Complete Care At Hagerstown
Inspection history, citations, penalties and survey trends for this long-term care facility in Hagerstown, Maryland.
- Location
- 14014 Marsh Pike, Hagerstown, Maryland 21742
- CMS Provider Number
- 215365
- Inspections on file
- 18
- Latest survey
- January 29, 2026
- Citations (last 12 mo.)
- 20 (1 serious)
Citation history
Health deficiencies cited at Complete Care At Hagerstown during CMS and state inspections, most recent first.
A cognitively impaired resident with a history of hemorrhagic stroke was incorrectly assessed on admission as unable to ambulate, which locked the elopement assessment and led to the resident being classified as not at risk for elopement despite prior functional independence and hospital therapy notes showing ambulation with a walker. After admission, the resident experienced falls while trying to walk, was documented as severely cognitively impaired and incapable of making decisions, and demonstrated improved mobility, poor safety awareness, wandering, and frequent statements about wanting to go home, but the facility did not reassess elopement risk or implement elopement precautions. On the day of the incident, the resident walked down the hall carrying personal items, exited the front door unchallenged while assigned staff were passing dinner trays, and was later found by a visitor lying on the ground in the parking lot in dark, cold conditions, having fallen and sustained abrasions and scrapes, while staff and leadership acknowledged that the resident had not been identified or monitored as an elopement risk.
Facility staff did not conduct required annual performance evaluations for multiple GNAs, preventing systematic identification of skill weaknesses and related training needs. Review of employee files showed that several GNAs hired for more than a year had no documented performance evaluation within the past year. In an interview, the DON and NHA confirmed there was no established process to ensure annual performance evaluations for nurse aides, resulting in a failure to monitor and assess aide performance as required.
Facility administration permitted a nephrology NP to conduct consultations, including on new admissions, without an executed contract and without required physician orders, in violation of facility policy. One resident’s consult documented a medication error that the NP did not report to staff, and the issue was only identified later by surveyors. Additional residents were also seen by this NP over several months with consult notes uploaded days after visits and no corresponding nephrology orders. The medical director reported that nephrology consults should be based on diagnosed need and attending physician orders, was not overseeing these consults, and confirmed there was no nephrologist signing off on the NP’s work.
Facility staff did not maintain an effective training program for all personnel. Orientation materials lacked behavioral health content based on the facility assessment, and the infection control module omitted the facility’s own infection prevention and control policies and procedures. Multiple GNAs, an LPN, and a laundry aide were not current with required computer-based trainings, including abuse, Resident Rights, and infection control. Corporate assigned annual CBT modules, but there was no system in place at the facility level to ensure staff completed the required education, and leadership could not provide a rationale for these deficiencies.
Facility staff failed to establish and implement a comprehensive nurse aide training program that ensured each aide received at least 12 hours of annual education, including dementia care, abuse prevention, and skills competencies. Review of three aides’ personnel files and computer-based training transcripts showed no documented annual performance evaluations and no evidence of completing the required 12 hours of competency-based training within the past year. The existing nurse aide training plan consisted only of computer-based modules without skills competency components, and leadership staff, including the NHA and acting Nurse Practice Educator, confirmed that a formal nurse aide training program had not been developed or implemented.
The facility failed to timely report multiple allegations of abuse, neglect, and injuries of unknown origin to the State Agency within required timeframes. In separate incidents, a resident reported inappropriate touching, another had a bruise and discoloration to the right knee and shin first identified by family, a ventilator‑dependent resident experienced loud and aggressive behavior and threatening statements from an RT, and another resident reported pain after an improper transfer to a bedside commode. In each case, staff such as a UM, RN, LPN, and other management were aware of the concerns earlier than the times documented in reports to the SA, delayed notifying leadership, or did not escalate the concerns as required, resulting in reports being submitted hours to days after the initial allegations or discovery of injuries.
Staff failed to uphold resident dignity and self-determination when one resident repeatedly and loudly requested help to use the bathroom due to stomach pain and fear of incontinence while an LPN at the nurses’ station acknowledged the need but continued medication tasks and phone use without providing or arranging timely toileting, leaving another staff member to address the ADL need only after a significant delay. In a separate case, a cognitively intact resident with a documented care plan and physician’s order not to be awakened between 11 p.m. and 7 a.m. was disturbed when an RN entered the room while the resident slept and pulled down the covers to check a colostomy bag, and additional TAR orders were scheduled during the no-disturbance period, requiring staff to wake the resident despite the clearly stated preference.
Two residents experienced failures in care and protection when an assigned GNA did not provide any ADL care to a fully dependent, incontinent resident for an entire shift, despite documentation indicating care had been provided, and an RT behaved loudly and aggressively toward a ventilator‑dependent resident, making threatening statements about tying the resident down and "hitting back." An LPN on the ventilator unit, though familiar with the abuse policy, delayed reporting concerns about the RT’s conduct to management, and the incident was not reported to the state agency until several hours after the aggressive behavior began.
A contracted respiratory therapist allegedly intimidated a resident by stating that if a patient hit him, he would hit back, while the resident was agitated and raising hands in a blocking manner. A GNA later heard a loud smack from the room and, upon questioning, was told by an LPN that the therapist had not hit the resident but had clapped near the resident’s ears. Both the GNA and LPN felt uncomfortable but did not immediately remove the therapist from patient care, despite the LPN’s knowledge of the abuse policy and the unit’s ventilator status. Concerns were not promptly reported to the unit manager or DON, resulting in a failure to ensure resident safety by immediately removing the alleged perpetrator from patient care following an abuse allegation.
A resident received a double dose of oxybutynin ER over an extended period due to a medication order error that was not reported or corrected when first identified. A nephrology NP consultant documented that the resident was on a duplicate oxybutynin dose and recommended monitoring for LUTS while not recommending continuation of that drug, but did not notify facility staff or follow up, instead only uploading the consult into the EHR days later. The DON later learned that the NP had chosen not to report the error because she did not want to get anyone in trouble, resulting in the medication error remaining unaddressed.
Physicians and NPs did not consistently enter and upload progress notes and orders at the time residents were seen, resulting in delays and failures in implementing treatment plans. A resident admitted after a fall with rib fractures had a nephrology NP consult that was uploaded days after the visit, and the DON confirmed that nephrology consults and recommendations were not being promptly communicated. The facility NP stated she does not review the MAR and was unaware of the nephrology consult, so a medication error went unidentified until raised by a surveyor. For the same resident, an attending physician’s H&P note, including medication reconciliation and new orders for Oxybutynin discontinuation and Trospium initiation, was completed and uploaded many hours after it was started and the orders were never implemented, leaving the resident on duplicate Oxybutynin. Another resident’s physician note was dated as if the resident had been seen two days before the note was actually created, delaying staff access to any new orders, and the DON reported that multiple physician notes from prior months were also uploaded several days after completion.
The facility failed to ensure GNAs were competent in providing care, as shown by two incidents and missing competency documentation. In one case, a resident who required moderate assistance for toileting per the care plan was left alone on the toilet by a GNA, leading to a bathroom fall after the resident attempted to self-transfer. In another case, a resident with a broken leg reported pain after being transferred by a GNA, who described providing contact guard support by holding the resident’s ankles and later lifting the resident’s legs off the bed, prompting the resident to cry out in pain. Review of both GNAs’ files revealed no evidence of required skills checklists, annual evaluations, or training records, and leadership acknowledged concerns about the lack of training and education.
A resident admitted after a fall with rib fractures and with overactive bladder and BPH was given duplicate oxybutynin ER therapy when staff followed two concurrent orders for 10 mg and 5 mg (2 tabs) every morning, resulting in a total daily dose of 20 mg instead of the single 10 mg dose documented on hospital discharge records and physician notes. The MAR showed both orders were administered over multiple days. A nephrology NP documented the duplicate dosing in a consultation note she uploaded herself but did not notify facility staff, and the DON reported that consultations were expected to be routed through the unit manager or ADON for review and entry.
Facility administration failed to maintain proper oversight and documentation for a nephrology NP consultant, allowing consultations on residents without a timely-uploaded record, without a pre-existing contract, and without alignment between the DON and medical director on when and how the NP should be used. Leadership did not maintain or review a current facility assessment, so needed staff competencies were not defined, and orientation materials omitted required behavioral health content. Multiple clinical and non-clinical staff, including GNAs, an LPN, an RN, an activity assistant, and a laundry aide, had not completed required annual trainings, and the infection control module lacked facility-specific policies. Nurse aide files lacked annual performance evaluations and evidence of 12 hours of competency-based training, and the nurse aide training program consisted only of generic computer modules, with no structured competency validation or educator consistently overseeing completion.
The facility failed to implement an effective process for communication between the governing body and the administrator, including how, how often, and what information should be communicated. The written governing body policy lacked an implementation date and, although it required members to be active, engaged, and involved in facility affairs with direct access to the administrator and compliance officer and participation in QAPI, there was no evidence that governing body members attended QAPI meetings. Documentation identified the administrator as the Compliance and Ethics Officer and the DON, social worker, and medical director as members of the Compliance and Ethics Committee, but QAPI sign-in sheets did not show governing body participation. The NHA reported being unaware of a policy on governing body involvement, confirmed that the governing body had not attended QAPI meetings, and stated that she had not contacted them since her return to the facility.
Facility leadership failed to complete and maintain a comprehensive facility-wide assessment of needed resources for competent resident care. When surveyors requested the assessment, the NHA initially could not locate it and later produced an incomplete “Facility Assessment Tool” that was dated earlier and listed multiple signatories. The NHA acknowledged she had not reviewed or developed a facility assessment since returning to her role, and also reported having had no contact with the governing body during that time, despite the assessment indicating governing body involvement. The deficiency is cross-referenced to F835 and F940.
Facility staff did not ensure that an Infection Preventionist (IP) participated in QAPI committee meetings as required. Review of QAPI meeting sign-in sheets over a 10‑month period showed that an IP did not attend at least quarterly, with half of the reviewed meetings lacking IP attendance. A corporate clinical resource nurse, serving as the acting QA coordinator and IP, reported that no staff member had been formally assigned as an IP during this time frame, resulting in the QAPI group not having all required members.
The facility did not conduct comprehensive investigations into two separate allegations of abuse and neglect. In one instance, a resident with cognitive and physical impairments reported rough care by a GNA, but the investigation lacked interviews about prior behaviors and did not assess if other residents felt unsafe. In another case, after a neglect allegation, only residents able to communicate were interviewed, and non-verbal residents under the same staff member's care were not assessed, leaving the investigation incomplete.
Surveyors identified that multiple residents who required assistance with ADLs, including incontinence care and showers, did not receive the necessary personal care as documented in their records. One resident was left soiled for hours, another received far fewer showers than scheduled, and a third had multiple shifts with no documentation of care provided. Staff interviews confirmed gaps in care and documentation, and discrepancies were found between paper and electronic schedules.
A resident was transferred to the hospital for shortness of breath after experiencing a change in condition. Documentation by an LPN indicated that PRN oxygen was administered, but review of the medical record found no physician's order for the oxygen use. The DON confirmed that no order was entered into the resident's record.
Staff with facial hair, including a dietary aide, the kitchen manager, and the corporate Certified Dietary Manager, were observed preparing and handling food in the kitchen without wearing beard restraints as required by professional standards. The deficiency was acknowledged by the Nursing Home Administrator and the involved staff when brought to their attention.
A binder intended to display the most recent federal survey results was missing these documents, and staff were unaware of the omission until it was pointed out during a survey. The only location for survey results in the facility did not contain the required information, as confirmed by the DON and Regional Nurse Consultant.
A resident who was cognitively intact and responsible for their own medical decisions was not provided with information or opportunities to formulate an advance directive. Review of the medical record and interviews with the Social Services Director confirmed that no documentation or materials regarding advance directives were offered or discussed with the resident.
