Future Care Charles Village
Inspection history, citations, penalties and survey trends for this long-term care facility in Baltimore, Maryland.
- Location
- 2327 North Charles Street, Baltimore, Maryland 21218
- CMS Provider Number
- 215324
- Inspections on file
- 18
- Latest survey
- October 7, 2025
- Citations (last 12 mo.)
- 28
Citation history
Health deficiencies cited at Future Care Charles Village during CMS and state inspections, most recent first.
A resident with a physician's order for topical ointment to be applied to the right hip for pain had 11 consecutive entries over three days documented by multiple staff indicating application to both hips, contrary to the order. Facility leadership confirmed staff selected the wrong indication in the electronic medical record system.
The facility staff failed to consistently document psychotropic medication side effects and behaviors for a resident and did not document resident consent prior to the installation of side rails for three residents. The DON confirmed the lack of documentation and the absence of a separate consent form for side rails.
The facility staff failed to send a copy of a resident's transfer to the hospital to the Ombudsman. A review revealed the resident was transferred to the emergency department, but the resident was not included in the admission/discharge list sent to the Ombudsman. The Regional Nursing Director acknowledged the oversight.
The facility staff failed to create patient-centered care plans for three residents, including one with oxygen therapy needs, one with significant weight loss, and one with dementia. The deficiencies were confirmed by the DON and other staff members during interviews.
The facility staff failed to provide a summary of a resident's stay and a copy of the most recent comprehensive assessment to a resident who initiated a discharge. The standard discharge process included providing discharge instructions, prescriptions, and a medication list, but did not ensure the inclusion of a summary of the resident's stay or the most recent comprehensive assessment.
The facility failed to ensure that residents requiring assistance with ADLs such as bathing and showering were provided these services. Three residents did not receive scheduled showers, and documentation was inconsistent. Staff interviews revealed confusion and gaps in the documentation process, and the facility lacked a comprehensive ADL policy.
The facility staff failed to prevent new pressure ulcers in two residents. One resident developed a left heel wound and a right upper buttock deep tissue injury after readmission, while another resident developed a new open wound on the left lower buttock. The facility lacked documentation to show that the second resident had refused to be turned prior to the wound's development.
The facility failed to complete annual performance reviews for an LPN and a GNA. The LPN had multiple disciplinary issues without a performance evaluation, and the GNA did not receive a required review after three months of employment. These deficiencies were confirmed by the DON and discussed with the administration team.
The facility failed to store medications and biologicals at the proper temperature, with a refrigerator thermometer reading 58 degrees F, above the required range of 36-46 degrees F. Staff confirmed the issue, and the facility's policy mandates proper temperature monitoring.
The facility failed to follow a resident's food intolerance list and honor requested double-portion meals. Despite the resident's repeated complaints about receiving inappropriate food items and insufficient portions, the facility did not make the necessary adjustments. The resident continued to receive items that could aggravate their condition, such as orange juice and acidic foods.
The facility failed to store food in accordance with professional standards, as observed by a surveyor. A bucket with labeled food items was found on the floor, and a stack of fresh bread trays was placed in a high foot traffic area, with the last tray nearly touching the floor. The Kitchen Director acknowledged the issue.
The facility staff failed to maintain infection control practices as evidenced by a resident's uncovered oxygen tubing and five used, unlabeled urinals left in a bathroom cabinet. The oxygen tubing and sterile water were not labeled or dated, and these findings were confirmed by GNAs. The DON stated that urinals should be labeled and changed when soiled, and oxygen tubing should be dated and changed weekly or when soiled.
The facility failed to ensure effective pest control as flying gnats were observed throughout the building. Residents reported ongoing issues with gnats during a council meeting, despite previous control efforts. The administration acknowledged the problem and provided maintenance logs showing recent treatments for fruit flies.
Incorrect Documentation of Topical Ointment Administration
Penalty
Summary
The facility failed to ensure that a resident's Treatment Administration Record (TAR) was documented in accordance with physician's orders. Specifically, a physician had ordered a topical ointment to be applied to the resident's right hip four times daily for pain. However, review of the Medication Administration Record (MAR) and TAR showed that three staff members documented 11 consecutive entries over a three-day period indicating the ointment was applied to both hips, rather than only the right hip as ordered. This inconsistency was identified during record review and confirmed by facility leadership, who verified that staff had selected the incorrect indication from the dropdown menu in the electronic medical record system.
