Frederick Villa Healthcare
Inspection history, citations, penalties and survey trends for this long-term care facility in Catonsville, Maryland.
- Location
- 711 Academy Road, Catonsville, Maryland 21228
- CMS Provider Number
- 215178
- Inspections on file
- 18
- Latest survey
- March 23, 2026
- Citations (last 12 mo.)
- 57
Citation history
Health deficiencies cited at Frederick Villa Healthcare during CMS and state inspections, most recent first.
A resident admitted with STEMI, CHF, atrial fibrillation, chronic embolism and thrombosis of deep veins, and hypertensive heart disease with heart failure had anticoagulant therapy changed from Eliquis to Xarelto per the hospital discharge summary, and Xarelto was ordered by the physician on admission. However, the baseline care plan created within 48 hours did not list the anticoagulant among current medications and did not include a care plan for anticoagulant therapy. The DON confirmed the resident was receiving Xarelto at admission and that it should have been included in the baseline care plan.
Facility staff failed to develop a comprehensive, person-centered care plan for a resident admitted with paraplegia, severe malnutrition, and multiple Stage IV pressure ulcers. The existing care plan included only general goals and basic interventions such as repositioning and nonspecific wound/dressing care, without specifying dressing types or frequencies. It omitted key interventions to prevent worsening heel ulcers (e.g., heel elevation or heel boots), did not address the ordered wound vac or required monitoring for seal integrity, infection, bleeding, or fluid leakage, and did not specify the type of mattress needed. During review, the DON acknowledged that the care plan was not comprehensive for the resident’s pressure wounds.
A resident admitted after a cerebral infarction with hemiplegia and hemiparesis had been diagnosed with a UTI in the hospital and started on Amoxicillin 500 mg TID, with instructions on the discharge summary to continue the antibiotic for five additional days. On review, the MAR contained no documentation that the Amoxicillin was administered after admission. During interviews, the DON reported having reviewed the discharge summary but believed the antibiotic had been completed in the hospital, and another staff member explained that the facility’s second-day chart check process for new admissions likely failed to identify and implement the ongoing antibiotic order.
A resident with a history of STEMI, CHF, A-fib, chronic embolism/DVT, and hypertensive heart disease was discharged from the hospital with instructions to switch from Eliquis to Xarelto, including a loading dose followed by a maintenance dose. Although Xarelto was ordered on admission, multiple erroneous Eliquis orders were entered by the pharmacy and verified by an LPN supervisor, then repeatedly discontinued by an RN Unit Manager who recognized that only Xarelto was intended. Despite these actions, Eliquis continued to appear on the MAR, and an LPN ultimately administered Eliquis 5 mg together with Xarelto 15 mg during a morning med pass, resulting in both anticoagulants being given concurrently and increasing the resident’s risk for bleeding.
Surveyors found that the facility failed to maintain complete and accurate medical records for two residents. One resident with paraplegia, multiple stage 4 pressure ulcers, a colostomy, and severe malnutrition had missing weekly wound care notes after an EMR system change, incomplete documentation of ordered colostomy output monitoring, and no nursing notes of nausea or vomiting despite staff recollections and a PRN ondansetron order. The same resident’s change-in-condition documentation omitted reported respiratory issues that were later reflected in hospital records and by the RN who sent the resident out. For both this resident and another recently admitted resident, there were care plan invitation letters but no corresponding documentation in the EMR that required care plan meetings after admission actually occurred, as confirmed by the regional social worker.
A deficiency was identified when ongoing pest infestations, including roaches, mice, ants, spiders, and other insects, were repeatedly documented in multiple care areas and common spaces. Despite the use of a pest management company, the NHA confirmed the continued presence of pests, and a complaint was filed regarding the issue. Surveyor review of logs and staff interviews confirmed that the facility's pest control program was not effective.
The facility did not ensure timely reporting of multiple allegations of abuse, neglect, and theft to the appropriate authorities. Several residents reported rough treatment, derogatory comments, delayed care, and missing property, but these incidents were not consistently documented or reported as required. Leadership interviews confirmed lapses in recognizing and reporting these events, resulting in noncompliance with regulatory standards.
