Creekside Center For Rehabilitation And Nursing
Inspection history, citations, penalties and survey trends for this long-term care facility in Hagerstown, Maryland.
- Location
- 1183 Luther Drive, Hagerstown, Maryland 21740
- CMS Provider Number
- 215113
- Inspections on file
- 18
- Latest survey
- February 6, 2026
- Citations (last 12 mo.)
- 34 (1 serious)
Citation history
Health deficiencies cited at Creekside Center For Rehabilitation And Nursing during CMS and state inspections, most recent first.
A resident experienced a change in condition that led to EMS being called and the resident being pronounced deceased, but the facility failed to notify the physician and document the change in condition and transfer decision. Record review showed a change in code status from full code to DNR and EMS involvement, yet there was no change in condition note, no documentation of who called EMS, and no physician order to send the resident to the hospital. The DON reported that nurses are expected to assess the resident, immediately notify the physician, obtain and document transfer orders, and record all actions taken, but confirmed that these steps and related documentation were missing in this case.
Surveyors found that the facility failed to report allegations of neglect and staff mistreatment to state authorities. A resident’s family had repeatedly found the resident in a very wet or soiled brief, with documentation showing delayed care due to the resident’s agitation, and another grievance described a GNA raising a fist toward a resident and making a hostile remark. Although these concerns were documented internally and one was referred for psychiatric services, there was no evidence that either allegation was reported as a Facility Reported Incident to OHCQ, and the NHA could not explain the failure to report.
A dependent resident with muscle weakness, morbid obesity, chronic pain, and mobility abnormalities required substantial/maximal assistance for showering but did not receive showers as scheduled. A prior shower order was discontinued, and although the DON stated that all residents are routinely scheduled for showers twice weekly based on room and bed assignment, documentation for one month showed only one scheduled and one unscheduled shower provided. There was no additional documentation of showers or refusals in the medical record, shower/skin sheets, or aide task records, despite the resident’s dependence on staff for this ADL.
A resident with severe cognitive impairment and high elopement risk was able to access an unsecured mechanical/boiler room after staff failed to ensure laundry and mechanical room doors were locked when unattended. The resident was found on the floor with minor injuries, and staff and maintenance interviews indicated the doors were likely propped open, allowing unauthorized access.
Two residents with bariatric needs suffered serious injuries after falls from beds that were not equipped with appropriate bariatric mattresses and frames. In both cases, staff failed to follow safety procedures and did not provide the required level of assistance or ensure the correct equipment was in place, resulting in fractures and hospitalizations.
The facility did not ensure timely reporting of alleged abuse incidents, as required by policy and regulations. In several cases, residents with significant medical and cognitive conditions experienced or were alleged to have experienced abuse or mistreatment, but staff failed to notify the administrator and state agencies within the mandated timeframes. Delays in reporting were confirmed through staff interviews and record reviews, with some incidents not reported for several days.
A facility failed to maintain complete documentation for an abuse allegation investigation involving a resident with dementia and other conditions. Required written and signed statements from all staff involved, including the reporter and other staff present during the incident, were missing from the investigation file. The Assistant Director of Nursing and Administrator confirmed that the investigation documentation was incomplete and that no additional information was available.
The facility failed to notify the local health department and post signage about a gastrointestinal outbreak affecting approximately 24 residents. The ADON, also the Infection Preventionist, did not inform the health department despite recognizing the outbreak, and there was no signage at the entrance to alert staff and visitors.
Facility staff failed to create a comprehensive care plan for a resident with a prosthetic eye, who also had Alzheimer's and Lewy Body Dementia. The care plan did not address the specific needs for cleaning the prosthetic eye or managing related behaviors, despite the resident's admission several months prior. The deficiency was confirmed by the DON.
A facility failed to renew a cleaning order for a resident's prosthetic eye after multiple hospitalizations. The resident, with Alzheimer's and other neurocognitive disorders, initially had their spouse manage the eye care. As the resident's condition worsened, staff took over, but the order was not reinstated post-hospitalization. The ADON discovered the omission during a chart audit and reinstated the order without notifying the physician or documenting communication with the spouse.
A resident with hypertension was administered Clonidine despite physician orders to hold the medication if systolic blood pressure exceeded 150. The facility also failed to notify the physician when the resident's systolic blood pressure was above 160, as required. These oversights were confirmed by the DON during a review.
A resident with cognitive impairments was inappropriately restrained by staff in a wheelchair against a wall, preventing movement. Despite the incident being reported, the staff member involved continued to work in the facility without proper documentation or disciplinary action. The facility's failure to address the incident led to a determination of immediate jeopardy, highlighting concerns for resident safety.
The facility failed to recognize and address changes in resident conditions, leading to immediate jeopardy. A resident received morphine routinely instead of as needed due to a physician's error, which was not communicated or corrected by staff. Another resident experienced ongoing abdominal issues and significant weight loss without timely medical consultation, resulting in their death from sepsis and shock. These failures highlight the facility's inability to promptly assess and address resident conditions and ensure proper medication administration.
A facility failed to prevent injuries to residents due to inadequate supervision and unsafe equipment. One resident sustained a severe leg laceration during a transfer, while another fell out of bed during ADL care, resulting in a hematoma. The facility's reliance on agency staff without proper orientation and missing information in the Kardex contributed to these incidents.
The DON was not working full-time in her designated role due to being assigned additional duties as the IP nurse after the previous IP nurse resigned unexpectedly. The facility, licensed for 80 beds, requires the IP responsibilities to occupy 40% of a full-time equivalent. The NHA acknowledged the issue and stated that another staff member is in training to take over the IP role.
The facility failed to implement proper transfer/discharge procedures, lacking essential information in notices and effective discharge planning. Residents were not informed of bed-hold policies, and some did not receive timely physician visits. Additionally, the facility did not provide required communication and behavioral health training to all staff, including new hires.
The facility's quality assessment and assurance program failed to prevent repeat deficiencies related to reasonable accommodation of needs, pharmacy services, unnecessary drug regimens, and medication error rates. Despite previous corrective actions, these issues persisted, as identified in recent and past surveys. The NHA acknowledged the recurrence of these deficiencies.
The facility failed to implement proper infection prevention and control measures, including inadequate use of PPE during resident care, improper handling of exposed needles during medication administration, and insufficient laundry and water management practices. Staff did not wear gowns when required, and the laundry room lacked separation between clean and soiled areas. Additionally, the facility's infection control policies were outdated and not reviewed annually.
The facility failed to provide mandatory effective communication training for direct care staff, as revealed by a review of employee files for five staff members. Interviews with HR and the DON indicated uncertainty about past training tracking methods, and despite recent efforts to provide training materials, no documentation of effective communication training was found.
The facility failed to ensure required training on abuse, neglect, exploitation, and dementia management was completed for several staff members. Documentation was missing or incomplete for multiple employees, including some who had no record of receiving necessary training. The DON and HR were unable to confirm past training, and recent efforts to provide training lacked proper documentation.
The facility failed to provide mandatory infection prevention and control training for its staff, as revealed by a review of employee files. Four GNAs had no documentation of receiving the required training, and interviews with HR and the DON indicated that training had not been consistently tracked or conducted. Despite some training materials being available, comprehensive documentation was lacking.
The facility failed to document that GNAs received the required in-service training, including abuse prevention and dementia management, and did not conduct annual performance reviews. A review of employee files showed a lack of training records, and the DON confirmed that training had not been occurring until recently. Limited evidence of training was found in the Annual Education Fair binder, with some staff lacking documentation of completed training.
The facility failed to provide mandatory effective communication training for its direct care staff, as required by the facility assessment. A review of employee files revealed no documentation of such training for GNAs hired between 2010 and 2022. Interviews with HR and the DON confirmed the absence of training records, and a review of corporate training materials and an Annual Education Fair binder did not show evidence of effective communication training.
The facility failed to conduct a comprehensive facility-wide assessment, omitting critical information such as the average number of residents and necessary staff competencies. The assessment did not evaluate the training program for staff, contractual individuals, and volunteers, resulting in several GNA staff members lacking essential training. Additionally, the facility did not include a risk assessment using an all-hazards approach, as identified during a staffing review.
