Future Care Capital Region
Inspection history, citations, penalties and survey trends for this long-term care facility in Landover, Maryland.
- Location
- 1051 Brightseat Road, Landover, Maryland 20785
- CMS Provider Number
- 215364
- Inspections on file
- 16
- Latest survey
- January 30, 2026
- Citations (last 12 mo.)
- 31
Citation history
Health deficiencies cited at Future Care Capital Region during CMS and state inspections, most recent first.
Facility staff failed to provide reasonable accommodations for residents by not ensuring call lights were within reach. During a tour, surveyors observed six residents without accessible call lights, with some cords hanging on the wall or on the floor. The RCSM confirmed the expectation for call lights to be available, highlighting a deficiency in accommodating resident needs.
Surveyors found that the facility failed to properly label enteral feeding supplies for four residents. Observations revealed unlabeled 60-cc enteral feeding syringes and tube feeding bags, despite physician orders and facility protocols requiring daily changes and labeling. This deficiency highlights a lapse in adherence to established tube feeding management procedures.
The facility failed to maintain accurate MOLST documentation for two residents. One resident's MOLST was outdated and did not reflect their severely impaired mental capacity, while another resident's MOLST lacked documentation of a surrogate, despite indicating informed consent by one. Staff confirmed these deficiencies, highlighting lapses in ensuring accurate care preferences and decision-making authorities.
The facility failed to notify the Ombudsman of a resident's hospital transfers, as required. The deficiency was identified during a review of the resident's medical records, revealing that notifications were not completed for two hospital transfers. The Regional Clinical Services Manager confirmed the oversight, and the Nursing Home Administrator acknowledged that notifications had not been made since the previous Administrator's tenure.
The facility failed to provide appropriate respiratory care for two residents. One resident was receiving oxygen therapy without a current physician order, despite it being required by the facility's policy. This oversight occurred after the resident's recent hospitalization. Another resident with a tracheostomy lacked a manual resuscitator bag in their room, contrary to physician orders for emergency supplies. These deficiencies highlight lapses in following prescribed respiratory care protocols.
A facility failed to follow up on a psychiatric consult for a resident, which recommended discontinuing one of two antidepressants. Despite the consult's findings, there was no documentation of follow-up actions by the physician or nursing staff. The DON confirmed the consult was due to the resident's depressive symptoms but acknowledged the lack of follow-up notes.
A facility failed to administer medication as prescribed for a resident. A nurse changed the timing of a seizure medication without consulting the doctor, and no documentation was found regarding this change. The incident was confirmed by the Regional Clinical Services Manager, and the facility's administrator expected the nurse to contact the physician before altering medication times.
The facility was found deficient in sanitary and safe food handling practices during an annual survey. Observations revealed outdated and unlabeled food items in the kitchen and a refrigerator on the VS2 unit. The VS2 Unit Manager admitted that unlabeled food should be discarded, and the Administrator acknowledged the labeling and dating issues.
Facility staff failed to accurately document the Morse Fall Scale (MFS) assessments for a resident, leading to incorrect fall risk assessments due to the omission of past fall history. The DON acknowledged the documentation errors but was unaware of the reasons for the omissions.
Facility staff failed to follow infection control practices by not performing hand hygiene before donning PPE. Despite a visible reminder sign, a nurse and two other staff members were observed removing PPE without sanitizing their hands. A RN confirmed the protocol was to perform hand hygiene first, but this was not adhered to.
The facility failed to notify two residents or their representatives in writing about the bed hold policy during transfers to an acute care facility. In one case, the family was informed by phone, but no documentation of the bed hold policy was found. In another case, documentation provided did not include the bed hold policy, despite claims it was issued.
Two residents experienced deficiencies in care: one did not receive prescribed medication for nausea, and another faced a delay in scheduling an orthopedic consult for spinal stenosis. The medication was available but not documented as administered, and the appointment was scheduled 14 days after the order, contrary to facility expectations.
Failure to Ensure Call Light Accessibility for Residents
Penalty
Summary
The facility staff failed to ensure that residents were provided reasonable accommodations, specifically regarding the accessibility of call lights. During an initial tour of the PPCU-1 unit, surveyors observed that six residents did not have call lights within reach. One resident was in bed with the call light cord hanging on the oxygen gauge on the wall, while two other residents had their call lights on the floor. Additionally, three more residents were observed without an available call light. The Regional Clinical Services Manager (RCSM) confirmed that the expectation was for call lights to be available for residents. This deficiency was identified through observations and interviews, indicating a failure to accommodate the needs and preferences of the residents in terms of call light accessibility.
