Complete Care At Heritage Llc
Inspection history, citations, penalties and survey trends for this long-term care facility in Dundalk, Maryland.
- Location
- 7232 German Hill Road, Dundalk, Maryland 21222
- CMS Provider Number
- 215135
- Inspections on file
- 20
- Latest survey
- February 25, 2026
- Citations (last 12 mo.)
- 34
Citation history
Health deficiencies cited at Complete Care At Heritage Llc during CMS and state inspections, most recent first.
Staff failed to accurately code multiple MDS assessments, leading to missing and incorrect entries for medications, falls, behaviors, and treatments. Anticonvulsant and antianxiety medications documented on MARs were not captured in the high-risk drug classes section for several residents, while one resident was incorrectly coded as receiving hypoglycemic medication despite no such orders. A resident’s documented fall was not coded in the falls section, and another resident’s oxygen therapy was omitted from the special treatments section while hospice services and limited life expectancy were incorrectly coded without supporting documentation. In addition, a resident with clearly documented aggressive and combative behaviors was coded as having no physical or verbal behavioral symptoms on the MDS.
A resident who was alert and oriented reported that a nurse repeatedly entered the room despite the resident’s request to keep the door closed and to stop coming in. A GNA accompanied the resident back to the room and informed an LPN of the resident’s wishes, but the LPN stated he did not care and entered anyway to give meds to the roommate. The resident continued to ask the LPN to leave, the situation escalated into yelling, and both the resident and the LPN used expletive language. The LPN told the resident to hit him, stated the resident would not do anything, and threatened to beat the resident, which was witnessed and later confirmed as verbal abuse by supervisory staff and the administrator.
A resident who was alert, oriented, and able to express needs had standing orders for showers on specific days but, over a two‑month period, received only bed baths instead of the ordered showers. The resident and the responsible party both reported that no showers had been provided during this time, and facility documentation confirmed only bed baths with one documented refusal related to diarrhea. The resident was agreeable to occasional bed baths but expected to be offered showers on scheduled shower days, which did not occur.
A resident with acute prostatitis did not receive IV antibiotics as ordered by the physician. Hospital discharge instructions included daily Ertapenem through the end of the month, but the final scheduled dose was not administered according to the MAR. The antibiotic regimen was later changed to Meropenem every 8 hours, and a scheduled evening dose was also not documented as given. The DON confirmed that staff failed to administer these ordered antibiotic doses.
Two residents did not receive respiratory care in accordance with professional standards. One resident with obstructive sleep apnea had a hospital discharge summary directing continuation of BiPAP for sleep, but BiPAP was neither ordered nor documented as administered for the first three nights after admission. Another resident with COPD, asthma, chronic myeloid leukemia, and a history of acute on chronic hypoxic hypercapnic respiratory failure had intermittent oxygen use documented in vital signs, yet there were no physician orders for oxygen therapy, tubing changes, humidification, O2 saturation goals, or basic oxygen care, despite facility policy requiring a provider order specifying liter flow and delivery device; the DON confirmed the absence of related documentation on the MAR and TAR.
Facility staff did not provide necessary personal hygiene and bathing assistance to two totally dependent residents. One resident was found with neglected toenail care, and another had no documented showers or bed baths for several months, despite being fully dependent due to significant physical limitations. Documentation and staff interviews confirmed the lack of provided care and incomplete records.
Two residents experienced significant delays in receiving prescribed medications and wound care treatments. One resident's medications were repeatedly administered several hours late, primarily due to short staffing and reliance on agency staff, as confirmed by MAR review and staff interviews. Another resident did not receive wound care or IV antibiotics until days after admission, with no documentation of earlier treatment. Facility leadership acknowledged the lack of timely care and absence of supporting documentation.
A resident who was alert and oriented experienced severe, unrelieved pain for several hours without timely assessment or administration of pain medication. Although pain medications were reportedly ordered and administered, there was no documentation in the MAR to support this, and no pain assessment was recorded. Staff interviews confirmed that pain management and documentation protocols were not followed, resulting in a significant delay in addressing the resident's pain before hospital transfer.
A nurse, unfamiliar with the facility and distracted during medication pass, administered Methadone to a resident instead of the prescribed Methylphenidate by failing to verify the medication name, dose, and form. The nurse did not follow the five rights of medication administration, and the error was only discovered after the medication was given. The resident was later found unresponsive and the incident was reported to the Medical Examiner.
