Forest Haven Nursing And Rehabilitation Ctr
Inspection history, citations, penalties and survey trends for this long-term care facility in Catonsville, Maryland.
- Location
- 701 Edmondson Avenue, Catonsville, Maryland 21228
- CMS Provider Number
- 215252
- Inspections on file
- 18
- Latest survey
- September 15, 2025
- Citations (last 12 mo.)
- 54
Citation history
Health deficiencies cited at Forest Haven Nursing And Rehabilitation Ctr during CMS and state inspections, most recent first.
Staff failed to provide required two-person assistance during bed positioning for a resident with complex medical needs, resulting in a fall and fracture. Another resident was allowed to keep and self-administer multiple medications at the bedside, despite facility policy and concerns about unsafe use, after staff did not provide the requested medications.
The facility did not conduct initial or ongoing competency assessments for nurse aides, as evidenced by the lack of skills assessments in an aide's file and confirmed by the administrator and DON. Interviews revealed that there was no formal process or skills lab in place to verify staff competency, and competency evaluations were not routinely performed.
Administration did not conduct annual performance reviews or provide regular in-service education for nurse aides, as confirmed by file reviews and staff interviews during an investigation into staff-to-resident abuse. The DON acknowledged that no yearly evaluations had been performed for nursing staff since assuming her role.
Surveyors observed multiple failures in food storage and kitchen sanitation, including grease buildup, debris, unsealed food containers, dirty equipment, and inadequate cleaning schedules. The kitchen and storage areas were found with dirt, dust, food particles, and mice traps, with several areas not being cleaned as required by professional standards.
Staff failed to properly dispose of garbage and refuse, with observations including littered cigarette butts, broken furniture, unsecured gates, piles of debris, and open dumpsters with scattered trash and pallets.
Administration failed to ensure systems for staff performance evaluation and required education, with only one annual evaluation in seven years for a GNA and insufficient training on cognitive impairment. Policies and procedures were not accessible to direct care staff, with only one nursing manual available and confusion among staff about their location. The facility also did not maintain an effective pest control program, as evidenced by ongoing pest complaints, unsanitary conditions, and unaddressed recommendations from the pest control company.
The facility did not ensure that its QAA committee included the Medical Director and an Infection Preventionist, as required. Attendance records showed repeated absences of these key members from QAPI meetings, and there was a lack of documentation for some scheduled meetings. The current Infection Preventionist attended some meetings only as an MDS nurse, not in the required role.
Surveyors found that the facility failed to maintain a safe and homelike environment, with observations of dust-covered vents and heaters, damaged doors and walls, cracked flooring, and missing closet and bathroom doors in resident rooms. The sole maintenance staff member reported the absence of a preventative maintenance program and insufficient time to address cleaning and repairs.
The facility did not maintain an effective pest control program, resulting in ongoing infestations of mice and cockroaches throughout the building. Multiple complaints and observations confirmed pest activity in resident rooms, the kitchen, and common areas, with unsanitary conditions and structural issues contributing to the problem. Pest control recommendations for improved sanitation and building maintenance were not implemented, and communication lapses among staff further hindered effective pest management.
A surveyor observed that food delivered to a resident was not at appropriate temperatures, with hot items such as an egg omelet and sausage measuring below standard serving temperatures. The Certified Dietary Manager confirmed the findings after testing a tray from the meal cart, and the Administrator was notified of the issue.
Staff did not timely report an allegation of abuse involving a resident's claim of stolen marijuana, and documentation was lacking for the reporting of a resident-to-resident altercation that resulted in injury. Required notifications to the state agency and documentation of incident reporting were not completed as mandated.
Facility staff failed to properly investigate allegations of misappropriation of property and abuse involving three residents. In one case, a resident's report of stolen property was not formally investigated. In two other cases, allegations of staff-to-resident abuse were not thoroughly investigated, with incomplete documentation, lack of witness statements, and failure to remove the accused staff from resident contact during the investigation.
Facility staff did not create or implement comprehensive, person-centered care plans for two residents, resulting in unmet needs related to medical appointments and management of a recurrent rash. One resident's care plan failed to address their preferences and behaviors regarding outside medical consults, while another resident's care plan did not provide specific approaches for a persistent skin condition, despite repeated specialist involvement and ongoing symptoms.
A resident with severe cognitive impairment and documented preferences for specific activities did not receive an individualized activities program. The care plan was not tailored to the resident's needs, lacked measurable goals, and there was minimal documentation of activity participation or one-to-one engagement by staff. Observations and records showed the resident was not regularly involved in activities, and staff interviews confirmed gaps in documentation and care planning.
