Fairland Center
Inspection history, citations, penalties and survey trends for this long-term care facility in Silver Spring, Maryland.
- Location
- 2101 Fairland Road, Silver Spring, Maryland 20904
- CMS Provider Number
- 215015
- Inspections on file
- 19
- Latest survey
- November 20, 2025
- Citations (last 12 mo.)
- 4
Citation history
Health deficiencies cited at Fairland Center during CMS and state inspections, most recent first.
Surveyors found overflowing trash, dirty and stained carpeting, unclean resident equipment, and damaged flooring throughout one floor and a nursing unit. The second-floor shower room had black substance on vents, a warped door, broken tiles, a rusty radiator, and peeling paint, with one shower lacking hot water for over a year while still in use. Facility leadership acknowledged these issues, but no immediate corrective actions were observed during the survey.
Surveyors found multiple instances where medications were not properly labeled, secured, or stored, including unattended and unlocked med carts, an unlabeled bottle of eye drops for a resident, expired medical supplies, and a narcotic medication stored in a zip lock bag. Staff confirmed that these practices did not meet facility guidelines and expectations.
Surveyors found significant sanitation and food safety issues, including improper storage of ice scoops, unsanitary dining and kitchen areas, unlabeled food, broken refrigerator seals, and structural disrepair in food prep areas. Staff were unable to verify food expiration dates due to missing labels, and food was not consistently covered during transport. Facility leadership acknowledged these concerns during the survey.
Surveyors identified multiple infection control deficiencies, including unsanitary storage of linens and medical supplies, improper hand hygiene and PPE use by staff, lack of up-to-date TB clearance documentation for two employees, and repeated findings of soiled linens and shared personal care items in a shower room. Staff interviews confirmed awareness of proper procedures, but observations revealed ongoing lapses.
Surveyors identified a failure to maintain adequate ventilation on the second floor, where closets used for biohazard trash and linen storage lacked proper ventilation and were coated in black soot-like debris. Staff and residents reported ongoing concerns about air quality, and inspection revealed missing and clogged HVAC filters, leading to persistent debris accumulation in the area.
A resident was found without access to their call device, which was placed out of reach behind a box on a nightstand. The resident confirmed they could not reach the device, and an LPN was initially unable to locate it, stating the resident always calls them. The issue was observed and acknowledged by the ADON.
A state surveyor observed an agency GNA verbally abusing a resident by repeatedly calling the resident 'crazy' and blaming the resident for work delays. The GNA refused to identify herself and was not wearing a name tag. The incident was confirmed as abuse by facility administration.
A resident was found with a red mark on the forehead by a family member, who reported it to staff but was told it was not reportable. Staff, including a unit manager, LPN, and DON, were aware of the mark and discussed it, but the incident was not reported to authorities as required until prompted by surveyors.
A resident was found with a red mark on the forehead by a family member, who reported it to staff. Staff did not initially report or investigate the incident, and key personnel were not asked to provide written statements. The DON assumed the mark was caused by a TV remote without evidence, and the allegation was only reported and investigated after surveyor intervention.
A resident did not receive necessary oral care, as observed by a surveyor and reported by a family member. Staff interviews revealed confusion over whether nurses or respiratory therapists were responsible for oral care, with respiratory therapists stating they only performed suctioning. Despite a medical order for oral care every shift, documentation was missing for several shifts, indicating the care was not consistently provided.
Surveyors identified that two residents did not receive care according to physician orders and facility protocols. One resident was not provided with required positioning devices or consistent turning and repositioning, and did not receive the prescribed frequency of physical therapy sessions. Another resident receiving psychotropic medications was not monitored for side effects as ordered, with documentation missing for nearly all shifts reviewed. These findings were based on observations, staff interviews, and record reviews.
A closet containing a carpet cleaning chemical was found unlocked and accessible in a resident area by a surveyor during environmental rounds with the DON and Director of Maintenance. Both staff confirmed the unsecured chemical, and attempts to lock the closet were unsuccessful, allowing continued access to the chemical.
A review of employee files and interviews with facility leadership revealed that one GNA did not have documented completion of required abuse training. Despite the facility's use of HealthStream for staff education and the migration of prior training records, no evidence of abuse training was found in the GNA's file or transcripts, confirming the deficiency.
Several residents did not receive the required two showers per week, as confirmed by resident and family interviews and review of clinical records. The DON verified that shower logs matched the reported numbers.
A resident's representative was not provided with written information or offered the opportunity to formulate an advance directive upon admission, despite the presence of a surrogate and certifications of incapacity in the medical record. Review of documentation and interviews with the DON confirmed that the required information and opportunity were not given or documented.
A resident was transferred to a hospital due to a change in condition, but the facility did not provide written notification of its bed hold policy to the resident or their representative as required. Staff interviews indicated inconsistent practices, and no documentation could be found to confirm that the policy was offered or provided at the time of transfer.
Two residents were not provided with summaries of their baseline care plans or medication lists within 48 hours of admission, and the required care plans were not completed on time. Staff interviews and medical record reviews confirmed that the process for timely completion and distribution of BLCPs was not followed or documented as required.
A resident's care plan was not reviewed or revised quarterly as required, with only the initial care plan present in the medical record and no evidence of interdisciplinary team review after admission. The facility's process for tracking care plan reviews did not prompt staff to complete the necessary updates.
A resident left the facility against medical advice, and although the NP notified the primary care provider and DON, the required physician discharge summary was not completed. The medical record lacked a recapitulation of the stay, final status summary, medication reconciliation, and post-discharge care plan, as confirmed by the DON.
A review of staff files revealed that several nurses and nurse aides lacked documentation of required training in areas such as behavioral health, tracheotomy care, ventilator care, resident rights, communication, and abuse prevention. Facility leadership confirmed that these records could not be found, indicating a failure to ensure all staff had completed necessary training prior to working on the units.