Inaccurate MDS Coding for Medications, Falls, Behaviors, and Treatments
Penalty
Summary
Facility staff failed to ensure that Minimum Data Set (MDS) assessments were accurately coded for multiple residents, resulting in omissions and inaccuracies in several MDS sections. For one resident receiving Gabapentin every eight hours for neuropathy, the anticonvulsant was not captured in Section N0415 (High-Risk Drug Classes) on two separate MDS assessments. Another resident experienced a documented fall, noted in the medical record as being found on the floor in a sitting position, but this fall was not coded in Section J1800 (any falls since admission/entry or prior assessment). A third resident had hypoglycemic medication use coded in Section N0415, despite the November MAR showing no hypoglycemic medications administered during that period. Additional inaccuracies were identified for a resident who received Lorazepam, an antianxiety medication, which was not captured in Section N0415 on a discharge MDS, and whose use of oxygen via nasal cannula was not coded in Section O (Special Treatments, Procedures, and Programs). The same resident was incorrectly coded in Section O as receiving hospice services and in Section J1400 as having a condition with a life expectancy of less than six months, despite no documentation supporting hospice services or such a prognosis. Another resident with documented aggressive and combative behavior, including agitation, psychosis, throwing objects at staff, and destroying property, was coded as having no physical or verbal behavioral symptoms in Section E0200. This resident was also receiving Gabapentin three times per day per the MAR, but the anticonvulsant was not captured in Section N0415. The MDS Coordinator confirmed these errors and noted that other staff had been filling in on MDS assessments during the primary coordinator’s leave.
Failure to Protect Resident From Verbal Abuse by Nursing Staff
Penalty
Summary
Facility staff failed to protect a resident from verbal abuse by a staff member. An alert and oriented resident, admitted in 2025, approached the nursing station and reported that a nurse kept entering the resident’s room despite the resident’s request to keep the door closed and to stop coming into the room. A geriatric nursing assistant accompanied the resident back to the room and informed the nurse of the resident’s request. The nurse stated he did not care and entered the room anyway, stating he needed to administer medications to the roommate. The resident repeatedly told the nurse to leave the room, but the nurse refused, leading the resident to begin yelling. The geriatric nursing assistant reported that the situation became heated, with the nurse and the resident speaking to each other “like they were on the streets” and both using expletive language. The nurse told the resident to hit him and stated that the resident was not going to do anything, and that he would “beat the [expletive]” out of the resident. The nursing supervisor, after being notified by the geriatric nursing assistant, went to the scene and personally heard the nurse threaten to beat the resident. The supervisor stated that the nurse was being abusive and that he was afraid the situation was going to become physical. The facility’s administrator later confirmed that the facility substantiated verbal abuse of the resident by the nurse.
Failure to Provide Ordered Showers and Honor Resident Bathing Preferences
Penalty
Summary
The facility failed to provide showers as ordered for a resident who required assistance with activities of daily living (ADLs). The resident had physician orders to receive showers on Tuesdays and Fridays during January and February 2026, but interviews and record review showed that these ordered showers were not provided. On 2/20/26, the resident’s responsible party reported that the resident had not received a shower in the prior two months, and the resident, who was alert, oriented, and able to express needs, confirmed not having had a shower during that period and expressed a desire for one. Documentation in the treatment and GNA records showed that the resident had only received bed baths, with one documented refusal of a shower/bed bath on a single occasion due to diarrhea, and there was no documentation that showers were offered on the scheduled shower days as ordered. The resident stated they were not opposed to receiving a bed bath occasionally but expected to be offered a shower on designated shower days rather than being given only bed baths. The surveyor’s review of records corroborated that showers were not provided in accordance with the care plan and orders for the months reviewed, and that the resident’s preference for showers on scheduled days was not honored, except for the one documented refusal related to diarrhea.
Failure to Administer Ordered IV Antibiotics as Prescribed
Penalty
Summary
Facility staff failed to administer ordered IV antibiotics as prescribed for a resident with acute prostatitis. The resident was admitted in December 2025 with a diagnosis including acute prostatitis, and the hospital discharge summary ordered Ertapenem 1 gm IV daily through 1/30/26. Review of the January 2026 Medication Administration Record showed the resident did not receive the ordered Ertapenem dose on 1/30/26. The resident’s antibiotic regimen was later changed by the physician to Meropenem 2 gm IV every 8 hours on 2/4/26. Review of the February 2026 Medication Administration Record revealed no evidence that the resident received the scheduled Meropenem dose on 2/15/26 at 10:00 PM. In an interview on 2/25/26 at 8:30 AM, the Director of Nursing confirmed that facility staff failed to administer the ordered antibiotic medications on both 1/30/26 and 2/15/26.
