Friends Nursing Home
Inspection history, citations, penalties and survey trends for this long-term care facility in Sandy Spring, Maryland.
- Location
- 17340 Quaker Lane, Sandy Spring, Maryland 20860
- CMS Provider Number
- 215211
- Inspections on file
- 13
- Latest survey
- June 16, 2025
- Citations (last 12 mo.)
- 0
Citation history
Health deficiencies cited at Friends Nursing Home during CMS and state inspections, most recent first.
Surveyors found incomplete refrigerator temperature logs, improper storage of ice cream tubs on the freezer floor, and salad dressings lacking expiration dates. During a follow-up, cold food items such as cheese, eggs, turkey, and hot dogs were stored above the required 41°F, indicating failures in food storage and temperature monitoring.
Surveyors found that multiple resident rooms had missing cove base in bathrooms, gaps between walls and floor tiles, black patches of growth, stained and missing floor tiles, and a lack of enclosed space for hanging clothing. These deficiencies were observed during facility rounds and confirmed in staff interviews, with the administrator noting that repairs had been delayed due to supply back orders following flood damage.
A resident with bilateral hand contractures and limited range of motion did not have a care plan addressing the use of hand splints or OT interventions. The interdisciplinary team, including nursing and OT staff, did not collaborate to create or update a care plan reflecting the resident's needs and therapy goals, despite documentation of contractures and the use of new orthotic devices.
A resident with hand contractures and limited range of motion did not have an updated care plan reflecting OT interventions or the use of hand/wrist splints. Despite OT involvement and recommendations, the care plan was not revised, and nursing staff used alternative measures such as rolled washcloths. The DON and Director of Rehabilitation confirmed the absence of a care plan addressing these needs.
A resident with limited mobility and a sacral wound experienced ongoing, unmanaged pain, including episodes of screaming and complaints of burning, despite having orders for scheduled and PRN pain medication. Staff failed to administer as-needed Tramadol for several days and did not consistently follow the care plan for pain management, resulting in inadequate relief and documentation of the resident's pain.
A resident with a stage IV pressure ulcer requiring Enhanced Barrier Precautions was not clearly identified within a shared room, and staff were unaware of which individual required these precautions. Additionally, the facility's Antibiotic Stewardship policy had not been reviewed or updated annually as required, with no documentation of review since 2018.
Surveyors found that call bell boxes in two resident rooms were hanging from the wall with exposed wires, indicating that essential equipment was not kept in safe operating condition. This was confirmed by the NHA, who stated that maintenance addresses such issues when they occur.
Two residents experienced serious injuries—one with burns from spilled hot coffee and another with multiple fractures of unknown origin. In both cases, the facility did not report the incidents to authorities within the required two-hour window and failed to complete investigations within five days, as mandated.
A resident reported being physically abused by a staff member, but the facility failed to notify the state survey agency within the required two-hour timeframe. The resident, with a history of serious medical conditions, reported the incident to a therapist, but the notification to the Administrator and subsequent report to the state agency were delayed, violating the facility's policy and the Elder Justice Act.
A resident was administered medicated eye drops intended for post-surgery use, despite the surgery not occurring. The error was due to a lack of communication and awareness among staff, including an LPN and the Assistant Director of Nursing, who followed the MAR without verifying the surgery status. The issue was identified after the previous DON informed the staff involved.
Deficient Food Storage and Temperature Monitoring
Penalty
Summary
Surveyors identified multiple failures in food storage, monitoring, and service during kitchen inspections. Temperature logs for all seven refrigerators were found to be incomplete for two consecutive shifts. In the walk-in freezer, nine large tubs of ice cream were observed stored directly on the floor. Additionally, in the walk-in refrigerator, two containers of salad dressing were labeled only with handwritten dates on the lids, lacking any expiration or use-by dates. During a follow-up visit, cold food items at the deli holding station and its refrigerator were found to be stored above the required 41°F, with temperatures ranging from 41.7°F to 44.0°F for various items including cheese, hard-boiled eggs, turkey, and hot dogs. These findings were confirmed through direct observation and temperature checks with facility staff.
