Complete Care At Multi Medical Center Llc
Inspection history, citations, penalties and survey trends for this long-term care facility in Towson, Maryland.
- Location
- 7700 York Road, Towson, Maryland 21204
- CMS Provider Number
- 215096
- Inspections on file
- 19
- Latest survey
- March 2, 2026
- Citations (last 12 mo.)
- 13
Citation history
Health deficiencies cited at Complete Care At Multi Medical Center Llc during CMS and state inspections, most recent first.
The facility failed to ensure meals were palatable and served at appropriate temperatures, affecting all residents. Several residents reported consistently receiving cold meals, such as scrambled eggs, and cold beverages not served at appropriate temperatures. The CDM acknowledged issues with timely delivery by nursing staff and provided only monthly tray testing results, despite ongoing complaints for at least three months.
A resident dependent on ADL care was observed with excessive mucous around their tracheostomy dressing and neck on multiple occasions. Despite the presence of an LPN, the resident remained soiled, as the LPN deferred suctioning to the Respiratory Therapist. The DON confirmed that nurses are trained to perform suctioning, yet the resident's condition was not promptly addressed.
A survey revealed that residents were unaware they could hold resident council meetings without facility staff present. During a meeting attended by fourteen residents, including the Resident Council President via iPad, it was confirmed that they did not know about this right. An Activities Assistant also expressed unawareness of this possibility, leading to a deficiency in respecting residents' rights to organize independently.
Residents were not informed about the identity or contact information of the facility Ombudsman, violating their rights to receive notices in a format and language they understand. During a resident council meeting, it was revealed that none of the residents knew the Ombudsman's name or how to contact them. Guest Services Director confirmed the residents' lack of awareness.
A facility staff member inaccurately coded a resident's MDS assessment, indicating the use of a trunk restraint when none was used. The error was confirmed by the MDS Coordinator after the resident denied using such a restraint.
A resident's medication administration was inaccurately documented by an LPN, who signed off that Metoprolol was given despite the resident's g-tube being clogged and orders prohibiting oral administration. The resident was later hospitalized for g-tube replacement.
A resident who was dependent on assistance for ADL care reported not receiving a shower since admission. Facility documentation lacked records of showers being provided or refused. The resident stated they were not offered a shower prior to the previous day, indicating a failure in care provision and documentation.
A resident received blood pressure medication outside the prescribed parameters on multiple occasions. The medication was supposed to be held if the systolic BP was less than 110 and heart rate less than 60, but it was administered despite readings below these thresholds. Interviews revealed that geriatric nursing aides are responsible for obtaining BP readings, and LPNs are to hold medication if parameters are not met, but this process was not followed.
A facility was found to have a medication error rate of 6.67% due to an LPN's failure to administer an antiviral medication on time and incorrect documentation of a Fortified Nutritional Shake that a resident refused. The DON acknowledged the errors and noted the availability of a Pyxis system for medication dispensing.
The facility staff failed to discard expired medications in one of the medication storage rooms. Expired items, including intravenous bags and vitamins, were found during a survey. Interviews revealed unclear responsibilities between the unit clerk and central supply personnel regarding the management of expired medications, leading to the oversight.
The facility failed to ensure that GNAs received annual dementia training, as there was no documentation confirming completion for four GNAs. The educator, who took over in July, could not verify the training due to a transition to electronic records. The administrator acknowledged incomplete education files due to previous filing issues, identified during a quality assessment meeting.
Deficiency in Meal Temperature and Palatability
Penalty
Summary
The facility staff failed to ensure that meals were palatable and served at appropriate temperatures, affecting all residents receiving meals from the facility's kitchen. During a tour of the units, several residents reported that their meals, including scrambled eggs, were consistently served cold. The certified dietary manager (CDM) acknowledged that meal carts were sent up in a timely manner, but nursing staff were not delivering the trays within 15 minutes of arrival. Additionally, the CDM stated that the hold temperature for hot food items was maintained at 140 degrees or greater, and the pellet bases/chargers had been replaced recently. A resident council meeting revealed that residents consistently experienced meals that were not warm or hot, with examples such as butter not melting on food. The surveyor observed that while the main courses were within safe temperature ranges, cold beverages like apple juice were not served at appropriate temperatures, with some readings as high as 80 degrees. The facility had been aware of residents' complaints about cold food for at least three months, but the CDM had not provided weekly tray testing results, only monthly ones, prior to the exit conference.
