Deer's Head Center
Inspection history, citations, penalties and survey trends for this long-term care facility in Salisbury, Maryland.
- Location
- 351 Deer's Head Hospital Road, Salisbury, Maryland 21801
- CMS Provider Number
- 215132
- Inspections on file
- 15
- Latest survey
- December 16, 2025
- Citations (last 12 mo.)
- 10
Citation history
Health deficiencies cited at Deer's Head Center during CMS and state inspections, most recent first.
The facility failed to protect residents from abuse, with incidents involving staff and resident interactions. A GNA physically and verbally abused a resident with dementia, and another staff member verbally abused a resident by cursing and ignoring requests for assistance. Additionally, a resident-to-resident physical abuse incident occurred, with inadequate documentation and preventive measures.
The facility failed to report abuse incidents to the state agency within the required timeframe. In one case, a GNA abused a resident, and the report was delayed by 21 hours. Another incident involved a resident feeling mistreated, with the report also delayed. A third case of resident-to-resident abuse was reported late, with insufficient documentation. These actions violated the facility's policy requiring reports within 2 hours of discovery.
A GNA verbally and physically abused a resident during transport to the shower. Despite the incident being reported, the GNA continued to work with the resident and on the unit for the rest of the day. The facility's policy requires immediate removal of staff involved in abuse allegations, but this was not followed, leading to a deficiency in protecting the resident.
A resident was transferred to the hospital without receiving the required written notice of transfer. The facility staff informed the resident's representative verbally, but there was no documentation of a written notice being provided. This deficiency was identified through a review of medical records and interviews with staff and the resident's family.
A facility failed to inform a resident and their representative of the bed hold policy during a hospital transfer. Staff interviews revealed that the policy was only discussed at admission and not provided in writing during transfers. This deficiency was identified when a resident was transferred to the hospital for a change in mental status, and the bed hold policy was not communicated.
A resident with dementia was administered Quetiapine, a psychotropic medication contraindicated for dementia patients, without proper documentation of a gradual dose reduction (GDR) or monitoring for side effects. The facility's medical staff failed to provide evidence of a GDR, and the resident's behavioral issues were not adequately monitored, leading to a deficiency finding.
The facility failed to maintain a medication error rate below 5%, with errors involving two residents and two staff members. An RN administered acetaminophen against the physician's order for a resident with a pain level of 7/10, and an LPN administered medications 1 hour and 27 minutes late. The facility's Medication Management Policy defines such discrepancies as medication errors.
A facility failed to ensure staff donned appropriate PPE when transferring a resident under Enhanced Barrier Precautions (EBP) due to a history of MRSA. Unit Manager and Geriatric Nursing Assistant were observed transferring the resident without gowns, despite EBP signage instructions. Errors in the facility matrix regarding the resident's precautions were acknowledged by the Assistant Director of Nursing.
Failure to Protect Residents from Abuse
Penalty
Summary
The facility failed to protect residents from abuse, as evidenced by multiple incidents involving both staff and resident interactions. In one case, a Geriatric Nursing Assistant (GNA) physically and verbally abused a resident with severe cognitive impairment during a transport to the shower. The resident, who was unable to communicate effectively due to vascular dementia, was yelled at and physically manipulated by the GNA after an incident of incontinence. This abuse was witnessed by other staff members, and the GNA was eventually terminated. However, the facility did not document any immediate assessment or follow-up on the resident's condition after the incident. Another incident involved a staff member verbally abusing a resident by turning off the call light and cursing at the resident without providing the requested assistance. The resident, who had previously experienced another verbal altercation with a different staff member, reported the incident, and the staff member was placed on administrative leave. Despite the resident's denial of current abuse, the facility's handling of the situation was inadequate, as there was a lack of immediate removal of the staff member from the unit. Additionally, the facility failed to prevent a resident-to-resident physical abuse incident. A resident with a history of dementia entered another resident's room and physically assaulted them with a call bell cord, resulting in minor injuries. The facility's documentation was insufficient, lacking staff witness statements and progressive notes on the victim's condition. The facility's response to the incident was inadequate, as there was no evidence of measures taken to prevent such occurrences in the future.
