Elkton Nursing And Rehabilitation Center
Inspection history, citations, penalties and survey trends for this long-term care facility in Elkton, Maryland.
- Location
- 1 Price Drive, Elkton, Maryland 21921
- CMS Provider Number
- 215269
- Inspections on file
- 30
- Latest survey
- January 29, 2026
- Citations (last 12 mo.)
- 73
Citation history
Health deficiencies cited at Elkton Nursing And Rehabilitation Center during CMS and state inspections, most recent first.
Staff failed to follow physician-ordered BP parameters for Midodrine administration for three residents with hypotension and orthostatic issues. One resident with recent hospitalization, deconditioning, and high fall risk received Midodrine when SBP was above the ordered hold threshold and had a dose held when SBP was below that threshold, both before and after a dose change. Another resident with an order to hold Midodrine for SBP above a specified level repeatedly received the drug despite SBP readings over that limit. A third resident, ordered Midodrine TID with a lower SBP hold parameter, also received doses when SBP exceeded the ordered limit and did not receive the drug when SBP was below it. The medical director confirmed that staff did not follow the ordered parameters and voiced concern about these out-of-parameter administrations.
A resident admitted with pneumonia did not receive multiple physician-ordered medications and treatments as evidenced by missing documentation on the MAR. Orders lacking documented administration included PICC line flushes, inhaled acetylcysteine every 6 hours, nebulized albuterol every 6 hours, and IV piperacillin every 6 hours for pneumonia over several shifts. Review of the MAR with the DON confirmed that these medications and treatments were not documented as given for this resident during the complaint survey review.
A resident with a Stage 3 right heel pressure ulcer and multiple comorbidities, including diabetes with neuropathy and severe protein-calorie malnutrition, had physician and wound care orders for continuous heel offloading using boots, pillows, and pressure-reduction measures, with the TAR showing heel boots signed off as applied each shift. However, on multiple observations the resident was found in bed with heels resting directly on the mattress, wearing only slipper socks and without heel boots in place, and the DON confirmed that no heel boots were present in the room despite documentation indicating their use.
A resident with multiple comorbidities, recent falls with head injury, orthostatic hypotension, and documented high fall risk was not provided with consistent fall-prevention interventions as outlined in the care plan. On observation, the resident’s call bell was under the bed and unreachable, the urinal was placed several feet away on a nightstand drawer handle, there were no fall mats by the bed, and the bed was not kept in the lowest position. The care plan required that the bed be in low position and that the urinal and common items be within reach, and therapy staff described the resident as impulsive and likely to try to get out of bed if needs were not within reach. Additionally, Midodrine was administered despite a systolic BP above the physician-ordered hold parameter, and the medical director confirmed it should have been held.
Surveyors found that staff failed to obtain ordered lab tests for two residents. One resident with diabetes and anemia had physician orders for a CBC, CMP, and magnesium level to be drawn on a specific date, but the medical record showed no lab results and no nursing documentation explaining the omission, which the DON confirmed. Another resident with pneumonia was seen by a PA for abnormal labs, and a repeat CBC was ordered and acknowledged in a nurse’s note, yet no labs were drawn before the resident was discharged, which the DON also confirmed.
A resident with impaired mobility and a care plan requiring Hoyer lift transfers with two-person assistance was not transferred according to protocol. Instead, a GNA attempted to assist the resident without the required equipment or help, leading to the resident attempting to transfer independently, falling, and sustaining a displaced distal femur fracture.
A resident receiving hospice care for a terminal illness experienced unmanaged pain due to staff failing to administer scheduled and as-needed morphine as ordered. Documentation on the MAR did not match the narcotic log, and there were significant gaps in medication administration. Staff and family reported the resident suffered a pain crisis, and facility leadership was unaware of the incident until after the fact.
A resident was denied the right to manage their own finances after the facility became their Representative Payee without proper notification or documentation of incapacity, despite assessments showing cognitive intactness. The resident was not given access to their funds or statements, and staff actions were based on an outstanding bill rather than a documented change in capacity. Additionally, residents could only access their funds during limited business hours, with no access after hours or on weekends, and there were occasions when the facility ran out of petty cash.
Surveyors found that several residents were denied their rights to dignity and self-determination, including a resident who missed medical appointments due to transportation issues with a replacement wheelchair, was not properly informed about changes to their Social Security payee status, and lacked support for discharge planning. Staff were repeatedly observed entering rooms without knocking or seeking permission, despite resident complaints. Additionally, some residents lacked access to personal clothing on weekends due to ongoing laundry staffing shortages.
Surveyors observed persistent pest issues, including flies, gnats, and ants, in multiple units and resident rooms. A resident reported flies landing on their head, food, and bed, and staff confirmed the ongoing presence of pests despite regular pest control visits. The deficiency was evident through direct observation and resident interviews.
A resident was physically abused by a GNA, who was witnessed slapping the resident on the face while assisting them off an elevator. The incident was observed by a laundry staff member and confirmed through the facility's investigation. The resident was evaluated at a hospital and returned to the facility, with the abuse substantiated by both witness accounts and internal review.
Two residents were not provided with full participation in their care planning process, as care plan meetings were conducted only with Social Services staff and lacked involvement from the required Interdisciplinary Team (IDT). Residents reported that their concerns were not addressed, and documentation confirmed the absence of other disciplines during these meetings.
Three residents experienced failures in receiving medically-related social services, including lack of support for discharge planning, missed medical appointments due to transportation issues, unaddressed concerns about personal funds and documentation, and insufficient assistance with guardianship changes, despite being cognitively intact and expressing clear preferences.
A resident missed multiple medical appointments over an extended period because the facility did not provide appropriate transportation arrangements after the loss of their original wheelchair. The replacement wheelchair was too large for the contracted taxi service, and although the resident was approved for a power wheelchair, delays in the facility's billing process prevented its delivery. Staff did not pursue alternative transportation options, and the resident's requests for help were not effectively addressed.
Surveyors identified multiple instances where the facility failed to maintain accurate and consistent medical records, including incorrect documentation of decision-making authority, missing or delayed documentation of a PICC dressing change, outdated or conflicting smoking assessments and care plans, and inconsistent recording of a resident's fall. These deficiencies involved several residents and were confirmed through observation, record review, and staff interviews.
Surveyors identified widespread environmental and equipment deficiencies, including stained and missing ceiling tiles, damaged molding, holes in walls, and torn or missing wheelchair and Geri-chair armrests. Several residents were affected by these issues, with one resident expressing a need for a replacement armrest and another's room found with tube feeding stains and dirty, ripped fall mats. Staff confirmed awareness of these problems, but many remained unresolved at the time of the survey.
Facility staff did not accurately code MDS assessments for several residents, resulting in failures to document significant weight loss, falls, and the administration of medications such as antibiotics, opioids, hypoglycemics, antiplatelets, and pain relievers. These discrepancies were confirmed through medical record reviews and staff interviews, showing that the MDS did not consistently reflect the care and clinical events experienced by residents.
The facility did not ensure residents received care according to professional standards, including sending a resident with heart failure and seizures to the ER unescorted, failing to document and assess after a resident's fall, not performing required neuro checks after unwitnessed falls, and delaying hospital transfer for a resident with a history of brain hemorrhage. Staff interviews and record reviews confirmed these lapses.
The facility did not consistently monitor and document vital signs as required by physician orders before administering blood pressure medications to three residents. Medications were given outside of prescribed parameters, including instances where heart rate or blood pressure readings should have resulted in holding the medication. The DON and nursing staff confirmed these findings during interviews.
Surveyors observed persistent flies and gnats in multiple facility areas, including resident rooms, hallways, the kitchen, and the rehab gym. A resident reported flies in their room for at least a week, and a fly was seen on a resident in bed with the DON present. Despite regular pest control services and fly lights, staff acknowledged the issue worsened with seasonal changes, indicating the pest control program was not effective.
Staff did not maintain resident dignity in two cases: one resident was fed while staff stood over them instead of sitting at eye level, and another resident with a Foley catheter had their catheter bag left uncovered and visible from the hallway, despite a care plan intervention requiring a privacy bag.
Facility staff did not inform a resident's representative when a new antipsychotic medication, Seroquel, was ordered and administered for depression in a resident with dementia. The lack of notification was confirmed by the DON after review of the medical record showed no evidence of communication regarding the medication change.
A resident's electronic medical record was left open and visible on an unattended medication cart in a hallway, exposing private medication information. An LPN acknowledged the error when informed by a surveyor, and the incident was reported to the DON.
A resident's PlayStation 5 went missing after being placed in facility storage during a hospital transfer. Despite assurances that belongings were secured, the device was not found upon the resident's return. Staff were aware of the loss, but no formal grievance or self-report was documented, and the resident ultimately replaced the item at personal expense.
A resident's PlayStation 5 went missing after being placed in facility storage during a hospital transfer. Despite the resident and a roommate raising concerns and a facility search being conducted, the item was not found, and the resident replaced it independently. The facility did not report the suspected misappropriation to the regulatory agency as required.
