Frostburg Rehab Center
Inspection history, citations, penalties and survey trends for this long-term care facility in Frostburg, Maryland.
- Location
- 1 Kaylor Circle, Frostburg, Maryland 21532
- CMS Provider Number
- 215115
- Inspections on file
- 15
- Latest survey
- September 17, 2025
- Citations (last 12 mo.)
- 54
Citation history
Health deficiencies cited at Frostburg Rehab Center during CMS and state inspections, most recent first.
A resident with severe cognitive impairment and total dependence for transfers sustained a leg fracture when a GNA performed a transfer alone, contrary to the care plan requiring a full lift and two staff. The incident was identified after a PTA noticed changes in the resident’s leg, and further review showed that not all clinical staff received required education on transfer procedures after the event.
The facility did not ensure an RN was present for at least 8 consecutive hours each day, with multiple weekends showing no RN coverage for extended periods. Staffing records and interviews confirmed that there were several instances where no RN was on duty for both day and night shifts, and the DON's occasional floor coverage did not meet the regulatory requirement.
Annual performance evaluations were not completed for several GNAs, with one not receiving an evaluation since hire and others lacking up-to-date appraisals. The HR Director confirmed that while a list of staff due for evaluation is generated and sent to nursing, the required evaluations were not completed as expected.
Surveyors found that the facility did not immediately report multiple allegations of abuse and an injury of unknown origin to the state office as required. In several cases, residents or their roommates reported rough or painful care by a GNA, and in another case, a resident was found with a head laceration of unknown cause. Despite these incidents being brought to the attention of the DON and administrator, required notifications to authorities were delayed or not made.
The facility did not conduct thorough investigations into multiple allegations of abuse and injuries of unknown origin involving two residents and one incident of injury. In each case, there was a lack of comprehensive assessments, staff and resident interviews, and proper documentation, despite concerns being reported to the DON and NHA.
A resident who required assistance with transfers sustained a forehead bruise when struck by a mechanical lift bar during a transfer performed by two GNAs. Review of records showed that one of the GNAs, an agency staff member, lacked documented training or competency in mechanical lift use, with only a self-evaluation on file and no evidence of formal assessment.
Residents were not consistently provided with water or fluids overnight, as evidenced by empty or undated cups and resident reports of not receiving water between late evening and early morning hours. Staff interviews confirmed there was no standardized procedure for overnight water distribution, resulting in inadequate hydration support.
The facility did not ensure that all residents received appropriate evening snacks when meals were scheduled more than 14 hours apart. A resident reported not receiving nighttime snacks, and observations confirmed that only a limited number of individually labeled snacks were provided, with no additional snacks available for others. Staff sometimes brought in their own snacks due to lack of facility-provided options, which was not approved by administration or therapy staff.
A resident with dementia exhibited repeated violent and aggressive behaviors, including hitting, attempting to bite, and making threats toward staff and other residents. Despite multiple documented incidents and the need for 1:1 supervision, there was no evidence that the physician or psychiatric provider was notified of these behaviors or that orders for increased supervision were obtained.
The facility failed to protect residents from abuse, including a case where a staff member verbally and emotionally abused a resident, and another case where a resident with dementia repeatedly exhibited aggressive behaviors toward peers and staff. Despite multiple incidents of aggression, including physical assaults and hospitalizations, there was no evidence of increased supervision or timely updates to the care plan to address the ongoing risks.
Surveyors found that MDS assessments were inaccurately coded for two residents: one receiving hospice care and another with orders for BiPAP therapy. In both cases, the MDS nurse coordinator confirmed the errors, as the assessments did not reflect the residents' actual care and services provided.
Surveyors identified that care was not provided according to professional standards in three cases: a resident who fell did not have vital signs taken or documented at the time of the incident; two residents received insulin injections without proper site rotation, contrary to standard guidelines; and a pressure-reducing mattress was set incorrectly for a resident's current weight, with adjustments made only after surveyor intervention.
A resident with respiratory failure was observed receiving oxygen at 4L/min via nasal cannula, despite a physician's order for continuous oxygen at 5L/min. Multiple LPNs and surveyors confirmed the discrepancy between the ordered and administered oxygen flow rates, and staff acknowledged the difference.
A resident with dementia and hypertension received metoprolol on multiple occasions despite physician orders to hold the medication for low systolic blood pressure or heart rate. Review of records showed the medication was administered six times when the resident's vital signs were below the specified parameters, contrary to the order and facility expectations.
