Ellicott City Healthcare Center
Inspection history, citations, penalties and survey trends for this long-term care facility in Ellicott City, Maryland.
- Location
- 3000 North Ridge Road, Ellicott City, Maryland 21043
- CMS Provider Number
- 215160
- Inspections on file
- 21
- Latest survey
- February 19, 2026
- Citations (last 12 mo.)
- 11
Citation history
Health deficiencies cited at Ellicott City Healthcare Center during CMS and state inspections, most recent first.
Surveyors identified multiple failures to maintain a safe, clean, and homelike environment, including resident rooms with cracked and heavily stained sinks, damaged drywall and unsanded spackle, loose shower thresholds, and a shower chair with jagged plastic where a person would sit. A resident reported frequent lack of soap, towels, and washcloths affecting their ability to bathe, and GNAs confirmed ongoing shortages of towels and washcloths that delayed ADL care such as bed baths and showers. In addition, water temperatures at resident bathroom sinks were repeatedly measured well above the stated acceptable range, with maintenance logs and surveyor checks showing temperatures in the mid‑120s to as high as 137°F, while leadership was initially unaware of these elevated readings.
A resident was observed over multiple days with long, unkempt fingernails and exceptionally long toenails that the resident reported as painful. An LPN confirmed the toenails were very long and caused discomfort during assessment. The LPN described a verbal process for requesting podiatry, while the Director of Social Services outlined a formal written Health Drive form process and confirmed no such form had been received at that time. The resident’s toenails remained very long on a later observation, demonstrating that appropriate nail care and podiatry services were not provided in a timely manner, affecting the resident’s dignity and comfort.
Two residents experienced verbal abuse by staff. In one case, a resident with heart failure, depression, and PTSD reported that an activities assistant accused her of taking advantage of others and then responded to her inquiry with profane, aggressive language, with other interviews revealing similar disrespectful comments to another resident. In a separate case, a resident with stroke-related hemiplegia, heart disease, depression, and dysphagia was addressed by a staff member in a loud, profane manner about eating, an interaction directly overheard by surveyors; the resident later stated that the CNA spoke to her that way at times and that she only sometimes felt safe.
Surveyors found that staff failed to provide and document adequate ADL care, including bathing and incontinence care, for two residents who were dependent on staff. One resident with multiple comorbidities, including diabetes and end-stage kidney disease requiring dialysis, was observed disheveled, with body odor, greasy hair, disheveled bedding, and a chest dressing falling off, and reported long waits for incontinence care and only minimal wet towel baths. Documentation for this resident showed multiple days without a recorded bed bath and only one documented bed bath in a later month. Another resident reported receiving showers only about every two months, and initial record review showed no evidence of showers or baths; the RCD cited a tracking error, and the DON later produced limited skin assessment sheets showing only a few bed baths and no showers documented.
An LPN was observed administering inhaled medications to a resident, giving one puff each of Fluticasone-Salmeterol and Albuterol. The medication administration record indicated that Fluticasone-Salmeterol and Umeclidinium Bromide were due, but only Fluticasone-Salmeterol and Albuterol were given. The LPN documented that both Fluticasone-Salmeterol and Umeclidinium Bromide were administered, resulting in a failure to follow professional standards for medication administration and documentation.
A resident who was dependent for self-care and cognitively intact was found with long, unclean fingernails, indicating a failure by staff to provide necessary nail care during routine hygiene. The resident reported not receiving needed assistance, and staff confirmed that nail care should have been addressed during shower care.
A resident reported that meals consistently arrived cold, and a test tray confirmed that both hot and cold foods were not maintained at proper temperatures. Observations showed that meal carts were left open during tray distribution, and staff acknowledged this was inconsistent with expectations for maintaining food temperature. These practices led to food being served at improper temperatures, potentially affecting all residents.
A resident with cognitive impairment and a court-appointed guardian experienced a fall while being transported to dialysis, resulting in pain and subsequent medical evaluation. Despite facility policy and accurate records indicating the need to notify the guardian, staff failed to inform the legal representative of the incident at the time it occurred, as confirmed by documentation and staff interviews.
Two residents experienced unresolved grievances related to missing personal items and care concerns, with facility staff failing to document investigations, resolutions, and notifications as required by policy. Communication lapses and incomplete follow-up led to prolonged periods without resolution or proper documentation of outcomes.
A facility did not fully investigate an abuse allegation after a resident with intact cognition reported that an unknown individual made an inappropriate comment at their doorway. Although the resident denied exposure and staff interviews were conducted, the facility failed to interview other residents on the unit as required by policy, resulting in an incomplete investigation.
A resident with paraplegia and multiple medical conditions, who was dependent on staff for ADLs, did not receive consistent assistance with bathing and fingernail care. Observations showed the resident's nails were excessively long and dirty over several days, and staff interviews confirmed that nail care and daily bed baths were not provided as required. Documentation of bathing was inconsistent, and supervisory staff acknowledged that the resident's hygiene needs were not met according to facility policy.
The facility failed to maintain a sanitary and comfortable environment, with multiple observations of disrepair and uncleanliness across three nursing units. Issues included crumbling ceilings, unfinished repairs, and stained walls. Residents reported long-standing problems, and staff interviews revealed ineffective communication and follow-through on maintenance and cleaning issues.
The facility failed to maintain complete and accurate medical records, with missing consult notes for two residents and incomplete documentation of wound care and medication administration for others. A resident's urology consult notes were incomplete until surveyor intervention, and another's oncology consult notes were missing. Wound care treatments and urine output were not consistently documented, raising concerns about whether treatments were performed. Additionally, discrepancies in medication administration times were noted, with the ADON attributing this to high patient ratios.
A cognitively intact resident with quadriplegia and an ileostomy experienced a violation of their rights when facility staff attempted to restrict access to a family member during care, despite the resident's wishes. The incident escalated when staff refused to provide care with the family member present, leading to police involvement. Eventually, the resident received care, but the situation caused significant agitation.
A facility failed to accurately code MDS assessments for a resident with a nephrostomy tube. The resident's admission and discharge MDS inaccurately documented the absence of an indwelling catheter and incorrectly noted urinary continence. These errors were confirmed by the Regional Resident Assessment Coordinator during a survey.
A resident with a suprapubic catheter did not have a care plan developed to address this specific medical need. Despite being assessed and documented for a care plan on a previous date, the facility failed to create one until after surveyor intervention. This deficiency was confirmed by the Assistant Director of Nursing.
The facility failed to provide necessary care for three residents, including leaving a resident in feces for hours, not showering another for 12 days, and inadequate incontinence care for a third. Documentation was lacking, with no assigned GNA for one resident and missing shower sheets for another. The ADON confirmed the need for improved documentation.
The facility staff failed to administer prescribed treatments and accurately monitor medical devices for three residents. A resident with a suprapubic catheter did not receive daily saline flushes or timely catheter changes. Another resident did not receive recommended dental treatment for gingivitis. Additionally, a resident with a nephrostomy tube was not properly assessed or monitored, leading to complications. These deficiencies were confirmed through medical record reviews and staff interviews.
The facility failed to provide timely and appropriate pressure ulcer care for two residents. One resident's treatment was not documented as completed on several occasions, and another resident did not receive the correct wound care upon admission. Staff shortages, particularly on weekends, contributed to these deficiencies, as confirmed by interviews with staff and the ADON.
A facility failed to specify the duration for which a Lidocaine 4% patch should be applied to a resident, resulting in its use beyond the recommended 8 to 12 hours. The order for the patch, documented in the resident's February 2025 MAR, lacked instructions on removal timing. This deficiency was confirmed by the ADON.
A resident with severe gingivitis did not receive a follow-up dental visit as recommended by a dentist. Despite the initial examination and recommendation for a periodic oral examination, the resident did not have a follow-up visit. This oversight was confirmed by the Assistant DON.
A resident admitted for subacute rehabilitation reported not receiving necessary physical therapy for discharge. The resident had previously received therapy, but it ceased without quarterly evaluations being conducted. The DOR confirmed the lack of evaluations, which should have occurred during quarterly MDS assessments. The ADON verified the absence of therapy evaluations in the resident's medical record.
