Egle Nursing Home
Inspection history, citations, penalties and survey trends for this long-term care facility in Lonaconing, Maryland.
- Location
- 57 Jackson Street, Lonaconing, Maryland 21539
- CMS Provider Number
- 215307
- Inspections on file
- 16
- Latest survey
- October 9, 2025
- Citations (last 12 mo.)
- 31
Citation history
Health deficiencies cited at Egle Nursing Home during CMS and state inspections, most recent first.
A resident with Alzheimer's disease and dementia was found with a right hip fracture of unknown origin. The facility's investigation included staff interviews and security footage review but did not include interviews with other residents. The DON acknowledged that interviewing other residents was not considered, which limited the ability to rule out abuse or improper staff handling.
Surveyors identified deficiencies in food storage and expiration date management at the facility. Uncovered pans of cooked food were found in the refrigerator, contrary to the facility's policy, and several canned food items lacked expiration dates. Staff struggled to determine expiration dates, requiring assistance from the food distributor.
The facility failed to review and revise care plans for two residents after assessments. One resident, with severe cognitive impairment and physical limitations, had a care plan that included bed rails, but the plan was not reassessed for effectiveness. Another resident, with severe cognitive impairment and behavioral symptoms, had multiple care plans that were not updated following the most recent MDS assessment. The MDS Coordinator and DON acknowledged these deficiencies.
A resident with a PEG feeding tube was not properly positioned during medication administration and feeding, as the head of bed was elevated only to about 10 degrees instead of the required 45 degrees. The staff member involved admitted to not following the care plan due to nervousness, and the DON confirmed the expectation for proper HOB elevation to prevent aspiration.
A GNA entered a resident's room without knocking or requesting permission, violating the resident's right to dignity and self-determination. The incident was reported to the DON, who noted that the GNA was confused because the door was usually open.
A facility failed to complete a comprehensive MDS assessment for a resident, omitting cognitive and mood evaluations. The MDS Coordinator confirmed the oversight, noting the Social Worker was responsible. The Social Worker acknowledged the error, citing an unrecognized change in the resident's health insurance requirements.
A facility failed to complete a Significant Change in Status MDS assessment within the required 14-day period after a resident experienced a significant decline in condition, including a left tibial plateau fracture. The MDS assessment was completed 24 days after the change was noted, and the MDS coordinator was unaware of the 14-day requirement.
Two residents' MDS assessments were inaccurately coded, leading to deficiencies. One resident's MDS failed to capture the diagnosis for antipsychotic medication use, despite available documentation. Another resident's MDS omitted a BIMS score assessed on the ARD, confirmed by the Social Service Director.
A resident with left hemiparesis due to a stroke did not receive the ordered palm protector to prevent worsening hand contracture. Despite an order for the device to be worn at all times, it was not observed in use, and staff interviews revealed a lack of adherence to the care plan due to oversight and workload issues.
A facility failed to explore alternatives and assess a resident's risk of entrapment before installing bed rails. The resident, with severe cognitive impairment and mobility issues, was unlikely to benefit from the rails. The facility also lacked ongoing evaluation and specific monitoring of the resident's use of bed rails, and did not conduct routine maintenance checks on bed equipment.
The facility failed to ensure timely documentation of physician visit notes for two residents. The EMRs showed that notes were dated after the actual visit dates, indicating a delay in documentation. The DON acknowledged the concerns but did not provide further comments.
A facility staff member failed to wear a gown while providing care to a resident with a PEG feeding tube, despite enhanced barrier precautions requiring both gloves and gowns. The resident needed extensive assistance, and signage indicated the need for these precautions. Interviews confirmed staff were trained and gowns were available, yet the deficiency occurred.
The facility failed to conduct regular inspections of bed frames, mattresses, and bed rails, relying instead on aides to report issues. This deficiency was identified during an observation of a resident with bed rails attached, and the maintenance director confirmed the lack of routine checks. The issue had the potential to affect all residents, and the nursing home administrator acknowledged the concerns.
A facility failed to provide full visual privacy for a resident in a shared room. The privacy curtain only extended to the length of the beds, which was inadequate for a resident using a bedside commode. The DON confirmed that the room's ceiling configuration prevented proper curtain installation.
The facility failed to maintain accurate medical records, including incorrect transcription of antipsychotic medication indications, lack of documentation for a wound evaluation, and missing records of a care plan meeting. These issues involved two residents, one with a Stage III pressure ulcer and another with mental health diagnoses.