Failure to Provide Ordered BiPAP and Properly Order/Document Oxygen Therapy
Penalty
Summary
The deficiency involves the facility’s failure to provide respiratory services in accordance with professional standards of practice for two residents who required such care. One resident was admitted with a diagnosis that included obstructive sleep apnea and had a hospital discharge summary directing continuation of BiPAP for sleep. Review of the resident’s December Treatment Administration Record showed that the BiPAP was not ordered or documented as administered until three days after admission, resulting in three nights without the prescribed BiPAP therapy. In an interview, the Administrator confirmed that facility staff did not administer the resident’s BiPAP during those three nights following admission. For another resident, admitted with COPD, asthma, and chronic myeloid leukemia, the medical record documented use of oxygen at 3 LPM via nasal cannula and a history and physical noting acute on chronic hypoxic hypercapnic respiratory failure, COPD, asthma, and home oxygen use of 2–3 liters, as well as recent community-acquired pneumonia and acute hypoxic respiratory failure while hospitalized prior to admission. The vital sign section of the electronic medical record showed intermittent use of oxygen; however, review of the December and January physician’s orders revealed no orders for oxygen therapy, tubing changes, humidification, oxygen saturation goals, or basic care related to oxygen therapy. The facility’s oxygen therapy policy required verification of a medical doctor order including liter flow and type of O2 delivery device. During an interview, the DON confirmed that the MAR and TAR contained no documentation of oxygen usage, tubing changes, or humidification for this resident.
Failure to Provide Personal Hygiene and Bathing Assistance to Dependent Residents
Penalty
Summary
Facility staff failed to provide necessary personal hygiene services to residents who were totally dependent on staff for activities of daily living (ADL). In one instance, a resident was observed to have long, yellowed, thickened, and misshapen toenails, with one toenail having fallen off. The resident’s Minimum Data Set (MDS) indicated total dependence on staff for personal hygiene. Interviews with staff revealed that toenail care was the responsibility of nurses or podiatry, but the resident had not been seen by podiatry until after the surveyor’s intervention, indicating a lack of timely care. Another resident, who was dependent for all ADLs due to diagnoses including muscular dystrophy and Friedreich ataxia, was reported by a family member to have not received a shower in years and to have a layer of filth on their head. Review of the resident’s medical record and facility documentation showed no evidence of showers or bed baths being provided over several months. The facility’s documentation systems, including Point of Care (POC) and paper shower sheets, lacked records of bathing or showering for this resident, except for two instances where refusal was documented. Staff interviews confirmed that showers were scheduled and assigned, but documentation was incomplete or missing. Both residents had care plans indicating total dependence on staff for personal hygiene and bathing, with goals for their ADL needs to be met. However, the lack of documented care and observations of poor hygiene demonstrated that the facility did not provide the required assistance with personal hygiene and bathing for these dependent residents.
Delayed Medication and Wound Care Administration
Penalty
Summary
The facility failed to provide timely medication administration and wound care treatment to two residents, as identified during a recertification and complaint survey. For one resident, multiple medications were administered 2-4 hours late on various days throughout the month, as confirmed by a review of the Medication Administration Records (MAR). The resident attributed the delays to agency staff frequently used by the facility, and a registered nurse confirmed that short staffing and lack of medication aides were common reasons for late medication passes. The Director of Nursing acknowledged awareness of the issue and stated that medication times had been adjusted in an attempt to address the problem, but late administration persisted. Another resident experienced a delay in wound care and IV antibiotic administration following admission. The wound treatment order was not placed until two days after admission, and there was no documentation of wound care prior to that order. Additionally, the resident's IV antibiotic, vancomycin, was ordered a day after admission, with the first dose administered later that day, and no evidence of earlier administration. Both the Director of Nursing and the Nursing Home Administrator confirmed there were no additional orders or documentation to support earlier treatment or medication administration.
Failure to Provide Timely Pain Management and Documentation
Penalty
Summary
A deficiency was identified when a resident experienced severe, unrelieved pain for an extended period without timely assessment or intervention. The resident, who was alert and oriented with a BIMS score of 15/15, began experiencing severe bilateral leg pain, rated at 10/10, starting in the evening and continuing into the following morning. Despite the resident's ongoing complaints and visible distress, there was no documented pain assessment or administration of pain medication during this time. Progress notes later indicated that pain medications and a lidocaine patch were ordered and reportedly administered, but the Medication Administration Record (MAR) did not reflect any such administration on the date in question. Staff interviews revealed that pain assessments are expected to be conducted every shift, and the DON confirmed that pain should be managed immediately with all interventions documented in the MAR. However, there was a five-hour gap between the initial documentation of severe pain and the resident's transfer to the hospital, during which no pain assessment or medication administration was documented. This failure to provide timely pain management and proper documentation constituted the identified deficiency.
