Encore At Turf Valley
Inspection history, citations, penalties and survey trends for this long-term care facility in Ellicott City, Maryland.
- Location
- 11150 Resort Road, Ellicott City, Maryland 21042
- CMS Provider Number
- 215355
- Inspections on file
- 16
- Latest survey
- June 18, 2025
- Citations (last 12 mo.)
- 0
Citation history
Health deficiencies cited at Encore At Turf Valley during CMS and state inspections, most recent first.
Surveyors found that various food items in the kitchen's refrigerator and freezer, including trays of French fries, biscuits, turkey sausage, bacon, and opened bags of cheese cubes, were not labeled with the date they were prepared or opened. This lack of date labeling was observed during a kitchen tour with dietary staff and reported to the DON.
A resident admitted for rehab after right knee surgery was incorrectly coded in the MDS as having no lower extremity impairment, despite documentation and staff confirmation of significant right lower extremity functional limitation, pain, and need for substantial assistance with mobility and dressing tasks.
Two residents who required assistance with eating were left without proper support, with meal trays placed out of reach and no staff present to help. One resident was also left uncovered and exposed to the hallway, compromising their dignity. Facility policy requiring trays to be held until staff are ready to assist was not followed, resulting in a failure to provide care in a manner that maintains dignity and respect.
Two residents were not provided with written information about their right to formulate an advance directive at admission, and there was no documentation verifying that this information was given as required. The deficiency was identified through record review and staff interviews, which confirmed the absence of necessary documentation.
A resident experienced multiple episodes of low blood pressure and abnormal vital signs, but the physician was not notified until over four hours after the initial changes were documented. The delay in communication was confirmed by the DON, with no evidence of earlier notification found in the medical record.
Protected health information for 27 residents, including names, insurance payor details, and care levels, was left visible on an unattended computer screen at the main nursing station. The screen was accessible to anyone passing by, and no staff were present to monitor it. The DON confirmed that PHI should not be left visible or accessible when unattended.
A facility did not report an allegation of abuse involving a resident to the appropriate authorities within the required two-hour timeframe. The incident was reported internally but not submitted to the Office of Health Care Quality until well after the mandated period, contrary to facility policy as confirmed by the DON.
A resident was given a breakfast tray intended for another resident with a different physician-ordered diet, due to an agency GNA delivering the wrong tray. The error was identified by staff, and the tray was removed after discovery. Medical records confirmed the dietary orders for both residents at the time of the incident.
A resident's medical record contained a progress note by an LPN indicating sacral wounds, while multiple entries in the TAR by various nursing staff documented the resident's skin as intact. Interviews with the ADON and an RN confirmed the absence of sacral wounds, and the DON acknowledged the documentation error.
Surveyors observed that more than ten dish crates were stored on the kitchen floor near the dishwasher, contrary to infection control protocols. The Dietary Manager confirmed that this was not the correct storage practice, highlighting a lapse in adherence to infection prevention procedures.
Failure to Date Label Stored Food Items in Kitchen
Penalty
Summary
During an initial kitchen tour, surveyors observed that multiple food items stored in the facility's refrigerator and freezer were not labeled with the date they were prepared or opened. Specifically, large trays of French fries, biscuits, turkey sausage, and bacon, as well as opened bags of Pepper jack and Swiss cheese cubes, were found in the refrigerator without any date markings. In the freezer, a tray containing frozen fruit pies and a half bag of frozen biscuits also lacked date labels. These findings were made in the presence of the Dietary Manager and Kitchen Supervisor, and the Director of Nursing was informed of the concerns. The absence of date labeling on these food items was identified as a failure to store food in accordance with professional standards.
Inaccurate MDS Coding for Functional Limitation in Range of Motion
Penalty
Summary
The facility failed to ensure that the Minimum Data Set (MDS) assessments were accurately coded for a resident admitted for rehabilitation following a right revision total knee replacement and infection, with a wound vac in place. During review of the resident's admission MDS assessment, it was found that Section GG0115, which addresses functional limitation in range of motion, was incorrectly coded as indicating no impairment in the lower extremity. However, documentation and staff interviews confirmed that the resident had significant impairment in the right lower extremity, including limited range of motion and pain, and required substantial to maximal assistance with lower body dressing, transfers, and mobility tasks. Physical therapy staff confirmed the resident's right lower extremity impairment, noting specific limitations in extension and flexion, and occupational therapy records also documented impaired range of motion and pain in the right knee. The MDS Coordinator acknowledged that the resident should have been coded for impairment on one side in the lower extremity section of the MDS. The deficiency was identified through record review and staff interviews, which demonstrated that the resident's functional impairment was not accurately reflected in the MDS assessment.