A resident experienced theft of personal items and cash after the lock on their bedside cabinet remained broken for one to two months, despite repeated reports to nursing staff. The unsecured drawer was observed open with valuables inside, and the resident was unable to secure their belongings. The DON acknowledged the failure to protect the resident's property and the lack of support for filing a grievance.
A resident reported missing hearing aids, but staff failed to initiate or follow the facility's grievance process. The grievance policy lacked identification of a Grievance Official, and staff were unclear about their roles in handling grievances. Although the grievance log showed the issue as resolved, the resident continued to report the hearing aids as missing, and key staff were unaware of the complaint or its resolution.
A resident received multiple doses of PRN Ativan without documentation of attempted non-pharmacological interventions or adequate behavioral indications for use. Nursing staff did not record required information in the eMAR or other available documentation systems, despite clear expectations for such documentation.
A resident with moderate cognitive impairment was transferred to a hospital, but there was no documentation that the resident's representative received written notification of the facility's bed hold policy or a transfer notice. Staff interviews confirmed uncertainty or lack of documentation regarding the process for providing these required notifications.
A resident's MDS assessment inaccurately documented insulin injections for seven days, despite no supporting diagnosis, orders, or evidence of injections in the medical record. The MDS nurse, who relied on the MAR for information, was unable to provide documentation to support the recorded insulin use and acknowledged the error after review.
A resident with schizoaffective disorder and developmental delay was admitted without completion of a required PASARR Level II evaluation. Record review and staff interview confirmed that neither a Level II review nor an exemption was documented, despite care planning for mental health and developmental conditions. The deficiency was acknowledged by facility staff during the survey.
Surveyors found that two residents did not have individualized care plans reflecting their assessed needs and preferences. One resident's care plan lacked details about preferred activities, pet visits, and outdoor time, and did not include current orders or documentation for pressure ulcer prevention equipment. Another resident's care plan omitted preferences for outdoor and religious activities and failed to address ongoing bilateral leg edema, despite staff awareness of these issues.
Two residents did not receive individualized or consistent activity programming in accordance with their assessed needs and preferences. One resident with cognitive impairment had a care plan lacking specific activities and documentation, with many days showing no activity participation. Another resident with dementia and hearing loss was left without meaningful engagement, and activity logs did not reflect their preferences for outdoor time or religious services.
A resident with significant hearing and vision impairment was not assisted in obtaining necessary hearing aid repairs, despite staff awareness of the issue. The hearing aid remained nonfunctional and unused, and staff interviews revealed a lack of communication and follow-through to address the resident's needs.
A resident with significant cognitive impairment and a stage 4 pressure ulcer did not consistently receive wound care as ordered due to errors in entering wound care orders, missed documentation of dressing changes, and incorrect air mattress settings. Staff failed to ensure the air mattress was set according to the resident's weight and did not maintain required documentation or current orders for its use, resulting in lapses in pressure ulcer prevention and care.
A bottle of toilet bowl cleaner containing bleach was found stored under the sink in a nourishment pantry secured by keypad entry. An LPN and the unit manager present at the time acknowledged the chemical should not have been stored there, indicating a failure to ensure safe and appropriate storage of toxic chemicals.
Surveyors found that annual performance evaluations were not completed for two GNAs, as only one evaluation was provided when requested. The Administrator confirmed the absence of required evaluations, and no further documentation was submitted before the survey ended.
A facility failed to accurately reconcile and document controlled medications, as required by policy. An RN inaccurately signed for both on-coming and off-going shifts during narcotic counts, and this error was confirmed by a unit manager. The DON acknowledged that the facility's narcotic reconciliation practices did not meet acceptable standards.
The facility failed to ensure timely communication and documentation of pharmacy recommendations during monthly medication regimen reviews for two residents. In one case, a pharmacist's report was sent late and another was missing from the medical record, while in another case, there was no documentation of provider review or action taken in response to pharmacy recommendations. The DON confirmed these lapses in the medication management process.
A resident with hypertension received blood pressure medication outside of prescribed parameters, as the medication was administered even when the systolic blood pressure was below the threshold specified in the medical orders. The DON confirmed that the medication was given inappropriately on multiple occasions, as documented in the eMAR.
Surveyors found expired lubrication jelly in the emergency cart and unattended diabetic lancets on a medication cart, both confirmed by nursing staff as improper. Additionally, all medication refrigerators lacked properly secured narcotic lock boxes, with some missing or broken, and maintenance staff were unaware of repair needs, contrary to facility policy.
A resident with documented dental issues reported never receiving dental care, despite being enrolled in a dental program and having monthly premiums deducted from their personal funds. The DON stated the resident refused services, but there was no documentation to support this, and the resident denied refusing care.
Surveyors identified that two residents had discrepancies between their MOLST forms and the corresponding physician orders in the EHR. In one case, a resident's MOLST allowed intubation while the EHR order did not, and in another, a resident's MOLST prohibited hospital transfer while the EHR order permitted it for unmanaged symptoms. These mismatches were confirmed by staff during the survey.
Staff did not consistently follow infection prevention and control protocols, including Enhanced Barrier Precautions and hand hygiene, for three residents with indwelling devices or infections. Lapses included not donning required PPE during high-contact care, failing to perform hand hygiene before and after glove use, and improper disposal of contaminated materials. These actions were acknowledged by the involved staff and unit managers.
A review of employee files found that several staff members did not have documentation showing they were offered the current COVID-19 vaccine or that they accepted or refused it. This was confirmed by both the regional Nurse Consultant and the DON, with one staff member no longer employed and no declination available for that individual.
A resident identified as an elopement risk, who required a WanderGuard device on their wheelchair, was observed unattended in the main entrance lobby. When the WanderGuard alarm was triggered during a demonstration, the doors did not close or lock as required, and staff were unaware of how to properly assess the system's function. The DON confirmed that elopement risk residents should be supervised and was not aware of the malfunction, resulting in a failure to maintain the safe operation of the WanderGuard exit system.
The facility did not promptly notify the attending provider, responsible party, or registered dietitian when a resident experienced significant weight loss while on tube feeding, and also delayed notification after another resident's fall and change in condition. Documentation and communication lapses led to delays in addressing these significant changes, contrary to facility policy.
A resident with severely impaired cognition did not consistently receive the necessary assistance with meals, as required by their assessment. Review of GNA ADL documentation showed multiple shifts over several months where meal assistance was not documented, and this lack of documentation was confirmed by the DON.
A resident with a history of hip surgery did not receive effective pain management, as staff failed to document pain assessments and the use of non-pharmacological interventions before administering PRN opioid medication. Additionally, there was no record of further pain management actions when the resident continued to experience pain after medication, contrary to provider orders and DON expectations.
A resident with a history of trauma from a house fire and family loss did not have a care plan that identified specific trauma triggers or interventions to prevent re-traumatization. The care plan only included an evaluation for a psych consult, and both the DON and social services director confirmed that more detailed interventions were expected.
A resident with a stage 3 pressure ulcer did not receive adequate wound care due to a failure in transcribing treatment orders into the MAR, resulting in the worsening of the ulcer and the development of two additional unstageable pressure ulcers. The resident was hospitalized with sepsis and cellulitis. Interviews revealed a lack of communication and responsibility among staff, and the family was not informed about the severity of the wounds.
The facility failed to prevent falls and implement necessary interventions for two residents. One resident, requiring two-person assistance, fell from bed due to inadequate supervision, resulting in a suspected fracture. Another resident with severe cognitive impairment experienced two unwitnessed falls, with no new interventions documented to prevent recurrence. The facility did not update care plans or adhere to its fall prevention policy.
Failure to Identify and Manage Elopement Risk for Cognitively Impaired Resident
Penalty
Summary
The deficiency involves the facility’s failure to identify a cognitively impaired resident as an elopement risk and to implement interventions to prevent elopement, resulting in the resident leaving the building unsupervised. The facility had an elopement and wandering policy requiring residents to be assessed for elopement risk on admission and throughout their stay, with high‑risk residents to receive an alarm bracelet and an individualized care plan. On admission, the nursing elopement assessment for this resident was completed by an LPN, who marked the resident as unable to ambulate; this locked the remainder of the elopement assessment and resulted in the resident being deemed not at risk for elopement. This determination was made despite hospital records showing that prior to admission the resident had been living at home, driving, and working, and that during the hospital stay the resident could ambulate with a rolling walker and assistance. Following admission, multiple clinical findings and events indicated that the resident’s condition and behavior had changed in ways relevant to elopement risk, but the facility did not reassess the resident for elopement until after the elopement occurred. Progress notes documented that the resident fell twice in the early morning of one day when attempting to get out of bed and walk, with staff noting the resident was unsteady. A care plan was initiated for noncompliance with using a walker. A Brief Interview for Mental Status determined the resident had severe cognitive impairment, and both the attending physician and a nurse practitioner documented that the resident was incapable of comprehending information and making decisions due to a hemorrhagic stroke. Therapy notes showed that the resident’s mobility improved, including ambulating 70 feet with a rolling walker and minimal assistance, which constituted a change in condition. Staff interviews later revealed that the resident frequently talked about going home, became more worked up when family prepared to leave, walked unassisted despite being unsteady, wandered without clear purpose, and had poor safety awareness. On the day of the elopement, the resident was observed by the receptionist walking down the hallway carrying a wash basin with items and a shoebox, then exiting through the front door; the receptionist was unsure if the individual was a resident and did not intervene before the resident left the building. The resident’s assigned LPN and GNA reported they were passing dinner trays and checking blood sugars and did not see the resident leave the unit. A visitor arriving for a Thanksgiving event later found the resident lying on the ground in the visitor parking lot in dark, cold weather, still carrying the basin and shoebox. Another LPN leaving the facility also saw the resident on the ground behind a parked car and initially did not recognize the person as a resident until noticing an adult brief. When interviewed, the resident stated they had gone outside to go home. The facility’s own investigation concluded that the resident left the facility, was outside for several minutes, and was found lying in the parking lot, and that staff had not previously identified or care planned the resident as an elopement risk despite documented behaviors and functional abilities that met the facility’s own criteria for elopement risk. The facility’s investigation file also showed that, prior to the incident, staff education on the elopement policy and elopement assessments had been started but not completed for all staff. Interviews with the interim DON and other staff confirmed that elopement assessments were expected on admission, quarterly, and with changes in condition or behavior, and that the resident’s behaviors—such as repeatedly talking about going home, packing belongings, and exit‑seeking—should have triggered reassessment. The NHA acknowledged that the resident was not being monitored as an elopement risk because the admission assessment had categorized the resident as not at risk, even though the NHA identified behaviors like wanting to go home and packing belongings as high‑risk indicators. These combined assessment failures, lack of reassessment after clear changes in condition and behavior, and lack of effective supervision and response to observed exit‑seeking behavior led to the resident’s elopement and subsequent fall in the parking lot, where the resident sustained an abrasion to the right side of the face and scrapes on both hands.
Removal Plan
- Resident #6 no longer resides in the facility.
- Complete updated elopement evaluations for all current residents to determine if any residents are at risk for elopement.
- Complete updated elopement evaluations by the Unit Managers and DON.
- Recheck alarm bracelets for proper placement and function for all residents determined to be at risk for elopement.
- Place any resident identified at increased risk for elopement on appropriate elopement precautions and update the care plan.
- Educate all facility licensed staff on the elopement policy and procedure, including the elopement risk evaluation process, to ensure elopement risk is reassessed.
- Educate all licensed nurses.
- Educate any licensed staff member unable to attend scheduled education upon arrival to the facility, and ensure education is provided prior to beginning their shift.
- Continue to educate all non-clinical staff on elopement policy and procedures, including identifying elopement risk signs and symptoms and reporting to appropriate clinical staff.
- Educate any facility staff member unable to attend scheduled education upon arrival at the facility, and ensure education is provided prior to beginning their shift.
- Validate education by administering quizzes randomly with 10% of staff weekly.
- Conduct audits monthly.
- Report findings at the monthly QAPI meeting to monitor progress towards improvement and recommendations.