A resident with an order for depression symptom monitoring did not have the required behavioral monitoring documented for a month. Review of the clinical record revealed the monitoring was not completed because responsibility was incorrectly assigned to ancillary staff rather than nursing, preventing the task from appearing on the MAR for nursing staff documentation.
A resident's medication regimen review identified a discrepancy between the discharge summary and the active physician order for Lidocaine, with the pharmacist recommending verification and correction. The DON confirmed that the physician did not address this recommendation, and the incorrect order remained active.
Staff failed to follow physician-ordered parameters for medication administration for two residents, including giving antihypertensive and insulin medications outside of specified blood pressure and blood sugar ranges, and administering PRN oxycodone for pain scores below the ordered threshold. The DON confirmed these medications were not given as ordered.
A resident was administered trazodone for insomnia without a documented diagnosis of insomnia in the medical record. The DON confirmed that there was no evidence of the required diagnosis to support the psychotropic medication order, resulting in a deficiency for failure to ensure medications were only used for specific, documented conditions.
Facility staff did not ensure that QAA committee meetings were held quarterly as required, and minimum required members were absent from several meetings. The NHA confirmed that a quarterly meeting was missed and that required attendance was not met at multiple meetings.
A deficiency was identified when mouse droppings and roaches were found in the facility, and it was determined that there was no ongoing preventative pest control program in place. The Director of Maintenance reported that pest control services had lapsed due to a payment issue, and pest issues were only addressed after being observed, rather than through regular prevention.
Staff failed to keep nurse staffing whiteboards current and accurate, with outdated information, missing staffing ratios, and absent names of GNAs. Required staffing postings were also not displayed at the facility entrance, as confirmed by staff interviews including the DON.
The facility failed to maintain a sanitary and comfortable environment, with issues such as water leaks, mold, and damaged furniture observed across multiple units. Ceiling tiles were stained or improperly fitted, and several bathrooms had mold and non-functional bathtubs. Interviews revealed a lack of awareness and action regarding these maintenance issues, impacting residents' right to a safe and clean environment.
A resident in a LTC facility was unable to wear their own clothing due to facility staff's failure to ensure the clothing was clean and available. Despite the resident's preference for personal attire, they were observed in a hospital gown, with their clothing found balled up and wrinkled in the room. Staff interviews revealed a lack of awareness and adherence to procedures for handling residents' clothing.
A resident with a history of epilepsy was administered incorrect doses of Trileptal due to a transcription error in the MAR. The facility failed to notify the physician of this significant medication error, which occurred over several days. The Medical Director confirmed that the physician should have been informed, and the DON acknowledged the issue.
The facility failed to thoroughly investigate multiple incidents of alleged abuse, neglect, and misappropriation of property. In one case, a resident reported inadequate care, but the investigation was incomplete. Another resident was found outside unattended, but the investigation documentation was missing. Additionally, a resident alleged assault by a staff member, but no investigation records were found. In another instance, a resident reported mistreatment, but the facility did not obtain a direct statement from the resident.
The facility failed to assist two residents with activities of daily living (ADLs). One resident was left in a soiled brief for several hours, including during breakfast, despite being dependent on staff for toileting. Another resident, who required assistance with personal hygiene, had excessively long nails with substances under them, as staff did not provide the necessary care. These actions were against the facility's policy of providing timely and adequate ADL assistance.
A resident with Alzheimer's and a history of wandering eloped from the facility despite wearing a wanderguard. The resident exited through an open side door and was found outside by staff. The facility failed to conduct a thorough investigation into the incident, and key staff were unavailable for interviews.
A resident with cerebral palsy and seizures was administered an incorrect dose of Trileptal due to multiple orders in the MAR, leading to extra doses being given. A DDR conducted by the pharmacist failed to identify this irregularity, and the issue was later acknowledged by the DON.
A resident with epilepsy and cerebral palsy was administered an incorrect dose of Trileptal due to conflicting medication orders, resulting in significant medication errors. The facility failed to notify the physician or investigate the error, as confirmed by the Medical Director and DON. No interventions were documented to prevent recurrence.
Facility staff failed to secure treatment carts, leaving them unlocked and unattended in a hallway accessible to residents. An LPN confirmed the carts were unlocked without explanation, and the Regulatory Compliance Advisor acknowledged the issue.
A facility failed to accurately document a resident's use of a wander/elopement alarm on the MDS, despite physician orders and nursing documentation indicating the use of such a device. The discrepancy was identified during a review of the resident's medical record.
The facility failed to ensure accurate medical records, as staff inaccurately documented a resident's wanderguard placement and functionality. Despite the wanderguard being discontinued, multiple LPNs documented it as functional and in place, which was confirmed as an error by the DON.
Failure to Maintain Safe, Clean, and Comfortable Resident Environment
Penalty
Summary
Surveyors identified multiple failures by the facility to maintain a safe, clean, and comfortable environment for residents. On several occasions, overflowing trash cans with bagged trash and cardboard were observed in a hallway closet, accompanied by strong, unpleasant odors. The trash cans and closet walls were dirty, with visible drip marks and black matter. Dirty carpeting with numerous dark stains, pieces of trash on the floor, and brown stains and drip marks on walls and handrails were also noted in resident hallways. Additionally, resident mobility equipment was found in an unclean condition with staining and debris, and furniture in a resident's room was missing drawer knobs. Further observations revealed significant maintenance issues. Multiple areas of damaged laminate flooring were present in main areas leading to the dining area and nursing station. The second-floor shower room had extensive deficiencies, including black substance on vents, a warped and damaged door, broken tiles, a rusty radiator touching the floor, peeling paint on the ceiling, and brown marks around light fixtures. Despite signage indicating a shower stall was out of order due to lack of hot water, the issue had persisted for over a year and a half, and the shower room continued to be used for resident bathing. Throughout the survey, these concerns were acknowledged by facility leadership, including the Director of Nursing, Director of Maintenance, and Regional Director of Nursing. However, no immediate corrective actions were observed during the survey period, and the environmental and maintenance deficiencies remained unaddressed, affecting the overall cleanliness and comfort of the resident environment.