Deficient Environmental Maintenance in Resident Rooms
Penalty
Summary
Surveyors observed that the facility failed to maintain a homelike environment for residents, as evidenced by multiple deficiencies in 13 resident rooms. Specifically, bathrooms in these rooms were missing cove base around the entire perimeter, resulting in a half-inch gap between the wall and floor tiles. In one bathroom, black patches of growth were noted at the rear base of the toilet, extending from the missing cove base area up the wall, with exposed and peeling paint. Additionally, floor tiles in one room were stained brown and rust in color near the head of the bed, and several rooms had missing floor tiles with exposed cement flooring. One room lacked an enclosed space for hanging clothing for resident use. During an interview, the Nursing Home Administrator stated that the cove base had been on back order for about a year due to flood damage that occurred approximately a year prior. These observations were made during facility rounds and interviews, and all findings were directly related to the physical environment and its failure to meet standards for safety, cleanliness, and comfort as required for residents.
Failure to Develop and Update Care Plan for Resident with Hand Contractures
Penalty
Summary
The facility failed to create, revise, and update a comprehensive care plan in a timely manner for a resident with significant physical limitations. Specifically, the resident was observed with bilateral hand contractures and was using white knit tube stockings on both arms, but was not wearing hand splints. The resident required maximum assistance with eating and drinking and was non-verbal at the time of observation. Review of the electronic medical record revealed that there was no care plan addressing the use of hand splints or occupational therapy (OT) interventions related to the resident's limited range of motion. Further investigation showed that the OT staff had not participated in any care plan meetings with the interdisciplinary team since a specified date, and there was no care plan referencing the use of bilateral hand orthotics or splints. The OT evaluation and plan of treatment documented a diagnosis of contractures of the bilateral hands and wrists, with a goal for the resident to tolerate bilateral hand orthotics without skin changes. However, there was no evidence that the interdisciplinary team, including nursing, had created a care plan reflecting these OT goals or the use of the new air pump style splint, which also lacked a physician order.
Failure to Update Care Plan for OT Interventions and Hand Splint Use
Penalty
Summary
The facility failed to revise and update a resident's care plan in a timely manner following the initiation of occupational therapy (OT) interventions for hand contractures. The resident, who was non-verbal and required maximum assistance with eating and drinking, was observed with white knit tube stockings on their contracted hands and arms, but was not wearing prescribed hand splints. Review of the electronic medical record revealed that there was no care plan addressing the use of hand splints or OT interventions for the resident's limited range of motion, despite OT involvement beginning over two months prior. The annual MDS assessment, which documented functional limitations in range of motion, had been completed, but the care plan was not updated to reflect the resident's current needs or the OT recommendations. Interviews with the DON confirmed that nursing staff were responsible for applying the splints and that OT had started working with the resident, but interventions such as rolled washcloths were being used instead. The DON acknowledged that interventions for the resident's hand contractures should have been included in the care plan and updated as OT recommendations changed. Further, the Director of Rehabilitation stated that rehabilitation staff had not participated in care plan meetings and that there was no care plan created in collaboration with nursing regarding the hand splints. The lack of an updated care plan persisted throughout the period of OT intervention.
Failure to Provide Timely and Appropriate Pain Management
Penalty
Summary
The facility failed to provide safe and appropriate pain management for a resident who required such services, as evidenced by multiple observations and interviews. The resident, who had limited physical mobility and a sacral wound, was observed on several occasions expressing significant pain, including verbal complaints of burning and screaming that could be heard in the hallway. The resident's son reported that the resident frequently complained of pain, especially when wet, and expressed dissatisfaction with the timeliness of care. On one occasion, the resident used the call bell due to pain but expressed fear that staff would not respond. Although a nurse responded within three minutes and acknowledged the resident's ongoing pain, it was revealed that the resident had not received their as-needed Tramadol for several days, despite ongoing complaints of pain. Review of the resident's care plan indicated that pain medication was to be administered as ordered, with effectiveness evaluated and side effects monitored. The care plan also specified offering pain medication prior to wound care and documenting and reporting pain complaints. However, the resident's pain was not managed according to these standards, as evidenced by the lack of timely administration of prescribed pain medication and insufficient evaluation of pain relief. Staff interviews confirmed that the resident was frequently in pain, and the care plan interventions were not consistently implemented.