The facility failed to conduct thorough investigations for injuries of unknown origin and allegations of abuse and neglect for several residents. One resident had unexplained bruises, but the facility did not complete the final report or interview other residents. Another resident's fall with injury lacked investigation documentation. A resident was restrained without proper investigation or documentation, and another's elopement was not properly investigated. Lastly, a resident's injury was not investigated or documented, despite a complaint of being bumped during a transfer and a subsequent tibial fracture diagnosis.
The facility failed to ensure timely and accurate physician documentation and medication review for several residents, leading to discrepancies in medication orders and delayed medical interventions. Issues included incorrect medication dosages, outdated medication lists, and delayed uploading of physician and NP notes to the facility's EMR, affecting the quality of care provided.
The facility failed to uphold residents' dignity during meal assistance, as staff were observed standing over residents while feeding them, contrary to the facility's policy. Interviews revealed staff were unaware of the policy, although they recognized the importance of eye contact. The DON confirmed the expectation for staff to be seated during meal assistance.
A facility failed to maintain a medication error rate below 5%, with errors observed in the administration of medications to four residents. Errors included incorrect timing, undocumented administration, incorrect dosages, and administering medications not ordered. These issues involved multiple staff members and were confirmed by the DON.
The facility failed to notify resident representatives and physicians of changes in condition and falls in a timely manner. One resident was found on the floor, but their representative was informed 24 hours later. Another resident with knee pain was not promptly communicated to the family or physician, despite visible distress. A third resident with multiple sclerosis and dementia experienced several falls without timely notification. Staffing levels were cited as a reason for these lapses.
A resident was transferred to the hospital without the required minimal information being provided to the receiving facility. The facility's policy did not specify the necessary documentation to be sent during a transfer, and the absence of a Hospital Transfer form was confirmed by the DON and Administrator.
A facility failed to create a care plan for a resident with a high elopement risk, as indicated by an assessment score. Despite the risk, the resident eloped, and no care plan was developed during their stay. The DON confirmed that a care plan should have been established.
A resident with a history of multiple sclerosis and dementia experienced frequent falls, but facility staff failed to conduct necessary assessments and neurological checks as per professional standards. The resident sustained multiple fractures, and there were instances where the doctor and family were not notified. The Medical Director cited staffing levels as a reason for the failure to adhere to fall protocols.
A resident requested a transfer to another facility shortly after admission, but the LTC facility failed to document or act on this request. Despite the resident's capability to make informed decisions and clear communication with the Social Worker, no evidence of discharge planning or actions taken was found. Interviews with the DON and Social Worker confirmed the oversight, leading to a deficiency noted by surveyors.
The facility failed to ensure timely physician visits for two residents, not adhering to the required schedule of every 30 days for the first 90 days and every 120 days thereafter, with NP visits in between. The facility's policy was outdated, and there was confusion over who was responsible for managing the visit schedule. The attending physician admitted to being behind on visits, and the process for ensuring timely visits was unclear.
A resident with dementia and identified elopement risk was found outside the facility, highlighting a failure to implement appropriate interventions. Despite a high elopement assessment score and a history of confusion and combativeness requiring a 1-1 sitter, no interventions were in place. The facility did not review the resident's hospital discharge information, which included critical details about their condition.
The facility failed to ensure a resident's call bell was within reach, despite the resident's cognitive impairment and dependency on staff. Additionally, call bells in several rooms were not responded to in a timely manner, with delays ranging from 7 to 10 minutes. The facility's policy required immediate response, but lacked an electronic auditing system to track response times.
The facility did not resolve repeated concerns from Resident Council meetings between January and June 2024, including issues with call light responses, staff phone use during care, and ice water distribution. Despite documented grievances, there was no evidence of investigation or feedback to residents. Interviews revealed ongoing resident frustration and lack of communication from staff, with some issues only addressed after surveyor intervention.
The facility failed to verbally inform residents of their rights and services during their stay. During a resident council meeting, it was reported that residents' rights were not reviewed at monthly meetings, despite documentation stating otherwise. The activities director confirmed that she did not review the rights as documented, and the nursing home administrator was unaware of this oversight.
The facility failed to ensure accurate documentation of advance directives and MOLSTs for two residents. One resident's advance directive was missing from the medical record, and another resident had conflicting MOLST orders regarding resuscitation status. The discrepancies were not resolved until additional documentation was provided and conflicting orders were voided.
A facility failed to monitor and prevent the misappropriation of a resident's medication. A resident had an order for oxycodone, and 90 tablets were received by a nursing supervisor. However, when the resident requested pain medication, it was discovered that all tablets were missing. The facility lacked documentation of the medication on the narcotic drug shift count sheet, and no complete investigation was conducted. Usual procedures for accounting for medications were not followed.
The facility failed to report injuries of unknown origin and abuse allegations to the state agency. A resident was hospitalized with an unexplained leg laceration, and the incident was not reported. Another resident's roommate witnessed rough handling by an aide, but the abuse was not reported timely. Additionally, a resident reported being attacked by a roommate, but the incident was initially misclassified, delaying proper reporting.
The facility failed to provide written notification to residents and their representatives when residents were transferred to the hospital. Three residents were transferred without receiving written notice, as required by regulations. Interviews with nursing staff revealed a lack of awareness about the need for written notification, and the facility's policy did not include this requirement.
The facility failed to provide written notification of the bed hold policy to residents and/or their representatives upon transfer to a hospital. This was evident in three cases where residents were hospitalized, and the Assistant Director of Nursing admitted to being unaware of the requirement for written notification.
A resident admitted to hospice care did not have a Significant Change in Status MDS assessment completed within the required 14-day timeframe. The assessment was completed 27 days after hospice admission, indicating a delay of 14 days. An interview with the MDS coordinator revealed a lack of awareness about the required timeframe for completing the assessment.
A resident with left-sided weakness due to a stroke did not receive a prescribed splint for contracture management, as observed during a resident council meeting and subsequent checks. Despite an order for the splint to be worn during the day, staff failed to apply it, and documentation errors were noted. The DON acknowledged the oversight, indicating a lapse in care for the resident's range of motion needs.
A resident with chronic kidney disease requiring dialysis did not have complete pre- and post-dialysis records maintained by the facility. The resident's dialysis communication binder was missing on several occasions, and vital information was not consistently documented. The ADON and DON confirmed these deficiencies, which could impact the resident's care management.
The facility failed to ensure proper physician oversight and medication management for residents, leading to deficiencies. A resident was readmitted with outdated medication orders, including a discontinued anticoagulant, without physician approval. Another resident's insulin was discontinued without documentation, and two residents lacked routine monitoring for chronic conditions like diabetes and high cholesterol. These issues highlight lapses in medication management and oversight.
The facility did not conduct annual performance reviews for GNAs, affecting five staff members who had been employed for over 12 months. The DON confirmed that performance reviews and competency evaluations were not completed since she took on her role.
The facility failed to maintain daily nurse staffing data for the required period, with missing reports for 16 days in February 2024. Despite requests, the facility could not provide the missing reports, and the issue was acknowledged by the DON and Regional Director for Clinical Operations.
A facility failed to consistently monitor and document a resident's behavior of lying on the floor, as observed on two occasions without staff present. The care plan acknowledged this behavior, but the Treatment Administration Record did not include it as a behavior to document. Interviews revealed confusion among nursing staff about documentation expectations, impacting medication management and leading to inconsistent practices.
Failure to Notify Physician and Document Change in Condition and Transfer
Penalty
Summary
The deficiency involves the facility’s failure to notify a resident’s physician of a significant change in condition and of the decision to transfer the resident from the facility. Record review for one resident who later died showed progress notes documenting a change in code status from full code to Do Not Resuscitate (DNR) and a subsequent note that EMS arrived to pronounce the resident deceased. However, there was no documentation of a change in condition assessment, no progress note describing the events leading up to EMS involvement, and no medical order indicating that the physician had ordered the resident to be sent to the hospital. During an interview, the DON stated that nursing staff are expected to immediately notify the physician after assessing a resident with a change or decline in health status, and that if the physician decides to send the resident to the hospital, an order should be entered and all actions documented in the medical record. When reviewing the resident’s record, the DON confirmed EMS had been called but could not identify who called and noted that the nurse should have documented this. The DON also confirmed there was no medical order to send the resident out and no change in condition documentation, and stated that the nurse should have completed a late entry if the situation had been chaotic. The DON acknowledged the concern that there was no documentation indicating that nursing staff notified the physician of the resident’s change in condition or the decision to transfer.