A resident with a recurrent leg rash and multiple chronic conditions did not have a cancelled dermatology appointment rescheduled as ordered by the physician. The lapse occurred due to a lack of communication between nursing and the staff responsible for scheduling, resulting in the resident not receiving timely follow-up care for the ongoing rash.
Staff did not follow physician orders or develop individualized interventions for a resident at risk for pressure ulcers, including missing required Braden Scale assessments and failing to specify or document turning, repositioning, and use of prescribed treatments. The resident subsequently developed a sacral wound, and documentation of preventive care remained inconsistent even after new interventions were ordered.
A resident with dementia and behavioral disturbances received a PRN order for Lorazepam that was not limited to 14 days and lacked a documented rationale for continuation beyond this period. The medication was administered without evidence that non-pharmacological interventions were attempted first, and required documentation was missing.
A resident was found with several medications, including medicated spray, topical cream, and various liquid medications, left unsecured on an over-the-bed table. The resident reported keeping these medications at the bedside due to staff refusal to retrieve them, and that a family member had supplied the medications. The DON confirmed the medications were not properly stored and had not been reported by staff. The attending physician was aware of the situation but proper storage was not maintained.
The facility did not conduct or document a comprehensive facility-wide assessment, resulting in missing and outdated information about resident census, staff levels, and resource needs. The assessment lacked a full evaluation of resident diagnoses, acuity, and care requirements, and did not address staff competencies, facility resources, or contracted services. The Nursing Home Administrator acknowledged these deficiencies during the survey.
Surveyors identified that the facility did not maintain an accurate inventory of a resident's personal belongings, including high-value items and their disposition after discharge, and failed to ensure consistent and complete documentation of end-of-life choices for another resident. Conflicting information was found between the EMR, paper records, and care plans regarding code status, and two active MOLST forms with different directives were present in the medical record.
A resident with a history of sexually inappropriate behavior was involved in multiple incidents of abuse and misappropriation of property. Despite being witnessed by staff, the facility failed to investigate or report these incidents to the State agency. The resident's behavior care plan noted various problematic behaviors, which were not adequately addressed, leading to further occurrences of abuse involving vulnerable residents.
A facility failed to implement abuse prevention policies by not notifying the administrator or state agency of abuse allegations involving a resident with dementia and a history of inappropriate behavior. The resident was involved in multiple incidents, including inappropriate sexual behavior and misappropriation of another resident's property, yet no investigations or reports were made.
A resident with dementia and other conditions was involved in multiple incidents of alleged abuse, including inappropriate contact and theft, affecting two other residents. Despite these events, the facility did not investigate or report the allegations to the State agency, as confirmed by the DON.
A resident was sent to the ER due to inappropriate behavior and was cleared for return, but the facility refused readmission without proper documentation or communication. The facility failed to issue a 30-day notice or inform the resident's representative and the State Ombudsman. Interviews revealed a lack of communication among staff and medical personnel regarding the resident's situation.
A facility failed to notify a resident, their representative, and the State Ombudsman about the resident's transfer to the hospital and subsequent refusal to readmit them. The resident was sent to the emergency room after inappropriate behavior with another resident. The facility did not issue a 30-day discharge notice or provide written correspondence, citing the absence of administrative staff during weekends.
A resident was sent to the ER due to inappropriate behavior and was cleared for return, but the facility refused re-admittance without issuing a 30-day notice or notifying the resident's representative. The facility cited safety concerns but failed to communicate properly, leading to a deficiency.
A facility failed to provide a bed hold policy to a resident transferred to the ER after inappropriate behavior. The resident was cleared for return but was not allowed back. The administrator admitted no notice or correspondence was sent to the resident's representative or Ombudsman, and the medical record lacked the bed hold policy.
A resident was not permitted to return to the facility after a brief hospitalization due to concerns about safety following inappropriate behavior. The facility did not issue a 30-day involuntary notice or inform the resident's representative or the State Ombudsman. Additionally, the resident was not provided with the bed hold policy, and the representative was unaware of the facility's refusal to re-admit the resident.
Failure to Provide Adequate Supervision and Safe Medication Management
Penalty
Summary
Facility staff failed to provide adequate supervision and safe care during activities of daily living for a resident with significant medical needs, including respiratory failure, heart failure, a vertebral fracture, hospice care, and dementia. The resident required extensive assistance from two staff members for repositioning in bed, as documented in the MDS assessment. However, a Geriatric Nursing Assistant provided care alone and left the resident unattended on her side in bed to retrieve supplies. During this absence, the resident fell from the bed and sustained a fracture to the left superior pubic ramus. The incident was confirmed by facility records and staff interviews, and the administrator acknowledged that staff did not follow the facility's ADL policy for supervision. Additionally, another resident was found to have multiple medications, including medicated spray, Desitin, Pepto Bismol, and cough syrup, stored openly at the bedside. The resident reported keeping these medications because staff would not provide them, and a family member supplied them. Facility policy prohibits residents from having medications at the bedside, and the DON was unaware of the situation until it was observed. Social Services staff and the attending physician confirmed that the resident had a history of keeping medications in the room and that self-administration was considered unsafe due to concerns about overuse. Despite these concerns, staff continued to allow the resident to keep and self-administer the medications.