Significant Medication Error: Methadone Administered Instead of Methylphenidate
Penalty
Summary
A significant medication error occurred when a registered nurse (RN), who was working their first shift at the facility as an agency nurse, administered Methadone to a resident instead of the prescribed Methylphenidate. The resident had been admitted with diagnoses including narcolepsy, muscle weakness, and recurrent falls, and was scheduled for discharge. The error happened when the RN, while administering medications, saw the letters 'M-E-T-H' on the medication administration record and assumed the medication was Methadone, without verifying the medication name, dosage, or form. The RN did not compare the medication pulled from the cart to the resident's medication administration record, did not confirm the medication, and did not check if the medication was in the correct form, resulting in the administration of a liquid Methadone dose instead of the prescribed tablet form of Methylphenidate. After realizing the error about an hour later, the RN assessed the resident, found them to be sleepy but with stable vital signs, and reported the incident to the nursing supervisor. The supervisor instructed the RN on documentation, contacting the on-call physician, and notifying the resident's family. The on-call provider was informed but was unable to obtain critical information from the RN, such as the resident's name, date of birth, and the exact dose of Methadone administered. The provider was told that the Methadone had been intended for another resident who was not currently admitted, and the RN could not locate the empty bottle or confirm the dose given. The provider relied on the RN's report that the resident was stable and did not recommend hospital transfer at that time. The RN admitted to not following the five rights of medication administration and reported being heavily distracted during the medication pass. The resident was found pulseless and without respirations by nursing staff later that evening, and the death was reported to the Medical Examiner's office. The facility's failure to ensure the resident was free from significant medication errors resulted in the identification of an Immediate Jeopardy situation by the Maryland Office of Health Care Quality.
Removal Plan
- Education of all nurses on medication administration with focus on the six-rights medication administration, opioid management, signs of opioid overdose, and in-house escalation protocol.
- Medicine Pass evaluations and competencies will be completed for all licensed nurses. Each nurse will undergo a thorough assessment of their medication administration skills. Any identified areas for improvement will be addressed through additional training, and successful completion will be documented in the employee's personnel file.
- Staff will be quizzed on their understanding of the opioid overdose management policy post education. The quizzes will cover key topics, including recognizing the signs and symptoms of opioid overdose, appropriate response protocols, and steps for escalation. Results will be reviewed, and any areas of concern will be addressed through additional training or clarification.
- Nursing staff will be quizzed on their understanding of the medication administration policy post education. The quiz will focus on the rights of medication administration. Any knowledge gaps identified will be addressed through additional training and support.
- Ongoing monthly medication evaluations will be conducted for all licensed nurses and Certified Medicine Aides by DON/designee. Each nurse will undergo a thorough assessment of their medication administration skills. Any identified areas for improvement will be addressed through additional training, and successful completion will be documented in the employee's personnel file.
- The results will be reported by the DON to the Quality Assurance Performance Improvement Committee until 100% compliance is achieved.
Latest citations in Maryland
The facility did not ensure that its Infection Preventionist (IP) met required qualifications for managing the Infection Prevention and Control Program. The DON reported serving as the IP but acknowledged lacking the specialized infection control training required for the role, and confirmed that no other staff member was currently qualified. Records showed that the previously qualified IP left several months earlier, and the Administrator and DON confirmed they were still seeking a replacement, leaving the infection control program without a properly trained leader.
Staff failed to consistently secure medications and medical supplies across three units, including an oxygen tank left on the floor behind a resident’s bed without a supporting device, a treatment cart with Collagenase Santyl cream left on top while two residents in power wheelchairs passed by, an unattended and unlocked treatment cart at a nursing station, and another treatment cart with Diclofenac gel and dressings left on top, indicating repeated lapses in maintaining locked and secure storage for drugs, biologicals, and related supplies.
The facility failed to provide sufficient dietitian coverage and timely nutritional assessments for several residents with significant dietary needs. A resident admitted for diabetic management with a high A1C was placed on a regular diet instead of the recommended carb-controlled diet and had only one weight taken in the first two weeks, with no dietitian review of the record. Another resident with prior significant weight loss had no documented dietitian follow-up despite continued weight loss, and a resident admitted with severe protein-calorie malnutrition experienced further significant weight loss without any dietitian assessment. The dietitian reported working limited hours and prioritizing certain high-risk cases, resulting in delayed or missed evaluations for new admissions and residents with ongoing nutritional concerns.
