Complete Care At Severna Park Llc
Inspection history, citations, penalties and survey trends for this long-term care facility in Severna Park, Maryland.
- Location
- 310 Genesis Way, Severna Park, Maryland 21146
- CMS Provider Number
- 215143
- Inspections on file
- 18
- Latest survey
- October 24, 2025
- Citations (last 12 mo.)
- 6
Citation history
Health deficiencies cited at Complete Care At Severna Park Llc during CMS and state inspections, most recent first.
Surveyors found that several residents did not have access to their call bells, with devices placed out of reach in drawers, on the floor, or on the opposite side of the bed. Staff acknowledged responsibility for ensuring call bell accessibility but did not follow a consistent process, resulting in residents being unable to summon assistance when needed.
Multiple residents were found to have nonfunctioning call bell systems, including cases where the alert signal could not be turned off or the call bell failed to signal staff. Some residents reported making repeated requests for repairs that were not addressed, and maintenance staff confirmed that no prior work orders had been submitted for certain rooms. The deficiency resulted in residents lacking reliable access to staff assistance.
Two residents experienced abuse by staff, including verbal aggression and physical force. In one case, a GNA used inappropriate language and yelled at a resident during care, as confirmed by a witness. In another case, a GNA forcibly removed tea bags from a resident's hands, causing pain and weakness, with the incident corroborated by both the resident and a witness. Both incidents were substantiated by the facility's investigation.
Surveyors found that the facility did not report suspected abuse and an injury of unknown origin to OHCQ within the required timeframe for two residents. In one case, a resident's hip fracture was reported late, and in another, staff delayed notifying the Administrator and OHCQ after a resident alleged inappropriate contact by a visitor. The facility's staff misunderstood or failed to follow required reporting timelines.
A resident with intact cognition reported that a GNA forcibly took tea bags from their hands, causing significant pain and weakness. While other residents assigned to the same staff member were interviewed and denied abuse, the facility did not perform required body checks on four non-verbal, cognitively impaired residents, resulting in an incomplete abuse investigation.
A resident who required supervision during meals, as indicated by their care plan and SLP recommendations, was incorrectly documented as independent for eating on multiple occasions. Staff interviews confirmed the resident needed supervision, and the discrepancy was attributed to staff misunderstanding documentation requirements.
The facility did not update care plans after significant events, such as a resident's abuse allegation or medication changes, and failed to ensure care plan meetings included all required interdisciplinary team members. Additionally, there was no documentation that residents were consistently invited to participate in their own care plan meetings, with only family members being invited in some cases.
Two residents experienced abuse by staff, including a GNA yelling and refusing to leave a resident's room, and another GNA providing rough incontinent care and holding a feces-soiled washcloth close to a resident's face. Both incidents were witnessed or reported, and staff failed to ensure residents were treated with respect and free from abuse.
Facility staff did not conduct a thorough investigation after a resident alleged being pushed and choked by a nursing staff member. The investigation lacked interviews with other residents to assess for possible widespread abuse, a gap confirmed by the Administrator during the survey.
Facility staff did not document the delivery of daily wound care for two residents with pressure ulcers, as required by physician orders. Review of treatment administration records revealed multiple dates where wound care was not recorded for wounds on the heel and sacrum. The DON confirmed the lack of documentation for these treatments.
Two residents experienced accidents due to inadequate supervision and failure to eliminate hazards, including a fall from a bed that flipped and a fall during a Hoyer lift transfer. In one case, required incident documentation and investigation were not completed as per facility policy.
A resident recovering from multiple fractures only had a physician order for Oxycodone to be administered for severe pain (pain score 7-10), but staff administered the medication 19 times for lower pain scores (0-6) without an appropriate order. This lack of specific orders for different pain levels resulted in medication being given outside the prescribed parameters.
A resident with a documented history of family trauma did not have trauma-informed interventions included in their care plan. Although the trauma was noted at admission, the care plan lacked specific measures to address these needs, as confirmed by the DON and Administrator.