Failure to Ensure Staff Competency Assessments
Penalty
Summary
Facility staff failed to ensure that nurse aides demonstrated competency in the skills and techniques necessary to care for residents' needs. During the investigation of an abuse allegation involving a resident, a review of a Geriatric Nursing Assistant's (GNA) employee file revealed that, although a general orientation checklist was present, there was no evidence of initial or ongoing skills assessments to confirm competency. The administrator confirmed that no such skills assessments existed for this staff member. Interviews with the Director of Nursing (DON) and the Human Resources director further revealed that the facility did not have a formal process for evaluating staff skills competency. The DON, who had recently assumed the position, stated that there was no formal method in place for verifying nurse and GNA competencies, and that the facility did not have a skills lab. The DON also indicated that, aside from pharmacy-conducted medication pass observations for nurses, no formal competency evaluations were conducted.
Failure to Complete Annual Performance Reviews and In-Service Education for Nurse Aides
Penalty
Summary
The facility administration failed to complete annual performance reviews for every nurse aide and did not provide regular in-service education based on the outcomes of such reviews. During the investigation of an allegation of staff-to-resident abuse, it was found that a Geriatric Nursing Assistant (GNA) had only one annual performance evaluation on file since being hired, with no subsequent yearly evaluations available. The Director of Nursing (DON) confirmed that annual performance evaluations for nursing staff had not been conducted since she assumed her position, and the Human Resources director corroborated this information. These findings were based on employee file reviews and staff interviews.
Deficient Food Storage and Sanitation Practices in Kitchen
Penalty
Summary
Facility staff failed to store, prepare, and serve food in accordance with professional standards of food service safety, as evidenced by multiple observations during two separate kitchen tours. Surveyors found grease layered on tiles, debris such as paper and plastic under and behind kitchen items, dust and dirt on floors, and mouse traps set throughout the kitchen. The prep supply area was dirty, insulation was coming off pipes under the sink, and food items like bread and elbow noodles were found on carts and the floor. An open bag of flour was left unsealed, and the clean food cart storage area had water-stained ceiling tiles, dirty floors, a large hole in the wall, and missing floor tiles. The cleaning schedule provided by the Dietary Manager did not include the dry storage area or specify that all floors should be mopped and trash cleaned up. Further observations included dirty mouse traps with food particles, sticky floors, vents and pipes with grease and dust buildup, and a refrigerator with a damaged seal. The bulletin board and air conditioning unit were dirty, and rolls of foil and plastic wrap were stored inappropriately. The stove, mixer, and meat slicer were left uncovered or uncleaned, and open containers of sugar were not properly sealed. Food carts, the fire suppression system, and the metal connection box had accumulations of dirt, food crumbs, and mice droppings. Hand sinks were blocked or dirty, and the hand sanitizer dispenser was unclean. The Administrator was made aware of these findings and had no additional comments.
Improper Disposal of Garbage and Refuse
Penalty
Summary
Facility staff failed to properly dispose of garbage and refuse, as observed during tours of the smoking and dumpster areas. Specific findings included cigarette butts littering the ground, broken pallets and chairs placed next to the building, unsecured gates that could be opened by residents, and piles of plywood, broken air conditioners, buckets, and trash in various locations. Additional observations included food serving carts in disrepair, a commercial hair drying unit leaning on metal doors, multiple air conditioners and food carts stored in the yard, ladders against the wall, an open shed filled with debris, and various pieces of trash and old furniture scattered around. In the dumpster area, dumpsters were found with open side doors, a pile of pallets, and milk containers scattered around, all contributing to improper refuse disposal.
Deficiencies in Staff Evaluation, Policy Accessibility, and Pest Control
Penalty
Summary
Facility administration failed to establish and ensure systems for evaluating staff performance and providing required education based on performance reviews and facility assessment. Review of an employee file for a GNA revealed only one annual performance evaluation over seven years of employment, and insufficient annual training on cognitive impairment and mental illness. Interviews with the DON and HR Director confirmed that annual performance evaluations were not conducted for nursing staff, and there was no formal process for ongoing competency verification or structured training needs assessment. Staff interviews indicated that policies and procedures were not readily available or accessible to all staff. Multiple staff members believed that policy binders were located in the nurse's station, but upon inspection, only a wound care policy binder was found. Other staff referenced policies being kept in various locations or with department heads, but the DON confirmed that direct care staff did not have access to policies and procedures on the units, and only one nursing manual was available in the facility. The facility also lacked an effective pest control program. Complaints and observations revealed ongoing issues with mice and cockroaches, unsanitary kitchen conditions, and structural deficiencies such as gaps and holes allowing pest entry. Pest control company recommendations for maintaining sanitation and building repairs were not implemented, and documentation showed only monthly pest control visits despite claims of increased frequency. Maintenance staff were not receiving pest control reports, and structural recommendations were not followed up, contributing to persistent pest issues.