Failure to Maintain Dignity in Resident's Tracheostomy Care
Penalty
Summary
The facility staff failed to provide a dignified existence to a resident dependent on Activities of Daily Living (ADL) care. This deficiency was observed in one of the three dependent residents assessed during the survey. On two separate occasions, the surveyor observed the resident in bed with a significant amount of mucous overflowing around the tracheostomy dressing and on the right side of their neck. Despite the presence of a Licensed Practical Nurse (LPN) in the room, the resident remained soiled with mucous, as the LPN indicated that the Respiratory Therapist was responsible for suctioning the resident. During an interview with the Director of Nursing (DON), it was confirmed that nurses are trained to suction residents, and respiratory therapists are available on the unit to provide care. However, the resident continued to be observed in a soiled state, indicating a failure in providing timely and appropriate care.
Residents Unaware of Right to Hold Independent Meetings
Penalty
Summary
During a survey, it was found that residents participating in the resident council meetings were unaware that they could hold meetings without facility staff being present. This issue was identified during a resident council meeting attended by fourteen residents, where the surveyor inquired about the resident council process. The residents, including the Resident Council President who attended via iPad video, expressed that they did not know they could conduct meetings independently of staff presence. Additionally, an interview with an Activities Assistant revealed that they were also unaware that residents could hold meetings without staff being present. This lack of awareness among both residents and staff led to the deficiency in honoring the residents' right to organize and participate in resident/family groups independently.
Residents Unaware of Ombudsman Contact Information
Penalty
Summary
Residents were not informed about the identity or contact information of the facility Ombudsman, which is a violation of their rights to receive notices in a format and language they understand. During a resident council meeting attended by fourteen residents, it was revealed that none of the residents knew the Ombudsman's name or how to contact them. This deficiency was confirmed through an interview with Guest Services Director #24, who acknowledged that the residents were not aware of the Ombudsman. The director mentioned that meeting dates and times for the resident council are posted in case the Ombudsman wants to attend, but there was no indication that the Ombudsman had been introduced to the residents or that their contact information had been shared.
Inaccurate MDS Assessment Due to Incorrect Coding
Penalty
Summary
The facility staff failed to ensure the accuracy of a Minimum Data Set (MDS) assessment for a resident. During an annual assessment, the staff incorrectly coded the MDS Section P 0100, indicating the use of a trunk restraint for the resident. However, upon review and observation, it was found that the resident did not use a trunk restraint, and the resident themselves denied its use. The MDS Coordinator confirmed that the MDS was coded incorrectly, leading to the inaccurate assessment.
Medication Administration Documentation Error
Penalty
Summary
The facility staff failed to meet professional standards by inaccurately documenting medication administration for a resident. The resident had physician orders for Keppra to be administered via g-tube twice daily for seizures and Metoprolol Tartrate by mouth twice daily for tachycardia. On May 31, 2023, the LPN documented that Keppra was not administered at 5 PM due to a clogged g-tube, yet later signed off that Metoprolol was administered at 9 PM. However, the Director of Nurses confirmed that the Metoprolol was not administered either by g-tube or mouth, as the resident was not to receive anything by mouth per physician order. The resident was subsequently transferred to the hospital on June 1, 2023, for g-tube replacement.
Failure to Provide Showers to Dependent Resident
Penalty
Summary
The facility staff failed to provide showers to a resident who was dependent on assistance for activities of daily living (ADL) care. This deficiency was identified when a resident, who was unable to stand independently, reported not receiving a shower since being admitted to the facility. Upon review of the facility's documentation in PointClickCare (PCC), there was no record of the resident receiving a shower, nor was there documentation indicating that the resident had refused a shower. The Director of Nursing (DON) confirmed that the documentation should have been present in the PCC system. Further investigation revealed that the facility later provided documentation indicating the resident had refused showers on specific dates. However, the resident stated they had not been offered a shower prior to the previous day and had not refused any showers. The resident was admitted to the facility on an unspecified date and should have received a shower at some point during their stay. The lack of documentation and the resident's account suggest a failure in providing necessary care and maintaining accurate records.