A facility failed to complete competency evaluations for a newly hired GNA, resulting in an incident of verbal abuse toward a resident. The DON confirmed that competency assessments were not performed at hire, and the GNA's file lacked required documentation. The GNA was terminated and reported following the substantiated abuse event.
Two residents were affected by the facility's failure to monitor behaviors for those on antipsychotic medications and to ensure psychotropic medications were prescribed and documented appropriately. One resident with multiple psychiatric diagnoses received antipsychotic drugs without documented behavioral monitoring, while another was prescribed Seroquel for reasons not supported by diagnosis, with the DON confirming the documentation was inappropriate.
Surveyors found that medications, including a liquid dose and a blister pack of antibiotics, were left unattended and unsecured on two separate units. In both cases, residents with severe cognitive deficits and wandering behaviors were present in the area, and staff were not immediately available to supervise or secure the medications.
Two residents were affected by inaccurate medical record documentation, including incorrect dates for neuro checks after a fall and conflicting information about Seroquel administration in psychiatric notes and the MAR. The DON confirmed these documentation errors during the survey.
Failure to Ensure Resident Call Bells Were Accessible
Penalty
Summary
Surveyors identified that the facility failed to ensure residents had access to their call bells, as required for communication with staff. During observations, four residents were found without accessible call bells: one resident's call bell was inside a bedside table drawer, another's was on the opposite side of the bed, a third had the call bell wrapped around a bed rail out of reach, and a fourth resident's call bell was found on the floor under a roommate's bed. These observations were made while residents were either in bed or seated in wheelchairs, and in all cases, the call bells were not within reach for the residents to summon assistance. Interviews with staff, including a registered nurse and a GNA, confirmed that it was their responsibility to ensure call bells were accessible, but there was no consistent process or schedule for checking call bell accessibility. The staff acknowledged the issue when it was pointed out and repositioned the call bells to make them accessible. The deficiency was further confirmed during dual observations with staff, who admitted the oversight and took immediate action to correct the placement of the call bells.
Failure to Maintain Functioning Call Bell System for Residents
Penalty
Summary
The facility failed to ensure that a functioning call bell system was available for residents, as evidenced by observations and interviews during a complaint survey. Out of seven residents reviewed for call bell function, multiple instances were found where the call bell system did not operate as intended. In one case, a resident's call bell triggered the alert signal but the signal could not be turned off using the wall button, requiring maintenance intervention. The resident reported having previously requested repairs for this issue, but no action had been taken prior to the survey. In another instance, a resident's call bell did not function at all and failed to signal staff when pressed. Staff confirmed that maintenance had not received any prior work orders for this issue. Further review and interviews revealed that additional residents had nonfunctioning call bells, with the Maintenance Director identifying and confirming several rooms where the call bell systems were not operational. Documentation showed that these deficiencies had not been previously addressed, and residents had experienced periods without reliable access to staff assistance through the call bell system. The lack of timely response to repair requests and the absence of maintenance work orders contributed to the ongoing deficiency in ensuring resident safety and communication.
Failure to Prevent Resident Abuse by Staff
Penalty
Summary
The facility failed to protect residents from abuse, as evidenced by two substantiated incidents involving staff members. In the first incident, a geriatric nursing assistant (GNA) engaged in verbally abusive behavior toward a resident, including yelling and using inappropriate language while providing care. This was corroborated by the resident's roommate's family member, who overheard the GNA's remarks and described escalating verbal aggression when the resident asked the GNA to stop. The facility's investigation confirmed the verbal abuse based on statements from those involved. In the second incident, another GNA was observed forcibly taking tea bags from a resident's hands, resulting in a tugging motion that the resident described as forceful enough to potentially pull them from their chair. The resident, who was cognitively intact with a BIMS score of 15, reported increased pain and weakness in their hands and arms following the incident, with a pain score of 9 out of 10 documented later that day. The incident was substantiated based on the resident's and a witness GNA's statements.