Failure to Properly Label, Secure, and Store Medications
Penalty
Summary
Facility staff failed to ensure that drugs and biologicals were properly labeled, secured, and stored according to accepted professional standards. Surveyors observed three unattended and unlocked medication carts on one wing, and an unlabeled bottle of Azelastine HCl 0.05% eye drops prescribed for a resident, which lacked an open date. Additionally, a plastic container with oxycodone 20mg tablets, labeled with the names of recently admitted residents, was found in an old zip lock bag. An expired Nisus NPWT Canister was also found in the medication storage room. Staff interviews confirmed that multi-use eye drops should be discarded 28 days after opening, and the findings of unlabeled, expired, and improperly stored medications were acknowledged by nursing staff and the DON. On another wing, a round white pill was found on the resident hallway floor, and an LPN disposed of it in the medication cart trash can. Surveyors also observed an unattended and unlocked medication cart on this wing, which was acknowledged by the Regional DON and the nurse assigned to the cart. The nurse confirmed that the facility's expectation is for medication carts to be locked when not in use.
Widespread Sanitation and Food Safety Deficiencies in Food Service Areas
Penalty
Summary
Surveyors identified multiple failures in the facility's food service and sanitation practices. Observations included ice scoops being stored improperly, such as inside or on top of plastic bags on ice carts, and dirty dishes and utensils being placed on the same carts as clean ice and disposable cups. The dining area was found to be unsanitary, with overflowing trash cans, trash and debris on the floor, sticky surfaces, and dirty utensils and dishes left out. Additionally, the kitchen was observed to have a broken refrigerator seal, unlabeled ready-to-eat food, and structural issues such as damaged windows, a ceiling with black debris, cracks, and peeling paint above food prep areas. The kitchen floor was also noted to have crumbs, debris, sticky areas, and pooled water. Further, food transported through resident hallways was not consistently covered, as plate lids did not fit securely. The kitchen window area had makeshift repairs with splintered wood and bent metal, and a food cutting board was stored inappropriately against the window sill. Staff interviewed were unable to provide information on food expiration due to lack of labeling. These deficiencies were acknowledged by various facility staff, including the Food Services Director and the Director of Nursing, during the survey process.
Infection Control Failures and Unsanitary Conditions Identified
Penalty
Summary
The facility failed to maintain a sanitary environment and implement appropriate infection prevention and control practices across multiple areas. Surveyors observed storage closets and supply rooms containing a mix of clean linens, care products, and various forms of trash, including used medical gloves, open and uncapped ointments, personal items, and soiled incontinence briefs in disarray. Some items, such as incontinence briefs, were found touching visibly stained walls, and clean linens were stored on floors coated with black debris and cobwebs. Additionally, respiratory and medical supplies were stored directly on the floor or uncovered on shelves, and personal items were mixed with medical supplies, further compromising sanitation. Staff were observed failing to follow proper infection control protocols, including hand hygiene and the use of personal protective equipment (PPE). In one instance, a nurse donned PPE but handled a personal cell phone and case with gloved hands before entering a resident's room, only correcting the error after surveyor intervention. Another nurse entered a resident's room and handled the resident's bed covers without performing hand hygiene before or after the interaction. There was also a lack of appropriate signage to indicate necessary precautions for residents requiring special infection control measures, such as those with tracheostomies and tube feedings. The facility did not maintain up-to-date documentation confirming that all employees were free from communicable tuberculosis (TB). Two employees' files lacked current evidence of TB clearance, with one file missing any documentation and another containing only an outdated chest x-ray report. Additionally, the 2nd floor shower room was repeatedly found in unsanitary condition, with soiled linens, used personal care items, and open bottles of soap left in the room. Staff interviews confirmed that residents should have individual bathing items, but shared and improperly stored items were observed on multiple occasions.
Failure to Maintain Adequate Ventilation and Air Quality
Penalty
Summary
The facility failed to ensure adequate ventilation on the second floor, as observed during a recertification and complaint survey. A closet used for biohazard trash was found with a ventilation cover on the floor and an uncovered ceiling vent, with no detectable air circulation. Another closet storing backup linens was observed to have no ventilation and contained linens coated in black soot-like debris, along with cobwebs covered in the same material. Staff confirmed that this black soot was a recurring issue in the hallway and had been present for several months. Interviews with facility staff revealed that both staff and residents had reported concerns about breathing in black debris in the affected area. Upon inspection, the Director of Maintenance discovered that HVAC units servicing the area were missing filters on the evaporator side, and the return air filters were heavily clogged with dust and had not been changed for an extended period. Although filters were eventually replaced and cleaned, the Director of Maintenance noted that debris had already accumulated within the ductwork, resulting in ongoing complaints from residents and families about belongings becoming covered in debris after only a few days.
Resident Call Device Not Accessible
Penalty
Summary
A deficiency was identified when a resident did not have access to their call device to request staff assistance. During an observation, the resident's call device was found behind a cardboard box on a nightstand several feet away, making it unreachable from the resident's bed. The resident confirmed in an interview that they could not reach the call device. When the Assistant Director of Nursing (ADON) and a Licensed Practical Nurse (LPN) were involved, the LPN was initially unable to locate the call device and indicated that the resident always calls them directly. The call device was ultimately found and the issue was acknowledged by the ADON.