Failure to Ensure Safe Transfer Procedures Resulting in Resident Injury
Penalty
Summary
A deficiency occurred when a resident with severely impaired cognition and total dependence on staff for transfers and mobility sustained a left leg fracture during a transfer. The resident’s care plan specified the use of a full mechanical lift and required two staff members for all transfers. However, on the day of the incident, a Geriatric Nursing Assistant (GNA) attempted to transfer the resident alone, resulting in the resident’s leg becoming twisted and subsequently fractured. Medical record review and staff interviews confirmed that the GNA was aware of the resident’s transfer status but failed to seek assistance from another staff member as required. The incident was discovered when a Physical Therapy Assistant noticed changes in the resident’s leg during a therapy session, which led to further assessment by an LPN and confirmation of the fracture at the emergency department. Further investigation revealed that not all clinical staff had received education on proper transfer procedures following the incident. Attendance records showed that several nurses and GNAs did not attend the post-incident education session, and there was no documentation of disciplinary action for those who missed the training. Additionally, the GNA involved had not received recent education or performance evaluations related to transfers.
Failure to Provide Required RN Coverage
Penalty
Summary
The facility failed to ensure that a registered nurse (RN) was present and working for at least 8 consecutive hours every day, as required. Review of staffing sheets for selected weekends in January, February, March, and July revealed multiple instances where no RN was on duty for both day and night shifts. Specifically, there was a continuous 60-hour period in January and a 48-hour period in July with no RN coverage. Additionally, in August, there was a 36-hour period without an RN present in the facility. These findings were confirmed through documentation review and interviews with the Director of Nursing (DON), the Nursing Home Administrator, and the Human Resources Director. The DON acknowledged working on the floor occasionally to cover shifts, but the records indicated that RN coverage was still lacking during the identified periods. The absence of an RN on duty for the required hours was verified by both staffing sheets and direct confirmation from facility leadership. The deficiency was found to have the potential to affect all residents in the facility, as there was no RN coverage during several extended periods.
Failure to Complete Annual Evaluations for GNAs
Penalty
Summary
The facility failed to ensure that annual performance evaluations were completed for geriatric nursing assistants (GNAs). A review of employee records showed that one GNA hired in March 2023 had not received an annual evaluation, while two other GNAs had not had evaluations completed within the past year, with their most recent appraisals dated prior to 2024. The Human Resource Director confirmed that although she generates a list of staff due for evaluation and sends it to nursing, it is nursing's responsibility to complete the evaluations, which had not occurred for the GNAs reviewed. These findings were confirmed through documentation review and interviews with facility staff.
Failure to Timely Report Abuse Allegations and Injuries of Unknown Origin
Penalty
Summary
The facility failed to immediately report allegations of abuse and injuries of unknown origin to the state office as required. In one instance, a resident's roommate reported that a GNA used a paper towel to wipe the resident's peri area, causing the resident to cry due to pain. This concern was reported to the DON, who only cautioned the staff member about their communication and did not report the incident to the state office. A second, similar grievance was also reported by the same roommate, indicating repeated behavior by the same GNA, but the DON considered it a repetition and did not take further action or report it. Additionally, another resident voiced concerns about a GNA being rough and touching them in an unwelcome manner during care. This concern was brought to the attention of the DON and the Nursing Home Administrator, but again, there was no immediate report to the state office. The report also details an incident where a resident was found on the floor with a head laceration and required hospital treatment. The injury was of unknown origin, and although the DON was notified shortly after the incident, the report to the Office of Health Care Quality was not made until two days later. The DON acknowledged the delay in reporting and could not provide a reason for the late submission. These findings were based on record reviews and staff interviews, which confirmed that the facility did not follow required procedures for timely reporting of abuse allegations and injuries of unknown origin.
Failure to Thoroughly Investigate Allegations of Abuse and Injuries of Unknown Origin
Penalty
Summary
The facility failed to thoroughly investigate multiple allegations of abuse and injuries of unknown origin involving several residents. For one resident, grievances were filed by a roommate regarding inappropriate and rough care by a GNA, including the use of a paper towel for incontinence care and causing the resident to cry. Despite these concerns being reported to the Director of Nursing (DON), there was no evidence of a comprehensive investigation, such as a head-to-toe assessment, staff interviews, or review of other residents under the care of the involved staff. The DON acknowledged only cautioning the staff member and did not initiate further investigation after a second, separate complaint. Another resident reported being handled roughly by a GNA, but again, the facility did not conduct a thorough investigation, as there was no documentation of a physical assessment, staff or resident interviews, or statements from the staff involved. Additionally, an incident involving a resident found on the floor with a fractured tibia was not fully investigated; the facility's file lacked comprehensive staff witness statements, resident assessments, and supporting documentation. The DON confirmed that the investigation was incomplete and that relevant information was missing from both the investigation file and the resident's medical record.