Failure to Maintain Infection Control Precautions and Annual Policy Review
Penalty
Summary
The facility failed to maintain proper infection prevention and control practices in two key areas. During observation rounds, an Enhanced Barrier Precautions sign was posted on the door of a resident room, but there was no indication as to which resident within the shared room the precautions applied to. When interviewed, a GNA staff member was unable to identify which resident required the enhanced barrier precautions. Review of medical records revealed that a resident in the room had a facility-acquired stage IV pressure ulcer requiring these precautions, but this information was not clearly communicated or identified for staff. Additionally, the facility did not conduct an annual review of its Infection Prevention and Control Program (IPCP), specifically the Antibiotic Stewardship policy. The policy was last revised in August 2018 and was due for review in August 2019. When asked for documentation of annual review, the administrator was unable to provide any evidence that the policy had been reviewed or updated since 2018, only noting that updating policies was an area needing attention.
Failure to Maintain Safe Call Bell Equipment
Penalty
Summary
Surveyors observed that essential equipment, specifically call bell boxes, were not maintained in safe operating condition in two out of thirteen resident rooms reviewed. During observation rounds, call bell boxes were found hanging from the wall with blue wires exposed. This deficiency was identified through direct observation and confirmed during an interview with the Nursing Home Administrator, who acknowledged that maintenance repairs the call boxes when they are dislodged.
Failure to Timely Report and Investigate Serious Injuries
Penalty
Summary
The facility failed to timely report allegations involving serious bodily injury and did not complete investigations within the required timeframes. In one incident, a resident sustained second-degree burns with clustered blisters on the left thigh after spilling hot coffee during breakfast. The incident occurred on 1/14/25, but the facility did not begin its investigation until 1/16/25 and did not report the incident to the State Survey Agency until 1/21/25, which exceeded the required two-hour reporting window for serious injuries. Additionally, the facility did not complete and submit the investigation report within the mandated five-day period, as the closure was not reported until 1/29/25. In another case, a resident was found with bruising and diagnosed with a displaced clavicle fracture and multiple rib fractures. The facility became aware of these injuries on 2/10/25, but did not submit the initial Facility Reported Incident (FRI) to the Office of Health Care Quality until the following day, missing the two-hour reporting requirement. The resident, who had moderate cognitive impairment and spoke Bengali, denied falling or being abused, and staff reported no witnessed falls or incidents. Despite the injuries being of unknown origin, the facility did not adhere to the required reporting timeframe.
Delayed Reporting of Abuse Allegation
Penalty
Summary
The facility failed to report an allegation of abuse to the state survey agency within the required two-hour timeframe. The incident involved a resident who reported being physically abused by a staff member. The resident, who had a medical history including dissection of the carotid artery, nontraumatic subarachnoid hemorrhage, hypertension, and anxiety disorder, was admitted to the facility on January 4, 2024. The resident had intact cognition and required partial/moderate assistance with various activities of daily living. On January 5, 2024, the resident reported to a physical therapist that they were struck four times on the arm by a staff member the previous night. This report was documented by the Assistant Director of Nursing at 11:51 AM. Despite the facility's policy requiring immediate reporting of abuse allegations, the state survey agency was not notified until 8:00 PM, over eight hours after the initial report was documented. The facility's Administrator was informed of the allegation at 6:00 PM, after leaving the facility, and subsequently filed the report. The delay in reporting violated the facility's policy and the Elder Justice Act, which mandates that abuse resulting in serious bodily injury be reported within two hours of knowledge. This deficiency highlights a failure in the facility's abuse reporting protocol, as staff did not notify the Administrator promptly, leading to a delayed report to the state survey agency.
