Forestville Rehabilitation And Wellness Center
Inspection history, citations, penalties and survey trends for this long-term care facility in Forestville, Maryland.
- Location
- 7420 Marlboro Pike, Forestville, Maryland 20747
- CMS Provider Number
- 215020
- Inspections on file
- 18
- Latest survey
- January 12, 2026
- Citations (last 12 mo.)
- 7
Citation history
Health deficiencies cited at Forestville Rehabilitation And Wellness Center during CMS and state inspections, most recent first.
Surveyors found that the facility did not report two mandatory reportable events to the State Survey Agency. One resident filed a concern that a GNA was roughly handling them, and another resident’s complainant reported a missing wallet/purse and wigs, indicating possible misappropriation. In both cases, the facility documented internal follow-up, but the Administrator and DON acknowledged that these allegations of abuse and misappropriation, which should have been reported to the Office of Health Care Quality, were not reported.
Two residents did not receive timely, ordered diagnostic and specialty services due to failures in the facility’s appointment scheduling process. For one resident, physician orders for a GI consult to evaluate G-tube removal and for an MBSS were not acted upon because the Unit Secretary reported never receiving the appointment request forms from nursing staff, and she only became aware of the needed appointments much later. For another resident with a documented neck mass, a CT neck ordered by the provider was not scheduled before the resident’s transfer to the hospital, where the CT was ultimately completed and an ENT evaluation with possible biopsy was recommended. After discharge, the provider ordered an ENT consult and biopsy, but the appointment was set more than two months later; the appointment scheduler stated this was the earliest date and informed the Unit Manager, who documented only that the family was notified of the date, while the family later reported they were merely told they could try to find an earlier appointment. The resident was subsequently rehospitalized, where a biopsy confirmed oropharyngeal cancer.
Two residents were affected by incomplete and inaccurate medical record documentation. For one resident, two physician certification forms regarding medical condition, decision-making, and treatment limitations were signed and dated but left blank in the section certifying decision-making capacity, and one form had an illegible date, contrary to facility expectations that a physician indicate whether the resident had or lacked capacity. For another resident with vascular dementia and a finger laceration, documentation conflicted on the injury site and pain status: a PA note described pain and active bleeding with bone exposure, while an RN marked on a pain observation tool that the resident did not verbalize or exhibit non-verbal pain. The same tool also incorrectly indicated the resident received scheduled pain medication and no PRN medication, despite the MAR showing only a PRN acetaminophen order and no scheduled pain medication, and other records confirming the injury was to the right pinky rather than the left side as documented in the PA note.
A resident with a known history of inappropriate sexual behaviors was able to repeatedly enter female residents' rooms and inappropriately touch others without adequate supervision or intervention, despite a care plan outlining the need for monitoring and redirection. Staff interviews and medical records confirmed ongoing behavioral issues and insufficient preventive actions prior to the implementation of 1:1 supervision.
A resident did not receive multiple scheduled medications and treatments, including high-risk drugs such as insulin, antibiotics, and antihypertensives, within the required timeframes. Audit findings showed repeated late administration over two days, with staff citing short staffing and competing clinical priorities as reasons. Facility policy required timely administration, especially for high-risk medications, but confusion over scheduling and documentation contributed to the deficiency.
Surveyors observed improper storage of ice scoops and disposable cups, with items placed in open containers and partially enclosed in plastic bags close to the floor in the nutrition room. Facility staff, including the DON, acknowledged these concerns during the survey.
Staff failed to perform hand hygiene during medication administration and resident care, as observed when an LPN administered medication and assisted a resident without sanitizing hands, and a GNA handled a resident's overbed table and straw without hand hygiene. Both staff members only acknowledged the issue after it was pointed out by the surveyor.
A resident experienced severe pain after a transfer by a physical therapist, who ignored the resident's request for assistance. Despite being on a pain management regimen, the resident's increasing pain was not adequately addressed or documented by staff. The resident's complaints were dismissed, and there was a lack of communication and documentation regarding the pain, leading to harm.
The facility failed to provide a safe and homelike environment, with surveyors observing water damage, structural issues, and inadequate maintenance responses in residents' rooms and bathrooms. Staff painted over stained ceiling tiles instead of replacing them, and additional deficiencies included non-functional heating/air conditioning units, missing knobs, and unsecured doors. The Director of Maintenance acknowledged these issues during a tour.
The facility failed to provide timely treatment and care, as evidenced by a resident who experienced severe leg pain and a fracture after being transferred without assistance, and another resident who was not consistently wearing a physician-ordered helmet for safety. Staff did not adequately address the pain or ensure the helmet was in place, leading to deficiencies in care.
A facility failed to include a discharge summary in a resident's medical record after their planned discharge following successful rehabilitation. During a survey, the absence of a physician discharge summary was noted, and the DON confirmed the missing document upon review.
A resident's dignity was compromised when a housekeeping staff member opened a shower room door without knocking, exposing the resident to others in the hallway. There were no signs indicating the room was occupied, and only staff had access codes to the entry key. An LPN confirmed the resident was independent and did not need assistance.
A resident's preference for showers over bed baths was not honored, as they reported not receiving a shower since a specific date despite requests. Observations noted inadequate personal care, including malodorous breath and dingy bed linens. The resident's records showed they required two-person assistance for bathing and had only received a shower once per week, contrary to their requests and physician orders.
