Complete Care At Laplata Llc
Inspection history, citations, penalties and survey trends for this long-term care facility in Laplata, Maryland.
- Location
- 1 Magnolia Drive, Laplata, Maryland 20646
- CMS Provider Number
- 215151
- Inspections on file
- 16
- Latest survey
- January 9, 2026
- Citations (last 12 mo.)
- 11
Citation history
Health deficiencies cited at Complete Care At Laplata Llc during CMS and state inspections, most recent first.
A resident with dementia, severe cognitive impairment, poor gait/balance, and incontinence experienced multiple falls, including two hip fractures, while staff failed to consistently update and individualize the fall care plan or implement ordered interventions. Although the care plan called for root cause review of each fall and a toileting program, several documented falls were never added to the care plan, no new interventions were implemented, and the toileting program was not carried out. The care plan lacked any intervention specifying the needed level of supervision, despite the resident’s impulsivity and frequent unassisted attempts to get up. After a fall resulting in a left hip fracture and subsequent readmission, the only new intervention was to place the wheelchair by the bed, which staff had already been doing, and there was still no documented fall analysis. Observation of the resident’s room revealed additional unaddressed hazards, including a high bed without fall mats, cluttered and low-lit areas, obstructed space preventing wheelchair placement by the bed, and a closed curtain that blocked staff visibility, all contributing to the cited deficiency in accident prevention and supervision.
Surveyors found that the facility failed to maintain a safe, clean, and homelike environment across multiple units and common areas. Hallways on several wings were lined with w/c, geriatric chairs, mechanical lifts, dressers, boxes, and other equipment, while handrails were used to store items such as gloves, trash bags, paper cups, paper towels, and hand sanitizer drip trays. A trash bag with linens was left on a resident room floor, and a bedside commode with an uncovered urine hat was stored at the end of a hallway. In the main dining room, large sheets of plastic were taped to the ceiling, partially covering vending machines and concealing building supplies. Shower rooms were used for storage of w/c, geriatric chairs, beds, clothing bags, and maintenance equipment, leaving only limited shower stalls accessible. An LPN confirmed that staff routinely store residents’ mobility devices in hallways, rooms, and shower areas.
A resident with a history of frequent refusals of medications, vitals, and nursing care had a care plan and physician order directing staff to notify the resident’s representative (RR) whenever treatments or procedures were refused. Despite ongoing daily medication refusals and two documented falls followed by ordered but refused x‑rays, labs, and imaging, records showed that while physicians were notified, the RR was not. Nursing notes later documented a change in the resident’s responsiveness, and the on‑call physician ordered continued monitoring and respect for the resident’s refusal of labs, yet there was still no documented contact with the RR as required by the care plan and orders. The resident was subsequently transferred to the hospital with a diagnosis of sepsis, and the DON could not provide documentation that the RR had been notified of these refusals or condition changes.
A resident repeatedly reported that current incontinence briefs were leaking more than previous ones, causing urine odor on clothing and leading to a missed facility event, along with concerns about missing medical shoe boots and bothersome construction odors. The first grievance was marked resolved without addressing the leaking brief issue, and a second grievance was closed after deciding to add a pad under the brief, without investigating the cause of the leakage or ensuring an effective intervention. The resident stated that staff were not responsive to these complaints, and the NHA, acting as Grievance Officer, acknowledged that the initial concern was not addressed and that the second grievance was not properly investigated.
An activity assistant asked a group of residents if they wanted to listen to music, then played it despite most declining, using music a resident described as derogatory, inappropriate, and excessively loud. This triggered a verbal confrontation between the assistant and a resident, escalating into yelling and cursing until a supervisor intervened and removed the staff member from the area. The recreation director reported prior complaints from this resident about the same staff member’s music, and the staff member’s file showed recent discipline for negative interactions in which a resident was singled out and became upset. Surveyors substantiated this as verbal abuse and failure to treat a resident with respect.
The facility failed to prevent misappropriation of controlled medications and to ensure proper destruction procedures were followed. A former unit manager RN removed and destroyed oxycodone from a med cart without a second licensed nurse present, then left early without notifying the nurse assigned to that cart. Later, another RN found the controlled substance destruction form on the former manager’s desk with signatures suggesting two staff had witnessed destruction, but one staff member reported he had only witnessed his own medications being wasted, not the additional narcotics listed. Surveyors reviewing Unit A narcotic logs found multiple days with missing entries, and the DON acknowledged that the facility’s investigation did not identify which residents’ medications were destroyed, did not verify whether medications documented as sent home or destroyed had actually been handled as recorded, and relied only on the fact that medications were signed off to conclude no other residents were affected.
The facility failed to meet required timeframes for reporting abuse allegations and misappropriation of medication to the SA and did not fully document when and to whom these concerns were reported. In one case, a resident’s family member reported during a care plan meeting that two male therapists had kicked the resident, but documentation of the time of the allegation, the chain of reporting, and the person notified was incomplete, and the report to the SA occurred later that day. In another case, staff reported concerns about misappropriation of a resident’s medication, but the SA was not notified until eight business days later, even though this incident was later classified as misappropriation of resident medication, a form of abuse.
The facility failed to thoroughly investigate and properly document multiple allegations of neglect, abuse, and misappropriation. One resident with chronic pain and no cognitive impairment reported not receiving pain meds for 24 hours, not getting preferred daily showers, and experiencing trauma triggers, yet the investigation lacked a resident statement, interviews with other residents or staff, and any documented inquiry into bathing preferences, pain control, or trauma screening. Another resident with a stroke and mild cognitive impairment alleged being kicked in the chest and stomach by two male staff, but the initial report omitted to whom the allegation was reported, the SSD’s statement lacked dates and times, and staff interviews were incomplete. In a separate incident, an RN unit manager destroyed two sheets of oxycodone without a witness, and the facility did not determine whose meds were destroyed or audit other narcotics documented as sent home or destroyed on that unit, relying only on the fact that medications were signed off.
Staff failed to consistently complete and sign end-of-shift narcotic count verifications for one medication cart on a unit, leaving multiple days without required two-nurse signatures despite facility policy requiring this process. A prior internal concern about alleged improper wasting of narcotics without a witness led surveyors to review narcotic logbooks and compare them with staff schedules, revealing that even when nurses worked double shifts, narcotic logs were often not signed between shifts. The DON acknowledged instructing staff working doubles to sign for both shifts, and facility policy required daily visual audits and spot checks of controlled substance documentation, but the shift-to-shift verification process was not maintained.