Failure to Thoroughly Investigate Injury of Unknown Origin
Penalty
Summary
The facility failed to thoroughly investigate an injury of unknown origin involving a resident with Alzheimer's disease, dementia, and muscle wasting and weakness. The resident was found sitting in a wheelchair with their right leg in an unnatural position, and a fracture was suspected. The resident was transferred to the hospital, where a right hip fracture was confirmed, requiring surgical intervention. The facility's investigation included interviews with all staff members involved in the resident's care and a review of security footage, which confirmed the resident remained in their room throughout the day. However, there was no evidence that any other residents were interviewed as part of the investigation. During interviews, the DON stated that her process for investigating injuries of unknown origin involved reviewing staff schedules and interviewing staff who had contact with the resident. She acknowledged that she did not consider interviewing other residents, even though this could have provided additional information about the incident. The surveyor noted that without interviewing other residents, the facility could not rule out possible abuse or determine whether staff handling may have contributed to the injury. The DON agreed that interviewing other residents would have been an important step in the investigation.
Deficiencies in Food Storage and Expiration Date Management
Penalty
Summary
The facility staff failed to properly store food items in the kitchen's walk-in refrigerator and did not have a process in place to determine the expiration date of food procured from vendors. During an initial tour of the kitchen, surveyors observed uncovered pans of cooked potatoes and rice pudding in the refrigerator, which were not loosely covered as required by the facility's policy for cooling food products. Staff #7, the Certified Dietary Manager, acknowledged that the pans were uncovered because the food was cooling, but later confirmed that the policy required pans to be loosely covered during cooling. Additionally, the surveyors found several canned food products in the dry storage room that were not labeled with a manufacturer's expiration date or a production date. Staff #7 was unable to determine the expiration dates of these products and had to contact the food distributor for assistance. Although some expiration dates were eventually determined, Staff #7 and Staff #13 were still in the process of verifying the expiration dates for certain products, such as canned apricots and applesauce, at the time of the survey. The Nursing Home Administrator was made aware of these concerns.
Failure to Review and Revise Care Plans
Penalty
Summary
The facility failed to review and revise care plans for residents after each assessment, as required. This deficiency was observed in the cases of two residents. For the first resident, who had severe cognitive impairment and physical limitations, the care plan included the use of bed rails as enablers. However, the resident was unable to utilize the bed rails due to their dependency on maximum assistance for mobility. Despite this, the care plan was not reassessed to determine the effectiveness of the interventions, such as the need for a bed alarm or assistance with toileting, and the necessity of the bed rails was not reevaluated. In the case of the second resident, who had severe cognitive impairment and exhibited behavioral symptoms, the facility failed to update the care plans following the resident's most recent MDS assessment. The resident's care plans addressed various issues, including behavioral symptoms, cognitive loss, communication, psychotropic drug use, pain management, and pressure ulcers. However, there was no documentation of care plan evaluations or revisions after the assessment, indicating a lack of evaluation of the resident's progress or the effectiveness of current interventions. The MDS Coordinator acknowledged the concerns regarding the failure to evaluate and revise care plans following the MDS assessments. The Director of Nurses was also made aware of these issues. The lack of timely review and revision of care plans for these residents highlights a deficiency in the facility's compliance with regulatory requirements for resident care planning.
Failure to Elevate Head of Bed for PEG Feeding
Penalty
Summary
The facility staff failed to ensure proper elevation of the head of bed (HOB) for a resident during medication administration and infusion of a percutaneous endoscopic gastrostomy (PEG) feeding. This deficiency was identified for one resident who was reviewed for tube feeding. The resident had a PEG feeding tube due to difficulty swallowing, as documented in their care plan. The care plan, initiated in December 2020, included an intervention to keep the HOB elevated at 45 degrees at all times. An attending provider's order from April 2023 also specified that the HOB should be elevated 45 degrees every shift. During an observation in May 2024, the resident was found lying on their back with the HOB elevated to only about a 10-degree angle while a staff member administered medications and resumed PEG feeding. The staff member confirmed that the HOB was not elevated to the required 45 degrees and admitted to elevating it only to about 15 degrees due to nervousness. The Director of Nursing stated that the expectation was for nurses to follow the provider's order to reduce the risk of aspiration, and acknowledged that the staff member had reported the failure to elevate the HOB correctly.
Failure to Respect Resident's Privacy
Penalty
Summary
The facility failed to honor a resident's right to a dignified existence and self-determination by not treating them with respect and dignity. This deficiency was identified when a Geriatric Nursing Assistant (GNA) entered a resident's room without knocking or requesting permission. The incident occurred during an interview with the resident, whose room door was closed at the time. The Director of Nurses (DON) was informed of the incident and acknowledged that the GNA had reported being thrown off by the door being closed, as it was usually kept open.