Lack of Annual Performance Evaluations for Nurse Aides
Penalty
Summary
Facility staff failed to ensure that geriatric nursing assistants (GNAs) received annual performance evaluations of their skills, as required to identify weaknesses and provide targeted training. Record review on 1/22/26 showed that GNA #37, hired in 11/2018, had no documented performance evaluation within the last 12 months. Similarly, GNA #14, hired in 2/2019, and GNA #36, hired in 4/2023, also had no evidence of a performance evaluation in the preceding year. In an interview on 1/22/26 at 12:21 PM, the DON and NHA acknowledged that the facility had no process in place to ensure that nurse aides received annual performance evaluations. This deficiency was cross-referenced to F947, indicating it related to training and competency requirements for staff.
Unauthorized Nephrology Consultations Without Orders or Contract Oversight
Penalty
Summary
Facility administration allowed a nephrology nurse practitioner (NP #13) to provide consultation services to residents without an established contract in place and without physician orders authorizing these consultations, contrary to facility policy. For Resident #16, a nephrology consult was completed on 1/13/26 and not uploaded until 1/15/26, and there was no physician order for this resident to be seen by a nephrologist or consultant. Within that consult, NP #13 documented a medication error on the resident’s medication administration record but did not notify facility staff; the error was instead brought to the DON’s attention by the survey team on 1/21/26, eight days after NP #13 identified it. The facility’s policy on Provision of Physician Ordered Services, revised 2/18/25, states that no diagnostic tests or consultation requests will be performed without specific orders from a physician, PA, NP, or CNS in accordance with state law. Further record review of four additional randomly selected residents showed that all had been seen by the same nephrology NP consultant beginning around 11/9/25, with consultation notes uploaded days after the visits and no corresponding physician orders for nephrology consultations. NP #13 was reportedly seeing every new admission based on lists provided by unit managers when she arrived. The facility medical director stated that the process for nephrology consultation should involve residents with a diagnosed need and an order from their attending physician, and acknowledged that the contract for this consultant was not signed until 1/27/26, despite her seeing residents since at least November 2025. He also stated that he was not the resource following up on NP #13’s consultations and that this should be an actual nephrologist, and there was no nephrologist signing off on NP #13’s consultations.
Failure to Maintain Effective Staff Training Program and Ensure Completion of Required Education
Penalty
Summary
Facility staff failed to develop and implement an effective training program for new and existing staff, contracted staff, and volunteers, as required by regulation and based on the facility assessment. Review of the facility’s orientation PowerPoint on 1/22/26 showed that behavioral health topics were not included, despite the requirement that such topics be based on the behavioral health needs identified in the facility assessment for the resident population. Although the list of computer-based training modules included required topics such as effective communication, Resident Rights, Elder Abuse, QAPI, Infection Control, Compliance and Ethics, and Behavioral Health, the infection control module did not include the facility’s own infection prevention and control policies and procedures. During interview, the NHA reported she did not have a copy of the previous NHA’s facility assessment and had not completed a new assessment since returning to the position in 8/2025, resulting in training topics not being aligned with the facility’s assessed needs. Review of individual staff computer-based training transcripts on 1/22/26 showed multiple staff members were not current with required trainings. One GNA had completed only four computerized training modules in 2024, with abuse being the only required topic listed, and had no completed trainings between 2021 and those 2024 modules. An LPN had last completed computerized training modules in 2022, and two other GNAs had not completed computerized training modules since 2024. A laundry aide had not completed Resident Rights training since 2023 and had not completed infection control training that included the facility’s policies and procedures. The Corporate Clinical Resource Nurse, who had served as interim DON and was acting as Nurse Practice Educator, stated that corporate determined and assigned annual computer-based training topics, but the facility had no system to ensure staff actually completed the assigned modules. When these concerns were reviewed with the NHA, she offered no rationale for the deficient practice.
Failure to Implement Required Annual Nurse Aide Training and Competency Program
Penalty
Summary
Facility staff failed to develop and implement a nurse aide training program that ensured each nurse aide received 12 hours of annual training, including competencies and education in dementia care and abuse prevention, and that training addressed weaknesses identified during annual performance evaluations. Record review on 1/22/26 showed that the personnel file for GNA #37, hired in 11/2018, contained no evidence of a performance evaluation or 12 hours of training with competencies in the last 12 months. Similarly, the file for GNA #14, hired in 2/2019, and the file for GNA #36, hired in 4/2023, lacked documentation of a performance evaluation or 12 hours of competency-based training in the last 12 months. Review of computer-based training transcripts for these three GNAs also failed to show completion of 12 hours of training with competencies in the last 12 months. On 1/16/26, review of the facility’s nurse aide training program/plan revealed it consisted only of a list of computer-based training modules and did not include skills competencies. The NHA and Corporate Clinical Resource Nurse Staff #3 confirmed that this list was their nurse aide training program, and the acting Nurse Practice Educator (Staff #13) stated that the facility had not developed and implemented a training program for nurse aides. These findings were cross-referenced with F730.
Failure to Timely Report Allegations of Abuse, Neglect, and Injuries of Unknown Origin
Penalty
Summary
The deficiency involves the facility’s failure to timely report allegations of abuse, neglect, and injuries of unknown origin to the State Agency (SA) within required timeframes after staff became aware of them. For one incident, a resident reported to a GNA that someone had been in the room and touched the resident inappropriately at 6:45 AM. The on‑call Unit Manager acknowledged being aware of the allegation before 9:30 AM but did not notify the Nursing Home Administrator (NHA) until 9:30 AM, and the report to the SA was not sent until 10:47 AM. The NHA, who was involved in abuse investigations and review of final reports, could not explain the discrepancy between the time the allegation was known and the time it was reported to the SA. In another incident, an injury of unknown origin involving discoloration and bruising to a resident’s right knee and shin was known to staff earlier than what was reported to the SA. A family member reported a bruise on the resident’s right knee on one evening, and an RN documented this in the progress notes the following day, which would have required reporting to the SA within 24 hours. However, the facility’s investigation file indicated that management did not recognize the injury of unknown origin until two days later in the morning, and the SA was not notified until late that morning. The RN involved stated she knew injuries of unknown origin should be reported to the NP and supervisor and that suspected abuse should be reported to the NHA within 2 hours, but she had no rationale for not reporting this injury when first made aware. The Corporate Clinical Resource Nurse confirmed the RN’s earlier awareness, and the NHA again could not explain the discrepancy in the reported awareness time. Additional deficiencies occurred when staff failed to promptly report allegations of abuse and improper care involving other residents. In one case, a respiratory therapist was documented as having loud, aggressive interactions with a ventilator‑dependent resident, including statements about tying the resident down or sending the resident out, and a statement that patients who hit the therapist would be hit back. A GNA described the resident as anxious with arms up blocking the therapist, and the LPN on the unit acknowledged knowing the abuse policy and recognizing the behavior as inappropriate but only texted the unit manager hours later; the facility did not report the allegation to the SA until approximately five hours after the start of the therapist’s documented aggression. In another case, a resident reported pain and an inappropriate transfer by a GNA during a move to a bedside commode, and the resident’s daughter later called to reiterate the resident’s pain and allegation. Although the GNA was reassigned and management was notified, no further action was taken until two days later when the resident continued to voice concerns and left AMA, and the SA was not notified of the allegation until that same day, well beyond the required reporting timeframe. The NHA acknowledged understanding that this reporting was late.
Failure to Honor Resident Dignity, ADL Needs, and Nighttime Preferences
Penalty
Summary
Facility staff failed to honor residents’ rights to dignity and self-determination by not addressing one resident’s ADL needs in a timely manner and by disregarding another resident’s clearly documented preference not to be disturbed during specified nighttime hours. During a unit tour, a resident later identified as Resident #7 was observed at the nurses’ station repeatedly and loudly requesting assistance to use the bathroom, stating they had stomach pain and did not want to soil themselves. An LPN at the nurses’ station verbally acknowledged that the resident needed a lift and should not stand, but then continued medication preparation and administration, later walking around the station and sitting at the desk on the phone without providing assistance, attempting to soothe the resident, or arranging for timely toileting. The observations showed that Resident #7 continued to call out for help for an extended period, from at least 11:03 AM until 11:15 AM, with visitors also present and concerned, while the LPN did not respond to the resident’s expressed need for toileting and relief of stomach pain. The resident’s care plan included that the resident was known to fixate on going to the bathroom and might sit on the commode without voiding, but the DON acknowledged that this did not excuse the lack of response from the nurse on the day of observation. ADL care was eventually provided at 11:24 AM by another staff member, an RN working in the role of a GNA, who took the resident to their room and placed them on the toilet, indicating a significant delay between the resident’s initial requests and the provision of toileting assistance. In a separate incident, the facility did not respect Resident #4’s documented preference and physician’s order not to be awakened between 11:00 PM and 7:00 AM. The resident had no cognitive impairment per a quarterly MDS and was able to voice needs, and the care plan and a physician’s order both specified that the resident was not to be woken during those hours. Despite this, an RN entered the resident’s room around 6:15 AM while the resident was asleep, pulled down the covers, and inspected the resident’s colostomy bag. Additionally, the Treatment Administration Record contained staff-entered orders scheduled between 11:00 PM and 7:00 AM, including turning and repositioning, catheter care, and administration of fluids, which required staff to wake the resident during the period they had expressly requested and been ordered not to be disturbed. The resident reported wanting staff to empty the colostomy bag before bedtime and stated being fully capable of requesting help when needed, and the unit manager confirmed awareness of the resident’s preference not to be awakened at night.
Failure to Provide ADL Care and Protect Residents From Intimidation and Abuse
Penalty
Summary
A staff member failed to provide required care and maintain respect and dignity for a dependent resident when a GNA assigned to Resident #10 did not provide any activities of daily living (ADL) care for an entire shift. The facility’s investigation documented that the GNA admitted he did not provide care all day, stating he believed the resident was a “no male” caregiver case, despite having signed off in documentation as providing ADL care to this resident on the previous day and earlier in the month. The resident’s MDS, completed shortly after the incident and reflecting the look‑back period that included the date of the allegation, showed the resident was dependent on staff for all ADLs, frequently incontinent of bladder, and always incontinent of bowel. The LPN assigned to the resident that day reported the resident never complained and that she did not notice the resident soiled, even though the MAR showed she had signed for applying powders and creams to multiple body areas that would have required assessment and recognition of any incontinence needing care. Another deficiency involved failure to protect a resident from intimidation and potential abuse by a respiratory therapist (RT). The RT documented that a ventilator‑dependent resident was repeatedly disconnecting from the ventilator and described the resident as combative, suggesting the resident be sent to the hospital if restraints were not used. A GNA present during the interaction reported that the RT was loudly and aggressively demanding help and stated that if the resident was not tied down, the resident would be sent out, and further reported that the RT told the resident that his patients know not to hit him because he hits back. The LPN caring for the resident acknowledged familiarity with the abuse policy and stated she knew the RT should have left but felt stuck due to working on a ventilator unit. She reported that she first texted her unit manager about the RT’s behavior later that afternoon and received only a brief response, and that she did not escalate the concern until the end of the shift, by which time the RT had gone home. The facility officially reported the incident to the state agency several hours after the onset of the RT’s documented aggressive behavior toward the resident.
Failure to Remove Alleged Abusive Respiratory Therapist From Resident Care
Penalty
Summary
The deficiency involves the facility’s failure to ensure resident safety by immediately removing an employee from patient care following an allegation of abuse or intimidation. A contracted respiratory therapist was alleged to have intimidated a resident by stating, in the presence of multiple staff, "I tell you like I tell all my patients, if you hit me, I hit back." A GNA reported that the resident was agitated and raising hands in a blocking manner, not attempting to hit the therapist, and that the therapist had been loud and agitated throughout the day. The GNA was upset by the incident and believed the nurse had reported the therapist. After the GNA left the room and was in the hall, she heard a loud “smack” sound; when the nurse exited the room, the GNA asked if the therapist had hit the resident, and the nurse responded that he had not, but had “clapped at [resident] ears.” The LPN caring for the resident recalled discussing the situation with the GNA and stated that both were uncomfortable but felt “stuck” because the therapist was the only respiratory therapist available on a ventilator unit. The LPN acknowledged familiarity with the abuse policy and that the therapist should have been removed from patient care but did not do so. According to interview statements, the unit manager documented first being notified of concerns about the therapist at 6:28 PM, which differed from the LPN’s account of earlier notification, and the DON was not notified of the concerns until a later date. The facility’s failure to immediately remove the therapist from resident care upon the allegation of abuse/intimidation and the delay in reporting up the chain of command led to the cited deficiency.