Surveyors observed a medication cart left unattended near a nursing station with insulin syringes, hypodermic needles, and a Budesonide inhaler on top, while the assigned RN was in a nearby bathroom and not supervising the cart. A ward clerk and unit manager were present in the area but were not responsible for the cart. During this period, two independently mobile residents were on the opposite side of the nursing station, out of direct staff view, including a resident with Alzheimer's disease and a care plan for eating and chewing inanimate objects. The unsecured medications and administration instruments on the unattended cart in proximity to these vulnerable residents constituted the cited deficiency.
The facility did not maintain three years of survey results for residents, families, and visitors to review. A surveyor’s review of the survey binder in the front lobby showed that it did not contain the required three years of survey reports. In an interview, the NHA confirmed he had reviewed the binder and stated that the facility’s standard was to keep only one year of survey results available, resulting in noncompliance with requirements for public access to survey findings.
A resident was transferred to the hospital without the required care plan goals or documentation being sent, as confirmed by medical record review and staff interviews. The DON made the transfer decision due to behavioral concerns, but the resident had not been assessed by psychiatric services or a physician, and the facility social worker was not involved in the process. Hospital staff reported receiving no paperwork or belongings with the resident.
A resident was transferred to the hospital due to behavioral issues without receiving the required discharge notice, care plan information, or documentation of appeal rights. The DON made the transfer decision without input from psychiatric services or the medical director, and hospital staff reported not receiving necessary paperwork or a bed hold notice.
A resident was transferred to the hospital without the required documentation, care plan goals, or belongings, and neither the resident nor their responsible party received necessary information prior to transfer. The transfer decision was made by the DON due to behavioral concerns, without assessment by a facility physician or psychiatric services, and hospital staff confirmed that no paperwork or bed hold notice was provided.
A resident was transferred to the hospital due to behavioral concerns without being provided a written bed hold notice or the required transfer documentation. Facility staff, including the DON and hospital liaison, confirmed that no paperwork or belongings were sent with the resident, and hospital social workers reported not receiving any bed hold notice or transfer information.
A resident was transferred to the hospital due to behavioral issues without being issued an involuntary discharge notice or having required transfer documentation and care plan information sent. The DON made the decision to transfer the resident, and hospital staff reported that no paperwork, belongings, or bed hold notice were provided, and the resident was not assessed by facility psychiatric services or a physician prior to transfer.
The facility failed to provide warm palatable food to residents, as evidenced by cold meals and inadequate measures to maintain food temperature. A resident confirmed the issue, and test trays showed food temperatures below acceptable levels. The facility lacked sufficient heated pellets and a pellet warmer, contributing to the deficiency.
The facility failed to accurately assess residents' use of side rails and functional status on the MDS. A resident had side rails documented as 'not used' despite their presence, and another had a physician order for side rails, yet the MDS indicated 'not used'. Additionally, a third resident had family consent for side rails, but the MDS inaccurately reported 'not used'. These inaccuracies were noted during a survey and discussed with the DON.
Facility staff failed to follow CDC guidelines for PPE removal during a COVID-19 outbreak. A GNA was observed removing PPE in the hallway instead of inside the resident's room and did not sanitize hands afterward. The GNA also took two food trays into a room without changing gloves or gown between residents. Interviews revealed a lack of recent PPE training and monitoring of staff compliance with infection control protocols.
The facility failed to maintain safe and accessible hallways in Units A, B, and D, with clutter including wheelchairs, chairs, and carts obstructing pathways and handrails. This clutter, due to maintenance activities and insufficient room space, persisted over several days despite being reported to management, raising concerns about emergency evacuation and resident safety.
A facility failed to honor a resident's advance directive, which requested all life-extending measures, including a gastrostomy tube for nutrition. Despite the resident's repeated hospitalizations for aspiration pneumonia and dehydration, the MOLST form indicated no artificial nutrition, influenced by the healthcare agent's opposition. This discrepancy was not addressed, leading to a deficiency in care.
A resident reported being hit by staff members, but the facility delayed reporting the abuse allegation to the state agency by 5 hours, exceeding the required 2-hour timeframe. The incident was brought to the attention of the DON during a complaint survey.
A facility failed to thoroughly investigate an alleged abuse incident where a resident was reportedly struck by a receptionist. The investigation did not include interviews with the resident's roommate or other residents, and the Assistant Director of Nursing could not recall who was interviewed. The Director of Nursing was informed of these findings.
Two residents were unnecessarily monitored with elopement deterrent devices due to the facility's failure to reassess their elopement risk after significant changes in their conditions. Despite assessments indicating low risk, the residents continued to be monitored with wanderguards, a decision made by the DON and Unit Managers. Interviews revealed a lack of clarity on the necessity of these devices.
A resident's care plan was not updated after multiple incidents of g-tube dislodgement, despite the facility's protocol requiring updates following a change in status. The resident needed hospital transfers for g-tube replacement on several occasions, but the care plan was last updated in September 2023. Interviews confirmed that unit managers are responsible for such updates, but this was not done in 2024.
The facility failed to document ADL care for two residents dependent on staff for bowel and bladder care. One resident, requiring extensive assistance, had care documented only twice out of ten potential times. Another resident, dependent due to comorbidities, had no care documented over several shifts. Staff interviews confirmed that ADL records should not have blanks.
The facility did not ensure trauma-informed care for a resident with a history of trauma, as no assessment or care plan was completed upon admission. A social worker confirmed that trauma-informed care assessments were not administered at the time of admission, although they were part of the facility's protocol. An assessment and care plan were only implemented after a complaint investigation.
The facility failed to properly assess and reassess two residents for bed rail use, leading to deficiencies in care. One resident experienced multiple falls and injuries without a reassessment after a change in functional status, while another continued using bed rails against assessment recommendations, resulting in a forehead injury. Staff interviews confirmed the use of bed rails to prevent falls, but there was no evidence of alternative safety measures being considered.
A facility failed to administer medications in accordance with professional standards, resulting in a resident receiving medications late on multiple occasions. Medications such as Tylenol, Prednisone, Metoprolol Tartrate, and Finasteride were administered outside the prescribed 1-hour time frame, as revealed in a medication administration audit. These findings were confirmed through observation, record review, and interviews, and discussed with the DON.
A facility failed to notify a physician of lab results for a resident with multiple comorbidities, including diabetes and anemia. A repeat CBC was ordered by an NP, but the lab report was not available in the medical record, and no physician was notified of the results. The lab report, containing several flagged results, was only reviewed 13 days later during a subsequent visit. The Medical Director confirmed the delay, and the report had to be printed by the DON upon request.
A facility failed to ensure an ordered lab report was available on the chart for a resident with diabetes and anemia. A repeat CBC was ordered by the NP, but the lab report was not available for review when needed. The DON later provided the report, confirming it was not on the chart initially. The Medical Director noted a 13-day delay in follow-up, and the process for lab notification was discussed.
