Future Care Canton Harbor
Inspection history, citations, penalties and survey trends for this long-term care facility in Baltimore, Maryland.
- Location
- 1300 South Ellwood Avenue, Baltimore, Maryland 21224
- CMS Provider Number
- 215176
- Inspections on file
- 23
- Latest survey
- September 18, 2025
- Citations (last 12 mo.)
- 7
Citation history
Health deficiencies cited at Future Care Canton Harbor during CMS and state inspections, most recent first.
Staff failed to maintain accurate and complete medical records for three residents, including lack of timely wound documentation for a resident with multiple pressure injuries, inaccurate documentation of a specialty mattress application for another resident, and the presence of two conflicting MOLST forms in a third resident’s record.
Staff did not administer the full course of a prescribed antibiotic to a resident with cystitis and a recent orthopedic procedure, resulting in only 4 out of 6 ordered doses being given over 3 days. The missed doses were confirmed through review of the medical and medication administration records.
Facility staff did not update a resident's care plan after the development of multiple Stage II pressure ulcers, failed to document timely wound assessments, and did not promptly notify the physician or family about the new wounds. Wound care interventions and documentation were delayed, and the care plan was only revised after the resident had been discharged.
A cognitively impaired resident reported being physically abused by a staff member, resulting in a bleeding nose. The nursing staff did not inform the DON or Executive Director immediately, and the accused staff member continued working until the next morning. The DON discovered the incident the following day through hospital records. The RN Night Supervisor did not remove the accused staff member, delaying the response to the abuse allegation. Discrepancies in staff accounts and the resident's behavioral history further complicated the situation, highlighting a deficiency in the facility's response to abuse allegations.
A facility failed to timely report the alleged abuse of a cognitively impaired resident by an Agency GNA. Despite immediate awareness by staff, the proper authorities were not informed until the following day after the resident self-contacted law enforcement and was transferred to a hospital. The DON and Executive Director were not informed until the next day, and the alleged perpetrator was not removed from the facility during the shift.
The facility staff failed to thoroughly investigate two separate abuse allegations involving a resident. The investigations lacked complete documentation and did not include interview statements from the resident, the resident's roommate, or other residents.
The facility failed to secure and monitor chemicals in an active resident area. A maintenance cart with cleaning chemicals was left unattended on the 3rd floor, where two residents, one with severe cognitive impairment, were observed. A floor tech acknowledged responsibility and moved the cart only after being prompted by the surveyor. These observations were confirmed by the ADON and reviewed with the DON.
Failure to Maintain Accurate and Complete Medical Records
Penalty
Summary
Facility staff failed to maintain complete and accurate medical records in accordance with accepted professional standards for three residents. For one resident who was totally dependent on staff and readmitted with four new stage II pressure injuries, the facility did not document the progression or healing of these wounds between readmission and discharge. The wound nurse did not enter timely wound assessments into the electronic medical record, and no paper documentation could be located. Additionally, the resident’s care plan was not updated to reflect the actual skin impairment and new interventions until several days after the wounds were identified. The family was not promptly presented with the updated care plan summary. For another resident admitted with a post-surgical orthopedic procedure, the medical record indicated that a physician ordered a specialty pressure-relieving mattress, and nursing staff documented its use every shift. However, interviews revealed that the mattress was not actually delivered or applied to the resident’s bed until several days after staff began documenting its use. The facility’s supply and nursing staff confirmed that the mattress had to be ordered and was not available until after the documentation had already begun. A third resident’s medical record contained two active and conflicting Maryland MOLST forms, one indicating full code status and another indicating do-not-resuscitate and other treatment limitations. The presence of two incongruent MOLST forms in the active record could have caused confusion for staff in an emergency. The back page of one MOLST form was also incomplete, and the forms were not properly voided or updated in accordance with state requirements.
Failure to Administer Prescribed Antibiotic as Ordered
Penalty
Summary
Facility staff failed to follow a physician's order to administer an antibiotic, Cefpodoxime Proextill, 100 mg orally every 12 hours for 3 days, to a resident admitted with a fractured right ankle and cystitis with pyuria. The physician's order was dated 01/18/25 at 9 AM, but the resident did not receive the first dose on 01/18/25. Nursing progress notes indicated that the charge nurse contacted the pharmacy to request the antibiotic be sent stat, but the resident ultimately received only 2 doses on 01/19/25 and 01/20/25, totaling 4 doses instead of the prescribed 6 doses over 3 days. This failure to administer the full course of antibiotic treatment as ordered was identified during a complaint survey and confirmed through review of the resident's medical record and medication administration record.
