Devlin Manor Nursing And Rehabilitation Center
Inspection history, citations, penalties and survey trends for this long-term care facility in Cumberland, Maryland.
- Location
- 10301 North East Christie Road, Cumberland, Maryland 21502
- CMS Provider Number
- 215244
- Inspections on file
- 16
- Latest survey
- March 20, 2026
- Citations (last 12 mo.)
- 7
Citation history
Health deficiencies cited at Devlin Manor Nursing And Rehabilitation Center during CMS and state inspections, most recent first.
A resident with pancreatic cancer and cirrhosis, including ascites and esophageal varices, had labs ordered that showed a significantly elevated ammonia level. The PA reviewed the abnormal result, documented "no new orders," and did not enter any treatment, monitoring parameters, or the intended order to recheck the ammonia level, nor a progress note explaining the assessment. Days later, the resident developed altered mental status and abdominal pain, and was sent to the ED at the family’s insistence, where an even higher ammonia level was found and hepatic encephalopathy was diagnosed, requiring treatment with lactulose and a multi-day hospitalization.
A cognitively impaired resident who depended on staff for most ADLs was being transferred with a mechanical lift when a GNA reported being hit by the resident and responded by cursing at and verbally degrading the resident, including making offensive remarks and threatening to withhold treats. Another staff member nearby overheard the GNA loudly say, “Don’t fucking hit me,” but did not report the incident because she believed the comment was directed at another staff member rather than the resident, resulting in unreported verbal abuse.
Staff failed to timely report a witnessed allegation of verbal abuse to the State Agency. A GNA verbally abused a resident during an evening shift, and on‑duty staff who observed the incident did not report it when it occurred. The DON later learned of the allegation the following morning and submitted the report to the State Agency several hours after that notification, rather than within 2 hours of the actual incident. The DON reported she believed the reporting timeframe began when she was informed of the allegation, leading to noncompliance with required abuse reporting timelines.
Staff failed to immediately remove a GNA from resident care after verbally abusing a cognitively impaired resident with dementia. During an evening shift, the GNA used profane language toward the resident while providing care, but other staff present did not recognize or report the incident as abuse at the time. The DON was not informed until the following morning, and staffing records confirmed that the GNA continued working for about 10 hours with vulnerable residents after the incident occurred.
Facility staff failed to ensure that a resident with pancreatic cancer and a prior Whipple procedure consistently received prescribed Creon with meals, resulting in multiple missed doses when the medication was not available. The MAR documented missed administrations due to the drug not being in stock or on order, and pharmacy records showed that refills were sent only after the supply had already run out. The DON knew the resident required Creon and that it was a special‑order medication but had no process to secure it before admission or to reorder in time, and staff instead contacted the family to bring medication from home. The facility’s medication ordering policy lacked provisions for special‑order drugs and there was no documentation that the hospital had instructed the family to supply the medication.
Two residents experienced delays in assessment and treatment after changes in condition were not promptly addressed by nursing staff. In one case, a resident sustained a hand laceration during care, which was not immediately assessed or documented by the LPN after being reported by aides, and was only discovered by family later. In another case, a resident developed facial bruising and a hematoma that was reported to nurses but not assessed or reported to a provider until the following day, resulting in delayed medical evaluation. Both incidents involved lapses in communication and failure to follow facility policy for timely intervention and documentation.
A resident with intact cognition and multiple medical conditions reported missing money to staff, who searched the room and provided a lock box but could not confirm the resident ever had the funds. The incident was initially treated as a grievance and not reported to the state agency as required. The allegation was only reported months later after being raised again, resulting in a late submission of the required investigation report.
A facility failed to include anticoagulant medication in a resident's care plan. The resident, with moderate decision-making impairment and conditions like paroxysmal atrial fibrillation, was prescribed Eliquis. However, the care plan lacked focus, goals, or interventions for the medication. Interviews with the MDS Coordinator and DON confirmed the omission, despite facility policy requiring comprehensive care plans.
Failure to Act on Elevated Ammonia Level Resulting in Hospitalization
Penalty
Summary
Facility staff failed to ensure that a resident’s abnormal laboratory result was appropriately evaluated and addressed by the practitioner. The resident had diagnoses including pancreatic cancer and cirrhosis of the liver with ascites and esophageal varices. A progress note indicated that a cancer center appointment was cancelled and that the NP’s order for labs, including an ammonia level, should be followed. The resident’s ammonia level, drawn the following day, was 76 (reference range 9–35) and marked as high. The result was circled, annotated “NNO” (no new orders), and noted to have no previous ammonia level for comparison, and was signed by PA #1. There were no new treatment orders, no monitoring orders, and no corresponding progress note documenting assessment or clinical reasoning in the medical record related to this abnormal result. Subsequently, the resident experienced a change in mental status and abdominal pain. A progress note documented that the resident was sent to the ED for further evaluation after the resident’s family insisted on transfer. In the ED, the resident was found to have an ammonia level of 180 (reference range 9–35) and was diagnosed with hepatic encephalopathy. The resident was treated with lactulose and remained hospitalized for six days before discharge. The attending physician/Medical Director later stated that the resident had an elevated ammonia level that PA #1 had missed and acknowledged that the family was not happy with the situation. During interview, PA #1 confirmed that she had reviewed the elevated ammonia level and had not written any orders. She stated that because the resident did not have a history of hepatic encephalopathy and nursing staff had not reported a change in mental status, she decided not to treat the resident and did not write monitoring orders, believing such monitoring to be part of routine nursing care. She also reported that she had intended to recheck the ammonia level in a couple of days but failed to enter the order into the medical record. This failure to order treatment or monitoring, and the omission of the planned repeat ammonia level, occurred despite the clearly abnormal lab value and contributed to the resident’s subsequent hospitalization for hepatic encephalopathy.