Failure to Maintain Required QAA Committee Membership and Meeting Attendance
Penalty
Summary
Facility staff failed to maintain a Quality Assessment and Assurance (QAA) committee that included the required members, specifically the Medical Director and an Infection Preventionist. Review of QAPI (Quality Assurance Performance Improvement) committee meeting attendance sheets from April 2024 through April 2025 revealed that the Infection Preventionist was absent from multiple meetings, including several quarterly meetings, and the Medical Director was also absent from several meetings. Additionally, there was no evidence that meetings were held in certain months, as no sign-in sheets or documentation were available for those periods. Further review indicated that although the current Infection Preventionist had recently assumed the role, neither the current nor former Infection Preventionists attended the required meetings in that capacity. The staff member who is now the Infection Preventionist was present at some meetings, but only in the role of an MDS nurse, not as the Infection Preventionist. The absence of these key committee members was confirmed through record review and staff interviews.
Failure to Maintain Safe and Homelike Environment
Penalty
Summary
Surveyors observed multiple deficiencies related to the facility's failure to maintain a safe and homelike environment for residents. On the second floor, hallway heaters and vents were found covered with dust, and in one resident's room, the bathroom door had scuff marks and peeling veneer near the doorknob. The sink in the same room was dripping water, the flooring was cracked in two places, and the wall outside the bathroom was damaged and unpainted. The heating vent under the sink was also caked with dust. In another room, there were gaps where pipes entered the wall, and the vent under the window, as well as hallway vents, were heavily dust-laden. Additionally, one resident's room was missing doors on both the closet and bathroom. During an interview, the Maintenance Assistant stated that the facility did not have a preventative maintenance program to ensure resident rooms were maintained in a safe and homelike manner. He indicated that maintenance was only performed when issues were reported by nursing staff and that he was the sole maintenance worker since February, which prevented him from keeping up with cleaning and repairs. The new Maintenance Director later acknowledged these concerns.
Failure to Maintain Effective Pest Control Program
Penalty
Summary
The facility failed to maintain an effective pest control program, resulting in ongoing issues with mice, cockroaches, and other pests throughout the building. Multiple complaints were received regarding mice infestations, rodent droppings in resident rooms and the kitchen, and sightings of pests by visitors and residents. Observations confirmed the presence of pests and pest evidence in various areas, including a large hole in a wall near food storage, cockroaches in resident rooms and bathrooms, and mouse traps placed in response to sightings. The kitchen was found to be unsanitary, with layers of grease and dirt, and pest control recommendations for improved sanitation and building maintenance were not implemented. Outdoor areas, such as the resident smoking area and dumpster area, were cluttered with debris and had open containers, further contributing to pest problems. A review of the pest control policy revealed missing implementation details and lack of a designated pest management coordinator. Pest control logs showed regular pest sightings, and receipts from the pest control company documented ongoing recommendations for structural repairs and increased sanitation, which were not followed. Interviews with maintenance staff indicated a lack of communication and follow-up on pest control reports and recommendations. The administrator reported treating areas based on pest logs and claimed to increase pest control visits when needed, but documentation did not support this. The facility's failure to address structural issues, maintain cleanliness, and implement pest control recommendations led to persistent pest infestations affecting the entire facility.
Failure to Serve Food at Safe and Palatable Temperatures
Penalty
Summary
The facility failed to ensure that food was delivered to residents at an appropriate and palatable temperature. During a lunch tray line observation, a surveyor and the Certified Dietary Manager (CDM) monitored the process of food delivery, including the use of a test tray. The food cart was parked in a hallway while nursing staff distributed trays to residents' rooms. When the CDM measured the temperatures of the test tray items, the egg omelet with cheese registered at 98°F, sausage at 90°F, and milk at 42°F. The CDM confirmed these temperatures, which did not meet the required standards for hot food service. The Administrator was informed of the food temperature concern.