A resident's PlayStation 5 went missing after being stored by facility staff during a hospital transfer. Despite the resident's grievance, only a building search was conducted, and no formal investigation or self-report was submitted to the regulatory agency. The resident replaced the item independently after the facility failed to resolve the issue.
A resident admitted with a left arm fracture did not receive a copy of their baseline care plan or admission medication list within 48 hours, as required. Documentation confirming delivery of these documents was incomplete, and the LPN responsible could not recall if the documents were provided.
A resident with hemiplegia and hemiparesis, fully dependent on staff for ADLs, did not receive scheduled showers on multiple occasions despite being care planned and assessed as needing total assistance. The DON confirmed that staff failed to provide showers as scheduled, even after requests from the resident's representative.
A resident who had been assigned readers by an eye doctor did not have glasses after returning from a hospital visit, despite repeatedly requesting assistance from staff. Observations confirmed the absence of glasses, and the DON acknowledged the issue.
A resident with a Stage III pressure ulcer on the right ankle did not receive required weekly skin assessments or timely wound treatments, including a five-day lapse in care after returning from the hospital. The DON confirmed missed assessments and treatments, resulting in a deficiency in pressure ulcer management.
Staff did not ensure that fall mats were correctly positioned for a resident with a history of falls and seizures, despite a care plan requiring mats to be at the bedside. On two occasions, the fall mat was found turned and placed against the wall instead of next to the bed, and this was confirmed by the Unit Manager.
A resident with a history of sepsis and UTI was observed with a Foley catheter and drainage bag touching the floor, in violation of facility policy. The catheter bag was not placed in a dignity bag, and the DON confirmed these lapses in care, which increased the risk of infection.
A resident with malnutrition and a gastrostomy was not assessed by the dietitian in a timely manner after admission and multiple hospital transfers. The DON confirmed that the assessment did not occur within the expected timeframe, as required by facility policy.
A resident with a tracheostomy and an order for humidified oxygen was found with an empty humidification bottle and reported waiting 30 minutes for suctioning after requesting assistance. The DON confirmed the lapse in care, and a nurse delayed suctioning while attending to other duties.
A resident with multiple chronic pain conditions did not receive prescribed pain medications on time due to recurring issues with pharmacy supply, medication order flagging, and delays in reordering. Nursing staff and the ADON confirmed that shortages of Methadone and Dilaudid had occurred, resulting in missed doses and inadequate pain management.
Surveyors found that staff left treatment and medication carts unlocked and unattended, with prescription ointments, creams, and various medications accessible. Some medications were not dated when opened, and expired medications were not discarded as required. Insulin vials and pens lacked proper dating, and medication cups with unidentified pills were found without resident names or labels. LPNs present during the observations acknowledged the lapses and were unable to provide explanations for some of the deficiencies.
A resident who experienced increased heart rate and low-grade fever had a stat EKG ordered by a nurse practitioner. Although an LPN reported that the EKG was performed, the signed and dated EKG report was not filed in the resident's medical record, as confirmed by a review of the electronic record and staff interview.
Facility staff did not arrange or assist with required outside medical appointments for three residents, including follow-ups with gynecology, neurology stroke clinic, and orthopedic surgery, despite physician orders and discharge instructions. Medical records and staff interviews confirmed the lack of scheduling and documentation for these essential services.
Two residents' medical records were found incomplete, with missing documentation of podiatry and orthopedic consults. One resident's record lacked several podiatry notes despite visible foot issues, and another resident's record did not include an orthopedic follow-up report. The DON confirmed these omissions, indicating a failure to maintain accurate and complete records.
The facility did not post up-to-date nurse staffing information, including resident census and actual hours worked by RNs, LPNs, and CNAs, at the start of the shift. Staffing schedules displayed in the lobby and at the nurse's station were outdated, and current information was only provided after the surveyor's inquiry.
Failure to Follow Midodrine Blood Pressure Parameters for Multiple Residents
Penalty
Summary
Facility staff failed to ensure residents’ drug regimens were free from unnecessary drugs by not following physician-ordered blood pressure (BP) parameters for Midodrine administration for three residents. One resident with a history of orthostatic hypotension, recent hospitalization for acute metabolic encephalopathy, infection, acute kidney injury, significant deconditioning, impaired mobility, chronic pain, nutritional deficits, and high fall risk was ordered Midodrine 5 mg, three tablets by mouth three times daily for hypotension, to be held for systolic blood pressure (SBP) greater than 120. The Medication Administration Record (MAR) showed Midodrine was administered on multiple dates when SBP readings were above 120, and on one date it was held when SBP was below 120, contrary to the order. After this resident returned from a hospital stay, the Midodrine order was changed to 10 mg three times daily with the same hold parameter, yet the MAR documented another administration when SBP exceeded 120. The DON later acknowledged awareness of these out-of-parameter administrations when they were brought to her attention. A second resident had a physician’s order for Midodrine 5 mg once daily for hypotension, to be held for SBP greater than 120, but the December and January MARs documented repeated administrations on days when SBP readings were above 120. A third resident had a physician’s order for Midodrine 5 mg three times daily for hypotension, to be held for SBP greater than 110, yet the December and January MARs showed numerous doses given when SBP exceeded 110. Additionally, on one occasion this resident’s SBP was below 110 and Midodrine was not administered, despite the order indicating it should have been given. During interview, the medical director confirmed that staff failed to follow the ordered parameters and expressed concern about Midodrine being administered outside of those parameters.
Failure to Administer Ordered IV Antibiotics and Respiratory Treatments
Penalty
Summary
Facility staff failed to administer medications and treatments as ordered by the physician for Resident #302, who was admitted with pneumonia. Review of the resident’s January 2026 Medication Administration Record on 1/29/26, conducted with the Director of Nursing, showed no documentation that multiple ordered medications and treatments were given. Specifically, there was no documentation that the PICC line was flushed every shift as ordered on the night shift of 1/7/26 and the day shift of 1/10/26. In addition, there was no documentation that Acetylcysteine solution 10 ml by inhalation every 6 hours was administered on 1/8, 1/9, and 1/10/26 at 6 AM, on 1/11/26 at 12 PM and 6 PM, and on 1/12/26 at 6 PM. There was also no documentation that Albuterol sulfate 3 ml via nebulizer every 6 hours was administered on 1/8, 1/9, and 1/10/26 at 6 AM, or that Piperacillin 4.5 grams IV every 6 hours for pneumonia was administered on 1/8, 1/9, and 1/10/26 at 6 AM. In an interview on 1/29/26 at 10:28 AM, the Director of Nursing confirmed these findings. These omissions were identified for 1 of 5 residents reviewed during a complaint survey and demonstrated that the resident did not receive medications and treatments according to physician orders as required.
Failure to Implement Ordered Heel Offloading for Resident With Stage 3 Pressure Ulcer
Penalty
Summary
The facility failed to provide ordered pressure ulcer treatment and preventive services for a resident with an existing right heel pressure ulcer. The resident was admitted with a right heel pressure ulcer and diagnoses including a left pubis fracture, type 2 diabetes mellitus with diabetic neuropathy and hyperglycemia, and severe protein-calorie malnutrition. An admission nursing note documented the presence of the right heel pressure ulcer, and a medical progress note directed staff to offload the right heel continuously with boots and pillows and avoid pressure on the affected area. A subsequent skin and wound note identified the right heel ulcer as Stage 3 and recommended floating the heels while in bed using pillows or boots and ongoing pressure reduction and turning/repositioning precautions per protocol. The January Treatment Administration Record contained a physician’s order to offload heels with green boots as tolerated every shift, and documentation showed the boots were signed off as worn each shift on 1/28/26. Despite these orders and documentation, multiple observations on 1/29/26 showed the resident’s heels were not offloaded as ordered. During the first observation, the resident was in bed on his/her back eating breakfast with both feet lying directly on the mattress, wearing gray slipper socks and no heel boots. When asked, the resident stated that staff sometimes elevated his/her feet but that there was nothing in place at that time. A second observation later that morning again showed the heels resting directly on the mattress without heel boots. A third observation showed a pillow under the bottom of the resident’s legs, with the resident still wearing gray slipper socks and no heel boots present. The DON, upon observing the resident and being informed that staff had been signing off that heel boots were being worn despite no heel boots being in the room, confirmed the finding.
