Collingswood Rehabilitation And Healthcare Center
Inspection history, citations, penalties and survey trends for this long-term care facility in Rockville, Maryland.
- Location
- 299 Hurley Avenue, Rockville, Maryland 20850
- CMS Provider Number
- 215092
- Inspections on file
- 19
- Latest survey
- January 7, 2026
- Citations (last 12 mo.)
- 55
Citation history
Health deficiencies cited at Collingswood Rehabilitation And Healthcare Center during CMS and state inspections, most recent first.
Staff failed to timely report injuries of unknown origin for two residents to state authorities. In one case, a family member informed a GNA about a contusion on a resident’s upper arm, but the GNA did not assess the resident and forgot to notify a nurse or other staff, and the injury was not brought to administration’s attention until the family later emailed the ADON, resulting in a multi-day delay in reporting to OHCQ. In the other case, nursing staff identified and treated a bruise on a resident’s thigh and informed the Dementia Unit Manager, who did not notify the DON or Administrator until several days later, causing a late Facility Reported Incident submission to OHCQ.
The facility failed to thoroughly investigate both an abuse allegation and an injury of unknown source. An alert, newly admitted resident with complex medical needs reported in writing being beaten during bath time on the second day of admission, but there was no documented resident interview, no interviews with other residents on the unit, incomplete staff interviews across all shifts, and no written statement from the nurse manager who received the allegation. In a separate case, a severely cognitively impaired, ventilator‑dependent resident exhibited pain with right arm movement, and an initial x‑ray suggested a wrist fracture later not confirmed at the hospital; however, the facility’s investigation only included statements from staff present at the time of the observed pain and one assisting GNA, with no interviews of staff from prior shifts or any residents regarding the injury of unknown source.
A resident who was his/her own decision maker received a notice of non-coverage with a planned discharge date and initially agreed to go home, with Social Services documenting plans for home health and transportation by taxi. After the resident’s family member told the Social Services assistant they wanted to appeal the discharge and believed the resident needed more time, the assistant informed staff that the resident would be staying and told the resident about the family’s wishes, but did not document this change in the discharge plan or the appeal in the medical record, resulting in an incomplete and inaccurate record.
Multiple wheelchairs were found to be unsanitary and in disrepair, including one used by a resident for an outside appointment that contained urine and fecal matter in the cushion. Several other wheelchairs had cracked, ripped, or missing armrests, with exposed foam and inadequate support. Housekeeping staff confirmed there was no prior cleaning or maintenance schedule for wheelchairs or their cushions.
Facility staff failed to accurately code MDS assessments for several residents, resulting in omissions and errors related to significant weight loss, falls, pressure ulcers, wounds, and the administration of medications such as hypoglycemics, antibiotics, anticoagulants, and opioids. These discrepancies were confirmed by MDS coordinators after review of medical records and medication administration records.
A resident with a leg amputation was not provided with their custom-made wheelchair during transport to a medical appointment, resulting in the use of other wheelchairs and repeated repositioning by staff. The facility lost the resident's specially fitted wheelchair on multiple occasions, and staff failed to follow up to ensure the resident had access to the necessary equipment, despite complaints from the resident's family and awareness among facility leadership.
Facility staff failed to promptly notify a physician after a resident with heart failure experienced a sudden and sustained drop in blood pressure, despite repeated attempts to reach the provider and ongoing monitoring. In a separate incident, another resident experienced a significant weight loss over three weeks, but there was no timely notification to the physician, dietician, or family, and the resident was not promptly assessed or discussed in risk meetings.
The facility did not report allegations of abuse, neglect, or injuries of unknown origin to the regulatory agency within the required 2-hour timeframe for three residents. Incidents included a non-verbal resident with a laceration, a resident with a dislocated shoulder and complex medical needs, and an allegation of physical abuse by a GNA. In each case, delays in internal notification and external reporting were confirmed.
Facility staff did not hold or document required quarterly care plan meetings for a resident with dementia, despite completing quarterly MDS assessments. Only one care plan meeting was documented, and there was no record of meetings or summaries for other required quarters, as confirmed by the DON and noted by the resident's representative.
A resident who required extensive two-person assistance for activities of daily living after hip surgery did not receive necessary turning, repositioning, or bowel and bladder care over several day shifts. Documentation showed that assigned GNAs did not perform these essential care tasks, and complaints included inadequate staffing and unanswered call bells.
Facility staff did not implement a consultant's recommendations for an appetite stimulant and protein supplement for a resident with anemia and thyrotoxicosis, and also failed to perform and document neurological assessments at required intervals after an unwitnessed fall for another resident, with inaccuracies in vital sign documentation as confirmed by the DON.