Failure to Follow Physician's Order for Post-Surgical Eye Drops
Penalty
Summary
The facility failed to adhere to a physician's order regarding the administration of medicated eye drops for a resident who was scheduled for cataract surgery. The order specified that the eye drops were to be administered three times daily for seven days following the surgery. However, the eye drops were administered prior to the surgery, which never occurred. This error was documented in the Medication Administration Record (MAR) and was carried out by multiple staff members, including the Assistant Director of Nursing and a licensed practical nurse. Interviews with staff revealed a lack of communication and awareness regarding the resident's surgical status. The licensed practical nurse and the Assistant Director of Nursing both administered the eye drops under the assumption that the surgery had taken place, as the order was present on the MAR. The error was only discovered after the previous Director of Nursing informed the staff involved. The current Director of Nursing acknowledged that the orders were not followed as written, and the facility's Administrator confirmed that the eye drops should not have been administered.
Latest citations in Maryland
The facility did not ensure that its Infection Preventionist (IP) met required qualifications for managing the Infection Prevention and Control Program. The DON reported serving as the IP but acknowledged lacking the specialized infection control training required for the role, and confirmed that no other staff member was currently qualified. Records showed that the previously qualified IP left several months earlier, and the Administrator and DON confirmed they were still seeking a replacement, leaving the infection control program without a properly trained leader.
Staff failed to consistently secure medications and medical supplies across three units, including an oxygen tank left on the floor behind a resident’s bed without a supporting device, a treatment cart with Collagenase Santyl cream left on top while two residents in power wheelchairs passed by, an unattended and unlocked treatment cart at a nursing station, and another treatment cart with Diclofenac gel and dressings left on top, indicating repeated lapses in maintaining locked and secure storage for drugs, biologicals, and related supplies.
The facility failed to provide sufficient dietitian coverage and timely nutritional assessments for several residents with significant dietary needs. A resident admitted for diabetic management with a high A1C was placed on a regular diet instead of the recommended carb-controlled diet and had only one weight taken in the first two weeks, with no dietitian review of the record. Another resident with prior significant weight loss had no documented dietitian follow-up despite continued weight loss, and a resident admitted with severe protein-calorie malnutrition experienced further significant weight loss without any dietitian assessment. The dietitian reported working limited hours and prioritizing certain high-risk cases, resulting in delayed or missed evaluations for new admissions and residents with ongoing nutritional concerns.
The facility failed to maintain adequate linen and incontinence supplies and did not keep resident care areas in good repair, resulting in delays and alterations in incontinence care and substandard environmental conditions. Staff reported that towels and washcloths were used instead of wipes and then discarded due to heavy soiling, and that linen deliveries to units were late, leaving residents waiting for care. Observations showed very limited numbers of clean washcloths and other linens on units and in the laundry, with no stock of disposable wipes or backup washcloth supply despite repeated reports to housekeeping. Additional observations revealed recliner chairs blocking a dining-area handwashing sink and kitchenette, multiple resident and shared bathrooms with unfinished spackle, chipped paint, musty odors, black substances near showers, missing threshold molding, exposed cracks and nails, and eroded, rusted baseboard heaters. Hallway handrails on both units were worn, chipped, and splintered, and a shower room contained fecal odors, dried brown stains on the toilet, and deteriorated fixtures, all contributing to a failure to provide a safe, clean, and homelike environment.
Facility staff did not thoroughly investigate two separate abuse allegations involving a resident and an injury of unknown origin involving another resident. In both cases, investigations focused on the directly affected resident and included staff interviews, but there were no interviews of other residents on the unit or documented assessments of those residents for signs of abuse or injuries of unknown origin, including residents unable to communicate due to cognitive status.
Two residents who were dependent on staff for oral care, including one with a tracheostomy, were observed with thick, white or milky substances coating their mouths and teeth, indicating inadequate oral hygiene. One resident communicated that staff did not brush their teeth and that staff "need to." In another case, despite oral care supplies being present in the room, the resident’s mouth and teeth remained unclean on multiple observations, with a thick milky substance caking the teeth and stringing between them when the resident tried to open their mouth. These findings showed that staff did not consistently provide oral care to residents who relied on them for this ADL.