Incomplete MDS Assessment for Resident
Penalty
Summary
The facility failed to complete a comprehensive Minimum Data Set (MDS) assessment for a resident, specifically omitting the assessment of cognitive patterns and mood. This deficiency was identified during a review of the resident's medical record, which showed that the annual assessment with an Assessment Reference Date (ARD) was not fully completed. The MDS is a federally mandated tool used to ensure that each resident's individual needs are identified and addressed through a standardized assessment process. During an interview, the MDS Coordinator confirmed that the cognitive and mood assessments for the resident had not been completed, attributing the responsibility to the Social Worker. The Social Worker acknowledged the oversight, explaining that a recent change in the resident's health insurance provider, which required completion of these assessments, had not been realized at the time of the assessment.
Failure to Timely Complete Significant Change MDS Assessment
Penalty
Summary
The facility failed to complete a Significant Change in Status Minimum Data Set (MDS) assessment within the required 14-day period following a significant decline in a resident's condition. This deficiency was identified during a recertification survey for one resident. The resident, who was admitted to the facility in June 2019, experienced a significant change in condition when they complained of left knee pain and swelling on February 13, 2024. An X-ray was ordered, and it was later determined that the resident had a left tibial plateau fracture on February 15, 2024. Despite the significant change in the resident's condition being identified on February 13, 2024, the Significant Change in Status MDS assessment was not completed until March 7, 2024, which was 24 days after the change was noted. The MDS coordinator, during an interview, acknowledged that she was unaware of the requirement to complete the assessment within 14 days of determining a significant change in a resident's condition. This oversight led to the facility's failure to comply with the federally mandated timeline for MDS assessments.
Inaccurate MDS Assessments for Two Residents
Penalty
Summary
The facility staff failed to ensure that Minimum Data Set (MDS) assessments were accurately coded for two residents. For Resident #64, the MDS assessment did not capture the diagnosis of delusions and hallucinations, which was the indication for the use of an antipsychotic medication. Although a physician's order report signed by an attending provider documented these diagnoses, the MDS coordinator forgot to record them in the MDS assessment. This oversight occurred despite the availability of the necessary documentation prior to the completion of the MDS. For Resident #35, the MDS assessment did not include the Brief Interview for Mental Status (BIMS) score, which was assessed on the same date as the Assessment Reference Date (ARD). The BIMS score of 15/15 was documented in a social service progress note, but it was not captured in the MDS assessment submitted four days later. The omission was confirmed by the Social Service Director, indicating a failure to include all relevant assessment information available during the lookback period.
Failure to Provide Ordered ROM Treatment
Penalty
Summary
The facility failed to ensure that a resident with limited range of motion received the necessary treatment and services to prevent further decline. Resident #43, who was admitted with left hemiparesis due to a stroke, required extensive assistance for self-care and had functional limitations in both upper and lower extremities. An order was in place for the resident to wear a left upper extremity palm protector at all times, except during bathing and hand hygiene, to prevent worsening of hand contracture. However, during an observation, the resident was found without the palm protector, and staff interviews revealed that the device was not consistently used as required. Staff interviews indicated a lack of adherence to the care plan, with a licensed practical nurse unaware of the palm protector's location and a geriatric nurse aide admitting to not checking for the device due to being too busy. The occupational therapy team confirmed the importance of the palm protector in preventing contracture worsening, yet it was not observed in use. This deficiency highlights a failure in the facility's responsibility to provide ordered treatments and services to maintain the resident's range of motion.
Failure to Assess and Monitor Bed Rail Use
Penalty
Summary
The facility failed to identify and use appropriate alternatives before installing bed rails for a resident, and did not assess the resident's risk of injury or entrapment prior to their use. The resident in question had severe cognitive impairment, dementia, hemiplegia, and hand contractures, and was dependent on assistance for all activities of daily living and mobility. Despite these conditions, the facility did not document any exploration of alternatives to bed rails or assess the risks of entrapment before installation. The resident's medical record included a physician's order for bed rails and a signed informed consent form from the resident's representative, acknowledging the risks and benefits of bed rail use. However, the facility did not provide evidence of ongoing evaluation to ensure the bed rails met the resident's needs or that specific monitoring and supervision were provided during their use. The physical therapist confirmed that the resident was unlikely to benefit from the bed rails due to their dependency and inability to grasp the rails. Additionally, the facility lacked a regular maintenance program to inspect bed frames, mattresses, and bed rails, relying instead on reports of issues to address problems. This lack of routine maintenance was acknowledged by the Maintenance Director and discussed with the Nursing Home Administrator, who recognized the concerns raised by the surveyors.