Failure to Timely Report Abuse Incidents
Penalty
Summary
The facility failed to report instances of abuse to the state agency within the required timeframe. In the first incident, a Geriatric Nursing Assistant (GNA) verbally and physically abused a resident after the resident defecated on the floor. This incident was witnessed by multiple staff members, including another GNA and two registered nurses. Despite the immediate awareness of the incident by the Assistant Director of Nursing (ADON), the self-report to the state agency was not filed until 21 hours later, contrary to the facility's policy that requires a report within 2 hours of discovery. In the second incident, a resident reported feeling like they were treated as 'a sack of potatoes' by staff, which they considered 'assault and battery.' The Nursing Home Administrator (NHA) was informed of this allegation, but the report to the state agency was delayed beyond the 2-hour requirement. The facility's policy clearly states that any allegation of abuse should be reported within 2 hours, yet this was not adhered to. The third incident involved resident-to-resident physical abuse, where one resident hit another with a call bell cord, resulting in minor injuries. The initial report to the state agency was submitted the following day, but the final report exceeded the 5-day submission timeframe. Additionally, there was a lack of documentation regarding the incident, including statements from staff or other residents, and no progressive notes or change of condition documentation related to the injuries sustained by the victim.
Failure to Protect Resident During Abuse Investigation
Penalty
Summary
The facility failed to protect residents from an alleged perpetrator during an abuse investigation. On 5/30/23, a Geriatric Nursing Assistant (GNA) was involved in an incident with a resident during which the resident defecated on the floor. The GNA responded by yelling at the resident and physically turning the resident's head to the floor, which was witnessed by other staff members. The investigation confirmed verbal and physical abuse by the GNA, who was eventually terminated and reported to the board of nursing. However, the GNA continued to work with the resident and on the unit for the rest of the day, despite the incident being reported to the Assistant Director of Nursing (ADON) shortly after it occurred. The facility's abuse prevention policy states that an employee involved in a staff-to-patient abuse allegation should be removed from patient care immediately. However, the ADON did not remove the GNA from the unit, citing that only Human Resources could relieve an employee from duty. The Chief Nursing Officer later indicated that the GNA should have been placed on administrative leave pending investigation. The GNA was placed on administrative leave the following day, but no evidence was found that the GNA's assignment or work hours changed on the day of the incident, indicating a failure to adhere to the facility's policy and protect the resident from further potential harm.
Failure to Provide Written Notice of Hospital Transfer
Penalty
Summary
The facility failed to provide written notice of transfer to a resident or their representative, as required by regulations. This deficiency was identified during a review of medical records and interviews with facility staff and the resident's family. Specifically, the issue was noted for a resident who was transferred to the hospital due to a change in mental status. A nursing progress note indicated that the resident's representative was informed verbally, but there was no documentation of a written notice being provided at the time of transfer. Interviews with facility staff revealed that the protocol for hospital transfers involved verbal communication with the resident's family, typically via phone calls, and documentation in the electronic record. However, there was no evidence of a written notice being given to the resident or their representative. The resident's representative confirmed that they were only informed verbally about the transfer and had never received written notification, which was consistent with past hospitalizations. This lack of written notification constitutes a failure to comply with regulatory requirements for resident transfers.
Failure to Communicate Bed Hold Policy During Hospital Transfers
Penalty
Summary
The facility failed to implement a process to ensure that residents and their representatives were informed of the bed hold policy upon transfer to a hospital. This deficiency was identified during a review of medical records and interviews with facility staff, specifically concerning a resident who was transferred to the hospital due to a change in mental status. The nursing progress note documented by a registered nurse indicated that the resident's representative was informed of the transfer, but there was no mention of the bed hold policy being communicated. Interviews with various staff members, including a registered nurse, the Assistant Director of Nursing, and a licensed social worker, revealed that the bed hold policy was not provided to residents or their families at the time of hospital transfer. The Assistant Director of Nursing confirmed that the policy was only given at the time of admission and followed upon the resident's return from the hospital. The social worker also confirmed that while the policy was discussed during admission, it was not provided in writing during hospital transfers.
