Crescent Cities Nursing & Rehabilitation Center
Inspection history, citations, penalties and survey trends for this long-term care facility in Riverdale, Maryland.
- Location
- 4409 East West Highway, Riverdale, Maryland 20737
- CMS Provider Number
- 215323
- Inspections on file
- 17
- Latest survey
- September 12, 2025
- Citations (last 12 mo.)
- 9
Citation history
Health deficiencies cited at Crescent Cities Nursing & Rehabilitation Center during CMS and state inspections, most recent first.
A resident suffered a right femur fracture after being struck by a Hoyer lift during a transfer, due to the facility's failure to ensure safe transfer practices. Despite the resident expressing fear of the lift, the incident was not reported or documented by staff, and no investigation was conducted. The facility's policies on reporting and using mechanical lifts were not followed, and training on lift use was inadequate.
The facility failed to provide palatable and appropriately tempered meals to residents, as evidenced by consistent complaints about cold and unappetizing food. Observations revealed delays in meal delivery due to inadequate equipment and staffing, with trays left on carts for extended periods. The Dietary Manager noted issues with heating equipment, and the Administrator acknowledged the need for improvements.
A cognitively impaired resident was not offered an alternate meal despite showing clear signs of disliking the served pureed meal. The Unit Manager did not follow the facility's policy to offer alternatives, although alternate options were available. The resident eventually received a preferred meal after staff intervention.
A resident with multiple pressure ulcers and deep tissue injuries was not provided with a recommended vascular consult and doppler exam, as identified during a survey. Despite the wound care team's recommendation and the facility staff's awareness, the necessary follow-up was not completed, leading to a deficiency.
A facility failed to maintain accurate medical records when an LPN marked a stool specimen collection task as completed for a resident, despite the task not being performed due to the resident not having a bowel movement. This discrepancy was confirmed by the Regional Clinical Nurse, who noted that a check sign on the TAR indicates task completion.
A resident admitted for subacute rehabilitation services was improperly discharged to another facility without adequate documentation or agreement. Despite expressing a desire to return home and having decision-making capacity, the resident was transferred without a discharge care plan or proper notification to their representative. The facility's Director of Social Services cited safety concerns and Medicaid application issues, but no documentation supported a resident-initiated discharge or agreement with the transfer.
A facility failed to issue a 30-day transfer notice to a resident before transferring them to another facility. The resident received a Notice of Medicare Non-Coverage indicating benefits would end soon, but was discharged without initiating or agreeing to the transfer. Interviews confirmed the resident wanted to return home, not be transferred.
A facility failed to provide adequate discharge planning for a resident admitted for aftercare of a right femoral fracture, high blood pressure, and cardiomyopathy. Despite plans for the resident to return home and being ordered occupational and physical therapy, the facility did not initiate a discharge care plan. Interviews revealed that the Discharge Planner discussed discharge and insurance benefits but was not responsible for the care plan, and the Director of Social Services confirmed the care plan was not initiated upon admission.
A facility failed to adequately monitor a resident's pain, leading to delayed treatment for a fractured ankle. The resident, who was non-verbal and had memory issues, did not have an alternative pain scale available for accurate pain assessment. The MAR lacked documentation for pain scores, preventing effective pain management.
The facility failed to maintain a medication error rate below five percent, with errors observed during medication administration for two residents. One resident received Plaquenil without proper timing confirmation, and another received sucralfate after eating and insulin at the wrong time. Staff did not adhere to the facility's medication administration policy.
The facility failed to ensure proper PPE use during wound care for a resident on Enhanced Barrier Precautions, as staff did not wear gowns. Additionally, an LPN improperly handled medication by administering a pill that had been dropped onto the medication cart. Both incidents were confirmed by staff and acknowledged by the Infection Preventionist.
A resident with severe cognitive impairment was not treated with dignity during meals. Staff stood over the resident while feeding, did not offer an alternate meal when the resident spat out food, and left a tube of A&D Ointment near the meal tray. The resident eventually received a preferred alternate meal after staff intervention.
The facility failed to properly review and document admission agreements for two residents, one with severe cognitive impairment and another unable to participate in the assessment. In both cases, the signatures and initials on the admission contracts were inconsistent and could not be verified, and the responsible employees were no longer employed at the facility.