The facility failed to maintain adequate linen and incontinence supplies and did not keep resident care areas in good repair, resulting in delays and alterations in incontinence care and substandard environmental conditions. Staff reported that towels and washcloths were used instead of wipes and then discarded due to heavy soiling, and that linen deliveries to units were late, leaving residents waiting for care. Observations showed very limited numbers of clean washcloths and other linens on units and in the laundry, with no stock of disposable wipes or backup washcloth supply despite repeated reports to housekeeping. Additional observations revealed recliner chairs blocking a dining-area handwashing sink and kitchenette, multiple resident and shared bathrooms with unfinished spackle, chipped paint, musty odors, black substances near showers, missing threshold molding, exposed cracks and nails, and eroded, rusted baseboard heaters. Hallway handrails on both units were worn, chipped, and splintered, and a shower room contained fecal odors, dried brown stains on the toilet, and deteriorated fixtures, all contributing to a failure to provide a safe, clean, and homelike environment.
Facility staff did not thoroughly investigate two separate abuse allegations involving a resident and an injury of unknown origin involving another resident. In both cases, investigations focused on the directly affected resident and included staff interviews, but there were no interviews of other residents on the unit or documented assessments of those residents for signs of abuse or injuries of unknown origin, including residents unable to communicate due to cognitive status.
Two residents who were dependent on staff for oral care, including one with a tracheostomy, were observed with thick, white or milky substances coating their mouths and teeth, indicating inadequate oral hygiene. One resident communicated that staff did not brush their teeth and that staff "need to." In another case, despite oral care supplies being present in the room, the resident’s mouth and teeth remained unclean on multiple observations, with a thick milky substance caking the teeth and stringing between them when the resident tried to open their mouth. These findings showed that staff did not consistently provide oral care to residents who relied on them for this ADL.
Staff failed to maintain complete and accurate medical records for multiple residents, including missing and inconsistent documentation of wound care, delayed pain assessment after discovery of an injury of unknown origin in a cognitively impaired resident, and inaccurate recording of a PPD test result that was documented as negative despite no evidence the injection was administered and no supporting nurse’s note. Residents reported not receiving certain treatments, while MAR entries either lacked signatures for completion or contained conflicting information about whether care was provided.
Surveyors found that the facility failed to consistently implement and communicate correct transmission-based precautions and PPE use. One resident with a Foley catheter related to wounds had no precaution signage posted, while another resident in a double room had a contact precautions sign at the door, yet the NP entered without PPE and the GNA provided high-contact care wearing only gloves. Staff in that room stated the resident was not on contact precautions and later reversed the sign to show no PPE requirement. Therapy staff reported they rely solely on posted signs to determine PPE, and surveyors identified broader issues with inaccurate signage and staff awareness of which residents required contact precautions.
Surveyors found that MDS assessments were inaccurately coded for two residents. In one case, a resident sustained a femoral neck fracture after a fall, but the subsequent significant change MDS did not code the fall as a major injury and failed to capture prn Tylenol use documented on the MAR within the look-back period. In the other case, a quarterly MDS indicated opioid use for a resident, but the MAR for the same period showed no prescribed opioid, indicating incorrect coding of high-risk drug classes.
A resident who had recently been admitted and experienced a fall received multiple doses of the narcotic analgesic Tramadol, but the facility failed to accurately document all administered doses on the Medication Administration Record (MAR). Review showed only one Tramadol dose recorded on the MAR, while the Controlled Drug Receipt/Record/Disposition Form on the med cart reflected three doses given over two days. In interview, the DON stated staff are expected to document narcotic administration on the MAR and confirmed that two administered doses were not recorded there, resulting in an incomplete and inaccurate medical record.
Unqualified Infection Preventionist Overseeing Infection Control Program
Penalty
Summary
The facility failed to ensure that its designated Infection Preventionist (IP) met the mandatory qualifications for overseeing the Infection Prevention and Control Program. During an interview on 3/24/26 at 10:00 AM, the DON confirmed that she/he was serving as the facility’s IP but had not completed the specialized training in infection control required for the position. The DON further stated that no other staff member currently met the qualifications to serve as IP. Record review showed that the previously qualified IP left the facility in October 2025, and as of the survey date, the position remained unfilled by a qualified individual. At 1:30 PM on the same day, the Administrator and DON confirmed they were still in the process of finding a qualified IP for the facility, leaving the Infection Prevention and Control Program without a properly trained and qualified leader. No specific residents, medical histories, or clinical conditions were described in relation to this deficiency.