A resident's food preferences were not honored, as they were repeatedly served shrimp despite disliking it. The FSM and Dietician failed to document the resident's preferences in the system, and the GNA's attempts to rectify the situation by contacting the kitchen were unsuccessful. The Quarterly Nutrition Assessment also did not reflect the resident's dislikes, indicating a deficiency in the facility's documentation and communication processes.
A resident with Multiple Sclerosis, requiring assistance and modified drinkware, sustained burns from a hot drink provided by a family member without staff knowledge. The facility failed to provide surveyors with QA and risk management records following the incident, and interviews revealed that documentation of a root cause analysis was missing.
A resident with Multiple Sclerosis sustained burns after spilling hot chocolate provided by a family member without staff knowledge or use of modified drinkware. The facility failed to maintain QA and risk management records for five years post-discharge, as required. Interviews confirmed that a root cause analysis was conducted, but documentation was missing.
Failure to Analyze Recurrent Falls and Implement Adequate Supervision and Environmental Controls
Penalty
Summary
Facility staff failed to identify and evaluate factors contributing to a resident’s recurrent falls and did not ensure appropriate interventions were implemented to prevent future occurrences. The resident had dementia with severe cognitive impairment, poor gait and balance, poor safety comprehension, incontinence, and a history of falls, and was assessed as high risk for falls. A fall care plan initiated months earlier included environmental decluttering, adequate lighting, appropriate footwear, and fall mats, with a goal to keep the resident free of falls. After a right hip fracture from a fall, the care plan called for a toileting program and for each fall to be reviewed for root cause and for the cause to be removed. However, the care plan did not include any intervention specifying the level of supervision needed to prevent falls. Multiple subsequent falls were documented on Change in Condition (CIC) forms, but these events were not consistently incorporated into the care plan, and new interventions were often not added. Falls on 6/16/25 and 7/1/25 were not listed on the care plan, no new interventions were implemented, and there was no evidence that staff reviewed these falls to determine their causes, despite the care plan directive to do so. A toileting program ordered to prevent falls was not implemented, as confirmed by review of the physician’s orders, MAR, and TAR, and by interview with an LPN who stated the resident was not on a toileting program. A later fall on 12/23/25 was added to the care plan, but only one new intervention (ensuring the bed was locked and in low position) was documented, again with no evidence of a fall review or root cause analysis. On 12/31/25, the resident sustained another fall, was found on the floor near the bathroom doorway while staff were passing lunch trays and administering medications, and was subsequently diagnosed with a left hip fracture requiring surgical intervention. After readmission, the fall care plan was updated with only one intervention to place the wheelchair beside the bed, an action staff had already been performing per LPN interview, and there was still no documented review of the fall for root cause or any intervention addressing the level of supervision needed. Observation of the resident’s new room showed additional unaddressed hazards: the bed was too high, there were no fall mats, the wheelchair was not beside the bed and there was no space to place it there, the curtain was closed preventing staff from seeing the resident, the room was far from the nurses’ station, and the roommate’s side was cluttered with low lighting and items protruding into the walkway. These conditions, combined with the resident’s impulsivity, poor safety awareness, and frequent attempts to get up unassisted, reflected the facility’s failure to maintain an environment free from accident hazards and to provide adequate supervision to prevent accidents.
Cluttered Hallways, Shower Rooms, and Dining Area Undermine Homelike Environment
Penalty
Summary
The deficiency involves the facility’s failure to provide a safe, clean, comfortable, and homelike environment on all nursing units and in common areas. During a tour of the C and D units, surveyors observed a partially disassembled hand sanitizer dispenser lying on a PPE cart, wheelchairs, geriatric chairs, and mechanical lifts stored in multiple hallways, and paper cups and a plastic drip tray placed on handrails. Additional items, including a box of gloves and a green mesh bag containing trash bags, were also stored on handrails outside resident rooms. On the A and B units, surveyors observed a trash bag with linens on the floor beside a resident bed, multiple hand sanitizer drip trays and a partial roll of paper towels on handrails, and a mesh bag with trash bags hanging from a handrail. At the end of one hallway, a bedside commode with an uncovered urine hat was present, and the short A wing hallway contained multiple dressers, boxes, and a large trash can stored near the recreation room. Wheelchairs, geriatric chairs, and mechanical lifts were stored in each hallway on the unit. In the main dining room, where residents eat meals and participate in activities, large pieces of plastic were hanging from the ceiling, secured with blue painter’s tape, partially covering vending machines and concealing a large assortment of building supplies. On a subsequent tour, an open, uncovered linen cart with linens and wash basins was observed between resident rooms, along with a box of gloves on the handrail and additional wheelchairs, geriatric chairs, a room chair, and mechanical lifts lining the hallways. One wheelchair contained basins, bleach wipes, toiletries, and trash bags on the seat, and a housekeeper had difficulty maneuvering a cleaning cart between these items and a medication cart. An LPN reported that staff store residents’ wheelchairs and geriatric chairs in hallways, resident rooms, and shower rooms. In the C and D shower room, wheelchairs, geriatric chairs, and a shower bed with large trash bags of clothing and shoes occupied shower stalls, while other stalls contained shower chairs and stretchers. In the A and B shower room, men were moving a bed from the shower room, and the women’s side was full of maintenance equipment; another room had a bed with bags of clothing, and the men’s side had three geriatric chairs blocking a back shower stall, leaving only two shower stalls accessible.
Failure to Notify Resident Representative of Treatment Refusals and Changes in Condition
Penalty
Summary
The deficiency involves the facility’s failure to notify a resident’s representative (RR) of changes in condition and refusals of treatment, despite a specific care plan and physician order requiring such notification. The RR had requested during a care plan meeting that staff call her whenever the resident refused medications, treatments, vitals, or procedures, and this request was incorporated into the care plan and entered as a physician order on the MAR to be acknowledged every shift from admission to discharge. Medical record review showed that the resident had ongoing, daily refusals of medications throughout the stay, and although the attending physician was notified, there was no documentation that the RR was informed of these refusals as required. Further review of the nursing progress notes showed that the resident experienced a fall in late summer, after which x‑rays and laboratory tests were ordered due to observed swelling; these tests were refused and never completed, and there was no documentation that the RR was notified. Later in the stay, the resident had another witnessed fall, and subsequent labs and imaging, including a urinalysis, were ordered and again refused in line with the resident’s documented history of refusals. The following day, nursing notes documented a change in condition with the resident being less responsive. The on‑call physician was notified and ordered monitoring and to respect the resident’s refusal of labs, with instructions to re‑offer if the condition changed or the resident became more agreeable. At no time, according to the record and interviews, was the RR notified or contacted to come in and assist, despite the existing care plan and orders. The resident was later transferred to the hospital for an extended stay with a diagnosis of sepsis, and the DON was unable to provide additional documentation showing that the RR had been notified of the refusals or changes in condition related to the falls and subsequent orders.
