Complete Care At Corsica Hills Llc
Inspection history, citations, penalties and survey trends for this long-term care facility in Centreville, Maryland.
- Location
- 205 Armstrong Street, Centreville, Maryland 21617
- CMS Provider Number
- 215114
- Inspections on file
- 17
- Latest survey
- January 12, 2026
- Citations (last 12 mo.)
- 21
Citation history
Health deficiencies cited at Complete Care At Corsica Hills Llc during CMS and state inspections, most recent first.
The facility failed to prevent and address abuse, leading to Immediate Jeopardy. A resident with cognitive impairment was physically abused by a nurse, and another resident with a fractured arm reported rough handling by a GNA. Investigations were inadequate, and monitoring of a resident with sexual impulse issues was inconsistent, leading to repeated inappropriate interactions.
The facility failed to implement its QAPI plan effectively, particularly in addressing potential deficient practices related to abuse prevention. Although an action plan was created for timely reporting of abuse allegations, there was no evidence of ongoing tracking, trending, or additional training as part of an effective QAPI program. Interviews revealed that while abuse prevention training was provided, there was no focus on sustaining compliance through the QAPI process.
The facility failed to document, investigate, and resolve grievances voiced by residents during Resident Council meetings. Concerns such as aides' attitudes, missing clothing, and issues with laundry were not addressed or discussed in the minutes. Residents reported unresolved issues, and the DON admitted to incomplete staff training. The Activities Director confirmed the lack of follow-up documentation, indicating a systemic issue in handling grievances.
The facility failed to ensure resident safety and conduct thorough investigations following abuse allegations. Incidents included delayed reporting of abuse by a nurse, incomplete documentation of resident interviews, and failure to interview relevant staff and residents. Additionally, a resident was not protected from being alone with the opposite sex, and a GNA with prior conduct issues continued working despite abuse allegations.
A resident reported an allegation of abuse, stating that a GNA caused them pain during care and did not listen to their requests to stop. The incident was also reported by the resident's roommate. The DON confirmed the resident felt their care preferences were ignored. The GNA was placed on administrative leave and later on a do-not-return list.
A facility failed to document and address grievances related to a resident's care, including medication dispensing and personal hygiene issues. Despite multiple discussions with the resident's family, no formal grievance was recorded, and the facility's grievance policy was not implemented until after the complaints. The DON acknowledged the grievance process should have been followed.
The facility failed to report abuse allegations within required timeframes for four residents. Incidents included verbal and physical abuse, and neglect, with delays in reporting to the SSA. In one case, a resident was told to urinate in her brief, and another resident's abuse was observed but not promptly reported. Documentation and procedural lapses were evident, as seen in the case of a resident who recanted an abuse allegation without proper documentation.
A facility failed to update a resident's care plan following two incidents of abuse. The existing care plans only addressed the resident's depression and cognitive decline, with no mention of the abuse incidents. This deficiency was identified during a survey and discussed with the DON and Regional President.
A facility failed to update a resident's care plan with dental recommendations after a consult revealed a fractured tooth requiring extraction, which the resident refused. The care plan did not reflect the resident's ongoing tooth pain or refusal of treatment, leaving staff unaware of these issues. Interviews with staff confirmed the oversight in updating the care plan.
Facility staff failed to provide necessary ADLs for a resident with Alzheimer's dementia, who was dependent on staff for care. Despite being scheduled for showers twice a week, the resident received only one shower in December and none in the first two weeks of February. Mouth care and incontinence care were also frequently marked as not applicable or left blank in documentation. The Memory Support Program Director was unaware of these issues, and the DON acknowledged the documentation errors.
A facility failed to complete a thorough admission assessment for a resident with dementia, resulting in the resident exiting the facility unsupervised. Additionally, residents in the dementia care unit were observed without activities, and a care plan for a resident with severe cognitive impairment was outdated, leading to a lack of meaningful engagement.
The facility did not post daily nurse staffing information, making it inaccessible to residents and visitors for three consecutive days. The DON was unaware of the requirement and stated they were working on completing the document for posting.
Failure to Prevent and Address Abuse in LTC Facility
Penalty
Summary
The facility staff failed to recognize and prevent abuse towards multiple residents, leading to an Immediate Jeopardy situation. For instance, a resident with moderately impaired cognition and behavioral disturbances was physically abused by a registered nurse who slapped the resident on the head multiple times after the resident became combative. The incident was not reported immediately, allowing the nurse continued access to vulnerable residents. Additionally, the psychiatric consult for the resident did not address the abuse, and the nurse involved had not completed required annual training. Another resident, who required non-weight-bearing care for a fractured arm, reported being handled roughly by a GNA, causing fear and distress. The facility's investigation into the incident was inadequate, as it failed to interview all relevant staff and residents, and the allegation of abuse was deemed inconclusive. The resident was found lying on their injured side, contrary to care instructions, and expressed fear of the GNA involved. Further deficiencies included a failure to report and address allegations of abuse in a timely manner, as seen in the case of a resident who was allegedly slapped by a GNA. The incident was not reported immediately, and the GNA continued to work in the facility. Additionally, a resident with a history of sexual impulse control issues was not adequately monitored, leading to repeated inappropriate interactions with other residents. The facility's interventions were delayed and inconsistently implemented, contributing to ongoing risks for residents.