Failure to Maintain Resident Dignity and Provide Timely Meal Assistance
Penalty
Summary
Surveyors observed that the facility failed to maintain resident dignity and provide appropriate assistance with meals for residents requiring help. One resident was found lying in bed with their brief exposed and uncovered, visible from the hallway due to an open curtain, and calling out for help to access their meal tray, which was placed out of reach on a bedside table pushed against the wall. The resident reported that their tray was often left on the table without being set up for them when meals were served. This situation was witnessed by the surveyor and brought to the attention of an LPN, who acknowledged the issue. Another resident, who was documented as dependent on staff for eating, was observed awake in bed, reaching upward, with their meal tray and water cup placed on a nightstand out of reach and without staff present to assist. Medical records confirmed the resident required staff assistance for eating. The facility's policy stated that trays should be held on the cart until staff are ready to assist with feeding, but this procedure was not followed, resulting in residents not receiving timely and dignified assistance with their meals.
Failure to Provide Advance Directive Information at Admission
Penalty
Summary
The facility failed to ensure that residents were provided with written information regarding their right to formulate an advance directive upon admission. Record review for two residents showed no documentation of advance directives or evidence that information about their rights to establish one was given at the time of admission. The surveyor was unable to locate any documentation verifying that the required information was presented to the residents, and the Director of Nursing (DON) was also unable to provide signed documentation confirming this. Although there were notes indicating that the social worker addressed the status of advance directives and that responsible parties were contacted after admission, there was no evidence that the residents themselves received the necessary information upon admission. The deficiency was identified through review of electronic medical records and interviews with facility staff, which confirmed the lack of required documentation.
Failure to Timely Notify Physician of Resident's Change in Condition
Penalty
Summary
The facility failed to notify a resident's physician in a timely manner following a significant change in the resident's condition. Documentation showed that the resident experienced multiple episodes of low blood pressure, with readings as low as 74/42, and other abnormal vital signs beginning at 5:00PM. Despite these changes, there was no evidence that the physician was notified until approximately 4 hours and 13 minutes later, at 9:13PM, when an electronic message was sent by an LPN to the physician. The physician responded at 9:34PM. The Director of Nursing confirmed that there was no documentation of earlier notification to the physician regarding the resident's condition. The delay in communication was verified through interviews and review of the medical record, and the concern was acknowledged by facility leadership during the survey process. The deficiency was identified for one resident reviewed for neglect during the survey.
Unattended Computer Screen Exposes PHI at Nursing Station
Penalty
Summary
A deficiency occurred when protected health information (PHI) for 27 residents, including their names, insurance payor information, and care levels, was left visible on an unattended computer screen at the main nursing station. The screen was positioned so that anyone passing by, including visitors and residents, could view the information. No staff member was present at the station during the observation, and the computer was not locked or turned off. The Director of Nursing confirmed in an interview that PHI should not be left accessible or visible when unattended and acknowledged that the information displayed constituted PHI. The incident was based on direct observation and staff interview, with no mention of corrective or follow-up actions taken at the time of the report.
Failure to Timely Report Alleged Abuse to Authorities
Penalty
Summary
The facility failed to report an allegation of abuse involving a resident within the required two-hour timeframe to the Survey Agency, specifically the Office of Health Care Quality (OHCQ). Documentation showed that the incident was reported to the facility at 2:00 PM, but the report was not submitted to OHCQ until the following morning at 10:00 AM, which exceeded the mandated reporting window. During an interview, the Director of Nursing confirmed that the facility's policy requires all abuse allegations to be reported within two hours of staff becoming aware, and acknowledged that this expectation was not met in this case.