Failure to Adequately Investigate and Resolve Resident Grievances About Incontinence Care
Penalty
Summary
The deficiency involves the facility’s failure to adequately address and resolve a resident’s grievances related to incontinence care and other concerns. Record review showed that on 12/9/25 three concerns about Resident #10 were reported to social services: the resident’s incontinence briefs were leaking more than previous ones and their clothing smelled of urine more frequently, two medical shoe boots were missing, and construction odors were bothering the resident. The grievance form indicated that the Nursing Home Administrator (NHA) investigated the grievance and signed it as resolved on 12/10/25, but the written response did not address the concern about the leaking incontinence briefs. A second grievance dated 12/24/25, completed by Unit Manager #4, documented that the same resident again reported leaking incontinence briefs that caused urine odor on their clothing and led them to miss a facility event. The resident stated that the previous briefs did not leak and that they had been complaining without anyone listening. The follow-up section stated that the current brief was not new and that a pad would be added under the brief, and it was marked as resolved. However, there was no documented investigation into why the briefs were leaking or what intervention would prevent recurrence. During an interview, the resident reported ongoing feelings that staff were not responsive to their grievances. In a separate interview, the NHA, who served as Grievance Officer, acknowledged that the incontinence brief concern was not addressed when first reported and that the second grievance was not investigated to ensure an effective resolution for the resident.
Verbal Altercation and Disrespectful Conduct by Activity Staff Toward a Resident
Penalty
Summary
Facility staff failed to protect a resident from verbal abuse and to ensure the resident was treated with respect. During a scheduled smoke break in the courtyard, an activity assistant asked a group of residents if they wanted to listen to music. Although the majority of residents reportedly declined, the activity assistant played music anyway. The resident reported that the music selections were derogatory, inappropriate for public listening, and extremely loud, making it difficult for residents to hear one another. This led to escalating verbal exchanges between the resident and the activity assistant. According to the investigation statements, the interaction progressed into a verbal altercation involving yelling and cursing between the resident and the activity assistant until a supervisor arrived and escorted the staff member from the courtyard and out of the facility for the remainder of the day. The Recreation Program Director reported that the resident had previously complained about the music played by this same activity assistant, and that the activity assistant had also approached him about these prior conflicts. Review of the activity assistant’s employee file showed disciplinary action less than three weeks earlier for negative interactions with a resident, in which a resident was singled out and became upset. Surveyors substantiated abuse based on these findings.
Failure to Prevent Misappropriation and Ensure Proper Destruction of Controlled Medications
Penalty
Summary
The deficiency involves the facility’s failure to protect residents’ medications from misappropriation and to ensure proper controlled substance handling and documentation. A facility-reported incident described that the former Unit A manager (an RN) removed two sheets of oxycodone from a medication cart and destroyed them without following required procedures, including having a second licensed nurse witness the destruction. The RN then left work early without notifying the nurse responsible for that medication cart. When the assigned nurse later attempted to appropriately waste medications from the cart, she discovered the narcotics were already gone. She contacted another RN, who located the Controlled Dangerous Substance Destruction Report on the former unit manager’s desk, bearing signatures and initials of that RN and another staff member. When the other staff member was interviewed, he stated he was only aware of his own medications being wasted and not the additional two narcotics listed on the form. During the survey, narcotic logbooks on Unit A were reviewed and showed multiple days with missing entries (“holes”) in the logs. The current Unit A manager explained that the facility’s process required two licensed nurses to be present for the entire destruction process, from gathering the medications through signing paperwork and destroying the drugs. The DON acknowledged the prior incident involving the former unit manager and stated that the facility’s investigation could not determine which residents’ medications had been destroyed, although she noted that pharmacy could have been contacted using prescription numbers to obtain that information. Review of narcotic logs showed that some medications were documented as sent home with residents and others as destroyed, which the DON said was based on physician orders. When asked, the DON reported that the facility did not go back to verify whether narcotics were actually sent home or destroyed on Unit A during the former unit manager’s tenure and confirmed that the only step taken to determine whether other residents were affected was to verify that all medications were signed off in the records.
Failure to Timely Report Abuse Allegations and Misappropriation of Medication
Penalty
Summary
The deficiency involves the facility’s failure to timely report allegations of abuse and misappropriation of resident property to the state agency (SA) within required timeframes, and incomplete documentation of when and to whom the allegations were reported. For one resident, documentation showed a care plan meeting note initiated by a unit manager on one date was incomplete, and a late-entry care plan note by the Social Services Director (SSD) indicated the care plan meeting occurred earlier that same day. The facility’s investigation file for this incident documented that the resident accused two male therapists of kicking the resident in the chest and stomach, and that staff became aware of the allegation at 4:00 PM, but failed to document to whom it was reported. The final investigation report indicated the allegation was reported by a family member during a care plan meeting. The SSD’s written statement did not include the date and time she was told of the allegation, nor when and to whom she reported it. Email confirmation showed the allegation was reported to the SA at 5:55 PM that day. In interview, the ADON stated she documented the date and time she became aware of the allegation on the initial report form and acknowledged she should have documented the date and time the SSD was told of the allegation but did not. The SSD reported in interview that the care plan meeting occurred at 2:30 PM, lasted about 45 minutes, and that she reported the allegation to the ADON between 3:19 PM and 3:30 PM. A second deficiency involved the facility’s failure to timely report a misappropriation of resident medication, which is classified as a form of abuse. The facility-reported incident showed that staff member #4 made the facility aware of the concern on one date, but the SA was not notified until eight business days later at 6:00 PM. Initially, during interview, the DON stated this was considered an unusual circumstance; however, after surveyor review and interviews, the incident was classified as misappropriation of resident medication. The survey team requested email confirmations of submissions to verify reporting timeframes and reviewed concerns about reporting timeframes throughout the survey and again during exit.