Failure to Protect Resident from Verbal Abuse by Agency Staff
Penalty
Summary
Facility staff failed to protect a resident from verbal abuse, as evidenced by an incident observed by a state surveyor. During the incident, an agency Geriatric Nursing Assistant (GNA), identified as Staff #22, was seen pointing at a resident in bed and repeatedly calling the resident 'crazy.' The GNA also blamed the resident for causing her to fall behind in her work and refused to identify herself when asked by the surveyor. The GNA was not wearing a name tag at the time of the incident. The surveyor documented that the GNA continued to verbally abuse the resident even after the surveyor identified herself. The facility's internal investigation included a review of Staff #22's statement, in which she did not acknowledge calling the resident 'crazy.' The Administrator confirmed the occurrence of abuse and noted that the Maryland Board of Nursing was notified. The incident involved an agency staff member who became upset during questioning and left the interview prematurely. The report does not provide additional details about the resident's medical history or condition at the time of the incident.
Failure to Timely Report Alleged Abuse
Penalty
Summary
Facility staff failed to report an allegation of abuse involving a resident who was found with a red mark on their forehead. A family member discovered the mark and brought it to the attention of staff, but was told it was not reportable. Photographic evidence confirmed the presence of the mark. Multiple staff members, including a unit manager and an LPN, were aware of the mark and discussed it internally, with the LPN asking the resident abuse-related questions and the GNA reporting the concern to the DON. Despite these actions, the incident was not reported to the appropriate authorities as required. The DON assumed the mark was caused by a TV remote, although no one witnessed this. The administrator later acknowledged that the family member had alleged someone hit the resident and confirmed the incident was reportable, but it had not been reported until after surveyor intervention. The failure to report the suspected abuse in a timely manner constituted a deficiency in the facility's abuse reporting procedures.
Failure to Investigate and Report Alleged Abuse
Penalty
Summary
Facility staff failed to thoroughly investigate an allegation of abuse involving a resident who was found with a red mark on their forehead. A family member discovered the mark and reported it to staff, who informed them it was not reportable. The incident was not initially documented or reported as required. Multiple staff members, including a unit manager and an LPN, observed or were informed about the mark but did not provide written statements or initiate a formal investigation at that time. The DON assumed the mark was caused by a TV remote, although no one witnessed this, and there was no evidence to support this explanation. Interviews revealed that neither the unit manager nor the LPN were asked to provide written statements regarding the incident. The administrator later acknowledged that the family member had alleged someone hit the resident, confirming the event was reportable. However, the allegation was not reported to the appropriate authorities or investigated until after surveyor intervention. The lack of timely reporting and investigation constituted a failure to respond appropriately to an alleged violation.
Failure to Provide Necessary Oral Care Due to Staff Role Confusion and Missed Documentation
Penalty
Summary
A deficiency was identified when a resident did not receive necessary oral care as required. The issue was first brought to attention by the resident's family member, who expressed concern about the resident's oral hygiene. Upon observation, the surveyor noted that the resident's tongue appeared yellow, dry, and crusty, and the front upper teeth had a thick, creamy film. This condition was confirmed during a joint observation with the unit manager, who stated that the respiratory therapist was responsible for oral care, performed one or two times per shift as recommended by respiratory therapy. Further interviews revealed confusion among staff regarding responsibility for oral care. Respiratory therapists reported that their duties were limited to suctioning and that nurses were responsible for oral care. A nurse confirmed that nurses were responsible for oral care and that it should be documented on the MAR/TAR, with an active medical order for oral care every shift. However, review of the treatment administration records showed missing documentation for oral care on several shifts, indicating that the required care was not consistently provided.
Failure to Follow Therapy Orders and Psychotropic Medication Monitoring
Penalty
Summary
The facility failed to provide appropriate treatment and care according to physician orders and resident needs for two residents. For one resident, surveyors observed multiple instances where the resident was lying in bed with their feet in a plantarflexed position, without the required support devices such as boots or splints, despite active medical orders for continuous offloading of heels and regular turning and repositioning every two hours. Therapy staff confirmed that the resident was not seen at the prescribed frequency of five times per week for physical therapy, and there was no documented reason for the missed sessions. Documentation for turning, repositioning, and floating heels was also found to be inconsistent, with several missed entries in the point of care records for the month reviewed. For another resident, the facility failed to ensure proper monitoring for side effects of psychotropic medications. The resident had active orders for two psychotropic medications and a specific order requiring every-shift documentation of whether the resident was free from side effects, with instructions to document any side effects in the progress notes. Review of the medication administration record revealed that this monitoring was not documented for 38 out of 40 shifts over a two-week period, and there were no progress notes indicating side effects or their absence. The DON confirmed that the required documentation was missing and acknowledged that nurses may have misinterpreted the order. These deficiencies were identified through direct observation, interviews with staff, and review of medical records and documentation. The failures included not following therapy recommendations and medical orders for positioning and support devices, as well as not completing required monitoring and documentation for psychotropic medication side effects.
Unsecured Chemical Storage in Resident Area
Penalty
Summary
A deficiency was identified when a surveyor, accompanied by the facility's Director of Maintenance and Regional Director of Nursing, observed that a closet on the A wing between two resident rooms was unlocked and contained a container of carpet cleaning chemical. The surveyor was able to freely access and open the closet door, directly observing the unsecured chemical. Both the Director of Maintenance and Regional Director of Nursing acknowledged and confirmed the surveyor's concern regarding the unsecured chemical. Further, when the Director of Maintenance attempted to lock the closet, it was found that the door could still be pulled open, indicating the locking mechanism was ineffective. The chemical was subsequently removed, but the deficiency was based on the initial unsecured storage.