A resident with multiple medical conditions experienced a significant, unrecognized weight loss over a three-week period. Facility staff did not perform weekly weights as recommended, failed to promptly notify the physician or dietician of the weight loss, and delayed assessment and intervention, contrary to facility policy.
Failure to Timely Report Injuries of Unknown Origin to State Authorities
Penalty
Summary
Facility staff failed to timely report injuries of unknown origin for two residents to the State of Maryland's Office of Health Care Quality (OHCQ). For one resident, a family member noticed a contusion on the resident's right upper arm while visiting and reported this skin issue to the assigned Geriatric Nursing Assistant (GNA) at approximately 2:30 PM. The family member asked that the resident not be disturbed because the resident was asleep, and the GNA did not assess the resident at that time. The GNA then unintentionally failed to report the family’s concern or the potential injury to a nurse or any other staff member before leaving for the day. The facility did not become aware of the injury until the family member emailed the Assistant Director of Nursing (ADON) several days later, at which point the injury of unknown origin was reported to OHCQ, resulting in a four-day delay from when the family first identified and reported the potential injury to staff. In a separate incident, another resident was observed by nursing staff with a bruise to the right thigh that was treated and documented as an injury of unknown origin. Nursing staff reported this injury to the Dementia Unit Manager, but the Dementia Unit Manager did not notify the Director of Nursing (DON) or the Administrator on the date the injury was discovered. Administration only became aware of the injury several days later when the Dementia Unit Manager reviewed the nursing documentation and recognized that the injury met criteria for an injury of unknown origin. The injury was then reported to the DON and subsequently to OHCQ, but this delay caused the facility to report the injury to the state agency late. Both incidents were confirmed through staff interviews and review of the facility-reported incident investigations.
Failure to Thoroughly Investigate Abuse Allegation and Injury of Unknown Source
Penalty
Summary
The deficiency involves the facility’s failure to thoroughly investigate an allegation of abuse for one resident. An alert and oriented resident with multiple diagnoses and complex medical needs was admitted following an acute hospitalization and later provided the Unit Manager with a handwritten note alleging that on the second day of admission the resident was “beaten up during bath time.” The note did not identify staff or the shift involved. Review of the investigation showed no documentation that the resident was interviewed about the allegation after staff became aware of it. The investigation file also contained an undated typed statement indicating that when social services went to visit the resident about an incident, the resident declined to talk and declined to write a statement, but the document did not identify the author, the social services staff involved, or the specific incident referenced. Further review of the abuse investigation revealed that no interviews were documented with other residents on the unit, despite the allegation of abuse. Instead, statements were obtained from resident representatives for three other residents who were documented as cognitively impaired and not interviewable, with no documentation explaining why residents themselves were not interviewed. Staff interview statements were only obtained from the nurse and GNA on the 7 AM–3 PM shift and the nurse and GNA on the 3 PM–11 PM shift for the date of the alleged incident. There was no documentation of interviews with the nurse and GNA assigned to the resident on the 11 PM–7 AM shift, and no written statement from the Unit Manager who originally received the handwritten abuse allegation from the resident. The deficiency also includes the facility’s failure to thoroughly investigate an injury of unknown source for another resident. This resident, admitted with multiple diagnoses, severe cognitive impairment, and ventilator dependence, displayed a facial grimace when staff moved the right arm during incontinence care, leading to an x-ray that suggested a possible hairline fracture of the right wrist, followed by a later hospital x-ray that showed no fracture. The facility’s investigation contained only three employee statements: from the RN and GNA providing care at the time of the observed grimace, and from a GNA who was not assigned to the resident but assisted with care that day. There was no documentation that staff from preceding shifts or days were interviewed, and no documentation that any residents were interviewed in response to the injury of unknown source.
Failure to Accurately Document Change in Discharge Plan and Appeal
Penalty
Summary
The deficiency involves the facility’s failure to maintain a complete and accurate medical record for a resident in accordance with accepted professional standards. Facility investigative documentation for a facility-reported incident showed that a resident, who was his/her own decision maker, left the facility in the early morning hours without informing staff and later returned home safely. Review of records also showed that the resident had been given a notice of non-coverage indicating the last covered day of the stay and the right to appeal, and the resident signed this notice. Further review of the resident’s medical record revealed a Social Services progress note documenting that the Social Services Assistant received the last covered day notice and that the resident was ready to go home and planned to discharge earlier than originally indicated, with home health to be set up and the resident planning to go home by taxi. In a subsequent interview, the Social Services Assistant stated that after providing the notice, she contacted a family member involved in the resident’s care, who expressed a desire to appeal the discharge and felt the resident needed more time. The Social Services Assistant reported that she informed staff there would be an appeal and that the resident would be staying, and she later told the resident about the family member’s wish for the resident to remain. She confirmed that she did not document this updated discharge plan and appeal information in the resident’s medical record, resulting in an incomplete and inaccurate record for the resident.