Failure to Document Psychotropic Medication Side Effects and Siderail Consent
Penalty
Summary
The facility staff failed to consistently document whether a resident was experiencing psychotropic medication side effects or behaviors. This was evidenced in the behavioral records of one resident, where multiple dates in November, December, and January showed no documentation for signs and symptoms of depression, inappropriate behaviors towards female staff, or psychotropic medication side effects. The Director of Nursing (DON) confirmed the lack of documentation during a review with the surveyor and acknowledged that the nursing team reviews orders and attempts to ensure they are carried out, but documentation was still incomplete on the specified dates. Additionally, the facility staff failed to document in the progress notes the consent of the resident or the resident representative prior to the installation of side rails. This was evident for three residents reviewed for siderail consent. The DON and staff confirmed that the facility does not have a separate consent form for side rails and that the clinical staff are expected to document the date and time of consent in the progress notes. However, the surveyor found no documentation in the electronic medical records for the consent prior to the installation of side rails. Late entry progress notes were found for the residents, but these were dated after the installation of the side rails, indicating a failure to obtain and document consent in a timely manner as per the facility's policy.
Failure to Notify Ombudsman of Resident Transfer
Penalty
Summary
The facility staff failed to send a copy of a resident's transfer to the hospital to the Ombudsman. This deficiency was evident in one of two resident records reviewed for transfer/discharge paperwork during the survey. Specifically, on 01/10/24, a review of a resident's electronic medical record revealed the resident was transferred to the emergency department on 10/20/23. On 01/23/24, the surveyor requested a copy of the resident's transfer notice sent to the responsible party and verification that a copy was sent to the Ombudsman. On 01/24/24, the surveyor received a copy of the October 2023 admission/discharge list that was emailed to the Ombudsman on 11/01/23, but the resident was not included on the list. During an interview on 01/24/24, the Regional Nursing Director acknowledged that the staff did not perform the quick editing, and when the Administrator pulled the report, the resident was not on the list, which was realized on 01/23/24.
Failure to Initiate Comprehensive Care Plans
Penalty
Summary
The facility staff failed to initiate patient-centered care plans for three residents, leading to deficiencies in their care. Resident #20 had an order for oxygen therapy, but no specific care plan was created to address this need. The Director of Nursing (DON) confirmed the absence of a patient-specific care plan for oxygen therapy during an interview. Similarly, Resident #32 experienced significant weight loss, yet no care plan was developed to address this issue. Both the DON and the dietician confirmed the lack of a care plan for weight loss during their respective interviews with the surveyor. Additionally, Resident #12, who had a diagnosis of dementia, did not have a care plan addressing this condition. The resident's electronic medical record and care plan meeting notes revealed that dementia was not discussed or included in the care plan. The DON and the social worker confirmed that the interdisciplinary team had not created a dementia care plan for Resident #12. These deficiencies were discussed with the DON, two regional RNs, and the administrator during the exit conference.
Failure to Provide Comprehensive Discharge Documentation
Penalty
Summary
The facility staff failed to provide a summary of a resident's stay and a copy of the most recent comprehensive assessment to a resident who initiated a discharge. This deficiency was identified during a review of Resident #241's electronic medical record, which revealed that the resident was discharged without receiving these critical documents. Interviews with the Director of Social Services and the Director of Nursing confirmed that the standard discharge process included providing discharge instructions, prescriptions, and a medication list, but did not ensure the inclusion of a summary of the resident's stay or the most recent comprehensive assessment. The surveyor's review of the discharge documentation for Resident #241 showed that while the resident received a post-discharge plan of care, prescriptions, and other necessary paperwork, there was no documentation to support that the resident received a summary of their stay or a comprehensive assessment. The Director of Social Services admitted that this information was not provided and suggested it could be obtained from the hospital, indicating a gap in the facility's discharge procedures. The Director of Nursing also confirmed that the discharge documentation typically provided did not include these essential documents, highlighting a systemic issue in the facility's discharge process.
Failure to Provide Scheduled Showers and Personal Hygiene Assistance
Penalty
Summary
The facility failed to ensure that residents requiring assistance with activities of daily living (ADLs) such as bathing and showering were provided these services. This deficiency was identified for three residents. Resident #82 had not been provided a shower since admission, despite expressing a preference for daily showers. The resident's Kardex indicated a schedule for showers twice a week, but this was not adhered to. Resident #32 reported receiving assistance with a shower only once a week, contrary to the expected twice-weekly schedule. Documentation for Resident #32 showed multiple instances where personal hygiene and shower assistance were not recorded or marked as not applicable. Similarly, Resident #38's records indicated missed documentation for personal hygiene and shower assistance on specific dates. Interviews with staff revealed inconsistencies and confusion regarding the documentation and provision of showers. Staff #31 mentioned that handwritten shower logs were used alongside electronic medical records, but there were gaps in documentation. Staff #5 and Staff #3 acknowledged the confusion and stated that GNAs were expected to document refusals and inform LPNs or RNs. However, the facility did not have a comprehensive ADL policy, only individual policies addressing specific aspects of personal care. The lack of consistent documentation and adherence to scheduled showers led to the deficiency, as confirmed during the exit interview with the administrator and Staff #5.