Failure to Implement Effective QAPI for Abuse Prevention
Penalty
Summary
The facility failed to implement its Quality Assessment and Performance Improvement (QAPI) plan effectively, particularly in addressing potential deficient practices related to abuse prevention. The facility's policy, dated 2020, aimed to continuously evaluate systems to ensure quality care and life. However, the facility did not gather, analyze, or re-evaluate data related to adverse events concerning abuse, which could potentially affect all 105 residents. Although an action plan was created in September 2022 for timely reporting of abuse allegations, there was no evidence of ongoing tracking, trending, or additional training as part of an effective QAPI program. Interviews with the Regional Clinical Consultant (RCC) and the Director of Nursing (DON) revealed that while abuse prevention training was provided, there was no focus on sustaining compliance through the QAPI process. The RCC admitted that there was no data collection, monitoring, or evaluation to demonstrate sustained compliance with abuse prevention. The DON confirmed that QAPI meetings were held monthly, but no additional information was available regarding the tracking, trending, or monitoring of abuse prevention efforts with an action plan developed as a result.
Failure to Address and Document Resident Grievances
Penalty
Summary
The facility failed to ensure that grievances voiced by residents during Resident Council meetings were documented, investigated, resolved, and followed up on. The Resident Council Minutes from multiple meetings did not indicate the names of residents who attended, nor did they show that concerns raised, such as aides having attitudes, missing clothing, and issues with laundry, were addressed or discussed. Additionally, concerns about being put to bed with clothes on, showers not being given, and call lights not being answered timely were not documented as resolved. This lack of documentation and follow-up was consistent across several meetings, indicating a systemic issue in handling grievances. During a resident group meeting, residents expressed that they had reported concerns about laundry and staff not introducing themselves, but had not received any follow-up. The DON acknowledged that training had been conducted for aides on certain issues but admitted that not all staff had been educated. The Activities Director stated that there was no follow-up documentation on whether concerns were addressed or resolved, and the Administrator received a copy of the Resident Council Minutes without any follow-up documentation. This failure to document and resolve grievances had the potential to leave resident concerns unaddressed throughout the facility.
Inadequate Response to Abuse Allegations and Investigation Failures
Penalty
Summary
The facility failed to ensure the safety of residents following allegations of abuse and did not conduct thorough investigations into these allegations. In one instance, a Registered Nurse was reported to have cursed and hit a resident, but the incident was not reported to the Director of Nursing until over an hour later, allowing the nurse continued access to vulnerable residents. Another case involved a resident who reported rough treatment by a staff member, but the investigation was incomplete, lacking proper documentation and failing to identify who conducted the interview. Further deficiencies were noted in the investigation of a resident's representative's report of neglect, where the facility did not interview other staff who might have had knowledge of the care provided. In another case, a resident was found in distress, and the investigation was deemed inconclusive due to a lack of interviews with other staff and residents who might have had relevant information. Additionally, a resident was not protected from being alone with residents of the opposite sex despite previous orders, and the facility failed to document interventions to prevent such occurrences. The facility also did not complete a thorough investigation into an allegation of physical abuse involving a GNA and a resident, as no additional interviews with other residents or staff were conducted. The GNA involved had previous write-ups for unprofessional conduct but continued to work at the facility until termination for unrelated reasons. These incidents highlight significant lapses in the facility's response to abuse allegations and the protection of residents.
Failure to Honor Resident's Right to Dignified Care
Penalty
Summary
The facility staff failed to honor a resident's right to a dignified existence by not listening to the resident during care. Resident #911 reported an allegation of abuse, stating that a GNA turned them, causing pain, and continued despite their request to stop. The incident was reported by the resident on 1/14/23, and the roommate also reported mistreatment by the same GNA. The Director of Nursing confirmed that Resident #911 felt the GNA was not listening to their care preferences. The GNA was placed on administrative leave and subsequently on a do-not-return list after the investigation.
Failure to Document and Address Resident Grievances
Penalty
Summary
The facility failed to ensure that residents and/or their representatives were afforded the right to file a grievance and receive a response regarding the action taken by the facility. This deficiency was identified during a recertification and complaint survey for one of the three residents reviewed. The issue was highlighted by a complaint concerning care concerns for a resident, which included improper medication dispensing, inconsistent staffing in the memory care unit, and inadequate personal hygiene care. Despite the complainant having communicated these concerns to the Memory Support Program Director (MSPD), Director of Nursing (DON), and the Administrator, no grievance was formally documented or addressed. The facility's failure to document and address grievances was further evidenced by the absence of any grievance records for the resident in question, despite multiple discussions with the resident's family about care concerns. The MSPD admitted to not completing a grievance form if she believed the issue could be addressed immediately, and the DON acknowledged that the grievance process should have been followed. Additionally, the facility's Resident and Family Grievances policy was not implemented until after the complaints were made, indicating a lack of proper grievance handling procedures at the time of the incident.