Lack of Documented Abuse Training for Nursing Staff
Penalty
Summary
The facility failed to provide evidence that all nursing staff had completed required abuse training, as demonstrated by the absence of documentation for one Geriatric Nursing Assistant (GNA) among five employee records reviewed during a recertification and complaint survey. The surveyor thoroughly reviewed the complete employee file for the GNA, including health, training/education, and general employee documents, and found no record of abuse training completion. The Assistant Director of Nursing (ADON) confirmed that such training is required prior to staff starting on the unit and is part of orientation, with annual training on safety and dementia also required. The facility uses HealthStream as its training platform, and the Director of Nursing (DON) stated that transcripts of completed training are printed and placed in employee files. Despite these procedures, a review of the GNA's HealthStream transcript revealed completion of 33 training courses, but none related to abuse training. The ADON and DON indicated that previous training records from a prior platform, Vita Learn, had been migrated to HealthStream, but no evidence of abuse training was found in either system or in the employee's file. The ADON/IP confirmed the absence of abuse training documentation after further review, substantiating the deficiency.
Failure to Provide Required Number of Weekly Showers
Penalty
Summary
Facility staff failed to ensure that residents received showers twice a week, as required. Three residents were identified during interviews and clinical record reviews as not having received the expected number of showers over a specified period. One resident reported receiving only one shower per week, with records confirming 17 showers out of a possible 20. Another resident also stated not receiving two showers weekly, with the same number of showers documented. A third resident's spouse reported only one shower per week, and records showed 12 showers out of a possible 20. The DON confirmed that the shower logs accurately reflected the number of showers provided.
Failure to Provide Advance Directive Information to Resident Representative
Penalty
Summary
A deficiency was identified when a resident's medical record was reviewed and it was found that, although a surrogate had been selected on the Maryland Orders for Life Sustaining Treatment (MOLST) form and two certifications of incapacity were present, there was no documentation that the resident's representative had been provided with written information or offered the opportunity to formulate an advance directive upon admission. The review of the hard chart and medical record did not reveal any evidence that information regarding advance directives was given or discussed with the resident's representative at the time of admission, nor was there documentation of any existing advance directive. The deficiency was confirmed through interviews and record reviews, including a discussion with the DON, who was unable to locate any documentation that the advance directive process had been followed for this resident. The lack of documentation indicated that the facility failed to ensure the resident representative was informed and given the opportunity to create or provide an advance directive as required.
Failure to Provide Written Bed Hold Policy Notification Upon Hospital Transfer
Penalty
Summary
The facility failed to provide written notification of its bed hold policy to a resident or the resident’s representative when the resident was transferred to an acute care hospital. Medical record review for the resident, who was receiving long-term care and was transferred to the hospital due to a change in condition, did not contain documentation that the bed hold policy was offered or provided at the time of transfer. The facility’s policy requires staff involved in the transfer, such as nursing, admissions, or social services, to provide the bed hold notice and authorization form to the resident and/or representative. Staff interviews revealed inconsistent practices regarding the provision of the bed hold policy. An LPN stated that the policy may not always be offered when residents are sent to the hospital, especially in urgent situations. An RN reported that the policy is typically communicated and distributed, with copies sent to the hospital, business office, and the resident’s family. However, when asked to produce documentation for this specific transfer, the RN was unable to locate any evidence in the medical record or elsewhere that the bed hold policy had been provided to the resident or their representative.
Failure to Complete and Distribute Baseline Care Plans Within Required Timeframe
Penalty
Summary
The facility failed to ensure that residents and/or their representatives were provided with summaries of their baseline care plans (BLCP), including a list of medications, and did not complete the BLCP within the required 48-hour timeframe following admission. Specifically, for two residents reviewed, there was no evidence in the medical records that a BLCP summary or medication list was provided within the mandated period. In one case, the section of the medical record designated for documenting that a copy was given to the resident or representative was left unchecked, and the assessment was completed after the 48-hour window. In the other case, the BLCP was completed after the required timeframe, and the responsible staff member confirmed the delay without providing a reason. Interviews with facility staff, including the DON and the Regional Director of Social Services, revealed inconsistencies in the process and responsibility for completing and distributing the BLCP. The staff acknowledged that the process was not followed as required, and there was a lack of documentation to support that residents or their representatives received the necessary information in a timely manner. These findings were based on a review of medical records and staff interviews during the recertification/complaint survey.
Failure to Complete Quarterly Care Plan Reviews
Penalty
Summary
The facility failed to revise care plans for residents on a quarterly basis as required. During a review of medical records and staff interviews, it was found that one resident had only a single care plan documented, which was created at the time of admission. There was no evidence in the medical record that the care plan had been reviewed or revised by the interdisciplinary team (IDT) after the initial development, despite the resident having been admitted for a period that would require at least one quarterly review. The Regional Director of Social Services confirmed during an interview that care plans are supposed to be reviewed every 90 days and acknowledged that the resident in question should have had at least one care plan revision since admission. The facility's process involves using an electronic medical record system to track care plan review tasks, but in this case, the system did not indicate that a review was due, and no subsequent care plan reviews were documented for the resident.
Failure to Complete Discharge Summary for Resident Leaving AMA
Penalty
Summary
A deficiency was identified when a resident left the facility against medical advice (AMA), and the facility failed to complete a required discharge summary. The medical record review showed that the resident expressed a desire to leave AMA, and this was documented by a nurse practitioner, who notified the primary care provider via voicemail and informed the Director of Nursing (DON) about the situation. Nursing progress notes indicated that the resident left the facility accompanied by paramedical transport, with no pain or distress noted, and that the nurse practitioner was made aware of the departure. Despite these actions, the medical record did not contain a discharge summary from the physician. Specifically, there was no documentation providing a recapitulation of the resident's stay, a final summary of the resident's status, reconciliation of pre-discharge and post-discharge medications, or a post-discharge plan of care. The DON confirmed during interviews that a discharge summary should have been completed for any resident leaving the facility, regardless of the circumstances, and acknowledged that this documentation was missing.