Failure to Protect Cognitively Impaired Resident From Verbal Abuse by Staff
Penalty
Summary
The deficiency involves the facility’s failure to protect a resident from verbal abuse by staff. Record review showed that the resident had severe cognitive impairment, unclear speech, intermittent understanding, and dependence on staff for most ADLs. During an evening shift, a GNA was assisting another GNA with transferring the resident using a mechanical lift when the resident reportedly hit the GNA. Witness accounts documented that the GNA responded by cursing, including statements such as “don’t fucking hit me,” and later, in reference to the resident, “fucked [his/her] ass straight up and [his/her] is a fucking retarded gimp,” and that the resident “won’t be getting any more ice cream” from her. Another staff member heard the raised voice and profanity but could not see into the room because the door was closed. The facility’s investigation file and interviews further showed that the GNA admitted to holding the resident’s arm down after being hit and later admitted to cursing at the resident. A CMA who was near the room at the time heard the GNA say, “Don’t fucking hit me,” but did not report the incident because she believed the comment was directed at the other GNA rather than the resident. The DON’s interviews with involved staff confirmed that the GNA’s voice was raised during the incident and that abusive language was used toward the resident, establishing that the resident was subjected to verbal abuse and that at least one staff member failed to recognize and report the allegation of abuse at the time it occurred.
Failure to Timely Report Witnessed Verbal Abuse Allegation to State Agency
Penalty
Summary
Staff failed to recognize and report an allegation of verbal abuse to the State Agency within the required timeframe. Record review showed that a Geriatric Nursing Assistant (GNA) verbally abused Resident #6 on 1/20/26 during the evening shift, between approximately 8:00 PM and 8:30 PM, and that this abuse was witnessed by facility staff who did not report the incident at the time it occurred. The facility’s investigation file for facility reported incident #2726923 documented that the DON became aware of the allegation of abuse on 1/21/26 at 9:32 AM, and an email confirmation showed the report was sent to the State Agency on 1/21/26 at 12:42 PM. During interview, Certified Medicine Aide (CMA) #5 confirmed she was present when the verbal abuse occurred on the evening of 1/20/26. The DON stated she believed the 2‑hour reporting timeframe began when she was notified of the allegation, rather than from the time the abuse occurred, resulting in the allegation not being reported within the required timeframe. This deficiency was identified for 1 of 4 facility‑reported incidents reviewed and is cross‑referenced to F600 and F610.
Failure to Remove Alleged Abusive Staff Member From Resident Care
Penalty
Summary
Facility staff failed to ensure that a staff member observed verbally abusing a resident was immediately removed from access to vulnerable residents. Record review showed that Resident #6 had dementia and was severely cognitively impaired per an MDS with an assessment reference date of 12/18/25. The facility’s investigation file for a reported incident indicated that on 1/20/26 during the evening shift, GNA #3 verbally abused Resident #6 while GNA #3 and GNA #4 were putting the resident back to bed, stating, “Do not fucking hit me.” Staff did not recognize this as abuse at the time, and it was not reported to the DON until 1/21/26 at 9:32 AM. Staff assignment sheets and time punches confirmed that GNA #3 worked the evening shift starting at 2:30 PM on 1/20/26 and continued working until 6:30 AM on 1/21/26, resulting in approximately 10 hours of continued work with vulnerable residents after the verbal abuse occurred. A CMA who was present confirmed the time frame of the incident as between 8:00 PM and 8:30 PM on 1/20/26. These findings show that the facility did not promptly remove the alleged perpetrator from resident care or immediately report the abuse to appropriate leadership after it occurred.