Failure to Thoroughly Investigate and Document Abuse, Neglect, and Misappropriation Allegations
Penalty
Summary
The deficiency involves the facility’s failure to conduct thorough investigations and maintain complete written records for abuse, neglect, and misappropriation allegations. For one resident with no cognitive impairment, chronic pain syndrome, and a documented preference for choosing between a shower or bed bath, the record did not show that staff determined or documented the resident’s bathing preference or frequency. When this resident later reported neglect concerns about pain medication not being given for 24 hours, not receiving daily showers as preferred, and experiencing trauma triggers related to stress and being in a nursing home, the facility’s investigation file lacked key elements. The initial report did not identify to whom the concerns were reported, and the final report did not include a resident statement, interviews with other residents about showers or trauma care, or staff statements. A census sheet used as part of the investigation had check marks and a note about residents having no concerns with pain medications but lacked dates, times, and the name or signature of the interviewer. There was no evidence that staff investigated why the resident was not receiving daily showers, why the resident’s pain was not controlled, or how trauma triggers had not been identified during trauma screening. For another resident with a history of stroke and mild cognitive impairment, the facility failed to fully document and investigate an allegation of physical abuse by staff. The resident’s physician documented a need for PT and OT, and care plan meeting notes were entered by the unit manager and social services director on different times and as a late entry. The initial abuse report documented that the resident accused two male therapists of kicking the resident in the chest and stomach, and that staff became aware of the allegation at a specific time, but did not state to whom it was reported. The final investigation report stated that a family member reported the allegation during a care plan meeting and that the resident said two staff members kicked the resident in the stomach on a prior evening. The abuse was deemed unsubstantiated because the alleged perpetrators were not identified and the resident could not clearly describe the incident, and it was noted there was only one male therapist in the facility. The SSD’s written statement did not include the date and time she was told of the allegation or when and to whom she reported it. Although statements were obtained from two male staff who cared for the resident that evening and from the male therapist, the facility did not obtain statements from other staff who worked that evening/night. In a separate incident involving potential misappropriation of narcotics, the facility failed to complete a thorough investigation and maintain adequate documentation. The initial information provided to surveyors consisted only of the initial report to the state agency and the Board of Nursing regarding an RN who had been a unit manager. According to these documents, the RN removed two sheets of oxycodone from a medication cart and destroyed them without following required procedures, including having a witness present. The DON stated that they were unable to determine whose medications were destroyed, although a call to the pharmacy with the prescription number could have clarified this. Review of narcotic logs showed that narcotics were sometimes documented as sent home with residents at discharge and sometimes as destroyed. The DON acknowledged that, during the investigation, they did not verify whether narcotics documented as sent home or destroyed on that unit during the RN’s tenure were accurate, and that their only verification was that all medications were signed off. No additional investigative information was provided to surveyors before exit.
Failure to Maintain Two-Nurse Narcotic Count Verification Between Shifts
Penalty
Summary
Facility staff failed to ensure that end-of-shift narcotic count verifications were consistently completed and signed by two nurses for one of two medication carts on the A wing. Review of the A wing narcotic logbooks on 1/7/26, prompted by a prior facility report from August 2025 regarding alleged improper wasting of narcotics by a former unit manager without a witness, showed multiple days between August 2025 and December 2025 where two-nurse verification at shift change was not documented. The A unit manager stated that two nurses are supposed to sign each shift and that staff working a double shift are to complete the narcotic count with the shift supervisor. She was informed of multiple gaps in the narcotic log, and copies of the logs from August through December were requested. The DON reported that her practice was to instruct staff working a double shift to sign their initials for both shifts, which she suggested could explain missing signatures. However, comparison of staff schedules for selected time frames with the narcotic logs and corresponding signatures, conducted with the DON on 1/8/26, revealed that staff still failed to consistently sign the narcotic log between shifts even when working double shifts. Review of the facility’s Controlled Substance Administration and Accountability policy, last revised 3/2023, showed that the controlled drug record is intended to document both narcotic disposition and patient administration, and that the charge nurse or designee is to conduct a daily visual audit of controlled substance documentation with spot checks for proper destruction documentation and physician orders for removed medications. Despite these policy requirements, the narcotic log shift-to-shift verification process was not maintained, as noted throughout the survey and again at exit on 1/9/26.
Unattended Medication Cart with Unsecured Medications and Needles Near Mobile Residents
Penalty
Summary
Facility staff failed to keep medications and related supplies secured from residents when a medication cart was left unattended and accessible near the C/D unit nursing station. During a tour at 4:20 PM, a surveyor observed a medication cart pushed up against the nursing station with 2 insulin syringes, 2 hypodermic needles, and a Budesonide steroid inhaler on top. A ward clerk was seated at the desk and the C/D unit manager was in her office, but neither was assigned to or in charge of the medication cart. The Nurse Practice Educator (NPE) arrived shortly thereafter, independently observed the same unsecured items on the cart, and began looking for the nurse responsible for the cart. The NPE was informed by staff at the nursing desk that the nurse assigned to the cart was in the bathroom. Moments later, a staff member exited a bathroom across from the nursing station and returned to the unattended medication cart, and it was verified that this was her cart and that she was an RN who had previously worked at the facility. During this time, two independently mobile residents were observed on the opposite side of the nursing station, in an area where they would not be visible to staff if they approached the cart. Review of the medical record for one of these residents showed a diagnosis of Alzheimer's disease and a care plan for eating and chewing inanimate objects. The unsecured medications and administration instruments on the unattended cart in the vicinity of these vulnerable residents were reported to the DON and discussed again with the facility at exit.
Failure to Provide Three Years of Survey Results for Public Review
Penalty
Summary
The facility failed to make the last three years of survey results available for residents, family members, and visitors to review. On 01/07/2026 at 12:18 PM, surveyors reviewed the survey binder located on a table in the front lobby and found that it did not contain the required three years of survey results. During an interview on 01/07/2026 at 12:20 PM, the Nursing Home Administrator stated that he had reviewed the binder and that the facility’s standard was to have only one year of survey results available in the binder, confirming that the facility was not maintaining three years of survey results for public review as required.
Failure to Provide Required Transfer Documentation to Hospital
Penalty
Summary
The facility failed to ensure that required information was sent to the hospital when a resident was transferred. Medical record review showed that the resident was admitted to the facility and later transferred to the hospital, but there was no documentation indicating that the resident's care plan goals or other required information were sent with the resident. Interviews with facility staff, including the DON and hospital liaison, confirmed that the transfer occurred without the necessary paperwork or belongings being provided to the hospital. The hospital social workers also stated that they did not receive any paperwork or a bed hold notice for the resident upon transfer. Further review revealed that the facility's social worker was not involved in the discharge process and did not attempt to find alternative placement for the resident. The DON made the decision to send the resident back to the hospital due to behavioral concerns, but the resident had not been assessed by facility psychiatric services or a physician prior to transfer. The facility hospital liaison communicated with the hospital social worker about the transfer, but did not provide the required documentation. The medical director was not involved in the decision to transfer the resident.
