Copper Ridge Nursing And Assisted Living Center
Inspection history, citations, penalties and survey trends for this long-term care facility in Sykesville, Maryland.
- Location
- 710 Obrecht Road, Sykesville, Maryland 21784
- CMS Provider Number
- 215265
- Inspections on file
- 19
- Latest survey
- December 11, 2025
- Citations (last 12 mo.)
- 18 (1 serious)
Citation history
Health deficiencies cited at Copper Ridge Nursing And Assisted Living Center during CMS and state inspections, most recent first.
A cognitively impaired resident with a history of wandering and exit-seeking behaviors was able to leave the facility unsupervised after staff failed to recognize and intervene appropriately. Despite documented behaviors indicating risk, no interventions were put in place, and the resident was mistaken for a visitor by staff, allowing them to exit the building. The resident was later found by police and returned after a hospital evaluation.
A review of employee files revealed that several direct care staff, including GNAs and an RN, did not have documentation of required Effective Communication training. The HR Director and Corporate Nurse were unable to produce records confirming the training was completed, citing a lack of systematic record maintenance.
A review of employee files and staff interviews revealed that several staff members, including GNAs and a Dietary Aide, did not have documentation of receiving required QAPI program training. The HR Director and Corporate Nurse were unable to produce or verify records of this mandatory education due to unsystematic record-keeping.
The facility did not report allegations of abuse, injuries of unknown source, and misappropriation of resident property within the required 2-hour timeframe after staff became aware of the incidents. Two residents with unexplained bruising and one resident with a narcotic medication discrepancy experienced delays in reporting to the State Agency, as confirmed by facility documentation and staff interviews.
The facility did not complete required annual performance evaluations for its Geriatric Nursing Assistants, as confirmed by staff and a review of personnel files.
A review of staff files revealed that not all employees received required infection control training, with one staff member lacking documentation of completion. The HR Director and Corporate Nurse were unable to produce or verify records of this training due to unsystematic maintenance of education records.
The facility did not consistently conduct or document interdisciplinary care plan meetings in accordance with required timelines following MDS assessments. For several residents, care plan meetings were either missing or not properly documented to match assessment dates, and staff interviews revealed confusion about the required timing for these reviews.
A resident with high cognitive function was subjected to verbal abuse by an LPN, who spoke aggressively and loudly, causing the resident to become visibly upset and cry. Multiple staff witnessed the incident, and the facility's investigation confirmed the occurrence of verbal abuse.
Surveyors found that two residents were administered psychotropic medications without proper documentation, evaluation, or justification. One resident received PRN Lorazepam almost daily over several months without a 14-day limitation or ongoing assessment, while another was prescribed Rexulti for behavioral symptoms that were not documented in their records. Staff interviews confirmed the lack of observed or recorded behaviors to support the medication orders.
A resident was transferred to the hospital for chest pain, but the facility did not provide written notice of the bed hold policy to the resident or their representative at the time of transfer. Documentation reviewed included only a late entry progress note, a blank bed hold notice, and an undated letter, with no evidence that the required written notice was given.
A resident was not provided with a summary of their baseline care plan and medication list within 48 hours of admission, as required. Review of records and staff interviews confirmed that the necessary documentation and resident acknowledgment were missing, resulting in a deficiency.
Surveyors identified that two residents did not receive care according to physician orders. One resident with weight loss did not have weekly weights obtained as ordered, with some weights missing and others not taken on the specified days. Another resident had a magnesium lab ordered following a pharmacist's recommendation, but the lab was never completed and no results were found. These deficiencies were confirmed through record review and staff interviews.
Surveyors identified that two residents receiving controlled medications had discrepancies between the controlled substance count sheets and the MAR. Doses of Lorazepam and Oxycodone were recorded as administered on count sheets but were missing from the MAR, and in some cases, the timing and dosage could not be reconciled. Interviews with an LPN and the DON confirmed that documentation was incomplete and did not meet facility policy.