Failure to Ensure Mechanical Lift Competency for Agency GNA
Penalty
Summary
The facility failed to ensure that staff had adequate training and competency in the use of a mechanical lift, as required by facility policy. A review of a resident's clinical record showed that the resident, who required assistance to transfer from bed to wheelchair, sustained a forehead hematoma when struck by the mechanical lift bar during a transfer. The incident involved two geriatric nursing assistants (GNAs), and documentation confirmed that the mechanical lift bar hit the resident in the head, resulting in a bruise. Further investigation revealed that one of the GNAs involved, an agency staff member, did not have documented evidence of training or competency in the use of the mechanical lift. The only available documentation for this GNA was a self-evaluation, with no verification of training or competency assessment by facility staff. Both the unit manager and the Human Resources Director confirmed the lack of evidence for proper training or competency for this staff member.
Failure to Provide Consistent Overnight Hydration
Penalty
Summary
The facility failed to ensure that residents consistently received water and other fluids in accordance with their needs and preferences, resulting in insufficient hydration support. Resident council minutes indicated that residents were not provided with ice or water between 11:00 PM and 7:00 AM. A review of a complaint also revealed concerns about the lack of water provision. During nighttime observations, staff were seen delivering water starting around 5:00 AM, but several residents were found with empty or nearly empty water cups, some of which were not dated or contained beverages from the previous day. These findings were confirmed by staff present during the observations. Interviews with the Administrator and DON revealed that there was no consistent procedure in place to ensure water was distributed to residents throughout the night. The DON believed new water cups were distributed around 5:00 AM, while the Administrator thought they were provided at the beginning of the night shift. The lack of a standardized process led to residents not having adequate access to water during overnight hours, as evidenced by multiple observations and resident reports.
Failure to Provide Required Evening Snacks Between Meals
Penalty
Summary
The facility failed to provide nutritional snacks to residents when meals were scheduled more than 14 hours apart, as required. On one unit, dinner was served at 5:00 PM and breakfast at 7:35 AM, exceeding the 14-hour interval. Residents reported not receiving evening snacks, and review of food and resident council meeting minutes confirmed these reports. Observations showed that only a limited number of individually labeled snacks were delivered with dinner trays, and no additional snacks were available on the unit. Staff confirmed that only these labeled snacks were provided, and there were not enough snacks for all residents who required them. Further investigation revealed that some staff, in the absence of facility-provided snacks, brought in their own snacks for residents, which was not approved by the facility administration or the speech therapist. The speech therapist emphasized that all snacks should be approved for residents' specific dietary and safety needs. Documentation showed discrepancies between the number of snacks delivered and the number of residents documented as having received snacks, indicating that not all residents had access to appropriate evening snacks as required.
Failure to Notify Provider of Resident's Aggressive Behaviors
Penalty
Summary
The facility failed to ensure that staff notified the physician or psychiatric provider when a resident with dementia exhibited repeated violent and aggressive behaviors. The resident, who had a history of aggression towards both staff and other residents, was admitted with a diagnosis of dementia and was prescribed multiple psychotropic medications. Despite multiple documented incidents of the resident hitting, attempting to bite, and making verbal threats towards staff and other residents, there was no evidence in the medical record that these behaviors were reported to the primary care or psychiatric provider on the days they occurred. The resident was also sent to the hospital for aggressive behaviors, but upon return, there was no documentation of changes in medication or increased supervision, nor was there evidence that the provider was informed of the ongoing aggression. Nursing notes detailed several episodes where the resident required 1:1 supervision, attempted to harm staff, and made threatening statements, yet there was no documentation of provider notification or orders for increased supervision. Interviews with nursing staff and the DON confirmed that such incidents should have been reported to the provider, but the medical record lacked evidence of timely communication. The deficiency was identified during a survey review of abuse prevention and reporting practices, with cross-reference to F 600.