Deficient Psychotropic Medication Management in Dementia Patient
Penalty
Summary
The facility was found to have administered a psychotropic medication, Quetiapine, to a resident with dementia, despite it being contraindicated for such patients. The resident, who did not have a history of schizophrenia, was observed to be excessively sedated during surveyor rounds. The medical record review revealed that the resident was prescribed Quetiapine in varying doses since April 2022, but there was no documentation of a gradual dose reduction (GDR) being attempted, as required. The facility's Medical Director and Certified Registered Nurse Practitioner (CRNP) were unable to provide sufficient documentation to verify that a GDR had been conducted, despite claims that it was attempted. Additionally, the facility failed to monitor the resident for extrapyramidal side effects associated with the psychotropic medication. The resident's behavioral report indicated episodes of resistance to care and physical aggression, yet there was no evidence of appropriate monitoring or intervention. The CRNP acknowledged the resident's behavioral issues but deferred the responsibility of behavioral monitoring to nursing staff. The lack of proper documentation and monitoring highlights the facility's failure to adhere to regulatory requirements for the use of psychotropic medications in residents with dementia.
Medication Error Rate Exceeds Acceptable Threshold
Penalty
Summary
The facility failed to maintain a medication error rate below 5 percent, as evidenced by a 31.25% error rate observed during a survey. This deficiency involved two residents and two staff members. One incident involved a Registered Nurse (RN) administering acetaminophen to a resident who reported a pain level of 7/10, despite the medication order specifying administration for pain levels between 1-6/10. The RN acknowledged the error during an interview, admitting that the medication should not have been administered as per the physician's order. Another incident involved a Licensed Practical Nurse (LPN) administering multiple medications to a resident 1 hour and 27 minutes after the scheduled time, exceeding the standard practice of administering medications within 1 hour before or after the scheduled time. The LPN confirmed the delay and noted that a note could be written in the Medication Administration Record (MAR) to explain the lateness. The facility's Medication Management Policy was reviewed, which defines a medication error as any discrepancy between the physician's order and what was administered.
Failure to Don Appropriate PPE During Resident Transfer
Penalty
Summary
The facility failed to ensure that appropriate personal protective equipment (PPE) was donned by staff when transferring a resident under Enhanced Barrier Precautions (EBP). This deficiency was identified during a survey when Unit Manager (UM) #28 and Geriatric Nursing Assistant (GNA) #35 were observed transferring Resident #4 without wearing the required gown, despite the resident's EBP order due to a history of methicillin-resistant staphylococcus aureus (MRSA). The EBP signage clearly instructed staff to wear gowns and gloves during high-contact activities, including transferring residents. During interviews, UM #28 acknowledged the oversight, admitting that she did not wear a gown and that she had informed GNA #35 of the EBP requirements. GNA #35, however, was unaware of the EBP meaning and did not don a gown during the transfer. The facility matrix provided to the survey team contained errors, including incorrect transmission-based precautions (TBP) status for Resident #4, which was later clarified as EBP. The Assistant Director of Nursing (ADON) admitted to errors in the matrix and promised to provide an updated copy.
Latest citations in Maryland
The facility did not ensure that its Infection Preventionist (IP) met required qualifications for managing the Infection Prevention and Control Program. The DON reported serving as the IP but acknowledged lacking the specialized infection control training required for the role, and confirmed that no other staff member was currently qualified. Records showed that the previously qualified IP left several months earlier, and the Administrator and DON confirmed they were still seeking a replacement, leaving the infection control program without a properly trained leader.
Staff failed to consistently secure medications and medical supplies across three units, including an oxygen tank left on the floor behind a resident’s bed without a supporting device, a treatment cart with Collagenase Santyl cream left on top while two residents in power wheelchairs passed by, an unattended and unlocked treatment cart at a nursing station, and another treatment cart with Diclofenac gel and dressings left on top, indicating repeated lapses in maintaining locked and secure storage for drugs, biologicals, and related supplies.
The facility failed to provide sufficient dietitian coverage and timely nutritional assessments for several residents with significant dietary needs. A resident admitted for diabetic management with a high A1C was placed on a regular diet instead of the recommended carb-controlled diet and had only one weight taken in the first two weeks, with no dietitian review of the record. Another resident with prior significant weight loss had no documented dietitian follow-up despite continued weight loss, and a resident admitted with severe protein-calorie malnutrition experienced further significant weight loss without any dietitian assessment. The dietitian reported working limited hours and prioritizing certain high-risk cases, resulting in delayed or missed evaluations for new admissions and residents with ongoing nutritional concerns.