A facility failed to ensure the correct person was identified to make medical treatment decisions on a MOLST form. A resident's initial request for full code status was changed to 'do not resuscitate/do not intubate' based on a surrogate decision maker's choice, despite the resident's initial wishes. The change was documented as discussed with the resident and family, although the resident was certified incapable of making medical decisions. The facility social worker acknowledged the inappropriate change.
The facility failed to report injuries of unknown origin for two residents within the required timeframes. One resident with a dislocated hip was reported to the SSA a day late, and the follow-up report was submitted eight days after the injury was discovered. Another resident's injury was not reported at all, as the facility believed they knew the cause. These actions violated the facility's policy and regulatory requirements for timely reporting.
The facility failed to thoroughly investigate injuries of unknown origin for two residents, as investigations lacked interviews with other residents to assess potential abuse or neglect by staff. One resident had a dislocated right hip with a comminuted fracture, and another sustained a right ankle fracture, but the causes were undetermined. The DON and Administrator confirmed the absence of resident interviews in the investigations.
The facility failed to follow physician orders and document care for two residents. One resident did not receive a dental consult despite a physician's order, and behavior monitoring was inadequately documented. Another resident's stool sample was not collected for analysis as ordered. The DON acknowledged these issues but could not provide explanations or solutions.
The facility's failure to update its Facility Assessment annually resulted in outdated staff and resident information, with the last update on February 6, 2023, and resident data from January 2022. This could negatively impact all 151 residents by not accurately assessing their current needs. The Administrator and RDO confirmed the need for current information.
Failure to Ensure Safe Transfer Leads to Resident Injury
Penalty
Summary
The facility failed to ensure the safe transfer of a resident, identified as R44, using a mechanical lift, resulting in a right femur fracture. R44, who was cognitively intact and required substantial assistance with transfers, was struck by a Hoyer lift, leading to the fracture. Despite R44 expressing fear of the lift due to a previous incident, this concern was not adequately addressed or documented by the staff. The incident was not reported to the Director of Nursing (DON) or the Administrator, and no investigation was initiated at the time of the incident. The facility's policies required that any unusual occurrences be reported and documented, and that mechanical lifts be used by two trained staff members. However, these protocols were not followed. LPN1, who was informed of the incident by a Geriatric Nursing Assistant (GNA), failed to report the incident or document an assessment of R44. The facility's records showed no evidence of an assessment or investigation into the incident, and the DON was unaware of the fracture until much later. Interviews with staff revealed a lack of communication and documentation regarding the incident. The Nurse Practitioner (NP) and other staff members did not report the fracture to the administration, and the facility did not conduct a root cause analysis. Additionally, the facility's training on mechanical lifts was insufficient, as it was not included in annual competency checks, contributing to the unsafe transfer and subsequent injury of R44.
Removal Plan
- Training on the use of mechanical lifts
- Reporting accidents/incidents to the Administrator or Director of Nursing
- Ongoing monitoring and evaluation
Deficiency in Food Palatability and Temperature
Penalty
Summary
The facility failed to serve food that was palatable, attractive, and at a safe and appetizing temperature for five residents reviewed for food palatability. This deficiency was identified through observations, interviews, and reviews of Resident Council Minutes and facility policies. The facility's policy required meals to be delivered within 30 minutes to maintain food quality and temperature, but residents consistently reported issues with food being cold, overcooked, or unappetizing. Specific complaints included cold eggs, burnt toast, and hard waffles, with residents expressing dissatisfaction with the lack of variety in meal alternatives. Observations and interviews revealed systemic issues in meal delivery, including inadequate equipment and staffing. The Dietary Manager noted that the heating machine lacked necessary pellets to keep food warm, and the Unit Manager reported insufficient staff to promptly serve meals. This resulted in delays, with trays observed sitting on serving carts for extended periods before being served to residents. The Administrator acknowledged the expectation for meals to be served promptly but noted that new equipment to maintain food temperature had not yet been implemented.