A resident with a history of amputation and neuropathy reported pain after a transfer by a PT, but the facility failed to notify the physician. Despite the resident's complaints and increased requests for Tylenol, the LPN did not contact the doctor, acknowledging the oversight.
A resident's cell phone was wrongfully taken by a GNA while the resident attempted to call 911 for their unwell roommate, whose call light was not answered. The phone was handed to a Nursing Supervisor and later returned after a complaint. The incident was confirmed by interviews with the involved residents and the DON.
A facility failed to conduct quarterly and as-needed care plan meetings for a resident, as required. The resident reported not being invited to participate in such meetings this year or the previous year. The DON stated that the SSD was responsible for organizing these meetings, with oversight from the CSW, who had only recently joined the company and had not been onsite. This lack of oversight and organization resulted in the deficiency.
Two residents did not receive showers as per their care plans, with inconsistent documentation in their EMRs. One resident reported irregular showers, while another's records lacked documentation of scheduled showers, despite receiving bed baths due to wounds. Staff acknowledged the need for proper documentation, but records did not consistently reflect care provided.
A facility failed to provide a resident-centered activities program for a resident, who was often observed lying in bed without engagement. Despite a care plan requiring staff-dependent activities due to cognitive deficits, no 1:1 activities were documented over 30 days, and only two group activities were recorded. Staff interviews confirmed the lack of regular 1:1 activities, and the Administrator could not provide evidence of such activities during the survey period.
A resident was unsafely transferred using a malfunctioning Hoyer lift, with GNAs attempting a manual adjustment while the shower chair's brakes were unlocked. The lift had a damaged remote cord, and maintenance staff were unaware of the damage and uncertain about weight limitations. Inspections focused mainly on battery checks, with the last documented inspection on 5/1/24.
A resident with a neurogenic bladder and an indwelling Foley catheter reported multiple UTIs over two years, indicating insufficient catheter care. Despite a physician's order for regular Foley care, the resident could not recall receiving it since returning from the hospital. An LPN claimed to have provided care but demonstrated a lack of knowledge about the correct cleaning procedure, cleaning only two centimeters instead of the required six inches as per facility policy.
A facility failed to administer oxygen to a resident as prescribed by physician orders. The resident was observed receiving 1 liter of oxygen instead of the ordered 3 liters. A staff member confirmed the error and corrected it after surveyor intervention. The resident's medical record showed a physician order for 3 liters of oxygen every shift for shortness of breath.
A facility failed to maintain a medication error rate of 5% or less, resulting in a 7.41% error rate. Two incidents were observed: one where an RN did not administer Xanax due to it being unavailable and failing to notify the pharmacy promptly, and another where the RN incorrectly prepared a Vitamin D supplement. These errors highlight deficiencies in the medication administration process.
The facility failed to ensure medications were date-labeled upon opening and that medication and treatment carts were securely locked. Nurses were unsure of the correct procedures for labeling insulin bottles, and several carts were found unlocked during the survey, contrary to facility policy.
Facility staff failed to deliver meals at appropriate temperatures. Breakfast trays were prepared and delivered with significant delays, resulting in food temperatures below acceptable levels. A resident dependent on staff for feeding received their meal 28 minutes after preparation. The Food Service Manager acknowledged that thermo-plates should have been used to maintain food temperatures.
The facility staff failed to properly store food, maintain sanitary conditions, and monitor freezer temperatures. A surveyor found unlabeled and undated food items in the refrigerator, frost-covered items in the freezer, and a missing thermometer. The Food Service Manager confirmed these issues, and the Dietary Aide was unable to check the freezer temperature. The Maintenance Director was informed about a faulty freezer door handle.
A facility failed to accurately document the dates on a resident's PASARR form. During a survey, it was found that the PASARR was missing from the resident's records. The social worker later provided the document, which was incorrectly dated by a social services designee, with both the form and the date of admission recorded as 1964 instead of the correct year, 2024, as per the resident's medical record.
The facility failed to maintain infection control precautions, with issues observed in the kitchen, utility rooms, and laundry areas. Exposed undergarments, improper storage of items, and outdated infection control policies were noted, highlighting lapses in maintaining cleanliness and updated procedures.
The facility failed to provide accessible call bells for residents, as observed during a survey. A resident's call bell was disconnected, another resident had no call bell, and a third resident's call bell was out of reach. Staff confirmed these issues, and the deficiency was reported to the Administrator.
Facility staff failed to maintain a safe and sanitary environment, with issues such as standing water and leaking pipes in the dishwashing area, and chemical buildup and structural damage in the laundry room. The Food Service Manager noted incorrect pipe sizes were used during previous maintenance, and the Maintenance Director was unaware of some issues.
A facility failed to verify the RN license of a newly hired staff member, leading to a deficiency. The individual presented a falsified license during the hiring process, which was not verified by the HR director. Concerns about the staff's clinical knowledge prompted the DON to check the license, revealing it was fraudulent. The staff member admitted to the falsification and was terminated.