Failure to Timely Report Abuse Allegations
Penalty
Summary
The facility failed to report allegations of abuse, neglect, or theft within the required timeframes to the state survey agency (SSA). This deficiency was identified during a recertification and complaint survey, affecting four residents. The facility's policy mandates that any alleged violations involving abuse must be reported immediately, but not later than two hours after the allegation is made. However, in the case of Resident #77, the allegation of verbal and physical abuse by a Geriatric Nurse Aide (GNA) was not reported to the Director of Nursing (DON) until the following morning, resulting in a delay in notifying the SSA. Resident #303 reported being told by staff to urinate in her brief, which she found uncomfortable and distressing. This incident was reported to a GNA, who then informed a Registered Nurse (RN). However, the incident was not reported to the Administrator or the DON until after noon, missing the two-hour reporting window. Similarly, Resident #921 was observed being abused by a Registered Nurse (RN), but the report to the DON was delayed, and the SSA was not notified within the required timeframe. In the case of Resident #928, an allegation of rough treatment and verbal abuse was made, but there was no evidence that this was reported to the SSA. The interview with the resident was conducted without proper documentation, and the resident later recanted the allegation. The DON was unable to confirm when the interview took place, indicating a lack of proper procedure and documentation in handling the incident. These failures highlight the facility's inability to adhere to its own policies and regulatory requirements for timely reporting of abuse allegations.
Failure to Update Care Plan After Abuse Incidents
Penalty
Summary
The facility failed to review and update the care plan for a resident following two incidents of abuse. The electronic health record for the resident did not show any updated care plans addressing these incidents, which occurred four days apart. The existing care plans only addressed the resident's depression and cognitive decline, without any mention of the abuse incidents. This deficiency was identified during a complaint and recertification survey and was discussed with the Director of Nursing and the Regional President at the exit meeting.
Failure to Update Care Plan with Dental Recommendations
Penalty
Summary
The facility failed to revise the care plan for a resident, identified as R73, to include recommendations from a dental consult. The dental consult on 05/11/24 recommended the extraction of tooth #20 due to a fracture and food impaction, which the resident refused. Despite this, the care plan was not updated to reflect the fractured tooth, the recommendation for extraction, or the resident's refusal, leaving staff unaware of the resident's ongoing tooth pain and the dentist's recommendations. Interviews revealed that the Medical Records Director and Unit Manager were responsible for ensuring follow-up from dental appointments was documented and communicated. However, the Unit Manager admitted that the care plan should have been updated to include the dentist's recommendations and the resident's refusal. The Resource Nurse confirmed that the care plan was not revised in a timely manner to address the resident's dental issues, which were significant to the resident's care and comfort.
Failure to Provide Scheduled ADLs for a Resident
Penalty
Summary
Facility staff failed to provide necessary activities of daily living (ADLs) for a resident who was dependent on them for care. The resident, who had Alzheimer's dementia with anxiety and was severely cognitively impaired, was documented as being dependent on staff for most ADLs according to the Minimum Data Set (MDS). Despite being scheduled for showers twice a week, the resident only received one shower in December and none in the first two weeks of February. Additionally, the resident's mouth care and incontinence care were frequently marked as not applicable (N/A) or left blank in the geriatric nursing assistant (GNA) documentation. The Memory Support Program Director was unaware of the documentation issues, despite frequent communication with the resident's family about care concerns. The Director of Nursing and other regional staff were informed of the deficiencies, and the DON acknowledged that the GNAs should not have documented N/A for those care categories. The failure to provide scheduled showers, mouth care, and incontinence care as documented indicates a significant lapse in the facility's care for the resident.
Deficiencies in Dementia Care and Resident Safety
Penalty
Summary
The facility failed to complete a thorough admission nursing assessment for a resident with a known history of dementia, leading to an incident where the resident was able to exit the facility unsupervised. The resident, who had been admitted following hospitalization for changes in vital signs and dementia-related behaviors, was not properly assessed for elopement risk upon admission. This oversight resulted in the resident exiting the facility through a side door, only to be noticed and brought back by a geriatric nursing assistant. The elopement assessment section of the nursing admission assessment was incomplete, failing to identify the resident's medical conditions that could lead to confusion or exit-seeking behaviors. Additionally, the facility did not ensure that residents in the dementia care unit had access to activities that would help them achieve their highest practicable physical, mental, and psychosocial well-being. Observations revealed that residents were left without activities on multiple occasions. A specific resident with severe cognitive impairment had a care plan that was not updated to reflect their current needs and abilities, resulting in a lack of meaningful engagement. The Memory Support Program Manager acknowledged the lack of activities but did not provide a rationale for the deficiency.
Failure to Post Daily Nurse Staffing Information
Penalty
Summary
The facility failed to comply with the regulatory requirement to post daily nurse staffing information, which was not available to residents or visitors during the first three days of the survey. Observations on three consecutive days revealed that the nurse staffing information was not posted or accessible at 8:35 AM each day. During an interview, the Director of Nursing (DON) admitted that the facility did not have the nurse staffing information posted and was unaware of the requirement to do so. The DON mentioned that they were in the process of completing the document for posting.
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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