Failure to Label Enteral Feeding Supplies
Penalty
Summary
The facility failed to adhere to proper tube feeding care and services for four residents, as observed by surveyors. During an initial tour, surveyors noted that three residents had 60-cc enteral feeding syringes at their bedsides that were not labeled with a date. Additionally, the tube feeding bag and tubing in another resident's room were also found to be unlabeled. These observations were made despite existing physician orders that required specific management of enteral feeding supplies, including changing syringes daily and labeling them appropriately. A review of the facility's Nursing Practice Manual revealed that the protocol required gastric syringes to be changed every 24 hours and labeled with the resident's name, date, and room number. Furthermore, the enteral product label was supposed to include the resident's name, room number, date, time, and rate, with the tubing label also requiring a date and time. The facility's failure to comply with these protocols resulted in the deficiency noted by the surveyors.
Deficiencies in MOLST Documentation and Surrogate Identification
Penalty
Summary
The facility failed to ensure the accuracy of the Medical Orders for Life-Sustaining Treatment (MOLST) for two residents. For one resident, the MOLST form was outdated and did not reflect the resident's current mental capacity, which was severely impaired following a hospitalization. The facility did not update the MOLST upon the resident's return, nor did they obtain a proper advance directive to guide care. Interviews with staff confirmed the resident's incapacity to make informed decisions, yet the MOLST remained unchanged. For another resident, the MOLST indicated that a discussion and informed consent had occurred with a surrogate, as per the Health Care Decisions Act. However, the facility failed to identify or document the surrogate in the resident's medical record. When the surveyor requested the MOLST, it was confirmed that no surrogate was listed, and the Social Services Department was reportedly addressing the issue. These deficiencies highlight lapses in ensuring accurate and up-to-date documentation of residents' care preferences and decision-making authorities.
Failure to Notify Ombudsman of Resident Hospital Transfers
Penalty
Summary
The facility failed to provide timely notification to the Ombudsman regarding the transfer of a resident to the hospital. This deficiency was identified during a review of the medical records of a resident who was transferred to the hospital on two occasions. The surveyor discovered that the required notification to the Ombudsman had not been completed for these transfers. During interviews, the Regional Clinical Services Manager confirmed that the notifications had not been made. The Nursing Home Administrator later acknowledged that notifications had not been completed since November, as the former Administrator was responsible for this task.
Deficiencies in Respiratory Care for Two Residents
Penalty
Summary
The facility failed to provide appropriate respiratory care for two residents, leading to deficiencies in their care. For one resident, an oxygen humidifier bottle was observed in their room without a current physician order for oxygen therapy. The resident's care plan included an intervention for oxygen as needed, and the Minimum Data Set (MDS) assessment indicated oxygen therapy as a special respiratory treatment. However, the resident did not have a physician order for oxygen at the time of the survey, which is a requirement according to the facility's oxygen policy. The lack of a physician order was attributed to the resident's recent hospitalization and subsequent return to the facility without the order being renewed. Another resident with a tracheostomy was found to be without a manual resuscitator bag (ambu bag) in their room, which is part of the required emergency supplies. The resident's medical record included physician orders for respiratory therapy to ensure that emergency supplies, including a backup trach, syringe, and manual resuscitator bag, were available at the bedside. The absence of the ambu bag was noted during the initial tour of the unit, indicating a failure to comply with the physician's orders and ensure the resident's safety in case of an emergency.
Lack of Follow-Up After Psychiatric Consult
Penalty
Summary
The facility staff failed to provide follow-up after a psychiatric consult for a resident. A psychiatric consult was ordered and completed, which recommended that the resident did not require two antidepressants based on their current presentation. However, there was no follow-up documentation from the physician or nursing staff regarding the psychiatric consult's recommendations. The Director of Nursing (DON) confirmed that the consult was initiated due to the resident's depressive symptoms following a previous hospital visit, but acknowledged the absence of follow-up notes addressing the psychiatric consult's findings.
