Complete Care At Springbrook
Inspection history, citations, penalties and survey trends for this long-term care facility in Silver Spring, Maryland.
- Location
- 12325 New Hampshire Avenue, Silver Spring, Maryland 20904
- CMS Provider Number
- 215052
- Inspections on file
- 15
- Latest survey
- December 19, 2025
- Citations (last 12 mo.)
- 6
Citation history
Health deficiencies cited at Complete Care At Springbrook during CMS and state inspections, most recent first.
Multiple residents did not receive medications as ordered due to improper administration techniques, lack of medication availability, and inaccurate documentation. Staff were observed extracting insulin from pens using syringes instead of pen needles, using unlabeled medication containers, and failing to notify physicians when medications were unavailable. The DON was unaware of these practices, and the pharmacist confirmed that the methods used were not appropriate.
Several residents who required assistance with ADLs and had limited mobility were found without access to a working call light system in their rooms and bathrooms. Despite facility policy requiring accessible call lights and prompt reporting of malfunctions, multiple work orders for broken call lights were left unresolved, and no manual call bells were provided. Staff and maintenance were aware of the ongoing issues, but residents remained unable to reliably summon help when needed.
Three residents experienced unsanitary and uncomfortable living conditions due to the facility's failure to replace a damaged, leaking commode toilet and to maintain cleanliness in resident rooms and bathrooms. Persistent odors, visible contamination, and delayed maintenance were observed, with staff and administration aware of the ongoing issues.
Three residents did not receive their prescribed medications as ordered, including a topical analgesic, a pain-relieving patch, an iron supplement, and an oral diabetes medication. In some cases, the correct medication was not available or was substituted with a different product, and in others, the nurse failed to administer the medication as ordered.
Surveyors identified an 11% medication error rate after observing multiple failures, including missed doses, incorrect medication administration, and improper handling of medications by nursing staff. Errors included not administering prescribed pain relief, antihypertensive, iron supplement, and diabetes medications, as well as substituting the wrong topical medication. Staff interviews confirmed these actions did not follow physician orders.
An opened Humalog insulin pen was found on a medication cart with only a handwritten room number and lacking required labeling such as patient name, physician name, and date opened. An LPN confirmed using the unlabeled pen for insulin administration, contrary to facility policy and pharmacy standards that require full labeling of all insulin pens.
Surveyors found that medications were not administered as ordered for several residents, with some doses given late and others not available at the time of administration. In multiple cases, nurses administered medications more than an hour after the scheduled time, and some medications had to be reordered or were missing entirely. There were also instances where medication administration techniques did not follow physician orders, and documentation showed incomplete dosing for prescribed treatments.
A resident with documented hearing and vision difficulties did not have a care plan or interventions developed to address these needs, despite assessments and therapy notes indicating sensory deficits and an order for cerumen impaction treatment. The DON confirmed the absence of a care plan for these issues.
A resident was served a lunch tray containing rice, despite rice not being listed on the resident's meal ticket and the resident's stated dislike for rice. The kitchen manager and administrator both acknowledged this as a staff error.
The facility failed to report abuse allegations within the required timeframe for three residents. A resident with severe cognitive impairment was allegedly slapped by nursing assistants, another with moderate impairment alleged mishandling by a nursing assistant, and a third resident reported verbal abuse by a night supervisor. In each case, the facility did not notify the state survey agency within the mandated two-hour window.
A facility failed to thoroughly investigate an allegation of neglect involving a resident with paraplegia and end-stage renal disease. The investigation lacked interviews with staff assigned to the resident, and the facility could not verify the neglect claim due to insufficient evidence.
The facility failed to provide adequate pressure ulcer care for two residents, resulting in missed treatments and lack of timely assessments. One resident's pressure ulcer deteriorated without prompt consultation with a physician or wound NP, while another resident did not receive prescribed wound treatments consistently. Interviews revealed a lack of awareness and documentation regarding these deficiencies.