Failure to Offer Alternate Meal to Cognitively Impaired Resident
Penalty
Summary
The facility failed to provide an alternate meal to a severely cognitively impaired resident, identified as R23, during a meal observation. R23, who had a BIMS score of five out of 15, indicating severe cognitive impairment, was observed spitting out each bite of the pureed meal being fed by the Unit Manager. Despite the resident's clear dislike for the meal, the Unit Manager did not offer an alternate meal, as per the facility's policy, which requires nursing staff to offer alternatives if a resident does not eat at least 25% of their meal or refuses food. The Assistant Dietary Manager later confirmed that there were alternate pureed meal options available, such as a pureed hamburger or hotdog, which R23 expressed a preference for. The resident eventually received the alternate meal and expressed satisfaction with it. Interviews with staff, including a Geriatric Nursing Assistant and the facility's Administrator, confirmed that alternate meals should be offered to residents who do not like their food, highlighting a lapse in adherence to the facility's meal delivery policy.
Failure to Follow Up on Recommended Vascular Consult
Penalty
Summary
The facility staff failed to follow up with outside resources for the care of a resident, leading to a deficiency identified during a recertification/complaint survey. The resident, who had multiple pressure ulcers and deep tissue injuries of the left foot, was assessed by the facility wound physician. The wound care team recommended a vascular consult with a doppler exam for further evaluation of the resident's vascular condition. Despite the facility staff being aware of this recommendation, the necessary vascular consult and doppler study were not completed. This oversight was confirmed during a review of the resident's medical record and interviews with the facility's Director of Nursing and Consultant Nurse.
Inaccurate Documentation of Stool Specimen Collection
Penalty
Summary
The facility failed to maintain complete and accurate medical records for Resident #513, as evidenced during a revisit survey. On January 8, 2025, a review of the resident's treatment administration record (TAR) showed that a stool specimen collection task was marked as completed on January 3, 2025, by LPN #13. However, an interview with the Nursing Home Administrator on January 9, 2025, revealed that the stool specimen was never collected because the resident did not have a bowel movement. This discrepancy was confirmed by the Regional Clinical Nurse, who stated that a check sign on the TAR indicates task completion, highlighting that LPN #13 inaccurately documented the task as completed.
Improper Resident Discharge Without Adequate Documentation
Penalty
Summary
The facility failed to permit a resident to stay in their facility without adequate reason and documentation, leading to a deficiency. The resident, admitted for subacute rehabilitation services, expressed a desire to return home, as documented in a psychological assessment and care plan note. Despite having the capacity to make decisions, the resident was issued a Notice of Medicare Non-Coverage and subsequently transferred to another facility for assisted living, although the discharge summary inaccurately stated the resident was transferred to an assisted living facility. The resident's representative was not informed of the discharge until after it occurred, and the resident was confused about the transfer, having wanted to return home. The facility's Director of Social Services reported that the resident was not able to discharge safely home due to a lack of community support and unwillingness to sign over assets for Medicaid application. However, there was no documentation of a resident-initiated discharge, agreement with the discharge, or a transfer notice. Additionally, the surveyor found no discharge care plan in the electronic medical record, despite claims from the Director of Social Services that one had been initiated. The Discharge Planner confirmed that the resident had expressed a desire to go home, not to another facility.
Failure to Provide 30-Day Transfer Notice
Penalty
Summary
The facility failed to issue a 30-day transfer notice to a resident prior to transferring them to another facility. This deficiency was identified during a recertification/complaint survey for one of the two residents reviewed for discharge. A record review revealed that the resident had been issued a Notice of Medicare Non-Coverage (NOMNC) on September 6, 2024, indicating that their benefits would end on September 11, 2024. The resident was subsequently discharged to another facility on September 10, 2024, without documentation of the resident initiating the transfer, agreeing to it, or receiving a 30-day discharge/transfer notice. Interviews with the Director of Social Services and the Discharge Planner confirmed that the discharge was not initiated by the resident, who had expressed a desire to return home rather than be transferred to another facility. The Nursing Home Administrator was made aware of these concerns during the survey.