A resident with a suprapubic catheter and neuromuscular bladder dysfunction was not scheduled for a timely follow-up appointment with a urologist after being discharged from the Emergency Department with a urinary tract infection. The deficiency was confirmed through medical record review and an interview with the Assistant DON.
Facility staff failed to follow infection control procedures, with a GNA observed providing care without a gown under Enhanced Barrier Precautions. Additionally, unlabeled and improperly stored personal care items were found in a shared bathroom, raising concerns about infection transmission. The ADON confirmed the issues but offered no further comments.
A facility failed to notify the correct resident representative of changes in condition for a resident with multiple sclerosis. Despite 17 documented changes, the medical POA was not informed, as the resident was incorrectly listed as 'self representative.' This issue was confirmed through medical record reviews and interviews with the resident's representative.
The facility failed to accurately code MDS assessments for several residents, leading to deficiencies in care planning. Errors included incorrect documentation of medication use, range of motion limitations, falls, and dental issues. These inaccuracies were confirmed by staff and highlight a failure in ensuring residents receive appropriate care based on accurate assessments.
The facility failed to conduct quarterly care plan meetings for two residents and did not update another resident's care plan after an elopement attempt. A resident reported not having a care plan meeting for some time, and records confirmed the absence of meetings. Another resident was unaware of any care plan meetings, with no documentation following MDS assessments. Additionally, a resident's care plan was not updated after an elopement attempt, despite a malfunctioning wanderguard and the need for new interventions.
The facility failed to document and administer PRN pain medication for three residents, neglecting to monitor their pain levels and the efficacy of the medication. Despite physician orders for Dilaudid, oxyCODONE, and Morphine, the medications were not consistently documented as given, and pain assessments were lacking. In one case, a resident's spouse called 911 due to inadequate pain management.
The facility failed to maintain a medication error rate below 5%, with 9 errors out of 26 opportunities. An LPN prepared medications for two residents at once, against policy. Another staff member signed off on an eye drop not administered, and a third staff member documented medications as given despite a resident's refusal. The DON was informed of the error rate.
The facility failed to label multi-dose medications with the date they were opened, as observed in two medication rooms and two medication carts. An antidiabetic injection pen, PPD vials, Tylenol tablets, and supplements were found opened without labels. Staff confirmed the medications were not labeled, and the DON expected all multi-use medications to be dated upon opening.
The facility failed to ensure timely medical follow-ups for three residents, resulting in missed appointments and unaddressed medical recommendations. A resident missed a urology appointment due to lack of transportation, another did not receive prescribed oral treatment after a dental visit, and a third had no follow-up appointments scheduled with specialists as recommended in their discharge summary. These deficiencies were confirmed by facility staff during a survey.
The facility failed to maintain residents' dignity by having staff stand over residents while assisting them with eating. Two residents, one with dementia and another confused, were observed being fed by staff who stood over them. The staff were unaware that standing while feeding was a dignity concern, despite expectations to sit at eye level during meal assistance.
The facility staff did not display the annual recertification survey results and plan of correction in an accessible location for residents, family members, and legal representatives. During a surveyor's inspection, it was observed that the State inspection results were not posted in an open area, and there was no sign indicating their location. The Nursing Home Administrator confirmed this oversight.
The facility failed to issue necessary Beneficiary Protection Notifications to a resident discharged from Medicare Part A services and two residents who remained in the facility after their skilled services ended. The NOMNC and SNFABNs were not provided, leaving residents without crucial information about their rights and financial liabilities.
A resident with mental health disorders was verbally abused by a housekeeping staff member, who yelled and threw a trash can, causing the resident to feel threatened. In another incident, a resident used inappropriate language towards another, leading to a physical altercation resulting in minor injuries. Both incidents highlight the facility's failure to protect residents from abuse.
The facility failed to report allegations of abuse and neglect within the required 2-hour timeframe to OHCQ for three residents. In one case, a resident alleged sexual abuse, but the report was delayed by over 4 hours. Another resident alleged verbal abuse, but the report lacked email confirmation. A third resident reported neglect, but the facility delayed reporting to OHCQ by two days. The NHA noted that emails are only kept for 30 days, indicating a lack of documentation for timely reporting.
The facility failed to notify residents' representatives in writing about the bed hold policy during hospital transfers. In two cases, representatives were informed verbally but did not receive written notifications. One resident was transferred due to breathing difficulties, and another due to a change in condition. The process of mailing the policy was not completed, leading to the deficiency.
The facility failed to provide baseline care plans to two residents within 48 hours of admission, as required. One resident did not receive a care plan or meeting with staff, and another resident's care plan did not address their tracheostomy and oxygen use. Interviews revealed confusion among staff about responsibilities for creating and providing care plans, and a lack of a clear process for addressing residents' personalized needs.
The facility failed to develop comprehensive care plans for two residents, leading to deficiencies. One resident did not have a dental care plan despite dental issues and recommendations for Peridex use. Another resident lacked a care plan for high-risk medications, including anticoagulants and insulin, upon admission and readmission. Interviews revealed a lack of a clear process for creating personalized care plans.
The facility failed to provide necessary assistance during meals for a resident with dementia, leading to soiled clothing and spilled juice. Additionally, another resident with severely impaired cognition was observed with long fingernails, despite requiring staff assistance for personal hygiene.
A resident with severe cognitive impairment was not provided activities that matched their preferences, as documented in their MDS assessment. Despite preferences for music, news, animals, outdoor time, and religious services, the resident only received 1:1 conversations and social visits, which did not align with their documented needs.
A resident with quadriplegia and multiple medical conditions did not receive adequate care, including bowel movement monitoring and dressing changes for pressure ulcers, due to staffing shortages. The resident, feeling neglected, called 911 and was hospitalized. Documentation confirmed the lack of care, and the ADON acknowledged staffing issues, particularly on weekends.
A resident with deep tissue injuries (DTIs) on admission did not receive timely treatment, with a delay of five days before care was initiated. Additionally, a required weekly skin assessment was missed, as confirmed by the Regional Nurse.
A facility failed to change the oxygen tubing for a resident dependent on oxygen every 7 days as per policy. The tubing was labeled with a date over a month old, and the resident was unsure when it was last changed. The unit manager confirmed the process is every 7 days, and records inaccurately showed the order was completed weekly.
A facility failed to accurately assess a resident with dementia and other conditions, leading to incorrect psychiatric documentation. Observations showed the resident was nonverbal and sleepy, yet assessments inaccurately noted normal speech and thought processes. Staff admitted to transcription errors and typos in the assessments.
A facility failed to obtain a urinalysis and urine culture and sensitivity for a resident as ordered by the physician following an incident of physical aggression. The order was entered into the electronic medical record but not placed in the lab system, resulting in the specimens not being obtained. This deficiency was confirmed by the Nursing Unit Manager and reviewed with the DON.
The facility failed to maintain accurate medical records for two residents. One resident's Morphine dosage was incorrectly documented, and a pain assessment was recorded after discharge. Another resident's follow-up note was dated post-discharge, with the NP admitting to late documentation. The NHA confirmed the absence of a written policy for timely documentation.
The facility failed to supply soap in a staff restroom by the Magnolia Unit nurses' station due to a malfunctioning automatic soap dispenser that needed batteries. The issue was observed by a surveyor, who informed the unit manager and maintenance director. Although the automatic dispenser was not repaired by the next day, a container of liquid soap was provided for staff use.
