Complete Care At Wheaton
Inspection history, citations, penalties and survey trends for this long-term care facility in Wheaton, Maryland.
- Location
- 4011 Randolph Road, Wheaton, Maryland 20902
- CMS Provider Number
- 215025
- Inspections on file
- 14
- Latest survey
- May 1, 2025
- Citations (last 12 mo.)
- 0
Citation history
Health deficiencies cited at Complete Care At Wheaton during CMS and state inspections, most recent first.
Surveyors found that the facility did not consistently revise care plans or hold timely care plan meetings for several residents. One resident attended only one care plan meeting in two years, while another had outdated care plans for discontinued medications. Additional residents had unresolved care plans for healed conditions or lacked documentation of required care plan meetings, with staff unable to provide missing records.
A resident with severe cognitive impairment and a history of aggressive behaviors was physically abused by an LPN after becoming agitated and striking the staff member. Two GNAs witnessed the LPN grab, pinch, and slap the resident but did not immediately intervene or report the incident, resulting in a delay in notifying facility leadership and addressing the abuse.
A resident experienced a witnessed fall, but facility staff did not complete a post-fall assessment, document the incident, or update the resident's care plan to reflect the event and the resident's condition. The Regional Clinical Nurse Manager confirmed that these required actions were not performed.
A resident was not invited to participate in their care plan meetings, with no documentation showing they were notified or invited to attend, despite facility policy requiring such invitations.
Surveyors found that the facility did not offer the opportunity to complete advance directives or provide educational materials about them to three residents or their representatives, as confirmed by documentation and staff interviews.
A resident who was recently hospitalized did not receive written notification of the facility's bed hold policy at the time of transfer. Review of the medical record and staff interviews confirmed that, although the bed hold policy was acknowledged at admission, the required written notice was not provided during the hospital transfer, and facility leadership stated this notification is not given.
A deficiency occurred when a resident's PASRR Level I screening was completed inaccurately, with all answers in a key section marked 'No', which should have triggered a Level II evaluation referral. No evidence of a Level II evaluation was found in the record, and the Social Worker confirmed the screening was not filled out correctly, resulting in the resident not receiving the required PASRR process.
The facility did not update care plans for three residents after significant events, including falls and G-tube dislodgement with hospital transfers. Despite documentation of these incidents and staff expectations that care plans be revised after changes in condition, no updates or new interventions were added to address the residents' needs.
A resident receiving oxygen therapy was observed without an oxygen warning sign posted on the room door, contrary to the facility's oxygen administration policy. Staff, including the ADON/IP, were unaware of the requirement to post such signage, and the facility did not routinely place oxygen signs on rooms where oxygen was in use.
The facility did not complete required annual performance evaluations for two GNAs, as confirmed by a review of employee records and staff interview. This deficiency was identified during the annual survey, with no evidence provided to show that evaluations for the previous two years had been conducted.
Surveyors identified that licensed staff failed to maintain a medication error rate below 5%, with three errors observed among 26 opportunities. An LPN withheld a scheduled antihypertensive without a physician's order and documented it as given, administered an eye drop to only one eye instead of both as ordered, and documented a vitamin as administered when it was not available. These actions resulted in inaccurate MAR entries and were confirmed through observation and staff interviews.
Surveyors found that medications were improperly stored and labeled, with loose and unlabeled pills, undated opened bottles, and expired medications for discharged or deceased residents left in medication carts and storage rooms. Staff interviews revealed inconsistent practices for medication disposal, including discarding refused medications in the trash and failing to document refrigerator temperatures for medication storage. These actions did not comply with facility policy or regulatory requirements.
A resident with dementia and cognitive communication deficit did not receive a dental evaluation or necessary dental services after admission, despite reporting pain while chewing and being observed eating with difficulty. Clinical review confirmed the absence of dental care, and an oral health assessment later identified decayed or broken teeth.
Surveyors identified multiple sanitation and food storage deficiencies, including undated opened food containers in the kitchen, lack of internal thermometers in cold storage, and unlabeled food items in a unit nourishment refrigerator. Staff confirmed that food items should be labeled and dated according to facility policy.
Surveyors found that dumpsters were left uncovered and items such as an old mattress, dresser, and soda can were placed next to the dumpsters. The Food Services Director confirmed that dumpsters are expected to be covered with lids.