The facility failed to maintain adequate linen and incontinence supplies and did not keep resident care areas in good repair, resulting in delays and alterations in incontinence care and substandard environmental conditions. Staff reported that towels and washcloths were used instead of wipes and then discarded due to heavy soiling, and that linen deliveries to units were late, leaving residents waiting for care. Observations showed very limited numbers of clean washcloths and other linens on units and in the laundry, with no stock of disposable wipes or backup washcloth supply despite repeated reports to housekeeping. Additional observations revealed recliner chairs blocking a dining-area handwashing sink and kitchenette, multiple resident and shared bathrooms with unfinished spackle, chipped paint, musty odors, black substances near showers, missing threshold molding, exposed cracks and nails, and eroded, rusted baseboard heaters. Hallway handrails on both units were worn, chipped, and splintered, and a shower room contained fecal odors, dried brown stains on the toilet, and deteriorated fixtures, all contributing to a failure to provide a safe, clean, and homelike environment.
Facility staff did not thoroughly investigate two separate abuse allegations involving a resident and an injury of unknown origin involving another resident. In both cases, investigations focused on the directly affected resident and included staff interviews, but there were no interviews of other residents on the unit or documented assessments of those residents for signs of abuse or injuries of unknown origin, including residents unable to communicate due to cognitive status.
Two residents who were dependent on staff for oral care, including one with a tracheostomy, were observed with thick, white or milky substances coating their mouths and teeth, indicating inadequate oral hygiene. One resident communicated that staff did not brush their teeth and that staff "need to." In another case, despite oral care supplies being present in the room, the resident’s mouth and teeth remained unclean on multiple observations, with a thick milky substance caking the teeth and stringing between them when the resident tried to open their mouth. These findings showed that staff did not consistently provide oral care to residents who relied on them for this ADL.
Staff failed to maintain complete and accurate medical records for multiple residents, including missing and inconsistent documentation of wound care, delayed pain assessment after discovery of an injury of unknown origin in a cognitively impaired resident, and inaccurate recording of a PPD test result that was documented as negative despite no evidence the injection was administered and no supporting nurse’s note. Residents reported not receiving certain treatments, while MAR entries either lacked signatures for completion or contained conflicting information about whether care was provided.
Surveyors found that the facility failed to consistently implement and communicate correct transmission-based precautions and PPE use. One resident with a Foley catheter related to wounds had no precaution signage posted, while another resident in a double room had a contact precautions sign at the door, yet the NP entered without PPE and the GNA provided high-contact care wearing only gloves. Staff in that room stated the resident was not on contact precautions and later reversed the sign to show no PPE requirement. Therapy staff reported they rely solely on posted signs to determine PPE, and surveyors identified broader issues with inaccurate signage and staff awareness of which residents required contact precautions.
Surveyors found that MDS assessments were inaccurately coded for two residents. In one case, a resident sustained a femoral neck fracture after a fall, but the subsequent significant change MDS did not code the fall as a major injury and failed to capture prn Tylenol use documented on the MAR within the look-back period. In the other case, a quarterly MDS indicated opioid use for a resident, but the MAR for the same period showed no prescribed opioid, indicating incorrect coding of high-risk drug classes.
A resident who had recently been admitted and experienced a fall received multiple doses of the narcotic analgesic Tramadol, but the facility failed to accurately document all administered doses on the Medication Administration Record (MAR). Review showed only one Tramadol dose recorded on the MAR, while the Controlled Drug Receipt/Record/Disposition Form on the med cart reflected three doses given over two days. In interview, the DON stated staff are expected to document narcotic administration on the MAR and confirmed that two administered doses were not recorded there, resulting in an incomplete and inaccurate medical record.
Unqualified Infection Preventionist Overseeing Infection Control Program
Penalty
Summary
The facility failed to ensure that its designated Infection Preventionist (IP) met the mandatory qualifications for overseeing the Infection Prevention and Control Program. During an interview on 3/24/26 at 10:00 AM, the DON confirmed that she/he was serving as the facility’s IP but had not completed the specialized training in infection control required for the position. The DON further stated that no other staff member currently met the qualifications to serve as IP. Record review showed that the previously qualified IP left the facility in October 2025, and as of the survey date, the position remained unfilled by a qualified individual. At 1:30 PM on the same day, the Administrator and DON confirmed they were still in the process of finding a qualified IP for the facility, leaving the Infection Prevention and Control Program without a properly trained and qualified leader. No specific residents, medical histories, or clinical conditions were described in relation to this deficiency.