A deficiency was identified when facility staff failed to document and respond to a consulting pharmacist's recommendations regarding a resident's medication regimen in a timely manner. The DON kept pharmacy recommendations in a binder rather than in the medical record, and the relevant Monthly Medication Review was not available until prompted by the surveyor, indicating a lapse in following established procedures.
Nursing staff did not follow physician orders for two residents regarding medication administration. One resident received a cardiac medication despite blood pressure readings below the ordered threshold or without a blood pressure check, and another received pain medication when their reported pain level was below the ordered range. The DON acknowledged the errors during review.
A resident reported never having been seen by a dentist since admission and expressed ongoing dental issues. Clinical records confirmed the absence of dental consults, and the DON stated she was unaware of the resident's dental concerns, resulting in a lack of routine dental services.
Staff failed to promptly discard expired protein drinks in two unit-based kitchens, with one staff member returning expired Mighty Shakes to the refrigerator after being notified, while another staff member immediately discarded the expired product.
The facility did not consistently monitor or document antibiotic use, as required by its stewardship program. Two residents receiving antibiotics for urinary tract infections were not included in risk meeting records, and key information such as lab results, signs and symptoms, and antibiotic start and end dates was missing from both the stewardship binder and meeting minutes. The DON confirmed these documentation gaps during the survey.
Two residents were found to have incomplete or missing documentation regarding their influenza and pneumococcal vaccination status. One resident had no record of either vaccine upon admission, and another lacked documentation for the pneumococcal vaccine. The DON confirmed that staff should have obtained and recorded this information, but it was not present in the records reviewed.
Surveyors identified that two residents lacked proper documentation of their COVID-19 vaccination status in their medical records, and one direct care staff member did not have vaccination status documented at the time of hire. The DON confirmed these documentation gaps during the review process.
A resident's call bell was repeatedly found out of reach, first on the floor and later wedged under a wardrobe, making it inaccessible for the resident to request assistance. Staff were aware of the issue but could not immediately resolve it, resulting in the call system remaining unavailable for several days.
Failure to Prevent Elopement of Cognitively Impaired Resident
Penalty
Summary
Facility staff failed to provide adequate supervision to prevent a cognitively impaired resident from eloping. The resident, who had diagnoses including mild neurocognitive disorder with behavioral disturbance and cognitive communication deficit, was admitted with two physician certificates indicating incapacity to make medical decisions. Initial assessments did not identify the resident as an elopement risk, but subsequent BIMS assessments showed moderate to severe cognitive impairment. Nursing progress notes documented behaviors such as refusing care, agitation, wandering, exit seeking, and safety concerns, but no interventions were implemented to address these behaviors. On the morning of the incident, the resident was observed to be agitated, attempting to leave, and even tried to break a window. Staff were notified of the resident's behavior, and a GNA was asked to monitor the resident, but was not assigned to provide one-to-one supervision. The resident was able to access the elevator and reach the kitchen area, where dietary staff mistook the resident for a visitor and allowed them to exit the building. Staff interviews confirmed that the resident did not appear to be a resident and was able to leave the facility without proper verification of identity. The facility's investigation determined that staff failed to recognize and appropriately supervise a resident with exit-seeking behaviors, resulting in the resident eloping from the facility. The resident was later found by police at a gas station several miles away and returned to the facility after a hospital evaluation. The deficiency was attributed to the lack of effective supervision and failure to implement measures to address the resident's documented behaviors and risks.
Failure to Provide Mandatory Effective Communication Training to Direct Care Staff
Penalty
Summary
Facility staff failed to ensure that all direct care staff received mandatory training on Effective Communication, as evidenced by a review of six employee files. Specifically, the files for three Geriatric Nursing Assistants and one Registered Nurse did not contain documentation showing completion of the required training. During the survey, the Human Resources Director was unable to provide evidence that the training had been completed for these staff members. Additionally, the Corporate Nurse confirmed that education records were not systematically maintained, making it impossible to determine if or when the training was provided.