Failure to Report Alleged Abuse and Neglect to State Authorities
Penalty
Summary
The deficiency involves the facility’s failure to report alleged abuse and neglect to the proper authorities as required. A complaint intake from Adult Protective Services, filed on behalf of a resident’s family, indicated that the family often found the resident in a saturated, wet brief or soiled while at the facility. Review of the facility’s grievance logs showed that on 12/08/2025, staff documented that the resident’s family reported the resident had been left sitting in a very wet brief, and that staff had delayed care due to the resident’s agitation. The documentation reflected an internal review and referral to psychiatric services, but there was no evidence that this allegation of neglect was reported to the Office of Health Care Quality (OHCQ). Further review of the grievance documentation revealed another grievance dated 09/31/2025 in which a Geriatric Nursing Assistant (GNA) was reported to have raised a fist toward a resident and stated, “Don’t tell me what to do. I know how to do my job.” There was no evidence that this allegation of staff mistreatment was reported to OHCQ. During interview, the Nursing Home Administrator acknowledged that allegations of abuse and neglect are reportable and could not provide a rationale for why these grievances were not reported as Facility Reported Incidents. The administrator also confirmed that the facility was using a templated, non–facility-specific policy. No additional evidence was provided to the surveyor before the conclusion of the survey.
Failure to Provide Scheduled Showers to Dependent Resident
Penalty
Summary
The deficiency involves the facility’s failure to ensure that a dependent resident received scheduled showers as required. The resident, admitted in mid-2025 with muscle weakness, morbid obesity, chronic pain, and gait and mobility abnormalities, had a prior medical order for showers on the day shift every Monday and Thursday, which was discontinued on 9/2/25. A quarterly assessment dated 9/18/25 documented in section GG that the resident required substantial/maximal assistance to safely complete shower activities, indicating dependence on staff for this ADL. A complainant reported that the resident would go 11 days without staff providing showers. Record reviews conducted in early February 2026 showed no active shower order and no documentation in the medication administration record that showers were being provided. Facility staff reported that shower/skin sheets are completed whenever a shower is given, and that all residents are scheduled for showers twice weekly based on room and bed number, which would have placed this resident’s showers on day shift every Wednesday and Saturday. Review of September 2025 shower/skin sheets showed only one documented shower on an evening shift, and review of nursing aide task documentation showed one additional shower on a day shift. No other documentation was found to show that showers were provided or refused on the other scheduled days. In an interview, the DON confirmed that in that month the resident received only one scheduled and one unscheduled shower and acknowledged the concern.
Failure to Secure Laundry and Mechanical Room Doors Resulting in Resident Injury
Penalty
Summary
Facility staff failed to ensure that the doors to the laundry room and mechanical/boiler room were locked when unattended, resulting in unauthorized access by a resident. On the evening of the incident, a Geriatric Nursing Assistant (GNA) was unable to locate a resident during evening care. After a search, the resident was found in the mechanical/boiler room, sitting on the floor near their wheelchair. The resident sustained a skin tear/laceration on the left shin and bruises on the left forearm and right elbow. The resident involved had a history of cognitive impairment, including diagnoses of Adjustment Disorder, Cognitive Communication Deficit, Delusional Disorders, and late-onset Alzheimer's Disease. The resident was assessed as high risk for elopement, with a severely impaired BIMS score. The resident used a wheelchair for mobility and had a care plan addressing elopement risk, wandering, and impaired safety. At the time of the incident, the resident could not recall how they entered the mechanical room and was disoriented, searching for a deceased spouse. Observations and interviews revealed that the laundry room doors were designed to lock automatically when closed, requiring a keypad code for entry, while the mechanical/boiler room door required a key from the laundry room side but did not automatically lock. Staff statements and maintenance inspection indicated that the doors were likely propped open, allowing the resident to access the unauthorized area. There was no evidence of mechanical malfunction with the door locks at the time of the incident.
Failure to Provide Appropriate Bariatric Beds and Supervision Resulting in Resident Injuries
Penalty
Summary
The facility failed to provide sufficient supervision, prevent avoidable accidents, follow appropriate safety procedures, and utilize the required number of staff during care for two residents who required bariatric beds and mattresses. In the first case, a resident with significant mobility impairments and a history of cerebral infarction, heart failure, and recent fractures was being provided incontinent care by a single aide. The resident was instructed to roll over and subsequently fell from the bed, resulting in multiple fractures. It was found that the mattress in use was too large for the bed frame, and staff had previously switched to a smaller bed frame without ensuring compatibility with the bariatric mattress. The care plan indicated the resident required maximum assistance and two staff for transfers, but this was not followed during the incident. In the second case, another resident with chronic respiratory failure, morbid obesity, and muscle weakness, who required substantial assistance with mobility and was at high risk for falls, was found on the floor with the mattress over them after turning in bed. This resident was using a standard mattress and bed despite documented requirements for a bariatric mattress and bed due to their height and weight. Staff interviews and documentation confirmed that the need for a bariatric mattress was communicated prior to admission, but the resident was not provided with the appropriate equipment at the time of the fall. The resident sustained acute fractures as a result of the incident. In both cases, there was a breakdown in communication and execution of safety protocols regarding the provision of appropriate beds and mattresses for residents with bariatric needs. Staff failed to ensure that the correct equipment was in place and did not follow established procedures for safe resident handling and supervision, directly leading to serious injuries for both residents.
Failure to Timely Report Alleged Abuse Incidents
Penalty
Summary
The facility failed to ensure that alleged violations involving abuse were reported immediately, but not later than 2 hours after the allegation was made, and not later than 24 hours to other officials, as required by federal and state regulations. In multiple instances, staff did not follow the facility's abuse prevention policy, which mandates prompt reporting of all alleged abuse, neglect, exploitation, or mistreatment. The deficiency was identified through interviews, observations, and record reviews for four residents who were reviewed for abuse. One incident involved a resident with chronic respiratory failure, COPD, morbid obesity, and chronic kidney disease, who was struck by objects during a disruptive event in the dining room. The incident was not reported to the state agency until several days after it occurred, despite the resident's family expressing concern and intent to press charges. Staff interviews confirmed delays in removing residents from the area and in notifying appropriate authorities. The administrator acknowledged that the abuse incident was not reported in a timely manner due to confusion over which agencies to notify. Other cases included a resident with severe cognitive impairment who was allegedly locked in a conference room by staff, with the incident not reported to the administrator or state agency until several days later. Another resident with dementia and Parkinson's disease was reportedly handled roughly by a staff member, but the allegation was not escalated to the administrator or reported to the state agency within the required timeframe. In each case, staff interviews and documentation revealed a lack of immediate reporting, despite facility policy and staff education on the required procedures.
Failure to Maintain Complete Abuse Investigation Documentation
Penalty
Summary
The facility failed to maintain complete documentation of an abuse allegation investigation involving a resident with dementia, Parkinson's disease, and delusional disorder. According to the facility's abuse prevention policy, all witness statements should be obtained in writing, signed, and dated, and the results of the investigation should be recorded on approved forms and provided to the Administrator. However, the investigation file for the incident included only one written statement from the Unit Manager, which was based on information reported by a staff member, and a handwritten, undated, and unsigned statement later identified as the resident's. There were no written or signed statements from the staff member who reported the abuse or from other staff present during the shift when the alleged abuse occurred. Interviews with the Assistant Director of Nursing (ADON) and the Administrator confirmed that the required staff statements were not obtained or maintained in the investigation file. The ADON acknowledged responsibility for conducting abuse investigations and stated that she should have collected statements from all staff involved, including the reporter, but was unable to locate them and had only begun to contact staff for statements after the deficiency was identified. The Administrator also confirmed that the investigation documentation was incomplete and that no further information was available regarding the abuse investigation.
Failure to Notify Health Department and Post Outbreak Signage
Penalty
Summary
The facility failed to adhere to infection control practices and guidelines by not notifying the local health department of a gastrointestinal outbreak and not posting appropriate signage to inform staff and visitors. During a tour of the facility, it was observed that several rooms had contact isolation signs with PPE available outside the doors. In one room, a resident was found with a basin in their lap due to nausea, indicating symptoms of the outbreak. The Assistant Director of Nursing (ADON), who also served as the Infection Preventionist, confirmed that approximately 24 residents were experiencing symptoms such as nausea, vomiting, diarrhea, coughing, and congestion over the past 24 hours. Despite recognizing the situation as a potential outbreak, the ADON had not notified the local health department, which is required when more than two residents are affected. Additionally, there was no signage at the facility's entrance to alert residents and visitors of the outbreak, further contributing to the deficiency.