Unreported Oxybutynin Dosing Error Identified but Not Acted Upon
Penalty
Summary
Facility staff failed to ensure that services met professional standards of quality when a medication error involving oxybutynin was not reported or acted upon after it was identified. Medical record review of one resident’s MAR showed that the resident had been ordered and receiving a double dose of oxybutynin chloride ER, 20 mg instead of the intended 10 mg, from 1/9/26 until the date of review on 1/21/26. Oxybutynin is identified in the report as an anticholinergic medication used to treat overactive bladder, with overdose symptoms that may include central nervous system overactivity, rapid heartbeat, high blood pressure, anxiety, headaches, fever, cardiac arrhythmia, vomiting, respiratory failure, paralysis, and coma. Further review of the resident’s medical record showed that a nephrology NP consultant completed a consultation on 1/13/26 and documented that the resident was receiving a duplicate dose of oxybutynin. In that consultation, the NP did not recommend continuation of oxybutynin, unlike two other urinary medications, and recommended monitoring for lower urinary tract symptoms (LUTS). However, the NP did not report the medication error to facility staff, did not follow up on the issue, and only uploaded the consult into the EHR on 1/15/26, two days after completion. In an interview, the DON stated that when she later questioned the NP about why the error had not been brought to anyone’s attention, the NP said she did not want to get anyone in trouble. These actions and inactions resulted in the medication error going unreported and unaddressed for an extended period.
Untimely Physician Documentation and Failure to Implement Treatment Orders
Penalty
Summary
Physicians and NPs failed to complete and upload progress notes and orders to the medical record in a timely manner and did not ensure that care plans and treatment orders were fully reviewed and implemented. For one resident admitted after a fall with rib fractures, a nephrology NP consultation performed on 1/13/26 was not uploaded and available to staff until 1/15/26, and the DON confirmed that this consultant had been uploading her own reports days after seeing residents, with recommendations not being communicated. The unit manager described a new process in which the nephrologist enters their own orders and uploads their own consults, and also stated that the facility had not been receiving anything directly from nephrology for about two months. The facility NP reported that she does not review the MAR, was unaware that the resident had a nephrology consult, and therefore did not identify a medication error until it was brought to the DON’s attention by the surveyor. For the same resident, the attending physician began a history and physical note on 1/12/26 but did not complete and sign it until 1/13/26, making it available about 36 hours after initiation. That note documented reconciliation of medications and included an order to discontinue a 10 mg dose of Oxybutynin while continuing two 5 mg tablets, and to start Trospium for overactive bladder; however, these changes were not implemented, and the resident continued on a duplicate Oxybutynin dose until 1/21/26. For another resident, the attending physician entered an effective date indicating the resident was seen on 1/12/26, but the note was not created and available in the record until 1/14/26, delaying access to any associated orders. The DON acknowledged that there were multiple physician notes from prior months that were uploaded days after completion and that the attending physician involved no longer worked at the facility.
Failure to Ensure GNA Competency in Resident Transfers and Toileting
Penalty
Summary
The deficiency involves the facility’s failure to ensure that GNAs possessed and demonstrated appropriate competencies for safe resident care, as evidenced by two resident incidents and missing competency documentation. In the first case, a resident who, according to the care plan, required moderate assistance of one staff member for toileting was left alone on the toilet by the assigned GNA. The resident attempted to transfer independently from the toilet and fell in the bathroom, which was the second fall within a week while attempting to use the toilet. The facility’s fall investigation, reviewed with the DON, confirmed that the GNA did not follow the resident’s care plan by failing to remain with and appropriately transfer the resident. Review of this GNA’s employee file showed no annual evaluations of skill sets or online training, and the acting Corporate Clinical Resource Nurse/NPE/IP/QA nurse stated she was not aware of where employee certificates were kept and did not provide additional documentation. In the second case, a facility-reported incident involved a resident with a broken left leg who complained of pain after being transferred by the assigned GNA. The resident reported pain to the nurse and stated they had been inappropriately transferred, and an investigation was not initiated until the resident’s daughter later called to report ongoing pain and the allegedly improper transfer to a bedside commode. During the facility’s investigation, the GNA reported that during the first transfer back to bed, she provided contact guard support by holding the resident’s ankles, and during a second transfer, she lifted the resident’s legs off the bed, at which point the resident began yelling that they were being hurt. Review of this GNA’s personnel file showed that, although she had been hired months earlier, there was no new-hire skills checklist or annual evaluation of GNA skills. The DON acknowledged concerns about the lack of training and education, and these concerns were presented to facility leadership during the survey.
Failure to Prevent Duplicate Oxybutynin Therapy
Penalty
Summary
Facility staff failed to ensure a resident’s drug regimen was free from unnecessary drugs by administering duplicate oxybutynin therapy over a sustained period. Medical record review showed that the resident was admitted after a fall with rib fractures for monitoring of routine healing and also had diagnoses of overactive bladder and benign prostatic hyperplasia. Review of the physician orders and MAR revealed two concurrent orders: Oxybutynin Chloride ER 5 mg (2 tablets) every morning for bladder spasms and Oxybutynin Chloride ER 10 mg every morning for urinary retention, both signed out by staff from 1/9/26 through 1/21/26. Review of the hospital discharge records and physician notes showed only a single intended order for Oxybutynin 10 mg daily, not a total of 20 mg per day. Further review of the resident’s medical record identified that a nephrology consultation completed at the facility by a consultant NP documented that the resident was receiving a duplicate dose of oxybutynin. The consultant NP uploaded her own consultation report with recommendations days after the visit. The DON stated that consultations should go to the unit manager or ADON for review and then be entered by them, and it was reviewed with the DON that the nephrology consultant was uploading her own reports. The DON later reported that the NP acknowledged identifying the medication error but did not bring it to anyone’s attention, stating she did not want to get anyone in trouble.
Deficient Administration of Consultant Services, Facility Assessment, and Staff Training
Penalty
Summary
Facility leadership failed to ensure appropriate conditions and oversight for a nephrology nurse practitioner (NP) consultant who had been seeing residents since November 9, 2025. At least five residents had nephrology consultations documented starting January 21, 2026, but the completed consultation notes were not uploaded into the medical record for several days, even when they contained recommendations or concerns. The DON reported that the NP would be seeing all new admissions and all residents with kidney disease, while the medical director stated that the consultant was not to see every new admission and that a physician order and an actual nephrologist following behind the NP were required. During the survey, it was identified that there had been no contract in place during the months the NP had been seeing residents, and the contract produced by the NHA was signed only the day before, demonstrating a lack of an established, consistent process for use of this consultant. The facility did not have an accessible, current facility-wide assessment to determine needed resources and staff competencies. When surveyors requested the facility assessment, the NHA was unable to locate it and had to request it from corporate, and she acknowledged she had not reviewed the assessment since assuming her role on August 25. As a result, the training and skill sets required for staff to care for the resident population had not been determined. Review of the orientation PowerPoint showed that required behavioral health training was not included, and personnel files for an LPN, an RN, an activity assistant, and multiple GNAs showed they were allowed to care for residents without having completed the required behavioral health training. Further review of the facility’s training program revealed that while computer-based modules existed for required topics such as effective communication, resident rights, elder abuse, QAPI, infection control, compliance and ethics, and behavioral health, the infection control module did not include the facility’s own infection prevention and control policies and procedures. Training transcripts showed that several GNAs, an LPN, and a laundry aide had not completed required annual trainings or had significant gaps since prior years. The acting NPE stated that although a training process was in place, no one was ensuring timely completion, and these staff continued to work. Additionally, nurse aide files for multiple GNAs lacked evidence of annual performance evaluations and 12 hours of training with competencies in the last 12 months, and the nurse aide training program provided by the NHA consisted only of a list of computer-based modules without competency components. The acting NPE confirmed that the facility had not developed and implemented a nurse aide training program based on evaluations, and the NHA acknowledged there was no consistent person in the educator role.
Failure to Implement Effective Governing Body Communication and QAPI Involvement
Penalty
Summary
The facility failed to establish and implement a process for communication between the administrator and the governing body, including the mode of communication, frequency, and content of what was to be communicated. Review of the Governing Body Policy and Procedure showed no implementation date and stated that governing body members were to be active, engaged, involved in facility affairs, have direct access to the administrator and compliance officer through executive board sessions, and be involved in the QAPI program. A letter designated the administrator as the Compliance and Ethics Officer and identified the DON, social worker, and medical director as members of the Compliance and Ethics Committee. However, review of QAPI meeting sign-in sheets showed no evidence that any governing body member attended these meetings. In an interview, the NHA stated she was not aware of a policy regarding governing body involvement with the facility, reported that governing body members had not attended QAPI meetings, and acknowledged she had not contacted them since her return to the facility.
Failure to Complete and Accurately Document Required Facility Assessment
Penalty
Summary
Facility leadership failed to conduct and document a comprehensive facility-wide assessment to determine necessary resources for competent resident care during routine operations and emergencies. On 1/16/26 at 10:55 AM, the Nursing Home Administrator (NHA) was informed that an extended survey was being conducted and was asked to provide the Facility Assessment. During an interview later that day at 12:21 PM with the NHA and the Nurse Educator/Infection Preventionist, the NHA stated she was unable to locate the assessment and needed to request it from the corporate office. When asked if she had reviewed or developed a facility assessment since assuming the position in 8/2025, she reported that she had not. At 1:30 PM on the same day, the NHA provided a document titled “Facility Assessment Tool,” dated 1/5/26, which indicated it had been completed by the NHA, Medical Director, Governing Body representative, and others; however, review showed it was incomplete. In a subsequent interview at 1:46 PM, the NHA confirmed she had not reviewed or completed a facility assessment until the surveyor requested it on 1/16/26, initially explaining this by stating she started in the position in 8/2025, although it was later reported she had previously served as the facility’s NHA from 2020–2024. In a later interview on 1/20/26 at 3:17 PM, the NHA reported she had not been in contact with the governing body since returning in 8/2025, meaning she could not have obtained input from a governing body member as documented on the assessment provided to the survey team. Cross references were made to F835 and F940.
Failure to Ensure Infection Preventionist Participation in QAPI Meetings
Penalty
Summary
Facility staff failed to ensure that the Infection Preventionist (IP) was in attendance at the Quality Assurance and Performance Improvement (QAPI) committee meetings as required. Record review of QAPI committee meeting sign-in sheets for the period from March 2025 through December 2025 showed that an IP had not attended the meetings on at least a quarterly basis, with 5 of 10 meetings reviewed lacking IP attendance. During an interview, the Corporate Clinical Resource Nurse, who was acting as the Quality Assurance coordinator and IP, stated that the facility had not had a staff member formally assigned as an IP for the past 10 months. This lack of an assigned IP and the resulting failure to have the IP present at QAPI meetings led to noncompliance with the requirement that the Quality Assessment and Assurance group include the required members and meet at least quarterly with appropriate representation.