Failure to Provide Mandatory QAPI Training to All Staff
Penalty
Summary
Facility staff failed to ensure that all employees received mandatory training on the elements and goals of the Quality Assurance and Performance Improvement (QAPI) program. During an extended survey, a review of six employee files revealed that four staff members, including two Geriatric Nursing Assistants, a Dietary Aide, and another staff member, did not have documentation indicating they had received the required QAPI training. The Human Resources Director was unable to provide evidence that the training had been conducted, and the Corporate Nurse confirmed that education records were not systematically maintained, making it impossible to determine if or when the training was provided. These findings were based on direct review of staff files and interviews with facility personnel, which confirmed the lack of documentation and systematic record-keeping for mandatory QAPI training among the staff reviewed.
Failure to Timely Report Alleged Abuse, Injuries of Unknown Source, and Misappropriation
Penalty
Summary
The facility failed to ensure that all alleged violations involving abuse, neglect, exploitation, mistreatment, injuries of unknown source, and misappropriation of resident property were reported immediately, but not later than 2 hours after the allegation was made. Specifically, for two residents with injuries of unknown origin, staff became aware of the incidents at 6:15 AM and 8:30 AM, but the initial self-reports to the State Agency were not sent until 11:51 AM and 11:31 AM, respectively, exceeding the required 2-hour reporting window. In both cases, the documentation confirmed the delay in reporting after staff became aware of the injuries. Additionally, an incident involving the alleged misappropriation of a resident's narcotic medication was not reported within the required timeframe. Staff identified a discrepancy in the medication records at 4:00 PM, but the initial self-report to the State Agency was not sent until nearly 24 hours later. These failures to report timely were acknowledged by the Nursing Home Administrator and relevant staff during interviews, with no further comments provided.
Failure to Complete Annual GNA Performance Reviews
Penalty
Summary
The facility failed to conduct yearly performance reviews for its Geriatric Nursing Assistants (GNAs) as required. During a complaint survey, a review of four GNA personnel files revealed that none contained evidence of annual performance evaluations. When the surveyor requested the performance reviews, facility staff, including Human Resources and a Corporate RN, confirmed that they were unable to locate any documentation indicating that these evaluations had been completed within the past 12 months. This deficiency was identified for all four GNA employee files reviewed.
Failure to Ensure Mandatory Infection Control Training for All Staff
Penalty
Summary
Facility staff failed to ensure that all employees received mandatory training for the Infection Control program, as required by the facility's infection prevention and control policies. During a review of six staff files, it was found that one staff member did not have documentation indicating completion of the required infection control training. The Human Resources Director was unable to provide evidence that the training was completed for this staff member, despite multiple attempts to locate the records. Additionally, the Corporate Nurse confirmed that education records were not systematically maintained, making it impossible to determine if or when the training was provided.
Failure to Conduct and Document Timely Interdisciplinary Care Plan Meetings
Penalty
Summary
The facility failed to conduct and document care plan meetings of the interdisciplinary team for residents at the time of quarterly revisions of their care plans, as required. Review of medical records and interviews revealed that for four out of six residents reviewed, there was either no documentation of care plan meetings or the documentation did not align with the timing of the Minimum Data Set (MDS) assessments. Specifically, care plan meetings were not held or not documented within the required timeframes following quarterly or annual MDS assessments, and sign-in sheets or progress notes did not consistently match the assessment dates. Interviews with facility staff, including the DON and MDS coordinator, confirmed that care plan meetings should be scheduled in relation to MDS assessments and involve an interdisciplinary team. However, discrepancies were found between staff statements and actual practice, with staff unable to provide clear answers regarding the required timing for care plan reviews after MDS assessments. The deficiency was validated by the DON when concerns were presented by surveyors.
Verbal Abuse of Resident by LPN
Penalty
Summary
A resident with a Brief Interview for Mental Status (BIMS) score of 14 out of 15 experienced verbal abuse from an LPN. The incident occurred when the LPN spoke aggressively and loudly to the resident after the resident asked a question, resulting in the resident becoming visibly upset and crying. The resident later reported feeling angry and hurt during a psychological supportive care session. Multiple staff members provided written statements confirming that the LPN used an aggressive tone and loud voice when addressing the resident. The facility's investigation, including witness interviews and review of the resident's medical record, substantiated that verbal abuse had occurred. The Nursing Home Administrator concluded that the incident constituted verbal abuse based on the evidence collected.