A resident with a physician's order to wear an Aspen cervical collar at all times was observed without the collar on multiple occasions, and nursing staff inaccurately documented on the TAR that the collar was worn, even on days when the resident refused or was not wearing it. The Unit Manager confirmed the documentation errors after reviewing the records.
The facility did not ensure that the QAA committee included all federally required members, specifically the Infection Preventionist, and failed to maintain clear and accurate attendance records for its meetings. The attendance sheets were inconsistent, and the listed federal requirements were incomplete, as confirmed by the Administrator.
A GNA provided a bed bath to a resident with an indwelling urinary catheter without wearing a gown, despite Enhanced Barrier Precautions being in place and clearly posted. The staff member was unaware of the resident's EBP status and did not use the required PPE during a high-contact care activity, resulting in non-compliance with infection control protocols.
A surveyor observed visibly dirty floor tiles with brown spills and a dirt-like substance in the laundry room, as well as an HVAC unit with rusty, dust-covered vent covers. The Environmental Services Supervisor acknowledged the need for cleaning during the inspection.
Surveyors found that the facility did not provide required written notifications to residents or their representatives when residents were transferred to the hospital. Multiple residents experienced hospital transfers without documented evidence that they or their representatives received written notice explaining the reason for transfer. Staff and management confirmed that no process was in place to ensure these notifications were provided.
Failure to Revise Care Plans and Conduct Timely Care Plan Meetings
Penalty
Summary
The facility failed to revise resident care plans and conduct timely care plan meetings as required, as evidenced by record reviews, staff and resident interviews, and documentation for four residents. One resident reported only attending a single care plan meeting over a two-year stay and did not recall receiving invitations for other meetings. Review of this resident's medical record confirmed that only two care plan meetings were documented in the past year, with attendance sheets and notes missing for other required periods. Staff interviews confirmed that no additional documentation could be found for the missing meetings. Another resident's care plan included anticoagulant therapy, but physician orders showed that the medication had been discontinued several months prior, and the care plan had not been updated to reflect this change. Similarly, a third resident had care plans for pressure ulcers, arterial ulcers, venous ulcers, and antiplatelet medication, despite no current physician orders or active conditions for these issues. Staff acknowledged that these care plans should have been resolved or updated to reflect the residents' current conditions. A fourth resident's family reported difficulty scheduling care plan meetings with the interdisciplinary team. Review of the electronic medical record showed only two documented care plan meetings and one scheduled meeting that the family did not attend, with no further documentation of additional meetings. Staff interviews confirmed that care plan meetings are expected to be held quarterly and documented, but no further records could be located for this resident.
Failure to Protect Resident from Physical Abuse and Delayed Reporting
Penalty
Summary
A resident with severe cognitive impairment, as indicated by a BIMS score of 0 out of 15, and a care plan noting potential for verbal and physical aggression related to dementia, was involved in an incident where a staff member allegedly engaged in physical abuse. The incident occurred when the resident became agitated and struck an LPN, after which the LPN was witnessed by two GNAs to have grabbed, pinched, and slapped the resident. Both GNAs present did not immediately intervene or report the alleged abuse as required by facility policy. The incident was not reported to the Nursing Home Administrator until several days after it occurred, resulting in a delay in the facility's awareness and response. Interviews with the involved staff confirmed the sequence of events, with one GNA expressing fear and lack of knowledge about reporting requirements. The delay in reporting and failure to immediately stop the alleged abuse constituted a failure to protect the resident from abuse as required by regulation.
Failure to Assess and Document Resident Fall
Penalty
Summary
A resident experienced a witnessed fall, but the facility failed to document the incident in the medical record. There was no incident report created for the fall, and no post-fall assessment was completed. The resident's care plan was not revised or updated to reflect the fall incident or the resident's condition following the event. During an interview, the Regional Clinical Nurse Manager confirmed that fall assessments are required after resident falls, but acknowledged that in this case, the required assessment and care plan revision were not completed. The deficiency was identified through a review of the resident's medical record and staff interviews, which revealed the lack of appropriate documentation and follow-up after the fall.
Resident Not Invited to Care Plan Meetings
Penalty
Summary
A deficiency was identified when a resident was not invited to participate in their care plan meetings, as required for person-centered care planning. The resident reported to the surveyor that they were not invited to and did not attend care plan meetings. Medical record review showed that while the resident attended one care plan meeting, there was no documentation that the resident was notified or invited to subsequent meetings. The facility's Regional Social Worker confirmed that there was no documented evidence of the resident being informed about the care plan meetings in question.