Failure to Initiate Discharge Care Plan for Resident
Penalty
Summary
The facility failed to provide adequate discharge planning for a resident, identified as Resident #829, during a recertification/complaint survey. The deficiency was identified when a complaint was reviewed, revealing concerns about the facility's failure to provide a discharge date for the resident. The medical record review showed that a discharge planning progress note was written by the Discharge Planner, indicating the plan for the resident to return home upon discharge. However, despite the resident being admitted for aftercare of a right femoral fracture, high blood pressure, and cardiomyopathy, and being ordered occupational and physical therapy, the facility did not initiate a discharge care plan. This care plan is essential for setting discharge goals and implementing interventions to help the resident achieve those goals. Interviews with facility staff further highlighted the deficiency. The Discharge Planner confirmed that while she discussed discharge and insurance benefits with the resident, she was not responsible for initiating the discharge care plan. The Director of Social Services, who was not employed at the facility at the time of the resident's admission, confirmed that a discharge care plan should have been initiated upon admission but was not. These findings were reviewed with the Nursing Home Administrator, confirming the lack of a discharge care plan for the resident.
Inadequate Pain Management and Monitoring
Penalty
Summary
The facility failed to provide adequate monitoring of a resident's pain, resulting in delayed treatment for a fractured right ankle. The deficiency was identified during a recertification/complaint survey for one of the 39 residents reviewed. The Medication Administration Record (MAR) for the resident did not include a space for nursing staff to document the resident's pain score at the time of assessment, which is crucial for monitoring and managing pain effectively. This lack of documentation prevented the healthcare team from accurately assessing the resident's pain and potentially contributed to the delay in identifying and treating the fracture. The resident in question was admitted with long and short-term memory issues and was non-verbal, necessitating the use of an alternative pain scale. However, the facility did not provide such a tool, which should have included observations of facial grimaces and behavior to assess pain levels. Interviews with the Director of Nursing and the Nurse Practitioner confirmed the absence of an alternative pain scale and the necessity for one, given the resident's inability to verbalize pain. This oversight in pain management documentation and assessment led to the resident's pain being inadequately monitored and treated.
Medication Administration Errors Exceed Acceptable Rate
Penalty
Summary
The facility failed to maintain a medication error rate of less than five percent, resulting in a 9.68% error rate during a medication pass observation. This deficiency was identified through observations, interviews, and record reviews. Specifically, three errors were observed out of 31 opportunities, which had the potential to impact two residents. The facility's policy on medication administration, which includes reviewing the five rights of medication administration, was not adhered to by the staff. One resident, who was readmitted with a diagnosis of systemic lupus erythematosus, was prescribed Plaquenil to be taken in the evening. However, a Certified Medicine Assistant administered the medication without confirming the correct timing or understanding the medication's purpose. Another resident, with diagnoses including diabetes mellitus and gastric protection, was prescribed sucralfate to be taken on an empty stomach and insulin glargine at bedtime. The Licensed Practical Nurse administered sucralfate after the resident had eaten and gave insulin in the morning instead of at bedtime, indicating a lack of awareness of the specific administration instructions.
Inadequate PPE Use and Medication Handling
Penalty
Summary
The facility failed to ensure that staff wore the appropriate personal protective equipment (PPE) during wound care for a resident on Enhanced Barrier Precautions (EBP). The resident, who had a history of clostridioides difficile colitis and a nephrostomy tube, required the use of gown and gloves during high-contact care activities. However, during an observation, neither the Licensed Practical Nurse (LPN) nor the Geriatric Nursing Assistant (GNA) wore gowns while performing wound care. Both staff members confirmed the omission, and the facility's Infection Preventionist acknowledged that gowns should have been worn. Additionally, during a medication administration, an LPN was observed dropping a pill onto the medication cart and then placing it back into the medication cup before administering it to a resident. The LPN confirmed the action, and the Director of Nursing stated that dropped medications should be disposed of and replaced. The Infection Preventionist also confirmed that medications dropped during administration should not be given to residents.