Failure to Implement Fall-Prevention Interventions and Follow Medication Parameters for High-Risk Resident
Penalty
Summary
Facility staff failed to ensure that safety interventions were consistently in place for a resident with a known high risk for falls and fall-related injury. The resident had multiple significant diagnoses, including a left pubis fracture, diabetes with neuropathy and hyperglycemia, altered mental status, severe protein-calorie malnutrition, anemia, and orthostatic hypotension, and had a recent history of falls with head injury, concussion, transient loss of consciousness, and memory impairment. Medical notes documented that the resident was disoriented, had impaired mobility, chronic pain, and was considered a high fall risk, with instructions to maintain fall precautions and optimize the environment, including keeping the urinal and call bell within reach. Despite these documented risks and care plan interventions, observations on the survey date showed the resident lying in bed with the call bell under the bed and not within reach, and the urinal hanging from a nightstand drawer handle approximately four feet away from the bed, also not within reach. There were no fall mats next to the bed, and later observation with the DON showed the bed in a medium-high position rather than in the lowest position as care planned. The resident reported difficulty standing and a history of multiple serious falls with fractures and skull injuries. The LPN present in the room acknowledged that the call bell was under the bed and expressed uncertainty about who was responsible for placing it on the bed. The resident’s care plan identified the resident as being at risk for falls and fall-related injury related to weakness, diabetes, orthostatic hypotension, pain, anemia, and use of cardiovascular and psychotropic medications, with specific interventions such as ensuring the urinal and common items were within reach, keeping the bed in the lowest position, and reminding the resident to use the call light for assistance. Additionally, the physician’s order for Midodrine specified that the medication should be held if the systolic blood pressure was greater than 120, yet the MAR showed the medication was administered when the systolic blood pressure was 128, outside the ordered parameters. The medical director confirmed that the Midodrine should have been held. Therapy staff described the resident as a fall risk, impulsive, and more sedated than previously, and indicated that if the resident could not reach needed items, the resident would attempt to get out of bed despite knowing it was unsafe.
Failure to Obtain Ordered Laboratory Tests for Two Residents
Penalty
Summary
Facility staff failed to obtain ordered laboratory tests for two residents as identified during a complaint survey. For one resident admitted in January 2026 with diagnoses including diabetes and anemia, physician orders dated 1/5/26 directed that a CBC, CMP, and magnesium level be completed on 1/6/26. Review of the medical record on 1/29/26 showed no laboratory results for that date and no nursing documentation explaining why the ordered labs were not completed. In an interview on 1/29/26 at 1:45 PM, the Director of Nursing confirmed that staff did not obtain the physician-ordered laboratory tests for this resident. For another resident admitted with a diagnosis including pneumonia, the medical record showed that a Physician Assistant evaluated the resident on 1/7/26 for abnormal laboratory results and documented an order to repeat a CBC in the morning. A nurse’s note later that night stated that labs from 1/7/26 were reviewed by the Physician Assistant and that the resident already had an order for a CBC in the morning. However, review of the laboratory results revealed that no labs were drawn on 1/8/26. This resident was discharged on 1/13/26 without the repeat CBC having been completed. In an interview on 1/29/26 at 10:28 AM, the Director of Nursing confirmed that the ordered CBC was not obtained for this resident.
Failure to Use Required Hoyer Lift Results in Resident Fracture
Penalty
Summary
A deficiency occurred when a resident, who required a Hoyer lift with two-person assistance for all transfers due to impaired mobility, was not transferred according to their care plan. The resident had a documented need for maximal assistance with transfers and was unable to ambulate. Despite these requirements, a Geriatric Nursing Assistant (GNA) failed to identify and follow the resident's transfer status, attempting to assist the resident without a Hoyer lift or a second staff member. The GNA did not consult the resident's medical chart or seek clarification from nursing staff regarding the appropriate transfer method. During the transfer, the resident attempted to stand and move independently, resulting in a fall and a displaced fracture of the distal femur, as confirmed by radiology. Interviews and documentation revealed that the GNA was present but did not intervene to prevent the resident from transferring unsafely, nor did they seek additional help. The resident reported attempting to transfer from a wheelchair to bed, referencing recent therapy sessions but ultimately being unable to move their feet and falling. The Director of Nursing and Director of Rehabilitation both confirmed that the resident required a Hoyer lift with two-person assistance at the time of the incident, and that the staff member failed to follow established protocols for safe transfers.
Failure to Follow Hospice Pain Management Orders Resulting in Resident Harm
Penalty
Summary
Facility staff failed to follow hospice pain management orders for a resident admitted with a terminal illness, resulting in unmanaged pain and harm. The resident had active orders for scheduled and as-needed morphine, with instructions to administer the medication every four hours, including waking the resident if asleep. Despite these orders, there was a significant gap of approximately 18 hours and 39 minutes during which no morphine was administered, as confirmed by a review of the medication administration record and the facility's narcotic log. Documentation inconsistencies were found, with doses recorded on the MAR but not on the narcotic log, and some doses not matching the prescribed amount. Staff interviews revealed that the resident experienced a pain crisis, characterized by symptoms such as tremoring, foaming at the mouth, minimal responsiveness, and moaning. Multiple staff members, including nursing and hospice personnel, acknowledged that the resident's pain was not managed according to the orders, and that the family expressed concern about the lack of pain control. The narcotic log showed crossed-out and rewritten orders, missing RX numbers, and a lack of proper documentation for medication administration. Staff also reported that no action was taken to address the failure in medication administration or to prevent recurrence. Leadership interviews indicated a lack of awareness and oversight regarding the incident. The DON and ADON were not informed of the pain crisis, and upon review, the DON confirmed that procedures for documenting and administering controlled medications were not followed. The DON also acknowledged that pain should have been controlled for a resident receiving hospice services and that the facility's procedures were not adhered to, as evidenced by the discrepancies between the MAR and narcotic log.
Failure to Honor Resident Financial Rights and Provide Ongoing Access to Personal Funds
Penalty
Summary
The facility failed to honor a resident's right to manage their own financial affairs and did not obtain written authorization to act as a fiduciary for the resident's funds. One resident reported that their Social Security payments stopped being deposited into their personal bank account after a facility physician signed a statement indicating the resident could not handle their finances. The resident was not informed about the change, denied access to their funds and statements, and was unable to obtain necessary documents or legal assistance. Record review showed that the resident was assessed as cognitively intact and had multiple physician certifications indicating adequate decision-making capacity, including for financial matters. However, the facility submitted an SSA-787 form stating the resident was incapable of managing funds, resulting in the facility being assigned as Representative Payee without proper communication or documentation of a change in capacity. Interviews with facility staff revealed that the decision to pursue Representative Payee status was based on the resident's outstanding unpaid bill, not on a documented change in mental capacity. The Business Office Manager and physician confirmed that no additional assessments or consults were conducted to support the claim of financial incapacity. The resident was not provided with statements or timely access to their funds until after surveyor intervention, and there was no evidence of communication to the resident regarding the change in management of their Social Security benefits. Additionally, the facility did not have a system in place to allow residents ongoing access to their personal funds. Residents could only withdraw money during business hours on weekdays, and there was no provision for access after hours or on weekends. There were also instances when the facility ran out of petty cash, further restricting residents' ability to access their funds as needed.
Failure to Ensure Resident Dignity, Self-Determination, and Access to Services
Penalty
Summary
Surveyors identified multiple deficiencies related to residents' rights to dignity, self-determination, and communication. One resident reported that care plan meetings were held at bedside with only a social worker present, and that they received only a care plan report and grievance form without meaningful discussion or support from other staff. The resident also experienced missed medical appointments for over a year due to the facility providing a replacement wheelchair that was too large for available transportation, despite being approved for a power wheelchair that was never received due to unpaid facility bills. The resident further reported a lack of support in discharge planning to return to their home state, loss of access to personal funds after the facility became their Social Security Representative Payee without proper communication or documentation, and an inability to obtain personal documents or legal assistance due to lack of funds. Record reviews confirmed the resident was cognitively intact and had decision-making capacity, yet the facility initiated the payee process citing incapacity, and failed to provide statements or timely access to personal funds. Surveyors also observed staff repeatedly entering residents' rooms without knocking or requesting permission, despite previous resident complaints and administrative awareness of the issue. Multiple residents confirmed that staff often failed to announce themselves before entering, and this concern had been reported to facility administration but remained unresolved. Direct observations by surveyors corroborated these reports, with staff entering rooms unannounced during the survey period. Additionally, residents reported not having access to their personal clothing, particularly on weekends, due to ongoing staffing shortages in the facility's laundry services. One resident was found to have no clothing in their room except for the outfit they were wearing, which they had slept in, while another was observed wearing a hospital gown and expressed a preference for personal clothing. The Director of Housekeeping confirmed that the position responsible for laundering personal items on weekends had been unfilled for months, resulting in extended wait times for laundry return and residents lacking appropriate clothing.
Failure to Maintain Effective Pest Control Program
Penalty
Summary
The facility failed to maintain an effective pest control program, resulting in the presence of pests such as flies, gnats, and ants in multiple areas. During observation rounds, a resident's room was found to have numerous black insects flying near and on the resident, their bed, and privacy curtain. The resident reported that flies were landing on their head, food, and bed. Additional observations on subsequent days revealed that the issue persisted, with several insects still present in the same room. Staff were made aware of the situation during these observations. Further inspection of other units revealed flies and gnats in hallways and shower rooms, as well as a trail of ants in another resident's room, attracted to food particles on the floor. These findings were confirmed by facility staff, including a GNA and a Unit Manager. Interviews with residents also indicated ongoing issues with flies and gnats throughout the building. The Director of Maintenance later confirmed that a pest control company visits the facility weekly, but the presence of pests remained evident during the survey.