Staff failed to maintain complete and accurate medical records for multiple residents, including missing and inconsistent documentation of wound care, delayed pain assessment after discovery of an injury of unknown origin in a cognitively impaired resident, and inaccurate recording of a PPD test result that was documented as negative despite no evidence the injection was administered and no supporting nurse’s note. Residents reported not receiving certain treatments, while MAR entries either lacked signatures for completion or contained conflicting information about whether care was provided.
Surveyors found that the facility failed to consistently implement and communicate correct transmission-based precautions and PPE use. One resident with a Foley catheter related to wounds had no precaution signage posted, while another resident in a double room had a contact precautions sign at the door, yet the NP entered without PPE and the GNA provided high-contact care wearing only gloves. Staff in that room stated the resident was not on contact precautions and later reversed the sign to show no PPE requirement. Therapy staff reported they rely solely on posted signs to determine PPE, and surveyors identified broader issues with inaccurate signage and staff awareness of which residents required contact precautions.
Surveyors found that MDS assessments were inaccurately coded for two residents. In one case, a resident sustained a femoral neck fracture after a fall, but the subsequent significant change MDS did not code the fall as a major injury and failed to capture prn Tylenol use documented on the MAR within the look-back period. In the other case, a quarterly MDS indicated opioid use for a resident, but the MAR for the same period showed no prescribed opioid, indicating incorrect coding of high-risk drug classes.
A resident who had recently been admitted and experienced a fall received multiple doses of the narcotic analgesic Tramadol, but the facility failed to accurately document all administered doses on the Medication Administration Record (MAR). Review showed only one Tramadol dose recorded on the MAR, while the Controlled Drug Receipt/Record/Disposition Form on the med cart reflected three doses given over two days. In interview, the DON stated staff are expected to document narcotic administration on the MAR and confirmed that two administered doses were not recorded there, resulting in an incomplete and inaccurate medical record.
Unqualified Infection Preventionist Overseeing Infection Control Program
Penalty
Summary
The facility failed to ensure that its designated Infection Preventionist (IP) met the mandatory qualifications for overseeing the Infection Prevention and Control Program. During an interview on 3/24/26 at 10:00 AM, the DON confirmed that she/he was serving as the facility’s IP but had not completed the specialized training in infection control required for the position. The DON further stated that no other staff member currently met the qualifications to serve as IP. Record review showed that the previously qualified IP left the facility in October 2025, and as of the survey date, the position remained unfilled by a qualified individual. At 1:30 PM on the same day, the Administrator and DON confirmed they were still in the process of finding a qualified IP for the facility, leaving the Infection Prevention and Control Program without a properly trained and qualified leader. No specific residents, medical histories, or clinical conditions were described in relation to this deficiency.
Unsecured Medications, Treatment Carts, and Oxygen Equipment
Penalty
Summary
Facility staff failed to ensure that drugs, biologicals, and related medical supplies were securely stored and properly maintained on multiple units. On one unit, an oxygen tank assigned to a resident was observed sitting on the floor behind the resident’s bed without any supporting device. On another unit, a treatment cart was observed with a tube of Collagenase Santyl cream labeled for a specific resident left on top of the cart, while residents in power wheelchairs passed by and staff were present at the nursing station. These observations showed that medications and oxygen equipment were not consistently secured as required. Further observations on additional units revealed an unattended and unlocked treatment cart at a nursing station, and on a separate occasion, a treatment cart with Diclofenac gel labeled for a resident left on top along with multiple packs of dressings. These incidents occurred across three units and on more than one date, demonstrating repeated failures to keep medications and treatment supplies in locked compartments or otherwise secured from unauthorized access.