A resident with a history of stroke and moderate cognitive impairment did not consistently have physician-ordered bed rails installed, despite a care plan indicating their necessity for safe bed mobility. The facility's failure to ensure the presence of bed rails, due to multiple bed replacements and inaccurate documentation by staff, resulted in a deficiency in accident prevention measures.
The facility failed to maintain complete medical records for at least five years post-discharge for two residents. One resident, with complex medical conditions, had no MARs or TARs available, while another resident's records were incomplete due to management changes. The facility's system limitations and transition issues led to this deficiency, as confirmed by the Administrator and DON.
Failure to Follow Professional Standards in Medication Administration
Penalty
Summary
The facility failed to provide medication administration that meets professional standards for five of eight sampled residents. For one resident with diabetes, staff were observed extracting insulin from an insulin lispro kwikpen using an insulin syringe, rather than the manufacturer-recommended pen needles. Multiple nursing staff confirmed this practice, citing a lack of compatible safety needles in the facility. The insulin pens used were also not properly labeled with the resident's name, dose, or route, only displaying handwritten dates and room numbers. Staff interviews revealed that this practice had been ongoing for several months, and the central supply manager had instructed staff to use insulin syringes due to supply shortages. The facility pharmacist confirmed that extracting insulin from pens with syringes is not appropriate and can damage the pen, potentially leading to dosing errors. Another resident with a prescription for a topical analgesic did not receive the medication as ordered, despite documentation indicating it had been administered. The nurse responsible stated she thought she had given the medication but had not. For a resident prescribed amlodipine for hypertension, the nurse withheld the medication due to low blood pressure, placed the tablet in an unlabelled medicine cup, and stored it in the medication cart with only a room number written on it. The nurse later administered the medication without a new physician order and could not recall if the resident's blood pressure had increased. The medication administration record did not reflect that the medication was given as ordered. Two additional residents did not receive their prescribed medications (vitron-C and Jardiance) because the medications were not available in the facility. The nurse did not notify the physician about the missed doses. The Director of Nursing confirmed that the affected residents should have received their medications as ordered and that documentation should be accurate. The DON was not aware that staff were using insulin syringes to extract insulin from pens.
Failure to Maintain Functional Call Light System in Resident Rooms
Penalty
Summary
The facility failed to provide a functioning call light system in resident bathrooms and bathing areas, as required by policy, for three residents. The policy mandates that each resident must have access to a call light at the bedside, toilet, and bathing area, with calls relayed directly to staff or a centralized location to ensure timely response. Staff are instructed to report any call light issues immediately and provide alternative solutions until repairs are made. However, multiple work orders for broken call lights remained unaddressed, and no manual call bells were provided in affected rooms. One resident, admitted with diagnoses including infectious gastroenteritis, congestive heart failure, and diarrhea, required assistance with activities of daily living (ADLs) due to limited mobility. This resident's call light was found detached from the wall, with no manual call bell available, making it difficult to summon staff when help was needed. Another resident, who was cognitively intact and dependent on staff for ADLs, reported that the call light in their shared room had not worked for four months, and no manual call bell was present. This resident also expressed concerns about staff responsiveness due to the ongoing issue. A third resident, also dependent on staff for ADLs and identified as a fall risk, was found in a room where both call lights were nonfunctional. Staff were unaware of the broken call lights until the time of observation and interview. The maintenance director acknowledged awareness of the issue and difficulties in obtaining replacement parts, while the administrator and DON were informed of the ongoing problems. Despite the facility's policy and the residents' needs, the lack of a working call system persisted, leaving residents without a reliable means to request assistance.