Failure to Prevent New Pressure Ulcers
Penalty
Summary
The facility staff failed to prevent new pressure ulcers from developing in two residents. Resident #242 was readmitted with an intact skin condition but developed two new wounds: a left heel wound and a right upper buttock deep tissue injury. The Director of Nursing confirmed that these wounds were not present upon readmission. Additionally, there were allegations that the resident was left in urine and not turned or repositioned every two hours, which could have contributed to the development of these pressure ulcers. Resident #92, who was admitted with chronic respiratory failure and incontinence, was identified as being at risk for pressure ulcers. Despite this, the resident developed a new open wound on the left lower buttock. The Unit Manager confirmed that the wound developed while the resident was in the facility and mentioned that the resident often refused to be turned. However, there was no documentation to support that the resident had refused to be turned prior to the wound's development. The Director of Nursing was made aware of this concern.
Failure to Complete Annual Staff Performance Reviews
Penalty
Summary
The facility failed to ensure annual staff performance reviews were completed as required, specifically for one Licensed Practical Nurse (LPN) and one Geriatric Nurse Aide (GNA). The LPN, hired in 2021, had no documentation of a performance evaluation in their file. Additionally, the LPN had multiple disciplinary notices for not following proper infection control procedures, failing to complete scheduled evaluations, and being insubordinate to a Nurse Practitioner. Despite these issues, no performance evaluation was conducted, as confirmed by the Director of Nursing (DON) and the Regional Nurse (RN) Staff. Similarly, the facility did not complete an annual performance review for a GNA who began working in June 2023. The DON confirmed that if the performance evaluation was not in the employee's file, it had not been completed. The DON also acknowledged that the GNA should have had a performance review after three months, which was not done. These deficiencies were discussed with the administration team during the exit interview.
Improper Medication Storage Temperature
Penalty
Summary
The facility failed to properly store medications and biologicals under proper temperature controls according to professional standards. During observation rounds of the facility's 2nd floor medication storage room, the refrigerator storing medications and biologicals was found to have a thermometer reading of 58 degrees F, which is above the required temperature range of 36 degrees F to 46 degrees F. Staff confirmed the temperature reading and acknowledged that the refrigerator was too hot. The facility's policy for medication storage mandates that medications requiring refrigeration must be kept in a secure refrigerator with a thermometer for temperature monitoring. This deficiency was discussed with the administrative staff during the exit conference.
Failure to Follow Food Intolerance List and Honor Meal Requests
Penalty
Summary
The facility failed to follow a resident's food intolerance list and honor requested double-portion meals. This was evident for one resident who had a history of gastro-esophageal reflux disease (GERD) and was on a modified diet. Despite the resident's repeated complaints about receiving inappropriate food items and insufficient portions, the facility did not make the necessary adjustments. The resident was observed in a weakened state, expressing the need for more food to regain strength, and continued to receive items that could aggravate their condition, such as orange juice and acidic foods. The resident's concerns were communicated to the dietician and kitchen manager, but no improvements were documented. The resident continued to receive inappropriate food items, such as broccoli and berries, which were not suitable for their condition. The facility's kitchen manager stated that larger portion meals required an order from the resident's attending physician, but no such order was documented. The lack of response to the resident's dietary needs and preferences led to ongoing dissatisfaction and potential health risks for the resident.
Improper Food Storage in Kitchen
Penalty
Summary
The facility failed to store food in accordance with professional standards for food service, which could potentially lead to contamination. During a tour of the kitchen, a surveyor observed a bucket with labeled food items and dates sitting on the floor. Additionally, a stack of fresh bread in eight large trays was found in a high foot traffic area, with the last tray less than one inch from the floor. The Kitchen Director acknowledged the situation and stated that she was about to move the bread.
Infection Control Deficiencies
Penalty
Summary
The facility staff failed to maintain infection control practices as evidenced by a resident's oxygen tubing being uncovered and draped over the oxygen concentrator, and five used, unlabeled, and undated urinals being left in the bathroom cabinet. During observation rounds, the surveyor noted that the oxygen tubing and sterile water connected to the oxygen concentrator were not labeled or dated. Additionally, five used urinals were found under the bathroom sink in another room. These findings were confirmed by the respective Geriatric Nursing Assistants (GNAs) present during the observations. The Director of Nursing stated that the expectation is for urinals to be labeled with the resident's room number, bed, and the date it was provided, and that oxygen tubing and sterile water should be dated and changed weekly or when soiled.
Failure to Ensure Effective Pest Control
Penalty
Summary
The facility failed to ensure effective pest control as flying gnats were observed throughout the building. During the survey, multiple observations of gnat sightings were made, including in one of the facility's rooms on the first day of the survey. During a resident council meeting, residents were seen swatting at gnats and expressed that the problem had been ongoing despite previous control efforts. The Regional Director of Operations and the Director of Nursing acknowledged the issue and stated that the building is treated weekly for pest concerns. Maintenance logs indicated that the facility was last treated for fruit flies on the second floor and in the kitchen area on two separate occasions. The administration team was made aware of the residents' concerns during the survey exit meeting.
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.