Failure to Protect Resident from Physical Abuse by Staff
Penalty
Summary
A facility failed to protect a resident from physical abuse perpetrated by an employee. The incident involved a Geriatric Nursing Assistant (GNA) who was observed by a laundry department staff member slapping a resident on the right cheek while attempting to assist the resident off an elevator. The resident was later reported by hospital staff to have stated being hit on the left side of the face by a staff member while at the facility. The incident was witnessed and reported by the laundry assistant, and the facility became aware of the event on the same day it occurred. Following the incident, the resident was sent to the hospital for a CT scan of the head, which was negative, and subsequently returned to the facility. The facility's internal investigation confirmed the physical assault by the GNA. The surveyor reviewed the incident through medical records, administrative records, interviews, and direct observation, confirming that the facility did not protect the resident from physical abuse as required.
Failure to Ensure Resident Participation and IDT Involvement in Care Planning
Penalty
Summary
The facility failed to ensure that residents were able to participate in the development, review, and revision of their care plans as required. For two residents reviewed, care plan meetings were conducted only at the bedside and attended solely by Social Services staff, without participation from the full Interdisciplinary Team (IDT). Residents reported that these meetings were not helpful, as the Social Worker present was unable to answer questions about medical care or business concerns, and residents were simply given a copy of their care plan and a grievance form. Documentation reviewed confirmed that only Social Services staff and the resident signed the care plan meeting sign-in sheets, with rare attendance by other disciplines. No evidence was found that the required IDT members participated in these meetings. Additionally, residents expressed dissatisfaction with the process, stating that their concerns, such as those related to depression or facility policies, were not addressed during the meetings. The Director of Social Services confirmed that the IDT was invited but did not usually attend bedside meetings, and no further documentation was available to support full IDT involvement. The lack of comprehensive team participation and inadequate opportunity for residents to discuss their care needs led to the deficiency.
Failure to Provide Adequate Medically-Related Social Services
Penalty
Summary
The facility failed to provide medically-related social services necessary for residents to attain or maintain their highest practicable physical, mental, and psychosocial well-being. One resident reported that care plan meetings were only attended by the social worker, with no other staff present to discuss care or address multiple concerns. The resident experienced missed medical appointments for over a year due to the loss of a wheelchair that fit into available transportation, and the replacement wheelchair was too large for the facility's only taxi service. Although the resident was approved for a power wheelchair, it was never received due to an unpaid bill. The resident also reported a lack of support for discharge planning to return to their home state and was not provided assistance in recovering lost personal documents or accessing personal funds after the facility became the resident's representative payee. Documentation showed the resident was cognitively intact, yet the facility submitted paperwork to Social Security indicating the resident was incapable of managing finances, without corresponding progress notes or communication to the resident about this change. Another resident expressed a desire to return to the community but was unable to do so due to lack of access to personal funds and was not informed about available programs such as the Waiver Program. The social services staff indicated that the resident's family was receiving survivor's benefits and paying privately, but no further assistance or documentation was provided to support the resident's expressed interest in community discharge. The care plan noted the need to assess the resident's preference for community return, but there was no evidence of follow-up or action taken in response to the resident's requests. A third resident, who had a court-appointed guardian, reported dissatisfaction with the guardian's support and expressed a desire for their granddaughter to become their power of attorney or guardian. The resident stated that requests for assistance in changing guardianship were met with dismissals about excessive paperwork. Documentation confirmed the resident was cognitively intact and had communicated their wishes, but there was no evidence of effective social services intervention to facilitate the requested change. These findings collectively demonstrate the facility's failure to provide adequate social services to support residents' rights, preferences, and access to necessary resources.
Failure to Assist Resident with Transportation for Medical Appointments
Penalty
Summary
The facility failed to assist a resident in making appropriate transportation arrangements to and from laboratory services outside of the facility, resulting in multiple missed medical appointments. The resident reported missing appointments for over a year due to the loss of their original wheelchair, which was compatible with the facility's contracted cab service. The replacement wheelchair provided by the facility was larger and could not fit in the available taxi, and the resident had not received an approved power wheelchair due to delays in payment processing. Despite the resident's repeated requests for assistance, including communication with the Social Worker, no effective solution was provided, and the resident was only given grievance forms without resolution. Record reviews confirmed that the resident missed several appointments because the available transportation could not accommodate the larger wheelchair. Staff interviews revealed that the facility was limited to scheduling with a single taxi service, which could not transport the resident's current wheelchair, and alternative transportation options were not pursued. The Director of Rehab Services confirmed that the resident was approved for a power wheelchair, but the facility's billing process delayed payment, preventing the resident from receiving the necessary equipment. Communication between facility staff and regional business offices showed ongoing delays in processing the invoice for the power wheelchair, with no payment status available at the time of the survey.
Failure to Maintain Accurate and Consistent Medical Records
Penalty
Summary
The facility failed to maintain accurate and up-to-date medical records for several residents, as evidenced by multiple discrepancies and omissions in documentation. For one resident, the care plan sign-in sheet and face sheet incorrectly listed a family member as the power of attorney for health care decisions, despite documentation showing the resident had decision-making capacity and the power of attorney was only for financial matters. The care conference invitation was also misaddressed, and the error was only identified after surveyor intervention. Another resident's peripherally inserted central catheter (PICC) dressing was observed without a date or time, and there was no documentation of a dressing change in the medical record, even though the change was reportedly performed. Additionally, two residents' smoking status assessments and care plans were not updated to reflect their current abilities and preferences. One resident was listed as an independent smoker on the facility's list, but the medical record and care plan still indicated the need for supervision, while another resident's assessment failed to indicate they smoked, despite care planning for independent smoking. A further deficiency was noted in the documentation of a resident's fall. Progress notes contained conflicting dates and times regarding when the fall occurred, with some notes indicating different days and times for the same incident. Staff confirmed that only one fall had occurred, but the medical record did not accurately reflect this, leading to confusion and inconsistency in the resident's documentation.
Environmental and Equipment Deficiencies Impact Resident Comfort and Safety
Penalty
Summary
Facility staff failed to maintain a safe, clean, and comfortable environment for residents, as evidenced by multiple environmental deficiencies observed during a complaint survey. On two of three nursing units, surveyors noted numerous stained and missing ceiling tiles, missing or damaged molding around over-the-bed tray tables, and exposed or damaged wall areas. In several resident rooms, there were holes in the walls, spackle left unpainted, torn wallpaper, and gaps in base molding. These issues were observed throughout the second-floor nursing unit, as well as in administrative offices, indicating a widespread lack of maintenance and housekeeping. Additional deficiencies were observed in resident equipment and furnishings. Several residents were found using wheelchairs with missing or damaged armrests, exposing foam or padding, and in one case, a resident expressed a desire for a replacement armrest. In the dining room, a resident's Geri-chair had a torn armrest with exposed padding. In another room, tube feeding stains were present on the floor, and fall mats were dirty, ripped, and had exposed padding. These conditions were confirmed by staff during the survey. Interviews with the Maintenance Director revealed that the facility was aware of the ceiling tile issues, which were attributed to a malfunctioning rooftop air conditioning unit causing condensation and leaks. The Maintenance Director also described ongoing efforts to replace damaged tray tables and repair wheelchairs, relying on reports from staff and a maintenance program. However, as of the time of the survey, many of these environmental and equipment deficiencies remained unaddressed, directly impacting the residents' living conditions.
Inaccurate Coding of MDS Assessments for Multiple Residents
Penalty
Summary
Facility staff failed to ensure that Minimum Data Set (MDS) assessments were accurately coded for multiple residents, as evidenced by discrepancies between the MDS documentation and the residents' medical records. In several cases, the MDS did not reflect significant clinical events or medication administration, such as substantial weight loss, falls, and the use of specific medications including antibiotics, opioids, hypoglycemics, antiplatelets, and pain relievers. For example, one resident experienced a weight loss of over 20 pounds, but the MDS did not indicate a 10% or greater weight loss. Another resident had two documented falls, but the MDS assessment stated no falls had occurred during the relevant period. Additional deficiencies were noted in the failure to accurately document medication administration. Several residents received medications such as insulin, antibiotics, opioids, antiplatelets, and pain medications, but these were not captured in the corresponding MDS assessments. In one instance, a resident received both scheduled and PRN pain medications, as well as topical antibiotics, but the MDS failed to record these treatments. Similarly, another resident received a PPD injection for tuberculosis screening, which was not documented in the MDS. These inaccuracies were confirmed through interviews with MDS coordinators and review of medication administration records (MARs). The findings indicate that the facility did not consistently ensure that the MDS assessments accurately reflected the residents' clinical status and care provided during the assessment periods, as required by federal regulations.
Failure to Provide Care and Timely Response After Falls and Medical Events
Penalty
Summary
The facility failed to provide treatment and care in accordance with professional standards of practice for multiple residents. In one instance, a resident with chronic congestive heart failure, seizures, diabetes, and anxiety was ordered by a physician to be sent to the emergency room for fluid overload and seizure activity. The resident was transported via non-emergency taxi without an escort, resulting in the resident waiting 20 minutes outside the emergency room before being assisted inside. Staff interviews revealed inconsistent practices regarding escorts for non-emergency transports, and the physician was not aware that the resident was unescorted. In another case, a resident who fell off the bed did not have the incident documented in the medical record on the day of the fall, and there were no follow-up assessments or timely physician notification. The first documentation occurred at least 12 hours after the fall, and vital signs recorded did not correspond to the time of the incident. The facility's policy required immediate notification and monitoring after a fall, which was not followed. The LPN involved admitted to forgetting to document the incident and not being familiar with the process at the time. Additional deficiencies included failure to conduct and document neurological checks after unwitnessed falls for two residents, despite facility policy requiring specific intervals for such assessments. In one case, neuro checks were not performed at all after four unwitnessed falls, and in another, the checks were completed at incorrect intervals and with inaccurate data. Furthermore, a resident with a history of intracerebral hemorrhage and recent skull surgery was not sent to the emergency room in a timely manner after a fall, despite an order for immediate transfer for imaging. These findings were confirmed through medical record reviews and staff interviews.