Insufficient Dietitian Coverage and Delayed Nutritional Assessments
Penalty
Summary
The deficiency involves the facility’s failure to employ sufficient food and nutrition staff, including adequate dietitian coverage, to ensure timely assessment and appropriate diets for residents with significant nutritional and diabetic needs. A resident admitted over two weeks earlier with multiple comorbidities and an A1C of 11.5% had a hospital discharge recommendation for a carbohydrate-controlled diet, but was placed on a regular diet at admission with no acknowledgment of the recommended diet until one week later, when the resident requested larger portions. As of the survey date, the dietitian had not yet seen or reviewed this resident’s medical record, and the resident reported not having seen a dietitian and being very frustrated with the meals. During the first two weeks after admission, only one weight was obtained for this resident, despite physician notes stating the resident’s weight was “stable.” Further review of other residents showed additional failures in timely dietitian assessment and follow-up. One resident, readmitted in January and previously seen by the dietitian in September for a 6.4 lb weight loss over 30 days, had no documented follow-up despite continued weight loss totaling 22 lbs since the last dietitian review. Another resident admitted at the end of February with severe protein-calorie malnutrition had not been seen by the dietitian after about a month in the facility, despite a documented 14 lb (7%) weight loss over two weeks. The dietitian reported working only 12 hours per week at the facility and stated that she must prioritize which residents to see, focusing first on residents with tube feedings and those identified in risk meetings, resulting in delayed or absent assessments for new admissions and residents with ongoing weight loss and malnutrition diagnoses.
Linen Shortages and Poor Environmental Maintenance Compromise Resident Care and Comfort
Penalty
Summary
The deficiency involves the facility’s failure to maintain an adequate supply of clean linens and appropriate incontinence wipes, resulting in delays and alterations in residents’ incontinence care, as well as the use of towels and washcloths in place of disposable wipes. During the initial tour, the surveyor observed that the linen supply on one nursing unit hallway was low. Complaint reviews included concerns about delays in incontinence care and bed linens not being changed regularly, with residents left without clean bedding. A complainant reported that there was not enough clean linen available for residents. Staff interviews confirmed that towels, sheets, and washcloths were being used to wipe residents for incontinence care due to the absence of wipes, and that many of these linens were being thrown away when soiled. Staff also reported a shortage of linen, that linen deliveries to the units were late, and that residents who preferred to get up before breakfast had to wait for care when linen was delayed. Further observations showed that the clean supply room contained no disposable wipes or cloths for incontinence care, and a resident reported that staff did not use wipes, that the resident had to purchase their own, and that heavily soiled towels or washcloths were discarded. A tour of all nursing unit linen carts and closets revealed only six clean washcloths and limited supplies of towels, gowns, and bed linens. In the laundry room, only three washcloths were present, and the laundry assistant stated that there were only three washcloths available for each nursing unit that morning, that the facility was short on linen supply, and that these concerns had been repeatedly reported to the Director of Housekeeping over the preceding month and again that morning. The laundry assistant confirmed there was no additional laundry in process. The DON stated that wipe squares should be used for incontinence care, but no such wipes were found in the clean medical supply room, and no backup supply of washcloths was present in the emergency linen supply. The Director of Housekeeping confirmed there was no backup supply of washcloths. The deficiency also includes environmental and maintenance issues affecting resident bathrooms, handrails, and common areas. In the main dining area, a recliner chair was observed positioned directly in front of the handwashing sink, and two recliner chairs were stored in front of the nutrition area kitchenette. Multiple resident bathrooms and shared bathrooms were repeatedly observed over several days with unfinished spackle on walls that needed resurfacing and painting, chipped paint around sinks, uneven boards nailed to walls under sinks that appeared to partially cover holes, musty odors, black substances between shower bases and walls, missing threshold transition molding exposing cracks, missing tiles, and a nail, as well as eroded and chipped paint on baseboard heaters with exposed dark brown metal and rust-like material. Hallway handrails on both nursing units were observed to be worn, with chips, splintering, holes, and areas where the wood finish had worn off. A shower room was observed with a foul fecal odor, dried brown stains on the back of the toilet seat and in the toilet bowl, and a baseboard heater with eroded, chipped paint and rust-like material, along with chipped paint on the handrail. These conditions were acknowledged by the Director of Maintenance and other leadership, and some areas were noted to be in the process of renovation, but the observed deficiencies remained present during the survey period. Overall, the facility did not maintain a safe, clean, comfortable, and homelike environment in good repair across both nursing units and the dining area. The lack of adequate linen and incontinence supplies, combined with the poor condition of resident bathrooms, handrails, and certain common areas, constituted the basis for the cited deficiency. The observations and staff and resident reports consistently described shortages of essential hygiene supplies, delayed care related to linen availability, and multiple unresolved environmental and maintenance issues in resident care areas and shared spaces.