Environmental Disrepair, Linen Shortages, and Excessive Hot Water Temperatures
Penalty
Summary
The deficiency involves the facility’s failure to maintain a safe, clean, comfortable, and homelike environment in multiple resident rooms and bathrooms. Surveyors observed in one resident’s bathroom a loose plastic threshold on the shower floor, a shower chair with a jagged piece of plastic where a person would sit, a severely discolored and cracked sink, and multiple gouges in the drywall. In another shared room, two residents identified a large, rough, unsanded spackled area on the wall without paint, additional unsanded or unpainted spackling, gouges in the drywall, stained sinks and toilets, gouges in the toilet bowl, and a gap in the wall near the pipes under the sink. A further resident’s bathroom showed extensive drywall damage with gouges, rough spackling, and holes around piping under the sink, while another resident’s room had peeling paint and drywall, a dresser drawer handle hanging by one screw, multiple areas of chipped paint, and a cracked, discolored bathroom sink. Another resident’s sink was noted to be slow to drain, cracked, and stained. The deficiency also includes the facility’s failure to ensure adequate linens and supplies for activities of daily living (ADLs). One resident reported that the facility was often out of soap, towels, and washcloths, which affected their ability to receive baths or showers. Two GNAs reported frequent or very often shortages of towels and washcloths, stating that these shortages caused delays in providing ADL care such as bed baths and showers, and that they had to plan ahead and improvise because the issue had been ongoing. The Nursing Home Administrator later acknowledged that a systemic change was needed after being informed that residents and staff reported linen shortages impacting timely care. A further deficiency was identified in the facility’s management of hot water temperatures in resident rooms. Surveyors measured bathroom sink water temperatures in several rooms and found readings ranging from 123.7°F to 126.3°F, above the range that maintenance staff stated should be maintained. Maintenance documentation from that same morning showed unit temperatures between 120.9°F and 126.7°F, which had not been reported to supervisors or the Administrator. Subsequent random checks by surveyors found additional room temperatures between 124.3°F and 128.9°F, and the Maintenance Director’s own log showed room temperatures up to 137°F. A resident cautioned surveyors to be careful when checking water temperatures, implying the water became excessively hot. The Administrator and Maintenance Director reported they were unaware of the elevated temperatures recorded by maintenance staff prior to the surveyors’ findings.
Failure to Provide Timely Nail Care and Podiatry Services Affecting Resident Dignity
Penalty
Summary
Surveyors identified a deficiency in resident dignity and quality of care related to nail care for one resident. On 2/11/26, the resident was observed sleeping in bed with fingernails that were long, unkempt, and had dark buildup underneath. On 2/13/26 at 1:26 PM, the resident’s uncovered foot was observed with exceptionally long toenails, and the resident stated, “I want them cut. They hurt me.” At 1:29 PM, an LPN assessed the toenails; the resident pulled the foot away and stated, “that hurts,” and the LPN verified that the toenails were very long. The LPN reported that the process to schedule a podiatry appointment was to verbally report the need to social work, while the Director of Social Services later described a different process requiring completion and submission of a Health Drive form by nursing and the practitioner. The Director of Social Services confirmed that no Health Drive forms had been received that day. On 2/17/26 at 9:15 AM, the resident’s toenails were again observed to remain very long, indicating that the condition persisted over several days without being addressed through appropriate nail care or timely podiatry services.
Failure to Protect Residents From Verbal Abuse by Staff
Penalty
Summary
The deficiency involves failure to protect residents from verbal abuse by staff. One resident with a history of heart failure, depression, and post-traumatic stress disorder reported that an activities assistant brought cigarettes to another resident and allegedly told that resident that she took advantage of others. When this was questioned, the activities assistant was reported to have become irate and responded with profanity, stating that she had bought the cigarettes and did not care who became upset, followed by additional profane language. The resident stated that this verbal attack upset her and that there had been three prior incidents involving the same staff member. The DON’s investigation, based on staff and resident interviews, substantiated the allegation and identified additional concerns about the staff member’s treatment of residents who were not considered “favorites,” including a separate instance in which the staff member was heard telling another resident that she would not give them anything even if they asked. In a separate incident, a resident with a history of stroke with left-sided hemiplegia, heart disease, depression, and dysphagia was subjected to verbally abusive language overheard directly by surveyors. While standing near the nurse station, surveyors heard a staff member loudly tell the resident to “get your s&it together and eat” and refer to the resident as a “grown a$$” individual, then observed the resident sitting in a geri-chair with a lunch tray and a blank expression as two staff walked away. When questioned, the resident stated that the nurse, identified as a nursing assistant, behaved like that with her sometimes and that she only sometimes felt safe in the facility. Although the resident later recanted, the NHA acknowledged that residents had expressed fear of retaliation from staff and confirmed that, based on the firsthand observations and written statements of the surveyor and survey coordinator, the abusive event occurred, and the allegation was substantiated even though the specific perpetrator could not be conclusively identified.
Failure to Provide and Document ADL Bathing and Incontinence Care
Penalty
Summary
The facility failed to provide adequate ADL care, including bathing and incontinence care, to residents who were dependent on staff. One resident with diabetes, end-stage kidney disease requiring dialysis, and gait and mobility abnormalities requiring assistance with ADLs was observed disheveled, with greasy hair, body odor, disheveled bedding, wearing only an incontinence brief, and with a chest dressing falling off. The resident reported often waiting up to five hours without incontinence care and stated they only received a small wet towel bath rather than thorough cleaning. Review of this resident’s records showed difficulty determining if baths were provided as ordered, and documentation indicated multiple dates in January when no bed bath was given and only one documented bed bath in February. The DON and RCD acknowledged concern that the resident had not been receiving baths as ordered. Another resident, who was dependent on staff for ADL care, reported receiving showers only about every two months and expressed a desire for more frequent showers. Record review initially revealed no evidence that staff had provided baths or showers for this resident. The RCD stated that an error had occurred and that showers and baths had not been tracked. The DON later confirmed they were unable to provide evidence that the resident had received a bath or shower due to a system error in setting up showers and baths. Subsequently provided skin assessment sheets documented only a limited number of bed baths on specific dates in January and February, with no record of any showers and no additional bed baths beyond those listed.
Failure to Administer and Document Medications as Ordered
Penalty
Summary
A deficiency was identified when a Licensed Practical Nurse (Staff #13) was observed administering medications to a resident. During the observation, the nurse gave one puff each of Fluticasone-Salmeterol and Albuterol inhalers. However, review of the medication administration record showed that Fluticasone-Salmeterol and Umeclidinium Bromide were due to be administered at that time, not Albuterol. The nurse signed off that both Fluticasone-Salmeterol and Umeclidinium Bromide had been given, despite only Fluticasone-Salmeterol and Albuterol being administered. This discrepancy was confirmed through record review and discussed with the Director of Nursing, who acknowledged the concern. The failure to administer medications as ordered and to accurately document medication administration did not meet professional standards of practice, as evidenced by the observed event and supporting documentation.
Failure to Provide Nail Care to Dependent Resident
Penalty
Summary
A deficiency was identified when a resident who was dependent for self-care was not provided with appropriate nail care. The resident, who was cognitively intact and had diagnoses including hemiplegia, hemiparesis, aphasia, and type 2 diabetes with complications, was observed to have long fingernails with brown-colored material underneath. The resident reported needing assistance with nail trimming but had not received it, and expressed concerns about overall care due to apparent short staffing. Staff interviews revealed that the expectation was for nail care to be assessed and provided during showers, and that the Geriatric Nursing Assistant responsible for the resident's recent shower should have checked and addressed the fingernails at that time. The deficiency was confirmed through direct observation and staff acknowledgment that the required care had not been provided as expected.
Failure to Maintain Safe and Palatable Food Temperatures During Meal Service
Penalty
Summary
The facility failed to ensure that food was delivered to residents at an appropriate and palatable temperature, as evidenced by observations and interviews during the survey process. A resident reported that meals consistently arrived cold, and this was corroborated by a test tray temperature observation, which showed that both hot and cold foods were not maintained at their required temperatures. Specifically, hot foods such as eggs and hot cereal were below the expected temperature, and cold items like milk and juice were above the recommended cold holding temperature. Staff interviews revealed that meal carts were left open during distribution, which contributed to the temperature decline of the food. Both nursing and dietary staff acknowledged that the expectation was to keep meal carts closed when not actively serving, but this was not consistently followed. The deficiency was further supported by direct observation of meal service practices, where only one Geriatric Nursing Assistant was distributing trays, and the meal cart was left open and unattended at times. Staff interviews confirmed that trays should be delivered immediately upon arrival to the unit and that the responsibility for maintaining food temperature was shared among GNAs and nurses. Despite these expectations, the observed practices did not align, resulting in food being served at improper temperatures. The issue was identified as having the potential to affect all residents receiving meals from the facility.