Failure to Monitor Vital Signs Prior to Medication Administration
Penalty
Summary
The facility failed to ensure that residents' drug regimens were free from unnecessary drugs by not adhering to physician orders regarding the monitoring of vital signs prior to medication administration. For one resident prescribed Carvedilol for hypertension, the physician's order required holding the medication if the heart rate was less than 50, but there was no documentation that heart rate was consistently monitored before administration. Similarly, another resident receiving Hydralazine for hypertension had an order to hold the medication if systolic blood pressure was less than 110, yet the medication was administered when the blood pressure was 100/62. In both cases, the Director of Nursing confirmed that the required monitoring was not performed as ordered. A third resident, with a history of orthostatic hypotension, was prescribed Midodrine with specific parameters to hold the medication if blood pressure exceeded certain thresholds. The medication was administered multiple times outside of these parameters, as documented in the Medication Administration Records. Interviews with nursing staff and the Director of Nursing confirmed that medications were given even when vital signs were outside the prescribed limits, and that the required monitoring and documentation were not consistently performed.
Failure to Maintain Effective Pest Control Program
Penalty
Summary
The facility failed to maintain an effective pest control program, as evidenced by the presence of numerous flies and gnats throughout multiple areas. Surveyors observed flies and gnats in the conference room, first-floor hallways, resident rooms, the kitchen, the rehab gym, and the conference room over the course of a week. In one instance, a resident reported that flies had been present in their room for at least a week and found them to be annoying. Additionally, a fly was observed on a resident while they were lying in bed with the DON present. Flies were also seen in the kitchen, including on storage racks and around the serving table during food plating. Staff interviews revealed that fly lights had been installed in the hallways and kitchen for the past two years, and pest control services were provided approximately twice a month, including spraying and treating drains. Despite these measures, staff acknowledged that the fly problem typically worsened at the beginning of summer. Pest control invoices confirmed regular service visits, but the persistent presence of pests indicated that the program was not effective in preventing or controlling infestations during the survey period.
Failure to Maintain Resident Dignity During Feeding and Catheter Care
Penalty
Summary
Facility staff failed to uphold residents' rights to dignity and privacy in two observed instances. In the first case, a geriatric nursing assistant was observed feeding a resident while standing over them, rather than sitting at eye level, which did not promote a dignified dining experience. In the second case, a resident with a Foley catheter, who had recently been admitted from the hospital with a urinary tract infection, was observed in bed with the catheter bag hanging visibly from the bed frame and not placed in a privacy or dignity bag, despite the resident's care plan specifying the use of a catheter privacy bag. Both deficiencies were directly observed by surveyors and confirmed with facility leadership.
Failure to Notify Resident Representative of New Medication Order
Penalty
Summary
Facility staff failed to notify a resident's representative when a new medication, Seroquel, was ordered for the resident. The resident, who had a diagnosis including dementia, was admitted in November 2024. On 12/18/24, the physician ordered Seroquel 25 mg in the morning and two tablets at bedtime for depression. There was no documentation in the medical record indicating that the resident's representative was informed of this new medication order. The medication was administered on 12/18/24 and 12/19/24, and subsequently discontinued after the resident was seen by the physician on 12/19/24. The Director of Nursing confirmed that the representative was not notified of the medication order.
Failure to Maintain Resident Medical Record Confidentiality
Penalty
Summary
Facility staff failed to maintain the privacy and confidentiality of a resident's medical records when an electronic medical record was left open and visible on a computer screen atop an unlocked and unattended medication cart in a hallway. The unattended cart, located outside a resident's room, displayed the resident's medications and allowed access to additional information. This lapse was observed by a surveyor, and the responsible LPN acknowledged leaving the computer screen open by mistake. The incident was brought to the attention of the Director of Nursing.
Failure to Safeguard Resident's Personal Property
Penalty
Summary
The facility failed to protect a resident's personal property from misappropriation. When the resident was transferred to the hospital, facility staff packed the resident's belongings and placed them in storage, assuring the resident that the items were secured. Upon the resident's return, the PlayStation 5 was missing. Multiple staff members, including the social work director and the ADON, were aware of the missing item, and a building search was conducted, but the device was not found. The resident ultimately replaced the PlayStation 5 at personal expense after waiting for a facility response. Interviews with staff and the resident's roommate confirmed that the PlayStation 5 had been missing since the resident's hospitalization, and the issue had been reported through various channels, including the Ombudsman. The current NHA was unable to locate a self-report or grievance related to the incident and could not determine a timeline or confirm the existence of the device. Documentation provided by the resident showed proof of purchase for a replacement PlayStation 5. The facility did not maintain adequate records or follow up on the reported loss, resulting in a failure to safeguard the resident's property.
Failure to Report Alleged Misappropriation of Resident Property
Penalty
Summary
The facility failed to report an allegation of misappropriation of property to the regulatory agency, specifically regarding a missing PlayStation 5 belonging to a resident. The incident occurred after the resident was transferred to the hospital, at which time the facility packed and stored the resident's belongings. Upon the resident's return, the PlayStation was missing, and the resident was informed that the items had been secured, but the location of the PlayStation could not be determined. The resident ultimately replaced the item independently after not receiving a resolution from the facility. Interviews with the resident's roommate and facility staff confirmed that the PlayStation was not found despite a building search, and there was no documentation of a self-report to the Office of Health Care Quality (OHCQ) regarding the missing property. The current Nursing Home Administrator was unaware of a self-report or the specific date of the incident, indicating that the required reporting procedures for suspected misappropriation were not followed.
Failure to Investigate and Report Misappropriation of Resident Property
Penalty
Summary
The facility failed to conduct a complete investigation into an allegation of misappropriation of property involving a resident's PlayStation 5. When the resident was transferred to the hospital, the facility packed and stored the resident's belongings, assuring the resident that the items were secured. Upon the resident's return, the PlayStation was missing, and the resident reported the loss to the facility. Despite the grievance being brought to the attention of the then Nursing Home Administrator, only a building search was conducted, and the item was not found. The resident ultimately replaced the PlayStation independently after receiving no resolution from the facility. Additionally, the facility did not submit a self-report or provide an investigation to the regulatory agency, the Office of Health Care Quality (OHCQ), as required. Interviews with staff and the current Nursing Home Administrator confirmed that no formal investigation or regulatory notification was completed regarding the missing property. The deficiency was identified during a complaint survey, with evidence from interviews and review of the complaint documentation.
Failure to Provide Baseline Care Plan and Medication List Upon Admission
Penalty
Summary
The facility failed to provide a resident and/or their responsible party with a copy of the baseline care plan and a list of admission medications within 48 hours of admission, as required. The deficiency was identified during a complaint survey involving a resident admitted with a nondisplaced fracture of the lateral condyle of the left humerus and a cast on the left arm. The resident was their own responsible party and had requested communication multiple times without receiving a response. A review of the resident's medical record showed that while the baseline care plan was initiated and reviewed with the resident, there was no documentation that copies of the baseline care plan and medication list were given to the resident or responsible party. The section of the record intended to confirm this action was left blank. During an interview, the LPN/unit manager responsible for the process could not recall if the documents were provided and confirmed there was no evidence of their delivery.
Failure to Provide Scheduled Bathing Assistance to Dependent Resident
Penalty
Summary
Facility staff failed to provide scheduled bathing assistance to a resident who was totally dependent on staff for activities of daily living due to hemiplegia and hemiparesis following a cerebral infarction. The resident was care planned and assessed as dependent for bathing, with showers scheduled for Mondays and Thursdays. Despite requests from the resident's representative, documentation showed that the resident did not receive showers on several scheduled days between admission and discharge. The Director of Nursing confirmed that staff did not administer showers as scheduled on these dates.
Failure to Provide Resident with Needed Glasses
Penalty
Summary
Facility staff failed to ensure that a resident had access to necessary vision services, specifically eyeglasses. The resident reported to staff that their glasses had been missing since returning from a hospital visit the previous year and stated that they had repeatedly asked staff for assistance in obtaining new glasses. Observations on two separate occasions confirmed that the resident did not have glasses. Medical record review showed that the resident had been seen by an eye doctor, who documented that the resident was assigned readers, but the resident still did not have glasses at the time of the survey. The Director of Nursing confirmed that the resident did not have glasses.