Missing Staff Training and Competency Documentation
Penalty
Summary
Facility staff failed to ensure that all nurses and nurse aides received the appropriate training and competencies necessary to care for residents, as evidenced by a review of five employee files. Three staff members were found to be missing documentation of required training in key areas such as behavioral health, tracheotomy care, ventilator care, resident rights, communication, and abuse prevention. Interviews with facility leadership confirmed that these training records could not be located despite searching through employee files. The deficiency was identified during a recertification and complaint survey, based on direct review of staff files and staff interviews.
Failure to Document Behavioral Symptom Monitoring for Depression
Penalty
Summary
Facility staff failed to document the monitoring of behavioral symptoms for one resident who had an order for depression symptom monitoring during the month of April. Clinical record review showed that the required behavior monitoring documentation was missing. During an interview, the DON and surveyor reviewed the electronic health record and found that the responsibility for monitoring had been incorrectly assigned to ancillary staff instead of nursing, resulting in the monitoring task not appearing on the Medication Administration Record for nursing staff to document.
Failure to Address Pharmacist's Medication Recommendation
Penalty
Summary
The facility failed to respond in a timely manner to a recommendation made by the consulting pharmacist regarding a resident's medication regimen. Specifically, the pharmacist identified a discrepancy in the resident's orders, noting that the discharge summary listed a Lidocaine 4% patch, while the active order in the system was for Lidocaine 4% gel. The pharmacist's recommendation, dated 2/18/25, requested verification and correction to ensure the correct item was active for the resident. Despite this recommendation, the Director of Nursing confirmed that the issue was not addressed by the physician, and a subsequent review of the resident's orders showed that the Lidocaine 4% gel order remained active. The resident's name was also missing from the facility's list of residents reviewed with no recommendations for February 2025, indicating a lapse in the medication regimen review process for this individual.
Failure to Administer Medications According to Ordered Parameters and Unnecessary Drug Use
Penalty
Summary
Facility staff failed to ensure that residents received medications according to physician-ordered parameters, resulting in the administration of unnecessary drugs. For one resident, Atenolol was administered on multiple occasions despite the resident's systolic blood pressure being below the ordered threshold of 110, and Humalog insulin was given even when the resident's blood sugar was below the ordered hold parameter of 100. These actions were confirmed through clinical record review and acknowledged by the Director of Nursing, who stated that administering insulin outside of parameters was an ongoing issue among nursing staff. Additionally, another resident was prescribed oxycodone to be administered as needed for moderate pain, defined as a pain score of 4-7. However, staff administered oxycodone when the resident's documented pain scores were below the ordered threshold, with pain assessments recorded as 2 or 3 at the time of administration. The Director of Nursing confirmed that the pain medication was not administered according to the physician's parameters, as evidenced by the medication administration records and pain assessments.
Psychotropic Medication Administered Without Documented Diagnosis
Penalty
Summary
Surveyors identified that a resident was receiving trazodone HCL 50 mg via gastrostomy tube at bedtime for insomnia. Upon review of the resident's medical record, there was no documented diagnosis of insomnia to support the use of this psychotropic medication. The order for trazodone specified its use for insomnia, but the required corresponding diagnosis was absent from the resident's medical documentation. Interviews with the Director of Nursing (DON) confirmed that all medications should have an indication and a matching diagnosis in the medical record. The DON verified that there was no evidence of an insomnia diagnosis for the resident in question and acknowledged the lack of documentation supporting the medication order. This failure to ensure that psychotropic medications were only used to treat a specific, diagnosed, and documented condition constituted the deficiency.
Failure to Hold Required QAA Meetings with Proper Attendance
Penalty
Summary
Facility staff failed to demonstrate compliance with requirements for the Quality Assessment and Assurance (QAA) committee, as evidenced by administrative record review and staff interviews. Over the past 12 months, QAA meetings did not occur on a quarterly basis, with a required meeting in October 2024 not held. Additionally, the minimum required committee members were not present at the quarterly meetings in April, July, and October 2024. The Nursing Home Administrator, who has been in charge of QA meetings since September 2024, confirmed these findings during an interview.
Failure to Maintain Preventative Pest Control Program
Penalty
Summary
The facility failed to maintain a preventative pest control program, as evidenced by the presence of mouse droppings and roaches within the building. During the recertification survey and investigation of a specific complaint, it was found that the facility did not have ongoing pest control services. The Director of Maintenance reported that, upon returning to their position in January 2025, they noticed the absence of pest control visits and could not locate any pest control logs. The Director also acknowledged having observed roaches in the facility in the past and stated that pest issues were only addressed after they were observed, rather than through a preventative program. Documentation provided to the surveyor confirmed that the last pest control service occurred in November 2024, and there was a lapse in services due to a payment issue, which resulted in the suspension of the pest control contractor's account. No pest control logs or current contracts were initially available for review, confirming the lack of an active preventative pest control program at the time of the survey.
Failure to Maintain Accurate and Timely Nurse Staffing Postings
Penalty
Summary
Facility staff failed to ensure that nurse staffing information was accurately posted and kept up to date on the staffing whiteboards for both nursing units. During multiple facility tours, surveyors observed that the whiteboards displayed outdated staffing information from previous days, lacked required staffing ratios, and in one instance, did not include the names of Geriatric Nursing Assistants on duty. Additionally, staffing information was not posted at the facility entrance as required. These deficiencies were confirmed through staff interviews, including with the Director of Nursing, who acknowledged the missing and outdated postings.