Lack of Comprehensive Care Plan for Resident with Prosthetic Eye
Penalty
Summary
Facility staff failed to develop a comprehensive, resident-centered care plan for a resident with a prosthetic eye. The resident, admitted in July 2023, had diagnoses including late-onset Alzheimer's disease, neurocognitive disorder with Lewy Bodies, and age-related physical debility. The resident's medical records indicated the need for daily cleaning of the prosthetic left eye, which involved removing the eye from the socket, cleansing it with normal saline solution, drying it, and replacing it. However, the care plan did not address the specific needs related to the prosthetic eye, nor did it provide strategies for managing the resident's behaviors associated with Alzheimer's disease and Lewy Body Dementia. The care plan that was in place was not tailored to the resident's specific needs and lacked detailed approaches for handling the prosthetic eye care. It included general interventions such as anticipating and meeting the resident's needs, speaking in a calm manner, and diverting attention, but these were not specific to the resident's situation. The deficiency was confirmed during a review with the Director of Nursing, highlighting the absence of a resident-centered care plan for the prosthetic eye since the resident's admission.
Failure to Renew Prosthetic Eye Care Order
Penalty
Summary
The facility failed to renew the cleaning order for a resident's prosthetic eye after multiple hospitalizations. The resident, who was admitted in July 2023 with Alzheimer's disease and other neurocognitive disorders, had a left prosthetic eye since childhood. Initially, the resident's spouse managed the prosthetic eye care, but as the resident's condition deteriorated, the facility staff took over. The order for daily cleaning of the prosthetic eye was initially included in the resident's treatment plan but was not reinstated after the resident's hospitalizations. The Assistant Director of Nursing (ADON) discovered the omission during a chart audit and reinstated the order without notifying the physician or documenting communication with the resident's spouse. The ADON acknowledged that the order was never officially discontinued by the physician and was inadvertently left off the treatment record due to the resident's frequent hospitalizations. The issue was discussed with the Director of Nursing and the Nursing Home Administrator, but there was no documentation of corrective actions taken at the time of the report.
Failure to Adhere to Medication Parameters and Notify Physician
Penalty
Summary
The facility failed to maintain a resident's drug regimen free from unnecessary drugs by not adhering to physician-ordered parameters for medication administration and failing to notify the physician when the resident's blood pressure exceeded specified limits. The resident, who had hypertension, was prescribed Lisinopril and Clonidine, with specific instructions to hold Clonidine if the systolic blood pressure was greater than 150. However, the medication was administered on multiple occasions when the resident's systolic blood pressure was above this threshold, including readings of 155/63, 176/80, 156/61, and 164/74. Additionally, the facility did not notify the physician when the resident's systolic blood pressure exceeded 160, as required by the physician's order. Instances of elevated systolic blood pressure without physician notification were documented on several dates in January and February 2025, with readings such as 168/73, 176/80, 161/72, 189/85, and 170/84. The Director of Nursing confirmed these errors during a review of the medications and the Medication Administration Record.
Failure to Protect Resident from Inappropriate Restraint
Penalty
Summary
The facility failed to protect residents from inappropriate use of physical restraints, as evidenced by an incident involving a resident who was restrained against a wall in their wheelchair by facility staff. The resident, who had a history of muscle weakness, gait abnormalities, anxiety disorder, and dementia, was unable to move independently due to the table being pushed against them. Despite being severely cognitively impaired, the resident was participating in physical therapy and was documented as able to walk with supervision. The incident was observed by staff, who reported it to their supervisor, but the staff member involved continued to have access to other vulnerable residents. The facility's investigation revealed that two staff members had secured the resident in a manner that prevented them from moving. The resident was found restrained in the sunshine room, and the incident was documented in the facility's records. Interviews with staff indicated that the incident was reported to the nursing department, but the staff member involved was not immediately removed from duty. The facility's human resources director confirmed that the staff member had been rehired without knowledge of their previous history, and there was no documentation in the employee's file regarding the incident. Further investigation showed that the staff member continued to work in the facility, including in the area where the incident occurred. The facility's director of nursing and nursing home administrator were unable to provide documentation or a clear explanation for the continued employment of the staff member involved. The facility's failure to document and act on the incident led to a determination of immediate jeopardy, which was later abated, but the deficient practice remained a concern for the safety of other residents.
Failure to Address Changes in Resident Conditions
Penalty
Summary
The facility failed to recognize and address changes in the condition of residents, leading to immediate jeopardy. For Resident #127, the facility did not respond to a pharmacy alert regarding a morphine order that was outside the recommended dose or frequency. The morphine was administered routinely instead of as needed, which was a mistake made by the attending physician and not caught by the admitting nurse. This error was not communicated to the physician, and the resident's decline in condition, including decreased food intake and nonverbal status, was not properly documented or reported to the physician, family, or hospice care. Resident #921 experienced ongoing abdominal concerns, including pain, nausea, vomiting, and significant weight loss over several months. Despite these symptoms and a recommendation for a gastrointestinal consult, the consult was not ordered until much later, and the resident's condition continued to deteriorate. The resident was eventually sent to the emergency room with a change in mental status and was diagnosed with sepsis, shock, and circulatory failure, leading to their death shortly after. The facility's failure to promptly assess and address changes in residents' conditions, ensure proper medication administration, and follow up on necessary medical consultations contributed to the deficiencies identified by the surveyors. These oversights resulted in significant negative outcomes for the residents involved.
Deficient Care and Supervision Leading to Resident Injuries
Penalty
Summary
The facility failed to ensure that staff provided care in a manner that prevented injuries to residents, as evidenced by incidents involving two residents. In the first case, a resident sustained a 15-centimeter leg laceration during a transfer from a wheelchair to a bed. The incident involved two agency geriatric nursing assistants (GNAs) who were unable to explain how the injury occurred. The Director of Nursing (DON) speculated that the injury might have been caused by the resident's leg catching on a metal piece of the wheelchair, but this was not consistent with the nature of the wound. The facility's investigation revealed that the resident required a mechanical lift for transfers, but this information was missing from the Kardex due to a computer glitch, and the agency staff were not properly oriented to the facility's expectations. In the second incident, another resident fell out of bed during activities of daily living (ADL) care and sustained a hematoma. The resident, who required extensive assistance for bed mobility, was being bathed by a GNA who asked the resident to roll over. The resident rolled off the bed onto the floor, resulting in a hematoma on the forehead. The facility's investigation noted that the mattress was larger than the bed frame, and the GNA had inappropriately rolled the resident away from herself, not towards her, which contributed to the fall. Both incidents highlight the facility's failure to provide safe equipment and adequate supervision to prevent accidents. The facility frequently used agency staff without providing formal orientation, relying on them to access care needs through the Kardex, which was not always accurate or available. The lack of a formal process to ensure agency staff were aware of the facility's expectations and the absence of critical information in the Kardex contributed to the unsafe care provided to the residents.
DON Overburdened with Dual Roles
Penalty
Summary
The facility failed to ensure that the Director of Nursing (DON) was working in her capacity on a full-time basis. This deficiency arose because the DON was assigned additional duties as the Infection Prevention (IP) nurse after the previous IP nurse resigned without notice. The resignation occurred on 7/22/24, and since then, the DON has been fulfilling both roles. The DON acknowledged that she should not be performing the IP nurse duties due to her responsibilities as the DON. The facility is licensed for 80 beds, which requires the IP responsibilities to occupy 40% of a full-time equivalent. The Nursing Home Administrator (NHA) confirmed awareness of the issue and mentioned that another staff member is currently in training to assume the IP nurse role.