Failure to Offer Advance Directives and Provide Educational Materials
Penalty
Summary
Surveyor record reviews and staff interviews revealed that the facility failed to offer residents the opportunity to complete an advance directive and did not provide educational materials regarding advance directives. Specifically, for three residents reviewed, documentation in their social services assessments indicated that none had an advance directive in place, and there was no evidence that the facility had offered them or their representatives the chance to complete one or provided relevant educational materials. The deficiency was confirmed through interviews with the Regional Social Worker, who acknowledged that the residents and their representatives were neither offered the opportunity to complete advance directives nor given educational materials about them. The lack of documentation and absence of these required actions were consistently found across all three residents reviewed for advance directives.
Failure to Provide Written Bed Hold Notification Upon Hospital Transfer
Penalty
Summary
Facility staff failed to provide written notification of the bed hold policy to a resident or the resident’s representative when the resident was transferred to the hospital. The deficiency was identified during a surveyor’s review of the medical record and interviews with both the resident and facility staff. The resident, who had a recent hospitalization due to stomach collapse, confirmed the transfer, and the medical record showed no documentation that written notification of the bed hold policy was given at the time of transfer. Further review revealed that while the resident had signed an admission packet acknowledging the bed hold policy upon initial admission, there was no evidence that the required written notification was provided at the time of the hospital transfer. During interviews, facility leadership confirmed that the facility does not provide written notification of the bed hold policy when residents are transferred to the hospital. No additional information or documentation was provided by the facility to demonstrate compliance with this requirement.
Failure to Accurately Complete PASRR Screening for Mental Disorders
Penalty
Summary
A deficiency was identified when the facility failed to conduct an accurate Preadmission Screening and Resident Review (PASRR) for a resident with mental disorders. Record review showed that the PASRR Level I screening for this resident had all answers in section D marked as 'No', which, according to the form, should have triggered a referral to Adult Evaluation and Review Services (AERS) for a Level II evaluation. However, there was no evidence of a PASRR Level II evaluation in the resident's record. During an interview, the Social Worker confirmed that the PASRR Level I was not completed correctly and acknowledged that the resident's mental disorders were not properly reflected in the screening. The Social Worker stated that the resident did not require a PASRR Level II, but also confirmed that the documentation was inaccurate and should not have indicated the need for a Level II evaluation. This failure resulted in the resident not receiving the appropriate PASRR process as required by federal regulations.
Failure to Revise Care Plans After Resident Condition Changes
Penalty
Summary
The facility failed to revise and update care plans for residents following significant changes in their condition, as evidenced by medical record reviews and staff interviews. For one resident who experienced a fall, the care plan was not updated to reflect the incident, and no fall-specific interventions were added or revised. The original care plan for this resident had not been updated since its initial creation several months prior, despite the occurrence of a fall that was documented in the nurse's notes. Another resident experienced multiple hospital transfers due to gastrostomy tube (G-tube) dislodgement and replacement, yet there was no documentation that a care plan addressing G-tube dislodgement and replacement was initiated or updated. Additionally, a third resident had a witnessed fall, but there was no evidence that the care plan was revised to address this event. Staff interviews confirmed that care plans are expected to be updated immediately following changes in a resident's condition, but this was not done for the residents reviewed.
Failure to Post Oxygen Warning Signage for Resident Receiving Oxygen Therapy
Penalty
Summary
Facility staff failed to follow appropriate respiratory care and services for a resident receiving oxygen therapy. During a tour, a resident was observed using oxygen with an oxygen humidifier bottle and tubing attached to a concentrator, but there was no oxygen usage sign posted on the resident's door or doorframe. Review of the resident's medical record confirmed physician orders for oxygen therapy and instructions to change the oxygen humidifier bottle tubing weekly. The resident's care plan also addressed oxygen therapy related to respiratory illness. Further review of the facility's oxygen administration policy revealed requirements to place an oxygen warning sign on the room door where oxygen is in use, change oxygen tubing and cannula weekly, and change the humidifier bottle every seventy-two hours or when empty. During an interview, the ADON/Infection Preventionist stated that tubing and humidifier bottles were changed weekly but was unaware of the requirement to post oxygen signage. The ADON acknowledged that the facility did not place oxygen signs on rooms where oxygen was in use, despite the policy stating this was required.