Failure to Notify Legal Representative of Resident Accident
Penalty
Summary
The facility failed to immediately notify a resident's legal representative following an accident involving the resident. According to the facility's policy, staff are required to inform the resident, their medical practitioner, and the resident's representative or guardian of any significant change in condition, including accidents that result in injury or have the potential to require physician intervention. In this case, a resident with a court-appointed guardian and a history of cognitive impairment, dementia, and end-stage renal disease experienced a fall while being transported in a wheelchair to dialysis. The resident panicked in the elevator, jumped from the wheelchair, and complained of knee pain, prompting a physician to order an x-ray. Documentation and interviews revealed that the resident's guardian was not notified of the incident at the time it occurred. The resident's care plan and admission records clearly indicated the presence of a court-appointed guardian, and the facility's computer system had been updated to reflect this information prior to the incident. Despite this, the eInteract Change in Condition Evaluation documented that only the resident was notified, not the guardian. Interviews with facility staff, including the LPN assigned to the resident and the Director of Social Services, confirmed that the guardian's contact information was accurate and available, but staff could not explain why the notification did not occur. The deficiency was identified through review of facility records, interviews with staff and the resident's guardian, and examination of facility policies. The guardian reported learning of the incident only after the resident was sent to the hospital days later for swelling and bruising. The facility's failure to notify the legal representative as required by policy and the resident's care plan constituted a lapse in communication regarding a significant change in the resident's condition.
Failure to Investigate and Resolve Resident Grievances
Penalty
Summary
The facility failed to properly investigate and resolve resident grievances related to missing personal property and care concerns for two residents. One resident, with a diagnosis of Alzheimer's disease and severe cognitive impairment, had multiple grievances submitted by their representative regarding missing personal items, including a blue blanket and a hoodie. Despite repeated communications and requests for written plans and updates, the facility's grievance forms lacked documentation of resolution, dates, and notification to the complainant. Interviews with staff revealed confusion about the process, lack of follow-up, and missing documentation, with the Director of Social Services unable to locate an initial grievance form and uncertain about whether written summaries were provided to complainants. Another resident, who was cognitively intact and had a history of cerebral infarction, diabetes, and adjustment disorder, submitted a grievance regarding care issues such as receiving regular showers, hair washing, therapy, laundry return, and timely assistance. The grievance form showed that only therapy services addressed the concerns, with no documented response from nursing or environmental services. The Director of Social Services and the Director of Nursing both acknowledged that the grievance was not fully resolved in a timely manner, and the Environmental Services Director stated he had not seen the grievance until much later. Facility policy required timely investigation and resolution of grievances, generally within five business days, but the documentation and interviews indicated that grievances were not consistently or thoroughly addressed. There was a lack of clear communication, follow-up, and documentation regarding the investigation and resolution of grievances, as well as notification to residents or their representatives about outcomes. These failures resulted in unresolved grievances and a lack of assurance that residents' rights to voice concerns without discrimination or reprisal were honored.
Failure to Thoroughly Investigate Alleged Abuse
Penalty
Summary
The facility failed to thoroughly investigate an allegation of abuse involving a resident who was admitted with a history of blindness in one eye and intact cognition. The resident's emergency contact reported that someone had entered the resident's room and exposed themselves. During the facility's investigation, the resident denied the allegation of exposure but reported that an unknown individual had made an inappropriate comment about the resident's breasts from the doorway before leaving. The police interviewed the resident, who again denied any exposure but confirmed the inappropriate comment. Law enforcement declined to investigate further and advised the facility to follow its own protocol. The facility's investigation included interviews with the resident and staff assigned to the area, but no witnesses were identified. A handwritten statement from an RN indicated that a resident had previously reported that four men entered the room and mentioned the word 'breast.' However, the facility did not conduct interviews with other residents on the same unit to determine if similar incidents had occurred, despite facility policy and statements from the ADON and DON indicating that such interviews should be part of the investigative process. This incomplete investigation led to the deficiency cited in the report.
Failure to Provide Adequate Personal Hygiene and Nail Care
Penalty
Summary
The facility failed to provide necessary care and services to maintain proper grooming and personal hygiene for a resident who was dependent on staff for activities of daily living (ADLs), including bathing and fingernail care. The resident, who had a history of osteomyelitis, necrotizing fasciitis, pressure ulcers, and complete paraplegia, was documented as being dependent on staff for oral hygiene, toileting, showering/bathing, dressing, and personal hygiene. Despite this, observations over several days revealed that the resident's fingernails were excessively long and had a black substance underneath, and the resident confirmed needing assistance with nail care. Staff interviews confirmed that nail care was the responsibility of nursing assistants and should be performed as needed, but the assigned staff could not recall the last time nail care was provided and acknowledged the resident's nails needed attention. Documentation showed inconsistent and infrequent bathing, with records indicating only a few bed baths or showers provided over several months, and some refusals or days marked as not applicable. However, staff interviews and observations indicated that the resident did not consistently refuse care, and when care was refused, it was not always properly documented or reported. Nursing assistants and supervisory staff acknowledged that the resident had not received daily bed baths or complete hygiene care, including washing of legs and feet and removal of socks for skin inspection, as expected by facility policy. Supervisory staff, including the ADON, DON, and clinical manager, confirmed that the resident's hygiene and grooming needs were not met according to facility expectations and policy. They agreed that the resident's nails were in poor condition and that daily bathing and complete hygiene care, including nail care, should have been provided. The lack of consistent documentation, failure to offer or provide daily hygiene care, and inadequate attention to the resident's grooming needs led to the deficiency identified during the survey.
Facility Fails to Maintain Sanitary and Comfortable Environment
Penalty
Summary
The facility staff failed to maintain a sanitary, orderly, and comfortable environment for residents, as evidenced by multiple observations of disrepair and uncleanliness across three of the four nursing units. Specific issues included a crumbling ceiling with mold and peeling paint in one room, unfinished repairs with exposed nails and spackle marks, and discolored ceiling tiles. Residents reported that some of these issues had persisted for months or even years without resolution, despite assurances from the facility that repairs would be made. In addition to structural disrepair, there were significant cleanliness issues observed. In one room, a dirty fracture bed pan and basin were found on the floor, filled with cans and empty Styrofoam cups. Another room had a kangaroo tube feeding pole with dark brown drip marks, and the wall and radiator were stained with maroon drip marks, possibly from wound cleanser or solution. These conditions were not addressed, leaving the environment unsanitary and uncomfortable for residents. Interviews with facility staff revealed a lack of effective communication and follow-through regarding maintenance and cleaning issues. Geriatric nursing assistants reported that they would inform their supervisors or the charge nurse about disrepair, but there was no indication that these reports led to timely action. The Nursing Home Administrator acknowledged the disrepair and stated that a company had been hired to address the issues, but work had not yet commenced. The Director of Environmental Services also recognized the need for cleaning and maintenance but did not take immediate action to rectify the problems.
Incomplete Medical Records and Documentation Issues
Penalty
Summary
The facility failed to maintain complete and accurate medical records for several residents, as evidenced by missing or incomplete documentation. For one resident, the urology consult notes from an appointment were incomplete until the surveyor intervened, revealing that the facility had not obtained the full notes until months later. Another resident's medical record lacked consult notes from two separate oncology appointments, despite staff confirming the resident attended these appointments. Additionally, the facility did not consistently document wound care treatments and urine output for another resident, with several days showing blank spaces in the treatment administration record (TAR). This lack of documentation raised concerns about whether the treatments were performed, as the standard practice is that if a treatment is not signed off, it is considered not done. Similarly, another resident's GNA tasks documentation showed multiple days with blank spaces, indicating incomplete records. Furthermore, a resident reported not receiving medication on time, and a review of the medication administration record (MAR) revealed discrepancies between the scheduled and actual documented administration times. The ADON acknowledged that nurses often documented medication administration at the end of the day due to high patient ratios, leading to inaccurate records. These deficiencies highlight significant lapses in maintaining accurate and complete medical records, which are crucial for ensuring proper resident care.