Facility Fails to Maintain Sanitary and Safe Environment
Penalty
Summary
The facility staff failed to maintain a sanitary, orderly, and comfortable environment, as evidenced by multiple deficiencies observed across several nursing units. During an environmental tour, it was noted that there was water dripping through the ceiling light in the shower of room Dogwood Vent D2-B 3 Bed, with towels on the floor and a musty odor present. The Rehab gym had a spackled ceiling with residual brown stains on the light, and room D1, which was unoccupied, had a toilet filled with feces, dead bugs, and debris on the floor. Ceiling tiles in the hallway and various rooms were stained, missing chunks, or improperly fitted, contributing to the unsanitary conditions. Additional observations included missing vinyl floor tiles, peeling plaster, and damaged furniture in several rooms. In room D8, there were brown circles on ceiling tiles, and the closet door handle was broken. The medical supply room had a ceiling tile covered with a brown stain, and room B12 had an opened enema on the windowsill, ripped pillows, and a ceiling with silver tape holding brown paper. The hallway carpets were stained, and several bathrooms had black mold/mildew, chipped porcelain, and non-functional bathtubs, which were not draining properly. Interviews with staff revealed a lack of awareness and action regarding the maintenance issues. The Maintenance Director had recently resigned, and the Regional Director of Maintenance was unaware of current projects to address the needed repairs. The Director of Housekeeping acknowledged that soiled laundry should not be stored in resident rooms and that many bathtubs were not draining, leading to unclean appearances. The Nursing Home Administrator was aware of the building's need for repairs, but the deficiencies persisted, impacting the residents' right to a safe, clean, and comfortable environment.
Resident's Right to Wear Personal Clothing Not Honored
Penalty
Summary
The facility failed to ensure that a resident's right to a dignified existence and self-determination was honored, as evidenced by the inability of a resident to wear their own clothing. The resident, who was dependent on staff for activities of daily living due to conditions including hemiplegia and heart disease, was observed on multiple occasions wearing a hospital gown instead of their personal clothing. The resident expressed a preference for wearing their own clothes but believed they did not have any available at the facility. Observations revealed that the resident's clothing was present in the room but was balled up and wrinkled, and it was unclear whether the clothing was clean or dirty. Interviews with facility staff, including GNAs and the DON, indicated a lack of awareness and responsibility regarding the resident's clothing. The GNAs were unsure if the resident had personal clothing, and the DON was unaware of the condition of the clothing found in the resident's room. The facility's policy required GNAs to bag and label soiled clothing and place it in the soiled linen closet, with the expectation that laundry staff would clean and return the clothing the same day. However, this process was not followed, resulting in the resident's clothing being neglected and the resident being unable to exercise their right to wear their own clothes.
Failure to Notify Physician of Medication Error
Penalty
Summary
The facility failed to notify the physician when a resident experienced a significant medication error. This deficiency was identified during a complaint survey for a resident who was administered the wrong dose of the anti-seizure medication, Trileptal (Oxcarbazepine), over a period of several days. The resident, who had a history of epilepsy and was admitted to the facility following an acute hospitalization, was supposed to receive 900 mg of Oxcarbazepine twice daily. However, due to a transcription error in the Medication Administration Record (MAR), the resident received incorrect doses on ten occasions between November 17 and November 23, 2023. The MAR contained two separate orders for Oxcarbazepine, leading to the administration of incorrect doses. Despite this error, there was no evidence in the medical record that the physician was informed of the medication error. During an interview, the Medical Director confirmed that the physician should have been notified of the error, especially since it occurred over multiple days. The Director of Nurses was made aware of these concerns and acknowledged them during the survey.
Failure to Conduct Thorough Investigations of Alleged Abuse and Neglect
Penalty
Summary
The facility failed to conduct thorough investigations into several incidents of alleged abuse, neglect, and misappropriation of property involving multiple residents. In one case, a resident reported inadequate care, including long response times to call bells, but the facility's investigation was incomplete as it only interviewed a small fraction of the staff who actually cared for the resident during the relevant period. Additionally, the investigation did not follow up on the resident's claims, leaving the issue unresolved. Another incident involved a resident who was found outside the facility unattended. The Director of Nursing (DON) was unable to locate the investigation documentation, and although some related documents were reproduced, there was no evidence of a thorough investigation being conducted. This lack of documentation and follow-up indicates a failure to properly address the incident of elopement. In a separate case, a resident alleged assault by a staff member, but the facility could not provide any investigation records, including interviews with the involved parties. Similarly, another resident reported mistreatment, but the facility failed to obtain a direct statement from the resident, despite having interviewed other staff and residents. These deficiencies highlight the facility's failure to adhere to its own policies and procedures for investigating allegations of abuse and neglect.
Failure to Assist Residents with ADLs
Penalty
Summary
The facility failed to provide adequate assistance with activities of daily living (ADLs) for two residents, R9 and R58, who were dependent on staff for such care. R9, who was cognitively intact and dependent on staff for toileting, was left in a soiled brief with feces from approximately 3:30 AM until after breakfast, which was served at 7:15 AM. Despite turning on the call light and requesting assistance, R9 was not helped until much later, and staff served breakfast while R9 was still in a soiled state. Observations confirmed a strong odor of urine and feces in R9's room, and staff interviews revealed a lack of timely assistance with incontinent care, which was against the facility's policy of checking residents every two hours. R58, who had a BIMS score indicating cognitive impairment and was dependent on staff for personal hygiene, was observed with excessively long nails and dark brown substances under the nail bed. Despite expectations for staff to trim the nails, this care was not provided, and the resident's representative was under the impression that nail care was the family's responsibility due to previous unfulfilled requests for staff assistance. This lack of personal hygiene care was contrary to the facility's policy, which mandates necessary ADL assistance to maintain good personal hygiene.