Failure to Provide Consistent Pressure Ulcer Care and Assessments
Penalty
Summary
Facility staff failed to provide appropriate treatment and services to prevent and heal pressure ulcers for a resident with a history of a Stage III pressure ulcer on the right ankle. The resident was admitted in October 2022 with this diagnosis, and a Wound Nurse Practitioner assessed the wound as a Stage III pressure ulcer on 12/31/24. Medical record review revealed that staff did not complete required weekly skin assessments, including measurements and treatment recommendations, on 2/11, 2/18, 3/20, and 3/27/25. Additionally, after the resident returned from the hospital on 2/27/25, facility staff failed to provide any wound treatment for the right ankle pressure ulcer until 3/4/25, resulting in a five-day gap in care. The Director of Nursing confirmed that weekly skin assessments and wound treatments were not performed on the specified dates, indicating a lapse in the facility's pressure ulcer care and prevention protocols.
Failure to Ensure Proper Placement of Fall Mats for Resident with Fall Risk
Penalty
Summary
Facility staff failed to ensure that fall mats were properly positioned for a resident with a history of falls and a diagnosis including seizures. The resident was admitted in March 2025 and had experienced a fall on 4/19/25, after which a care plan was initiated specifying that fall mats should be placed on the floor at the bedside while the resident was in bed. On two separate observations on 6/25/25, the fall mat intended for the left side of the resident's bed was found turned and placed against the wall at the head of the bed, rather than next to the bed as required by the care plan. The Unit Manager confirmed that the fall mat was not in the correct position and acknowledged that the resident was supposed to have fall mats next to the bed at all times.
Failure to Maintain Proper Catheter Care and Infection Control
Penalty
Summary
A deficiency was identified when a resident with a Foley catheter was observed lying in bed with the catheter and urine visible from the hallway. The bottom of the catheter collection bag and the blue tubing were noted to be touching the floor, contrary to the facility's Urinary/Catheter Care Policy, which specifies that drainage bags should not touch the floor. Additionally, the catheter collection bag was not placed in a dignity bag as required. The Director of Nursing confirmed these findings during the surveyor's visit to the resident's room. The resident had a significant medical history, including multiple hospital admissions for sepsis, urinary tract infection, and bacteremia. The most recent hospitalization involved the placement of a Foley catheter and treatment for a pseudomonas UTI. Upon return to the facility, the Foley catheter was not changed, and the improper handling of the catheter and drainage bag was observed, increasing the risk of infection as documented in the facility's policy.
Delayed Dietitian Assessment for Resident at Risk of Malnutrition
Penalty
Summary
Facility staff failed to ensure timely nutritional assessment for a resident with a diagnosis of malnutrition and a gastrostomy. The resident was admitted with these conditions and experienced multiple hospital transfers and returns. Despite the resident's high risk for malnutrition, the dietitian did not assess the resident until several days after the most recent readmission. The Director of Nursing confirmed that the facility's expectation is for the dietitian to assess residents within the week of admission, but this did not occur for this resident, as documented in the medical record and confirmed during interview.
Failure to Provide Timely Respiratory Care and Humidified Oxygen
Penalty
Summary
Facility staff failed to provide necessary respiratory care for Resident #12, who has a tracheostomy and a physician's order for humidified oxygen. During observation, the resident was found in bed with an empty humidification bottle attached to their oxygen setup. The resident reported having requested suctioning approximately 30 minutes prior, but only a GNA had entered the room, and a nurse had not yet performed the suctioning. The Director of Nursing confirmed the empty humidification bottle and the resident's unmet request for suctioning. The Unit Manager, after being notified, delayed suctioning the resident while performing other tasks before eventually returning to provide the care. Medical record review confirmed the resident's need for humidified oxygen and tracheostomy care, and the DON acknowledged the failure to meet the resident's respiratory needs.
Failure to Provide Timely Pain Medication Due to Pharmacy and Reordering Issues
Penalty
Summary
The facility failed to provide timely pharmaceutical services to meet the needs of a resident with complex pain management requirements. The resident, admitted with systemic sclerosis with polyneuropathy, bilateral below-knee amputations, phantom limb pain, muscle spasms, type 2 diabetes with neuropathy, and chronic pain, was prescribed multiple pain medications including Gabapentin, Methadone, hydromorphone (Dilaudid), and Acetaminophen. There were repeated instances where the facility ran out of the resident's pain medications, particularly Methadone and Dilaudid. Staff interviews confirmed that medication shortages had occurred, with the Assistant Director of Nursing (ADON) acknowledging ongoing issues with pharmacy supply and timely reordering, despite previous attempts to resolve the problem. On the day of the survey, the resident reported not receiving Methadone since the previous night due to the facility being out of stock, a situation corroborated by both nursing staff and the ADON. The ADON indicated that the pharmacy had flagged the medication order, but there was no notification received that morning, and the medication had not arrived as expected. The issue was attributed to problems with pharmacy communication, medication dosage flagging, and delays in reordering, resulting in the resident not receiving prescribed pain management as ordered.
Unsecured Medication Carts and Improper Medication Management
Penalty
Summary
Facility staff failed to keep treatment and medication carts locked when unattended and did not properly date or discard medications and biologicals as required. On two separate nursing units, surveyors observed unlocked and unattended carts containing prescription ointments, creams, and various medications. Some medications, such as Mupirocin ointment, were found without caps, and others, like Ketoconazole cream and Betamethasone Dipropionate, were dispensed months prior and not discarded. Additionally, medication cups with unidentified pills were found in the cart drawers without any resident names or labels. Further review revealed that insulin vials and pens were not dated when opened, and some, such as Lispro insulin, were kept beyond the manufacturer's recommended 28-day use period after opening. Staff members present during these observations acknowledged the lapses, with one LPN unable to explain the presence of multiple medication cups or the correct expiration period for insulin. The facility's own policy requires that medication carts be locked when unattended and that all medications be properly labeled and discarded when expired, but these procedures were not followed during the survey.
Failure to File Signed and Dated EKG Report in Medical Record
Penalty
Summary
The facility failed to file a signed and dated EKG report in the medical record for one resident. The resident had experienced an increased heart rate and low-grade fever, prompting a nurse to consult with a nurse practitioner, who ordered a stat EKG, chest x-ray, and urinalysis. Although the EKG was reportedly performed later that day, a review of the resident's medical record did not contain any evidence of the EKG being completed or filed, as confirmed by both the electronic results tab and the miscellaneous section of the record. During an interview, the LPN explained that the EKG should have been downloaded into the medical record but was not, resulting in the absence of the required documentation.
Failure to Arrange Required Outside Medical Appointments
Penalty
Summary
Facility staff failed to arrange and assist residents in obtaining required outside professional services as ordered by their physicians. In one case, a resident with a history of perineal bleeding and suspected endometrial thickening had a physician's order to schedule a gynecology appointment, but there was no documentation that the appointment was ever scheduled or attended. The Director of Nursing confirmed the absence of any record regarding the gynecology appointment. Additionally, another resident admitted after an intracerebral hemorrhage was ordered to follow up at a neurology stroke clinic, but the appointment was not kept, and the facility staff canceled it despite family involvement. A third resident, admitted for rehabilitation following orthopedic surgery, was not scheduled for the required orthopedic follow-up prior to discharge, and there was no documentation of such an appointment in the discharge plan. These findings were confirmed through medical record review and staff interviews.
Failure to Maintain Complete and Accurate Medical Records
Penalty
Summary
The facility failed to maintain complete and accurate medical records in accordance with accepted professional standards for two residents. For one resident admitted with a diagnosis of Tinea Unguium, the medical record did not contain documentation of several podiatry visits, despite the resident exhibiting elongated, thickened toenails and dry, cracked skin upon observation. The missing podiatry notes were later obtained from the podiatrist's office but were not present in the resident's official medical record at the time of review. The Director of Nursing confirmed the absence of these records in the resident's file. For another resident admitted for rehabilitation following an orthopedic procedure, the medical record lacked documentation of an orthopedic follow-up appointment, including the findings and recommendations from that visit. The Director of Nursing confirmed that the consult report from the orthopedic follow-up was not included in the resident's medical record. These omissions demonstrate a failure to safeguard and maintain resident-identifiable information and medical records as required.
Failure to Post Current Nurse Staffing Information
Penalty
Summary
The facility failed to post the required daily nurse staffing information, including the resident census and the total number and actual hours worked by Registered Nurses, Licensed Practical Nurses, and Certified Nursing Aides, at the beginning of the shift. Upon entrance to the facility and observation of the lobby and first floor nurse's station, the posted staffing schedules were found to be dated several days prior and not current for the day of the survey. The staffing coordinator provided updated schedules only after being approached by the surveyor, confirming that the required information had not been posted at the start of the shift as mandated.
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The facility did not ensure that its Infection Preventionist (IP) met required qualifications for managing the Infection Prevention and Control Program. The DON reported serving as the IP but acknowledged lacking the specialized infection control training required for the role, and confirmed that no other staff member was currently qualified. Records showed that the previously qualified IP left several months earlier, and the Administrator and DON confirmed they were still seeking a replacement, leaving the infection control program without a properly trained leader.
Staff failed to consistently secure medications and medical supplies across three units, including an oxygen tank left on the floor behind a resident’s bed without a supporting device, a treatment cart with Collagenase Santyl cream left on top while two residents in power wheelchairs passed by, an unattended and unlocked treatment cart at a nursing station, and another treatment cart with Diclofenac gel and dressings left on top, indicating repeated lapses in maintaining locked and secure storage for drugs, biologicals, and related supplies.