Failure to Respect Resident's Rights and Dignity
Penalty
Summary
The facility failed to honor a resident's right to a dignified existence and self-determination by attempting to restrict the resident's access to a family member during care, which was inconsistent with the resident's wishes. The incident involved a resident who was cognitively intact and dependent on assistance for all activities of daily living due to quadriplegia and an ileostomy. On the evening of the incident, the resident required assistance with a leaking ileostomy bag. When two geriatric nursing assistants (GNAs) arrived to provide care, one of them asked the resident's family member to leave the room for privacy reasons, despite the resident's expressed permission for the family member to stay. The situation escalated when the GNA refused to provide care with the family member present and called a nurse, who also attempted to remove the family member. The nurse threatened to call the police when the family member refused to leave, leading to both the family member and the nurse contacting law enforcement. After the police mediated the situation, the resident eventually received care, but the incident left the resident agitated for the rest of the evening. Interviews with staff revealed a lack of awareness of the resident's rights and the facility's failure to respect the resident's wishes, as the staff prioritized privacy over the resident's expressed desire for the family member's presence during care.
Inaccurate MDS Coding for Resident with Nephrostomy Tube
Penalty
Summary
The facility staff failed to ensure that Minimum Data Set (MDS) assessments were accurately coded for a resident during a complaint survey. The resident in question had a medical history that included a right hydroureteronephrosis secondary to a pelvic mass lesion, with a right nephrostomy tube in place. Despite this, the admission MDS with an assessment reference date of December 11, 2024, inaccurately documented that the resident did not have an indwelling catheter, including a nephrostomy tube, and incorrectly noted the resident's urinary continence as occasionally incontinent instead of not rated. Further review of the discharge return anticipated MDS with an assessment reference date of December 19, 2024, revealed similar inaccuracies. The assessment again failed to capture the presence of the nephrostomy tube and incorrectly documented the resident's urinary continence. These inaccuracies were confirmed during an interview with the Regional Resident Assessment Coordinator, who reviewed both MDS assessments with the surveyor.
Failure to Develop Care Plan for Suprapubic Catheter
Penalty
Summary
The facility staff failed to ensure that a resident's care plan included the necessary interventions for the resident's specific medical needs. The resident, who was admitted with a diagnosis of neuromuscular dysfunction of the bladder and had a suprapubic catheter, did not have a care plan developed for the catheter. Although the resident was assessed on 10/3/24, and it was documented that a care plan would be developed, the facility did not create a care plan addressing the suprapubic catheter until after surveyor intervention on 2/26/25. This oversight was confirmed by the Assistant Director of Nursing during an interview on 2/27/25.
Failure to Provide Adequate Care and Documentation
Penalty
Summary
The facility staff failed to provide necessary activities of daily living for three residents who were dependent on assistance. Resident #8 was left in feces for approximately six hours after returning from dialysis, despite requests for assistance. The resident's responsible party (RP) made multiple calls to the facility, but the resident was not changed until after midnight. The staffing sheet for that day showed no geriatric nursing assistant (GNA) assigned to the resident's room, and there was no documentation of care being provided during the evening shift. Resident #24 did not receive a shower for the first 12 days after being admitted to the facility for rehabilitation and strengthening. The resident required substantial assistance with bathing, but the GNA documentation report showed blank spaces for most days in January, with no refusals documented. Interviews with staff revealed that shower sheets, which should document whether a shower was offered, accepted, or refused, were not available for this resident, and the Assistant Director of Nursing confirmed these findings. Resident #18 received inadequate incontinence care, leading to extended periods of lying in waste. The resident required partial assistance with activities of daily living, but the GNA documentation report for December showed blank spaces for personal hygiene and toilet hygiene on several days. The Assistant Director of Nursing acknowledged the need for better documentation, indicating a systemic issue with record-keeping and care provision in the facility.
Failure to Administer Treatments and Monitor Medical Devices
Penalty
Summary
The facility staff failed to administer treatments as ordered by the physician for three residents, leading to deficiencies in care. Resident #8, who was admitted with a suprapubic catheter, did not receive the prescribed daily saline flushes for 11 days following readmission from the hospital. Additionally, the facility staff did not schedule or perform the required catheter changes every four weeks, as recommended by the urologist. Interviews with the nurse practitioner and the Assistant Director of Nursing confirmed these lapses in care. Resident #16 did not receive the recommended dental treatment for severe gingivitis. After a dental examination, the dentist advised the use of Peridex on a toothette swab after breakfast and before sleep. However, the facility staff failed to order and administer this treatment, as confirmed by a review of the resident's medical records and an interview with the Assistant Director of Nursing. Resident #18, who was admitted with a nephrostomy tube, was not accurately assessed or monitored. The initial nursing assessment failed to document the presence of the nephrostomy tube, and the admission MDS inaccurately indicated no indwelling catheter. There was no documentation of monitoring the nephrostomy site for infection or measuring urine output. A provider note later documented issues with the nephrostomy tube, including leakage and a displaced suture, leading to the resident being sent to the hospital. Interviews with nursing staff and the Assistant Director of Nursing highlighted the lack of documentation and monitoring for the nephrostomy tube.
Failure to Provide Timely Pressure Ulcer Care
Penalty
Summary
The facility failed to provide timely treatment and services to prevent and heal pressure ulcers for two residents. Resident #23 was admitted with a sacral ulcer and later developed additional wounds on the legs. The treatment administration record (TAR) showed that prescribed treatments for the sacral ulcer and leg wounds were not documented as completed on several occasions, indicating they may not have been performed. The facility was also short-staffed, particularly on weekends, which contributed to the lack of wound care. Interviews with staff confirmed that if treatments were not signed off, they were likely not done. Resident #18 was admitted with a Stage 2 pressure ulcer on the buttocks and sacrum. The hospital discharge summary included specific wound care orders, but these were not implemented upon admission to the facility. Instead, a different treatment order was placed on the TAR, and the correct treatment was not started until two days after admission. This delay in implementing the appropriate wound care regimen contributed to the deficiency. Interviews with the Assistant Director of Nursing (ADON) confirmed the findings of the surveyors. The ADON acknowledged that the standard practice is that if a treatment is not signed off, it is considered not done. The ADON also confirmed that the correct treatment for Resident #18 was not initiated upon admission, as the hospital's discharge orders were not followed. These failures in providing timely and appropriate wound care led to the identified deficiencies.
Failure to Specify Duration for Lidocaine Patch Application
Penalty
Summary
The facility failed to maintain a resident's drug regimen free from unnecessary drugs by not specifying the duration for which a Lidocaine 4% patch should be applied. This oversight was identified during a review of the resident's February 2025 Medication Administration Record (MAR), which showed a standing order from January 11, 2025, for the application of the Lidocaine patch to the lower back once daily for pain. However, the order lacked instructions on when the patch should be removed, leading to its application for longer than the recommended 8 to 12 hours. This deficiency was confirmed by the Assistant Director of Nurses (ADON) during a discussion on March 3, 2025.
Failure to Provide Recommended Dental Care
Penalty
Summary
The facility staff failed to ensure that a resident received dental services as recommended. The resident was admitted to the facility and was seen by a dentist for an initial examination, during which severe gingivitis was noted. The dentist recommended a follow-up periodic oral examination six months later. However, the resident did not have a follow-up dental visit as scheduled. This deficiency was confirmed during an interview with the Assistant Director of Nursing, who acknowledged that the resident had not received the necessary dental care within the recommended timeframe.