Failure to Prevent Resident Elopement
Penalty
Summary
The facility failed to provide adequate supervision to prevent a vulnerable resident, identified as an elopement risk, from leaving the facility unattended. The resident, who had Alzheimer's Dementia with behavioral disturbance, was admitted with a history of wandering and attempted elopement. Despite wearing a functioning wanderguard, the resident was able to exit the facility unnoticed and was found outside by a dining service staff member. The incident report did not document how the resident managed to leave the facility undetected. The resident's medical records indicated a history of wandering and attempts to elope, with a care plan in place addressing the risk of elopement due to cognitive loss and dementia. On a specific occasion, the resident was observed walking towards the main road and was redirected back inside. The CRNP noted that the resident had exited through a side door that was left open, which was an uncommon event, but consistent with the resident's history of wandering due to Alzheimer's disease and dementia. The Director of Nurses (DON) was unable to locate the investigation report for the incident and confirmed that the facility did not complete a thorough investigation when the resident eloped. The DON reported that the administrative personnel had changed since the incident, and some staff familiar with the case were unavailable for interviews. The facility was unable to provide evidence of a comprehensive investigation, although some documents related to elopement drills and evaluations were reproduced.
Failure to Identify Medication Irregularities in Drug Regimen Review
Penalty
Summary
The facility staff failed to ensure that medication irregularities were identified during monthly drug regimen reviews for a resident. The resident, who was admitted in mid-November 2023 with diagnoses including cerebral palsy and seizures, was administered an incorrect dose of the anti-seizure medication Trileptal (oxcarbazepine) from November 19, 2023, to November 23, 2023. The hospital discharge summary indicated that the resident should continue with oxcarbazepine 900 mg twice a day, but the Medication Administration Record (MAR) showed two separate orders for oxcarbazepine, leading to the resident receiving an extra dose on multiple occasions. On November 21, 2023, a Drug Regimen Review (DDR) was conducted by the consulting pharmacist, who documented that no irregularities were found. However, the pharmacist failed to identify the irregularity of multiple oxcarbazepine orders and did not refer this issue to the physician. This oversight was later acknowledged by the Director of Nurses, who expressed that the pharmacist should have identified the discrepancy in the resident's medication orders.
Significant Medication Error Due to Incorrect Dosing of Anti-Seizure Medication
Penalty
Summary
The facility failed to ensure that residents were free from significant medication errors, as evidenced by the case of a resident who was administered the wrong dose of Trileptal (Oxcarbazepine), an anti-seizure medication. The resident, who had a history of epilepsy and cerebral palsy, was admitted to the facility following an acute hospitalization. The hospital discharge summary specified that the resident should continue Oxcarbazepine 900 mg twice daily. However, the Medication Administration Record (MAR) showed that the resident received an extra dose of Oxcarbazepine on multiple occasions between November 17 and November 23, 2023, due to two conflicting medication orders. The medical record review revealed that there was no evidence of physician notification or investigation into the medication error. During interviews, the Medical Director and the Director of Nurses (DON) acknowledged that the physician should have been notified of the error, and an incident report should have been completed. Despite these acknowledgments, no additional information or interventions to prevent recurrence were provided by the time of the survey exit.
Unattended and Unlocked Medication Carts
Penalty
Summary
The facility staff failed to ensure that treatment carts were locked and secured when unattended, as observed on one of the three nursing hallways. On December 3, 2024, at 1:41 PM, two medication carts were parked side by side in the C wing hallway, with a nurse preparing medication in front of the first cart. By 1:50 PM, the carts were observed to be unlocked and unattended, accessible to residents and not within direct observation of authorized staff. The surveyor stood near the carts for five minutes before a Licensed Practical Nurse (LPN) approached and confirmed the carts were unlocked without providing an explanation. The Regulatory Compliance Advisor was informed of the situation and acknowledged the concerns without further comment.
Inaccurate Documentation of Resident Assessment on MDS
Penalty
Summary
The facility failed to accurately document a resident's assessment on the Minimum Data Set (MDS). Specifically, the Admission MDS for a resident indicated that the resident did not use a wander/elopement alarm, despite clinical physician orders and nursing documentation showing that the resident had a wander guard/wander elopement device in use since 11/4/23. This discrepancy was identified during a review of the resident's medical record by the surveyor on 5/9/24. Further review of the medical record revealed that the Treatment Administration Records (TAR) for November 2023 documented the use of the wander guard/wander elopement device for the resident. Additionally, an elopement evaluation completed on 11/14/23 indicated that the resident had a history of elopement, wandering, and a desire to go home. The Director of Nursing (DON) was informed of the inaccurate coding in the MDS assessment, which did not align with the physician's orders and the TAR documentation.
Inaccurate Documentation of Wanderguard Placement and Functionality
Penalty
Summary
The facility failed to ensure accurate medical records in accordance with accepted professional standards of practice. Specifically, staff inaccurately documented a resident's wanderguard placement and functionality. A review of Resident #1's progress note indicated that the wanderguard order was discontinued on 04/11/2024, but the physician orders did not reflect this discontinuation until 04/23/2024. Despite the removal of the wanderguard on 04/11/2024, multiple LPNs documented that the wanderguard was functional and in place from 04/12/2024 to 04/22/2024. This discrepancy was confirmed during an interview with the Director of Nursing, who acknowledged the error in documentation and the failure to update the resident's medical record accurately. The deficiency was identified during a review of Resident #1's Treatment Administration Record (TAR) and progress notes. The TAR contained orders to check the functionality and placement of the wanderguard every shift, yet the documentation inaccurately reflected that the wanderguard was still in use after it had been discontinued. The Director of Nursing confirmed that the order to discontinue the wanderguard was not entered into the resident's medical record, leading to the inaccurate documentation by multiple LPNs. This failure to maintain accurate medical records compromised the facility's adherence to professional standards of practice.
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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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