Failure to Ensure Proper Use and Monitoring of Psychotropic Medications
Penalty
Summary
The facility failed to ensure compliance with regulations regarding the use of psychotropic medications for two residents. For one resident with dementia, depressive disorder, and anxiety disorder, Lorazepam was ordered and administered as needed (PRN) over an extended period, with orders being renewed continuously from March through June. The medication was given almost daily, sometimes twice a day, without a documented 14-day limitation for PRN use as required. After an initial psychiatric evaluation in April noting the medication's effectiveness, there was no further documented evaluation or rationale for the continued use of Lorazepam, despite its frequent administration. For another resident, a psychotropic medication (Rexulti) was ordered for behavior management related to dementia. However, review of the resident's Minimum Data Set (MDS) and treatment administration records over several months showed no documented behavioral symptoms or incidents that would justify the use of such medication. Staff interviews confirmed that behaviors were not observed or documented during this period, and the psychiatric nurse practitioner acknowledged that the order was based on a single observation of agitation and confusion, with no subsequent behavioral incidents recorded. These findings demonstrate that the facility did not ensure psychotropic medications were prescribed and administered in accordance with regulatory requirements, including proper documentation, ongoing evaluation, and justification for continued use. The lack of appropriate monitoring and documentation resulted in residents receiving unnecessary medications or medications without the required oversight.
Failure to Provide Written Bed Hold Policy Notice Upon Hospital Transfer
Penalty
Summary
The facility failed to provide written notice of the bed hold policy to a resident or their representative when the resident was transferred to the hospital. Review of the medical record showed that the resident was transferred for evaluation of chest pain, but there was no evidence that written notice of the bed hold policy was given at the time of transfer. The surveyor requested documentation, but the only evidence provided was a late entry progress note stating that the resident and family were notified verbally, a blank bed hold notice form, and an undated letter with a handwritten note indicating it was mailed to the resident's daughter. During an interview, the Nursing Home Administrator (NHA) confirmed that the facility's process is to provide the bed hold policy before a resident leaves for transfer and to keep a copy of the notice. However, the NHA was unable to produce any written evidence that the required notice was given to the resident or their representative at the time of transfer. The surveyor confirmed that the documentation provided did not meet the requirement for written notice.
Failure to Provide Baseline Care Plan and Medication Summary Upon Admission
Penalty
Summary
The facility failed to ensure that a resident was provided with a summary of their baseline care plan (BLCP), including a list of medications, within 48 hours of admission. Review of the resident's medical record showed no evidence that the BLCP or a summary of medications was given to the resident or their representative as required. The BLCP document for the resident was found, but the section for the resident or representative's signature and date, which would confirm receipt of the information, was left blank. Interviews with the DON and NHA confirmed that there was no documentation to show the resident received the BLCP and medication summary within the required timeframe. The deficiency was identified during a recertification/complaint survey, and the lack of proper documentation and resident acknowledgment led to the finding.
Failure to Follow Physician Orders for Weights and Lab Tests
Penalty
Summary
The facility failed to follow physician orders for two residents as identified during a recertification and complaint survey. For one resident with documented weight loss, medical records showed that weekly weights were ordered to be obtained every Sunday for two separate four-week periods. However, weights were either missing or not obtained on the specified days as ordered. Specifically, two out of four required weights were not obtained during the first period, and the remaining weights were not taken on the correct day. In the second period, one required weight was missing, and the others were not obtained on the ordered day. These findings were confirmed by the Nursing Home Administrator during a review of the records. For another resident, a medication regimen review conducted by a pharmacist resulted in a recommendation to order a serum magnesium level, which was agreed to and signed by the provider. An order for the magnesium level was subsequently placed, but there was no evidence in the medical record that the lab was completed or that results were obtained. The Director of Nursing confirmed that no lab results were available for the ordered test. These deficiencies were identified through review of medical records and staff interviews.