Failure to Assess Rehabilitation Needs
Penalty
Summary
The facility staff failed to assess a resident's need for rehabilitation services, resulting in a deficiency. A resident was admitted for subacute rehabilitation but reported not receiving physical therapy, which was necessary for discharge. The resident had received physical and occupational therapy until a specified date, after which no therapy was provided. The Director of Rehabilitation confirmed the absence of quarterly evaluations for the resident, which should have been conducted during quarterly MDS assessments. The resident's medical record showed quarterly MDS assessments were completed, but no evidence of therapy evaluations was found, as confirmed by the Assistant Director of Nursing.
Failure to Timely Obtain Outside Urology Services
Penalty
Summary
The facility staff failed to obtain outside professional services in a timely manner for a resident who required specialized care. The resident, who was admitted with a diagnosis including neuromuscular dysfunction of the bladder and had a suprapubic catheter, was discharged from the Emergency Department with a urinary tract infection and instructed to schedule a follow-up appointment with Chesapeake Urology within a week. However, as of ten days after the emergency visit, the resident had not seen the urologist or had a scheduled appointment. This deficiency was confirmed through a review of the resident's medical record and an interview with the Assistant Director of Nursing.
Infection Control Lapses in Patient Care and Equipment Storage
Penalty
Summary
The facility staff failed to adhere to infection control procedures during patient care, as observed in two of the five units during a complaint survey. On two separate occasions, a geriatric nursing assistant (GNA) was observed providing direct patient care to a resident under Enhanced Barrier Precautions without wearing a protective gown, despite signage indicating the requirement for gown and gloves. The Assistant Director of Nursing (ADON) confirmed that the GNA should have been wearing a gown when providing care under these conditions. Additionally, infection control lapses were noted in a shared bathroom between two rooms. Two unlabeled pink plastic basins and a bedpan were found improperly stored, with the basins stacked and a wet washcloth draped over them, and the bedpan left on the floor without protective covering. Staff confirmed the findings and acknowledged the concerns, indicating a lack of proper labeling and storage procedures for personal care items, which could contribute to the transmission of infections. The ADON was informed of these issues but did not provide further comments.
Failure to Notify Resident Representative of Changes in Condition
Penalty
Summary
The facility failed to notify the correct resident representative of changes in condition for a resident with multiple sclerosis and contractures. The resident had 17 documented changes in condition between October 2023 and March 2024, as recorded in 'eInteract' forms. However, the medical power of attorney (POA), who was the designated representative according to the resident's Advanced Directives, was not informed of these changes. Instead, the resident was incorrectly documented as 'self representative' in the medical records. This deficiency was highlighted during an interview with the resident's representative, who expressed concerns about not being notified of the resident's decline, which eventually led to the resident's passing in June 2024. The issue was further confirmed through a review of the medical records, which showed that 6 out of 11 changes requiring notification to the representative did not occur. The deficiency was discussed with the Regional Nurse and the Nursing Home Administrator during the survey process.
Inaccurate MDS Assessments Lead to Care Deficiencies
Penalty
Summary
The facility failed to ensure accurate coding of Minimum Data Set (MDS) assessments for several residents, leading to deficiencies in care planning and service provision. For Resident #27, the MDS assessment inaccurately recorded antiplatelet use, despite no documentation or provider's order supporting this during the observation period. Staff confirmed this was an error. Similarly, Resident #92's MDS assessment incorrectly noted no functional limitations in range of motion, although previous assessments indicated impairments, which staff later confirmed as a coding error. Resident #563's MDS assessment failed to document a fall and the use of several medications, including Gabapentin for pain relief, antidepressants, diuretics, and antiplatelet medications, despite these being recorded in the medical record. The MDS Coordinator acknowledged these omissions. Additionally, Resident #20's MDS did not reflect dental issues, such as missing and loose teeth, despite a recent dental visit recommending treatment, which was not followed up in the medical orders. For Resident #75, the MDS assessment did not capture the use of oxygen upon admission and inaccurately recorded the administration frequency of insulin. These errors were confirmed by the MDS Coordinator. These inaccuracies in MDS assessments highlight a failure in the facility's processes to ensure residents receive appropriate care based on accurate assessments.
Failure to Conduct Care Plan Meetings and Update Care Plans
Penalty
Summary
The facility staff failed to conduct quarterly care plan meetings for several residents, including Resident #101 and Resident #27. Resident #101 reported not having a care plan meeting for some time, and a review of their medical records confirmed the absence of meetings in October 2023 and August 2024. The Social Worker, who started in June 2024, was unsure why the August meeting did not occur. Similarly, Resident #27, who was alert and oriented, was unaware of any care plan meetings, and records showed no meetings following MDS assessments in May and June 2024. Interviews with staff confirmed the lack of documentation for these meetings. Additionally, the facility failed to update Resident #6's care plan after an elopement attempt in July 2024. The resident, who had a history of attempting to leave the facility, managed to exit despite wearing a wanderguard, which was found to be malfunctioning. Although the device was replaced, the care plan was not updated to include new interventions, such as providing the resident with soda to prevent future elopement attempts. The Director of Nursing confirmed that no new interventions were added to the care plan after the incident.
Failure to Document and Administer Pain Medication
Penalty
Summary
The facility failed to consistently document the administration of as-needed (PRN) pain medication and monitor the residents' pain levels and the efficacy of the medication. This deficiency was identified during an annual survey for three residents. For Resident #151, the physician ordered Dilaudid for pain management, but the medication was not documented as administered on several occasions, and there was no monitoring of the resident's pain level or the effectiveness of the medication. Similarly, Resident #81 was prescribed oxyCODONE for pain, but the medication was not documented as given on multiple dates, and there was no monitoring of the resident's pain level or the medication's efficacy. The Director of Nursing confirmed that the facility staff failed to administer the pain medication as ordered by the physician. In the case of Resident #169, who was admitted following surgery, the facility did not administer the prescribed Morphine and Tylenol for pain management. The resident's pain was not assessed, and there was no documentation of pain assessments in the medical record. Despite the availability of Morphine in the facility's Omnicell system, the medication was not provided, leading to the resident's spouse calling 911 to return the resident to the hospital.
Medication Error Rate Exceeds 5%
Penalty
Summary
The facility failed to maintain a medication error rate of less than 5%, as evidenced by 9 errors out of 26 opportunities. During a medication administration observation, an LPN prepared medications for two residents simultaneously, contrary to the facility's policy of preparing one resident's medication at a time. The LPN admitted to the error when questioned by the surveyor. Another staff member administered medications to a resident but failed to give an ordered eye drop, which was signed off as given. The staff member acknowledged the oversight and mentioned reordering the medication from the pharmacy. Additionally, a third staff member prepared and signed off on medications for a resident who refused to take them. The staff member attempted to administer the medications with applesauce, but the resident continued to refuse and spat them out. The staff member had already signed the medications as given and later stated that the system would not allow her to correct the documentation. The surveyor noted that an antihypertensive medication was signed off as given, but it was not observed being administered. The director of nursing was informed of the medication error rate during an interview.
Failure to Label Multi-Dose Medications
Penalty
Summary
The facility failed to properly store medications by not labeling multi-dose medications with the date they were opened. This deficiency was observed in two medication rooms and two medication carts during the survey. In the Dogwood unit medication room, an antidiabetic injection pen for a resident was found in the refrigerator with one dose remaining, but it was not labeled with the opening date. Additionally, a multi-dose vial of purified protein derivative (PPD) injection was opened but not labeled with the date it was opened. Staff confirmed that these medications were not labeled as required. Further observations in the Cedar unit medication room revealed a multi-use vial of PPD that was opened and not labeled with the date it was opened. On the Cherry unit medication cart, a multi-use container of Tylenol 500mg tablets was found opened and not labeled with the opening date. Similarly, on the Magnolia unit long hallway medication cart, multi-use containers of Calcium Carbonate 500mg and Vitamin D supplement were opened but not labeled with the dates they were opened. Staff confirmed that these medications were also not labeled with the opening dates, and the director of nursing stated that the expectation was for all multi-use medications to be labeled with the date of opening.