Failure to Provide Timely Discharge Notification and Required Documentation
Penalty
Summary
The facility failed to provide timely notification of discharge to a resident, their representative, and the ombudsman prior to or during the resident's transfer back to the hospital. Medical record review showed no documentation that the required discharge notice or care plan goals were sent to the hospital at the time of transfer. Additionally, there was no evidence that the education provided included a review of the specific information required to be sent to the receiving facility. The resident was transferred due to behavioral issues, including wandering, aggression, and combativeness, but had not been assessed by facility psychiatric services or a facility physician prior to the transfer. Interviews with facility staff and hospital personnel confirmed that the resident was sent back to the hospital without the necessary paperwork, belongings, or a bed hold notice. The DON made the decision to transfer the resident and communicated with the hospital, but the hospital social workers reported not receiving any documentation or notification of appeal rights. The facility hospital liaison and medical director were not directly involved in the decision or the transfer process, and the required notifications and documentation were not provided as mandated.
Failure to Provide Required Documentation and Information During Resident Transfer
Penalty
Summary
The facility failed to provide required documentation and information to a resident or their responsible party prior to transferring the resident to the hospital. Medical record review showed that the resident was admitted to the facility and later transferred to the hospital, but there was no documentation indicating that the resident's care plan goals or other necessary information were sent to the hospital at the time of transfer. Additionally, there was no evidence that the resident or their responsible party received education or review of the specific information required to be sent to the receiving facility. The resident's belongings were also not sent with them, and no bed hold notice was provided. Interviews with facility staff, including the DON, hospital liaison, and medical director, revealed that the decision to transfer the resident was made by the DON due to behavioral concerns, but the resident had not been assessed by a facility physician or psychiatric services prior to transfer. Communication between facility staff and the hospital was limited to verbal notification, and the hospital social workers confirmed that no paperwork or belongings accompanied the resident. The medical director stated they had no input in the transfer decision.
Failure to Provide Bed Hold Notice and Required Transfer Documentation
Penalty
Summary
The facility failed to provide a written bed hold notice to a resident or the resident’s representative prior to the resident’s transfer to the hospital. Medical record review showed no documentation that a bed hold notice was given, nor was there evidence that the required care plan goals or specific transfer information were sent to the hospital at the time of transfer. Interviews with facility staff, including the DON and hospital liaison, confirmed that the resident was transferred due to behavioral issues without being seen by facility psychiatric services or a facility physician, and that no paperwork or belongings accompanied the resident to the hospital. Further interviews with hospital social workers revealed that the hospital did not receive any paperwork or a bed hold notice for the resident upon transfer. The DON acknowledged making the decision to send the resident back to the hospital and confirmed that the resident was not under involuntary discharge. The facility hospital liaison and medical director also confirmed a lack of involvement in the transfer decision and absence of required documentation, resulting in the deficiency.
Failure to Issue Involuntary Discharge Notice and Provide Required Transfer Documentation
Penalty
Summary
The facility failed to issue an involuntary discharge notice to a resident prior to transferring the resident to the hospital, which resulted in the resident not being informed of their legal rights as required for residents in long-term care. The resident, who had been admitted to the facility and later transferred to the hospital due to behaviors such as wandering, aggression, and combativeness, did not have documentation in their medical record indicating that care plan goals or required transfer information were sent to the hospital. Additionally, there was no evidence that the resident was assessed by facility psychiatric services or a facility physician prior to the transfer. Interviews with facility staff, including the DON and hospital liaison, revealed that the decision to send the resident back to the hospital was made by the DON, and the hospital was informed that the resident would not be returning to the facility. The hospital social workers confirmed that no paperwork, belongings, or bed hold notice accompanied the resident upon transfer, and the facility medical director stated they had no input in the decision. The lack of proper documentation and communication regarding the resident's transfer and discharge process led to the deficiency.
Failure to Provide Warm Palatable Food to Residents
Penalty
Summary
The facility staff failed to implement measures to provide warm palatable food to residents, as evidenced by observations and interviews. A complaint was reviewed regarding cold meals, and during an interview, a resident confirmed that their food was sometimes not warm. A test tray was requested during lunch service, and it was found that the food was only slightly warm. The tray lacked a heated base or pellet, which are typically used to maintain food temperature. Additionally, trays were observed being delivered on an open rack without any means to keep the food warm. Further interviews revealed that the facility had insufficient heated pellets and no pellet warmer, which contributed to the issue. The Food Service Manager (FSM) was unaware of how long it had been since heated pellets were used and did not know if a pellet warmer had been ordered. Another test tray during lunch service showed food temperatures well below acceptable levels, with a chicken thigh at 85°F, corn at 98°F, and roasted potatoes at 82°F. These findings were reviewed with the Administrator and Director of Nursing.
Inaccurate MDS Assessments for Side Rails and Functional Status
Penalty
Summary
The facility failed to complete accurate assessments for residents regarding the use of side rails and the functional use of extremities on the quarterly and annual Minimum Data Set (MDS). For Resident #29, the MDS inaccurately coded the use of bed rails as 'not used' across multiple assessments, despite observations and documentation indicating the presence of 1/2 size side rails. Additionally, the MDS inaccurately reported 'no impairment' in the resident's extremities, contradicting nursing documentation and observations. MDS staff acknowledged that information is primarily gathered electronically, with occasional resident observations to confirm electronic records. For Resident #5, a physician order for 1/4 side rails as enablers was documented, yet the MDS inaccurately coded 'not used' for bed rails in several assessments. Similarly, Resident #30 had a family consent for side rails, and observations confirmed their presence, but the MDS inaccurately reported 'not used' for side rails in both annual and quarterly assessments. These discrepancies were discussed with the facility's Director of Nursing, highlighting a pattern of inaccurate MDS assessments related to side rail usage and functional status.
Improper PPE Removal During COVID-19 Outbreak
Penalty
Summary
Facility staff failed to adhere to the Centers for Disease Control's guidelines for removing personal protective equipment (PPE) during a COVID-19 outbreak. Observations revealed that a Geriatric Nursing Assistant (GNA) exited a resident's room wearing a gown, gloves, mask, and shield, and removed the gown and gloves in the hallway instead of inside the room. The GNA did not sanitize his hands after removing the PPE and was observed touching his mask and face shield multiple times. Additionally, the GNA took two food trays into a resident's room simultaneously without changing gloves or gown between residents, which is against infection control practices. Interviews with the Unit Manager and Infection Control Preventionist highlighted a lack of recent PPE training and monitoring of staff compliance with infection control protocols. The Unit Manager acknowledged that staff should have intervened when witnessing improper PPE removal. The Infection Control Preventionist admitted that the last PPE training was conducted three months prior and that no additional training had been provided since the COVID-19 outbreak began. The facility's infection control practices were not aligned with CDC guidelines, as PPE was not consistently removed and discarded before leaving the resident's room.