Failure to Reconcile Controlled Substance Administration Records
Penalty
Summary
The facility failed to ensure that drug records for controlled substances were maintained in a manner that allowed for reconciliation between dispensed and administered medications. During a review of medical records and controlled medication count sheets for two residents, multiple discrepancies were identified. For one resident prescribed Lorazepam 0.5 mg as needed for anxiety, the count sheet indicated doses were administered on two occasions, but there was no corresponding documentation in the Medication Administration Record (MAR). For another resident admitted for recovery from a pelvic fracture and prescribed Oxycodone for pain management, the count sheet documented several administrations of both 5 mg and 10 mg doses, but these were not reflected in the MAR, and in one instance, the timing and dosage could not be reconciled between the two records. Interviews with an LPN and the Director of Nursing confirmed that facility policy requires controlled medication administrations to be documented accurately and consistently on both the count sheet and the MAR. The discrepancies found during the survey indicated that this process was not followed, as the records for the administration of controlled substances could not be reconciled, leading to a deficiency in pharmaceutical services for the residents involved.
Failure to Timely Document and Respond to Pharmacy Recommendations
Penalty
Summary
The facility failed to document and respond to recommendations made by consulting pharmacists in a timely manner for one resident reviewed for unnecessary medication use. The DON described the process for handling pharmacy recommendations, which involved printing and placing them in a binder in her office rather than in the resident's medical record or electronic chart. During the survey, the DON was unable to locate the relevant Monthly Medication Review (MRR) for the resident in question, and it was later revealed that the MRR had been held by a staff member until the day before the surveyor's inquiry. There was no documentation in the resident's record to show that the pharmacy's recommendation had been reviewed or acted upon prior to the surveyor's intervention. The deficiency was identified through medical record review and staff interviews, which showed that the facility did not follow its own procedures for timely documentation and response to pharmacy recommendations. The lack of documentation and delayed response to the pharmacist's recommendations regarding the resident's medication regimen, specifically concerning eligibility for Gradual Dose Reduction (GDR), was confirmed by the DON. This failure was evident for one out of five residents reviewed during the survey.
Failure to Administer Medications According to Physician Orders
Penalty
Summary
Facility nursing staff failed to administer medications according to physician orders for two residents. For one resident, the physician ordered Metoprolol 50 mg to be given twice daily, with instructions to hold the medication if the systolic blood pressure was less than 110 or the heart rate was less than 60. On two occasions, the medication was administered despite the resident's blood pressure being below the specified threshold or not being checked at all prior to administration. There were no progress notes documenting the rationale for administering the medication against the ordered parameters. For another resident, the physician ordered Oxycodone 5 mg to be given every six hours as needed for pain, only if the resident rated their pain between 5 and 10 on a 0 to 10 scale, and to hold for sedation, decreased respirations, or altered mental status. The medication was administered on three occasions when the resident reported a pain level of 4, which was outside the ordered parameters. The DON acknowledged these findings during an interview and was uncertain about when staff education on this issue had last occurred.
Failure to Provide Routine Dental Services
Penalty
Summary
Facility staff failed to ensure that a resident received routine dental services. The resident, who was interviewed, reported never having been seen by a dentist since admission and expressed ongoing dental issues and a desire for care. A review of the clinical record confirmed that the resident had not received any dental consults since admission. During an interview, the DON stated there were no dental consults in the record because she was unaware of any dental problems and believed the resident did not have issues. The surveyor clarified that the resident had reported dental concerns and emphasized that routine dental visits should occur regardless of reported problems.