Multiple residents reported staff being rough, making inappropriate comments, or providing aggressive care, but the facility did not conduct timely or thorough investigations or document required assessments. In several cases, allegations were not immediately reported, investigated, or followed up with resident assessments, and staff interviews and protective measures were lacking.
Surveyors found that two residents experienced persistent pest infestations, including flies and gnats, in their rooms, with complaints also referencing ants and mice. Maintenance staff did not routinely check rooms unless issues were reported, and pest control measures were insufficient to resolve the problem. Additionally, another resident's room was observed to have longstanding maintenance issues, such as unpainted walls, a corroded faucet, loose plaster, a displaced ceiling tile, and a non-functioning light, all of which contributed to an environment that was not safe, clean, or homelike.
A staff member used a resident's bank card and account information to withdraw funds for personal use, with multiple unauthorized transactions identified through a police investigation. The administrator was unaware of the extent of the staff member's actions and could not confirm if the resident received the withdrawn funds, despite facility policy prohibiting such conduct.
A resident's discharge paperwork was found to be incomplete, with missing information in several sections of the discharge planning tool, including responsible party details, physician information, required signatures, and the medication list. Staff interviews confirmed that all sections should have been completed prior to discharge, but this was not done, and the DON acknowledged the concern.
Surveyors identified that two residents did not have baseline care plans, including medication lists, properly provided or documented within 48 hours of admission. In both cases, required signatures and evidence of delivery to the resident or their representative were missing, and documentation was not present in the EHR as expected. Staff interviews confirmed the deficiencies in the care plan process.
A resident lost the ability to perform activities of daily living (ADLs) without a documented medical reason, as the facility did not ensure that such declines only occurred when medically necessary.
Three residents did not receive appropriate pain management, including lack of pain monitoring, failure to schedule pain management appointments, and improper administration of PRN pain medications without following pain scale parameters or attempting non-pharmacological interventions. Pain medications were sometimes given when pain was not present, and documentation was incomplete or missing.
Two residents did not have complete or accurate documentation in their medical records. One received a one-time dose of Narcan that was not recorded on the MAR, and another had a therapeutic boot recommended by an orthopedist, but its use was not documented on the Treatment Administration Record. These actions resulted in incomplete medical records, contrary to professional standards.
A GNA began caring for residents before completing mandatory training in abuse prevention, dementia care, and infection control, with required education not finished until nearly two months after hire. The NHA confirmed that essential training should have been completed during orientation, but the staff member worked with residents prior to receiving this education.
Baseline Care Plan Omitted Resident’s Anticoagulant Therapy
Penalty
Summary
The facility failed to ensure that a resident’s baseline care plan reflected the resident’s current medications at the time of admission. The resident was admitted with diagnoses including ST elevation myocardial infarction (STEMI), congestive heart failure, atrial fibrillation, chronic embolism and thrombosis of deep veins, and hypertensive heart disease with heart failure. The hospital discharge summary documented that the resident’s anticoagulant therapy had been changed from Eliquis to Xarelto, with a loading dose of Xarelto 15 mg twice daily starting on 12/7/2025 and a planned transition to Xarelto 20 mg daily on 12/29/2025. Upon admission, the physician orders at the facility included Xarelto as an anticoagulant medication. Record review showed that the resident’s baseline care plan, dated 12/10/2025, did not list anticoagulant medication among the resident’s current medications and did not include any care plan addressing anticoagulant therapy. During an interview, the DON confirmed that the resident was taking Xarelto at the time of admission and acknowledged that the anticoagulant medication should have been included in the baseline care plan. This omission occurred despite the requirement that the baseline care plan, provided within 48 hours of admission, detail the components of care the facility intends to provide, including current medications.