Resident Received Incorrect Diet Due to Meal Tray Delivery Error
Penalty
Summary
A resident was observed receiving the incorrect breakfast tray, which was intended for another resident with a different prescribed diet. The meal ticket on the tray indicated it belonged to a resident who was ordered a Dysphagia Level 2 diet, while the affected resident was ordered a regular diet by the physician. Staff interviews revealed that an agency GNA mistakenly delivered the wrong tray, and the error was subsequently identified and the tray removed. The incident was reported to the LPN and later brought to the attention of the DON. Medical record reviews confirmed the dietary orders for both residents involved at the time of the incident.
Inaccurate Medical Assessment Documentation for Resident
Penalty
Summary
The facility failed to ensure the accuracy of medical assessment documentation for a resident. A review of the resident's medical record revealed a skilled progress note by an LPN documenting the presence of sacral wounds. However, subsequent reviews of the Treatment Administration Record (TAR) for the same period showed that multiple nursing staff consistently documented the resident's skin as intact during weekly and twice-weekly assessments. No additional documentation or evidence of sacral wounds was found in the resident's medical record. Interviews with the Assistant Director of Nursing (ADON) and a Registered Nurse (RN) confirmed that the resident did not have any sacral wounds, and the ADON acknowledged that the earlier documentation was incorrect. The Director of Nursing (DON) also confirmed that the documentation was entered in error and should be removed from the resident's chart. The deficiency was identified during the survey process as a result of these inconsistencies in the resident's medical documentation.
Improper Storage of Dish Crates Compromises Infection Control
Penalty
Summary
During an initial kitchen tour, surveyors observed more than ten dish crates stored directly on the floor next to and across from the dishwasher. Both the Dietary Manager and Kitchen Supervisor were present during these observations. When questioned, the Dietary Manager confirmed that dish crates should not be stored on the floor. These findings were based on direct observation and staff interviews, indicating a failure to adhere to infection control practices and procedures for proper storage of dish trays in the kitchen.
Latest citations in Maryland
The facility did not ensure that its Infection Preventionist (IP) met required qualifications for managing the Infection Prevention and Control Program. The DON reported serving as the IP but acknowledged lacking the specialized infection control training required for the role, and confirmed that no other staff member was currently qualified. Records showed that the previously qualified IP left several months earlier, and the Administrator and DON confirmed they were still seeking a replacement, leaving the infection control program without a properly trained leader.
Staff failed to consistently secure medications and medical supplies across three units, including an oxygen tank left on the floor behind a resident’s bed without a supporting device, a treatment cart with Collagenase Santyl cream left on top while two residents in power wheelchairs passed by, an unattended and unlocked treatment cart at a nursing station, and another treatment cart with Diclofenac gel and dressings left on top, indicating repeated lapses in maintaining locked and secure storage for drugs, biologicals, and related supplies.
The facility failed to provide sufficient dietitian coverage and timely nutritional assessments for several residents with significant dietary needs. A resident admitted for diabetic management with a high A1C was placed on a regular diet instead of the recommended carb-controlled diet and had only one weight taken in the first two weeks, with no dietitian review of the record. Another resident with prior significant weight loss had no documented dietitian follow-up despite continued weight loss, and a resident admitted with severe protein-calorie malnutrition experienced further significant weight loss without any dietitian assessment. The dietitian reported working limited hours and prioritizing certain high-risk cases, resulting in delayed or missed evaluations for new admissions and residents with ongoing nutritional concerns.
The facility failed to maintain adequate linen and incontinence supplies and did not keep resident care areas in good repair, resulting in delays and alterations in incontinence care and substandard environmental conditions. Staff reported that towels and washcloths were used instead of wipes and then discarded due to heavy soiling, and that linen deliveries to units were late, leaving residents waiting for care. Observations showed very limited numbers of clean washcloths and other linens on units and in the laundry, with no stock of disposable wipes or backup washcloth supply despite repeated reports to housekeeping. Additional observations revealed recliner chairs blocking a dining-area handwashing sink and kitchenette, multiple resident and shared bathrooms with unfinished spackle, chipped paint, musty odors, black substances near showers, missing threshold molding, exposed cracks and nails, and eroded, rusted baseboard heaters. Hallway handrails on both units were worn, chipped, and splintered, and a shower room contained fecal odors, dried brown stains on the toilet, and deteriorated fixtures, all contributing to a failure to provide a safe, clean, and homelike environment.