Failure to Timely Report Allegations of Abuse and Injuries of Unknown Origin
Penalty
Summary
The facility failed to report suspected abuse, neglect, or theft to the Office of Health Care Quality (OHCQ) within the required timeframe for two residents. In the first case, a resident sustained a left hip fracture of unknown origin, and the initial report to OHCQ was submitted nearly 24 hours after the incident, exceeding the required 2-hour reporting window. The final investigation report was also delayed, being submitted beyond the five working days requirement. The Director of Nursing (DON) incorrectly stated that the facility was required to report within 24 hours, indicating a misunderstanding of the regulatory timeframe. In the second case, a resident alleged inappropriate physical contact by a male visitor, reporting the incident to the Psych Social Worker, Unit Manager (UM), and Social Services Director (SSD). Despite the resident expressing that they did not feel abused and did not want the incident reported, staff failed to immediately notify the Administrator as required by facility policy. The Administrator only became aware of the allegation after the resident's representative contacted the facility the following day. The initial report to OHCQ was submitted more than 24 hours after staff first became aware of the allegation, exceeding the required timeframe. Documentation confirming timely reporting to the Administrator and OHCQ was not provided.
Failure to Conduct Comprehensive Abuse Investigation
Penalty
Summary
The facility failed to thoroughly investigate an allegation of abuse involving a resident with intact cognition who reported that a Geriatric Nurse Assistant (GNA) forcibly took tea bags from their hands, resulting in increased pain and weakness in the resident's wrists and arms. The incident was witnessed by another GNA, who described a tugging motion between the staff member and the resident. The resident later reported a pain level of 9 out of 10 and ongoing weakness and tingling in the affected areas. Medical records confirmed the resident was cognitively intact at the time of the incident. During the investigation, the facility interviewed other residents assigned to the alleged staff member, with seven residents denying any abusive encounters. However, the facility did not conduct skin assessments or body checks for four cognitively impaired, non-verbal residents who were also under the care of the alleged perpetrator. Both the DON and the Nursing Home Administrator confirmed that body checks for non-verbal or vulnerable residents were expected as part of the abuse investigation process, but these assessments were not performed.
Inaccurate Documentation of Required Supervision During Meals
Penalty
Summary
The facility failed to maintain accurate documentation regarding the level of assistance required for a resident during meals. The resident's care plan and a speech-language pathologist's recommendation both specified that the resident required supervision while eating. However, a review of the Activities of Daily Living (ADL) documentation for May and June showed that the resident was repeatedly marked as 'Independent' for eating on several dates, which contradicted the care plan and professional recommendations. Interviews with the unit manager confirmed that the resident should not have been considered independent, as supervision was necessary during meals. The unit manager was unable to explain why the resident was documented as independent on those occasions. The administrator acknowledged that the discrepancy was likely due to staff not understanding the difference between 'Independent' and 'Supervision' when documenting the resident's level of assistance.
Failure to Revise Care Plans and Hold Proper Interdisciplinary Care Plan Meetings
Penalty
Summary
The facility failed to ensure that care plans were revised and care plan meetings were held as required for several residents. In one case, a resident who reported an allegation of abuse did not have their behavioral care plan updated following the incident, despite the care plan being last revised prior to the event. Another resident continued to have an active care plan for anticoagulant therapy even after the medication was discontinued, with no update to reflect the change in treatment until it was brought to staff attention during the survey. Additionally, care plan meetings did not consistently include all required interdisciplinary team members. Documentation showed that meetings for one resident were attended by social services, nursing, and the dietician, but not always by the full interdisciplinary team as required. In some instances, the family was notified but did not attend, and there was inconsistency in the presence of therapy staff and other disciplines based on the resident's needs. There was also a lack of documentation confirming that residents were invited to attend their care plan meetings. For one resident, records indicated that only the family had been invited to multiple care plan meetings, with the resident attending just one meeting since admission. There was no evidence in the documentation that the resident had been invited or had declined to attend the other meetings, and the facility could not provide documentation to confirm that invitations were extended to the resident as per their stated process.