Failure to Thoroughly Investigate Abuse Allegations and Injuries of Unknown Origin
Penalty
Summary
Facility staff failed to thoroughly investigate allegations of potential abuse involving one resident and an injury of unknown origin involving another resident. For one resident, there were two separate allegations of abuse occurring on different days in early February. The facility’s investigation packets included interviews with staff who cared for or were scheduled to work with this resident on the days of the alleged incidents, and the investigations focused solely on this resident. However, there were no interviews conducted with other residents on the unit to inquire about abusive or neglectful treatment by the staff who were working during the times of the allegations. The surveyors noted that, although the allegations were not validated, there was no documentation that other residents were interviewed, if able, or assessed for signs or symptoms of injury. In a separate incident, another resident was identified on March 4 with a new bruise on the right eye, documented as a change in condition at 4:09 AM. This resident had a BIMS score of 99, indicating the resident was unable to complete an interview and therefore could not report how the injury occurred. The facility’s investigation identified a potential cause of the injury but did not reach a definitive resolution. Additionally, there were no interviews of other residents on the unit regarding possible abuse, nor were there documented assessments of other residents for injuries of unknown origin, particularly for those unable to speak for themselves, as in this resident’s case.
Failure to Provide Oral Care to Dependent Residents
Penalty
Summary
The deficiency involves the facility’s failure to provide oral care to residents who were dependent on staff for activities of daily living, specifically oral hygiene. One resident with a tracheostomy was observed with a thick, sticky white substance in the mouth and was noted to intermittently chew on nearby bedding. This resident made good eye contact and, when asked if staff brushed their teeth, shook their head no and mouthed that staff “need to.” According to the resident’s Minimum Data Set (MDS) dated 2/11/26, the resident was dependent on staff for oral care. Another resident, also dependent on staff for oral care per the 3/11/26 MDS, was observed sitting propped up in bed and able to respond with smiles. During the initial observation, the inside of this resident’s lips and upper and lower teeth had a thick, clear, white milky substance visible when the resident tried to open their mouth to smile. Oral care supplies were present in the nightstand, but the resident’s mouth and teeth were not clean. On a subsequent observation with the DON, NHA, and Corporate VP of clinical services, the same resident again had a thick, clear, milky substance between the lips and caking the teeth, which would string between the teeth when the resident attempted to open their mouth, demonstrating a lack of consistent oral care for residents dependent on staff for this ADL.
Incomplete and Inaccurate Medical Record Documentation for Treatments and Assessments
Penalty
Summary
Facility staff failed to maintain complete and accurate medical records and documentation for multiple residents. For one resident with wound care needs, review of the MAR showed that wound care and related treatments were signed as completed on the dates initially reported, despite the resident’s ongoing complaints that wound dressings were not being changed. When additional dates were reviewed, there were missing staff signatures for wound care on two specific dates, as well as three instances where application of A&D ointment to the resident’s feet was not signed off out of 24 days reviewed. Another resident with severe cognitive impairment, as evidenced by a BIMS score of 00, was found to have an injury of unknown origin (a bruise on the left hand). Documentation showed that a change in condition was initiated late in the morning, but a formal pain evaluation was not initiated and completed until that night, and the resident was unable to explain how the injury occurred or verbalize pain using a standard pain scale. For a third resident, documentation related to the admission PPD test was inconsistent and incomplete. The MAR contained an entry indicating “9” for the administration date, meaning “see nurse’s note,” but there was no corresponding nurse’s note. Despite the absence of a signed administration of the PPD injection, staff documented the PPD result as “negative” on the scheduled read date. The resident reported never receiving the PPD injection, and the DON confirmed that the facility had been out of PPD solution at the time, so the test would not have been administered. These findings demonstrate failures in accurate documentation of treatments and assessments, including wound care, pain assessment, and TB screening, as well as missing or incomplete supporting notes in the medical record.