Failure to Thoroughly Investigate Allegations of Abuse and Neglect
Penalty
Summary
The facility failed to thoroughly investigate allegations of abuse and neglect involving two residents. In the first case, a resident with Alzheimer's disease, depressive disorder, and a femur fracture alleged that a GNA was rough during care, causing bleeding. Although the resident initially refused assessment, a later skin check showed no injury. The facility's internal investigation included interviews with some staff and residents, but did not document whether staff were asked about prior observations of rough or unprofessional behavior by the GNA, nor whether other residents felt unsafe or had experienced similar issues. The investigation was concluded as unsubstantiated without fully determining if other residents were at risk. In the second case, following an allegation of neglect by another resident against a staff member, the facility suspended the alleged perpetrator and interviewed some residents on the staff member's assignment who could communicate. However, the investigation did not include head-to-toe assessments of non-verbal residents who had also been under the care of the alleged perpetrator. The DON acknowledged that these residents, who could not speak for themselves, were not assessed as part of the investigation, resulting in an incomplete review of the potential neglect incident.
Failure to Provide and Document Required ADL Care
Penalty
Summary
The facility failed to provide necessary assistance with activities of daily living (ADLs) to residents who were unable to perform these tasks independently. In one case, a resident who was totally dependent on staff for incontinence care was found soiled by EMTs and ER staff after being unable to obtain help for over two hours, as documented in both emergency medical records and the resident's own report. Review of the resident's medical record and ADL documentation revealed multiple shifts with no recorded incontinence care provided, and the interim DON confirmed the lack of documentation for the identified periods. Another resident, diagnosed with dementia and severe cognitive impairment, was scheduled to receive two showers per week but received only one shower per month over a four-month period, as shown by a review of the ADL documentation. Discrepancies were found between the paper shower schedules and the electronic health record, and staff confirmed that showers were not properly scheduled in the EHR. A third resident, admitted for rehabilitation and nursing care after a serious fall and hospitalization, had multiple shifts with no documentation of personal care, including hygiene, eating, dressing, and toileting. The DON and NHA were unaware of the lack of documentation and could not provide evidence that care was given during these periods.
Failure to Maintain Accurate and Complete Medical Records for Oxygen Administration
Penalty
Summary
The facility failed to ensure that resident records were accurate and complete for a resident who was transferred to the hospital due to shortness of breath. Review of the clinical record showed that the resident experienced a change in condition and was given new orders for oxygen and other treatments by the on-call provider. Documentation from an LPN indicated that PRN oxygen at two liters per minute was administered. However, further review of the resident's medical record did not reveal any physician's order for the oxygen use. The Director of Nursing confirmed that no such order was entered into the resident's medical record.
Failure to Use Beard Restraints During Food Preparation
Penalty
Summary
Facility staff failed to adhere to professional standards for food safety by not wearing beard restraints during meal preparation and food handling in the kitchen. On two separate occasions, a dietary aide with a long beard was observed making pancakes and preparing resident meal trays without a beard restraint. Additionally, during a subsequent observation, both the corporate Certified Dietary Manager and the kitchen manager, who both had facial hair, were present in the kitchen without beard restraints. These staff members acknowledged not wearing the required protective equipment when questioned. The kitchen manager was informed of the deficiency but did not acknowledge it at the time, while the Nursing Home Administrator later acknowledged the findings during interviews. No information about residents' medical history or condition at the time of the deficiency is provided in the report.
Failure to Provide Accessible Survey Results
Penalty
Summary
The facility failed to ensure that the most recent federal survey results were readily accessible to residents, family members, and legal representatives. During an observation of the entrance hallway, a binder labeled as containing survey results did not include the most recent federal survey findings. The front desk receptionist was unaware of the missing documents until notified by surveyors and subsequently informed the administrator. Both the Regional Nurse Consultant and the Director of Nursing confirmed that the required federal survey tags were not present in the binder. It was also confirmed that the front desk was the only location in the facility where survey results were kept.
Failure to Provide Advance Directive Information to Cognitively Intact Resident
Penalty
Summary
The facility failed to provide a cognitively intact resident with information and opportunities to formulate an advance directive. Upon review of the resident's medical record, there was no evidence of an advance directive or documentation that information or materials regarding advance directives had been offered. The Social Services Assessment and Documentation for the resident indicated that no conversation or materials related to advanced care planning were provided, and all relevant questions were answered in the negative. During interviews, the Social Services Director confirmed that the resident did not have an advance directive in place and that there was no documentation showing that information or opportunities to complete one had been provided. The resident was responsible for making their own medical decisions, and there was no durable power of attorney for healthcare on file. The lack of documentation and provision of information was acknowledged by the Social Services Director during the survey.
Failure to Protect Resident Property Due to Broken Cabinet Lock
Penalty
Summary
A resident reported that personal items, including body wash, shampoo, and $12.00 in cash, were stolen from their room. The resident stated that the lock on their bedside cabinet had been broken for approximately one to two months and that repeated notifications to nursing staff about the issue did not result in any action. During observations, the surveyor noted that the resident's bedside cabinet drawer was open, with a bank envelope containing money and a hearing aid visible and unsecured, and that the resident was unable to lock the drawer. On a subsequent observation, the drawer was again found ajar while the resident was not present in the room. The Director of Nursing acknowledged that the broken lock failed to protect the resident's property and that the resident could not file a grievance without staff assistance.
Failure to Identify Grievance Official and Resolve Resident Grievance
Penalty
Summary
The facility failed to properly identify a Grievance Official in its grievance policy, ensure the policy was followed for processing grievances, and make prompt efforts to resolve a resident's grievance. A resident reported missing hearing aids to staff, who acknowledged the complaint but did not initiate or follow the formal grievance process. The grievance policy reviewed by surveyors was incomplete, lacking the name and contact information of the Grievance Official. Staff interviews revealed confusion about the grievance process, with some staff unaware of their responsibilities or the steps required to resolve grievances. Grievance forms were not readily available at the nurses' station as expected, and there was no clear documentation or follow-up on the resident's complaint. A review of the grievance log showed that the resident had previously filed a grievance regarding the missing hearing aids, which was marked as resolved and signed by the Nursing Home Administrator. However, the resident continued to report the hearing aids as missing, and staff members, including the Social Services Department and unit manager, were unaware of the grievance or its resolution. The Nursing Home Administrator, who identified himself as the Grievance Official, was also unaware of the grievance filed months earlier and acknowledged that the process had failed the resident.
Failure to Document NPIs and Indications Prior to PRN Psychotropic Medication Administration
Penalty
Summary
The facility failed to ensure that a resident was free from unnecessary psychotropic medication use, specifically regarding the administration of Ativan (Lorazepam) on an as-needed basis. Record review showed that the medication was administered 16 times in one month, but there was no documentation that non-pharmacological interventions (NPIs) were attempted or provided prior to giving the medication. Additionally, there was a lack of documentation indicating that the resident exhibited behaviors that would justify the use of the psychotropic medication on several occasions. Interviews with the Nurse Manager revealed that nursing staff are expected to document both the behaviors leading to the administration of psychotropic medications and the NPIs attempted beforehand. Multiple avenues for such documentation were available, including the eMAR, medication orders, progress notes, and behavior monitoring tasks. Despite these expectations and available methods, the required documentation was not present in the resident's medical record for the identified dates.
Failure to Provide Written Transfer Notice and Bed Hold Policy Upon Hospital Transfer
Penalty
Summary
A review of the medical record for a resident with moderate cognitive impairment revealed that, following the resident's transfer to an acute care facility, there was no documentation that the resident's representative was provided with written notification of the facility's bed hold policy or a written transfer notice including the reason for transfer. Interviews with facility staff, including an LPN, the director of nursing, and the receptionist, confirmed uncertainty or lack of documentation regarding the process for ensuring these notifications were sent. The deficiency was identified during a review of records and staff interviews, which showed that the required written notifications were not provided as mandated.
Inaccurate MDS Assessment of Insulin Administration
Penalty
Summary
The facility failed to ensure that Minimum Data Set (MDS) assessments accurately reflected a resident's medication usage. Specifically, a review of one resident's medical record showed that the MDS assessment documented insulin injections being administered on all seven days of the assessment period. However, there was no documentation in the medical record to support that the resident had a diagnosis of diabetes, any current or past orders for insulin, or any evidence that injections were given during the look-back period. The MDS nurse reported using the Medication Administration Record (MAR) to complete Section N Medications but was unable to provide supporting documentation for the recorded insulin administration. Upon review, the nurse acknowledged the error in the MDS assessment.
Failure to Complete Required PASARR Level II Evaluation
Penalty
Summary
The facility failed to ensure that a required Level II Preadmission Screening and Resident Review (PASARR) evaluation was completed for a resident with documented mental health and developmental conditions. Record review showed that the resident's PASARR Level I screening did not indicate a trigger for Level II evaluation or a 30-day short-term admission exemption, and there was no evidence of further screening or exemption coordination prior to admission. Despite the resident being care planned for agitation, schizoaffective disorder, and developmental delay, the necessary Level II evaluation was not conducted as required. During staff interview, the facility's social worker confirmed that both preadmission and post-admission PASARR Level I forms lacked documentation of a Level II review or exemption. The post-admission PASARR specifically noted that a Level II was required for intellectual disability, but no Level II clearance was obtained. The deficiency was acknowledged by facility staff and administration during the survey, with no additional evidence provided to demonstrate compliance.
Failure to Develop and Implement Comprehensive, Resident-Centered Care Plans
Penalty
Summary
The facility failed to develop and implement comprehensive, resident-centered care plans for two residents, as identified during a recertification survey. For one resident with significant cognitive impairment and limited mobility, the care plan did not specify the individual's preferred independent activities, nor did it address important preferences such as pet visits and going outside for fresh air, despite these being documented as very important in the Minimum Data Set (MDS) assessment. Additionally, the care plan for pressure ulcer prevention referenced the use of a bariatric air mattress and required checks for placement and function every shift, but there was no current physician order for the mattress, and documentation of these checks was missing after a certain date. The air mattress was also found to be set incorrectly, and staff were unclear about the correct settings and responsibilities for monitoring the equipment. For another resident, the activity care plan was not individualized to include the resident's preferences for going outside and participating in religious services, as indicated in the MDS assessment. The care plan only mentioned watching TV as an independent activity, omitting other significant preferences. The activities director confirmed that these preferences were not addressed in the care plan. Additionally, this same resident was admitted with pitting edema in both legs, and ongoing provider notes documented continued edema. However, the care plan did not address the resident's edema, despite staff and the director of nursing acknowledging the presence of this condition since admission. These omissions demonstrate a lack of comprehensive and individualized care planning based on residents' assessed needs and preferences.
Failure to Provide Individualized and Ongoing Activity Programs
Penalty
Summary
The facility failed to provide an ongoing program of activities that met the needs and preferences of its residents, as evidenced by the experiences of two residents. For one resident with significant cognitive impairment and limited physical mobility, the care plan did not specify the independent activities the resident enjoyed, nor did it address important preferences such as pet visits or going outside, despite these being identified as very important in the resident's Minimum Data Set (MDS) assessment. Documentation of activity participation was inconsistent, with many days lacking any record of activities, and family or friend visits were frequently documented as the sole activity. The Activity Director confirmed that he did not individualize the care plan to reflect the resident's specific interests and was unaware of which residents received pet visits. Activity documentation over a three-month period showed significant gaps, with many days unaccounted for and limited evidence of meaningful engagement in activities tailored to the resident's preferences. The care plan had not been updated to reflect the resident's current interests or to ensure that important preferences were being met. Another resident, who had dementia and hearing difficulties, was observed sitting in a wheelchair in their room without any meaningful activity. The resident expressed a lack of engagement and was unaware of available activities. The care plan for this resident included goals for participation in group, one-on-one, or independent activities, and the MDS assessment indicated a strong preference for going outside and participating in religious services. However, activity logs showed minimal participation, with only a few documented activities and no evidence that the resident's stated preferences were being addressed.