Failure to Maintain Sanitary and Safe Wheelchairs
Penalty
Summary
The facility failed to maintain wheelchairs in a sanitary, comfortable, and well-maintained condition, as evidenced by observations and interviews during a complaint survey. One resident attended a medical appointment in a wheelchair with a cushion that was found to contain urine and fecal matter, emitting a strong odor that had been a source of complaints for months. Upon inspection, the gel pad and pillow cover were visibly soiled, and the family, as well as medical staff at the appointment, were disturbed by the condition. Housekeeping staff confirmed that prior to this incident, there was no established schedule for cleaning or maintaining wheelchairs or their cushions, and the wheelchair in question appeared to have never been cleaned. Further observations revealed multiple wheelchairs across two nursing units in disrepair, including cracked and ripped vinyl on armrests, missing armrests, and exposed foam. Several residents were observed using these damaged wheelchairs, which lacked proper padding and support. The Nursing Home Administrator was made aware of these issues by both staff and family members, confirming the lack of a maintenance process for wheelchairs prior to the incident.
Inaccurate MDS Coding for Resident Assessments
Penalty
Summary
Facility staff failed to ensure that Minimum Data Set (MDS) assessments were accurately coded for multiple residents, as evidenced by discrepancies between medical records and MDS documentation. For several residents, significant clinical events and treatments were not properly recorded in the MDS. One resident experienced a substantial weight loss and a fall, neither of which were accurately reflected in the corresponding MDS sections. Additionally, the administration of hypoglycemic medications and insulin was omitted from the MDS, while an opioid was incorrectly documented as administered when it was not present in the medication administration record. Another resident was admitted with bilateral heel wounds and received ongoing wound care and antibiotics, but the MDS failed to capture the presence of pressure ulcers, venous ulcers, and related treatments. The same resident's MDS also did not reflect the administration of multiple medications, including insulin, diuretics, opioids, antidepressants, antibiotics, and anticoagulants, despite clear documentation in the medical and treatment records. Similar omissions were found for other residents, where falls, pressure ulcers, and the use of specific medications such as antibiotics and anticoagulants were not accurately coded in the MDS, even though these events and treatments were documented elsewhere in the medical record. In one case, a resident's MDS assessment incorrectly indicated the presence of a pressure ulcer that had already healed, and failed to document the use of antiplatelet, hypoglycemic, and antipsychotic medications that were administered during the assessment period. Interviews with MDS coordinators confirmed the presence of these errors across multiple assessments, indicating a pattern of inaccurate MDS coding that did not align with the residents' actual clinical status and care provided.
Failure to Provide Resident with Custom-Made Wheelchair for Transport
Penalty
Summary
The facility failed to ensure that a custom-made wheelchair was available and provided for a resident with a leg amputation during transport to a medical appointment. Staff statements and interviews revealed that the resident, who typically used a geri chair or remained in bed, was transferred to a standard wheelchair for an appointment, during which the resident began sliding out of the chair. Multiple staff members intervened to reposition the resident and eventually transferred the resident to a high-back wheelchair with a pillow for support. The resident did not report pain or injury during the incident. Further investigation revealed that the resident's custom-made wheelchair, provided by the VA and specifically fitted to accommodate the resident's needs following a leg amputation, had been lost by the facility on more than one occasion. The resident's daughter reported that the resident was repeatedly placed in other residents' wheelchairs for appointments, and that complaints about the missing wheelchair had been made to various staff and administrators. The facility's NHA confirmed that the custom wheelchair could not be located and acknowledged that there was no follow-up by staff to ensure the resident had access to the appropriate equipment.
Failure to Timely Notify Physician and Family of Change in Condition and Significant Weight Loss
Penalty
Summary
Facility staff failed to notify a resident's physician in a timely manner following a significant change in condition. One resident, admitted with heart failure, experienced a sudden drop in blood pressure. Nursing notes documented that the resident's blood pressure fell to 70/54 and continued to decline over several hours. Despite repeated attempts to page the provider, there was no response, and the physician was not notified promptly. The family was present and refused hospital transfer, but the facility did not escalate the situation to the Medical Director as expected when the primary physician could not be reached. In another case, a resident experienced a significant weight loss of 25.8 lbs (20%) over three weeks. The medical record did not show timely notification to the physician, dietician, or family when the weight loss was identified. The dietician did not assess the resident until 11 days after the weight loss was documented, and the resident was not evaluated in weekly risk meetings until 13 days later. Facility policy required prompt notification of significant changes in condition, but this was not followed in these instances.