Failure to Implement and Communicate Correct Transmission-Based Precautions
Penalty
Summary
Surveyors identified a deficiency in the facility’s infection prevention and control program related to inconsistent and incorrect implementation of transmission-based precautions and PPE use. During a complaint investigation focused on residents on transmission-based precautions, one resident with a visible Foley catheter was observed in the room with physical therapy, but there were no signs posted indicating any need for PPE, despite the resident being a new admission with a Foley catheter placed related to wounds. In another double-occupancy room, a contact precautions sign was posted at the doorway, but the nurse practitioner was in the room on a personal phone with no PPE, and the assigned GNA was repositioning the resident in bed while wearing only gloves. When questioned, the NP, RN, and GNA all stated that the resident in the room was not on contact precautions, and the GNA reported that signs were hanging at all doors and that this particular resident’s sign was “just wrong.” The surveyor observed the GNA later return to the room and turn the sign around to indicate no PPE requirement. Subsequent interviews revealed that therapy staff relied on posted signage to determine PPE use and that if the sign was wrong, the PPE used would be wrong. Overall, surveyors found problems with signage accuracy and staff awareness of which residents required contact precautions, as well as observed failures to follow appropriate PPE use for residents who should have been on contact precautions.
Inaccurate MDS Coding for Falls, Pain Management, and High-Risk Medications
Penalty
Summary
Facility staff failed to ensure Minimum Data Set (MDS) assessments were accurately coded for two residents reviewed during a complaint survey. For one resident, a facility-reported incident showed that the resident was found seated on the floor beside the bed and was diagnosed with a non-displaced femoral neck impaction fracture of the left hip following an x-ray. Despite this fall with a major injury, the subsequent significant change MDS dated 11/4/25 did not code the fall with major injury in Section J1900C. Review of the resident’s Medication Administration Records for October and November 2025 showed administration of Tylenol on 10/31/25 at 9:30 PM, which fell within the 5-day look-back period for the MDS, but Section J0100 (prn pain) of the same significant change MDS did not capture the use of Tylenol. For another resident, review of a quarterly MDS with an assessment reference date of 10/15/25 showed that Section N0415 (High-Risk Drug Classes) documented the use of an opioid medication. However, review of the resident’s October 2025 Medication Administration Record did not show that the resident had been prescribed an opioid during that period. In both cases, MDS staff later confirmed that these were errors in MDS coding, demonstrating that the assessments did not accurately reflect the residents’ clinical status and medication use as documented in their medical records.
Incomplete Documentation of Narcotic Administration on MAR
Penalty
Summary
The facility failed to maintain complete and accurate medical records in accordance with accepted professional standards for one resident receiving narcotic medication. The resident, admitted in March 2026, had a fall on 3/6/26 and was sent to the hospital on 3/9/26. Review of the March 2026 Medication Administration Record (MAR) showed documentation of a single 25 mg dose of Tramadol administered on 3/8/26 at 9:23 AM. However, review of the resident’s Controlled Drug Receipt/Record/Disposition Form, kept on the nurse’s medication cart and not in the medical record, showed that Tramadol 25 mg was administered three times between 3/8/26 and 3/9/26: at 11:00 AM and 9:00 PM on 3/8/26, and at 9:00 AM on 3/9/26. In interview, the DON stated that staff are expected to document narcotic administration on the MAR and confirmed that only one of the three Tramadol doses reflected on the controlled drug record was documented on the resident’s MAR. This discrepancy between the controlled substance record and the MAR, with missing documentation of two administered doses of Tramadol on the official medical record, constituted the failure to maintain a complete and accurate medical record for the resident.
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