Failure to Timely Report Allegations of Abuse and Resident-to-Resident Altercation
Penalty
Summary
Facility staff failed to report an allegation of abuse in a timely manner to the State Agency. In one instance, a resident became agitated and accused staff of stealing marijuana, which is not permitted in the facility. The nurse documented the resident's allegation in the medical record, the 24-hour report, and verbally reported it to the oncoming nurse and the nursing supervisor. However, the allegation was not reported to administration or the State Agency, and the Clinical Services Director later confirmed that the incident was not reported as required. In a separate incident, one resident struck another on the head with a cane, resulting in a laceration. The facility's investigation did not include documentation of when the incident was reported to the Office of Health Care Quality (OHCQ) or when the final report was sent. The Nursing Home Administrator was unable to provide documentation of the reporting, as email confirmations had been deleted and were unavailable for review by the surveyor.
Failure to Investigate Allegations of Abuse and Misappropriation
Penalty
Summary
Facility staff failed to investigate an allegation of misappropriation of property for one resident who reported that their marijuana was stolen. The resident, who had previously expressed frustration about not being allowed to use marijuana for pain management, reported the alleged theft to nursing staff, who documented the complaint in the medical record and 24-hour report, and informed the oncoming nurse and supervisor. However, no formal investigation was conducted by administration or clinical leadership after the allegation was made. In a separate incident, the facility did not conduct a thorough investigation into an allegation that a Geriatric Nursing Assistant (GNA) threw cookies at a resident, striking them on the nose. The facility's documentation lacked statements from staff or residents regarding the alleged event, and the GNA in question was not removed from resident contact during the investigation period, despite working multiple shifts on the unit where the resident resided. The investigation relied on limited and, in one case, outdated staff statements, and did not include comprehensive interviews or evidence collection. Additionally, the facility failed to conduct a complete investigation into an allegation of abuse involving another resident with a mental health disorder and dementia. The investigation file did not contain a statement from the resident or from all potential witnesses, and although the accused GNA denied contact with the resident, there was no further inquiry into their assignment or possible interaction. The DON and Administrator acknowledged that an interview with the resident had occurred but could not provide documentation of it, and the investigation file was incomplete.
Failure to Develop and Implement Comprehensive, Person-Centered Care Plans
Penalty
Summary
Facility staff failed to develop and implement comprehensive, person-centered care plans for two residents, resulting in unmet needs related to medical appointments and skin care. For one resident, the medical record showed multiple physician orders for dental, cardiology, neurosurgery, and neurology consults, but there was no evidence that these appointments were attended. The resident often scheduled and canceled appointments independently, and staff did not maintain documentation of when or where the resident went for these appointments. Interviews with the Administrator and Transportation/Scheduler confirmed that the facility was not consistently involved in arranging or tracking the resident's outside medical visits, and the care plan did not address the resident's preferences or behaviors regarding appointment scheduling and attendance. Another resident experienced a recurrent rash on the lower legs, with documentation of ongoing symptoms and repeated courses of topical treatment. The resident was seen by both dermatology and rheumatology, and follow-up appointments were ordered, but the care plan addressing skin integrity was generic and not tailored to the resident's persistent and recurring condition. The care plan lacked specific, measurable actions or approaches to address the ongoing rash, despite repeated documentation of the issue and multiple specialist referrals. In both cases, the facility's care planning process did not adequately address the residents' individual needs, preferences, or the complexity of their medical situations. The deficiencies were identified through medical record review and staff interviews, which revealed gaps in documentation, lack of comprehensive planning, and insufficient coordination of care for residents with ongoing or complex health concerns.
Failure to Provide Resident-Centered Activities Program
Penalty
Summary
Facility staff failed to provide an activities program that met the needs and preferences of a resident with severe cognitive impairment. The resident, who had a diagnosis of dementia with behavioral disturbance and a BIMS score indicating severe cognitive impairment, had documented preferences for activities such as reading, listening to music, being around animals, keeping up with the news, participating in group activities, going outside, and engaging in religious practices. Despite these documented preferences, the care plan for activities was not individualized and lacked measurable goals and specific approaches tailored to the resident's needs. Observations during the survey revealed that the resident was either in their room or ambulating in the hallway and was never observed participating in any activities or receiving one-to-one engagement from staff. Review of activity participation logs showed that activities were only provided on a few days each month, with no documentation of daily or individualized activities, and no records of participation for two consecutive months. The care plan inaccurately stated that the resident was independent in meeting their activity needs, despite evidence of cognitive impairment and the need for staff engagement. Interviews with the Activity Director confirmed that one-to-one visits and group activity invitations were supposed to be documented, but there was a lack of documentation to support that these interventions occurred regularly. The absence of a resident-centered care plan and insufficient documentation of activity participation led to the finding that the facility did not meet regulatory requirements for providing an activities program that addresses the unique needs and preferences of the resident.