Failure to Assist Resident in Accessing Hearing Services
Penalty
Summary
A deficiency occurred when the facility failed to assist a resident with significant hearing impairment in gaining access to necessary hearing services. The resident, who is legally blind and hard of hearing, reported to staff that their hearing aid was not working and required a new battery or repair. Despite staff being aware of the issue, the hearing aid remained nonfunctional and was observed unused in the resident's bedside cabinet. Multiple observations confirmed that the resident was not wearing the hearing aid during daily activities, and documentation in the medical record indicated the resident's high level of hearing impairment and need for hearing aids. Interviews with nursing staff revealed a lack of follow-through and communication regarding the resident's need for hearing aid repair. While some staff acknowledged the problem and indicated they would inform the unit manager, the unit manager reported not being made aware of the issue. Additionally, staff reported not receiving training or education on the use or maintenance of hearing aids. The Director of Nursing acknowledged the facility's failure to assist the resident in accessing hearing services to maintain hearing abilities.
Failure to Accurately Implement Wound Care Orders and Air Mattress Settings for Pressure Ulcer Prevention
Penalty
Summary
The facility failed to ensure that wound care orders for a resident with a history of pressure ulcers were accurately entered into the electronic health record and that wound care was provided according to those orders. The resident, who had significant cognitive impairment and limited mobility, had a stage 4 pressure ulcer on the left hip. Medical record review showed inconsistencies in the documentation and implementation of wound care orders, including discrepancies in the frequency of dressing changes and missing documentation for several scheduled dressing changes. Orders from the wound specialist were sometimes entered incorrectly, such as being documented as every other day instead of daily, and there were instances where the site of the wound was not specified in the order. Additionally, the facility failed to maintain proper settings and documentation for the resident's bariatric air mattress, which was part of the care plan to prevent further pressure ulcers. The air mattress was observed to be set at 350 lbs, while the resident's weight ranged from 153 to 171 lbs, and staff were unaware of the correct setting. There was also a lack of a current physician order for the air mattress and no documentation that staff were checking the mattress for placement and function every shift as required by the care plan. The previous order for the mattress had been discontinued and not renewed upon the resident's re-admission. Interviews with nursing staff and the DON revealed confusion and lapses in the process for entering and verifying wound care orders and for ensuring the air mattress was set and checked appropriately. Staff acknowledged that errors had occurred in entering orders into the electronic health record and that documentation for required interventions was missing or incomplete. These failures resulted in the facility not providing pressure ulcer care and prevention measures as ordered and documented in the resident's care plan.
Improper Storage of Toxic Chemical in Nourishment Pantry
Penalty
Summary
During a recertification survey, it was observed that a bottle of toilet bowl cleaner containing bleach was stored underneath the sink in the nourishment room of the [NAME] Hall Pantry, which was secured by keypad entry. This area was one of four nourishment pantries inspected. Both an LPN and the unit manager were present during the observation and acknowledged that the chemical should not have been stored in that location. The presence of the hazardous chemical in the nourishment area constituted a failure by the facility to ensure that toxic chemicals were stored safely and appropriately, as required to keep the area free from accident hazards and to provide adequate supervision to prevent accidents.
Failure to Complete Annual Performance Evaluations for GNAs
Penalty
Summary
The facility failed to ensure that Geriatric Nursing Assistants (GNAs) received annual performance evaluations as required. During the recertification survey, surveyors requested the 2024 annual performance evaluations for three GNAs. The facility was able to provide the evaluation for one GNA but did not have evaluations available for the other two GNAs. The Administrator confirmed that there was no evidence of completed evaluations for these two staff members. The Director of Nursing was informed of these concerns, and no additional documentation was provided before the survey concluded.
Failure to Accurately Reconcile and Document Controlled Medications
Penalty
Summary
The facility failed to establish and maintain accurate systems for reconciling controlled medications according to acceptable standards of practice. During a review of the narcotic books, it was found that one out of four narcotic reconciliations was inaccurately documented. Specifically, a registered nurse signed for both the on-coming and off-going shifts, with the off-going shift signature being inaccurate. The nurse reported that this was how she was trained during orientation and appeared confused about the importance of accurate narcotic shift count documentation. Further review by the unit manager confirmed the early and inaccurate documentation of the nurse's initials on the narcotic sheet. The facility's policy requires two licensed nurses to account for all controlled substances and access keys at the end of each shift, but this standard was not followed. The Director of Nursing acknowledged that the facility's narcotic reconciliation practice did not meet acceptable standards.
Deficient Medication Regimen Review and Documentation
Penalty
Summary
The facility failed to ensure timely reporting and documentation of pharmacy recommendations during the monthly medication regimen review (MRR) process for two of five residents reviewed for unnecessary medications. For one resident, the pharmacist's MRR report for March was sent late, resulting in the attending physician signing the report after the subsequent month's review had already been conducted. Additionally, the MRR report for April was missing from the resident's medical record. The Director of Nursing (DON) confirmed that the pharmacist's recommendations were not communicated to the facility in a timely manner, and the facility's MRR policy did not specify a timeframe for the attending physician to respond to urgent needs identified by the pharmacist. For another resident, a review of pharmacy recommendations revealed that there was no documentation in the medical record indicating whether the attending provider had reviewed the pharmacist's recommendations or what actions, if any, were taken in response. The DON acknowledged that the required documentation of provider review and response to pharmacy recommendations was lacking. These deficiencies were identified through records review and staff interviews, highlighting lapses in the facility's medication management and documentation processes.
Failure to Adhere to Blood Pressure Medication Parameters
Penalty
Summary
The facility failed to ensure that a resident’s drug regimen was free from unnecessary medications. A review of medical orders showed that the resident, who had a diagnosis of hypertension, was prescribed a blood pressure medication to be administered every morning and at bedtime, with explicit instructions to hold the medication if the systolic blood pressure was less than 120. Despite these parameters, the medication was administered on multiple occasions when the resident’s systolic blood pressure was below the specified threshold. A review of the electronic Medication Administration Record (eMAR) for April 2025 revealed that the blood pressure medication was given outside the prescribed parameters on several dates and times. The DON confirmed during an interview that the medication was administered inappropriately on these occasions, as indicated by the eMAR documentation.
Failure to Secure and Properly Store Medications and Controlled Substances
Penalty
Summary
Surveyors identified that the facility failed to maintain medical products within expiration dates and in secure locations, as well as failed to have a system to secure access to controlled medications. Specifically, expired lubrication jelly packets were found in the emergency cart, and the Assistant Director of Nursing confirmed their use for airway procedures and acknowledged their expiration. Additionally, diabetic lancets were left unattended on a medication cart in a resident hallway without a nurse present, which was confirmed by both a nurse and the Director of Nursing as inappropriate. Further observations revealed that all four medication refrigerators in the facility lacked properly affixed or present narcotic lock boxes for controlled substances. In some cases, the narcotic box was unattached and could be removed with the shelf, while in others, the lock box was missing or the lock had been broken for at least a week. The Director of Maintenance was unaware of a repair request for the broken lock, and the facility's policy required a substantially constructed storage unit with two locks for controlled substances in areas without automated dispensing systems.
Failure to Provide Routine Dental Services and Lack of Documentation
Penalty
Summary
A deficiency was identified when a resident, who had been in the facility since late 2019 and was cognitively intact, reported never having seen a dentist during their stay. The resident's care plan, initiated in early 2021, documented broken teeth and likely cavities, but there was no evidence in the medical record that dental services had been provided to address these issues. Interviews with the DON revealed that the facility uses a program called Healthdrive to enroll residents for dental services, and the DON initially stated that the resident had refused these services. However, upon review, there was no documentation to support that the resident had refused dental care. The resident also denied ever declining dental services. Additionally, records showed that the facility was deducting a monthly premium from the resident's personal funds for dental services, yet there was no documentation of services provided or refusals.
Failure to Ensure Consistency Between MOLST Forms and EHR Orders
Penalty
Summary
The facility failed to ensure that orders for life-sustaining treatment in the electronic health record (EHR) matched the orders documented on the Maryland Orders for Life Sustaining Treatment (MOLST) forms, and did not maintain the accuracy of physician orders. For one resident, the MOLST form indicated a No CPR (DNR) status with permission to intubate, while the EHR contained an order for DNR and Do Not Intubate (DNI), which did not match the MOLST. Nursing staff reported referencing the MOLST form on the crash cart for code status during emergencies, but would check the EHR for code status during changes in condition. The discrepancy was acknowledged by staff, and it was noted that the MOLST was updated after the EHR order, but the EHR was not promptly updated to reflect the new MOLST instructions. In another case, a resident's MOLST form indicated No CPR, no intubation, and no transfer to the hospital, while the physician's order in the EHR stated DNR, DNI, but allowed transfer to the hospital for unmanaged symptoms. This mismatch between the MOLST and the physician's orders was confirmed by the Director of Nursing and the Nursing Home Administrator during the survey. No additional evidence was provided to resolve the discrepancies by the end of the survey.
Failure to Adhere to Infection Control and Hand Hygiene Protocols
Penalty
Summary
Staff failed to follow appropriate infection prevention and control practices for three residents requiring Enhanced Barrier Precautions (EBP) or other infection control measures. For one resident with an indwelling Foley catheter, a CNA transferred the resident without donning gown or gloves, and an LPN entered the room without performing hand hygiene, then hugged and repositioned the resident without using required PPE. Both staff members acknowledged the lapses in infection control. For another resident with a nephrostomy, an LPN entered the room without hand hygiene, donned gloves but not a gown, and began a dressing change. After being prompted by a surveyor, the LPN washed hands, donned a gown, and completed the procedure, but then disposed of the dirty dressing in the hallway while still wearing contaminated PPE. The LPN admitted to not following EBP or proper hand hygiene protocols. A third resident, who was being treated for MRSA and had diabetes, received an injectable medication from a nurse who failed to perform hand hygiene before donning gloves and after removing them. The nurse admitted to missing these steps despite having received prior education on hand hygiene. The facility's policy required hand hygiene before and after glove use, between resident contacts, and prior to medication preparation, but these protocols were not followed during the observed incidents.
Failure to Document COVID-19 Vaccine Offer and Refusal for Staff
Penalty
Summary
The facility failed to offer the most recent COVID-19 vaccine or document the refusal of the vaccine for staff members, as required. During a survey, review of six randomly selected employee files revealed that five staff members did not have documentation indicating they were offered the current COVID-19 vaccine, nor was there documentation of acceptance or refusal. This lack of documentation was confirmed by both the regional Nurse Consultant and the Director of Nursing. The Director of Nursing also reported that one of the staff members was no longer employed at the facility and no declination could be provided for that individual.
Failure to Maintain Safe Operation of WanderGuard Exit System
Penalty
Summary
The facility failed to maintain the safe operating condition of an exit equipped with the WanderGuard System, which is designed to prevent elopement among residents identified as being at risk. Six residents were identified as elopement risks, and one resident, who was non-ambulatory and required a WanderGuard device on their wheelchair, was observed unattended in the main entrance lobby on multiple occasions. Record review confirmed that this resident was care planned for WanderGuard use and required supervision. Staff interviews revealed a lack of knowledge regarding how to assess the functionality of the WanderGuard system. During a demonstration, the WanderGuard alarm was triggered as the resident's wheelchair approached the main entrance, but the sliding glass doors did not close or lock as intended, allowing the possibility for a resident to exit the building. The DON confirmed that elopement risk residents should be supervised and was unaware that the doors could remain open when the WanderGuard system was activated. The deficiency was further substantiated by direct observation and staff acknowledgment that the system did not function as required to ensure resident safety.
Failure to Timely Notify Providers and Representatives of Significant Changes in Condition
Penalty
Summary
The facility failed to notify the attending physician, resident's representative, and registered dietitian in a timely manner when there were documented changes in residents' conditions. In one case, a resident who received all nutrition via tube feedings was identified as having severe malnutrition and was expected to gain weight. However, the resident experienced a significant weight loss of more than 5% in one week and nearly 8% in less than two weeks. Despite facility policy requiring immediate notification of significant weight changes, there was no documentation that the physician, nurse practitioner, registered dietitian, or responsible party were notified of the weight loss until more than a week after it was first identified. Nursing progress notes also failed to document the significant weight loss promptly, and the weight loss was not reported to the dietitian until ten days after it occurred. Additionally, the facility did not immediately notify the attending provider and representative of another resident's fall and subsequent changes in condition, including increased discomfort and changes in the appearance of a surgical incision. The fall and change in condition were reported two and five days later, respectively, rather than immediately as required. Interviews with the DON confirmed that changes in condition should be reported immediately, but the records showed delays in notification. These deficiencies were identified through record review and staff interviews, and were evident for one out of three complaints reviewed during the recertification survey and for one out of three residents reviewed for tube feeding. The lack of timely notification and documentation regarding significant changes in residents' conditions constituted a failure to follow facility policy and regulatory requirements.