Failure to Develop Comprehensive Care Plan for Resident With Stage IV Pressure Ulcers
Penalty
Summary
Facility staff failed to develop a comprehensive, person-centered care plan for a resident admitted with extensive Stage IV pressure ulcers. The resident was admitted with paraplegia due to a motor vehicle accident, Stage IV pressure ulcers to the left buttock, sacral region, and left ankle, a local infection of the skin and subcutaneous tissue, and unspecified severe protein-calorie malnutrition. A pressure ulcer care plan was created and initiated with a goal that the resident would be free from signs of infection and that the ulcers would improve by the next review date. The listed interventions included carefully drying between toes without applying lotion between them, positioning the resident off affected areas, changing position every two hours and as needed, and a general directive for wound/dressing care "as order" with instructions to observe and change dressings and record observations at a frequency to be specified. The care plan was not comprehensive or resident-centered for the type and severity of the resident’s pressure ulcers. It did not specify the types of wound dressings or the frequency of dressing changes and observations. The plan omitted interventions to prevent further worsening of heel ulcers, such as elevating the heels or using heel boots. It also failed to include any information about the ordered wound vac, including monitoring for an intact seal, assessing for infection, bleeding, or fluid leakage. Additionally, the care plan did not address the type of mattress the resident should use. During review of the pressure ulcer care plan with the DON, the DON acknowledged that the care plan was not comprehensive for the resident’s pressure wounds present on admission.
Failure to Continue Prescribed Post-Hospital Antibiotic Therapy
Penalty
Summary
Facility staff failed to provide ordered treatment and care by not administering a prescribed antibiotic following a resident’s hospital discharge. The resident was admitted with hemiplegia and hemiparesis after a cerebral infarction affecting the left dominant side and had been diagnosed with a urinary tract infection in the hospital, for which Amoxicillin 500 mg three times daily was initiated. The hospital discharge summary specified that this Amoxicillin regimen was to be continued for an additional five days after discharge. Review of the resident’s January 2026 MAR showed no evidence that the Amoxicillin was administered upon admission. During interviews, the DON acknowledged reviewing the discharge summary and initially believing the antibiotic had been given in the hospital, and another staff member stated that the facility’s process includes a second-day chart check for new admissions and believed the antibiotic order was missed.
Concurrent Administration of Eliquis and Xarelto Due to Medication Order Errors
Penalty
Summary
The facility failed to ensure a resident remained free from significant medication errors when both Eliquis and Xarelto were ordered and administered contrary to the hospital discharge instructions. The resident was admitted with diagnoses including STEMI, congestive heart failure, atrial fibrillation, chronic embolism and thrombosis of deep veins, and hypertensive heart disease with heart failure. The hospital discharge summary documented that Eliquis had been changed to Xarelto, with a loading dose of Xarelto 15 mg twice daily starting on 12/7/2025 and a planned transition to Xarelto 20 mg daily on 12/29/2025. Upon admission, Xarelto was ordered as directed; however, multiple Eliquis orders were subsequently entered and then discontinued on 12/10/2025, 12/11/2025, and 12/15/2025. The DON stated that the Eliquis order was stopped and restarted to change the indication from DVT to atrial fibrillation. The LPN supervisor reported that the Eliquis orders were created by the pharmacy and verified with the provider, but he could not explain why they were created. The Unit Manager RN acknowledged that the resident was supposed to be on Xarelto per the hospital discharge orders and identified the Eliquis orders as errors on multiple dates, contacting the provider to verify the correct Xarelto order and discontinuing Eliquis each time. Despite these discontinuations, Eliquis continued to appear on the MAR. Review of the December 2025 MAR showed that on 12/16/2025 at the 9:00 AM medication pass, the resident received Eliquis 5 mg along with Xarelto 15 mg, resulting in the administration of both anticoagulants. LPN #18 confirmed administering both medications as documented. The DON later confirmed, upon review of the MAR, that the resident received both Xarelto and Eliquis during that medication administration, and that the resident should have remained on Xarelto per the hospital discharge orders. The administration of both anticoagulant medications increased the resident's risk for bleeding.