Unsecured Medications, Treatment Carts, and Oxygen Equipment
Penalty
Summary
Facility staff failed to ensure that drugs, biologicals, and related medical supplies were securely stored and properly maintained on multiple units. On one unit, an oxygen tank assigned to a resident was observed sitting on the floor behind the resident’s bed without any supporting device. On another unit, a treatment cart was observed with a tube of Collagenase Santyl cream labeled for a specific resident left on top of the cart, while residents in power wheelchairs passed by and staff were present at the nursing station. These observations showed that medications and oxygen equipment were not consistently secured as required. Further observations on additional units revealed an unattended and unlocked treatment cart at a nursing station, and on a separate occasion, a treatment cart with Diclofenac gel labeled for a resident left on top along with multiple packs of dressings. These incidents occurred across three units and on more than one date, demonstrating repeated failures to keep medications and treatment supplies in locked compartments or otherwise secured from unauthorized access.
Insufficient Dietitian Coverage and Delayed Nutritional Assessments
Penalty
Summary
The deficiency involves the facility’s failure to employ sufficient food and nutrition staff, including adequate dietitian coverage, to ensure timely assessment and appropriate diets for residents with significant nutritional and diabetic needs. A resident admitted over two weeks earlier with multiple comorbidities and an A1C of 11.5% had a hospital discharge recommendation for a carbohydrate-controlled diet, but was placed on a regular diet at admission with no acknowledgment of the recommended diet until one week later, when the resident requested larger portions. As of the survey date, the dietitian had not yet seen or reviewed this resident’s medical record, and the resident reported not having seen a dietitian and being very frustrated with the meals. During the first two weeks after admission, only one weight was obtained for this resident, despite physician notes stating the resident’s weight was “stable.” Further review of other residents showed additional failures in timely dietitian assessment and follow-up. One resident, readmitted in January and previously seen by the dietitian in September for a 6.4 lb weight loss over 30 days, had no documented follow-up despite continued weight loss totaling 22 lbs since the last dietitian review. Another resident admitted at the end of February with severe protein-calorie malnutrition had not been seen by the dietitian after about a month in the facility, despite a documented 14 lb (7%) weight loss over two weeks. The dietitian reported working only 12 hours per week at the facility and stated that she must prioritize which residents to see, focusing first on residents with tube feedings and those identified in risk meetings, resulting in delayed or absent assessments for new admissions and residents with ongoing weight loss and malnutrition diagnoses.
Linen Shortages and Poor Environmental Maintenance Compromise Resident Care and Comfort
Penalty
Summary
The deficiency involves the facility’s failure to maintain an adequate supply of clean linens and appropriate incontinence wipes, resulting in delays and alterations in residents’ incontinence care, as well as the use of towels and washcloths in place of disposable wipes. During the initial tour, the surveyor observed that the linen supply on one nursing unit hallway was low. Complaint reviews included concerns about delays in incontinence care and bed linens not being changed regularly, with residents left without clean bedding. A complainant reported that there was not enough clean linen available for residents. Staff interviews confirmed that towels, sheets, and washcloths were being used to wipe residents for incontinence care due to the absence of wipes, and that many of these linens were being thrown away when soiled. Staff also reported a shortage of linen, that linen deliveries to the units were late, and that residents who preferred to get up before breakfast had to wait for care when linen was delayed. Further observations showed that the clean supply room contained no disposable wipes or cloths for incontinence care, and a resident reported that staff did not use wipes, that the resident had to purchase their own, and that heavily soiled towels or washcloths were discarded. A tour of all nursing unit linen carts and closets revealed only six clean washcloths and limited supplies of towels, gowns, and bed linens. In the laundry room, only three washcloths were present, and the laundry assistant stated that there were only three washcloths available for each nursing unit that morning, that the facility was short on linen supply, and that these concerns had been repeatedly reported to the Director of Housekeeping over the preceding month and again that morning. The laundry assistant confirmed there was no additional laundry in process. The DON stated that wipe squares should be used for incontinence care, but no such wipes were found in the clean medical supply room, and no backup supply of washcloths was present in the emergency linen supply. The Director of Housekeeping confirmed there was no backup supply of washcloths. The deficiency also includes environmental and maintenance issues affecting resident bathrooms, handrails, and common areas. In the main dining area, a recliner chair was observed positioned directly in front of the handwashing sink, and two recliner chairs were stored in front of the nutrition area kitchenette. Multiple resident bathrooms and shared bathrooms were repeatedly observed over several days with unfinished spackle on walls that needed resurfacing and painting, chipped paint around sinks, uneven boards nailed to walls under sinks that appeared to partially cover holes, musty odors, black substances between shower bases and walls, missing threshold transition molding exposing cracks, missing tiles, and a nail, as well as eroded and chipped paint on baseboard heaters with exposed dark brown metal and rust-like material. Hallway handrails on both nursing units were observed to be worn, with chips, splintering, holes, and areas where the wood finish had worn off. A shower room was observed with a foul fecal odor, dried brown stains on the back of the toilet seat and in the toilet bowl, and a baseboard heater with eroded, chipped paint and rust-like material, along with chipped paint on the handrail. These conditions were acknowledged by the Director of Maintenance and other leadership, and some areas were noted to be in the process of renovation, but the observed deficiencies remained present during the survey period. Overall, the facility did not maintain a safe, clean, comfortable, and homelike environment in good repair across both nursing units and the dining area. The lack of adequate linen and incontinence supplies, combined with the poor condition of resident bathrooms, handrails, and certain common areas, constituted the basis for the cited deficiency. The observations and staff and resident reports consistently described shortages of essential hygiene supplies, delayed care related to linen availability, and multiple unresolved environmental and maintenance issues in resident care areas and shared spaces.