Failure to Report Allegations of Abuse and Misappropriation to State Agency
Penalty
Summary
The deficiency involves the facility’s failure to timely report allegations of abuse and misappropriation to the State Survey Agency, the Office of Health Care Quality (OHCQ), as required. Review of facility concern forms for October 2025 showed that one resident submitted a concern form on 10/30/2025 alleging that an assigned geriatric nursing assistant was roughly handling the resident. The facility documented that the geriatric nursing assistant was removed from the assignment and that the Director of Nursing was made aware, but there was no report of this allegation of suspected abuse/neglect to OHCQ. This omission was identified during the recertification/complaint survey through document review. A second concern form from October 2025 documented an allegation from another resident’s complainant that a wallet/purse and wigs were missing from the resident’s belongings, constituting an allegation of misappropriation. The facility’s documented response was to search the room and for the Unit Manager RN to request a receipt from the complainant, but the allegation was not reported to OHCQ. During interviews, the Administrator, who serves as the Grievance Officer, described the grievance process and acknowledged that these specific allegations of abuse, neglect, and misappropriation were not reported to OHCQ. The DON also confirmed that rough handling of a resident is considered physical abuse and that a missing purse or wallet is considered misappropriation, and both are mandatory reportable events that were not reported.
Failure to Timely Arrange Ordered GI, Diagnostic, and ENT Services
Penalty
Summary
The deficiency involves the facility’s failure to follow physician orders and arrange necessary gastrointestinal and diagnostic services for two residents. For one resident, the medical record showed a physician order dated 11/12/25 to schedule a gastrointestinal (GI) appointment for evaluation for gastrostomy tube (G-tube) removal, and a separate order dated 08/13/25 for a modified barium swallow study (MBSS). Interviews with the DON, a Unit Manager LPN, and the Unit Secretary established that the facility’s process required a nurse to relay appointment requests to the Unit Secretary, who would then schedule the appointment and return the details to the nurse for order updating and family notification. The Unit Secretary stated she never received any request for this resident’s MBSS or GI consult and was unaware these appointments needed to be scheduled until 01/07/26, at which point she began making calls to schedule them. The deficiency also includes the facility’s failure to timely arrange a critical diagnostic test and specialty consultation for another resident with a neck mass. The resident’s provider assessed the resident on 10/30/25 and ordered a neck ultrasound, which was performed the same day and showed a left neck solid mass measuring 3 x 2 x 2 cm with a recommendation for a CT of the neck and chest. A CT neck order was placed on 10/30/25 at 11:11 PM, but the CT was not scheduled by the facility before the resident was transferred to the hospital on a later date at 6:30 AM per family request for neck pain management. During that hospital stay from 11/10/25 to 11/11/25, the resident received a CT scan of the neck, which revealed enlarged, partially necrotic, and enhancing left-sided lymph nodes suspicious for metastatic lymphadenopathy, and an ENT evaluation with possible biopsy was recommended. The hospital discharge summary instructed that an appointment with the ENT doctor be made or verified within one week. Following the hospital discharge, the facility provider wrote an order on 11/12/25 for an ENT appointment and possible biopsy, but the ENT appointment was scheduled for 1/22/26. The appointment scheduler stated that this was the earliest available date and that, when a specific time window is required, she informs the doctor’s office so they can adjust the schedule; she confirmed she communicated the details of this case to the Unit Manager. The Unit Manager reported informing the resident’s family member of the earliest ENT appointment and stated the family member said they would look for an earlier appointment themselves, leading the Unit Manager to take no further action to adjust the schedule. However, a progress note documented only that the family was updated about the 1/22/26 appointment as the earliest available, and the family member later stated they were told they could seek an earlier appointment but did not indicate they would handle scheduling entirely on their own. The resident was later transferred back to the hospital for neck pain management, where a biopsy was performed and oropharyngeal cancer was diagnosed. The DON acknowledged that the CT scan and ENT consultation were not arranged in a timely manner.
Incomplete Capacity Certifications and Inaccurate Pain and Injury Documentation
Penalty
Summary
The deficiency involves the facility’s failure to maintain complete and accurate medical records in accordance with accepted professional standards for two residents. For one resident, review of the medical record showed two “Physician’s Certifications Related to Medical Condition, Decision Making, and Treatment Limitations” forms. Although both forms were signed and dated, the section titled “Certification Regarding Decision Making Capacity” was left blank on each form. The provider did not check either box to indicate whether the resident had adequate decision-making capacity or lacked adequate decision-making capacity, including for life-sustaining treatments. During an interview and dual review of the forms, the Regional Director of Clinical Services confirmed that the forms were not completed and acknowledged that it was the facility’s expectation that the physician check one of the boxes. The date on one form, completed by the Medical Director, was also illegible and not easy to decipher. For the second resident, the deficiency centers on inaccurate and inconsistent documentation related to an injury and pain assessment. A facility-reported incident described a GNA calling the assigned nurse to the resident’s room for a laceration to the right pinky finger with bright red blood and swelling. However, a progress note by a physician assistant from a video visit documented the resident as presenting with a laceration to the left leg with bone exposure and active bleeding, and further described the left fifth digit with bone exposure at the base. The resident had a history of vascular dementia and was a poor historian due to cognitive impairment. Review of a Pain Observation Tool for the same date showed that an RN documented “No” to the question asking whether the resident verbalized and/or exhibited non-verbal symptoms of pain, despite the physician assistant’s note stating the resident was experiencing pain and the wound was actively bleeding. Additional review of the Pain Observation Tool revealed further inaccuracies in medication documentation. In the section on pain relief, the RN documented that the resident received scheduled pain medication (“Yes”) and did not receive PRN pain medication (“No”). A dual review of the December medication administration record showed the resident did not have an order for scheduled pain medication but did have an order for PRN acetaminophen 325 mg, two tablets by mouth every six hours as needed for pain or fever, with a maximum daily dose specified. The DON confirmed that this documentation was not accurate. The DON also stated that the resident only had a laceration to the right pinky finger, and a hospital discharge summary verified that the resident was seen for a laceration to the right pinky, further demonstrating discrepancies between the medical record entries and the resident’s actual condition.