Failure to Reschedule Dermatology Appointment as Ordered
Penalty
Summary
Facility staff failed to follow physician orders for a resident who had a recurrent rash on the lower legs. The resident, who had diagnoses including dementia, hypertension, and hypothyroidism, had been prescribed the same ointment multiple times and was under the care of both rheumatology and dermatology for the rash. Medical records showed that the resident was seen by rheumatology and dermatology as ordered, but a dermatology appointment scheduled for February was cancelled due to an elevator malfunction at the hospital. Although there was a physician order to reschedule the dermatology appointment, there was no documentation that the follow-up appointment was ever scheduled. Interviews revealed that the staff member responsible for scheduling appointments and transportation was not notified by nursing to reschedule the dermatology appointment. The attending physician confirmed that the expectation was for the appointment to be rescheduled if missed, and was unaware that it had not been done. The deficiency was identified when it was found that the resident continued to have a rash and lacked current treatment or follow-up with dermatology as ordered.
Failure to Implement and Document Individualized Pressure Ulcer Prevention Measures
Penalty
Summary
Facility staff failed to implement appropriate individualized interventions for a resident identified as at risk for developing pressure ulcers. Upon admission, the resident was noted to have redness to the groin and buttock, but the documentation did not specify the size or whether the redness was blanchable. Physician orders included daily and weekly skin checks, weekly Braden Scale assessments for four weeks, and application of a moisture barrier cream. However, staff did not complete the required weekly Braden Scale assessments as ordered, and the interim plan of care did not specify individualized interventions to address the resident's skin integrity risk. The comprehensive care plan also lacked specific measures for turning and repositioning, use of prescribed moisture barrier cream, and the pressure-reducing device, despite the resident's dependence on staff for mobility and hygiene. The resident later developed an open area on the sacrum, which was first identified as unstageable, prompting new interventions such as an alternating pressure mattress, urinary catheter, and scheduled turning and repositioning. Documentation revealed that staff did not consistently record turning and repositioning assistance both before and after these interventions were added to the care plan. Interviews with the attending physician and DON confirmed that appropriate interventions were not in place or documented prior to the development of the pressure ulcer, and that staff failed to follow physician orders and facility protocols for residents at risk of pressure ulcers.
Failure to Limit and Document PRN Psychotropic Medication Orders
Penalty
Summary
Facility staff failed to ensure compliance with regulations regarding the use of as needed (PRN) psychotropic medications for a resident with dementia and behavioral disturbances. A physician order for Lorazepam, to be administered prior to blood draws, was written as a PRN order without a 14-day limitation or a specified duration and discontinuation date. The medical record did not contain documentation from the physician providing a rationale for continuing the PRN order beyond 14 days, as required by regulation. Additionally, review of the medication administration record showed that Lorazepam was administered to the resident, but there was no documentation indicating that non-pharmacological interventions were attempted prior to giving the medication. These findings were confirmed during interviews with the Director of Nursing and the Nursing Home Administrator, who acknowledged the lack of appropriate documentation and understanding of the requirements for PRN psychotropic medication orders.
Medications Improperly Stored at Bedside
Penalty
Summary
Facility staff failed to ensure that all medications and biologicals were stored in locked, temperature-controlled compartments as required. During an observation, a resident was found with multiple medications, including medicated spray, Desitin, Pepto Bismol, liquid pectate, severe congestion liquid medication, and cough syrup, left out in the open on the over-the-bed table in the resident's room. The resident stated that these medications were kept at the bedside because staff refused to retrieve them, and that a family member had purchased and brought the medications to the facility. The DON confirmed the presence of these medications during a follow-up observation and noted that staff had not reported this situation. The attending physician was aware of the medications at the bedside and had discussed the issue with the resident and administration multiple times, but proper storage was not ensured. These findings were reviewed with the Nursing Home Administrator and Clinical Services Director.
Failure to Conduct and Document Comprehensive Facility-Wide Assessment
Penalty
Summary
The facility failed to conduct and document a comprehensive and accurate facility-wide assessment to determine the resources necessary to care for residents competently during both routine operations and emergencies. During a complaint survey, the facility provided a binder labeled as the facility assessment, but review of its contents revealed significant omissions and outdated information. The facility profile lacked current data, such as the average resident census and accurate staff information, and did not include the average number of staff on nights. Additionally, the profile listed contact information for previous administrators and maintenance directors, indicating it was not up to date. Further review showed that the assessment did not adequately evaluate the resident population's needs, including an analysis of diseases, conditions, physical and cognitive abilities, and overall acuity. The comorbidity report was limited to 50 residents and did not provide a comprehensive assessment of the entire population. The assessment also failed to address the specific care requirements for residents, such as the types of diseases and disabilities present, and did not evaluate the staff competencies necessary to meet these needs. There was no documentation of staff education, training, or health information technology resources relevant to the resident population. The facility assessment was also missing evaluations of the facility's physical resources, such as buildings, vehicles, equipment, and contracted services. There was no evidence of an assessment of ethnic, cultural, or religious factors that could affect care, nor was there documentation of an evaluation of the number of staff required to meet resident needs. The list of contracted providers did not include an evaluation of how these services would meet regulatory, operational, or training requirements. These deficiencies were acknowledged by the Nursing Home Administrator during the survey.