Failure to Protect Residents from Verbal and Physical Abuse
Penalty
Summary
A staff member failed to treat a resident with respect and free from verbal and physical abuse, as evidenced by a witnessed verbal altercation between a resident and a Geriatric Nursing Assistant (GNA). The GNA was overheard yelling and cursing at the resident, refusing to leave the resident's room until a supervisor intervened and separated them. The resident reported that the GNA was yelling because the resident did not want to see pictures on the phone about previous staff and wanted the GNA to leave. The incident was witnessed and documented in the facility's investigation packet. In a separate incident, another resident reported that a male GNA was rough during incontinent care, causing pain, and held a feces-soiled washcloth close to the resident's face, asking if the resident wanted to stay like that. The resident reported the incident to the Unit Manager, who confirmed being told about rough care but not about the washcloth. The GNA admitted to being told he was hurting the resident but denied causing pain and continued care. The DON was unaware of the incident until informed by surveyors and later confirmed the GNA's behavior as inappropriate.
Failure to Thoroughly Investigate Abuse Allegation
Penalty
Summary
Facility staff failed to thoroughly investigate an allegation of abuse made by a resident, who reported being pushed and choked by a nursing staff member. The facility's investigation into the incident did not include interviews with other residents to determine whether there was evidence of widespread abuse by staff. This omission was confirmed during an interview with the Administrator, who acknowledged that the investigation lacked resident interviews to disprove broader abuse concerns. The deficiency was identified during a complaint/annual survey, and the findings were based on medical record review and staff interviews. The report specifically notes that the investigation was incomplete due to the absence of additional resident interviews related to the abuse allegation.
Failure to Document Daily Wound Care for Pressure Ulcers
Penalty
Summary
Facility staff failed to document the delivery of daily wound care for residents with pressure ulcers, as evidenced by a review of medical records and treatment administration records (TARs) for two residents. One resident, observed with specialized heel protectors, had a physician order for daily wound care to the left heel, but the TAR showed no documentation of treatment on several specified dates. The Director of Nursing (DON) confirmed the absence of documentation for these dates and acknowledged that wound care should be signed or initialed when performed. A second resident, who had physician orders for daily wound care to the right heel and sacrum, also had missing documentation in the TAR for multiple dates across two months. The DON reviewed the records and confirmed that there was no documentation for the required wound care on the specified dates for both the right heel and sacral wounds. No additional documentation was provided by the facility at the time of the survey exit.
Failure to Prevent Accidents and Complete Required Incident Documentation
Penalty
Summary
The facility failed to ensure residents were free from accident hazards and did not provide adequate supervision to prevent accidents, as evidenced by two separate incidents involving two residents. In the first case, a resident was found on the floor in their room after their bed had flipped onto its side, though not onto the resident. Despite facility policy requiring completion of an incident report and documentation of all assessments and actions following a fall, no incident report or investigation was completed for this event. The Director of Nursing confirmed that the required documentation was not done, and no additional documentation was provided to the surveyor. In the second case, another resident reported falling to the floor when a Hoyer lift tilted during a transfer from wheelchair to bed. The resident subsequently experienced back pain and was transferred to the emergency department. The incident was documented in the medical record, and interviews revealed that the transfer was being performed in the hallway due to limited space in the resident's room. The Hoyer lift involved was removed from service and inspected, but no mechanical issues were found. The facility had been in the process of replacing older Hoyer lifts, and the one involved in the incident was replaced following the event.
Failure to Obtain Orders for Pain Management at Lower Pain Levels
Penalty
Summary
A deficiency was identified when a resident admitted after a fall with multiple fractures, requiring healing and physical therapy, did not have a physician order to address and medicate pain levels below a score of 7. The medical record review showed that the only pain medication order was for Oxycodone 5 mg, 2 tablets every 4 hours as needed for severe pain, defined as a pain score of 7-10. Despite this, the medication administration record indicated that Oxycodone was administered 64 times, including 19 instances for pain scores between 0-6, for which there was no corresponding physician order. This issue was confirmed through review of the resident's records and discussion with the facility's Director of Nursing.