Failure to Thoroughly Investigate Abuse Allegations and Injuries of Unknown Origin
Penalty
Summary
Facility staff failed to thoroughly investigate allegations of potential abuse involving one resident and an injury of unknown origin involving another resident. For one resident, there were two separate allegations of abuse occurring on different days in early February. The facility’s investigation packets included interviews with staff who cared for or were scheduled to work with this resident on the days of the alleged incidents, and the investigations focused solely on this resident. However, there were no interviews conducted with other residents on the unit to inquire about abusive or neglectful treatment by the staff who were working during the times of the allegations. The surveyors noted that, although the allegations were not validated, there was no documentation that other residents were interviewed, if able, or assessed for signs or symptoms of injury. In a separate incident, another resident was identified on March 4 with a new bruise on the right eye, documented as a change in condition at 4:09 AM. This resident had a BIMS score of 99, indicating the resident was unable to complete an interview and therefore could not report how the injury occurred. The facility’s investigation identified a potential cause of the injury but did not reach a definitive resolution. Additionally, there were no interviews of other residents on the unit regarding possible abuse, nor were there documented assessments of other residents for injuries of unknown origin, particularly for those unable to speak for themselves, as in this resident’s case.
Failure to Provide Oral Care to Dependent Residents
Penalty
Summary
The deficiency involves the facility’s failure to provide oral care to residents who were dependent on staff for activities of daily living, specifically oral hygiene. One resident with a tracheostomy was observed with a thick, sticky white substance in the mouth and was noted to intermittently chew on nearby bedding. This resident made good eye contact and, when asked if staff brushed their teeth, shook their head no and mouthed that staff “need to.” According to the resident’s Minimum Data Set (MDS) dated 2/11/26, the resident was dependent on staff for oral care. Another resident, also dependent on staff for oral care per the 3/11/26 MDS, was observed sitting propped up in bed and able to respond with smiles. During the initial observation, the inside of this resident’s lips and upper and lower teeth had a thick, clear, white milky substance visible when the resident tried to open their mouth to smile. Oral care supplies were present in the nightstand, but the resident’s mouth and teeth were not clean. On a subsequent observation with the DON, NHA, and Corporate VP of clinical services, the same resident again had a thick, clear, milky substance between the lips and caking the teeth, which would string between the teeth when the resident attempted to open their mouth, demonstrating a lack of consistent oral care for residents dependent on staff for this ADL.