Failure to Maintain Resident Dignity During Meals
Penalty
Summary
The facility failed to ensure that a resident was treated with dignity and respect during meals. The resident, who was severely cognitively impaired and had a history of depression and cerebrovascular accident, was observed calling for help while lying in bed with a meal tray in front of them. The resident's meal tray was placed next to a large tube of A&D Medicated Ointment, which is used for incontinent care, and should not have been left near food. Staff confirmed that the ointment should not be at the bedside, especially near food, and removed it. During the meal, the Unit Manager stood over the resident while attempting to feed them, which is against the facility's practice of sitting down and making eye contact with residents during feeding. The Unit Manager did not offer the resident an alternate meal when the resident repeatedly spat out the food, despite the availability of alternate pureed meal options. The resident expressed a preference for a pureed hamburger, which was eventually provided after the Assistant Dietary Manager confirmed the availability of alternate meals. Interviews with various staff members, including a Certified Medicine Aide, Geriatric Nursing Assistant, and Licensed Practical Nurse, reiterated the importance of sitting down to feed residents and not leaving ointments near food. The facility's Administrator and Assistant Director of Nursing also confirmed these practices, emphasizing the need to offer meal alternatives and maintain dignity during feeding.
Failure to Properly Review and Document Admission Agreements
Penalty
Summary
The facility failed to provide and review admission agreements with the appropriate resident or representative for two residents during a recertification/complaint survey. The first resident, admitted in early February 2024, was assessed with a Brief Interview of Mental Status (BIMS) score of '00', indicating severe cognitive impairment. Despite having an identified representative, the admission contract was electronically signed with initials that did not match either the resident or the representative. The Admissions Director was unable to verify the signature, and the employee responsible for completing the form was no longer employed at the facility. The second resident was noted to be unable to participate in the admission assessment due to mental status and was only oriented to 'self'. The admission contract contained neatly entered initials on one page and an illegible signature on another, which did not match, raising concerns about the validity of the signature. The resident was not identified as their own representative, and the person who should have received the admission contract was not properly documented. The discrepancies were confirmed by the Administrator and Admissions Director, and the responsible employee was no longer with the facility.
Incorrect Surrogate Decision Making on MOLST Form
Penalty
Summary
The facility failed to ensure the correct person was identified to make medical treatment decisions on the Maryland Order for Life Sustaining Treatment (MOLST) form for Resident #818. Upon admission in October 2022, the resident's MOLST form indicated a full code status, reflecting the resident's request for cardiopulmonary resuscitation (CPR). However, a subsequent MOLST form was completed, changing the resident's status to 'do not resuscitate/do not intubate' based on the surrogate decision maker's choice, despite the resident's initial wishes. The change was documented as having been discussed with the resident and family, although the resident was certified incapable of making medical decisions. The facility social worker acknowledged the inappropriate change during an interview.
Failure to Timely Report Injuries of Unknown Origin
Penalty
Summary
The facility failed to report an injury of unknown origin for Resident 18 within the required two-hour timeframe and did not submit the investigative results within five working days to the State Survey Agency (SSA). Resident 18, who was admitted with a right femur fracture and cognitive communication deficit, was found to have a dislocated right hip with comminuted fracturing of the proximal right femur. The facility became aware of this injury on July 23, 2024, but did not report it to the SSA until July 24, 2024, at 6:00 PM, which was one day after the injury was discovered. Furthermore, the follow-up investigation report was submitted eight days after the facility learned of the injury, exceeding the five-day requirement. In another instance, the facility did not report an injury of unknown origin for Resident 807 to the state agency. On April 3, 2023, a nurse observed a dark discoloration on the resident's right upper arm, but the resident could not explain how it occurred. The Director of Nursing (DON) later provided investigation documents, including staff statements and a root cause analysis, but there was no evidence that the injury was reported to the state agency. The DON explained that the injury was not reported because the facility believed they knew how it occurred, based on a Geriatric Nursing Assistant's (GNA) statement about the resident's behavior. The Director of Nursing confirmed that the initial and five-day summary reports for Resident 18 were submitted late, and the injury for Resident 807 was not reported at all. These failures to report injuries of unknown origin in a timely manner are contrary to the facility's policy and regulatory requirements, which mandate immediate reporting to the state agency within two hours for serious injuries and within five days for investigative results.