Facility staff did not thoroughly investigate two separate abuse allegations involving a resident and an injury of unknown origin involving another resident. In both cases, investigations focused on the directly affected resident and included staff interviews, but there were no interviews of other residents on the unit or documented assessments of those residents for signs of abuse or injuries of unknown origin, including residents unable to communicate due to cognitive status.
Two residents who were dependent on staff for oral care, including one with a tracheostomy, were observed with thick, white or milky substances coating their mouths and teeth, indicating inadequate oral hygiene. One resident communicated that staff did not brush their teeth and that staff "need to." In another case, despite oral care supplies being present in the room, the resident’s mouth and teeth remained unclean on multiple observations, with a thick milky substance caking the teeth and stringing between them when the resident tried to open their mouth. These findings showed that staff did not consistently provide oral care to residents who relied on them for this ADL.
Staff failed to maintain complete and accurate medical records for multiple residents, including missing and inconsistent documentation of wound care, delayed pain assessment after discovery of an injury of unknown origin in a cognitively impaired resident, and inaccurate recording of a PPD test result that was documented as negative despite no evidence the injection was administered and no supporting nurse’s note. Residents reported not receiving certain treatments, while MAR entries either lacked signatures for completion or contained conflicting information about whether care was provided.
Surveyors found that the facility failed to consistently implement and communicate correct transmission-based precautions and PPE use. One resident with a Foley catheter related to wounds had no precaution signage posted, while another resident in a double room had a contact precautions sign at the door, yet the NP entered without PPE and the GNA provided high-contact care wearing only gloves. Staff in that room stated the resident was not on contact precautions and later reversed the sign to show no PPE requirement. Therapy staff reported they rely solely on posted signs to determine PPE, and surveyors identified broader issues with inaccurate signage and staff awareness of which residents required contact precautions.
Surveyors found that MDS assessments were inaccurately coded for two residents. In one case, a resident sustained a femoral neck fracture after a fall, but the subsequent significant change MDS did not code the fall as a major injury and failed to capture prn Tylenol use documented on the MAR within the look-back period. In the other case, a quarterly MDS indicated opioid use for a resident, but the MAR for the same period showed no prescribed opioid, indicating incorrect coding of high-risk drug classes.
A resident who had recently been admitted and experienced a fall received multiple doses of the narcotic analgesic Tramadol, but the facility failed to accurately document all administered doses on the Medication Administration Record (MAR). Review showed only one Tramadol dose recorded on the MAR, while the Controlled Drug Receipt/Record/Disposition Form on the med cart reflected three doses given over two days. In interview, the DON stated staff are expected to document narcotic administration on the MAR and confirmed that two administered doses were not recorded there, resulting in an incomplete and inaccurate medical record.
Unqualified Infection Preventionist Overseeing Infection Control Program
Penalty
Summary
The facility failed to ensure that its designated Infection Preventionist (IP) met the mandatory qualifications for overseeing the Infection Prevention and Control Program. During an interview on 3/24/26 at 10:00 AM, the DON confirmed that she/he was serving as the facility’s IP but had not completed the specialized training in infection control required for the position. The DON further stated that no other staff member currently met the qualifications to serve as IP. Record review showed that the previously qualified IP left the facility in October 2025, and as of the survey date, the position remained unfilled by a qualified individual. At 1:30 PM on the same day, the Administrator and DON confirmed they were still in the process of finding a qualified IP for the facility, leaving the Infection Prevention and Control Program without a properly trained and qualified leader. No specific residents, medical histories, or clinical conditions were described in relation to this deficiency.
Unsecured Medications, Treatment Carts, and Oxygen Equipment
Penalty
Summary
Facility staff failed to ensure that drugs, biologicals, and related medical supplies were securely stored and properly maintained on multiple units. On one unit, an oxygen tank assigned to a resident was observed sitting on the floor behind the resident’s bed without any supporting device. On another unit, a treatment cart was observed with a tube of Collagenase Santyl cream labeled for a specific resident left on top of the cart, while residents in power wheelchairs passed by and staff were present at the nursing station. These observations showed that medications and oxygen equipment were not consistently secured as required. Further observations on additional units revealed an unattended and unlocked treatment cart at a nursing station, and on a separate occasion, a treatment cart with Diclofenac gel labeled for a resident left on top along with multiple packs of dressings. These incidents occurred across three units and on more than one date, demonstrating repeated failures to keep medications and treatment supplies in locked compartments or otherwise secured from unauthorized access.