Incomplete and Inaccurate Medical Record Documentation for Two Residents
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 with paraplegia, multiple stage 4 pressure ulcers, local skin infection, and severe protein-calorie malnutrition, the medical record initially contained only a few wound notes despite weekly wound care visits. The wound care NP reported that the facility changed electronic systems and that prior wound notes had not transferred into the EMR; the DON later produced printed wound notes that had not been in the record. For the same resident, a change-in-condition note documented hypotension and critical labs with normal respiratory rate and oxygen saturation and no mention of breathing problems, while hospital records from the same day documented shortness of breath and use of a non-rebreather mask at 15 L/min. The RN who sent the resident out stated the resident was having respiratory issues and acknowledged he failed to document this. Additional documentation gaps for this resident included incomplete GNA task records for colostomy output, despite an order to monitor bowel movements every shift. Several shifts in December, January, and February lacked documentation of bowel movements, and the DON stated that if tasks were not signed off, they were not done. A complaint alleged the resident could not keep food down; although there was a PRN order for ondansetron for nausea and vomiting and staff and the physician both recalled an episode of vomiting, there was no nursing documentation of nausea or vomiting in the medical record. Another complaint alleged the facility failed to hold mandated care plan meetings; while there was a letter inviting the family to a care plan meeting on a specific date, there was no documentation in the medical record that the meeting occurred, and the regional social worker confirmed there were no social work notes and that the meeting should have been documented in the assessment section. For a second resident admitted in October 2025, the medical record did not contain documentation that a care plan meeting was held after admission. The EMR’s miscellaneous section contained only a care plan invitation letter for a meeting scheduled in January 2026, with nothing documented for the months immediately following admission. The regional social worker confirmed there was no documentation related to a post-admission care plan meeting for this resident and that only the January meeting notes could be found. These omissions collectively demonstrate that the facility did not maintain complete, accurate, and properly filed medical record documentation for assessments, treatments, changes in condition, and care plan meetings for the residents reviewed.
Failure to Maintain Effective Pest Control Program
Penalty
Summary
The facility failed to maintain an effective pest control program, as evidenced by multiple documented sightings of roaches, mice, ants, spiders, water bugs, flies, and gnats in various patient care areas, medication rooms, break rooms, laundry, conference rooms, and shower rooms. The pest problem logs reviewed by the surveyor showed repeated entries of pest infestations over several months, including in resident rooms and critical care areas. These logs indicated that the issue was ongoing and widespread throughout the facility. During interviews, the Nursing Home Administrator acknowledged the presence of roaches and rodents in the facility, attributing the problem to the building's age and its location near woods and water. Despite the facility having a pest management company, the logs and staff interviews confirmed that pest sightings continued to occur, and a complaint had been filed regarding the infestation. The surveyor verified and confirmed the presence of pests during the investigation, establishing that the facility's pest control measures were not effective in preventing or addressing infestations.
Failure to Timely Report Alleged Abuse, Neglect, and Theft
Penalty
Summary
The facility failed to ensure timely reporting of alleged abuse, neglect, exploitation, or mistreatment of residents to the appropriate authorities, as required. Multiple residents reported incidents of staff being rough, making hurtful statements, refusing care, and other forms of mistreatment. In several cases, residents reported these concerns to staff or surveyors, but there was no documented evidence that the facility initiated timely investigations or reported the allegations to the Office of Health Care Quality (OHCQ) within the required timeframes. For example, two residents alleged that a nurse was rough and had a poor attitude, but the concerns were not reported to OHCQ, and there was no documentation of a timely investigation. Another resident reported that a GNA made derogatory comments about their weight and delayed providing care, but these incidents were not reported as abuse or neglect to OHCQ, and the actions taken were only documented as customer service issues. Additionally, the facility failed to report an incident of alleged theft in a timely manner. A resident's cellphone went missing, and although staff were notified on the day of the incident, the report to OHCQ was not made within the required 24-hour period. In another case, a resident alleged being pushed into bed by a GNA, but the initial self-report to OHCQ was not made within the mandated 2-hour window. Furthermore, a resident reported ongoing issues with a roommate to a GNA, but the allegation was not reported to the state agency, and the facility only addressed the issue internally by arranging a room change. Interviews with facility leadership, including the DON and NHA, revealed a lack of consistent understanding and execution of reporting requirements. In several instances, staff acknowledged that incidents were not reported as abuse or neglect, and documentation was either lacking or delayed. The facility's failure to recognize, document, and report these allegations in a timely manner resulted in noncompliance with regulatory requirements for reporting suspected abuse, neglect, or theft.