Failure to Provide Required Meal Assistance to Cognitively Impaired Resident
Penalty
Summary
A deficiency was identified when a resident with severely impaired cognition, as documented in the Minimum Data Set (MDS), did not consistently receive the required assistance with meals. The resident's medical record indicated a need for set up or clean up help during meals. However, a review of geriatric nurse aides' (GNAs) activity of daily living (ADL) documentation revealed missing records of meal assistance for multiple shifts over a three-month period. Specifically, there was no documentation of meal assistance for 4 shifts in November, 9 shifts in December, and 8 shifts in January. The director of nursing confirmed the lack of documentation during an interview.
Failure to Document and Implement Effective Pain Management Interventions
Penalty
Summary
A deficiency was identified when a resident with a history of post-right hip surgery for a fracture did not receive effective pain management as required. The resident had provider orders for non-pharmacological interventions (NPIs) to be attempted and documented prior to administering PRN opioid pain medication for pain levels between 4 and 10. Review of the medical record and medication administration records (MAR) revealed that while the resident received pain medication on multiple occasions for reported pain levels within the ordered range, there was no documentation of pain assessments prior to medication administration, including the specific location and type of pain, nor any record of which NPIs were attempted before giving the medication. Additionally, after administration of pain medication, the resident continued to experience pain at lower levels on several dates, but the records did not indicate what actions, if any, staff took to further manage the resident's ongoing pain. During an interview, the DON confirmed that her expectation was for staff to attempt NPIs before administering pain medication and to continue managing the resident's pain if it persisted, but the documentation did not reflect these practices.
Failure to Provide Trauma-Informed Care in Resident Care Plan
Penalty
Summary
The facility failed to provide appropriate trauma-informed care for a resident with a documented history of trauma related to surviving a house fire and the loss of family. The resident's care plan, initiated on 11/22/24, included only a single intervention to evaluate the resident for a psychiatric consult. The care plan did not identify the resident's specific trauma triggers or outline interventions to mitigate or eliminate those triggers, which are necessary to prevent re-traumatization. Interviews with the DON and the social services director confirmed that the care plan lacked sufficient detail regarding triggers and staff interventions to address the resident's trauma history.
Failure to Provide Adequate Wound Care Leads to Hospitalization
Penalty
Summary
The facility failed to provide adequate wound care to a resident with a stage 3 pressure ulcer, resulting in the worsening of the ulcer and the development of two additional unstageable pressure ulcers. The resident was admitted with multiple diagnoses, including a stage 3 pressure ulcer, and had specific wound care orders from a Nurse Practitioner for daily dressing changes. However, these orders were not transcribed into the Medication Administration Record (MAR) until eleven days after admission, leading to missed treatments. During this period, the resident's pressure ulcer increased in size, and two new unstageable pressure ulcers developed, ultimately resulting in the resident being hospitalized with sepsis and cellulitis. Interviews with facility staff revealed a breakdown in communication and responsibility regarding the transcription and implementation of wound care orders. The Licensed Practical Nurse (LPN) responsible for wound care did not recall the resident and was not present during the wound care rounds with the Nurse Practitioner. The Director of Nursing (DON) confirmed that the treatment orders were not transcribed into the Electronic Health Record (EHR) in a timely manner, preventing the charge nurses from completing the necessary daily treatments. Additionally, the family of the resident was not informed about the severity of the wounds, and the care plan was not updated to reflect the changes in the resident's condition.
Failure to Prevent Falls and Implement Interventions
Penalty
Summary
The facility failed to ensure that residents were free from accidents and did not implement necessary interventions after a fall to prevent recurrence. This was evident in the case of a resident who had a fall on 10/23/24, resulting in a suspected hairline fracture in the right foot. The resident, who required assistance from two staff members for bed mobility and bathing, was left unattended by a GNA who failed to review the resident's Kardex before providing care. The GNA admitted to not intervening when the resident was too close to the edge of the bed, leading to the resident rolling out of bed and sustaining injuries. Another resident with severe cognitive impairment and a history of falls was found on two separate occasions lying on the floor after unwitnessed falls. The resident, who required extensive assistance for activities of daily living, was found with a red mark and bump on the forehead after the first fall and a laceration on the back of the head after the second fall. Despite these incidents, the facility did not document any new interventions to prevent further falls, and the resident's care plan had not been updated with new fall interventions since 7/19/2021. The facility's policy on fall prevention required assessing each resident's risk factors and updating care plans with effective interventions. However, the facility failed to adhere to this policy, as evidenced by the lack of new interventions following the falls experienced by the residents. Interviews with staff, including the DON, revealed that the interdisciplinary team should have evaluated the falls to identify contributing factors and implement new interventions, but this was not done.
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The facility did not ensure that its Infection Preventionist (IP) met required qualifications for managing the Infection Prevention and Control Program. The DON reported serving as the IP but acknowledged lacking the specialized infection control training required for the role, and confirmed that no other staff member was currently qualified. Records showed that the previously qualified IP left several months earlier, and the Administrator and DON confirmed they were still seeking a replacement, leaving the infection control program without a properly trained leader.
Staff failed to consistently secure medications and medical supplies across three units, including an oxygen tank left on the floor behind a resident’s bed without a supporting device, a treatment cart with Collagenase Santyl cream left on top while two residents in power wheelchairs passed by, an unattended and unlocked treatment cart at a nursing station, and another treatment cart with Diclofenac gel and dressings left on top, indicating repeated lapses in maintaining locked and secure storage for drugs, biologicals, and related supplies.
The facility failed to provide sufficient dietitian coverage and timely nutritional assessments for several residents with significant dietary needs. A resident admitted for diabetic management with a high A1C was placed on a regular diet instead of the recommended carb-controlled diet and had only one weight taken in the first two weeks, with no dietitian review of the record. Another resident with prior significant weight loss had no documented dietitian follow-up despite continued weight loss, and a resident admitted with severe protein-calorie malnutrition experienced further significant weight loss without any dietitian assessment. The dietitian reported working limited hours and prioritizing certain high-risk cases, resulting in delayed or missed evaluations for new admissions and residents with ongoing nutritional concerns.
The facility failed to maintain adequate linen and incontinence supplies and did not keep resident care areas in good repair, resulting in delays and alterations in incontinence care and substandard environmental conditions. Staff reported that towels and washcloths were used instead of wipes and then discarded due to heavy soiling, and that linen deliveries to units were late, leaving residents waiting for care. Observations showed very limited numbers of clean washcloths and other linens on units and in the laundry, with no stock of disposable wipes or backup washcloth supply despite repeated reports to housekeeping. Additional observations revealed recliner chairs blocking a dining-area handwashing sink and kitchenette, multiple resident and shared bathrooms with unfinished spackle, chipped paint, musty odors, black substances near showers, missing threshold molding, exposed cracks and nails, and eroded, rusted baseboard heaters. Hallway handrails on both units were worn, chipped, and splintered, and a shower room contained fecal odors, dried brown stains on the toilet, and deteriorated fixtures, all contributing to a failure to provide a safe, clean, and homelike environment.
Facility staff did not thoroughly investigate two separate abuse allegations involving a resident and an injury of unknown origin involving another resident. In both cases, investigations focused on the directly affected resident and included staff interviews, but there were no interviews of other residents on the unit or documented assessments of those residents for signs of abuse or injuries of unknown origin, including residents unable to communicate due to cognitive status.
Two residents who were dependent on staff for oral care, including one with a tracheostomy, were observed with thick, white or milky substances coating their mouths and teeth, indicating inadequate oral hygiene. One resident communicated that staff did not brush their teeth and that staff "need to." In another case, despite oral care supplies being present in the room, the resident’s mouth and teeth remained unclean on multiple observations, with a thick milky substance caking the teeth and stringing between them when the resident tried to open their mouth. These findings showed that staff did not consistently provide oral care to residents who relied on them for this ADL.
Staff failed to maintain complete and accurate medical records for multiple residents, including missing and inconsistent documentation of wound care, delayed pain assessment after discovery of an injury of unknown origin in a cognitively impaired resident, and inaccurate recording of a PPD test result that was documented as negative despite no evidence the injection was administered and no supporting nurse’s note. Residents reported not receiving certain treatments, while MAR entries either lacked signatures for completion or contained conflicting information about whether care was provided.
Surveyors found that the facility failed to consistently implement and communicate correct transmission-based precautions and PPE use. One resident with a Foley catheter related to wounds had no precaution signage posted, while another resident in a double room had a contact precautions sign at the door, yet the NP entered without PPE and the GNA provided high-contact care wearing only gloves. Staff in that room stated the resident was not on contact precautions and later reversed the sign to show no PPE requirement. Therapy staff reported they rely solely on posted signs to determine PPE, and surveyors identified broader issues with inaccurate signage and staff awareness of which residents required contact precautions.
Surveyors found that MDS assessments were inaccurately coded for two residents. In one case, a resident sustained a femoral neck fracture after a fall, but the subsequent significant change MDS did not code the fall as a major injury and failed to capture prn Tylenol use documented on the MAR within the look-back period. In the other case, a quarterly MDS indicated opioid use for a resident, but the MAR for the same period showed no prescribed opioid, indicating incorrect coding of high-risk drug classes.
A resident who had recently been admitted and experienced a fall received multiple doses of the narcotic analgesic Tramadol, but the facility failed to accurately document all administered doses on the Medication Administration Record (MAR). Review showed only one Tramadol dose recorded on the MAR, while the Controlled Drug Receipt/Record/Disposition Form on the med cart reflected three doses given over two days. In interview, the DON stated staff are expected to document narcotic administration on the MAR and confirmed that two administered doses were not recorded there, resulting in an incomplete and inaccurate medical record.
Unqualified Infection Preventionist Overseeing Infection Control Program
Penalty
Summary
The facility failed to ensure that its designated Infection Preventionist (IP) met the mandatory qualifications for overseeing the Infection Prevention and Control Program. During an interview on 3/24/26 at 10:00 AM, the DON confirmed that she/he was serving as the facility’s IP but had not completed the specialized training in infection control required for the position. The DON further stated that no other staff member currently met the qualifications to serve as IP. Record review showed that the previously qualified IP left the facility in October 2025, and as of the survey date, the position remained unfilled by a qualified individual. At 1:30 PM on the same day, the Administrator and DON confirmed they were still in the process of finding a qualified IP for the facility, leaving the Infection Prevention and Control Program without a properly trained and qualified leader. No specific residents, medical histories, or clinical conditions were described in relation to this deficiency.
Unsecured Medications, Treatment Carts, and Oxygen Equipment
Penalty
Summary
Facility staff failed to ensure that drugs, biologicals, and related medical supplies were securely stored and properly maintained on multiple units. On one unit, an oxygen tank assigned to a resident was observed sitting on the floor behind the resident’s bed without any supporting device. On another unit, a treatment cart was observed with a tube of Collagenase Santyl cream labeled for a specific resident left on top of the cart, while residents in power wheelchairs passed by and staff were present at the nursing station. These observations showed that medications and oxygen equipment were not consistently secured as required. Further observations on additional units revealed an unattended and unlocked treatment cart at a nursing station, and on a separate occasion, a treatment cart with Diclofenac gel labeled for a resident left on top along with multiple packs of dressings. These incidents occurred across three units and on more than one date, demonstrating repeated failures to keep medications and treatment supplies in locked compartments or otherwise secured from unauthorized access.