The facility failed to provide sufficient dietitian coverage and timely nutritional assessments for several residents with significant dietary needs. A resident admitted for diabetic management with a high A1C was placed on a regular diet instead of the recommended carb-controlled diet and had only one weight taken in the first two weeks, with no dietitian review of the record. Another resident with prior significant weight loss had no documented dietitian follow-up despite continued weight loss, and a resident admitted with severe protein-calorie malnutrition experienced further significant weight loss without any dietitian assessment. The dietitian reported working limited hours and prioritizing certain high-risk cases, resulting in delayed or missed evaluations for new admissions and residents with ongoing nutritional concerns.
The facility failed to maintain adequate linen and incontinence supplies and did not keep resident care areas in good repair, resulting in delays and alterations in incontinence care and substandard environmental conditions. Staff reported that towels and washcloths were used instead of wipes and then discarded due to heavy soiling, and that linen deliveries to units were late, leaving residents waiting for care. Observations showed very limited numbers of clean washcloths and other linens on units and in the laundry, with no stock of disposable wipes or backup washcloth supply despite repeated reports to housekeeping. Additional observations revealed recliner chairs blocking a dining-area handwashing sink and kitchenette, multiple resident and shared bathrooms with unfinished spackle, chipped paint, musty odors, black substances near showers, missing threshold molding, exposed cracks and nails, and eroded, rusted baseboard heaters. Hallway handrails on both units were worn, chipped, and splintered, and a shower room contained fecal odors, dried brown stains on the toilet, and deteriorated fixtures, all contributing to a failure to provide a safe, clean, and homelike environment.
Facility staff did not thoroughly investigate two separate abuse allegations involving a resident and an injury of unknown origin involving another resident. In both cases, investigations focused on the directly affected resident and included staff interviews, but there were no interviews of other residents on the unit or documented assessments of those residents for signs of abuse or injuries of unknown origin, including residents unable to communicate due to cognitive status.
Two residents who were dependent on staff for oral care, including one with a tracheostomy, were observed with thick, white or milky substances coating their mouths and teeth, indicating inadequate oral hygiene. One resident communicated that staff did not brush their teeth and that staff "need to." In another case, despite oral care supplies being present in the room, the resident’s mouth and teeth remained unclean on multiple observations, with a thick milky substance caking the teeth and stringing between them when the resident tried to open their mouth. These findings showed that staff did not consistently provide oral care to residents who relied on them for this ADL.
Staff failed to maintain complete and accurate medical records for multiple residents, including missing and inconsistent documentation of wound care, delayed pain assessment after discovery of an injury of unknown origin in a cognitively impaired resident, and inaccurate recording of a PPD test result that was documented as negative despite no evidence the injection was administered and no supporting nurse’s note. Residents reported not receiving certain treatments, while MAR entries either lacked signatures for completion or contained conflicting information about whether care was provided.
Surveyors found that the facility failed to consistently implement and communicate correct transmission-based precautions and PPE use. One resident with a Foley catheter related to wounds had no precaution signage posted, while another resident in a double room had a contact precautions sign at the door, yet the NP entered without PPE and the GNA provided high-contact care wearing only gloves. Staff in that room stated the resident was not on contact precautions and later reversed the sign to show no PPE requirement. Therapy staff reported they rely solely on posted signs to determine PPE, and surveyors identified broader issues with inaccurate signage and staff awareness of which residents required contact precautions.
Surveyors found that MDS assessments were inaccurately coded for two residents. In one case, a resident sustained a femoral neck fracture after a fall, but the subsequent significant change MDS did not code the fall as a major injury and failed to capture prn Tylenol use documented on the MAR within the look-back period. In the other case, a quarterly MDS indicated opioid use for a resident, but the MAR for the same period showed no prescribed opioid, indicating incorrect coding of high-risk drug classes.
A resident who had recently been admitted and experienced a fall received multiple doses of the narcotic analgesic Tramadol, but the facility failed to accurately document all administered doses on the Medication Administration Record (MAR). Review showed only one Tramadol dose recorded on the MAR, while the Controlled Drug Receipt/Record/Disposition Form on the med cart reflected three doses given over two days. In interview, the DON stated staff are expected to document narcotic administration on the MAR and confirmed that two administered doses were not recorded there, resulting in an incomplete and inaccurate medical record.
Unqualified Infection Preventionist Overseeing Infection Control Program
Penalty
Summary
The facility failed to ensure that its designated Infection Preventionist (IP) met the mandatory qualifications for overseeing the Infection Prevention and Control Program. During an interview on 3/24/26 at 10:00 AM, the DON confirmed that she/he was serving as the facility’s IP but had not completed the specialized training in infection control required for the position. The DON further stated that no other staff member currently met the qualifications to serve as IP. Record review showed that the previously qualified IP left the facility in October 2025, and as of the survey date, the position remained unfilled by a qualified individual. At 1:30 PM on the same day, the Administrator and DON confirmed they were still in the process of finding a qualified IP for the facility, leaving the Infection Prevention and Control Program without a properly trained and qualified leader. No specific residents, medical histories, or clinical conditions were described in relation to this deficiency.
Unsecured Medications, Treatment Carts, and Oxygen Equipment
Penalty
Summary
Facility staff failed to ensure that drugs, biologicals, and related medical supplies were securely stored and properly maintained on multiple units. On one unit, an oxygen tank assigned to a resident was observed sitting on the floor behind the resident’s bed without any supporting device. On another unit, a treatment cart was observed with a tube of Collagenase Santyl cream labeled for a specific resident left on top of the cart, while residents in power wheelchairs passed by and staff were present at the nursing station. These observations showed that medications and oxygen equipment were not consistently secured as required. Further observations on additional units revealed an unattended and unlocked treatment cart at a nursing station, and on a separate occasion, a treatment cart with Diclofenac gel labeled for a resident left on top along with multiple packs of dressings. These incidents occurred across three units and on more than one date, demonstrating repeated failures to keep medications and treatment supplies in locked compartments or otherwise secured from unauthorized access.
Insufficient Dietitian Coverage and Delayed Nutritional Assessments
Penalty
Summary
The deficiency involves the facility’s failure to employ sufficient food and nutrition staff, including adequate dietitian coverage, to ensure timely assessment and appropriate diets for residents with significant nutritional and diabetic needs. A resident admitted over two weeks earlier with multiple comorbidities and an A1C of 11.5% had a hospital discharge recommendation for a carbohydrate-controlled diet, but was placed on a regular diet at admission with no acknowledgment of the recommended diet until one week later, when the resident requested larger portions. As of the survey date, the dietitian had not yet seen or reviewed this resident’s medical record, and the resident reported not having seen a dietitian and being very frustrated with the meals. During the first two weeks after admission, only one weight was obtained for this resident, despite physician notes stating the resident’s weight was “stable.” Further review of other residents showed additional failures in timely dietitian assessment and follow-up. One resident, readmitted in January and previously seen by the dietitian in September for a 6.4 lb weight loss over 30 days, had no documented follow-up despite continued weight loss totaling 22 lbs since the last dietitian review. Another resident admitted at the end of February with severe protein-calorie malnutrition had not been seen by the dietitian after about a month in the facility, despite a documented 14 lb (7%) weight loss over two weeks. The dietitian reported working only 12 hours per week at the facility and stated that she must prioritize which residents to see, focusing first on residents with tube feedings and those identified in risk meetings, resulting in delayed or absent assessments for new admissions and residents with ongoing weight loss and malnutrition diagnoses.