Failure to Prevent and Investigate Resident-to-Resident Abuse
Penalty
Summary
The facility failed to investigate and take appropriate action to prevent further abuse involving a resident with a documented history of inappropriate sexual behaviors. Medical record review showed that the resident had a care plan in place due to repeated attempts to touch female staff and residents, as well as entering female residents' rooms without permission. Despite these known behaviors, the interventions outlined in the care plan, such as monitoring and redirection, were not effectively implemented, as evidenced by continued incidents of inappropriate touching and unsupervised entry into other residents' rooms. On a specific occasion, the resident was witnessed inappropriately touching another resident, which led to the implementation of 1:1 supervision and a room change. Interviews with staff confirmed that prior to this incident, the resident had been able to access other residents' rooms and engage in inappropriate behaviors without adequate supervision. Social worker progress notes over an extended period also documented ongoing behavioral issues, indicating a pattern of insufficient preventive measures and lack of thorough investigation into the resident's actions.
Failure to Administer Medications and Treatments Timely According to Orders and Standards
Penalty
Summary
The facility failed to ensure timely administration of medications, adherence to medical care orders, and compliance with professional standards of quality for one resident reviewed during a complaint survey. Multiple medications, including high-risk drugs such as antihypertensives, insulin, antibiotics, and wound care treatments, were not administered within the prescribed timeframes. The facility's policy outlined specific requirements for medication administration, including the need for certain medications to be given at exact times and for high-risk medications to be administered within one hour of the scheduled time. Despite these policies, audit reports showed that numerous medications were given several hours late over two consecutive days, and wound care orders were also not completed within the required shift times. Interviews with facility staff revealed that the delays in medication administration were attributed to staffing shortages and competing clinical priorities, such as a nurse attending to another patient in critical condition. Staff members, including an LPN and the Director of Clinical Operations, confirmed that medications like antibiotics, blood pressure medications, and insulin are expected to be administered within a strict one-hour window and should not be liberalized. However, the audit showed that these medications were not given within the required timeframes, and there was confusion regarding the scheduling and documentation of liberalized versus non-liberalized medications. Further, the Medical Director did not express concern about the timeliness of medication administration and deferred to facility staff and regulations for guidance. Documentation reviewed by the surveyor included a resident's complaint about not receiving short-acting insulin as ordered. Additional interviews with nursing leadership indicated that staff were performing multiple roles due to staffing shortages, which contributed to the failure to administer medications and treatments as ordered.
Improper Storage of Ice Scoops and Cups in Nutrition Room
Penalty
Summary
The facility failed to adhere to professional standards for food service safety as observed during a survey related to a complaint about ice storage and handling for resident ice water. During the survey, an ice scoop was found stored on top of and partially within a plastic bag inside an ice scoop holder in the second floor nutrition room. Additionally, an ice scoop for an ice cooler was observed on the bottom rack of an open metal cart, approximately three inches from the hallway floor, stored in an open plastic container and partially enclosed in a plastic bag. A container of disposable plastic drinking cups was also stored on the bottom rack of the cart, similarly close to the floor. These storage practices were observed and confirmed by facility staff, including the Medical Record Coordinator and the Director of Nursing. No information about specific residents, their medical history, or their condition at the time of the deficiency was provided in the report.
Failure to Ensure Staff Hand Hygiene During Resident Care and Medication Administration
Penalty
Summary
The facility failed to ensure staff performed proper hand hygiene during medication administration and resident care, as observed by the surveyor during two separate incidents. In the first instance, a Licensed Practical Nurse (LPN) was observed administering medication to a resident without performing hand hygiene before or after the process. The LPN assisted the resident with taking pills and using a straw, then exited the room still holding the used medication cup and straw, again without performing hand hygiene. The LPN only performed hand hygiene after the surveyor intervened and pointed out the concern. In the second instance, a Geriatric Nursing Assistant (GNA) entered a resident's room, moved the overbed table, and handled a straw for the resident's ice water without performing hand hygiene before or after the interaction. The GNA exited the room without sanitizing their hands, and only acknowledged the concern when it was brought up by the surveyor. Both incidents were confirmed and acknowledged by the facility's Director of Nursing during the survey.