Deficiencies in Transfer/Discharge Procedures and Staff Training
Penalty
Summary
The facility administration failed to develop and implement procedures to ensure the highest practicable wellbeing of residents, as evidenced by deficiencies in transfer/discharge notices and discharge planning. Notices for several residents lacked essential information, such as the right to appeal the transfer/discharge, contact details for the state entity handling appeals, and guidance on obtaining and submitting appeal forms. Additionally, the notices included a proposed date for a post-discharge planning meeting that was set approximately 10 days after the residents' transfer or discharge, which caused confusion among residents and their representatives. The facility also failed to provide written notice of the bed-hold policy to residents and their representatives at the time of transfer to the hospital. This issue was identified in a previous survey, and although a plan was developed to correct it, the facility continued to rely on telephone notifications rather than written ones. Furthermore, the facility did not have an effective discharge planning process, as evidenced by the lack of discharge plans of care and assessments for residents' post-discharge needs. The social worker confirmed that no written protocol existed for discharge planning, and discharge plans were not formally documented. Additional deficiencies were noted in the facility's failure to ensure timely physician visits, with some residents not being seen by their attending physician within the required 60-day period. The medical records staff was unaware of the need to differentiate between visits by attending physicians and nurse practitioners. Furthermore, the facility did not provide required communication and behavioral health training to all staff, including new hires, as mandated by federal regulations. The human resources director and nursing home administrator acknowledged the lack of a comprehensive education plan for new hires, which contributed to these training deficiencies.
Recurrent Deficiencies in Quality Assessment and Assurance Program
Penalty
Summary
The facility failed to maintain an effective quality assessment and assurance program, as evidenced by the recurrence of deficiencies identified in previous surveys. During the recertification survey, it was observed that the facility did not implement effective processes to prevent repeat deficiencies related to reasonable accommodation of needs, pharmacy services, drug regimen free from unnecessary drugs, and medication error rates. These deficiencies were initially identified in the recertification surveys concluded in 2018 and 2019, but the corrective actions taken were insufficient, leading to the continuation of these issues in the current survey. The Nursing Home Administrator acknowledged the recurrence of these deficiencies during discussions with surveyors.
Infection Control Deficiencies in LTC Facility
Penalty
Summary
The facility failed to implement proper infection prevention and control measures, as evidenced by several deficiencies. Staff did not don appropriate personal protective equipment (PPE) when providing direct care to residents with specific medical needs. For instance, a staff member assisted a resident with a central line for dialysis without wearing a gown, despite the requirement for Enhanced Barrier Precautions (EBP). Similarly, another staff member provided care to a resident with open wounds without wearing a gown, only using gloves, which is insufficient for infection control. Additionally, during medication administration, a Licensed Practical Nurse (LPN) was observed handling an exposed needle without proper infection control measures. The LPN placed the syringe with the exposed needle on a tissue box while performing hand hygiene, which poses an infection risk. This incident was acknowledged as a concern by the Director of Nursing (DON) during the survey. The facility also demonstrated inadequate infection control practices in their laundry processing and water management systems. The laundry room lacked physical separation between clean and soiled areas, and staff processed soiled laundry without appropriate PPE. Furthermore, the facility did not have a system to identify and prevent the growth of Legionella in the water system, as they had not studied the water flow to identify potential pathogen growth areas. The facility's infection prevention and control policies were outdated and not reviewed annually, failing to specify critical procedures for reporting communicable diseases and using isolation measures.
Lack of Effective Communication Training for Direct Care Staff
Penalty
Summary
The facility failed to include effective communications as mandatory training for direct care staff, as evidenced by a review of employee files for five staff members. The review revealed that none of the selected employees had documentation indicating they received effective communications training. This deficiency was identified during an extended survey, where the importance of effective communication in understanding and responding to residents was emphasized. The lack of training documentation was noted for staff members with various dates of hire, ranging from 2010 to 2022. Interviews with the Human Resources (HR) staff and the Director of Nurses (DON) revealed that there was uncertainty about how mandatory in-service training was previously tracked. The HR staff mentioned that training materials had been sent by the corporate office since early 2024, but there was no confirmation of effective communication training prior to that. The DON acknowledged that staff training had not been occurring until recently and that the corporate office had been providing monthly training materials since April 2024. Despite these efforts, the surveyor found no documentation in the corporate training materials or the Annual Education Fair binder to indicate that effective communication training had been provided to the facility staff.
Deficiency in Staff Training on Abuse and Dementia Care
Penalty
Summary
The facility failed to ensure that required training on abuse, neglect, exploitation, misappropriation of resident property, and dementia management was completed for several staff members. During the survey, it was found that three out of five staff members reviewed did not have documentation indicating they had received the necessary training. The Human Resources representative, Staff #10, was unable to confirm training that occurred prior to January 2024, and the Director of Nurses (DON) acknowledged that staff training had not been consistently conducted until recently. The facility had received training materials from the corporate office since April 2024, but there was no documentation to confirm that staff had received the training. Further investigation revealed that some staff members had incomplete or missing records of training. For instance, Staff #29 had an undated record indicating abuse training but no evidence of dementia training, while Staff #31 had no record of either training. Additionally, a review of the facility's active staff roster showed that several active GNAs and other employees had not received abuse training. Staff #41, who was terminated, also lacked documentation of completed abuse training. The DON and the Regional Director for Clinical Operations were made aware of these concerns but did not provide further comments.
Failure to Provide Mandatory Infection Control Training
Penalty
Summary
The facility failed to provide mandatory infection prevention and control training that included written standards, policies, and procedures for the program. This deficiency was identified during an extended survey, where a review of five randomly selected employee files revealed that four employees had no documentation of having received the required training. The employees in question, all GNAs, had hire dates ranging from 2010 to 2022, yet their files lacked evidence of infection control training. The only partial evidence found was for one staff member, whose record indicated attendance at a training session, but lacked a signature to confirm participation. Interviews with the HR staff and the DON revealed that the facility had not consistently tracked or conducted mandatory training sessions. The HR staff, who joined the facility in late 2023, was unaware of how training was previously documented and could not confirm any training prior to January 2024. The DON acknowledged that training had not been occurring until recently, with corporate training materials only being provided since April 2024. Despite the presence of a binder labeled Annual Education Fair, which contained some training records, there was no comprehensive documentation to confirm that all staff had received the necessary infection control training.
Deficiency in GNA Training and Performance Documentation
Penalty
Summary
The facility failed to provide documentation that Geriatric Nursing Assistants (GNAs) received the required in-service training of no less than 12 hours per year, including abuse prevention and dementia management training. Additionally, there was no evidence of annual performance reviews for GNAs who had been employed for more than 12 months. This deficiency was identified during a review of five randomly selected employee files, which revealed a lack of documentation indicating that the GNAs had received any training or education in the past year. The Human Resources (HR) staff, specifically Staff #10, acknowledged the absence of training records and performance evaluations, noting that the employee files were in place before her hire in late 2023. The Director of Nurses (DON) confirmed that staff training had not been occurring until recently, with the corporate office only starting to send monthly training materials since April 2024. However, the training materials provided were limited to Resident Rights and Transmission-Based Precautions, with no documentation of staff attendance or completion of training. Further review of the Annual Education Fair binder showed limited evidence of training for some staff, with undated or incomplete records of training topics such as abuse and dementia. Notably, there was no documentation for one staff member, Staff #31, indicating they had received any annual training. The DON and the Regional Director for Clinical Operations were informed of these concerns, acknowledging the lack of evidence for required in-service training and competency evaluations for GNAs.
Lack of Effective Communication Training for Direct Care Staff
Penalty
Summary
The facility failed to provide mandatory effective communication training for its direct care staff, as required by the facility assessment. During a survey, a review of five randomly selected employee files revealed that none of the employees had documentation indicating they received effective communication training. The employees in question were GNAs with varying dates of hire, ranging from 2010 to 2022. The absence of this training was confirmed through interviews with the Human Resources staff and the Director of Nurses (DON), who both acknowledged the lack of documentation and training. The Human Resources staff member, hired in late 2023, was unable to confirm any training that occurred prior to January 2024, as the previous tracking method was unclear. The DON indicated that training materials had been sent by the corporate office since April 2024, but a review of these materials did not show evidence of effective communication training. Additionally, a binder labeled Annual Education Fair contained limited training records for some staff but did not include effective communication training. Despite being made aware of these concerns, no further documentation was provided to the surveyor by the time of their exit from the facility.