Failure to Protect Residents from Abuse and Inadequate Supervision of Aggressive Behaviors
Penalty
Summary
The facility failed to protect residents from abuse, as evidenced by two substantiated incidents involving both staff-to-resident and resident-to-resident abuse. In the first incident, a cognitively intact resident reported that a staff member threatened to remove them from the facility following a resident-to-resident altercation. The resident became visibly upset, exhibited behavioral changes, and withdrew from activities. The facility's investigation confirmed that the staff member had verbally and emotionally abused the resident. In the second incident, a resident with dementia and a history of aggressive and agitated behaviors repeatedly exhibited physical aggression toward other residents and staff. Despite multiple documented episodes of aggression, including hitting, biting, and making threats, as well as being sent to the hospital for these behaviors, there was no evidence that the facility increased supervision or updated the care plan with new interventions upon the resident's return. The resident continued to display aggressive behaviors, culminating in an incident where the resident physically assaulted another resident, resulting in injury. Throughout the period reviewed, documentation failed to show that the primary care or psychiatric providers were consistently notified of the resident's escalating behaviors, nor was there evidence of orders for increased supervision or implementation of 1:1 monitoring as an ongoing intervention. The care plan addressing aggressive behavior was not updated after significant incidents, and staff interviews confirmed that increased supervision was not documented or ordered following hospitalizations for aggressive behavior.
Inaccurate MDS Coding for Hospice and BiPAP Therapy
Penalty
Summary
The facility failed to ensure that Minimum Data Set (MDS) assessments were accurately coded for two residents. For one resident under hospice care since March, the quarterly MDS assessment incorrectly indicated that the resident was not receiving hospice care, despite medical records and staff interviews confirming ongoing hospice services. The error was identified during a review of the MDS assessment and confirmed by the MDS nurse coordinator, who acknowledged the resident should have been coded as receiving hospice care. In a separate case, another resident with chronic respiratory failure, CHF, and COPD had an active order and care plan for BiPAP therapy. However, the annual MDS assessment did not reflect the use of BiPAP therapy, despite documentation and physician orders supporting its use. The MDS nurse coordinator confirmed responsibility for completing the relevant MDS section and acknowledged the omission, verifying that the assessment was inaccurately coded.
Failure to Follow Professional Standards in Post-Fall Assessment, Insulin Administration, and Pressure Mattress Settings
Penalty
Summary
The facility failed to provide care in accordance with professional standards of practice for three residents. In the first instance, a resident with dementia and high blood pressure experienced a fall, but there was no documentation that a set of vital signs was obtained at the time of the initial assessment or prior to physician notification. The only vital signs recorded were from before the fall, and the first post-fall vital signs were not documented until several hours later. The DON confirmed that the expectation is for vital signs to be taken immediately after a fall, but this was not done or documented in this case. In the second instance, insulin administration practices did not adhere to standards of care regarding site rotation. Two residents received insulin injections in the same location repeatedly, as documented in the MAR, and staff interviews confirmed that there was no standard practice for rotating injection sites. This was contrary to established guidelines, which recommend systematic rotation within an area to prevent complications. The Nursing Home Administrator acknowledged the lack of adherence to a standard of care for insulin administration and site rotation. The third deficiency involved the use of a pressure-reducing mattress for a resident with a history of significant weight loss. The mattress was set for a weight range much higher than the resident's current weight, as confirmed by both observation and staff interviews. The settings were only adjusted after surveyor intervention, despite the care plan specifying that mattress settings should be based on the resident's weight and checked for proper functioning.
Failure to Administer Oxygen as Ordered
Penalty
Summary
Surveyors determined that the facility failed to administer oxygen therapy as ordered by the physician for a resident with respiratory failure. The physician's order specified continuous oxygen at 5 liters per minute via nasal cannula. However, on multiple occasions, the resident was observed receiving only 4 liters per minute. These observations were confirmed by two LPNs and a second surveyor, and the discrepancy between the ordered and administered oxygen flow rates was acknowledged by staff. The resident's medical record and treatment administration record both reflected the physician's order for 5 liters, but the actual administration did not match the prescribed amount.
Failure to Prevent Significant Medication Errors
Penalty
Summary
The facility failed to ensure that a resident was free from significant medication errors, as evidenced by the administration of metoprolol despite specific physician-ordered parameters to hold the medication. The resident, who had diagnoses including dementia and hypertension, had an order for metoprolol extended release 25 mg daily, with instructions to hold the medication if the pulse was less than 60 or if the systolic blood pressure (SBP) was less than 130. Review of the Medication Administration Record for March 2025 showed that the medication was administered on six occasions when the resident's SBP was below the ordered threshold, and in one instance, the heart rate was also below the specified parameter. The DON confirmed that staff are expected to follow medication order parameters, and the surveyor verified that the medication was given contrary to these instructions.
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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Every citation, penalty and Plan of Correction is sourced from public CMS records (latest release May 27, 2026) and official state health department websites — never guesswork.
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