Failure to Maintain Sanitary and Functional Resident Rooms and Bathrooms
Penalty
Summary
The facility failed to maintain a safe, functional, sanitary, and comfortable environment for three residents. One resident, who was dependent on staff for all activities of daily living and had diagnoses including spastic quadriplegic cerebral palsy and spinal stenosis, was observed in a room with several dark spots, dried food droppings, and black and brown substances on the walls. The resident reported that the facility did not adequately clean the room or walls. Two other residents, one with unspecified dementia and chronic kidney disease requiring substantial to maximum assistance with personal hygiene, and another with end stage renal disease and a history of falls who was independent with ADLs, experienced ongoing issues with a damaged and leaking commode toilet in their shared bathroom. Both residents reported strong, persistent odors and visible contamination in the bathroom, including black and brown substances on the stool area, stained and discolored floor tiles, and a pervasive smell of urine and human waste. One resident stated the issue had persisted for over two months, leading them to use staff bathrooms instead. Interviews with the Housekeeping Director and Maintenance Director confirmed that the bathroom required significant repairs, including floor and toilet replacement, and that the odor could not be eliminated despite repeated cleaning. Both directors indicated that the administrator was aware of the ongoing plumbing and maintenance issues, which had been present for several months. A private plumber's work order documented repairs to the toilet bowl and recommended further replacement of toilet bolts and pipes.
Failure to Administer Physician-Ordered Medications
Penalty
Summary
The facility failed to administer medications as ordered by physicians for three residents. One resident with a history of seizures, hypertension, diabetes, and dysarthria did not receive a prescribed topical analgesic (Biofreeze) to the right shoulder as ordered. During observation, the assigned nurse did not administer the medication and later stated she thought she had done so. Another resident with polyneuropathy, diabetes, osteoarthritis, knee pain, vitamin D deficiency, and anemia did not receive a prescribed Salonpas pain relieving patch (lidocaine) to the knees or a Vitron-C tablet for anemia. The nurse on duty administered a different medication (lidocaine and prilocaine cream) instead of the prescribed patch and did not administer the Vitron-C tablet, citing unavailability of the medication. A third resident with diabetes, osteomyelitis, and peripheral vascular disease did not receive a prescribed Jardiance oral tablet for diabetes, as the medication was not available at the time of administration. Both the pharmacist and the Director of Nursing confirmed that these residents should have received their medications as ordered. The deficiencies were identified through record review, medication administration observations, and staff interviews.
Medication Error Rate Exceeds Acceptable Threshold Due to Multiple Administration Failures
Penalty
Summary
The facility failed to maintain a medication error rate below 5%, resulting in an observed error rate of 11% with 5 errors out of 43 opportunities. Specific incidents included a nurse failing to administer a prescribed topical analgesic to a resident as ordered, and another nurse not administering an antihypertensive medication due to low blood pressure, subsequently storing the medication in an unlabelled cup in the medication cart and later administering it without confirming the resident's blood pressure status. Additionally, a nurse administered the wrong topical medication to a resident, substituting a lidocaine and prilocaine cream for a prescribed lidocaine patch. Two further errors involved the non-administration of prescribed medications (an iron supplement and a diabetes medication) due to unavailability, with staff confirming that the residents did not receive these medications as ordered. Interviews with staff and the pharmacist confirmed that all residents should receive medications as per physician orders, and the Director of Nursing also acknowledged this expectation. The observed failures included both omissions and incorrect administration of medications, as well as improper medication handling and storage practices, directly contributing to the elevated medication error rate identified during the survey.
Unlabeled Insulin Pen Found on Medication Cart
Penalty
Summary
Surveyors observed that an opened and used Humalog (insulin lispro) pen was stored on the West Wing Medication Cart without a label indicating the patient name, physician name, or date used. The only identifying mark on the insulin pen was a room number handwritten with a black marker. Staff Nurse #6 confirmed that he administered insulin using this unlabeled pen and believed that the room number was sufficient for identification. The facility's policy, as provided by the Director of Nursing, requires that insulin pens be clearly labeled with the resident name, physician name, date dispensed, type of insulin, amount to be given, frequency, and expiration date. Further interviews with the Director of Nursing and the pharmacy consultant confirmed that all insulin pens must be labeled with the patient's name, physician name, and date opened. The pharmacy consultant also stated that any opened, unlabeled insulin pens should not be used and that the facility should notify the pharmacy to order a new, properly labeled pen. The failure to label the insulin pen as required by both facility policy and professional standards led to the identified deficiency.