Linen Shortages and Poor Environmental Maintenance Compromise Resident Care and Comfort
Penalty
Summary
The deficiency involves the facility’s failure to maintain an adequate supply of clean linens and appropriate incontinence wipes, resulting in delays and alterations in residents’ incontinence care, as well as the use of towels and washcloths in place of disposable wipes. During the initial tour, the surveyor observed that the linen supply on one nursing unit hallway was low. Complaint reviews included concerns about delays in incontinence care and bed linens not being changed regularly, with residents left without clean bedding. A complainant reported that there was not enough clean linen available for residents. Staff interviews confirmed that towels, sheets, and washcloths were being used to wipe residents for incontinence care due to the absence of wipes, and that many of these linens were being thrown away when soiled. Staff also reported a shortage of linen, that linen deliveries to the units were late, and that residents who preferred to get up before breakfast had to wait for care when linen was delayed. Further observations showed that the clean supply room contained no disposable wipes or cloths for incontinence care, and a resident reported that staff did not use wipes, that the resident had to purchase their own, and that heavily soiled towels or washcloths were discarded. A tour of all nursing unit linen carts and closets revealed only six clean washcloths and limited supplies of towels, gowns, and bed linens. In the laundry room, only three washcloths were present, and the laundry assistant stated that there were only three washcloths available for each nursing unit that morning, that the facility was short on linen supply, and that these concerns had been repeatedly reported to the Director of Housekeeping over the preceding month and again that morning. The laundry assistant confirmed there was no additional laundry in process. The DON stated that wipe squares should be used for incontinence care, but no such wipes were found in the clean medical supply room, and no backup supply of washcloths was present in the emergency linen supply. The Director of Housekeeping confirmed there was no backup supply of washcloths. The deficiency also includes environmental and maintenance issues affecting resident bathrooms, handrails, and common areas. In the main dining area, a recliner chair was observed positioned directly in front of the handwashing sink, and two recliner chairs were stored in front of the nutrition area kitchenette. Multiple resident bathrooms and shared bathrooms were repeatedly observed over several days with unfinished spackle on walls that needed resurfacing and painting, chipped paint around sinks, uneven boards nailed to walls under sinks that appeared to partially cover holes, musty odors, black substances between shower bases and walls, missing threshold transition molding exposing cracks, missing tiles, and a nail, as well as eroded and chipped paint on baseboard heaters with exposed dark brown metal and rust-like material. Hallway handrails on both nursing units were observed to be worn, with chips, splintering, holes, and areas where the wood finish had worn off. A shower room was observed with a foul fecal odor, dried brown stains on the back of the toilet seat and in the toilet bowl, and a baseboard heater with eroded, chipped paint and rust-like material, along with chipped paint on the handrail. These conditions were acknowledged by the Director of Maintenance and other leadership, and some areas were noted to be in the process of renovation, but the observed deficiencies remained present during the survey period. Overall, the facility did not maintain a safe, clean, comfortable, and homelike environment in good repair across both nursing units and the dining area. The lack of adequate linen and incontinence supplies, combined with the poor condition of resident bathrooms, handrails, and certain common areas, constituted the basis for the cited deficiency. The observations and staff and resident reports consistently described shortages of essential hygiene supplies, delayed care related to linen availability, and multiple unresolved environmental and maintenance issues in resident care areas and shared spaces.
Failure to Thoroughly Investigate Abuse Allegations and Injuries of Unknown Origin
Penalty
Summary
Facility staff failed to thoroughly investigate allegations of potential abuse involving one resident and an injury of unknown origin involving another resident. For one resident, there were two separate allegations of abuse occurring on different days in early February. The facility’s investigation packets included interviews with staff who cared for or were scheduled to work with this resident on the days of the alleged incidents, and the investigations focused solely on this resident. However, there were no interviews conducted with other residents on the unit to inquire about abusive or neglectful treatment by the staff who were working during the times of the allegations. The surveyors noted that, although the allegations were not validated, there was no documentation that other residents were interviewed, if able, or assessed for signs or symptoms of injury. In a separate incident, another resident was identified on March 4 with a new bruise on the right eye, documented as a change in condition at 4:09 AM. This resident had a BIMS score of 99, indicating the resident was unable to complete an interview and therefore could not report how the injury occurred. The facility’s investigation identified a potential cause of the injury but did not reach a definitive resolution. Additionally, there were no interviews of other residents on the unit regarding possible abuse, nor were there documented assessments of other residents for injuries of unknown origin, particularly for those unable to speak for themselves, as in this resident’s case.
Failure to Provide Oral Care to Dependent Residents
Penalty
Summary
The deficiency involves the facility’s failure to provide oral care to residents who were dependent on staff for activities of daily living, specifically oral hygiene. One resident with a tracheostomy was observed with a thick, sticky white substance in the mouth and was noted to intermittently chew on nearby bedding. This resident made good eye contact and, when asked if staff brushed their teeth, shook their head no and mouthed that staff “need to.” According to the resident’s Minimum Data Set (MDS) dated 2/11/26, the resident was dependent on staff for oral care. Another resident, also dependent on staff for oral care per the 3/11/26 MDS, was observed sitting propped up in bed and able to respond with smiles. During the initial observation, the inside of this resident’s lips and upper and lower teeth had a thick, clear, white milky substance visible when the resident tried to open their mouth to smile. Oral care supplies were present in the nightstand, but the resident’s mouth and teeth were not clean. On a subsequent observation with the DON, NHA, and Corporate VP of clinical services, the same resident again had a thick, clear, milky substance between the lips and caking the teeth, which would string between the teeth when the resident attempted to open their mouth, demonstrating a lack of consistent oral care for residents dependent on staff for this ADL.
Incomplete and Inaccurate Medical Record Documentation for Treatments and Assessments
Penalty
Summary
Facility staff failed to maintain complete and accurate medical records and documentation for multiple residents. For one resident with wound care needs, review of the MAR showed that wound care and related treatments were signed as completed on the dates initially reported, despite the resident’s ongoing complaints that wound dressings were not being changed. When additional dates were reviewed, there were missing staff signatures for wound care on two specific dates, as well as three instances where application of A&D ointment to the resident’s feet was not signed off out of 24 days reviewed. Another resident with severe cognitive impairment, as evidenced by a BIMS score of 00, was found to have an injury of unknown origin (a bruise on the left hand). Documentation showed that a change in condition was initiated late in the morning, but a formal pain evaluation was not initiated and completed until that night, and the resident was unable to explain how the injury occurred or verbalize pain using a standard pain scale. For a third resident, documentation related to the admission PPD test was inconsistent and incomplete. The MAR contained an entry indicating “9” for the administration date, meaning “see nurse’s note,” but there was no corresponding nurse’s note. Despite the absence of a signed administration of the PPD injection, staff documented the PPD result as “negative” on the scheduled read date. The resident reported never receiving the PPD injection, and the DON confirmed that the facility had been out of PPD solution at the time, so the test would not have been administered. These findings demonstrate failures in accurate documentation of treatments and assessments, including wound care, pain assessment, and TB screening, as well as missing or incomplete supporting notes in the medical record.
Failure to Implement and Communicate Correct Transmission-Based Precautions
Penalty
Summary
Surveyors identified a deficiency in the facility’s infection prevention and control program related to inconsistent and incorrect implementation of transmission-based precautions and PPE use. During a complaint investigation focused on residents on transmission-based precautions, one resident with a visible Foley catheter was observed in the room with physical therapy, but there were no signs posted indicating any need for PPE, despite the resident being a new admission with a Foley catheter placed related to wounds. In another double-occupancy room, a contact precautions sign was posted at the doorway, but the nurse practitioner was in the room on a personal phone with no PPE, and the assigned GNA was repositioning the resident in bed while wearing only gloves. When questioned, the NP, RN, and GNA all stated that the resident in the room was not on contact precautions, and the GNA reported that signs were hanging at all doors and that this particular resident’s sign was “just wrong.” The surveyor observed the GNA later return to the room and turn the sign around to indicate no PPE requirement. Subsequent interviews revealed that therapy staff relied on posted signage to determine PPE use and that if the sign was wrong, the PPE used would be wrong. Overall, surveyors found problems with signage accuracy and staff awareness of which residents required contact precautions, as well as observed failures to follow appropriate PPE use for residents who should have been on contact precautions.
Inaccurate MDS Coding for Falls, Pain Management, and High-Risk Medications
Penalty
Summary
Facility staff failed to ensure Minimum Data Set (MDS) assessments were accurately coded for two residents reviewed during a complaint survey. For one resident, a facility-reported incident showed that the resident was found seated on the floor beside the bed and was diagnosed with a non-displaced femoral neck impaction fracture of the left hip following an x-ray. Despite this fall with a major injury, the subsequent significant change MDS dated 11/4/25 did not code the fall with major injury in Section J1900C. Review of the resident’s Medication Administration Records for October and November 2025 showed administration of Tylenol on 10/31/25 at 9:30 PM, which fell within the 5-day look-back period for the MDS, but Section J0100 (prn pain) of the same significant change MDS did not capture the use of Tylenol. For another resident, review of a quarterly MDS with an assessment reference date of 10/15/25 showed that Section N0415 (High-Risk Drug Classes) documented the use of an opioid medication. However, review of the resident’s October 2025 Medication Administration Record did not show that the resident had been prescribed an opioid during that period. In both cases, MDS staff later confirmed that these were errors in MDS coding, demonstrating that the assessments did not accurately reflect the residents’ clinical status and medication use as documented in their medical records.
Incomplete Documentation of Narcotic Administration on MAR
Penalty
Summary
The facility failed to maintain complete and accurate medical records in accordance with accepted professional standards for one resident receiving narcotic medication. The resident, admitted in March 2026, had a fall on 3/6/26 and was sent to the hospital on 3/9/26. Review of the March 2026 Medication Administration Record (MAR) showed documentation of a single 25 mg dose of Tramadol administered on 3/8/26 at 9:23 AM. However, review of the resident’s Controlled Drug Receipt/Record/Disposition Form, kept on the nurse’s medication cart and not in the medical record, showed that Tramadol 25 mg was administered three times between 3/8/26 and 3/9/26: at 11:00 AM and 9:00 PM on 3/8/26, and at 9:00 AM on 3/9/26. In interview, the DON stated that staff are expected to document narcotic administration on the MAR and confirmed that only one of the three Tramadol doses reflected on the controlled drug record was documented on the resident’s MAR. This discrepancy between the controlled substance record and the MAR, with missing documentation of two administered doses of Tramadol on the official medical record, constituted the failure to maintain a complete and accurate medical record for the resident.
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