Cluttered Hallways Compromise Safety in Nursing Units
Penalty
Summary
The facility failed to maintain a safe environment for residents across three of its four nursing units, specifically Units A, B, and D. On Unit A, the hallway was cluttered with various items including wheelchairs, dining room chairs, isolation carts, and even a bedpan with a toilet plunger, leaving less than three feet of maneuverable space. This clutter was due to maintenance activities that required moving furniture from rooms into the hallway. The Unit Manager was unaware of the clutter and had not addressed it, raising concerns about emergency evacuation procedures. On Unit B, the hallway was similarly obstructed with Geri chairs, wheelchairs, medication carts, and breakfast carts, making handrails inaccessible and the hallway crowded. The DON was informed of these issues, which persisted over several days. On Unit D, the hallway was obstructed by reclining chairs, wheelchairs, and dining room chairs, reportedly due to insufficient space in resident rooms for GNAs to provide morning care. Despite being informed of the safety concerns, the clutter remained over multiple days, indicating a systemic issue with maintaining clear and accessible hallways.
Failure to Honor Resident's Advance Directive
Penalty
Summary
The facility failed to adhere to the wishes of a resident as outlined in their advance directive, which specified that all measures should be taken to extend their life, including the use of a gastrostomy tube for nutrition if necessary. Despite this, the MOLST form on file indicated that artificially administered nutrition should not be given, a decision that was influenced by the resident's healthcare agent who opposed the use of a feeding tube. This discrepancy between the advance directive and the MOLST form was not addressed by the facility, leading to a failure in honoring the resident's documented preferences. The resident, who had multiple comorbidities including dementia and dysphagia, experienced repeated hospitalizations due to aspiration pneumonia and dehydration. During these hospitalizations, evaluations indicated a high risk of aspiration and recommended that the resident be NPO pending further assessments. Despite these recommendations and the resident's significant weight loss, the facility did not implement the use of a feeding tube as per the advance directive, due to the healthcare agent's opposition. Interviews with facility staff, including the nurse practitioner and social worker, revealed that there was an assumption that the healthcare agent's decisions overrode the advance directive. The facility's Director of Nursing acknowledged the issue and indicated that they were contacting the healthcare agent for further consultation. However, the failure to align the MOLST with the advance directive and to follow the resident's stated wishes constituted a deficiency in the facility's care practices.
Failure to Timely Report Allegation of Abuse
Penalty
Summary
The facility staff failed to report an allegation of abuse in a timely manner to the State Agency. This deficiency was identified during a complaint survey involving a resident who reported being hit on the cheeks by a male and female staff member. The incident occurred at approximately 3:00 AM and was reported to a Licensed Practical Nurse at 5:30 PM on the same day. However, the facility did not report the allegation to the state agency until 10:30 PM, which was 5 hours after the staff became aware of the incident, instead of the required 2-hour timeframe. The Director of Nursing was informed of these findings during the survey.
Incomplete Investigation of Alleged Resident Abuse
Penalty
Summary
The facility staff failed to thoroughly investigate an allegation of resident abuse involving a resident who was reportedly struck on the hand by a receptionist. The incident was reported by a family member, who also mentioned that the resident's roommate confirmed the event. The facility's investigation included an assessment of the resident and statements from staff, but it was unable to conclude whether the alleged abuse occurred. However, the investigation was incomplete as it did not include interviews with the resident's roommate or other residents who might have had relevant information. During an interview, the Assistant Director of Nursing, who was responsible for the investigation, admitted to not remembering who was interviewed and failed to provide evidence of interviews with the roommate or other residents. Initially, she claimed the roommate was not alert, then changed her statement to say the roommate was alert but not oriented. The investigation file lacked documentation of any resident interviews, highlighting a significant gap in the investigation process. The Director of Nursing was informed of these findings.
Failure to Reassess Residents' Elopement Risk
Penalty
Summary
The facility staff failed to properly assess two residents after significant changes in their conditions, leading to unnecessary monitoring with elopement deterrent devices. Resident #22, who had previously eloped from the facility, was assessed multiple times in 2024 and found to be a low elopement risk. Despite this, the resident continued to be monitored with a wanderguard, a decision attributed to the Director of Nursing and Unit Managers. Interviews with facility staff confirmed that the resident was no longer considered an elopement risk, yet the monitoring device remained in use until it was eventually removed. Similarly, resident #28, who also had a history of elopement, was not reassessed for elopement risk after the initial incident in 2022. The only subsequent assessment in 2023 indicated a low risk, yet the resident continued to be monitored with a wanderguard. Interviews with the Assistant Director of Nursing and the Director of Nursing revealed a lack of clarity on the necessity of the monitoring device, highlighting a failure to reassess the resident's condition appropriately.
Failure to Update G-Tube Care Plan After Change in Status
Penalty
Summary
The facility failed to update a resident's care plan following a change in status, specifically concerning the care of the resident's g-tube. The resident experienced multiple incidents where the g-tube became dislodged, necessitating hospital transfers for replacement on several occasions, including in August 2022, September 2023, July 2024, and October 2024. Despite these incidents, the facility did not update the care plan with new interventions after the dislodgements in July and October 2024, with the last update occurring in September 2023. Interviews with facility staff, including the C/D Unit Manager and the Nurse Educator, confirmed that the responsibility for updating care plans after a change in status lies with the unit managers. However, the C/D Unit Manager did not update the care plan following the incidents in 2024. The Director of Nursing was informed of this failure by the surveyor, highlighting a lapse in the facility's protocol for maintaining current and effective care plans for residents experiencing changes in their medical status.
Failure to Document ADL Care for Dependent Residents
Penalty
Summary
The facility failed to document care provided to residents who were dependent on staff for activities of daily living (ADL), specifically related to bowel and bladder care. For Resident #11, who was coded as requiring extensive assistance and frequently incontinent, there were multiple days where staff did not document the provision of bowel and bladder care. During a specific period, care was documented only twice out of a potential ten times. This lack of documentation was confirmed through interviews with facility staff, who acknowledged that ADL records should not have any blanks. Similarly, for Resident #16, who was dependent on staff for ADL care due to multiple comorbidities and was frequently incontinent, there was a lack of documentation for incontinence care over several shifts. The records showed no documentation of care provided during specific evening and night shifts, and no bowel movements were recorded over 11 shifts. Interviews with staff confirmed that documentation should occur every shift, highlighting a consistent failure in maintaining accurate records of care provided.