Inadequate Pain Management Leads to Resident Harm
Penalty
Summary
The facility failed to provide adequate pain management for a resident who complained of severe pain, resulting in harm. The resident, who was receiving multiple medications for pain management, reported a popping sound and severe pain in the right leg during a transfer by a physical therapist. Despite the resident's complaints and the presence of two geriatric nursing assistants, the physical therapist insisted on performing the transfer alone and did not respond to the resident's pain complaints. The resident later called 911 due to the pain, but the facility dismissed the call, citing the resident's dementia. The resident's medical records indicated that they were on a regimen of pain medications, including Tramadol, Gabapentin, Lidocaine Patch, Cymbalta, and PRN Acetaminophen. However, the records showed that the resident had not requested Tylenol since September until after the incident. The Medical Administration Record documented the administration of Tylenol for a pain level of 2/10 on several occasions, but there was no evidence of further assessment or escalation of care despite the resident's increasing pain levels reported during therapy sessions. Interviews with staff revealed a lack of communication and documentation regarding the resident's pain. The physical therapist claimed to have notified the charge nurse of the resident's pain, but there was no documentation to support this. The LPN responsible for administering PRN Tylenol did not contact the physician despite the resident's ongoing pain complaints. The facility's failure to adequately assess, document, and address the resident's pain resulted in a delay in appropriate treatment and management of the resident's condition.
Facility Fails to Maintain Safe and Homelike Environment
Penalty
Summary
The facility failed to maintain a safe, clean, and homelike environment for its residents, as evidenced by multiple observations of water damage and inadequate maintenance responses. During an initial tour, a surveyor observed significant water damage in the room and bathroom of two residents, including brown stains on ceiling tiles, a pool of water with black debris on the bathroom floor, and structural damage such as bubbled and cracked walls. The toilet paper dispenser was detached, and gnats were present in the bathroom. Staff responses to these issues were inadequate, with the Environmental Services Manager only noting the need for a deep scrub of the floor and the Maintenance Associate painting over stained ceiling tiles instead of replacing them, due to a lack of available tiles. Further observations during a tour with the Director of Maintenance revealed additional deficiencies, including a non-functional heating/air conditioning unit, missing knobs, chipping paint, and trim issues in various rooms. A crawling bug was found in a bathtub, and blinds in several rooms needed replacement. The shower room door on the first floor did not lock, compromising security. These issues were acknowledged by the Director of Maintenance, who stated an intention to conduct a walkthrough and make necessary repairs. The administration team was informed of these concerns at the time of the survey exit.
Failure to Provide Timely Treatment and Ensure Safety Measures
Penalty
Summary
The facility failed to provide timely treatment and care according to orders and resident preferences, as evidenced by two specific incidents involving residents. In the first case, a resident complained of pain and a possible fracture after being transferred by a physical therapist without assistance, despite the resident's request for help. The resident reported severe pain in the right leg, which was not adequately addressed by the staff. The resident's pain was documented multiple times, but there was no evidence of appropriate follow-up or communication with the nursing staff or physician until an x-ray was ordered weeks later, revealing an acute fracture. In the second incident, the facility did not ensure that a resident's helmet was in place as ordered by the physician. The resident was observed multiple times without the helmet, which was supposed to be worn at all times for safety. Staff interviews revealed a lack of adherence to the physician's orders, with the helmet being removed or not placed on the resident as required. The staff's misunderstanding of the helmet's necessity and the physician's orders contributed to the deficiency. These deficiencies highlight a failure in communication and adherence to care plans and physician orders, resulting in inadequate care for the residents involved. The incidents demonstrate a lack of timely response to resident complaints and a failure to ensure safety measures were consistently applied, as evidenced by the observations and staff interviews conducted during the survey.
Missing Discharge Summary in Resident's Medical Record
Penalty
Summary
The facility failed to include a discharge summary in a resident's medical record following their planned discharge. This deficiency was identified during a survey when a review of the medical record for a resident revealed the absence of a physician discharge summary after the resident was discharged from the facility. The resident had been discharged after successful rehabilitation. An interview with the Director of Nursing confirmed the lack of a discharge summary in the medical record, as the DON was unable to locate it upon review.
Resident Dignity Compromised Due to Inadequate Privacy Measures
Penalty
Summary
The facility failed to treat a resident with dignity by exposing them in a public area. During observation rounds on the 1st floor, a surveyor witnessed a housekeeping staff member opening the shower room door wide open without knocking or checking if it was occupied. This action exposed a resident who was showering to others in the hallway, including residents, staff, and surveyors. There were no signs or notices outside the door indicating that the shower room was in use or that knocking was required before entry. The door had an entry key on the outside, and only staff had codes to access it. The Licensed Practical Nurse confirmed that the resident was independent and did not require assistance while showering, and there was no other system in place to indicate the room's occupancy.
Failure to Honor Resident's Bathing Preferences
Penalty
Summary
The facility failed to honor a resident's choice to receive showers twice a week, as evidenced by observations and interviews conducted by the surveyor. The resident expressed a preference for showers over bed baths and reported not receiving a shower since a specific date, despite having requested them. Observations noted the resident in a hospital gown with malodorous breath and yellow-stained teeth, indicating a lack of proper oral hygiene assistance. The resident's bed linens were also observed to be dingy, further suggesting inadequate personal care. The surveyor reviewed the resident's electronic medical records, which documented that the resident required two-person assistance for bathing and had only received a shower once per week over a four-week period, contrary to the resident's requests and physician orders. The facility's failure to provide showers as per the resident's choice and physician's directive was confirmed through documentation and staff interviews, highlighting a deficiency in promoting and facilitating resident self-determination and choice in personal care routines.