Failure to Ensure Availability of Essential Pancreatic Enzyme Medication
Penalty
Summary
Facility staff failed to ensure that a resident with pancreatic cancer who had undergone a Whipple procedure consistently received the prescribed pancreatic enzyme medication, Creon, upon admission and throughout the stay. The hospital discharge summary documented the need for Creon with meals to assist with digestion and nutrient absorption, and the resident’s orders specified Creon capsules three times daily. Review of the MAR showed multiple missed doses on specific dates when the medication was not administered because it was not available, with nurses documenting that the drug was not available from the pharmacy, was on order, or was pending physician evaluation. On the day of admission, the assigned RN did not administer Creon because it had not been ordered from the pharmacy and documented the missed dose accordingly. Pharmacy dispensing records showed that Creon was shipped in 100‑capsule quantities on three separate dates, which coincided with documented missed doses when the facility allowed the supply to run out before refills arrived. The DON acknowledged awareness prior to admission that the resident required Creon and its importance with each meal, yet there was no process in place to ensure the medication was available at admission or to prevent running out between refills. The DON reported that staff asked the family to provide the medication from home and that special‑order medications took longer to obtain because they required her signature and were not stocked at the pharmacy. The facility’s policy on ordering and receiving medications lacked an implementation date and did not include provisions for special‑order medications, and there was no documentation that the hospital case manager had instructed the family to bring the medication at admission.
Failure to Timely Assess and Intervene After Resident Change of Condition
Penalty
Summary
The facility failed to timely assess and implement interventions after a change of condition for two residents, resulting in delays in assessment and treatment. In the first case, a resident with severe cognitive impairment and dependence for activities of daily living sustained a deep laceration to the right hand during care when the resident grabbed a side rail while being turned. The incident was initially reported by the geriatric nursing assistants to an LPN, but there was no immediate nursing assessment or documentation. The injury was ultimately discovered by the resident's family, prompting a registered nurse to assess the wound and arrange for emergency care. Witness statements revealed that the LPN did not recall being informed of the injury, and there was a lack of timely follow-up and documentation as required by facility policy. In the second case, another resident with moderate cognitive impairment and a history of falls was observed with facial bruising and a hematoma by staff. The discoloration was reported to nurses at the station, but there was confusion among staff regarding who was responsible for assessing and reporting the injury. The assigned nurse did not document or report the injury, and no immediate assessment or notification to the medical provider occurred. The following day, the resident was found with more extensive bruising and swelling, at which point a full assessment was completed, and the resident was sent to the emergency room. Interviews with staff indicated that the initial report of the injury was not acted upon in a timely manner, and the required procedures for injuries of unknown origin were not followed. Both incidents demonstrate a failure to follow facility policy regarding timely assessment, documentation, and communication of changes in resident condition. Staff interviews revealed lapses in communication and uncertainty about responsibilities, resulting in delays in care and treatment for the affected residents. The deficiencies were identified through interviews, record reviews, and facility document reviews, which confirmed that the required interventions and notifications were not completed as specified in the facility's policies.
Failure to Timely Report Allegation of Misappropriation of Property
Penalty
Summary
The facility failed to timely report an allegation of misappropriation of property to the state survey agency, as required by policy. A resident, who had a history of congestive heart failure, type II diabetes mellitus, and acute respiratory failure with hypoxia, reported missing money in January. The resident, who was cognitively intact, informed the social worker that $225 was missing from their belongings. Staff searched the resident's room and provided a lock box for valuables, but could not locate the money or confirm if the resident ever possessed the amount claimed. Despite the allegation being reported to multiple staff members, including a Geriatric Nursing Assistant and the Director of Nursing, the incident was not reported to the state agency at that time. The facility's policy required immediate reporting of any alleged violations involving abuse, neglect, exploitation, or misappropriation of resident property. However, the staff treated the incident as a grievance rather than a reportable allegation because they could not verify the resident had the missing money. The allegation resurfaced in April, at which point the facility reported it to the state agency, several months after the initial report by the resident. The required 5-day investigation report was also submitted late, outside of the mandated timeframe. Interviews with staff revealed that the decision not to report the incident in January was based on the inability to substantiate the resident's claim. Staff, including the social worker and unit managers, stated that they did not observe the resident with the alleged sum and only reported the incident after it was brought up again months later. The administrator confirmed that the facility typically reported such allegations within two hours but, in this case, delayed reporting due to doubts about the validity of the claim.
Failure to Include Anticoagulant in Resident's Care Plan
Penalty
Summary
The facility failed to develop a comprehensive care plan for a resident who was receiving anticoagulant medication, specifically Eliquis. The resident, who was admitted with diagnoses including unspecified disorders of the brain and paroxysmal atrial fibrillation, was noted to have a moderately impaired decision-making ability. Despite the resident's condition and the physician's order for Eliquis, the care plan did not include any focus, measurable goals, or interventions related to the use of anticoagulant medication. Interviews with the MDS Coordinator and the Director of Nurses confirmed that the care plan should have included information about the anticoagulant medication. The MDS Coordinator stated that care plans are typically updated during each quarterly assessment, and acknowledged that the anticoagulant should have been included. The Director of Nurses also confirmed that the resident was receiving Eliquis and that this information should have been part of the care plan. The facility's policy requires the development of a comprehensive care plan that meets professional standards of quality care, which was not adhered to in this case.
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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