Failure to Administer Medications as Ordered and Ensure Medication Availability
Penalty
Summary
Surveyors identified that the facility failed to ensure medications were administered as ordered for multiple residents. In several observed instances, medications scheduled for administration at specific times were given more than an hour late, and some medications were not available at the time of administration. For example, one resident did not receive lactulose as it was unavailable, and other medications were administered over an hour past the scheduled time. Another resident was missing multiple medications, including an inhaler and furosemide, which had to be reordered, and received the remaining medications late. Additional review of medication administration records revealed that some medications, such as Flonase nasal suspension, were also not available as ordered. The acting DON confirmed that the facility had some ability to pull missing medications from emergency supply but acknowledged the issue of unavailability. Further deficiencies were observed in medication administration technique and documentation. One resident with a gastric tube did not have the tube flushed with water after medication administration as ordered, which was confirmed by the nurse involved. Another resident did not receive all prescribed doses of a medication for cerumen impaction, as the medication was only administered for three days instead of the four days ordered. These findings were corroborated by interviews with nursing staff and review of medication administration records, which showed missed or incomplete doses and deviations from the facility's medication administration policy.
Failure to Develop Care Plan for Sensory Deficits
Penalty
Summary
The facility failed to develop and implement a comprehensive care plan addressing the hearing and vision deficits of a resident. Physical Therapy notes indicated that the resident was educated and engaged in a home exercise program to improve lower extremity strength, and the therapist communicated with the unit manager about the resident's inability to see and hear. The Minimum Data Set (MDS) assessments showed changes in the resident's hearing ability, and the Medication Administration Record (MAR) documented an order for Debrox otic solution for cerumen impaction in the left ear. Despite these documented needs and changes, a review of the resident's care plan revealed that no interventions or care plans were developed for the identified hearing or vision difficulties. The acting Director of Nursing confirmed during an interview that no care plan or interventions were in place for these needs.
Failure to Honor Resident Food Preferences
Penalty
Summary
Facility staff failed to honor a resident's food preferences during meal service. During lunch observation, a resident refused his lunch tray because it contained rice, which he dislikes. Review of the resident's meal ticket confirmed that rice was not listed as part of his meal preferences. The kitchen manager acknowledged that this was an error, and the administrator agreed that the kitchen staff made a mistake in this instance.
Failure to Timely Report Abuse Allegations
Penalty
Summary
The facility failed to report allegations of abuse within the required timeframe for three residents. Resident #27, who had severe cognitive impairment, was allegedly slapped by two nursing assistants. The facility was informed of this incident on the morning of December 22, 2022, but did not notify the state survey agency until later that afternoon, missing the required two-hour reporting window. The Administrator was unaware of the late reporting and could not determine why it occurred. Resident #32, with moderate cognitive impairment, alleged that a nursing assistant dropped their legs while providing care. The facility was informed of this allegation on March 24, 2022, but did not report it to the state survey agency until later that evening, again missing the two-hour reporting requirement. The Director of Nursing, who was not employed at the time of the incident, confirmed the reporting delay, and the Administrator was unsure why the report was late. Resident #13, who had no cognitive impairment, alleged verbal abuse by a night supervisor and reported the incident to a corporate representative. The facility was informed of the allegation on December 4, 2023, but did not notify the state survey agency until later that day, outside the required timeframe. The Director of Nursing and the Administrator confirmed the late reporting, acknowledging that the incident should have been reported within two hours of awareness.
Failure to Conduct Thorough Investigation into Alleged Neglect
Penalty
Summary
The facility failed to conduct a thorough investigation into an allegation of neglect involving a resident with a medical history of paraplegia, end-stage renal disease, pressure ulcer, and dependence on renal dialysis. The resident, who had intact cognition, was transferred to the hospital and subsequently passed away. A family member alleged neglect through a certified letter, claiming the facility did not provide safe and proper medical services to the resident over a specified period. The facility's investigation documents lacked interviews with staff who were directly assigned to care for the resident during the alleged period of neglect. The facility's policy required a comprehensive investigation into allegations of abuse or neglect, including interviews with relevant staff. However, the investigation only included witness statements from staff who were not assigned to the resident during the critical period. The Administrator acknowledged the absence of interviews with the appropriate staff and admitted to losing the certified letter that initiated the investigation. Consequently, the facility was unable to verify the neglect allegation due to insufficient evidence from the investigation.