Failure to Investigate Injuries of Unknown Origin
Penalty
Summary
The facility failed to thoroughly investigate injuries of unknown origin for two residents during a recertification/complaint survey. For one resident, who was admitted with a right femur fracture and cognitive impairments, an x-ray revealed a dislocated right hip with comminuted fracturing of the proximal right femur. Despite the severity of the injury, the facility's investigation did not include interviews with other residents to determine if there was any abusive or neglectful treatment by staff. The Director of Nursing confirmed that resident interviews were not conducted as part of the investigation. Similarly, another resident sustained a fracture to the right ankle, but the facility was unable to determine the cause or timing of the injury. The investigation into this incident also lacked interviews with other residents to assess potential abuse or neglect by facility staff. The Administrator confirmed that the investigation did not include resident interviews to rule out staff misconduct, indicating a failure to adhere to the facility's policy on thoroughly investigating injuries of unknown origin.
Failure to Follow Physician Orders and Document Care
Penalty
Summary
The facility staff failed to provide treatment and care in accordance with professional standards for two residents during a recertification/complaint survey. For one resident, the medical record indicated a change in condition with swelling in the right lower jaw, prompting a physician's order for a dental consult. However, there was no documentation of the dental consult being obtained, and the Director of Nursing (DON) could not provide evidence of the consult or explain the lack of documentation. Additionally, the same resident had orders for behavior monitoring, but the Medication Administration Records (MAR) lacked detailed documentation of observed behaviors, interventions, and outcomes as required by the physician's order. The DON acknowledged a systems error but could not clarify how nurses were expected to document behaviors under these circumstances. For another resident, the facility failed to follow a physician's order to obtain and send a stool sample for laboratory analysis to investigate the cause of constipation. The electronic medical record review revealed no evidence of the stool sample being collected and sent for analysis, which was confirmed by the DON. These deficiencies highlight lapses in following physician orders and maintaining accurate documentation, impacting the quality of care provided to the residents.
Outdated Facility Assessment and Resident Data
Penalty
Summary
The facility failed to update its Facility Assessment annually, which is necessary to ensure that the resources required to care for residents are accurately determined. The most recent update to the Facility Assessment was on February 6, 2023, and it did not include current staff names or accurate resident assessments. The resident data included in the assessment was outdated, reflecting Minimum Data Set (MDS) data from January 1, 2022, to January 30, 2022. This oversight could negatively impact all 151 residents by not adequately assessing and determining their current needs. During an interview, the Administrator and the Regional Director of Operations acknowledged the outdated nature of the Facility Assessment and the necessity for current resident information to provide appropriate care.
Latest citations in Maryland
The facility did not ensure that its Infection Preventionist (IP) met required qualifications for managing the Infection Prevention and Control Program. The DON reported serving as the IP but acknowledged lacking the specialized infection control training required for the role, and confirmed that no other staff member was currently qualified. Records showed that the previously qualified IP left several months earlier, and the Administrator and DON confirmed they were still seeking a replacement, leaving the infection control program without a properly trained leader.
Staff failed to consistently secure medications and medical supplies across three units, including an oxygen tank left on the floor behind a resident’s bed without a supporting device, a treatment cart with Collagenase Santyl cream left on top while two residents in power wheelchairs passed by, an unattended and unlocked treatment cart at a nursing station, and another treatment cart with Diclofenac gel and dressings left on top, indicating repeated lapses in maintaining locked and secure storage for drugs, biologicals, and related supplies.
The facility failed to provide sufficient dietitian coverage and timely nutritional assessments for several residents with significant dietary needs. A resident admitted for diabetic management with a high A1C was placed on a regular diet instead of the recommended carb-controlled diet and had only one weight taken in the first two weeks, with no dietitian review of the record. Another resident with prior significant weight loss had no documented dietitian follow-up despite continued weight loss, and a resident admitted with severe protein-calorie malnutrition experienced further significant weight loss without any dietitian assessment. The dietitian reported working limited hours and prioritizing certain high-risk cases, resulting in delayed or missed evaluations for new admissions and residents with ongoing nutritional concerns.
The facility failed to maintain adequate linen and incontinence supplies and did not keep resident care areas in good repair, resulting in delays and alterations in incontinence care and substandard environmental conditions. Staff reported that towels and washcloths were used instead of wipes and then discarded due to heavy soiling, and that linen deliveries to units were late, leaving residents waiting for care. Observations showed very limited numbers of clean washcloths and other linens on units and in the laundry, with no stock of disposable wipes or backup washcloth supply despite repeated reports to housekeeping. Additional observations revealed recliner chairs blocking a dining-area handwashing sink and kitchenette, multiple resident and shared bathrooms with unfinished spackle, chipped paint, musty odors, black substances near showers, missing threshold molding, exposed cracks and nails, and eroded, rusted baseboard heaters. Hallway handrails on both units were worn, chipped, and splintered, and a shower room contained fecal odors, dried brown stains on the toilet, and deteriorated fixtures, all contributing to a failure to provide a safe, clean, and homelike environment.