Unsecured Medications, Treatment Carts, and Oxygen Equipment
Penalty
Summary
Facility staff failed to ensure that drugs, biologicals, and related medical supplies were securely stored and properly maintained on multiple units. On one unit, an oxygen tank assigned to a resident was observed sitting on the floor behind the resident’s bed without any supporting device. On another unit, a treatment cart was observed with a tube of Collagenase Santyl cream labeled for a specific resident left on top of the cart, while residents in power wheelchairs passed by and staff were present at the nursing station. These observations showed that medications and oxygen equipment were not consistently secured as required. Further observations on additional units revealed an unattended and unlocked treatment cart at a nursing station, and on a separate occasion, a treatment cart with Diclofenac gel labeled for a resident left on top along with multiple packs of dressings. These incidents occurred across three units and on more than one date, demonstrating repeated failures to keep medications and treatment supplies in locked compartments or otherwise secured from unauthorized access.
Insufficient Dietitian Coverage and Delayed Nutritional Assessments
Penalty
Summary
The deficiency involves the facility’s failure to employ sufficient food and nutrition staff, including adequate dietitian coverage, to ensure timely assessment and appropriate diets for residents with significant nutritional and diabetic needs. A resident admitted over two weeks earlier with multiple comorbidities and an A1C of 11.5% had a hospital discharge recommendation for a carbohydrate-controlled diet, but was placed on a regular diet at admission with no acknowledgment of the recommended diet until one week later, when the resident requested larger portions. As of the survey date, the dietitian had not yet seen or reviewed this resident’s medical record, and the resident reported not having seen a dietitian and being very frustrated with the meals. During the first two weeks after admission, only one weight was obtained for this resident, despite physician notes stating the resident’s weight was “stable.” Further review of other residents showed additional failures in timely dietitian assessment and follow-up. One resident, readmitted in January and previously seen by the dietitian in September for a 6.4 lb weight loss over 30 days, had no documented follow-up despite continued weight loss totaling 22 lbs since the last dietitian review. Another resident admitted at the end of February with severe protein-calorie malnutrition had not been seen by the dietitian after about a month in the facility, despite a documented 14 lb (7%) weight loss over two weeks. The dietitian reported working only 12 hours per week at the facility and stated that she must prioritize which residents to see, focusing first on residents with tube feedings and those identified in risk meetings, resulting in delayed or absent assessments for new admissions and residents with ongoing weight loss and malnutrition diagnoses.
Linen Shortages and Poor Environmental Maintenance Compromise Resident Care and Comfort
Penalty
Summary
The deficiency involves the facility’s failure to maintain an adequate supply of clean linens and appropriate incontinence wipes, resulting in delays and alterations in residents’ incontinence care, as well as the use of towels and washcloths in place of disposable wipes. During the initial tour, the surveyor observed that the linen supply on one nursing unit hallway was low. Complaint reviews included concerns about delays in incontinence care and bed linens not being changed regularly, with residents left without clean bedding. A complainant reported that there was not enough clean linen available for residents. Staff interviews confirmed that towels, sheets, and washcloths were being used to wipe residents for incontinence care due to the absence of wipes, and that many of these linens were being thrown away when soiled. Staff also reported a shortage of linen, that linen deliveries to the units were late, and that residents who preferred to get up before breakfast had to wait for care when linen was delayed. Further observations showed that the clean supply room contained no disposable wipes or cloths for incontinence care, and a resident reported that staff did not use wipes, that the resident had to purchase their own, and that heavily soiled towels or washcloths were discarded. A tour of all nursing unit linen carts and closets revealed only six clean washcloths and limited supplies of towels, gowns, and bed linens. In the laundry room, only three washcloths were present, and the laundry assistant stated that there were only three washcloths available for each nursing unit that morning, that the facility was short on linen supply, and that these concerns had been repeatedly reported to the Director of Housekeeping over the preceding month and again that morning. The laundry assistant confirmed there was no additional laundry in process. The DON stated that wipe squares should be used for incontinence care, but no such wipes were found in the clean medical supply room, and no backup supply of washcloths was present in the