Failure to Complete Annual Performance Evaluations for GNAs
Penalty
Summary
The facility failed to complete annual performance evaluations for two Geriatric Nursing Assistants (GNAs) as required. A review of employee records on April 8, 2025, revealed that no performance reviews for 2023 and 2024 were present for these two GNAs. This was confirmed during an interview with the Nursing Home Administrator, who acknowledged that the annual evaluations had not been conducted for the specified years. No additional evidence was provided by the facility to demonstrate that the required performance evaluations had been completed for these staff members. The deficiency was identified during the annual survey, where it was noted that performance evaluations are necessary to determine in-service education needs and assess competencies of GNAs. The absence of these evaluations for the two staff members was directly observed in their employee records and confirmed by facility leadership.
Medication Error Rate Exceeds 5% Due to Administration and Documentation Failures
Penalty
Summary
Licensed staff failed to maintain a medication error rate below 5 percent, as evidenced by three errors out of 26 observed opportunities, resulting in an 11.54% error rate. For one resident, an LPN withheld a scheduled dose of Amlodipine due to a heart rate of 59 bpm without a physician's order to do so and documented the medication as administered on the Medication Administration Record (MAR), despite not giving it at the scheduled time. For another resident, the LPN administered Brimonidine Tartrate Ophthalmic Solution to only one eye when the physician's order specified both eyes, and failed to administer Cholecalciferol (Vitamin D) because it was not available, yet documented it as given on the MAR. The LPN stated that she would typically notify the pharmacy and physician when medication is unavailable and document accordingly, but in these instances, the MAR was inaccurately completed. The errors were confirmed during medication administration reconciliation and through staff interviews, with the LPN acknowledging the discrepancies in documentation and administration. The deficiencies were brought to the attention of facility leadership.
Improper Medication Storage, Labeling, and Disposal Practices Identified
Penalty
Summary
Surveyors identified multiple deficiencies in the facility's medication storage and labeling practices during observations of medication carts and storage rooms. In one instance, two Tylenol tablets and a vitamin tablet were found stored in a medication cup inside a cart after a resident refused them, and the LPN stated that refused medications were discarded in a trash can. Additional issues included an open, undated insulin pen, loose pills, and individually packaged medications not labeled with resident names. Similar findings were observed in other medication carts, including loose tablets, opened and undated bottles of supplements, and expired medications belonging to discharged or deceased residents. Further observations in medication storage rooms revealed medications for discharged or expired residents stored in open pharmacy bags, as well as expired enteral feeding formula. The refrigerator temperature log for medication storage was missing signatures for several days, and the unit manager admitted to lapses in monitoring and documentation. Staff interviews confirmed inconsistent practices for disposing of medications, with some stating that medications were returned to the pharmacy, while others described crushing and flushing non-narcotics or using a drug buster for narcotics, often without clear documentation or adherence to policy. The facility's policies require proper labeling, dating, and secure storage of all medications, as well as appropriate disposal in accordance with state and federal regulations. However, staff interviews and direct observations demonstrated a lack of compliance with these requirements, including improper storage of loose and unlabeled medications, failure to date opened bottles, retention of expired medications, and inconsistent documentation of refrigerator temperatures.
Failure to Provide Timely Dental Services
Penalty
Summary
A resident with diagnoses including dementia and cognitive communication deficit was admitted to the facility and had not received a dental evaluation or dental services since admission. The resident reported experiencing pain when chewing food, which was observed by the surveyor during a breakfast meal, where the resident took small bites and consumed limited food, stating pain in the right jaw while chewing. Review of the clinical record confirmed that the resident had not seen a dentist since admission, and an oral health evaluation later revealed the presence of 1-3 decayed or broken teeth. The registered dietitian noted that during a previous interview regarding weight loss, the resident did not mention dental pain at that time.
Sanitation and Food Storage Deficiencies Identified
Penalty
Summary
Surveyor observations and facility record review revealed that the facility failed to maintain proper sanitation in food storage areas both in the kitchen and on one nursing unit. During an initial kitchen tour, a personal coffee mug was found on a meal tray cart, and employee personal items such as a coat, backpack, and keys were stored in the chemical storage room. Additionally, opened containers of stir fry sauce, distilled vinegar, and salt were found undated on a food prep table shelf. The walk-in freezer and refrigerator lacked internal thermometers, with only external thermometers present at the time of observation. On a nursing unit, the nourishment refrigerator contained two rolls of bread and a bag of red grapes, all stored without labels or dates, contrary to the facility's policy requiring labeling and dating of food items brought in by family and visitors. The LPN Unit Manager confirmed that the expectation was for all food items in the nourishment refrigerators to be labeled and dated. These sanitation and food storage concerns were acknowledged by facility staff during the survey.