Deficient Facility-Wide Assessment and Staff Training
Penalty
Summary
The facility failed to conduct and document a comprehensive facility-wide assessment, which is essential for determining the resources necessary to care for residents competently during both day-to-day operations and emergencies. The assessment lacked critical information, such as the facility's average number of residents, which is necessary for evaluating the facility's capacity and physical characteristics. Additionally, the assessment did not adequately address staff competencies required to provide the level and types of care needed for the resident population, which includes residents with behavioral health care needs, mental illness diagnoses, and dementia or Alzheimer's diagnoses. The facility's assessment also failed to evaluate the training program to ensure that training needs are met for all new and existing staff, contractual individuals providing services, and volunteers. This deficiency was evident as the facility did not have a system in place to provide staff with the required training and competencies. A review of employee files revealed that several GNA staff members had not received necessary training, such as abuse training, behavior management training, communications training, and infection control and prevention training. Furthermore, these staff members had not completed the required 12 hours of continuing education or received annual performance reviews. Moreover, the facility assessment did not include a facility-based and community-based risk assessment utilizing an all-hazards approach. This omission was identified during a Sufficient and Competent Nurse Staffing review and an extended survey review. The Director of Nurses and the Regional Director for Clinical Operations acknowledged these concerns when they were discussed with them, indicating a recognition of the deficiencies in the facility's assessment process.
Failure to Investigate Injuries and Allegations
Penalty
Summary
The facility failed to conduct thorough investigations for injuries of unknown origin and allegations of abuse and neglect for five residents. For one resident, bruises were discovered by a Geriatric Nursing Assistant (GNA) during routine care, but the facility did not complete the final report to the state agency, omitting the alleged perpetrator and a summary of the investigation. Additionally, the facility did not interview other residents who were under the care of the same GNA. Another resident experienced a fall with injury, but the facility lacked any documentation related to the investigation of this incident. In another case, a resident was restrained in the facility's sunshine room, but the facility failed to maintain the investigation and documentation in the employees' files. Furthermore, a resident's elopement was not properly investigated, lacking statements, interviews, and preventive education. Lastly, a resident with an injury of unknown origin was not investigated or documented in the medical record, despite the resident's complaint of being bumped during a transfer and later being diagnosed with a tibial fracture. The facility was unable to provide any investigation related to this incident reported to the Office of Health Care Quality.
Deficiencies in Physician Documentation and Medication Review
Penalty
Summary
The facility failed to ensure that physician notes were available in the medical record and that a comprehensive review of residents' total treatment was completed at each visit. This deficiency was identified during a complaint survey conducted alongside a recertification survey, affecting four out of six residents reviewed for quality of care. The issues included incorrect medication orders and discrepancies between hospital discharge orders and facility admission orders, as well as missing or delayed physician notes in the residents' medical records. For Resident #911, there were significant discrepancies in medication orders upon admission. The resident was prescribed an incorrect dosage of Lasix, receiving double the intended amount, and was also given the wrong dose of Synthroid for the first two days of their stay. The Medical Director attributed these discrepancies to the use of hospital electronic records that did not accurately reflect the medications the resident was receiving in the nursing home. This lack of accurate medication documentation and review contributed to the deficiency. Resident #921's records revealed a lack of timely and accurate physician notes, with medications not being reviewed or updated appropriately. The resident's progress notes contained outdated and incorrect medication lists, and there was a delay in documenting necessary medical interventions, such as a gastroenterology consult. Similar issues were found with Resident #9 and Resident #914, where physician and nurse practitioner notes were not uploaded to the facility's electronic medical record in a timely manner, hindering the staff's ability to provide informed care. These failures in documentation and medication review processes highlight the facility's deficiency in maintaining accurate and up-to-date medical records for its residents.
Failure to Maintain Resident Dignity During Meal Assistance
Penalty
Summary
The facility failed to maintain residents' dignity during meal assistance, as observed by surveyors. On three separate occasions, staff members were seen standing over residents while feeding them, which is against the facility's policy. Specifically, a GNA was observed standing over a resident in bed, and two other GNAs were seen standing over residents in the dining room. Interviews with staff revealed a lack of awareness of the feeding policy, although they acknowledged the importance of maintaining eye contact with residents during feeding. The Director of Nursing was also unaware of the specific feeding policy but confirmed the expectation for staff to be seated and maintain eye contact while assisting residents with meals. The facility's policy, 'Assistance with Meals,' explicitly states that staff should not stand over residents during meal assistance.
Medication Administration Errors Exceed Acceptable Rate
Penalty
Summary
The facility failed to maintain a medication error rate of less than 5%, as evidenced by multiple errors during medication administration observations involving four residents. The errors were identified across three different hallways and involved three staff members, including an agency certified medication aide, an agency LPN, and a staff LPN. The errors included administering medications at incorrect times, failing to document administered medications, administering incorrect dosages, and giving medications that were not ordered. For Resident #5, an LPN administered Finasteride at the wrong time and failed to document the administration of three other medications that were not observed to be given. Resident #476 received an incorrect dosage of calcium and had a medication administered without documentation. Resident #11 was given a lidocaine patch that was not ordered, and Resident #54 received two medications that were not ordered, while another medication was documented as given but not observed to be administered. The surveyor reviewed these concerns with the Director of Nursing, who confirmed discrepancies in documentation and administration. The errors were significant enough to result in a medication error rate exceeding the acceptable threshold, indicating a deficiency in the facility's medication administration process.
Failure to Notify Representatives and Physicians of Changes in Condition
Penalty
Summary
The facility failed to ensure timely notification of resident representatives and physicians regarding changes in condition and occurrences of falls. This deficiency was evident in the cases of three residents. One resident, admitted for aftercare related to a fall with fractures, was found on the floor in the bathroom, but their representative was not notified until 24 hours later. The resident was documented as alert and oriented to self only, with a designated medical power of attorney, yet the facility did not complete a change in condition notification as per their policy. Another resident complained of knee pain and was treated with Tylenol, but the family was not informed of the injury until days later, despite the resident's continued complaints of pain and an eventual x-ray. The physician was also not notified in a timely manner, even though the resident was crying in pain and had a visible knee deformity. Additionally, a third resident with a history of multiple sclerosis, dementia, and frequent falls experienced several falls without timely notification to the doctor and family. In one instance, the resident was sent to the hospital after an unwitnessed fall, but there was no evidence of an assessment or notification to the family and doctor. The facility's failure to follow their fall protocol was discussed in Quality Assurance Committee meetings, with staffing levels cited as a reason for the lapses.
Failure to Provide Required Transfer Information
Penalty
Summary
The facility staff failed to provide the minimal required information to the receiving provider at the time of transfer for a resident who was hospitalized. The deficiency was identified during a survey when it was found that a Hospital Transfer form was not present in the medical record of a resident who was transferred to the hospital for evaluation of lethargy, low blood pressure, and low sodium level. Although a nursing progress note indicated that some information, such as the resident's Medical Orders for Life-Sustaining Treatment (MOLST), capacity, current medication orders, and a copy of the bed hold policy, was sent with the resident, it did not include the resident's Comprehensive Care Plan goals, identification and contact information for the resident's representative, or the practitioner responsible for the resident's care. The surveyor's review of the facility's policy for Transfer or Discharge, Emergency, revealed that the policy did not specify the documentation required to be sent to the receiving facility at the time of a resident's transfer. The Director of Nursing and the Administrator confirmed the absence of the Hospital Transfer form and the lack of evidence that the required minimal information was sent to the hospital. This oversight was evident for one of the four residents reviewed for hospitalization during the survey.
Failure to Develop Elopement Care Plan
Penalty
Summary
The facility failed to develop a care plan addressing a resident's potential for elopement, which was identified through a completed elopement assessment. The assessment, conducted on 5/1/23, resulted in a score of 15, indicating a risk for elopement. Despite this, the resident actually eloped on 5/2/23, and no care plan was developed during the resident's two-week stay at the facility. This deficiency was confirmed during an interview with the current Director of Nursing on 7/25/24, who acknowledged that a care plan should have been created to address the elopement risk.
Failure to Conduct Neurological Checks After Resident Falls
Penalty
Summary
Facility staff failed to conduct necessary assessments and neurological checks following a fall experienced by a resident, identified as Resident #914. The resident was found on the floor with a head laceration and was sent to the emergency room for increased confusion, where a CT scan revealed multiple fractures. Despite the resident being cognitively intact as per the MDS assessment, staff did not perform a head-to-toe assessment or neurological checks after the fall, which is a deviation from professional standards of practice. The resident had a history of multiple sclerosis, dementia, and frequent falls, with documented incidents on several dates. However, staff consistently failed to perform assessments and neurological checks when indicated. Additionally, there were instances where the facility staff did not notify the doctor and family following the resident's falls. The Medical Director acknowledged the issue during Quality Assurance Committee meetings, attributing the failure to adhere to fall protocols to staffing levels.