Insufficient Dietitian Coverage and Delayed Nutritional Assessments
Penalty
Summary
The deficiency involves the facility’s failure to employ sufficient food and nutrition staff, including adequate dietitian coverage, to ensure timely assessment and appropriate diets for residents with significant nutritional and diabetic needs. A resident admitted over two weeks earlier with multiple comorbidities and an A1C of 11.5% had a hospital discharge recommendation for a carbohydrate-controlled diet, but was placed on a regular diet at admission with no acknowledgment of the recommended diet until one week later, when the resident requested larger portions. As of the survey date, the dietitian had not yet seen or reviewed this resident’s medical record, and the resident reported not having seen a dietitian and being very frustrated with the meals. During the first two weeks after admission, only one weight was obtained for this resident, despite physician notes stating the resident’s weight was “stable.” Further review of other residents showed additional failures in timely dietitian assessment and follow-up. One resident, readmitted in January and previously seen by the dietitian in September for a 6.4 lb weight loss over 30 days, had no documented follow-up despite continued weight loss totaling 22 lbs since the last dietitian review. Another resident admitted at the end of February with severe protein-calorie malnutrition had not been seen by the dietitian after about a month in the facility, despite a documented 14 lb (7%) weight loss over two weeks. The dietitian reported working only 12 hours per week at the facility and stated that she must prioritize which residents to see, focusing first on residents with tube feedings and those identified in risk meetings, resulting in delayed or absent assessments for new admissions and residents with ongoing weight loss and malnutrition diagnoses.
Linen Shortages and Poor Environmental Maintenance Compromise Resident Care and Comfort
Penalty
Summary
The deficiency involves the facility’s failure to maintain an adequate supply of clean linens and appropriate incontinence wipes, resulting in delays and alterations in residents’ incontinence care, as well as the use of towels and washcloths in place of disposable wipes. During the initial tour, the surveyor observed that the linen supply on one nursing unit hallway was low. Complaint reviews included concerns about delays in incontinence care and bed linens not being changed regularly, with residents left without clean bedding. A complainant reported that there was not enough clean linen available for residents. Staff interviews confirmed that towels, sheets, and washcloths were being used to wipe residents for incontinence care due to the absence of wipes, and that many of these linens were being thrown away when soiled. Staff also reported a shortage of linen, that linen deliveries to the units were late, and that residents who preferred to get up before breakfast had to wait for care when linen was delayed. Further observations showed that the clean supply room contained no disposable wipes or cloths for incontinence care, and a resident reported that staff did not use wipes, that the resident had to purchase their own, and that heavily soiled towels or washcloths were discarded. A tour of all nursing unit linen carts and closets revealed only six clean washcloths and limited supplies of towels, gowns, and bed linens. In the laundry room, only three washcloths were present, and the laundry assistant stated that there were only three washcloths available for each nursing unit that morning, that the facility was short on linen supply, and that these concerns had been repeatedly reported to the Director of Housekeeping over the preceding month and again that morning. The laundry assistant confirmed there was no additional laundry in process. The DON stated that wipe squares should be used for incontinence care, but no such wipes were found in the clean medical supply room, and no backup supply of washcloths was present in the emergency linen supply. The Director of Housekeeping confirmed there was no backup supply of washcloths. The deficiency also includes environmental and maintenance issues affecting resident bathrooms, handrails, and common areas. In the main dining area, a recliner chair was observed positioned directly in front of the handwashing sink, and two recliner chairs were stored in front of the nutrition area kitchenette. Multiple resident bathrooms and shared bathrooms were repeatedly observed over several days with unfinished spackle on walls that needed resurfacing and painting, chipped paint around sinks, uneven boards nailed to walls under sinks that appeared to partially cover holes, musty odors, black substances between shower bases and walls, missing threshold transition molding exposing cracks, missing tiles, and a nail, as well as eroded and chipped paint on baseboard heaters with exposed dark brown metal and rust-like material. Hallway handrails on both nursing units were observed to be worn, with chips, splintering, holes, and areas where the wood finish had worn off. A shower room was observed with a foul fecal odor, dried brown stains on the back of the toilet seat and in the toilet bowl, and a baseboard heater with eroded, chipped paint and rust-like material, along with chipped paint on the handrail. These conditions were acknowledged by the Director of Maintenance and other leadership, and some areas were noted to be in the process of renovation, but the observed deficiencies remained present during the survey period. Overall, the facility did not maintain a safe, clean, comfortable, and homelike environment in good repair across both nursing units and the dining area. The lack of adequate linen and incontinence supplies, combined with the poor condition of resident bathrooms, handrails, and certain common areas, constituted the basis for the cited deficiency. The observations and staff and resident reports consistently described shortages of essential hygiene supplies, delayed care related to linen availability, and multiple unresolved environmental and maintenance issues in resident care areas and shared spaces.