Expired Nutritional Shakes Not Discarded Promptly
Penalty
Summary
Facility staff failed to discard protein drinks that were past their use by date in two out of three unit-based kitchens observed during a recertification/complaint survey. During a tour of the Eastern Shore nursing unit kitchen, two 4-ounce cartons of vanilla reduced sugar Mighty Shake with a use by date of 5/30/25 were found in the refrigerator, and the staff member present stated she would take care of it but appeared to return them to the refrigerator. In the Baltimore nursing unit kitchen, one 4-ounce carton of the same product, also past its use by date, was found and immediately discarded by the staff member present. The Dietary Manager was informed of these findings and confirmed that the expired Mighty Shakes had been discarded after the surveyor's notification. No information about specific residents, their medical history, or their condition at the time of the deficiency was provided in the report.
Inadequate Monitoring and Documentation of Antibiotic Use
Penalty
Summary
The facility failed to adequately monitor and track antibiotic use among residents, as evidenced by record reviews and staff interviews. The antibiotic stewardship program was found to be lacking in consistent and complete documentation. Although the Director of Nursing (DON) stated that antibiotic use was discussed in daily clinical, weekly risk, and monthly QAPI meetings, the stewardship binder and meeting minutes reviewed by the surveyor contained incomplete or missing information. Key details such as resident admission dates, lab results, signs and symptoms, antibiotic start and end dates, and side effects were frequently absent from the records. The DON indicated that some of the documentation was maintained by the pharmacist and that reviews were conducted through the electronic medical record system, but this information was not consistently reflected in the meeting minutes or stewardship binder. Specifically, two residents who were prescribed antibiotics for urinary tract infections were not listed in the facility's risk meeting minutes, and their antibiotic use was not adequately tracked in the available documentation. The DON acknowledged these gaps when questioned by the surveyor. The lack of comprehensive and consistent monitoring and documentation of antibiotic use led to the identified deficiency in the facility's antibiotic stewardship program.
Failure to Screen and Document Flu and Pneumococcal Vaccinations
Penalty
Summary
The facility failed to adequately screen and document the vaccination status for influenza (Flu) and pneumococcal vaccines for two out of five residents whose immunization records were reviewed during a recertification and complaint survey. Specifically, one resident admitted in January 2025 had no documented record for either the Flu or Pneumococcal vaccine. The Director of Nursing (DON) confirmed that staff should have offered the Flu vaccine and obtained the pneumococcal vaccination status upon admission, but there was no data available for this resident. Another resident, admitted in May 2025, also lacked documentation of their pneumococcal vaccine status. When questioned, the DON indicated she would look for additional information, but no further documentation was provided. These findings demonstrate a failure by the facility to ensure proper screening and documentation of required vaccinations for eligible residents as per CDC recommendations.
Failure to Document COVID-19 Vaccination Status for Residents and Staff
Penalty
Summary
The facility failed to maintain proper documentation of COVID-19 vaccination status for both residents and staff, as identified during a recertification and complaint survey. For two residents, one admitted in May 2025 and another in August 2023, there was either no documentation of COVID-19 vaccination status in the medical record or missing information regarding primary vaccination, despite a recorded refusal of a booster dose. The absence of this documentation was confirmed through medical record review and interviews with the DON, who acknowledged the gaps when questioned by the surveyor. Additionally, a review of employee health files revealed that one staff member hired in December 2024 for direct resident care did not have documentation of COVID-19 vaccination status at the time of hire. Although a declination form was later provided, it was signed only after the surveyor's inquiry, indicating the facility did not have this information on file as required. These findings demonstrate lapses in the facility's process for tracking and recording COVID-19 vaccination status for both residents and staff.
Resident Call Bell Inaccessible in Room and Bathroom
Penalty
Summary
The facility failed to ensure that all residents had access to a functioning call system, as observed during the recertification and complaint survey. Specifically, one resident's call bell was found on the floor and out of reach while the resident was in bed during the initial screening. Subsequent observations revealed that the call bell remained inaccessible, having become wedged under the resident's wardrobe. Staff were made aware of the issue but were unable to immediately resolve it, and the call bell remained out of reach for several days. The deficiency was confirmed through direct observation and staff interviews, with the Nursing Home Administrator being notified of the ongoing issue.
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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