Failure to Document Physician Visit Notes Timely
Penalty
Summary
The facility staff failed to ensure that physician progress notes were written, signed, and dated at each required visit for two residents. For one resident, the electronic medical record (EMR) and paper medical record showed discrepancies in the dates of the physician's visit notes. The notes were dated after the actual visit dates, indicating a delay in documentation. The Director of Nurses (DON) was informed of these concerns and acknowledged them, believing that the physician dictated the notes on the day of the visit. Similarly, for another resident, the EMR revealed that the physician's visit notes were not documented on the day of the visit. The notes were dated several days after the actual visit dates. The DON was made aware of these issues and acknowledged the concerns but did not provide further comments. This deficiency was identified during a review of residents for unnecessary medications.
Failure to Follow Enhanced Barrier Precautions
Penalty
Summary
The facility staff failed to adhere to proper infection prevention and control protocols by not wearing the required personal protective equipment (PPE) when providing direct care to a resident with a percutaneous endoscopic gastrostomy (PEG) feeding tube. Specifically, during an observation, a geriatric nurse aide was seen giving a bed bath to the resident while only wearing gloves, neglecting to wear a gown as mandated by the enhanced barrier precautions. These precautions are essential for reducing infection transmission during high-contact care activities for residents with medical devices such as feeding tubes. The resident in question required extensive assistance for all self-care needs and was on enhanced barrier precautions, as indicated by signage on the resident's door. Despite the availability of gowns in the resident's room and staff training on these precautions, the nurse aide did not comply with the requirement to wear a gown. Interviews with the staff, including the director of nursing, confirmed that all staff were expected to follow these precautions, yet the deficiency occurred, highlighting a lapse in adherence to infection control protocols.
Failure to Conduct Regular Bed Inspections
Penalty
Summary
The facility failed to conduct regular inspections of bed frames, mattresses, and bed rails, which is a crucial part of their maintenance program to prevent potential entrapment risks. This deficiency was identified during an observation of a resident lying in bed with bilateral bed rails attached. The maintenance director confirmed that no routine maintenance checks were performed on the beds or bed rails, and the facility relied on aides to report any issues to maintenance for further inspection. The deficiency was evident for one resident reviewed for accidents, but it had the potential to affect all residents in the facility. The maintenance director stated that the facility's protocol involved aides assessing the beds and notifying maintenance if there were any problems. However, there was no structured routine maintenance program in place to ensure the equipment was inspected and maintained according to the manufacturer's recommendations and requirements. The nursing home administrator acknowledged the concerns when they were discussed.
Failure to Provide Full Visual Privacy in Shared Room
Penalty
Summary
The facility failed to provide full visual privacy for a resident residing in a non-private room. This deficiency was identified during a recertification survey for a newly admitted resident who occupied a bed in a shared room. The privacy curtain between the two beds only extended to the length of the beds, failing to provide complete visual privacy. The resident used a bedside commode in the room for bowel and bladder elimination, which further necessitated the need for adequate privacy. The Director of Nursing confirmed the observation and noted that the room's ceiling configuration prevented the installation of a track for suspended curtains, unlike other rooms in the facility.
Deficiencies in Medical Record Documentation
Penalty
Summary
The facility failed to maintain complete and accurate medical records for its residents, as evidenced by several deficiencies. For one resident, the facility did not accurately transcribe the indication for the use of the antipsychotic medication Seroquel. The medication was prescribed for dementia with psychosis and specific behaviors, but the psychiatric progress note indicated the primary diagnoses as adjustment disorder with anxiety and depressed mood, generalized anxiety disorder, and delusional disorder, with Seroquel continued for delusional disorder. This discrepancy was confirmed by the Director of Nurses during the survey. Additionally, the facility did not document a wound evaluation for the same resident who had a Stage III pressure ulcer on the left ankle. Although the wound was assessed during a dressing change, the evaluation and measurements were not recorded in the electronic health record. Furthermore, another resident's medical record lacked documentation of a care plan meeting following a Minimum Data Set assessment. The Social Service Director and Director of Nursing could not provide evidence of the meeting in the medical record, although an email indicated it occurred.
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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Every citation, penalty and Plan of Correction is sourced from public CMS records (latest release May 27, 2026) and official state health department websites — never guesswork.
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