Failure to Timely Report Allegations of Abuse and Injuries
Penalty
Summary
The facility failed to report allegations of abuse, neglect, or injury of unknown origin to the regulatory agency, the Office of Health Care Quality (OHCQ), within the required 2-hour timeframe for three residents. In one case, a non-verbal, cognitively impaired resident was found with a laceration to the right thumb, but the incident was not documented or reported by the LPN on duty, and facility administration only became aware the following day. The self-report to OHCQ was sent more than 24 hours after the injury was discovered. In another instance, a resident with multiple complex medical conditions, including tracheostomy, G-tube, diabetes, hemiplegia, and ventilator dependence, was found to have a dislocated shoulder. The injury was confirmed, but the report to OHCQ was not made until the following day, exceeding the 2-hour reporting requirement. A third incident involved an allegation of physical abuse by a GNA, reported by a resident's spouse. The DON was not notified until the next morning, and the initial report to OHCQ was sent several hours after the required timeframe. Documentation from staff revealed inconsistencies in awareness and reporting of the alleged abuse. In all three cases, the DON confirmed the findings of late reporting during interviews, although the DON was not employed at the facility at the time of the incidents.
Failure to Hold and Document Required Quarterly Care Plan Meetings
Penalty
Summary
Facility staff failed to conduct quarterly care plan meetings for a resident diagnosed with dementia, as required following comprehensive and quarterly MDS assessments. The medical record review showed that while quarterly MDS assessments were completed, there was only documentation of a care plan meeting in April and a scheduled meeting in September, with no evidence of meetings in January and July. Additionally, there was no documentation summarizing or detailing what was discussed during the April and September care plan meetings. The resident's representative expressed concerns about the facility's lack of communication. The Director of Nursing confirmed that the required quarterly care plan meetings were not held for the resident in January and July, and that documentation of the content of the meetings that did occur was missing from the medical record.
Failure to Provide Required ADL Assistance and Repositioning
Penalty
Summary
A deficiency was identified when a resident, admitted for rehabilitation following surgery for a periprosthetic hip fracture and requiring extensive assistance with two-person support for transfers, bed mobility, dressing, toileting, and general hygiene, did not receive necessary care on multiple day shifts. Documentation review revealed that the assigned geriatric nursing assistant (GNA) failed to perform required turning, repositioning, and bowel and bladder care for the resident over three consecutive days. Additionally, complaints were made regarding inadequate staffing, lack of resident changing, turning, repositioning, and unanswered call bells. These findings were based on direct review of the resident's medical record and GNA documentation.
Failure to Follow Consultant Recommendations and Neuro Check Protocols
Penalty
Summary
Facility staff failed to provide care in accordance with consultant recommendations for a resident admitted with anemia and thyrotoxicosis. The resident was evaluated by a consultant who recommended starting an appetite stimulant and a prosource protein supplement due to poor appetite and low albumin levels. Despite these recommendations, the staff did not initiate either intervention before the resident was discharged from the facility. The Director of Nursing confirmed that these recommendations were not addressed. Additionally, staff did not properly perform and document neurological assessments following an unwitnessed fall for another resident. According to facility policy, neuro checks should be completed at specific intervals after such an event. However, the medical record showed that neuro checks were not performed or documented at the required times, and some entries included inaccurate or reused vital signs. The Director of Nursing confirmed that neuro checks were completed at incorrect intervals and with inaccuracies.
Failure to Recognize and Respond to Significant Resident Weight Loss
Penalty
Summary
Facility staff failed to recognize and respond to significant weight loss in a resident admitted for comprehensive rehabilitation with multiple diagnoses, including cerebral infarction, hypertension, type 2 diabetes with hyperglycemia, and a sacral wound. Upon admission, the resident's weight was documented as 128 lbs, a notable decrease from the ideal body weight of 154 lbs. Despite a dietician's recommendation for weekly weights and monitoring due to malnutrition risk, weekly weights were not performed after admission. The next recorded weight, taken three weeks later, showed a further drop to 102.2 lbs, representing a 20% loss. There was no evidence that the physician, dietician, or family were notified of this significant weight loss as required by facility policy. Additionally, the dietician did not assess the resident until 11 days after the documented weight loss, and the resident was not discussed in weekly risk meetings until 13 days after the weight loss was identified. The facility's policy required immediate notification of the dietician in writing for significant weight changes, but this was not followed. Interviews with the physician confirmed the expectation for prompt notification in such cases, which did not occur.
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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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.
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