Improper Disposal of Garbage and Refuse
Penalty
Summary
During a tour of the facility's outside dumpster area, surveyors observed that the dumpsters were not covered with their attached lids. Additionally, items such as an old mattress, a dresser, and a soda can were found next to the dumpsters. The Food Services Director confirmed that the expectation is for dumpsters to be covered with lids and acknowledged the surveyor's observation. These findings were reviewed with the Licensed Nursing Home Administrator and the Regional Clinical Nurse Consultant. No further information was provided by the facility at the time of exit. No residents or specific patient information was mentioned in relation to this deficiency.
Inaccurate Documentation of Cervical Collar Use
Penalty
Summary
A deficiency was identified when the facility failed to maintain accurate medical records for a resident who was required to wear an Aspen cervical collar at all times following a fall that resulted in a head injury and cervical fracture. The physician's order specified that the collar should remain in place at all times, with removal only permitted for skin checks and ADL care, and to be replaced every shift. However, during multiple observations, the resident was not wearing the cervical collar as ordered. Further review of the resident's medical records revealed inconsistencies in documentation. Although the resident had refused to wear the cervical collar on several occasions, nursing staff signed the Treatment Administration Record (TAR) indicating the collar was worn on those days, as well as on days when the resident was observed without the collar. The Unit Manager confirmed that the nurses were not accurately documenting the resident's refusals on the TAR, despite the refusals being noted in progress notes.
QAA Committee Lacked Required Members and Accurate Attendance Documentation
Penalty
Summary
The facility failed to ensure that the Quality Assessment and Assurance (QAA) committee included the minimum required members and met the federal requirements for attendance documentation. Record review of QAA attendance sheets revealed inconsistencies, including missing signatures for the Infection Preventionist (IP) at several meetings and unclear documentation of who attended on multiple dates. The attendance sheets also incorrectly listed the federal requirements for committee membership, omitting the IP. During an interview, the Administrator acknowledged issues with the attendance system and confirmed that the documentation did not clearly indicate who was present at the meetings.
Failure to Follow Enhanced Barrier Precautions During Resident Care
Penalty
Summary
A deficiency was identified when a Geriatric Nursing Assistant (GNA) provided a bed bath to a resident with an indwelling urinary catheter without wearing a gown, despite Enhanced Barrier Precautions (EBP) being in place. The EBP sign was posted on the resident's door, indicating that staff must use personal protective equipment (PPE), including gloves and a gown, during high-contact resident care activities. The resident's medical record confirmed an order for EBP, specifically requiring PPE during such activities. During an interview, the GNA was unaware that the resident was on EBP and acknowledged that gloves and a gown were required for care under these precautions. The failure to wear a gown during a high-contact activity, such as a bed bath, constituted non-compliance with the facility's infection prevention and control program as outlined by CMS and CDC guidelines for residents with indwelling medical devices.
Failure to Maintain Sanitary Laundry Room Environment
Penalty
Summary
During a tour of the laundry room, the surveyor observed that the floor tiles in the area with washing machines were visibly dirty, with brown spills covering an area of approximately 1.5 ft by 1.5 ft in front of a platform where washing machine chemicals were stored. A brown dirt-like substance was also noted throughout the length of the laundry room leading to the platform. In the clean area of the laundry room, an HVAC unit was found with three rusty grille vent covers that had thick layers of dust. The Environmental Services Supervisor acknowledged the need for cleaning. These observations were made in the presence of facility staff and were reported to the Nursing Home Administrator.
Failure to Provide Written Notification for Hospital Transfers
Penalty
Summary
The facility failed to provide written notification to residents and, when applicable, their representatives regarding the reason for transfer to the hospital. This deficiency was identified through staff interviews and medical record reviews for three residents who were transferred to the hospital on multiple occasions. In each case, there was no evidence in the medical records that written notification was given to the resident or their representative at the time of transfer. The Regional Clinical Nurse Manager confirmed during interviews that the facility did not have a process in place for providing such notifications. For one resident, documentation showed multiple hospital transfers without written notification. Another resident's record indicated that a family member requested a hospital transfer and called 911, but there was still no documentation of written notification being provided. Staff interviews revealed that while the process for preparing transfer documentation was described, there was no evidence that the required written notifications were actually given to the residents or their representatives during these transfers.
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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