Failure to Maintain Accurate Resident Property Inventory and End-of-Life Documentation
Penalty
Summary
The facility failed to maintain an accurate and complete inventory of a resident's personal belongings, as well as failed to document the disposition of those belongings upon the resident's discharge. One resident's medical record did not contain an inventory of personal items, including a motorized wheelchair and marijuana, despite staff acknowledging the presence and storage of these items. There was no documentation regarding the final disposition of these belongings after the resident was transferred to the hospital, and the facility was unable to provide a policy specific to the inventory of residents' belongings beyond a general admission policy. Additionally, the facility did not ensure accurate and complete documentation of residents' end-of-life choices. For another resident, the electronic medical record (EMR) indicated a code status of 'Full Code,' while the paper record contained an active MOLST form indicating 'Do Not Resuscitate/Do Not Intubate' (DNR/DNI) status. Staff interviews revealed reliance on both the EMR and paper chart for code status, but discrepancies existed between the two sources. The resident's care plan and a nurse practitioner's note also contained conflicting information regarding code status, and two active MOLST forms with different directives were found in the medical record. These deficiencies were evident during a complaint survey and were confirmed through record review, staff interviews, and observation. The lack of a consistent process for documenting and updating both personal property inventories and end-of-life directives led to incomplete and conflicting records for the residents involved.
Failure to Protect Residents from Abuse
Penalty
Summary
The facility failed to protect residents from abuse, as evidenced by multiple incidents involving a resident with a history of sexually inappropriate behavior. This resident, diagnosed with dementia and other mental health issues, was involved in several incidents of sexual abuse and misappropriation of property. On one occasion, the resident was found inappropriately touching another resident, who was unable to consent due to their condition. Despite the severity of these incidents, the facility did not conduct investigations or notify the State agency as required. The resident's behavior care plan noted various problematic behaviors, including sexual inappropriateness, which were not adequately addressed by the facility. The resident was observed engaging in inappropriate sexual conduct with multiple residents, including a bed-bound and demented resident, and another resident who was quadriplegic and dependent on staff for care. These incidents were witnessed by staff members, yet the facility failed to take appropriate action to prevent further occurrences or to report the incidents to the appropriate authorities. Additionally, the facility did not investigate or report an incident where the resident took personal items from another resident, causing distress. The lack of timely and appropriate response to these incidents highlights a significant deficiency in the facility's ability to protect residents from abuse and to comply with regulatory requirements for reporting and investigating allegations of abuse.
Failure to Report and Investigate Abuse Allegations
Penalty
Summary
The facility failed to implement abuse prevention policies, as evidenced by the staff's failure to immediately notify the facility administrator of allegations of resident abuse, sexual abuse, and misappropriation of resident property. This was evident in the cases of two residents during a complaint survey. Resident #1, who had a history of dementia and sexually inappropriate behavior, was found by a staff member in a compromising situation with another resident. Despite the incident being reported to a nurse and the physician being notified, the facility did not investigate or report the incident to the State Regulatory Agency. Additionally, Resident #1 was later observed attempting to touch female residents inappropriately, yet no investigation or notification to the state agency was conducted. Furthermore, Resident #1 was involved in an incident where personal items belonging to another resident, Resident #3, were taken, causing distress to Resident #3, who is quadriplegic and dependent on nursing staff. Despite the facility administrator being informed, no investigation or state agency notification occurred. Resident #1 was also observed engaging in further inappropriate behavior towards Resident #3, yet the facility again failed to investigate or report the incident. These failures highlight a significant deficiency in the facility's adherence to abuse prevention policies and reporting requirements.
Failure to Investigate Allegations of Abuse
Penalty
Summary
The facility failed to initiate investigations into multiple reported allegations of abuse involving two residents. Resident #1, who has a history of dementia, mood disturbance, psychotic disturbance, and bipolar disease, was involved in several incidents. On one occasion, Resident #1 was found in a compromising situation with another resident, Resident #4, which was reported by a staff member but not investigated or reported to the State agency. Additionally, Resident #1 was observed attempting inappropriate physical contact with female residents in the hallways, yet this incident also went uninvestigated and unreported. Furthermore, Resident #1 was involved in an incident where personal items belonging to Resident #3, who is quadriplegic and dependent on nursing staff, were taken, causing distress to Resident #3. Later, Resident #1 was observed hitting Resident #3. Despite these occurrences, the facility did not conduct investigations, obtain witness statements, or notify the State agency about these allegations of abuse. The Director of Nursing confirmed the lack of action during an interview.