Failure to Ensure Timely Medical Follow-Ups for Residents
Penalty
Summary
The facility staff failed to ensure timely medical follow-ups for three residents, leading to deficiencies in care. Resident #81 missed a scheduled urology appointment on June 13, 2024, due to the facility's failure to arrange transportation. This oversight was discovered during a medical record review on September 3, 2024, and confirmed by the Director of Nursing on September 9, 2024. Similarly, Resident #20 did not receive the recommended Peridex treatment following a dental visit on August 14, 2024, as the consult recommendations were not added to the physician orders or medication administration record. This was identified during a review on September 3, 2024, and confirmed by the Director of Nursing. Additionally, Resident #159 did not have follow-up appointments scheduled with consultant physicians as recommended in the hospital discharge summary dated August 13, 2024. The resident was supposed to see urology, have surveillance for a toe issue, and consult with gastroenterology within 1-2 weeks of discharge, but none of these appointments were scheduled. This deficiency was confirmed by the Regional Nurse on September 9, 2024. These failures highlight a lack of coordination and follow-through in ensuring residents receive necessary medical care and follow-up appointments.
Failure to Maintain Resident Dignity During Meal Assistance
Penalty
Summary
The facility failed to maintain residents' dignity by having staff stand over residents while assisting them with eating. This deficiency was observed in two residents. Resident #48, admitted in July 2024 with dementia and requiring assistance with eating, was fed by staff #41 who stood while assisting the resident during a meal observation. Staff #41 was unaware that standing while feeding was a dignity concern. Similarly, Resident #140, who had been living in the facility since December 2023 and required assistance due to confusion, was fed by staff #40 who stood over the resident while they were lying in bed. Staff #40 also did not know that sitting was required to maintain dignity. Interviews with staff, including a unit manager and the DON, confirmed that staff were expected to sit at eye level when assisting residents with meals to uphold their dignity.
Failure to Display Survey Results
Penalty
Summary
The facility staff failed to display the results of the annual recertification survey and the plan of correction in a location that was easily accessible to residents, family members, and legal representatives. This deficiency was observed during a surveyor's inspection of the lobby, which took place from August 27, 2024, through September 9, 2024. During this period, there was no evidence of the State inspection results being posted in an open and readily accessible area for review by residents, staff, and visitors. Additionally, there was no sign indicating where the state survey results were located. An interview with the Nursing Home Administrator on September 9, 2024, confirmed that the facility staff did not place the survey inspection results in a location that was easily accessible for review by any persons.
Failure to Issue Beneficiary Protection Notifications
Penalty
Summary
The facility failed to provide necessary Beneficiary Protection Notifications to residents who were discharged from Medicare Part A services with benefit days remaining. Specifically, a resident was discharged from a Medicare-covered Part A stay to their home without receiving a Notice of Medicare Non-Coverage (NOMNC), which should have been issued at least two days before the last day of Medicare coverage. This notice is crucial as it informs the beneficiary of their right to an expedited review of the termination of services. The absence of this documentation was confirmed by the social services director, who acknowledged that there was no proof of the NOMNC being issued. Additionally, two residents who remained in the facility after their Medicare Part A services ended did not receive Skilled Nursing Facility Advance Beneficiary Notices (SNFABNs). These notices are essential for informing residents about potentially non-covered services and allowing them to make informed decisions regarding their care. The social services team, which was in transition, was unaware of the requirement to issue SNFABNs, and thus, these residents were not provided with the necessary information to understand their financial liability and options for continued care.
Failure to Protect Residents from Abuse
Penalty
Summary
The facility staff failed to protect a resident from verbal abuse by a staff member, as evidenced by an incident involving Resident #47. The resident, who had a history of mental health disorders including PTSD and schizoaffective disorder, reported that a housekeeping staff member, Staff #37, yelled at them for entering the bathroom after it had been sprayed. The altercation escalated when the staff member threw a trash can on the ground, causing the resident to feel threatened. Witnesses, including the resident's roommate and other staff members, corroborated the resident's account, noting that the staff member had a history of being disrespectful and rude to residents. In a separate incident, the facility's investigation revealed that Resident #54 was involved in a verbal altercation with another resident, Resident #37, in the courtyard. Resident #54 used inappropriate language, which led to Resident #37 physically assaulting them, resulting in minor injuries. Witnesses confirmed the altercation, and the police were called. Resident #54 was taken to the hospital for evaluation and returned to the facility the following day. Both incidents highlight the facility's failure to protect residents from abuse, whether verbal or physical, by staff or other residents. The facility's investigation substantiated the allegations, and the staff member involved in the first incident was terminated. The incidents underscore the need for effective measures to prevent abuse and ensure the safety and well-being of all residents.
Failure to Timely Report Allegations of Abuse and Neglect
Penalty
Summary
The facility failed to report allegations of abuse within the required 2-hour timeframe to the Office of Health Care Quality (OHCQ) for three residents during the annual and complaint survey. In the first case, a resident alleged sexual abuse by a staff member, but the initial report was sent to OHCQ over 4 hours after the incident was reported to the RN. The Director of Nursing confirmed the delay, and there were no email confirmations to verify the exact time of the report submission. In the second case, a resident alleged verbal abuse by housekeeping staff, but the report to OHCQ was not confirmed with email documentation, and the Nursing Home Administrator (NHA) could not find any email confirmations for previous reports. In the third case, a resident reported neglect due to missed showers, and the incident was reported to the corporate hotline, but the facility did not report it to OHCQ until two days later. The DON was not informed until the day the report was sent to OHCQ, and there were no email confirmations to validate the report's timing. The NHA stated that emails are only kept for 30 days, and if there is no email, it indicates the report was not done. These failures to report in a timely manner were evident for three of the eight residents reviewed during the survey.
Failure to Provide Written Notification of Bed Hold Policy
Penalty
Summary
The facility failed to notify residents and/or their representatives in writing of the facility's bed hold policy upon transfer to an acute care facility. This deficiency was identified for two residents who were reviewed for hospitalization. In the case of one resident, the representative was informed of the bed hold policy via phone but did not receive a written notification. The resident had been admitted to the facility in February 2023 and was transferred to the hospital for evaluation due to difficulty breathing. Despite the verbal communication, there was no documentation showing that the bed hold policy was mailed to the representative. For another resident, the medical record review indicated a change in condition that led to a transfer to the emergency room. Although the representative was notified of the transfer, there was no written notification of the bed hold policy. A licensed practical nurse mentioned that the policy was usually discussed over the phone and then printed for the social services department to mail. However, the social services director did not receive the necessary documentation to mail the policy to the representative, resulting in a failure to provide written notification.
Failure to Provide Baseline Care Plans Within 48 Hours
Penalty
Summary
The facility failed to provide a baseline care plan to residents within 48 hours of admission, as required. This deficiency was identified during an annual survey for two residents. One resident reported not receiving a baseline care plan or having a meeting with facility staff to discuss their care. A review of the resident's medical record confirmed the absence of a baseline care plan. Interviews with facility staff, including the Social Worker and Director of Nursing, revealed confusion about who was responsible for creating and providing the baseline care plan to residents. The Regional Nurse confirmed the failure to provide the care plan within the required timeframe. For another resident, the facility did not initiate a care plan addressing the resident's tracheostomy and oxygen use within 48 hours of admission. The admission MDS failed to identify the resident's oxygen use, and the care plan was not updated to reflect the resident's needs. Additionally, there was no documentation that the baseline care plan was provided to the resident. Interviews with the MDS coordinator and Unit Manager revealed a lack of a clear process for ensuring that care plans addressed residents' personalized needs and care concerns. The Director of Nursing acknowledged the discrepancy between the expected process and the staff's understanding and implementation.