Surveyors found that the facility failed to develop and implement comprehensive care plans for two residents. One resident used a motorized wheelchair and had a documented safety assessment and an ED note describing a leg injury that occurred while using the device, yet the care plan contained no documentation or interventions related to motorized wheelchair use. Another resident had a documented diagnosis of PTSD and a history of childhood sexual abuse, and while the care plan noted trauma as a focus, it listed no specific interventions to address PTSD or the trauma history.
Surveyors identified that the facility failed to revise person-centered care plans after significant changes in two residents’ conditions. For one resident, the MOLST and paper chart were updated from Full Code to DNR-B with No CPR and palliative/supportive care orders, but the care plan continued to list the resident as Full Code. For another resident who sustained a fall with injuries and was sent to the ER, the existing fall-prevention care plan was not updated to reflect the incident or any new interventions, and no timely review was documented. During interviews, the rehab director reported that therapy provides recommendations after falls but does not revise care plans, and the DON and regional administrator confirmed that no care plan revisions or fall investigation documentation were available.
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.
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.
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 Develop Comprehensive Care Plans for Motorized Wheelchair Use and PTSD
Penalty
Summary
Surveyors identified a failure to develop and implement comprehensive care plans for two residents. For one resident who used a motorized wheelchair, interviews with the DON, Administrator, and Occupational Therapist confirmed that the resident had a power mobility device and that a safety assessment for its use had been completed by therapy. The resident’s medical record included an Emergency Department physician note documenting the resident’s report that they were in their motorized wheelchair when they sustained a leg skin tear or laceration after running into their bed. The facility’s matrix and records showed the resident had been admitted and later discharged, and a power mobility indoor driving assessment dated several months prior was provided. Despite this information and the confirmed use of a motorized wheelchair, review of the resident’s care plan showed no documentation addressing the resident’s use of a motorized wheelchair. For another resident, record review showed documentation in the facility matrix and in a Quarterly MDS that the resident had a medical diagnosis of post-traumatic stress disorder (PTSD) and a history of trauma related to childhood sexual abuse. The resident’s care plan focus reflected this trauma history; however, the only listed intervention for that focus was the word “trauma,” with no specific interventions identified to address the PTSD diagnosis or trauma history. During an interview, the Nursing Home Administrator was informed that the resident had a PTSD diagnosis, but the surveyor could not locate any detailed interventions in the care plan beyond the generic trauma notation.
Failure to Revise Care Plans After Code Status Change and Resident Fall
Penalty
Summary
The deficiency involves the facility’s failure to ensure person-centered care plans were timely updated and revised by the interdisciplinary team following significant changes in residents’ status and events. For one resident, a social services note documented that the Maryland MOLST was reviewed and changed from Full Code to DNR-B on a specified date, and the paper chart contained a MOLST form with orders for No CPR, Option B, Palliative and Supportive Care. However, the resident’s care plan still contained a focus stating that the resident’s Full Code MOLST would remain in place through the review date, and this care plan was not revised to reflect the updated code status. During record review with the Nursing Home Administrator, it was confirmed that the MOLST had been updated but the care plan had not been revised accordingly. The deficiency also includes the facility’s failure to revise a resident’s care plan after a fall event. A progress note by an LPN documented that another resident experienced a fall, sustained several injuries, and was transferred to the emergency room. Review of this resident’s care plan showed that no revisions were made to the existing fall interventions in response to the fall, and the care plan was not documented as reviewed and revised until a later date. During interviews, the Director of Rehabilitation stated that therapy makes recommendations and sees residents after falls but does not revise the care plan and was unsure if nursing was responsible for care plan revisions. The DON and Regional Administrator confirmed that no care plan revisions had been made in response to the fall and that there was no recollection or documentation of a fall investigation.
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.
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.
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