Medication Administration Deficiency
Penalty
Summary
The facility failed to ensure medications were administered as prescribed by the medical provider for one resident. During an interview, the resident's daughter reported that a night nurse changed the time of a seizure medication without consulting the doctor. There was no documentation found in the resident's record regarding the change in medication timing. A review of the Clinical Incident Report revealed that a registered nurse did not administer the medication as ordered and scheduled. The Regional Clinical Services Manager confirmed that the nurse did not document the reason for the time change. The facility's administrator stated that she would expect the nurse to contact the physician before making any changes to the ordered medication times.
Deficiency in Food Handling Practices
Penalty
Summary
The facility failed to ensure sanitary and safe food handling practices, which was identified during an annual survey. Observations in the kitchen revealed outdated food items, including a lemon pie with no open date or year and a container labeled with an open date but no discard date or year. Additionally, containers of teriyaki and soy sauce were not labeled or dated. In a separate refrigerator on the Vital Strong 2 (VS2) unit, an unlabeled and undated container of fruit, a bag with a resident's name and room number but no date, and a grey cooler bag with no name or date were found. The VS2 Unit Manager admitted that unlabeled food should be discarded and expressed uncertainty about how the food was placed there, as the refrigerator is kept locked to prevent unauthorized access. The Administrator acknowledged the labeling and dating issues.
Inaccurate Documentation of Morse Fall Scale Assessments
Penalty
Summary
The facility staff failed to accurately document the Morse Fall Scale (MFS) assessments for a resident, which was evident during a review of the resident's medical record. The resident had a history of falls on multiple occasions, but the MFS assessments did not accurately record this past history, leading to an incorrect assessment of the resident's fall risk. Specifically, the resident's fall risk was inaccurately assessed as moderate and low risk on different occasions due to the omission of past fall history in the MFS assessments. During an interview, the Director of Nursing (DON) acknowledged the incorrect documentation of the MFS post-fall assessments but was unaware of the reasons for the omission of the past history of falls. This deficiency was identified for one resident reviewed for falls, highlighting a lapse in maintaining accurate medical records in accordance with accepted professional standards.
Infection Control Breach: Hand Hygiene Omission
Penalty
Summary
The facility staff failed to adhere to infection control practices before donning personal protective equipment (PPE) during an annual survey. Observations revealed that a Licensed Practical Nurse and two other staff members removed PPE from a cart without performing hand hygiene, despite a visible sign reminding them to sanitize their hands before taking a gown. During an interview, a Registered Nurse confirmed that the protocol required staff to perform hand hygiene before removing PPE, yet the observed staff did not follow this procedure.
Failure to Provide Bed Hold Policy Notification
Penalty
Summary
The facility failed to notify residents or their representatives in writing about the bed hold policy when residents were transferred to an acute care facility. This deficiency was identified for two residents who were reviewed for hospitalization. In the case of the first resident, the family was informed of the transfer to the hospital via phone, but there was no documentation of the bed hold policy in the resident's chart or electronic system. The Unit Nurse Manager confirmed that the bed hold policy was not provided to the resident or the family, and this issue was raised as a concern by the Regional Clinical Services Manager. For the second resident, a closed record review revealed that the resident was transferred out with an order from a Nursing Practitioner, but there was no documented notification to the family, nor was there a bed hold policy in place. Although the Regional Clinical Services Manager provided hard copies of documents to support that the bed hold policy was issued, these documents only included an Emergency Department transfer form and a notice of facility-initiated transfer form, with no bed hold policy found. The lack of documentation of the bed hold policy was noted as a concern during further interviews.
Medication Administration and Appointment Scheduling Deficiencies
Penalty
Summary
The facility staff failed to administer medication to a resident who had been evaluated by a medical provider for nausea. Despite the medication being available in the facility's Pyxis MedStation, there was no documentation confirming that the medication was given. The Director of Nursing (DON) was unable to provide records showing the medication was administered and confirmed that staff could not recall if the medication was given. Additionally, the facility did not schedule an outside medical appointment in a timely manner for another resident diagnosed with spinal stenosis who complained of back pain. Although pain medications were administered, an orthopedic consult was ordered but not scheduled until 14 days later, with the appointment set for over a month after the order. The DON could not identify the reason for the delay, which was not in line with the facility's usual practice.
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.
Trusted data from CMS and state health departments
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.
Trusted by long-term care providers and associations.