Failure to Notify Physician of Resident's Change in Condition
Penalty
Summary
The facility failed to notify the physician of a change in condition for a resident, which was identified during a survey. The resident, who had a below-the-knee amputation, diabetic neuropathy, and rheumatoid arthritis, reported hearing a popping sound and experiencing pain during a transfer by a physical therapist. Despite the resident's complaints of pain and the presence of two GNAs in the room, the physical therapist instructed them not to assist, and neither the therapist nor the nurse responded to the resident's report of pain. The resident later called 911 due to the pain, but the facility dismissed the call, citing the resident's dementia. The resident's medical records showed they were on multiple pain medications, including Tramadol, Gabapentin, and Tylenol, with the latter being administered as needed. The MAR indicated that the resident began requesting Tylenol for pain on November 22, 2023, and continued to do so frequently, which was a change from their previous pattern. An LPN confirmed administering the Tylenol but did not contact the physician about the increased pain medication requests, acknowledging that perhaps they should have done so.
Misappropriation of Resident's Property
Penalty
Summary
The facility failed to protect a resident from the wrongful use of their belongings, specifically a cell phone, which constitutes misappropriation of property. The incident involved a Geriatric Nursing Assistant (GNA) who took a resident's cell phone while the resident was attempting to call 911 for their roommate, who was not feeling well and whose call light was not being answered by the staff. The GNA removed the phone from the room and handed it over to the Nursing Supervisor, who instructed the GNA to return it to the resident. Interviews with the involved residents confirmed the sequence of events. The resident who attempted to call 911 stated that the GNA took their phone and only returned it after they complained to the nursing supervisor. The roommate corroborated this account, stating that they had asked their roommate to call 911 due to feeling unwell and the staff's failure to respond to the call light. The Director of Nursing validated that the phone was taken without permission, confirming the misappropriation of the resident's property.
Failure to Conduct Timely Care Plan Meetings
Penalty
Summary
The facility failed to ensure that care plan meetings were provided to a resident quarterly and as needed, as required by regulations. This deficiency was identified during a survey when a resident reported not being invited to participate in care plan meetings. The resident stated that they had not had a care plan meeting this year and did not recall having one the previous year. Upon request, the facility could only provide three invitations for care plan meetings, with the most recent being scheduled for a future date, and the others dating back to 2022. The Director of Nursing (DON) explained that care plan meetings should occur quarterly, as needed, and when there is a significant change in the resident's status. The responsibility for organizing these meetings and ensuring residents receive invitations was assigned to the Social Services Designee (SSD), who is not licensed and is currently in school. Oversight was supposed to be provided by the Corporate Social Worker (CSW), who had only been with the company for 30 days and had not been onsite. This lack of oversight and organization led to the failure to conduct timely care plan meetings for the resident in question.
Failure to Document and Provide Scheduled Showers
Penalty
Summary
The facility staff failed to ensure that residents' plans of care were followed and updated according to professional nursing standards, specifically regarding the provision of showers. Resident #134 reported not receiving regular showers since their arrival at the facility, with documented showers only on specific dates. The electronic medical records (EMR) lacked consistent documentation of bathing, and there was a discrepancy between the resident's account and the staff's claims. The Unit Manager confirmed the resident's scheduled shower days but was unable to provide the necessary documentation to verify compliance with the care plan. Similarly, Resident #126's EMR showed a lack of documentation for scheduled showers, with only a few recorded instances of showering. The Unit Manager acknowledged that the resident typically received bed baths due to their wounds, but staff failed to document these occurrences. The Director of Nursing emphasized the importance of documenting care provided and any refusals by residents, yet the records did not reflect consistent adherence to this protocol. These deficiencies highlight a failure in maintaining accurate records and ensuring that residents receive the care outlined in their plans.
Failure to Implement Resident-Centered Activities Program
Penalty
Summary
The facility failed to implement an ongoing resident-centered activities program designed to meet the interests and support the physical, mental, and psychosocial well-being of each resident, specifically for one resident. Observations and interviews revealed that the resident was often found lying in bed without any activities or engagement, such as TV or music, in their room. The resident's care plan indicated a need for staff-dependent activities, cognitive stimulation, and social interaction due to cognitive deficits, with goals for participation in 1:1 visits and movie matinees. However, there was no documentation of any 1:1 activities over the past 30 days, and only two group activities were recorded. Interviews with facility staff, including an LPN and the Activities Lead, confirmed that the resident did not regularly participate in activities and that 1:1 activities were not being conducted as planned. The Activities Lead admitted to not performing regular 1:1 activities with the resident, although they expressed an intention to start. The Administrator was unable to provide evidence of 1:1 room visits for the resident during the specified period. Throughout the survey, the resident was not observed participating in any activities, either group or individual, nor being transported to or from group activities.
Unsafe Transfer and Equipment Maintenance Deficiency
Penalty
Summary
The facility failed to ensure the safety of a resident during a transfer using a Hoyer lift. The incident involved two Geriatric Nursing Assistants (GNAs) attempting to transfer a resident from the lift to a reclining shower chair. The lift malfunctioned, preventing the resident from being raised to the necessary height for a safe transfer. The GNAs were observed attempting to manually adjust the resident while the shower chair's brakes were unlocked, posing a risk to the resident's safety. The surveyor intervened and communicated the safety concerns to the staff, who then locked the chair and completed the transfer. Further investigation revealed that the Hoyer lift used in the transfer had a damaged remote cord, with tape wrapped around it and exposed wiring. The Director of Maintenance was unaware of the damage and expressed uncertainty about the lift's weight limitations. Maintenance staff reported that their inspections primarily involved checking the battery, and the last documented inspection was on 5/1/24. The damaged lift was observed being moved to another hallway for use, indicating a lack of proper equipment maintenance and safety checks.