emergency linen supply. The Director of Housekeeping confirmed there was no backup supply of washcloths. The deficiency also includes environmental and maintenance issues affecting resident bathrooms, handrails, and common areas. In the main dining area, a recliner chair was observed positioned directly in front of the handwashing sink, and two recliner chairs were stored in front of the nutrition area kitchenette. Multiple resident bathrooms and shared bathrooms were repeatedly observed over several days with unfinished spackle on walls that needed resurfacing and painting, chipped paint around sinks, uneven boards nailed to walls under sinks that appeared to partially cover holes, musty odors, black substances between shower bases and walls, missing threshold transition molding exposing cracks, missing tiles, and a nail, as well as eroded and chipped paint on baseboard heaters with exposed dark brown metal and rust-like material. Hallway handrails on both nursing units were observed to be worn, with chips, splintering, holes, and areas where the wood finish had worn off. A shower room was observed with a foul fecal odor, dried brown stains on the back of the toilet seat and in the toilet bowl, and a baseboard heater with eroded, chipped paint and rust-like material, along with chipped paint on the handrail. These conditions were acknowledged by the Director of Maintenance and other leadership, and some areas were noted to be in the process of renovation, but the observed deficiencies remained present during the survey period. Overall, the facility did not maintain a safe, clean, comfortable, and homelike environment in good repair across both nursing units and the dining area. The lack of adequate linen and incontinence supplies, combined with the poor condition of resident bathrooms, handrails, and certain common areas, constituted the basis for the cited deficiency. The observations and staff and resident reports consistently described shortages of essential hygiene supplies, delayed care related to linen availability, and multiple unresolved environmental and maintenance issues in resident care areas and shared spaces.
Failure to Thoroughly Investigate Abuse Allegations and Injuries of Unknown Origin
Penalty
Summary
Facility staff failed to thoroughly investigate allegations of potential abuse involving one resident and an injury of unknown origin involving another resident. For one resident, there were two separate allegations of abuse occurring on different days in early February. The facility’s investigation packets included interviews with staff who cared for or were scheduled to work with this resident on the days of the alleged incidents, and the investigations focused solely on this resident. However, there were no interviews conducted with other residents on the unit to inquire about abusive or neglectful treatment by the staff who were working during the times of the allegations. The surveyors noted that, although the allegations were not validated, there was no documentation that other residents were interviewed, if able, or assessed for signs or symptoms of injury. In a separate incident, another resident was identified on March 4 with a new bruise on the right eye, documented as a change in condition at 4:09 AM. This resident had a BIMS score of 99, indicating the resident was unable to complete an interview and therefore could not report how the injury occurred. The facility’s investigation identified a potential cause of the injury but did not reach a definitive resolution. Additionally, there were no interviews of other residents on the unit regarding possible abuse, nor were there documented assessments of other residents for injuries of unknown origin, particularly for those unable to speak for themselves, as in this resident’s case.
Failure to Provide Oral Care to Dependent Residents
Penalty
Summary
The deficiency involves the facility’s failure to provide oral care to residents who were dependent on staff for activities of daily living, specifically oral hygiene. One resident with a tracheostomy was observed with a thick, sticky white substance in the mouth and was noted to intermittently chew on nearby bedding. This resident made good eye contact and, when asked if staff brushed their teeth, shook their head no and mouthed that staff “need to.” According to the resident’s Minimum Data Set (MDS) dated 2/11/26, the resident was dependent on staff for oral care. Another resident, also dependent on staff for oral care per the 3/11/26 MDS, was observed sitting propped up in bed and able to respond with smiles. During the initial observation, the inside of this resident’s lips and upper and lower teeth had a thick, clear, white milky substance visible when the resident tried to open their mouth to smile. Oral care supplies were present in the nightstand, but the resident’s mouth and teeth were not clean. On a subsequent observation with the DON, NHA, and Corporate VP of clinical services, the same resident again had a thick, clear, milky substance between the lips and caking the teeth, which would string between the teeth when the resident attempted to open their mouth, demonstrating a lack of consistent oral care for residents dependent on staff for this ADL.