Failure to Administer Blood Pressure Medication as Ordered
Penalty
Summary
Facility staff failed to administer blood pressure medication as ordered by the physician for a resident. The medication, Metoprolol Succinate 25mg extended release, was prescribed to be taken every 24 hours with specific parameters to hold the dose if the systolic blood pressure was less than 110 and heart rate less than 60. However, the medication was administered on multiple occasions when the resident's blood pressure readings were below the prescribed parameters, specifically on 09/26/24, 10/04/24, 10/08/24, 10/11/24, and 10/14/24. During interviews, the Unit Manager explained that geriatric nursing aides are responsible for obtaining blood pressure readings and communicating them to the assigned nurse. The Licensed Practical Nurse stated that medication orders are reviewed, and if blood pressure readings are outside the ordered parameters, the medication should be held, and the doctor notified. Despite this process, the medication was not held as required by the physician's order, leading to the deficiency.
Medication Error Rate Exceeds 5% Due to Documentation and Administration Issues
Penalty
Summary
The facility was found to have a medication error rate greater than 5%, specifically 6.67%, during a survey. This deficiency was identified through observations and record reviews involving a resident. On the morning of November 6, a surveyor observed an LPN preparing medications for a resident, but the antiviral medication due at 9:00 am was missing from the medication cart. Additionally, the resident refused to take a Fortified Nutritional Shake, which the LPN subsequently poured down the sink and discarded the cup. Further review of the Medication Administration Audit Record revealed discrepancies in the documentation. The LPN signed off the antiviral medication as administered at 11:43 am, which was 1 hour and 43 minutes past the scheduled time. The Fortified Nutritional Shake was also signed off as given, despite the resident's refusal and the LPN's disposal of the shake. During an interview, the DON acknowledged the errors and noted that the Pyxis system was available for medication dispensing, although it was unclear if the antiviral medication was stocked there. The DON also stated that any medication not administered should be documented as such, and the physician and responsible party should be informed.
Expired Medications Not Discarded in Medication Storage Room
Penalty
Summary
The facility staff failed to discard expired medications in one of the four medication storage rooms assessed during the survey. During an observation of the medication storage room on the Evergreen unit, the surveyor found several expired items, including three intravenous bags of 10% Dextrose, an Infuvite Adult Multiple vitamin vial, a Biopatch Protective Disk, and a Thick & Easy Clear Drink. These items had expiration dates ranging from March 2024 to October 2024. The Nurse Unit Manager was informed of these findings and subsequently discarded the expired items. Interviews with the Evergreen Unit Clerk and Central Supply Personnel revealed a lack of clarity and responsibility regarding the management of expired medications. The Evergreen Unit Clerk stated that she occasionally checks for expiration dates, but primarily relies on central supply personnel for restocking and removing expired items. Conversely, the Central Supply Personnel indicated that she restocks the medication supply room but does not handle expired items, considering it the responsibility of the nurse or nurse manager. This miscommunication and lack of defined roles contributed to the oversight in managing expired medications.
Deficiency in Annual Dementia Training for GNAs
Penalty
Summary
The facility staff failed to ensure that geriatric nursing assistants (GNAs) received annual dementia training, as evidenced by the lack of documentation in the files of four GNAs. During a review of employee files, it was found that there was no confirmation of completed dementia training within the last 12 months for these GNAs. The facility's educator, who assumed the role in July 2024, stated that annual competencies, including dementia training, are typically conducted in April. However, she was unable to provide verification of the training due to the transition from paper documentation to an electronic system. The facility's administrator acknowledged an issue with employee education records not being properly filed by the previous educator, which resulted in incomplete education files. This issue was identified during a quality assessment performance improvement meeting in September 2024. The facility is in the process of implementing a new virtual education software to address the documentation challenges. Despite these efforts, the deficiency in ensuring annual dementia training for GNAs was evident during the survey.
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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