Deficiency in Foley Catheter Care
Penalty
Summary
The facility staff failed to provide appropriate and sufficient care for a resident with an indwelling urinary catheter, leading to a deficiency. The resident, who has a neurogenic bladder, reported having 4-5 urinary tract infections (UTIs) over the two years they have had the Foley catheter. The medical record indicated a physician's order for continuous drainage with specific instructions for Foley catheter care every shift and as needed, including cleaning with soap and water, securing straps, and documenting output. However, the resident could not recall receiving Foley care since returning from the hospital, indicating a lapse in the care routine. During an interview, an LPN claimed to have provided Foley care earlier in the day, but the resident contradicted this, suggesting a possible oversight or miscommunication. The LPN demonstrated a lack of knowledge regarding the proper cleaning procedure, as she was unsure of the correct length of the catheter tubing to clean. The facility's Catheter Care Policy and Procedures specify cleaning approximately six inches of the catheter from the meatus downward, but the LPN only cleaned about two centimeters. This discrepancy highlights a failure to adhere to established care protocols, contributing to the resident's recurrent UTIs.
Failure to Administer Prescribed Oxygen Levels
Penalty
Summary
The facility failed to administer oxygen to a resident as prescribed by physician orders. During observation rounds, it was noted that the resident was receiving 1 liter of oxygen with humidification via aerosol collar, contrary to the physician's order for 3 liters. A staff member confirmed the discrepancy and adjusted the oxygen level after surveyor intervention. The resident's medical record indicated a physician order dated several months prior, specifying the need for 3 liters of oxygen every shift for shortness of breath.
Medication Administration Errors Lead to Elevated Error Rate
Penalty
Summary
The facility failed to maintain a medication error rate of 5% or less, resulting in a 7.41% error rate during a survey. This deficiency was observed in two separate incidents involving medication administration by RN #6. In the first incident, RN #6 did not administer Xanax to a resident as prescribed due to the medication not being available in the medication cart. Despite the facility's protocol requiring immediate notification to the pharmacy and the Unit Manager when a controlled medication is missing, RN #6 did not follow this procedure, delaying the process by over three hours. In the second incident, RN #6 incorrectly prepared a Vitamin D supplement for another resident. The nurse intended to dispense Vitamin D3 125 mcg but instead retrieved Vitamin D 25 mcg. This error was identified by the surveyor, who intervened and prompted RN #6 to verify the medication and dosage. Both incidents highlight a failure in the medication administration process, contributing to the facility's elevated medication error rate.
Medication Labeling and Cart Security Deficiencies
Penalty
Summary
The facility failed to ensure that medications were properly date-labeled upon opening, as observed during a survey. On the second floor, a registered nurse's medication cart contained bottles of Lantus, Lispro, and Glargine for two residents, all of which had open seals but lacked date labels. The nurse explained that facility policy requires medications to be dated when opened, and insulin expires 28 days after opening. However, she was unsure why the bottles were not labeled by the person who opened them and incorrectly dated a bottle she did not open. On the first floor, another nurse's cart contained an open bottle of Lantus without a date label, and the nurse was unsure of the correct date to use. The Director of Nursing confirmed that the nurse who opens an insulin bottle is responsible for dating it immediately. Additionally, the survey revealed issues with medication and treatment cart security. On one occasion, a medication cart outside a resident's room was found unlocked, and the drawers could be opened without difficulty. A unit manager locked the cart upon noticing the surveyor's presence. The Director of Nursing stated that carts should be locked when not in use. Another incident involved an unlocked treatment cart on Unit 2 South Hall, which was also easily opened. An LPN locked the cart after observing the surveyor and mentioned that it was likely left unlocked by a nurse performing treatments.
Failure to Serve Meals at Appropriate Temperatures
Penalty
Summary
Facility staff failed to ensure that food was delivered to residents at an appropriate and palatable temperature. On the morning of May 30, 2024, the kitchen staff began preparing breakfast trays at 7:05 am. The surveyor observed the preparation of breakfast trays starting at 7:58 am, and by 8:43 am, the last resident tray was prepared. A test tray was requested by the surveyor, and at 8:53 am, the food cart, along with the surveyor and Regional Healthcare Service #11, departed the kitchen to Unit 2. The last food cart arrived on the unit at 8:55 am, but the last breakfast tray was delivered to a resident at 9:08 am, who was dependent on staff for feeding. The resident's food was warmed by GNA #60, and the resident was fed breakfast at 9:11 am, 28 minutes after the tray was prepared. The temperatures of the food on the test tray were checked at 9:11 am by Regional Healthcare Service #11 using a thermometer. The recorded temperatures were: Orange Juice 72.8 F, Oatmeal 113.7 F, Ground Sausage 114.4 F, Eggs 106.4 F, and Turkey Bacon 94.6 F. During an interview later that morning, the Food Service Manager was informed of the test tray temperatures and stated that all meal trays should be served using a thermo-plate to maintain appropriate food temperatures, but was unsure why the dietary staff did not use them.