Failure to Timely Investigate and Document Abuse Allegations
Penalty
Summary
The facility failed to thoroughly investigate and document allegations of abuse in a timely manner for multiple residents. In several instances, residents reported that staff were rough, mean, or made inappropriate comments during care. For example, two residents reported that a nurse was rough and had a poor attitude, but there was no evidence that the facility conducted a timely or thorough investigation after these concerns were reported to a unit manager and later to the Director of Nursing (DON). The only documentation provided was a single statement form, with no further evidence of interviews, assessments, or protective measures taken while the investigation was pending. Another resident reported that a Geriatric Nursing Aide (GNA) made hurtful comments about the resident's weight and was rude during care. Although the incident was documented as a concern, there was no evidence that the facility conducted a thorough investigation, assessed the resident, or interviewed staff and residents in a timely manner. The Nursing Home Administrator (NHA) acknowledged that the incident was not treated as abuse and that the GNA was only verbally instructed not to return to the resident's room. Additional incidents included a resident calling 911 to report being aggressively grabbed by a nurse, with a significant delay in conducting required assessments after the NHA was notified. In another case, a family member reported aggressive care by a GNA, but the resident's assessment was not completed until the following day. The DON confirmed that immediate assessments and investigations were not performed as required in these cases.
Failure to Maintain Safe, Clean, and Homelike Environment
Penalty
Summary
Surveyor observations and resident interviews revealed that the facility failed to maintain a safe, clean, comfortable, and homelike environment for its residents. In two separate rooms, residents reported persistent issues with flies and gnats, which were also directly observed by the surveyor at multiple times during the facility tour. A complaint had previously documented problems with pest control, including ants, fruit flies, gnats, and mice. The Maintenance Director confirmed that routine checks of resident rooms were not performed unless an issue was reported, and that fly traps and spraying were not permitted in resident rooms. The Administrator acknowledged the ongoing pest issue and indicated that pest control services were in place, but could not specify the frequency of visits or provide immediate evidence of effective pest management. Despite some pest control measures, the presence of flies and gnats persisted in resident rooms at the time of the survey. In a separate incident, a complaint and subsequent observation of another resident's room revealed that the room had not been painted in years, with visible old paint where items had been removed from the walls. The bathroom faucet was corroded, plaster on the walls was loose and flaky, a ceiling tile was ajar, and the light above one bed was not functioning due to a missing bulb and pull cord. The resident confirmed the light had not worked for some time. The Nursing Home Administrator agreed that these conditions did not constitute a comfortable, homelike environment.
Staff Misappropriation of Resident Funds
Penalty
Summary
Facility staff failed to protect a resident from misappropriation of property when a Geriatric Nursing Assistant (GNA) used the resident's bank card and account information to access funds for personal benefit. The GNA admitted to withdrawing $100 at the resident's request, but denied making other withdrawals. However, a police investigation revealed 28 transactions over several months, with the GNA's name associated with withdrawals via a cash app. Bank records showed two significant withdrawals to the GNA's cash app prior to his termination. The resident confirmed that the staff member used their bank card and stated there had been no further incidents since the last event. The facility administrator was unaware of the GNA's actions until after the staff member's termination and could not confirm whether the withdrawn funds were given to the resident. The administrator also did not know the reason for the GNA's termination and was unable to provide a clear policy regarding staff obtaining money for residents. Facility policy prohibits misuse or abuse of nursing home funds, dishonesty, theft, and misrepresentation, but the events indicate that these policies were not effectively enforced in this case.
Incomplete Discharge Documentation for Resident
Penalty
Summary
The facility failed to ensure that discharge documentation for a resident was fully completed. Upon review of the resident's closed medical record, it was found that several sections of the Engage Discharge Planning Tool were left blank, including responsible parties' information, primary physician information, staff and resident or responsible party signatures, and the medication list. Additionally, the section regarding whether a pharmacy printout of the medication regimen was attached was not completed, and no medication list or indication of its status was present in the record. Interviews with facility staff revealed that the discharge paperwork is typically initiated by the social worker and completed by various disciplines, including the physician, nurse, rehab, activities, and dietician. The unit manager stated that medication lists are not routinely printed out, and new prescriptions are provided to residents on paper. The social worker confirmed that all sections of the discharge planning tool should be completed before the resident or responsible party receives the paperwork. The Director of Nursing acknowledged the concern when informed of the incomplete documentation, and no additional documentation related to the resident's discharge was provided.