Failure to Document and Communicate Resident Transfer
Penalty
Summary
The facility failed to ensure proper documentation and communication regarding the transfer or discharge of a resident, as evidenced by the case of Resident #1. Resident #1 was sent to the emergency room under an emergency petition after being witnessed engaging in inappropriate sexual behavior with another resident. Despite being cleared for discharge back to the nursing facility, the facility refused to accept Resident #1's return, citing concerns for the safety of female residents. However, the facility did not issue a 30-day involuntary notice, nor did it provide written correspondence to the resident's representative or the local State Ombudsman's office. Additionally, no documentation was sent with the resident to the hospital. Interviews with facility staff and medical personnel revealed a lack of communication and coordination regarding Resident #1's situation. The Director of Nursing (DON) admitted that the facility was aware of Resident #1's behaviors for over a year but did not take appropriate steps to address the issue. The covering physician and the on-call nurse practitioner were not adequately informed or involved in the decision-making process. Furthermore, Resident #1's representative was not notified about the facility's refusal to readmit the resident, leaving them unaware of the resident's status. The facility medical director was also not involved in discussions about the decision to deny Resident #1's return.
Failure to Notify Resident and Representative of Transfer and Discharge
Penalty
Summary
The facility failed to properly notify a resident, their representative, and the local State Ombudsman about the resident's transfer to the hospital and the subsequent refusal to readmit the resident. This deficiency was identified during a complaint survey involving a resident who was sent to the emergency room after being observed engaging in inappropriate sexual behavior with another resident. The facility did not issue a 30-day involuntary discharge notice or provide any written correspondence regarding the transfer or discharge to the relevant parties. The facility's Director of Nursing and administrator acknowledged that no notifications were made, citing the absence of administrative staff during weekends as a reason for the oversight. The resident's covering physician and representative were also not informed about the resident's status or the facility's decision not to readmit them. The facility medical director was not involved in the decision-making process regarding the resident's return, despite being aware of the incidents involving the resident and another resident who was a victim of the inappropriate behavior.
Failure to Ensure Safe and Orderly Resident Discharge
Penalty
Summary
The facility failed to ensure a safe and orderly transfer or discharge for a resident, leading to a deficiency identified during a complaint survey. The issue arose when a resident, who had been involved in inappropriate sexual behavior with another resident, was sent to the emergency room under an emergency petition. Despite being cleared for discharge back to the nursing facility, the facility refused to accept the resident's return, citing concerns for the safety of female residents. This decision was made without issuing a 30-day involuntary discharge notice or notifying the resident's representative or the local State Ombudsman's office. The facility's actions were further complicated by the lack of administrative staff present during the weekend when the incident occurred. The facility administrator admitted that no written correspondence was sent to the resident's representative or included with the resident when they were sent to the hospital. The resident's representative was not informed that the resident would not be accepted back into the facility, nor were they made aware that the resident was no longer residing there. This lack of communication and failure to follow proper discharge procedures contributed to the deficiency identified in the survey.
Failure to Provide Bed Hold Policy During Resident Transfer
Penalty
Summary
The facility failed to provide a copy of the bed hold policy to a resident when they were transferred to the emergency room. This deficiency was identified during a complaint survey involving a resident who was sent to the emergency room under an emergency petition after being observed for the second time in a 10-day period engaging in inappropriate behavior with another resident. The resident was evaluated and cleared for discharge back to the nursing facility, but the facility refused to allow the resident to return. During an interview, the facility administrator admitted that no 30-day involuntary notice or written correspondence was sent to the resident's representative or the local State Ombudsman's office, nor was it sent with the resident to the hospital. Additionally, the resident's medical record did not contain a copy of the facility bed hold policy upon their transfer to the hospital.
Facility Fails to Re-admit Resident After Hospitalization
Penalty
Summary
The facility failed to permit a resident to return after a brief hospitalization, which was identified during a complaint survey. The resident was sent to the emergency room under an emergency petition after being observed for the second time in a 10-day period engaging in inappropriate sexual behavior with another resident. The resident was evaluated and cleared for discharge back to the nursing facility, but the facility refused to accept the resident back, citing concerns for the safety of female residents. The facility did not issue a 30-day involuntary notice, nor did they send any written correspondence to the resident's representative or the local State Ombudsman's office. Additionally, the resident was not provided with a copy of the facility's bed hold policy upon being sent to the hospital. The resident's representative was not informed that the facility would not accept the resident back, nor were they made aware that the resident was no longer residing at the facility.
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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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