Failure to Provide Trauma-Informed Care
Penalty
Summary
The facility failed to develop and implement a process to ensure that residents with a history of trauma received appropriate trauma-informed care. This deficiency was identified during a review of the medical records and interviews, specifically for one resident out of three reviewed for trauma-informed care. The medical record review revealed that the resident was admitted to the facility without an assessment or care plan to ensure trauma-informed care was provided. An interview with a social worker indicated that trauma-informed care assessments were conducted on admission and annually, but at the time of the resident's admission, the facility was not administering these assessments. It was noted that a trauma-informed care assessment was eventually completed, and a care plan was implemented after a complaint investigation.
Failure to Properly Assess and Reassess Bed Rail Use
Penalty
Summary
The facility failed to properly assess and reassess residents for the use of bed rails, leading to deficiencies in care. For Resident #26, there was a lack of documentation regarding attempted interventions or alternatives to bed rails, despite a significant change in the resident's functional status. The resident had a history of falls and injuries, including a fractured nasal bone, yet the facility did not conduct a reassessment after these incidents. Observations showed the resident using half side rails, contrary to the documented use of quarter side rails, and there was no follow-up assessment after the noted decrease in the resident's extremity functionality. For Resident #3, the facility also failed to adhere to the assessment recommendations. Despite an assessment on 3/27/24 advising against the use of bed rails, the resident continued to use them, resulting in a discoloration on the forehead from resting against the rail. Interviews with staff confirmed the continued use of bed rails to prevent falls, but there was no evidence of reassessment or consideration of alternative safety measures following the change in the resident's condition.
Failure to Administer Medications Timely
Penalty
Summary
The facility failed to ensure that residents were free from significant medication errors, as evidenced by the staff's failure to administer medications in accordance with professional standards. This deficiency was identified for one resident who was reviewed for medication administration. The resident's medication administration audit for November 2023 revealed that medications were consistently administered late, outside the 1-hour time frame specified. Specifically, Tylenol, Prednisone, Metoprolol Tartrate, and Finasteride were all administered outside the prescribed time frames on multiple occasions. These findings were confirmed through observation, record review, and interviews, and were discussed with the Director of Nursing.
Failure to Notify Physician of Lab Results
Penalty
Summary
The facility failed to ensure that a physician was notified of lab results for a resident with multiple comorbidities, including uncomplicated diabetes and anemia. The resident was seen by a Nurse Practitioner (NP) who ordered a repeat CBC due to leukocytosis noted in previous labs. However, the lab report from the ordered test was not available in the resident's medical record, and there was no documentation indicating that any physician was notified of the results. The lab report contained several flagged high and low results, which were not addressed until 13 days later when the NP saw the resident again. The Medical Director confirmed that the lab results were reviewed only during the subsequent visit by the NP, and a repeat CBC was ordered at that time. The surveyor noted that the lab report was not on the chart and had to be printed by the Director of Nursing (DON) upon request. This delay in reviewing and addressing the lab results highlights a deficiency in the facility's process for ensuring timely notification and follow-up on lab results.
Lab Report Unavailability on Chart
Penalty
Summary
The facility failed to ensure that an ordered lab report was available on the chart for review, as evidenced during a complaint survey. The medical record review for a resident with multiple comorbidities, including uncomplicated diabetes and anemia, revealed that a repeat CBC was ordered by the Nurse Practitioner (NP) on a specific date. However, the lab report and results for this test were not available on the chart when reviewed by the surveyor. The Director of Nursing (DON) later provided the lab report, confirming that it was not on the chart or available for review at the time it was needed. The Medical Director confirmed that the lab was followed up on 13 days after the initial order when the NP saw the resident again, and a repeat CBC was ordered. The process of notification for labs was discussed, and it was noted that the lab should have been on the chart for review and signed by the physicians/NPs. The deficiency was identified as the lab report not being available on the chart, which delayed the review and follow-up of the flagged results.
Failure to Honor Resident's Food Preferences
Penalty
Summary
The facility staff failed to honor a resident's food preferences, specifically regarding the resident's dislike of shrimp. During a complaint survey, it was found that the resident did not have their food preferences accurately documented in the facility's system. The Food Service Manager (FSM) and the Dietician were responsible for identifying and entering these preferences, but no dislikes were listed for the resident in question. The resident confirmed that they did not like shrimp and had been served it multiple times, despite staff efforts to provide alternatives. Interviews with staff revealed that the Geriatric Nursing Assistant (GNA) was aware of the resident's dislike for shrimp and had contacted the kitchen several times to request an alternative meal. However, the issue persisted, indicating a breakdown in communication and documentation processes. The most recent Quarterly Nutrition Assessment did not identify the resident's food preferences or dislikes, further highlighting the deficiency in the facility's system for managing resident dietary needs.
Failure to Provide QA and Risk Management Records After Resident Burn Incident
Penalty
Summary
The facility administration failed to provide a surveyor with quality assurance (QA) and risk management records following an incident where a resident sustained burns from hot liquid. This deficiency was identified during a complaint survey involving a resident who had been admitted to the facility due to complications from Multiple Sclerosis (MS). The resident required extensive assistance and modified drinkware/utensils due to numbness in their hands and fingers. On a specific date, the resident suffered burns on their thighs and chest after spilling a hot drink, which was given to them by a family member without the facility staff's knowledge and without using the modified drinkware/utensils. Interviews with the Nurse Educator/Former Unit B Manager confirmed the incident and indicated that a risk management investigation and QA activities were completed following the burn incident. However, during interviews with the Director of Nursing (DON) and the Executive Director, it was revealed that the facility could not locate any documentation of a root cause analysis, risk management, or QA activities related to the incident. Both the DON and the Executive Director acknowledged that such analyses and assessments would typically be conducted to determine if the incident posed a potential problem for other residents.
Failure to Maintain QA and Risk Management Records
Penalty
Summary
The facility administration failed to maintain quality assurance (QA) and risk management records for five years after a resident was discharged, as required by professional standards. This deficiency was identified during a complaint survey involving a resident who sustained burns from spilling a hot drink. The incident occurred when a family member provided the resident with hot chocolate without the facility staff's knowledge, and without using the resident's modified drinkware/utensils. The resident, who had Multiple Sclerosis and required extensive assistance due to numbness in hands and fingers, was unable to handle the hot liquid safely, resulting in burns on the thighs and chest. Interviews with the Nurse Educator/Former Unit B Manager, the Director of Nursing (DON), and the Executive Director confirmed that a risk management investigation and QA activities were conducted following the incident. However, the facility was unable to locate the root cause analysis or any related documentation for the incident. Both the DON and the Executive Director acknowledged that such analyses and assessments would have been conducted to determine if the incident posed a potential problem for other residents, but the absence of these records indicates a failure to maintain necessary documentation as per regulatory requirements.
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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