Failure to Provide and Document Baseline Care Plans Upon Admission
Penalty
Summary
The facility failed to ensure that a baseline care plan (BLCP), including a current list of medications, was provided to residents and/or their representatives and documented in the medical record within 48 hours of admission. For two residents reviewed, there was no evidence in the electronic health record (EHR) that the BLCP was present under the designated section, nor was there documentation that the BLCP had been provided to the resident or their representative. In one case, a resident with severely impaired cognition, as indicated by a BIMS score of 0, had a BLCP signed by the resident instead of the representative, contrary to facility expectations. The Director of Nursing (DON) confirmed that the required documentation and signatures were missing and that the BLCP was not properly scanned into the EHR. In another instance, a resident with dementia and a BIMS score of 2 had a BLCP with missing signatures from both the staff and the resident or representative, and there was no evidence that the BLCP or medication list had been provided. The DON and Regional Director of Clinical Operations (RDCO) verified that the required fields were incomplete and that the documentation process had not been followed as expected. These findings were based on medical record reviews and staff interviews conducted during the recertification survey.
Failure to Prevent Unjustified Decline in ADL Abilities
Penalty
Summary
Residents experienced a decline in their ability to perform activities of daily living (ADLs) without a documented medical reason to justify the loss. The facility failed to ensure that residents maintained their ADL abilities unless a medical condition necessitated the decline, as required by regulations.
Failure to Provide Safe and Appropriate Pain Management
Penalty
Summary
The facility failed to provide safe and appropriate pain management for three residents, as evidenced by lack of pain monitoring, failure to schedule necessary pain management appointments, and improper administration of pain medications. One resident, following hospital discharge, was recommended to follow up with a pain management clinic and spine specialist. Although physician orders and a pain care plan were in place, there was no evidence that pain was monitored or recorded every shift, and the resident did not have a scheduled appointment with the pain specialist until after surveyor intervention. The resident continued to experience pain and was unaware of any scheduled follow-up, indicating a breakdown in communication and care coordination. Another resident was administered PRN pain medication even when their pain level was documented as zero, and there was no evidence that non-pharmacological interventions were attempted prior to medication administration. The physician's order did not include non-pharmacological interventions, and the Medication Administration Record did not reflect their use. The DON confirmed that pain medication should not be given when pain is absent and that non-pharmacological interventions should be implemented, but these standards were not followed. A third resident with chronic pain and opioid dependence had PRN orders for both acetaminophen and oxycodone without specific pain scale parameters. Review of records showed inconsistent pain management, with medications given for pain scores that did not align with best practices (e.g., oxycodone for a pain score of 1). There was also no documentation of non-pharmacological interventions prior to medication administration. Staff interviews confirmed that pain medications should be administered according to pain severity and that non-pharmacological interventions should be attempted and documented, but these practices were not consistently followed.
Incomplete and Inaccurate Medical Record Documentation for Two Residents
Penalty
Summary
The facility failed to maintain complete and accurate medical records for two residents, as required by professional standards. In the first instance, a resident who had returned from a leave of absence was administered a one-time dose of Narcan after exhibiting unresponsiveness and excessive drowsiness. Although the administration of Narcan was documented in the nursing progress notes, the Medication Administration Record (MAR) for the month did not include documentation of the Narcan administration. Additionally, there was no documented evidence that the resident’s behavior was being routinely monitored following the event. In the second instance, another resident was admitted with a therapeutic boot and had an orthopedist consultation recommending continued use of the boot for weight bearing as tolerated. However, there was no evidence in the clinical record that nursing staff documented the use of the boot on the Treatment Administration Record, despite the expectation that such recommendations would be followed. These omissions resulted in incomplete and inaccurate medical records for both residents.
Failure to Provide Timely Abuse Education to Newly Hired GNA
Penalty
Summary
The facility failed to provide required abuse education to a geriatric nursing assistant (GNA) upon hire, as evidenced by a review of staff training records and administrative interviews. One GNA, who was later falsely accused of sexual abuse by a resident, was hired and began caring for residents before completing mandatory training in infection control, dementia care, and abuse prevention. The training was not completed until nearly two months after the hire date, despite facility policy requiring such education during orientation. The Nursing Home Administrator confirmed that the staff member worked with residents prior to completing the required training.
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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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