Failure to Provide Adequate Pressure Ulcer Care
Penalty
Summary
The facility failed to provide necessary treatment and services to promote healing of pressure ulcers for two residents. For one resident, the facility did not consistently complete and document weekly wound assessments as per the care plan. Additionally, there was a failure to promptly consult with the attending physician or wound nurse practitioner (NP) regarding the deterioration of a pressure ulcer. The resident had a medical history including type 2 diabetes mellitus and peripheral vascular disease, and was admitted with two Stage III pressure ulcers. Despite initial improvements, a new Stage II pressure injury developed and later deteriorated to an unstageable condition without timely intervention or documentation of assessments. For the second resident, the facility did not provide wound treatments as ordered. The resident had a medical history of multiple sclerosis, type 2 diabetes mellitus, and a Stage IV pressure ulcer of the sacral region. The facility's records indicated that the resident's sacral wound treatments were not administered as prescribed, with several treatments missed over a period of time. This resident's wound was debrided weekly by a wound physician, but the facility failed to consistently follow the prescribed treatment regimen, leading to missed treatments and delayed initiation of new treatment orders. Interviews with facility staff revealed a lack of awareness and documentation regarding the missed treatments and changes in wound conditions. The Director of Nursing (DON) and other staff members confirmed that there was no documentation of the wound nurse practitioner being notified of changes in the wound conditions, and there was a lack of consistent wound assessments and timely implementation of treatment recommendations. The facility's policies on pressure injury prevention and management, as well as notification of changes, were not adhered to, contributing to the deficiencies observed.
Failure to Implement Physician-Ordered Bed Rails
Penalty
Summary
The facility failed to consistently implement a physician-ordered intervention for bed rails for a resident, which was intended to assist with safe bed mobility and minimize the risk of falls. The resident, who had a history of cerebral infarction, end-stage renal disease, and moderate cognitive impairment, was admitted to the facility with a care plan that included the use of 1/4 side rails for turning and repositioning. Despite the physician's order and consent from the resident's responsible party, the bed rails were not consistently installed on the resident's bed. Observations and interviews revealed that the resident's bed was replaced multiple times due to mechanical issues, and the new beds did not always come with the required side rails. Nursing staff documented that the side rails were in place, even when they were not, indicating a lack of verification and adherence to the physician's order. The resident reported that the facility was supposed to install bed rails but had not done so, and staff interviews confirmed that the bed rails were not present at times due to bed replacements. The facility's policies on fall prevention and bed rail use were not followed, as evidenced by the lack of consistent implementation of the bed rail intervention. The nursing staff and maintenance personnel failed to ensure that the bed rails were installed on the resident's bed, despite the documented need and physician's order. This oversight led to a deficiency in providing adequate supervision and accident prevention measures for the resident.
Failure to Maintain Complete Medical Records
Penalty
Summary
The facility failed to maintain complete medical records for a minimum of five years from the date of discharge for two residents, as required by their policy. Resident #33, who was admitted with complex medical conditions including acute hematogenous osteomyelitis and end-stage renal disease, had no Medication Administration Records (MARs) or Treatment Administration Records (TARs) available for review. The facility's Administrator acknowledged the inability to retrieve these records from the electronic medical record system for records older than three years, which was contrary to the facility's policy. Similarly, Resident #34, who had a medical history of chronic obstructive pulmonary disease, dementia, and other conditions, was discharged from the facility without complete MARs and TARs for several months prior to discharge. The facility was unable to provide these records, and the Administrator indicated that the records might have been lost during a management transition. Additionally, therapy notes for Resident #34 were not available due to a change in the therapy service provider. Interviews with the facility's Administrator and Director of Nursing confirmed that the expectation was to maintain complete medical records for at least five years post-discharge. However, due to system limitations and management changes, the facility failed to comply with this requirement, resulting in incomplete medical records for the residents in question.
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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