Failure to Update Wound Care Plan and Document Pressure Ulcer Progression
Penalty
Summary
Facility staff failed to update a resident's skin and wound care plan after the resident was readmitted with four new Stage II pressure ulcers. The care plan, which was initially focused on prevention due to the resident's fragile skin and decreased mobility, was not revised to address the actual presence of pressure injuries. Nursing interventions specific to the new wounds were not added until after the resident had already been discharged from the facility. Additionally, staff did not document timely assessments of the resident's wounds to demonstrate healing or deterioration. There was a lack of consistent documentation in the electronic medical record regarding the status of the wounds between the time of readmission and the resident's subsequent transfer to the hospital. The wound nurse reported that assessments were sometimes completed on paper and entered into the electronic record later, but no paper or written assessments could be located for this resident. Wound assessments for the identified pressure injuries were entered as late entries after the resident had left the facility. The facility also failed to notify the resident's physician and family promptly about the development of the Stage II wounds. The care plan summary indicating the presence of a pressure injury was not communicated to the family until several days after readmission. The physician did not document skin assessments on multiple dates during the resident's stay, and the wound care physician did not assess the resident, as the facility's practice was not to involve the wound care physician for Stage I or II wounds unless specifically requested.
Failure to Address Abuse Allegation Promptly
Penalty
Summary
In the report provided, it was identified that a cognitively impaired resident (resident #1) in a long-term care facility was subjected to physical abuse by a facility staff member (Agency GNA #1). The incident occurred on 2/12/24 when resident #1 alleged being punched in the nose by Agency GNA #1. The abuse was reported by resident #1 to nursing staff, and it was observed that resident #1 had a bleeding nose following the alleged incident. Despite this, Agency GNA #1 was allowed to continue working until the next morning, raising concerns about the immediate jeopardy faced by all residents in the facility due to the failure to promptly address the abuse allegation. The investigation revealed that the facility's nursing staff failed to inform the Director of Nursing (DON) or the Executive Director immediately after the alleged abuse was reported by resident #1. It was only discovered by the DON the following day when reviewing local hospital records of resident #1's emergency room visit. Additionally, the facility's RN Night Supervisor #5 did not remove Agency GNA #1 from the building after resident #1's complaint, leading to a delay in addressing the abuse allegation and ensuring resident safety. The failure to take immediate action to protect resident #1 from further harm highlighted a critical deficiency in the facility's response to abuse allegations. Further interviews with staff and review of witness statements indicated discrepancies in the accounts provided by Agency GNA #1 and other staff members regarding the alleged abuse incident. Despite resident #1's history of behavioral issues, including physical and verbal aggression towards staff, the facility's handling of the abuse allegation raised concerns about the protection of vulnerable residents from harm. The lack of timely reporting, inconsistent responses from staff, and failure to remove the accused staff member promptly all contributed to the deficiency in protecting resident #1 from physical abuse within the facility.
Failure to Timely Report Alleged Abuse
Penalty
Summary
The facility failed to report the alleged abuse of a cognitively impaired resident to the proper authorities in a timely manner. The incident involved a resident who was admitted to the facility with diagnoses including Bipolar Disorder, Heart Disease, and Colostomy status. The resident, who was cognitively intact with a BIMS score of 15/15, alleged that an Agency GNA punched them in the nose. Despite the resident's immediate report of the incident to facility staff, the proper authorities were not informed until the following day after the resident self-contacted law enforcement and was transferred to a local hospital for treatment. The facility's investigation revealed that multiple staff members, including an Agency LPN and RN Night Supervisor, were aware of the resident's allegation on the day it occurred. However, the Director of Nursing (DON) and the Executive Director were not informed until the next day when the DON reviewed the hospital records. The facility's failure to promptly report the incident to the State of Maryland's Office of Health Care Quality (OHCQ), the Baltimore City Department of Aging, and local law enforcement was acknowledged by the Regional Director of Operations and the Regional Clinical Services Manager. Additionally, the investigation highlighted that the RN Night Supervisor failed to remove the alleged perpetrator, Agency GNA #1, from the facility after the resident's allegation. Instead, the GNA continued to work the remainder of their shift. The facility administration could not provide an explanation for this oversight. The DON eventually suspended the GNA and initiated the abuse investigation after becoming aware of the incident through the hospital records. The facility's delayed response and failure to follow proper reporting protocols were significant deficiencies identified in the surveyor's report.
Failure to Thoroughly Investigate Abuse Allegations
Penalty
Summary
The facility staff failed to thoroughly investigate allegations of abuse involving a resident. In the first incident, the resident's sister reported that a Geriatric Nursing Assistant (GNA) was rough with care and told the resident to shut up. The facility's investigation included interviews and statements from staff and other residents, but some statements lacked titles, dates, and identification of the persons completing the forms. Additionally, there were no interview statements from the resident, the resident's roommate, or other residents, making the investigation incomplete. The Director of Nursing (DON) confirmed the lack of thorough documentation during an interview with the surveyor. In the second incident, the same resident alleged that staff took their call bell and shut the door. The facility's investigation included staff interviews but did not have any interview statements from the resident, the resident's roommate, or other residents. The surveyor informed the DON that the investigation was not thorough due to the absence of these critical interviews. The DON was unable to provide additional information to validate that the allegation was thoroughly investigated.