Failure to Thoroughly Investigate Abuse Allegations and Injuries of Unknown Origin
Penalty
Summary
Facility staff failed to thoroughly investigate allegations of potential abuse involving one resident and an injury of unknown origin involving another resident. For one resident, there were two separate allegations of abuse occurring on different days in early February. The facility’s investigation packets included interviews with staff who cared for or were scheduled to work with this resident on the days of the alleged incidents, and the investigations focused solely on this resident. However, there were no interviews conducted with other residents on the unit to inquire about abusive or neglectful treatment by the staff who were working during the times of the allegations. The surveyors noted that, although the allegations were not validated, there was no documentation that other residents were interviewed, if able, or assessed for signs or symptoms of injury. In a separate incident, another resident was identified on March 4 with a new bruise on the right eye, documented as a change in condition at 4:09 AM. This resident had a BIMS score of 99, indicating the resident was unable to complete an interview and therefore could not report how the injury occurred. The facility’s investigation identified a potential cause of the injury but did not reach a definitive resolution. Additionally, there were no interviews of other residents on the unit regarding possible abuse, nor were there documented assessments of other residents for injuries of unknown origin, particularly for those unable to speak for themselves, as in this resident’s case.
Failure to Provide Oral Care to Dependent Residents
Penalty
Summary
The deficiency involves the facility’s failure to provide oral care to residents who were dependent on staff for activities of daily living, specifically oral hygiene. One resident with a tracheostomy was observed with a thick, sticky white substance in the mouth and was noted to intermittently chew on nearby bedding. This resident made good eye contact and, when asked if staff brushed their teeth, shook their head no and mouthed that staff “need to.” According to the resident’s Minimum Data Set (MDS) dated 2/11/26, the resident was dependent on staff for oral care. Another resident, also dependent on staff for oral care per the 3/11/26 MDS, was observed sitting propped up in bed and able to respond with smiles. During the initial observation, the inside of this resident’s lips and upper and lower teeth had a thick, clear, white milky substance visible when the resident tried to open their mouth to smile. Oral care supplies were present in the nightstand, but the resident’s mouth and teeth were not clean. On a subsequent observation with the DON, NHA, and Corporate VP of clinical services, the same resident again had a thick, clear, milky substance between the lips and caking the teeth, which would string between the teeth when the resident attempted to open their mouth, demonstrating a lack of consistent oral care for residents dependent on staff for this ADL.
Incomplete and Inaccurate Medical Record Documentation for Treatments and Assessments
Penalty
Summary
Facility staff failed to maintain complete and accurate medical records and documentation for multiple residents. For one resident with wound care needs, review of the MAR showed that wound care and related treatments were signed as completed on the dates initially reported, despite the resident’s ongoing complaints that wound dressings were not being changed. When additional dates were reviewed, there were missing staff signatures for wound care on two specific dates, as well as three instances where application of A&D ointment to the resident’s feet was not signed off out of 24 days reviewed. Another resident with severe cognitive impairment, as evidenced by a BIMS score of 00, was found to have an injury of unknown origin (a bruise on the left hand). Documentation showed that a change in condition was initiated late in the morning, but a formal pain evaluation was not initiated and completed until that night, and the resident was unable to explain how the injury occurred or verbalize pain using a standard pain scale. For a third resident, documentation related to the admission PPD test was inconsistent and incomplete. The MAR contained an entry indicating “9” for the administration date, meaning “see nurse’s note,” but there was no corresponding nurse’s note. Despite the absence of a signed administration of the PPD injection, staff documented the PPD result as “negative” on the scheduled read date. The resident reported never receiving the PPD injection, and the DON confirmed that the facility had been out of PPD solution at the time, so the test would not have been administered. These findings demonstrate failures in accurate documentation of treatments and assessments, including wound care, pain assessment, and TB screening, as well as missing or incomplete supporting notes in the medical record.