Incomplete and Inaccurate Medical Record Documentation for Treatments and Assessments
Penalty
Summary
Facility staff failed to maintain complete and accurate medical records and documentation for multiple residents. For one resident with wound care needs, review of the MAR showed that wound care and related treatments were signed as completed on the dates initially reported, despite the resident’s ongoing complaints that wound dressings were not being changed. When additional dates were reviewed, there were missing staff signatures for wound care on two specific dates, as well as three instances where application of A&D ointment to the resident’s feet was not signed off out of 24 days reviewed. Another resident with severe cognitive impairment, as evidenced by a BIMS score of 00, was found to have an injury of unknown origin (a bruise on the left hand). Documentation showed that a change in condition was initiated late in the morning, but a formal pain evaluation was not initiated and completed until that night, and the resident was unable to explain how the injury occurred or verbalize pain using a standard pain scale. For a third resident, documentation related to the admission PPD test was inconsistent and incomplete. The MAR contained an entry indicating “9” for the administration date, meaning “see nurse’s note,” but there was no corresponding nurse’s note. Despite the absence of a signed administration of the PPD injection, staff documented the PPD result as “negative” on the scheduled read date. The resident reported never receiving the PPD injection, and the DON confirmed that the facility had been out of PPD solution at the time, so the test would not have been administered. These findings demonstrate failures in accurate documentation of treatments and assessments, including wound care, pain assessment, and TB screening, as well as missing or incomplete supporting notes in the medical record.
Failure to Implement and Communicate Correct Transmission-Based Precautions
Penalty
Summary
Surveyors identified a deficiency in the facility’s infection prevention and control program related to inconsistent and incorrect implementation of transmission-based precautions and PPE use. During a complaint investigation focused on residents on transmission-based precautions, one resident with a visible Foley catheter was observed in the room with physical therapy, but there were no signs posted indicating any need for PPE, despite the resident being a new admission with a Foley catheter placed related to wounds. In another double-occupancy room, a contact precautions sign was posted at the doorway, but the nurse practitioner was in the room on a personal phone with no PPE, and the assigned GNA was repositioning the resident in bed while wearing only gloves. When questioned, the NP, RN, and GNA all stated that the resident in the room was not on contact precautions, and the GNA reported that signs were hanging at all doors and that this particular resident’s sign was “just wrong.” The surveyor observed the GNA later return to the room and turn the sign around to indicate no PPE requirement. Subsequent interviews revealed that therapy staff relied on posted signage to determine PPE use and that if the sign was wrong, the PPE used would be wrong. Overall, surveyors found problems with signage accuracy and staff awareness of which residents required contact precautions, as well as observed failures to follow appropriate PPE use for residents who should have been on contact precautions.
Inaccurate MDS Coding for Falls, Pain Management, and High-Risk Medications
Penalty
Summary
Facility staff failed to ensure Minimum Data Set (MDS) assessments were accurately coded for two residents reviewed during a complaint survey. For one resident, a facility-reported incident showed that the resident was found seated on the floor beside the bed and was diagnosed with a non-displaced femoral neck impaction fracture of the left hip following an x-ray. Despite this fall with a major injury, the subsequent significant change MDS dated 11/4/25 did not code the fall with major injury in Section J1900C. Review of the resident’s Medication Administration Records for October and November 2025 showed administration of Tylenol on 10/31/25 at 9:30 PM, which fell within the 5-day look-back period for the MDS, but Section J0100 (prn pain) of the same significant change MDS did not capture the use of Tylenol. For another resident, review of a quarterly MDS with an assessment reference date of 10/15/25 showed that Section N0415 (High-Risk Drug Classes) documented the use of an opioid medication. However, review of the resident’s October 2025 Medication Administration Record did not show that the resident had been prescribed an opioid during that period. In both cases, MDS staff later confirmed that these were errors in MDS coding, demonstrating that the assessments did not accurately reflect the residents’ clinical status and medication use as documented in their medical records.
Incomplete Documentation of Narcotic Administration on MAR
Penalty
Summary
The facility failed to maintain complete and accurate medical records in accordance with accepted professional standards for one resident receiving narcotic medication. The resident, admitted in March 2026, had a fall on 3/6/26 and was sent to the hospital on 3/9/26. Review of the March 2026 Medication Administration Record (MAR) showed documentation of a single 25 mg dose of Tramadol administered on 3/8/26 at 9:23 AM. However, review of the resident’s Controlled Drug Receipt/Record/Disposition Form, kept on the nurse’s medication cart and not in the medical record, showed that Tramadol 25 mg was administered three times between 3/8/26 and 3/9/26: at 11:00 AM and 9:00 PM on 3/8/26, and at 9:00 AM on 3/9/26. In interview, the DON stated that staff are expected to document narcotic administration on the MAR and confirmed that only one of the three Tramadol doses reflected on the controlled drug record was documented on the resident’s MAR. This discrepancy between the controlled substance record and the MAR, with missing documentation of two administered doses of Tramadol on the official medical record, constituted the failure to maintain a complete and accurate medical record for the resident.
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Every citation, penalty and Plan of Correction is sourced from public CMS records (latest release May 27, 2026) and official state health department websites — never guesswork.
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