Failure to Secure and Monitor Chemicals
Penalty
Summary
The facility failed to secure and monitor chemicals in an active resident area. During a random tour on the 3rd floor, a maintenance cart with four cans of Ultra Power Foam for stripping and cleaning floors was observed. Additionally, a can of the foam was found on the railing next to a room. The chemicals remained unattended as two residents, one with severe cognitive impairment and another cognitively intact, were observed in the area. A floor tech acknowledged responsibility for the chemicals and moved the cart only after being prompted by the surveyor. These observations were confirmed by the Assistant Director of Nursing and reviewed with the Director of Nursing.
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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.
Surveyors found that the facility failed to develop and implement comprehensive care plans for two residents. One resident used a motorized wheelchair and had a documented safety assessment and an ED note describing a leg injury that occurred while using the device, yet the care plan contained no documentation or interventions related to motorized wheelchair use. Another resident had a documented diagnosis of PTSD and a history of childhood sexual abuse, and while the care plan noted trauma as a focus, it listed no specific interventions to address PTSD or the trauma history.
Surveyors identified that the facility failed to revise person-centered care plans after significant changes in two residents’ conditions. For one resident, the MOLST and paper chart were updated from Full Code to DNR-B with No CPR and palliative/supportive care orders, but the care plan continued to list the resident as Full Code. For another resident who sustained a fall with injuries and was sent to the ER, the existing fall-prevention care plan was not updated to reflect the incident or any new interventions, and no timely review was documented. During interviews, the rehab director reported that therapy provides recommendations after falls but does not revise care plans, and the DON and regional administrator confirmed that no care plan revisions or fall investigation documentation were available.
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.
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.
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 Develop Comprehensive Care Plans for Motorized Wheelchair Use and PTSD
Penalty
Summary
Surveyors identified a failure to develop and implement comprehensive care plans for two residents. For one resident who used a motorized wheelchair, interviews with the DON, Administrator, and Occupational Therapist confirmed that the resident had a power mobility device and that a safety assessment for its use had been completed by therapy. The resident’s medical record included an Emergency Department physician note documenting the resident’s report that they were in their motorized wheelchair when they sustained a leg skin tear or laceration after running into their bed. The facility’s matrix and records showed the resident had been admitted and later discharged, and a power mobility indoor driving assessment dated several months prior was provided. Despite this information and the confirmed use of a motorized wheelchair, review of the resident’s care plan showed no documentation addressing the resident’s use of a motorized wheelchair. For another resident, record review showed documentation in the facility matrix and in a Quarterly MDS that the resident had a medical diagnosis of post-traumatic stress disorder (PTSD) and a history of trauma related to childhood sexual abuse. The resident’s care plan focus reflected this trauma history; however, the only listed intervention for that focus was the word “trauma,” with no specific interventions identified to address the PTSD diagnosis or trauma history. During an interview, the Nursing Home Administrator was informed that the resident had a PTSD diagnosis, but the surveyor could not locate any detailed interventions in the care plan beyond the generic trauma notation.
Failure to Revise Care Plans After Code Status Change and Resident Fall
Penalty
Summary
The deficiency involves the facility’s failure to ensure person-centered care plans were timely updated and revised by the interdisciplinary team following significant changes in residents’ status and events. For one resident, a social services note documented that the Maryland MOLST was reviewed and changed from Full Code to DNR-B on a specified date, and the paper chart contained a MOLST form with orders for No CPR, Option B, Palliative and Supportive Care. However, the resident’s care plan still contained a focus stating that the resident’s Full Code MOLST would remain in place through the review date, and this care plan was not revised to reflect the updated code status. During record review with the Nursing Home Administrator, it was confirmed that the MOLST had been updated but the care plan had not been revised accordingly. The deficiency also includes the facility’s failure to revise a resident’s care plan after a fall event. A progress note by an LPN documented that another resident experienced a fall, sustained several injuries, and was transferred to the emergency room. Review of this resident’s care plan showed that no revisions were made to the existing fall interventions in response to the fall, and the care plan was not documented as reviewed and revised until a later date. During interviews, the Director of Rehabilitation stated that therapy makes recommendations and sees residents after falls but does not revise the care plan and was unsure if nursing was responsible for care plan revisions. The DON and Regional Administrator confirmed that no care plan revisions had been made in response to the fall and that there was no recollection or documentation of a fall investigation.
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.
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.
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