Incomplete and Inaccurate Medical Record Documentation for Treatments and Assessments
Penalty
Summary
Facility staff failed to maintain complete and accurate medical records and documentation for multiple residents. For one resident with wound care needs, review of the MAR showed that wound care and related treatments were signed as completed on the dates initially reported, despite the resident’s ongoing complaints that wound dressings were not being changed. When additional dates were reviewed, there were missing staff signatures for wound care on two specific dates, as well as three instances where application of A&D ointment to the resident’s feet was not signed off out of 24 days reviewed. Another resident with severe cognitive impairment, as evidenced by a BIMS score of 00, was found to have an injury of unknown origin (a bruise on the left hand). Documentation showed that a change in condition was initiated late in the morning, but a formal pain evaluation was not initiated and completed until that night, and the resident was unable to explain how the injury occurred or verbalize pain using a standard pain scale. For a third resident, documentation related to the admission PPD test was inconsistent and incomplete. The MAR contained an entry indicating “9” for the administration date, meaning “see nurse’s note,” but there was no corresponding nurse’s note. Despite the absence of a signed administration of the PPD injection, staff documented the PPD result as “negative” on the scheduled read date. The resident reported never receiving the PPD injection, and the DON confirmed that the facility had been out of PPD solution at the time, so the test would not have been administered. These findings demonstrate failures in accurate documentation of treatments and assessments, including wound care, pain assessment, and TB screening, as well as missing or incomplete supporting notes in the medical record.
Failure to Implement and Communicate Correct Transmission-Based Precautions
Penalty
Summary
Surveyors identified a deficiency in the facility’s infection prevention and control program related to inconsistent and incorrect implementation of transmission-based precautions and PPE use. During a complaint investigation focused on residents on transmission-based precautions, one resident with a visible Foley catheter was observed in the room with physical therapy, but there were no signs posted indicating any need for PPE, despite the resident being a new admission with a Foley catheter placed related to wounds. In another double-occupancy room, a contact precautions sign was posted at the doorway, but the nurse practitioner was in the room on a personal phone with no PPE, and the assigned GNA was repositioning the resident in bed while wearing only gloves. When questioned, the NP, RN, and GNA all stated that the resident in the room was not on contact precautions, and the GNA reported that signs were hanging at all doors and that this particular resident’s sign was “just wrong.” The surveyor observed the GNA later return to the room and turn the sign around to indicate no PPE requirement. Subsequent interviews revealed that therapy staff relied on posted signage to determine PPE use and that if the sign was wrong, the PPE used would be wrong. Overall, surveyors found problems with signage accuracy and staff awareness of which residents required contact precautions, as well as observed failures to follow appropriate PPE use for residents who should have been on contact precautions.
Inaccurate MDS Coding for Falls, Pain Management, and High-Risk Medications
Penalty
Summary
Facility staff failed to ensure Minimum Data Set (MDS) assessments were accurately coded for two residents reviewed during a complaint survey. For one resident, a facility-reported incident showed that the resident was found seated on the floor beside the bed and was diagnosed with a non-displaced femoral neck impaction fracture of the left hip following an x-ray. Despite this fall with a major injury, the subsequent significant change MDS dated 11/4/25 did not code the fall with major injury in Section J1900C. Review of the resident’s Medication Administration Records for October and November 2025 showed administration of Tylenol on 10/31/25 at 9:30 PM, which fell within the 5-day look-back period for the MDS, but Section J0100 (prn pain) of the same significant change MDS did not capture the use of Tylenol. For another resident, review of a quarterly MDS with an assessment reference date of 10/15/25 showed that Section N0415 (High-Risk Drug Classes) documented the use of an opioid medication. However, review of the resident’s October 2025 Medication Administration Record did not show that the resident had been prescribed an opioid during that period. In both cases, MDS staff later confirmed that these were errors in MDS coding, demonstrating that the assessments did not accurately reflect the residents’ clinical status and medication use as documented in their medical records.
Incomplete Documentation of Narcotic Administration on MAR
Penalty
Summary
The facility failed to maintain complete and accurate medical records in accordance with accepted professional standards for one resident receiving narcotic medication. The resident, admitted in March 2026, had a fall on 3/6/26 and was sent to the hospital on 3/9/26. Review of the March 2026 Medication Administration Record (MAR) showed documentation of a single 25 mg dose of Tramadol administered on 3/8/26 at 9:23 AM. However, review of the resident’s Controlled Drug Receipt/Record/Disposition Form, kept on the nurse’s medication cart and not in the medical record, showed that Tramadol 25 mg was administered three times between 3/8/26 and 3/9/26: at 11:00 AM and 9:00 PM on 3/8/26, and at 9:00 AM on 3/9/26. In interview, the DON stated that staff are expected to document narcotic administration on the MAR and confirmed that only one of the three Tramadol doses reflected on the controlled drug record was documented on the resident’s MAR. This discrepancy between the controlled substance record and the MAR, with missing documentation of two administered doses of Tramadol on the official medical record, constituted the failure to maintain a complete and accurate medical record for the resident.
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