Failure to Implement and Communicate Correct Transmission-Based Precautions
Penalty
Summary
Surveyors identified a deficiency in the facility’s infection prevention and control program related to inconsistent and incorrect implementation of transmission-based precautions and PPE use. During a complaint investigation focused on residents on transmission-based precautions, one resident with a visible Foley catheter was observed in the room with physical therapy, but there were no signs posted indicating any need for PPE, despite the resident being a new admission with a Foley catheter placed related to wounds. In another double-occupancy room, a contact precautions sign was posted at the doorway, but the nurse practitioner was in the room on a personal phone with no PPE, and the assigned GNA was repositioning the resident in bed while wearing only gloves. When questioned, the NP, RN, and GNA all stated that the resident in the room was not on contact precautions, and the GNA reported that signs were hanging at all doors and that this particular resident’s sign was “just wrong.” The surveyor observed the GNA later return to the room and turn the sign around to indicate no PPE requirement. Subsequent interviews revealed that therapy staff relied on posted signage to determine PPE use and that if the sign was wrong, the PPE used would be wrong. Overall, surveyors found problems with signage accuracy and staff awareness of which residents required contact precautions, as well as observed failures to follow appropriate PPE use for residents who should have been on contact precautions.
Inaccurate MDS Coding for Falls, Pain Management, and High-Risk Medications
Penalty
Summary
Facility staff failed to ensure Minimum Data Set (MDS) assessments were accurately coded for two residents reviewed during a complaint survey. For one resident, a facility-reported incident showed that the resident was found seated on the floor beside the bed and was diagnosed with a non-displaced femoral neck impaction fracture of the left hip following an x-ray. Despite this fall with a major injury, the subsequent significant change MDS dated 11/4/25 did not code the fall with major injury in Section J1900C. Review of the resident’s Medication Administration Records for October and November 2025 showed administration of Tylenol on 10/31/25 at 9:30 PM, which fell within the 5-day look-back period for the MDS, but Section J0100 (prn pain) of the same significant change MDS did not capture the use of Tylenol. For another resident, review of a quarterly MDS with an assessment reference date of 10/15/25 showed that Section N0415 (High-Risk Drug Classes) documented the use of an opioid medication. However, review of the resident’s October 2025 Medication Administration Record did not show that the resident had been prescribed an opioid during that period. In both cases, MDS staff later confirmed that these were errors in MDS coding, demonstrating that the assessments did not accurately reflect the residents’ clinical status and medication use as documented in their medical records.
Incomplete Documentation of Narcotic Administration on MAR
Penalty
Summary
The facility failed to maintain complete and accurate medical records in accordance with accepted professional standards for one resident receiving narcotic medication. The resident, admitted in March 2026, had a fall on 3/6/26 and was sent to the hospital on 3/9/26. Review of the March 2026 Medication Administration Record (MAR) showed documentation of a single 25 mg dose of Tramadol administered on 3/8/26 at 9:23 AM. However, review of the resident’s Controlled Drug Receipt/Record/Disposition Form, kept on the nurse’s medication cart and not in the medical record, showed that Tramadol 25 mg was administered three times between 3/8/26 and 3/9/26: at 11:00 AM and 9:00 PM on 3/8/26, and at 9:00 AM on 3/9/26. In interview, the DON stated that staff are expected to document narcotic administration on the MAR and confirmed that only one of the three Tramadol doses reflected on the controlled drug record was documented on the resident’s MAR. This discrepancy between the controlled substance record and the MAR, with missing documentation of two administered doses of Tramadol on the official medical record, constituted the failure to maintain a complete and accurate medical record for the resident.
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