Failure to Provide Trauma-Informed Care Planning
Penalty
Summary
The facility failed to provide trauma-informed care for a resident who disclosed a history of family trauma that led to running away from home at a young age. Upon review of the resident's medical record, it was found that although the trauma was documented at admission, there was no evidence that the care plan included interventions addressing the resident's past trauma. The DON confirmed that trauma-informed assessments are required at admission and after changes in condition, but acknowledged that no care plan interventions were created for this resident's trauma history. Both the DON and the Administrator verified the absence of trauma-related interventions in the resident's care plan.
Failure to Assess GNA Competency at Hire Leads to Abuse Incident
Penalty
Summary
The facility failed to ensure that Geriatric Nursing Assistants (GNAs) were competent in their skill sets, as evidenced by the lack of completed competency skills evaluations or check-off sheets for a newly hired GNA involved in a substantiated incident of verbal abuse toward a resident. Upon review of the employee file, it was found that no competency assessment had been conducted at the time of hire, and the Director of Nursing confirmed that staff competencies were only assessed if an incident occurred, rather than as part of the initial orientation process. Although 60-day and 90-day evaluations were present in other new employee files, the GNA in question did not reach the 30-day mark before being terminated and reported for the abuse incident.
Failure to Monitor Antipsychotic Use and Ensure Appropriate Psychotropic Medication Documentation
Penalty
Summary
The facility failed to adequately monitor the behaviors of a resident receiving antipsychotic medications and did not ensure that residents were free from unnecessary medications. One resident with diagnoses including Bipolar Disorder, Psychosis, Major Depressive Disorder, and Schizoaffective Disorder was prescribed Fluphenazine and Olanzapine. Although a care plan was initiated for hallucinations, anxiousness, and agitation, there was no evidence in the medical record that the resident's behaviors were being monitored as required. Staff interviews confirmed the lack of documented behavioral monitoring for this resident. Additionally, another resident was prescribed Seroquel, a psychotropic medication, with the reason for use documented incorrectly in the Medication Administration Record. The medication was listed as being prescribed for sundowning and as a supplement, which was acknowledged by the DON as inappropriate and not supported by the resident's medical diagnosis. These findings demonstrate failures in both monitoring and documentation related to the use of psychotropic medications.
Unsecured Medications Observed on Units with Cognitively Impaired Residents
Penalty
Summary
Surveyors observed that the facility failed to properly secure medications on two separate nursing units. On one occasion, a medicine cup containing a clear liquid was left unattended on top of a medication cart in a secure dementia unit. Two residents with documented severe cognitive deficits and wandering behaviors were present in the immediate area, and no staff were observed nearby at the time. The medication cart was later identified as belonging to an RN, who confirmed the medication was for another resident. In a separate incident, a blister pack containing 28 tablets of an antibiotic was found unattended at a nursing station desk. The medication was intended for a resident and had been separated for different halls, but was not secured in the appropriate medication cart. The medication remained unattended until a staff RN was questioned and subsequently secured the medication. Both incidents involved residents with significant cognitive impairments and occurred in areas where staff were not present to supervise the medications.
Failure to Maintain Accurate Medical Records and Documentation
Penalty
Summary
The facility failed to maintain complete and accurate medical records for two residents, as evidenced by errors in documentation related to neurological checks and psychiatric medication records. For one resident who experienced a fall, neurological checks were documented with incorrect dates, with entries reflecting dates that did not correspond to the actual event. Despite a correction to one entry, subsequent documentation continued to show inconsistent and inaccurate dates. The DON confirmed the expectation for accurate documentation and acknowledged the issue when it was brought to her attention. For another resident, psychiatric notes inaccurately stated that Seroquel had been discontinued months prior, and therefore a gradual dose reduction (GDR) was not attempted. However, a review of the Medication Administration Record (MAR) did not show an order for Seroquel at the time indicated in the psychiatric notes, and the first order for Seroquel appeared months later. The DON and surveyor confirmed the discrepancies between the psychiatric notes and the MAR, indicating inaccurate documentation regarding the resident's medication history.
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.
Trusted data from CMS and state health departments
Every citation, penalty and Plan of Correction is sourced from public CMS records (latest release May 27, 2026) and official state health department websites — never guesswork.
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