Deficiencies in Food Storage and Sanitation Practices
Penalty
Summary
The facility staff failed to properly store food, maintain sanitary conditions, and consistently monitor freezer temperatures, as observed during a survey. During an initial inspection of the kitchen, a surveyor found a white powdery substance on a communal coffee dispenser, brown spots on a food tray rack, and a sticky substance on the kitchen floor. Additionally, the refrigerator contained several unlabeled and undated food items, including a black plastic bag of fruit, a clear bag of bagels, a container of Aquafina water, a bag with beets, and a container with a sandwich. The Food Service Manager confirmed these findings and acknowledged that the items should have been discarded, following the first-in, first-out principle. Further inspection revealed additional issues, such as frost covering items in the freezer, a missing thermometer, and an incomplete freezer temperature log. The freezer contained multiple containers of juice on the floor and an unlabeled container of cooked chicken strips without a date. The Food Service Manager stated that the freezer door might have been left open over the weekend, and the Dietary Aide responsible for logging temperatures was unable to check the freezer temperature due to the missing thermometer. The Maintenance Director was informed about the faulty freezer door handle, which was in the process of being addressed.
Inaccurate Documentation of PASARR Dates
Penalty
Summary
The facility failed to accurately document the dates on a resident's Preadmission's Screening and Resident Review (PASARR) form. This deficiency was identified during a surveyor's review of a resident's record, where it was found that there was no PASARR in the resident's paper or electronic chart. Upon inquiry, the social worker indicated that all PASARRs are kept in social services and promised to provide the document. When the PASARR was eventually provided, it was discovered that the form was incorrectly dated by a social services designee, with both the form and the date of admission recorded as 4/8/1964, instead of the correct date of 4/8/2024 as documented in the resident's medical record.
Infection Control Deficiencies in Facility
Penalty
Summary
The facility staff failed to maintain infection control precautions and ensure that the policies and procedures related to infection control were updated. During a survey, several deficiencies were observed. In the kitchen, a dietary aide was seen with exposed undergarments despite previous verbal counseling, and another staff member placed cheese on a cutting board with food particles. On Unit 2 East wing, items such as hand sanitizer and shampoo were improperly stored on a linen cart, contrary to the facility's usual practice of retrieving linen from the Clean Utility Room. Further observations revealed a dirty, uncovered trash can with used gloves in a clean utility room, along with an uncovered IV pole and a dirty walking cane. In the laundry facility, clean linens were left uncovered in the hallway, and personal items were found in the clean laundry folding area. Structural issues such as holes in the wall and a dirty filter on a washing machine were noted. Additionally, the facility's Antibiotic Stewardship Plan had not been reviewed or updated since February 2022, indicating a lapse in maintaining current infection control policies.
Deficiency in Resident Call Bell Accessibility
Penalty
Summary
The facility failed to ensure that residents had access to functioning call bells, as observed during the surveyor's initial tour. For Resident #3, the call bell was found pulled out from the wall, rendering it unusable until reconnected. Resident #66 was observed without a call bell in their room, and upon inquiry, the staff confirmed the absence of a call bell. Resident #66 expressed willingness to use a call bell if provided, and Resident #3 reported that they had been assisting Resident #66 by communicating their needs. Additionally, Resident #49's call bell was found gathered and hung out of reach behind their bed. The resident indicated the location of the call bell when asked, and a staff member confirmed the resident's capability to use it. After the surveyor's intervention, the call bell was retrieved and given to the resident. These observations were shared with the facility Administrator, highlighting the deficiency in providing residents with accessible call systems.
Deficient Environmental Conditions in Facility
Penalty
Summary
Facility staff failed to maintain a safe, sanitary, and comfortable environment, as observed in multiple areas. In the dishwashing area, there were multiple areas of standing water and a leaking pipe under the sink, with a hole around a pipe and corrosion on several pipes under the stainless-steel tables. The Food Service Manager reported that plumbers had serviced the pipes the previous summer but used the wrong size pipes, leading to leaks. In the clean laundry room, two holes were observed in the wall above the door near a vent, and there was a buildup of green and white washing chemicals on the wall near the washing machines. A taped hose was leaking, and in the dryer room, plaster was falling from the ceiling and missing from the wall below the window. The Maintenance Director was unaware of the leaking hose and chemical buildup, attributing the plaster peeling to heat from the dryers.
Failure to Verify Nursing License Leads to Deficiency
Penalty
Summary
The facility failed to ensure that a newly hired nursing staff member had an active, valid registered nurse license, as required by state laws. This deficiency was identified during a survey when it was discovered that one of the five licensed healthcare professional employee files reviewed contained fraudulent documentation. The individual, referred to as Staff #56, applied for a registered nurse position and presented a falsified RN license during the hiring process. The human resources director, Staff #57, did not verify the authenticity of the license on the Maryland Board of Nursing (MBON) website before the hiring interview or the employee's orientation. Concerns about Staff #56's clinical knowledge and decision-making were raised by a night shift nursing supervisor, prompting the Director of Nursing (DON) to verify the license, which was found to be non-existent on the MBON website. Staff #56 admitted to the falsification and was subsequently terminated. The facility's failure to verify the licensure of the applicant as part of the pre-hiring process led to this deficiency. The incident was reported to the police, OHCQ, the Ombudsman, and the MBON after the discovery.
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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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