The facility failed to maintain daily posted nurse staffing information in a readily accessible format as required. During an observation on the nursing unit with the DON, it was found that staffing information for the current day shift, including hours worked by RNs, LPNs, and CNAs, as well as the resident census, was posted on a large white wipe board. Separate paper documentation with specific staff room assignments was also posted, but this did not include the actual hours worked for nurses and aides. The surveyor noted that the required information regarding hours worked was only available on the wipe board and not on the saved posted assignment sheets, and the DON confirmed that hours worked were kept on other reports rather than with the posted assignment sheets, which are required to be kept for 18 months.
Failure to Immediately Notify Physician and Family After Resident Fall
Penalty
Summary
The facility staff failed to immediately notify a resident's physician and responsible party when a resident had fallen and received an injury. This deficiency was identified during a complaint survey for one resident who had been admitted for rehabilitation after neck surgery. The resident was noted to be unsteady on their feet and required maximum assistance from two staff members while ambulating with a walker. Additionally, the resident was on anticoagulant medication, which increased the risk of complications from falls. On the night of the incident, the resident was found on the floor by a registered nurse at 3:30 am, with new bruising and skin tears. Despite the facility's policy requiring immediate notification of the physician and the resident's representative in such cases, the physician and the resident's family were not informed until later in the morning. The physician, upon being notified, instructed the nursing staff to send the resident to the emergency room to rule out bleeding in the brain. The delay in notification and subsequent medical assessment constituted a failure to adhere to the facility's policy and ensure timely medical intervention.
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.
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