Failure to Address Resident's Transfer Request
Penalty
Summary
The facility failed to provide appropriate discharge planning for a resident who requested a transfer to another facility. The resident, who was capable of making informed decisions, expressed a desire to return to a different facility shortly after admission, citing that their current placement was due to their daughter's preference for proximity. Despite the resident's clear requests communicated to the Social Worker on two separate occasions, there was no documentation or evidence that the facility staff took any action to address or facilitate the resident's transfer request. Interviews with the Director of Nursing and the Social Worker confirmed the resident's requests were acknowledged but not acted upon. The Social Worker admitted to recalling the resident's insistence on transferring but was unable to provide any documentation of actions taken to address the request. The facility's failure to document or act on the resident's transfer request was further highlighted when the Administrator could not provide any evidence of measures taken to arrange the transfer, resulting in a deficiency noted by the surveyors.
Deficiency in Physician Visit Scheduling
Penalty
Summary
The facility failed to ensure that physician visits were conducted every 30 days for the first 90 days and at least every 120 days thereafter, with nurse practitioner (NP) visits in between to ensure a visit every 60 days. This deficiency was identified for two residents reviewed for quality of care. The facility's policy on physician visits was outdated and did not align with regulatory requirements, lacking a method to track these visits. For one resident, the attending physician failed to visit in the second month after admission and did not conduct visits every 120 days in subsequent years. The physician admitted to being behind on visits, and the medical director confirmed this after reviewing the available notes. For another resident, the physician failed to conduct the required third visit within the first 90 days of admission and did not maintain the 60-day visit schedule. The facility's process for ensuring timely visits was unclear, with conflicting reports on who was responsible for managing the schedule. The Assistant Director of Nursing (ADON) claimed not to manage the visits, while the Director of Nursing (DON) and Medical Record staff indicated that the ADON was responsible. The Regional Director of Clinical Operations later addressed the issue with the attending physician, but the process remained unclear.
Failure to Implement Elopement Interventions for Resident with Dementia
Penalty
Summary
The facility failed to implement appropriate interventions for a resident with identified elopement potential and documented altered mental status. The incident involved a resident who was found outside the facility by the previous Director of Nursing (DON) on the morning of 5/2/23. The resident, who was not initially recognized by the DON, was on their knees outside the facility and expressed intentions of going home to pay bills and see their dog. This incident highlighted the lack of appropriate interventions for a resident with a known risk of elopement. The resident had been documented on a hospital discharge summary as having intermittent confusion and lacking capacity, requiring a 1-1 sitter due to behaviors of confusion and combativeness. Despite this, no interventions were implemented at the time of the resident's discharge to the facility. An elopement assessment completed on 5/1/23 resulted in a score of 15, indicating a high risk, yet there was no documentation or review with a supervisor regarding this score, nor were any care plans or interventions put in place. The current DON acknowledged that the admitting staff should have reviewed the hospital discharge information to understand the resident's mobility and behavioral history.
Failure to Ensure Call Bell Accessibility and Timely Response
Penalty
Summary
The facility failed to accommodate the needs of a resident by not ensuring that the call bell was within reach. Resident #64, who was admitted with dementia and moderate cognitive impairment, was observed on multiple occasions with the call bell device out of reach. On one occasion, the resident was found sitting in a wheelchair with the call bell clipped to the middle of the bed, and on another, lying on the bed with the call bell attached to the head of the bed. The resident expressed an inability to reach the call bell, and staff confirmed this issue. The Director of Nursing acknowledged that the call bell should be within reach and later found it out of reach again, necessitating repositioning. Additionally, the facility did not respond to call bells in a timely manner, as observed in several instances across different rooms. Call bells were activated for extended periods, ranging from 7 to 10 minutes, before being addressed by staff. The facility's call bell policy, which was undated and lacked the facility's name, required immediate response to call bells, with a goal of responding within 5 minutes. However, the facility did not have an electronic system to audit call bell response times, relying instead on observational audits.
Failure to Address Resident Council Concerns
Penalty
Summary
The facility failed to address and resolve repeated concerns reported during Resident Council meetings from January to June 2024. The issues consistently raised by residents included the promptness of call light responses, staff using their phones while providing care, and the lack of ice water distribution during certain times of the day. Despite these concerns being documented in the meeting minutes, there was no evidence that the facility took appropriate action to investigate or resolve these grievances as per their Resident Grievance/Complaints Procedures, which require a written summary of the investigation results within five working days. Interviews conducted with residents and staff further highlighted the facility's inaction. Residents expressed frustration over the lack of feedback and resolution regarding their concerns, including additional issues such as blurry and fuzzy televisions. Interviews with the activity director and the nursing home administrator revealed that there was no follow-up or communication with the residents about the actions taken to address their concerns. It was only after the surveyor's intervention that the issue with the residents' TV cable was resolved, indicating a lack of proactive measures by the facility to address resident grievances.
Failure to Verbally Inform Residents of Their Rights
Penalty
Summary
The facility failed to ensure that residents were verbally provided with a notice of their rights and services during their stay. This deficiency was identified during a resident council meeting conducted as part of the annual survey. During the meeting, six residents, including the resident council president, reported that residents' rights were not reviewed at the monthly council meetings. A review of the meeting minutes from January to June 2024 indicated that residents' rights were documented as reviewed each month. In an interview with the activities director, staff #51, it was revealed that she did not review residents' rights at the monthly meetings as documented. The nursing home administrator was informed of this issue and indicated that she was unaware that residents' rights were not being reviewed at the resident council meetings.
Failure to Maintain Accurate Advance Directives and MOLSTs
Penalty
Summary
The facility failed to ensure that an advanced directive was obtained and properly documented for each resident, as well as maintaining only one active Maryland Orders for Life Sustaining Treatment (MOLST) for each resident. This deficiency was identified during a review of the medical records for two residents. For the first resident, the medical record did not contain an advance directive, despite the MOLST being completed per the advance directive. The facility's staff, including the Social Worker and Director of Nursing (DON), were unable to locate the advance directive in the electronic health record, paper chart, or business office until the resident's spouse provided a copy. For the second resident, the medical record review revealed a discrepancy with two active MOLSTs containing conflicting orders regarding resuscitation status. The paper chart contained a Do Not Resuscitate (DNR) order, while the electronic health record showed another active MOLST indicating full code status. The advance directive was not initially found in the medical record, and the conflicting MOLST orders were not resolved until the full code order was voided. These findings highlight the facility's failure to maintain accurate and complete documentation of residents' advance directives and MOLSTs.
Failure to Monitor and Prevent Misappropriation of Resident Medication
Penalty
Summary
The facility failed to monitor and prevent the misappropriation of resident property, specifically the medication of Resident #21. Resident #21 had been residing at the facility since December 2022 and had an order for oxycodone 10mg, one tablet every 8 hours as needed for pain. On June 15, 2023, staff #52, a nursing supervisor, received 90 tablets of oxycodone 10mg from the pharmacy for Resident #21. However, when Resident #21 requested pain medication on June 29, 2023, it was discovered that all 90 tablets were missing from the narcotic box where they were stored. The facility's documentation was insufficient, as there was no record of the 90 pills on the narcotic drug shift count sheet for June 2023. The nursing home administrator could not provide documentation of a complete investigation into the missing medications. Interviews with the previous DON and the current DON revealed that the usual procedure of signing the narcotic drug sheet count to account for medications was not followed, and there was no documentation of the medication being counted from the time it was delivered until it was discovered missing.
Failure to Report Injuries and Abuse Allegations
Penalty
Summary
The facility failed to develop a process to ensure that injuries of unknown origin and allegations of abuse were reported to the state agency. This deficiency was evident in several cases. In one instance, a resident was transported to the hospital with a 15 cm laceration on their right lower leg, and the facility staff could not explain how the injury occurred. Despite an investigation by the Director of Nursing (DON), the incident was not reported to the State Agency. Additionally, the Nursing Home Administrator (NHA) was aware of the incident but did not recognize it as an injury of unknown origin, thus failing to report it as required. In another case, a resident's roommate witnessed rough behavior from an aide, who did not use a Hoyer lift and allegedly tossed the resident into bed. Although immediate action was taken to prevent the aide from entering the facility again, the allegation of abuse was not reported to the state agency within the required timeframe. Furthermore, a resident reported being attacked by a roommate, but the incident was initially documented as a verbal altercation, and the facility failed to identify it as an abuse allegation. The facility eventually submitted a report to the Office of Health Care Quality, but the investigation was inconclusive due to insufficient information.
