Fahrney-keedy Memorial Home
Inspection history, citations, penalties and survey trends for this long-term care facility in Boonsboro, Maryland.
- Location
- 8507 Mapleville Road, Boonsboro, Maryland 21713
- CMS Provider Number
- 215337
- Inspections on file
- 15
- Latest survey
- February 19, 2025
- Citations (last 12 mo.)
- 0
Citation history
Health deficiencies cited at Fahrney-keedy Memorial Home during CMS and state inspections, most recent first.
The facility failed to store and prepare food according to professional standards, with several opened and expired items found in the refrigerator. Additionally, dietary aides were observed mishandling food, such as not changing gloves or washing hands after touching various surfaces, and not wearing hair restraints. These deficiencies were noted during a kitchen inspection.
The facility failed to follow infection control protocols, including droplet precautions for a resident with pneumonia, lacking a Legionella Water Management Program, and not adhering to Enhanced Barrier Precautions (EBP) for residents requiring high-contact care. Staff were observed not wearing appropriate PPE, and the facility's water management policy lacked necessary details. These deficiencies were confirmed through staff interviews and observations.
A resident's dignity was compromised when their urine collection bag was not placed in a privacy bag, making it visible from the hallway. The resident, who had a Foley catheter, was observed during a facility tour, and the RN confirmed the lack of a privacy bag. The DON acknowledged the issue, which was noted as a deficiency in maintaining resident dignity.
The facility failed to conduct thorough investigations for abuse allegations involving three residents. In one case, a resident reported verbal abuse by an LPN, but other residents cared for by the LPN were not assessed. In another case, a resident alleged abuse by agency staff, but the facility did not assess other residents cared for by the staff. In the third case, a resident's abuse complaint was not substantiated, and the investigation lacked interviews with other residents or a medical assessment.
A facility failed to notify a resident and their representative in writing of the bed hold policy upon transfer to a hospital. The resident, who was alert and cognitively intact, was transferred for medical reasons, but the facility did not provide the required documentation. Interviews revealed that the policy was not consistently communicated to long-term residents.
A resident receiving tube feedings had a care plan with conflicting instructions regarding dietary intake supervision. Staff noted the resident as independent, while the Kardex required 1 to 1 supervision for oral intake. Observations showed the resident unsupervised with liquids, highlighting a failure to update the care plan to meet the resident's needs.
A resident with Alzheimer's Dementia, dependent on staff for self-care, was found with long toenails despite a care plan directive to trim them on shower days. The resident's representative had informed staff of the issue weeks prior, but the toenails remained untrimmed until a surveyor's intervention. An LPN and the DON confirmed that the GNAs were responsible for this task, highlighting a lapse in care.
A resident with an indwelling catheter was observed with their urine collection bag placed directly on the floor, contrary to the care plan which required the bag to be positioned below the bladder and away from the entrance. The RN confirmed the observation and corrected the placement by hanging the bag on the bedframe. The DON acknowledged the concern.
A facility failed to serve a meal according to a resident's dietary needs and preferences. A surveyor observed that a meal tray intended for a resident on a mechanical soft diet contained apple pie instead of the specified cinnamon applesauce. The Food Service Manager confirmed the error, acknowledging that the dietary staff should have adhered to the resident's meal ticket. The nursing home administrator was informed of the issue.
A facility failed to report an abuse allegation involving a resident to the State Agency within the required 2-hour timeframe. The resident informed an LPN of the abuse, but the Nursing Home Administrator was not notified until days later, and the state agency was informed even later. The facility lacked documentation to prove timely reporting, as confirmed by interviews with the social services director and DON.
Deficient Food Storage and Handling Practices
Penalty
Summary
The facility failed to store and prepare food in accordance with professional standards, as observed during a kitchen inspection. The walk-in refrigerator contained several opened food items, such as Greek yogurt, pineapple juice, and various seasonings, without labels indicating their open and use-by dates. Additionally, several other food items, including Italian dressing, chopped garlic, and cooked meats, were found with expired use-by dates. Staff #4, the food services manager, acknowledged the labeling issues and removed the expired items after the surveyor's intervention. Further observations revealed lapses in food handling practices by the kitchen staff. Staff #5, a dietary aide, was seen handling food trays without changing gloves or washing hands after touching various surfaces, including a phone. Staff #7 was observed without a hair restraint while handling food, and Staff #6 used the same gloves to touch a food warmer and then bread without changing them. These actions were brought to the attention of Staff #4, who acknowledged the concerns and indicated that hand hygiene training was provided to staff upon hire and annually.