Insufficient Dietitian Coverage and Delayed Nutritional Assessments
Penalty
Summary
The deficiency involves the facility’s failure to employ sufficient food and nutrition staff, including adequate dietitian coverage, to ensure timely assessment and appropriate diets for residents with significant nutritional and diabetic needs. A resident admitted over two weeks earlier with multiple comorbidities and an A1C of 11.5% had a hospital discharge recommendation for a carbohydrate-controlled diet, but was placed on a regular diet at admission with no acknowledgment of the recommended diet until one week later, when the resident requested larger portions. As of the survey date, the dietitian had not yet seen or reviewed this resident’s medical record, and the resident reported not having seen a dietitian and being very frustrated with the meals. During the first two weeks after admission, only one weight was obtained for this resident, despite physician notes stating the resident’s weight was “stable.” Further review of other residents showed additional failures in timely dietitian assessment and follow-up. One resident, readmitted in January and previously seen by the dietitian in September for a 6.4 lb weight loss over 30 days, had no documented follow-up despite continued weight loss totaling 22 lbs since the last dietitian review. Another resident admitted at the end of February with severe protein-calorie malnutrition had not been seen by the dietitian after about a month in the facility, despite a documented 14 lb (7%) weight loss over two weeks. The dietitian reported working only 12 hours per week at the facility and stated that she must prioritize which residents to see, focusing first on residents with tube feedings and those identified in risk meetings, resulting in delayed or absent assessments for new admissions and residents with ongoing weight loss and malnutrition diagnoses.
Linen Shortages and Poor Environmental Maintenance Compromise Resident Care and Comfort
Penalty
Summary
The deficiency involves the facility’s failure to maintain an adequate supply of clean linens and appropriate incontinence wipes, resulting in delays and alterations in residents’ incontinence care, as well as the use of towels and washcloths in place of disposable wipes. During the initial tour, the surveyor observed that the linen supply on one nursing unit hallway was low. Complaint reviews included concerns about delays in incontinence care and bed linens not being changed regularly, with residents left without clean bedding. A complainant reported that there was not enough clean linen available for residents. Staff interviews confirmed that towels, sheets, and washcloths were being used to wipe residents for incontinence care due to the absence of wipes, and that many of these linens were being thrown away when soiled. Staff also reported a shortage of linen, that linen deliveries to the units were late, and that residents who preferred to get up before breakfast had to wait for care when linen was delayed. Further observations showed that the clean supply room contained no disposable wipes or cloths for incontinence care, and a resident reported that staff did not use wipes, that the resident had to purchase their own, and that heavily soiled towels or washcloths were discarded. A tour of all nursing unit linen carts and closets revealed only six clean washcloths and limited supplies of towels, gowns, and bed linens. In the laundry room, only three washcloths were present, and the laundry assistant stated that there were only three washcloths available for each nursing unit that morning, that the facility was short on linen supply, and that these concerns had been repeatedly reported to the Director of Housekeeping over the preceding month and again that morning. The laundry assistant confirmed there was no additional laundry in process. The DON stated that wipe squares should be used for incontinence care, but no such wipes were found in the clean medical supply room, and no backup supply of washcloths was present in the emergency linen supply. The Director of Housekeeping confirmed there was no backup supply of washcloths. The deficiency also includes environmental and maintenance issues affecting resident bathrooms, handrails, and common areas. In the main dining area, a recliner chair was observed positioned directly in front of the handwashing sink, and two recliner chairs were stored in front of the nutrition area kitchenette. Multiple resident bathrooms and shared bathrooms were repeatedly observed over several days with unfinished spackle on walls that needed resurfacing and painting, chipped paint around sinks, uneven boards nailed to walls under sinks that appeared to partially cover holes, musty odors, black substances between shower bases and walls, missing threshold transition molding exposing cracks, missing tiles, and a nail, as well as eroded and chipped paint on baseboard heaters with exposed dark brown metal and rust-like material. Hallway handrails on both nursing units were observed to be worn, with chips, splintering, holes, and areas where the wood finish had worn off. A shower room was observed with a foul fecal odor, dried brown stains on the back of the toilet seat and in the toilet bowl, and a baseboard heater with eroded, chipped paint and rust-like material, along with chipped paint on the handrail. These conditions were acknowledged by the Director of Maintenance and other leadership, and some areas were noted to be in the process of renovation, but the observed deficiencies remained present during the survey period. Overall, the facility did not maintain a safe, clean, comfortable, and homelike environment in good repair across both nursing units and the dining area. The lack of adequate linen and incontinence supplies, combined with the poor condition of resident bathrooms, handrails, and certain common areas, constituted the basis for the cited deficiency. The observations and staff and resident reports consistently described shortages of essential hygiene supplies, delayed care related to linen availability, and multiple unresolved environmental and maintenance issues in resident care areas and shared spaces.
Failure to Thoroughly Investigate Abuse Allegations and Injuries of Unknown Origin
Penalty
Summary
Facility staff failed to thoroughly investigate allegations of potential abuse involving one resident and an injury of unknown origin involving another resident. For one resident, there were two separate allegations of abuse occurring on different days in early February. The facility’s investigation packets included interviews with staff who cared for or were scheduled to work with this resident on the days of the alleged incidents, and the investigations focused solely on this resident. However, there were no interviews conducted with other residents on the unit to inquire about abusive or neglectful treatment by the staff who were working during the times of the allegations. The surveyors noted that, although the allegations were not validated, there was no documentation that other residents were interviewed, if able, or assessed for signs or symptoms of injury. In a separate incident, another resident was identified on March 4 with a new bruise on the right eye, documented as a change in condition at 4:09 AM. This resident had a BIMS score of 99, indicating the resident was unable to complete an interview and therefore could not report how the injury occurred. The facility’s investigation identified a potential cause of the injury but did not reach a definitive resolution. Additionally, there were no interviews of other residents on the unit regarding possible abuse, nor were there documented assessments of other residents for injuries of unknown origin, particularly for those unable to speak for themselves, as in this resident’s case.
Failure to Provide Oral Care to Dependent Residents
Penalty
Summary
The deficiency involves the facility’s failure to provide oral care to residents who were dependent on staff for activities of daily living, specifically oral hygiene. One resident with a tracheostomy was observed with a thick, sticky white substance in the mouth and was noted to intermittently chew on nearby bedding. This resident made good eye contact and, when asked if staff brushed their teeth, shook their head no and mouthed that staff “need to.” According to the resident’s Minimum Data Set (MDS) dated 2/11/26, the resident was dependent on staff for oral care. Another resident, also dependent on staff for oral care per the 3/11/26 MDS, was observed sitting propped up in bed and able to respond with smiles. During the initial observation, the inside of this resident’s lips and upper and lower teeth had a thick, clear, white milky substance visible when the resident tried to open their mouth to smile. Oral care supplies were present in the nightstand, but the resident’s mouth and teeth were not clean. On a subsequent observation with the DON, NHA, and Corporate VP of clinical services, the same resident again had a thick, clear, milky substance between the lips and caking the teeth, which would string between the teeth when the resident attempted to open their mouth, demonstrating a lack of consistent oral care for residents dependent on staff for this ADL.
Incomplete and Inaccurate Medical Record Documentation for Treatments and Assessments
Penalty
Summary
Facility staff failed to maintain complete and accurate medical records and documentation for multiple residents. For one resident with wound care needs, review of the MAR showed that wound care and related treatments were signed as completed on the dates initially reported, despite the resident’s ongoing complaints that wound dressings were not being changed. When additional dates were reviewed, there were missing staff signatures for wound care on two specific dates, as well as three instances where application of A&D ointment to the resident’s feet was not signed off out of 24 days reviewed. Another resident with severe cognitive impairment, as evidenced by a BIMS score of 00, was found to have an injury of unknown origin (a bruise on the left hand). Documentation showed that a change in condition was initiated late in the morning, but a formal pain evaluation was not initiated and completed until that night, and the resident was unable to explain how the injury occurred or verbalize pain using a standard pain scale. For a third resident, documentation related to the admission PPD test was inconsistent and incomplete. The MAR contained an entry indicating “9” for the administration date, meaning “see nurse’s note,” but there was no corresponding nurse’s note. Despite the absence of a signed administration of the PPD injection, staff documented the PPD result as “negative” on the scheduled read date. The resident reported never receiving the PPD injection, and the DON confirmed that the facility had been out of PPD solution at the time, so the test would not have been administered. These findings demonstrate failures in accurate documentation of treatments and assessments, including wound care, pain assessment, and TB screening, as well as missing or incomplete supporting notes in the medical record.
Failure to Implement and Communicate Correct Transmission-Based Precautions
Penalty
Summary
Surveyors identified a deficiency in the facility’s infection prevention and control program related to inconsistent and incorrect implementation of transmission-based precautions and PPE use. During a complaint investigation focused on residents on transmission-based precautions, one resident with a visible Foley catheter was observed in the room with physical therapy, but there were no signs posted indicating any need for PPE, despite the resident being a new admission with a Foley catheter placed related to wounds. In another double-occupancy room, a contact precautions sign was posted at the doorway, but the nurse practitioner was in the room on a personal phone with no PPE, and the assigned GNA was repositioning the resident in bed while wearing only gloves. When questioned, the NP, RN, and GNA all stated that the resident in the room was not on contact precautions, and the GNA reported that signs were hanging at all doors and that this particular resident’s sign was “just wrong.” The surveyor observed the GNA later return to the room and turn the sign around to indicate no PPE requirement. Subsequent interviews revealed that therapy staff relied on posted signage to determine PPE use and that if the sign was wrong, the PPE used would be wrong. Overall, surveyors found problems with signage accuracy and staff awareness of which residents required contact precautions, as well as observed failures to follow appropriate PPE use for residents who should have been on contact precautions.
Inaccurate MDS Coding for Falls, Pain Management, and High-Risk Medications
Penalty
Summary
Facility staff failed to ensure Minimum Data Set (MDS) assessments were accurately coded for two residents reviewed during a complaint survey. For one resident, a facility-reported incident showed that the resident was found seated on the floor beside the bed and was diagnosed with a non-displaced femoral neck impaction fracture of the left hip following an x-ray. Despite this fall with a major injury, the subsequent significant change MDS dated 11/4/25 did not code the fall with major injury in Section J1900C. Review of the resident’s Medication Administration Records for October and November 2025 showed administration of Tylenol on 10/31/25 at 9:30 PM, which fell within the 5-day look-back period for the MDS, but Section J0100 (prn pain) of the same significant change MDS did not capture the use of Tylenol. For another resident, review of a quarterly MDS with an assessment reference date of 10/15/25 showed that Section N0415 (High-Risk Drug Classes) documented the use of an opioid medication. However, review of the resident’s October 2025 Medication Administration Record did not show that the resident had been prescribed an opioid during that period. In both cases, MDS staff later confirmed that these were errors in MDS coding, demonstrating that the assessments did not accurately reflect the residents’ clinical status and medication use as documented in their medical records.
Incomplete Documentation of Narcotic Administration on MAR
Penalty
Summary
The facility failed to maintain complete and accurate medical records in accordance with accepted professional standards for one resident receiving narcotic medication. The resident, admitted in March 2026, had a fall on 3/6/26 and was sent to the hospital on 3/9/26. Review of the March 2026 Medication Administration Record (MAR) showed documentation of a single 25 mg dose of Tramadol administered on 3/8/26 at 9:23 AM. However, review of the resident’s Controlled Drug Receipt/Record/Disposition Form, kept on the nurse’s medication cart and not in the medical record, showed that Tramadol 25 mg was administered three times between 3/8/26 and 3/9/26: at 11:00 AM and 9:00 PM on 3/8/26, and at 9:00 AM on 3/9/26. In interview, the DON stated that staff are expected to document narcotic administration on the MAR and confirmed that only one of the three Tramadol doses reflected on the controlled drug record was documented on the resident’s MAR. This discrepancy between the controlled substance record and the MAR, with missing documentation of two administered doses of Tramadol on the official medical record, constituted the failure to maintain a complete and accurate medical record for the resident.
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