Failure to Provide Written Notification for Hospital Transfers
Penalty
Summary
The facility failed to provide written notification to residents and their representatives when residents were transferred to the hospital. This deficiency was identified during a survey, where it was found that three out of four residents reviewed for hospitalization did not receive written notice of their transfer. Specifically, Resident #924 was transferred to the hospital for evaluation of lethargy, low blood pressure, and low sodium levels, but there was no written notification provided to the resident or their representative. The facility's policy did not include a requirement for written notification, which contributed to this oversight. Similarly, Resident #45 was transferred to the hospital due to difficulty breathing and lethargy, and although an attempt was made to notify the representative by phone, no written notice was documented. Resident #33 was also transferred to the hospital, but again, there was no written notification provided. Interviews with the Director of Nursing and Assistant Director of Nursing revealed a lack of awareness regarding the requirement for written notification, further highlighting the facility's failure to comply with regulatory standards.
Failure to Provide Written Bed Hold Policy Notification
Penalty
Summary
The facility failed to notify residents and/or their representatives in writing of the bed hold policy upon transfer to an acute care facility. This deficiency was identified for three residents who were hospitalized. For Resident #33, there was no written evidence of the bed hold policy being provided when the resident was sent to the hospital due to a change in medical condition. The Assistant Director of Nursing (ADON) admitted that the policy was sometimes communicated verbally and was unaware of the requirement for written notification. Similarly, Resident #45 was transferred to the emergency room for evaluation due to lethargy and difficulty breathing, but there was no record of the bed hold policy being mailed to the resident's representative. In the case of Resident #68, who was hospitalized in July 2024, the facility also failed to provide written notification of the bed hold policy. The ADON confirmed that the policy was typically discussed verbally and not provided in writing, indicating a lack of awareness of the requirement for written notification.
Late Completion of Significant Change in Status MDS Assessment
Penalty
Summary
The facility failed to complete a Significant Change in Status Minimum Data Set (MDS) assessment within the required 14-day timeframe for a resident who was admitted to hospice care. This deficiency was identified for one resident who had been living in the facility since May 2023. The resident was admitted to hospice care on July 2, 2024, but the Significant Change in Status MDS assessment was not completed and signed until July 29, 2024, which was 27 days after the hospice admission and 14 days late. An interview with the MDS coordinator revealed a lack of awareness regarding the timeframe for completing the assessment following a resident's admission to hospice care. The coordinator confirmed that the assessment was completed late and acknowledged that it should have been completed by July 15, 2024.
Failure to Provide Splint for Resident with Limited ROM
Penalty
Summary
The facility failed to provide appropriate care for a resident with limited range of motion, as evidenced by the lack of adherence to the attending provider's order for a left resting hand splint. The resident, who had been residing in the facility since 2017, had a diagnosis of left-sided weakness due to a stroke and required maximal to full assistance for self-care needs. An order was in place since August 2023 for the resident to wear a splint during the day for contracture management. However, during a resident council meeting and subsequent observations, it was noted that the resident was not wearing the splint as required. Further investigation revealed discrepancies in documentation and staff awareness regarding the splint application. An occupational therapy discharge summary indicated that nursing staff had been educated on the application and purpose of the splint. Despite this, a licensed practical nurse erroneously documented that the splint was applied when it was not, and a geriatric nurse aide was unaware of the reason for the splint not being used. The director of nursing acknowledged the error in documentation, highlighting a failure in ensuring the resident received the necessary treatment to prevent further decline in range of motion.
Failure to Obtain Dialysis Records for Resident
Penalty
Summary
The facility staff failed to obtain pre- and post-dialysis treatment records for a resident who required dialysis services. The resident, admitted in June 2024 with chronic kidney disease and dependent on hemodialysis, had an attending provider's order to receive dialysis three times a week. The order specified that on dialysis days, a new dialysis form filled with the resident's full vitals, including weight, should be sent. However, during an observation on August 1, 2024, it was noted that the resident's dialysis communication binder was not with the resident or the facility driver. Further review of the resident's dialysis binder revealed missing communication forms for several dates in July 2024, and incomplete pre-dialysis vitals for August 1, 2024. Interviews with the assistant director of nursing (ADON) and the director of nursing (DON) confirmed the absence of post-dialysis weights on specific dates and the lack of communication forms for other dates. The DON acknowledged that the failure to complete the dialysis communication form could hinder the effective assessment and management of the resident's care by both facility and dialysis staff.
Deficiencies in Physician Oversight and Medication Management
Penalty
Summary
The facility failed to ensure that residents' care was properly overseen by a physician, leading to several deficiencies. Resident #905 was readmitted to the facility after a hospital stay with previous medication orders still active, including the anticoagulant Eliquis, which had been discontinued due to bleeding risks. Despite the hospital's adjustment of the resident's medication, the facility administered the old orders without physician approval, indicating a lapse in medication management and oversight. Resident #920 experienced a similar issue where insulin was discontinued without proper documentation or physician approval. The resident, who was diabetic and unable to provide an accurate medical history, was admitted with a sliding scale insulin order that was discontinued the following day. The facility staff failed to review the discharge medications from the hospital, leading to a gap in the resident's diabetes management. Additionally, Resident #9 and Resident #57 were not monitored appropriately for their chronic conditions. Resident #9, with high cholesterol and diabetes, did not have routine lab tests ordered to evaluate the effectiveness of their treatment. Similarly, Resident #57, admitted with diabetes, had not had an A1c test since admission, despite the requirement for biannual testing. These oversights highlight a failure in the facility's process for ensuring routine monitoring and physician oversight of residents' medical conditions.
Failure to Conduct Annual GNA Performance Reviews
Penalty
Summary
The facility failed to conduct yearly performance reviews for Geriatric Nursing Assistants (GNAs) at least every 12 months, as required. This deficiency was identified during a review of personnel files and staff interviews, affecting five GNAs (Staff #29, #31, #32, #33, #34) who had been employed for more than 12 months. The surveyor found no documentation of annual performance reviews in the employee files of these staff members. The Director of Nurses (DON) confirmed that performance reviews and competency evaluations had not been completed since she assumed her role.
Failure to Maintain Daily Nurse Staffing Data
Penalty
Summary
The facility staff failed to maintain the posted daily nurse staffing data for a minimum of 18 months, as required by State law. During a review for sufficient and competent nurse staffing, it was found that the Daily Staffing Reports for February 2024 were incomplete, with missing reports for 16 out of 29 days. The surveyor requested these reports on August 1, 2024, but the facility was unable to provide them for the specified dates. The issue was discussed with the Director of Nurses and the Regional Director for Clinical Operations, who acknowledged the concerns. Despite further requests, only one additional report dated February 28, 2024, was provided before the surveyor's exit on August 5, 2024.
Inconsistent Monitoring and Documentation of Resident Behaviors
Penalty
Summary
The facility failed to ensure consistent monitoring and documentation of a resident's behaviors, specifically for a resident who frequently placed themselves on the floor. On two separate occasions, the resident was observed lying on the floor, once near the nursing station and once in the hallway near their room, without staff present. The care plan for the resident acknowledged this behavior, indicating that the resident was comfortable on the floor and dependent on staff for needs. However, the Treatment Administration Record (TAR) did not include lying on the floor as a behavior to be documented, and the record for the day in question incorrectly marked that no behaviors were observed. Interviews with facility staff, including the Assistant Director of Nursing (ADON) and the Director of Nursing (DON), revealed confusion among nurses, particularly agency nurses, regarding the documentation of resident behaviors. The Geriatric Psychiatric Nurse Practitioner also noted a lack of documentation, which impacted medication management. The DON confirmed that the expectation was for nurses to document behaviors on the TAR and provide detailed progress notes if behaviors were observed. However, there was no confirmation that nurses received education on behavior charting, leading to inconsistent documentation practices.
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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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