Infection Control Deficiencies in LTC Facility
Penalty
Summary
The facility failed to adhere to proper infection control protocols, as evidenced by multiple deficiencies observed during the survey. Resident #71, diagnosed with pneumonia, was placed on droplet precautions, requiring healthcare personnel to wear an N-95 mask, gown, and gloves. However, a Geriatric Nursing Assistant was observed in the resident's room wearing only a surgical mask, without the necessary gown and N-95 mask, despite the droplet precaution sign posted outside the room. This lapse in protocol was confirmed by the Director of Nursing and acknowledged by the GNA involved. The facility also lacked a comprehensive Legionella Water Management Program. Although a policy was in place, it did not include a detailed description or diagram of the water system, nor did it identify areas prone to Legionella growth. During an interview, the maintenance staff admitted to not having a plan in place to prevent Legionella and other waterborne pathogens, despite understanding the requirements outlined in the policy. Additionally, the facility failed to implement Enhanced Barrier Precautions (EBP) for residents requiring high-contact care. Resident #85, who had a wound requiring daily dressing changes, was not provided care in accordance with EBP guidelines. An LPN performed a dressing change without wearing a gown and failed to perform hand hygiene between glove changes. Similarly, CNAs providing care to Resident #39, who had a history of MDRO infection, did not wear gowns as required by EBP protocols. These deficiencies were confirmed through interviews with the staff involved and the Director of Nursing.
Failure to Maintain Resident Dignity with Urine Collection Bag
Penalty
Summary
The facility failed to ensure the dignity of a resident by not maintaining privacy for the resident's urine collection bag. During an initial tour, it was observed that the urine collection bag of a resident was not placed in a privacy bag and was visible from the hallway. This observation was made for one of the three residents reviewed for dignity. The resident had been readmitted from the hospital with a Foley catheter in place, and the care plan included positioning the catheter bag and tubing below the bladder level and away from the entrance room door. Upon interviewing the RN assigned to the resident, it was confirmed that the urine collection bag was indeed visible and not in a privacy bag. The RN attempted to find a privacy bag but was unsuccessful. The Director of Nursing was later informed of the issue and acknowledged the concern. The deficiency was noted as the facility did not adhere to the dignity standards by failing to provide a privacy bag for the urine collection bag, which was visible from outside the resident's room.
Failure to Conduct Thorough Abuse Investigations
Penalty
Summary
The facility failed to conduct thorough investigations for allegations of abuse involving three residents. In the first case, an environmental services aide reported verbal abuse of a resident by an LPN. Although the resident and their roommate were interviewed, there was no documentation of assessments or interviews of other residents cared for by the LPN during that shift. The Director of Nursing (DON) confirmed the lack of documentation for these additional assessments and interviews. In the second case, an allegation of abuse was made by a resident against an agency nursing staff. The facility assessed the resident's skin and obtained statements from the alleged perpetrator and other staff, but did not document assessments or interviews of other residents cared for by the alleged perpetrator. The DON acknowledged this oversight. In the third case, a resident's complaint of abuse was not substantiated after several staff testimonies and an interview with the resident, who was found to be confused. The DON admitted that the investigation did not meet facility expectations, as it lacked interviews with other residents or a resident assessment by a Nurse Practitioner or Physician.
Failure to Notify Resident of Bed Hold Policy
Penalty
Summary
The facility failed to notify a resident and/or their representative in writing of the facility's bed hold policy upon the resident's transfer to an acute care facility. This deficiency was identified during a review of five residents who were hospitalized, specifically affecting one resident. The resident, who was alert, oriented, and cognitively intact, had been residing in the facility since August 2023. A nurse's note indicated that the resident was transferred to the hospital for lethargy, unresponsiveness, and increased tremors on December 22, 2024. However, there was no documentation showing that the facility's bed hold policy was communicated in writing to the resident's representative. Interviews with facility staff revealed inconsistencies in the communication of the bed hold policy. A nursing supervisor mentioned that a packet including the bed hold policy was given to 911 staff during transfers, but the admissions director admitted that the policy was not addressed with long-term residents, including the resident in question. The director of nursing acknowledged the oversight and the nursing home administrator understood the concern regarding the failure to notify the resident and/or representative in writing of the bed hold policy upon transfer.