Failure to Develop Comprehensive Care Plans
Penalty
Summary
The facility staff failed to develop comprehensive care plans for two residents, leading to deficiencies identified during an annual survey. For one resident, there was a lack of follow-up on dental care recommendations after a dentist visit, which included the use of Peridex, a prescription oral mouthwash. Despite the resident's visible dental issues and discomfort, no dental care plan was initiated, and there was no indication that dental concerns were triggered by the MDS staff. This oversight was confirmed during a review with the MDS coordinator and the DON. For another resident, the facility did not develop a care plan related to the use of high-risk medications, including anticoagulants, antianxiety, antidepressants, and insulin. Although the resident was admitted and readmitted with these medications, a care plan was not initiated until several weeks later. Interviews with the MDS coordinator and the Unit Manager revealed a lack of a clear process for ensuring that care plans are created with personalized needs and care concerns. The staff confirmed that there was no established procedure for incorporating hospital discharge information and CAA findings into the care plan.
Failure to Provide Adequate Assistance and Personal Hygiene
Penalty
Summary
The facility failed to provide adequate assistance to a resident during meals, as observed on multiple occasions. A resident, who had been diagnosed with dementia and required one-on-one assistance with feeding due to impulsive oral intake, was seen attempting to feed themselves without staff assistance. This resulted in the resident's gown being soiled with food particles, and juice being spilled on the floor. Despite the care plan indicating the need for assistance, staff were not present to aid the resident during mealtime, as confirmed by staff interviews and observations. Additionally, the facility did not ensure proper personal hygiene for another resident who was unable to perform activities of daily living due to severely impaired cognition. This resident was observed with long fingernails on multiple occasions, despite having a care plan that required staff to perform all personal hygiene tasks. Staff interviews confirmed that the resident's nails were not trimmed as needed, which could potentially lead to skin injuries.
Failure to Meet Resident's Activity Preferences
Penalty
Summary
The facility failed to provide activities that met the needs and preferences of a resident with severe cognitive impairment. Observations on two separate occasions showed the resident lying in bed and not participating in any activities. The resident's Minimum Data Set (MDS) assessment indicated a preference for activities such as listening to music, keeping up with the news, being around animals, going outside for fresh air, and participating in religious services. However, a review of the activity logs for the month of August showed that the resident was only involved in 1:1 conversations, social time, or family visits, which did not align with the documented preferences. Interviews with the activity director revealed that the activities provided did not meet the resident's preferences as recorded in the MDS assessment. The activity director acknowledged the concern that the activities offered were not in accordance with the resident's stated preferences. This deficiency highlights a failure in the facility's responsibility to ensure that the resident's activity preferences were considered and incorporated into their care plan, as required by federal regulations.
Inadequate Care and Staffing Shortage Leads to Resident Distress
Penalty
Summary
The facility failed to provide adequate care to meet the physical, mental, and psychosocial needs of a resident who was quadriplegic and had multiple medical conditions, including pressure ulcers and constipation. The resident, feeling neglected, had not had a bowel movement for 6 to 7 days and called 911 for assistance, leading to hospitalization. Documentation revealed that the resident did not receive necessary care, such as bowel movement monitoring, oral and personal hygiene, and dressing changes for pressure ulcers on specific dates. The staffing schedule indicated a significant shortage of Geriatric Nursing Assistants (GNAs) on the unit, with a high resident-to-GNA ratio, particularly on the weekend when the deficiency occurred. The Assistant Director of Nursing (ADON) confirmed the lack of documentation for essential care tasks and acknowledged the staffing issues, especially during weekends. The absence of documentation suggested that the required care was not provided, contributing to the resident's distress and subsequent hospitalization.
Failure to Provide Timely Pressure Ulcer Care
Penalty
Summary
The facility staff failed to provide timely and adequate treatment for pressure ulcers for Resident #263, as identified during an annual survey. Upon admission, the resident was noted to have bruising on the left heel, which was not measured. Further assessments revealed deep tissue injuries (DTIs) on the left heel, right heel, and right great toe, which were present on admission. However, no treatment was initiated for these DTIs until five days after admission, indicating a delay in care. Additionally, the facility staff did not conduct a weekly skin assessment with measurements on April 18, 2024, as required. This lapse in regular monitoring and documentation was confirmed by an interview with the Regional Nurse, who acknowledged the failure to assess the pressure ulcers with measurements on admission, the delay in initiating treatment, and the missed weekly wound assessment.
Failure to Change Oxygen Tubing as Per Policy
Penalty
Summary
The facility failed to adhere to its policy of changing oxygen tubing every 7 days for a resident dependent on oxygen. During an observation and interview, it was noted that the oxygen tubing for a resident was labeled with a date over a month old, indicating it had not been changed since 7/18/24. The resident expressed uncertainty about when the equipment was last changed and mentioned concerns about the noise from the oxygen regulator. An interview with the unit manager confirmed that the process for changing oxygen tubing is every 7 days, and a review of the resident's physician orders and medication administration record showed that the order was signed off as completed weekly for July and August, despite the tubing not being changed as required.
Inaccurate Psychiatric Assessment of Resident with Dementia
Penalty
Summary
The facility failed to appropriately assess a resident diagnosed with dementia and other conditions, including encephalopathy, aphasia, and dysphagia, following a cerebrovascular accident. During observations, the resident was noted to be nonverbal and sleepy, with a history of stroke and anxiety. Despite these observations, the psychiatric assessments conducted on two consecutive days in July inaccurately documented the resident's speech, thought process, and other mental health indicators as normal and organized. These discrepancies were attributed to transcription errors and typos by the psychiatric staff involved. The psychiatric assessments failed to accurately reflect the resident's condition, as noted by the surveyor and confirmed by the psychiatric staff during interviews. The assessments incorrectly described the resident's speech and thought processes, and included inappropriate counseling recommendations such as sleep hygiene and mindfulness, which were not suitable given the resident's nonverbal state and cognitive impairments. These errors were acknowledged by the psychiatric staff, who admitted to mistakes in their documentation.
Failure to Obtain Ordered Lab Tests for Resident
Penalty
Summary
The facility failed to obtain a urinalysis and urine culture and sensitivity for a resident as ordered by the resident's physician. This deficiency was identified during an annual recertification survey following a complaint that the resident had been physically aggressive towards a staff member. On the day of the incident, the resident's physician assessed the resident and ordered a psychiatric consult and lab tests, including a CBC, CMP, urinalysis, and urine culture and sensitivity, due to the resident's abnormal behavior. However, a review of the resident's medical record revealed that the urinalysis and urine culture and sensitivity were not conducted. An interview with the Nursing Unit Manager confirmed that while the order was entered into the electronic medical record system, it was not placed in the lab system, and thus, the specimens were not obtained. This oversight was acknowledged by the nursing unit manager and reviewed with the Director of Nursing.
Inaccurate Medical Record-Keeping for Two Residents
Penalty
Summary
The facility failed to maintain complete and accurate medical records for two residents, as identified during an annual and complaint survey. For one resident, there was a discrepancy in the documentation of Morphine dosage; the physician's history indicated a dosage of 50 mg three times a day, while the records showed 15 mg three times a day. Additionally, a pain assessment was documented after the resident had already been discharged to the hospital, which was confirmed as an error by the regional nurse. For another resident, a nurse practitioner's follow-up note was dated after the resident had been discharged from the facility. The nurse practitioner admitted to documenting the visit three days after it occurred, which was against the facility's unwritten policy of documenting within 48 hours. The Nursing Home Administrator confirmed the lack of a written policy for physician documentation, which contributed to the inaccurate record-keeping.
Failure to Provide Soap in Staff Restroom
Penalty
Summary
The facility failed to provide soap in a staff restroom located by the Magnolia Unit nurses' station, which is crucial for maintaining proper infection prevention and control. This deficiency was identified during a surveyor's observation on 8/30/24 at approximately 11:00 am, when it was noted that the automatic soap dispenser in the restroom was malfunctioning due to needing batteries. The Magnolia Unit Manager was unaware of the issue until informed by the surveyor. The Maintenance Director, who was present for another repair, was also informed of the malfunctioning dispenser. Despite the concern being raised to the Executive Director later that day, the automatic soap dispenser remained unrepaired by the following day, although a container of liquid soap was made available for staff use in the restroom.
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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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