Inadequate Review and Revision of Resident Care Plan
Penalty
Summary
The facility failed to ensure that a resident's care plan was reviewed and revised to meet their needs, specifically regarding tube feeding and dietary intake. The resident, who was admitted in early 2024, received nutrients through tube feedings and by mouth. However, the care plan contained conflicting interventions, indicating both independence and the need for supervision during intake. Staff documentation predominantly noted the resident as independent, while the Kardex specified 1 to 1 supervision for any oral intake and a clear liquid diet. Observations and interviews revealed inconsistencies in the care provided. A Geriatric Nursing Assistant (GNA) reported that the resident was a tube feeder but also received meal trays, with staff only setting up the tray and adjusting the bed. During an observation, the resident was seen with a cup of water without supervision, contrary to the Kardex instructions. The Director of Nursing acknowledged the discrepancy and indicated a need to update the care plan and consult with a speech therapist to ensure the resident's safety with liquids.
Failure to Provide ADL Assistance for Resident with Long Toenails
Penalty
Summary
The facility failed to ensure that a resident who could not carry out activities of daily living (ADL) received the necessary care and assistance. This deficiency was identified for a resident with Alzheimer's Dementia, who was observed sitting in a wheelchair with long toenails, despite the resident's representative having informed the staff about this issue three weeks prior. The resident's Minimum Data Set (MDS) assessment indicated a substantial to maximal dependence on staff for self-care needs, and the care plan included an intervention to check and trim nails on bath days. Despite the care plan's directive, the resident's toenails were not trimmed on the designated shower days, as confirmed by an observation and subsequent interviews. A Licensed Practical Nurse (LPN) acknowledged that the Geriatric Nurse Aides (GNAs) were responsible for trimming toenails for residents without diabetes on shower days, yet this task was not completed for the resident in question. The Director of Nursing (DON) also confirmed that the GNAs should have clipped the resident's toenails, indicating a lapse in the facility's adherence to the care plan for the resident's ADL needs.
Inappropriate Catheter Care for Resident
Penalty
Summary
The facility failed to provide appropriate treatment and services for a resident with an indwelling catheter. This deficiency was identified during an observation on the initial tour of the facility, where a resident was found in bed with their urine collection bag placed directly on the floor. The Registered Nurse assigned to the resident confirmed the observation and subsequently hung the urine collection bag on the bedframe. The resident's care plan, reviewed later, indicated that the resident was readmitted from the hospital with a Foley catheter in place, and included interventions such as positioning the catheter bag and tubing below the level of the bladder and away from the entrance room door, as well as providing catheter care on each shift and as needed. The Director of Nursing acknowledged the concern during an interview.
Failure to Serve Meal According to Resident's Dietary Needs
Penalty
Summary
The facility failed to serve a meal to a resident according to a predetermined menu that incorporated the resident's preferences and dietary needs. During an observation on 1/30/25, a surveyor requested a test tray and noted discrepancies between the meal ticket and the actual meal served to the resident. The meal ticket for the resident specified a mechanical soft diet with cinnamon applesauce as dessert, but the tray contained apple pie instead. The Food Service Manager acknowledged the error, stating that the dietary staff should have provided applesauce, not apple pie, due to the resident's mechanical soft food texture requirement. The nursing home administrator was informed of this issue on 2/3/25.
Failure to Timely Report Abuse Allegation
Penalty
Summary
The facility failed to report an allegation of abuse involving Resident #406 to the State Agency within the required timeframe. The resident reported the abuse to an evening nursing supervisor, an LPN, on the morning of March 1, 2024. However, the Nursing Home Administrator was not informed until March 4, 2024, at 11:15 AM, and the initial report to the state agency was not made until 11:59 AM on the same day. The final report was sent on March 8, 2025. Interviews with the social services director and the director of nursing confirmed that the facility was aware of the allegation on March 1, 2024, and had initiated an investigation, but lacked documentation to prove timely reporting to the state agency.
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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