Future Care Chesapeake
Inspection history, citations, penalties and survey trends for this long-term care facility in Arnold, Maryland.
- Location
- 305 College Parkway, Arnold, Maryland 21012
- CMS Provider Number
- 215186
- Inspections on file
- 16
- Latest survey
- February 4, 2026
- Citations (last 12 mo.)
- 4
Citation history
Health deficiencies cited at Future Care Chesapeake during CMS and state inspections, most recent first.
The facility did not ensure that nursing staff completed and had documentation of annual clinical skills competency training. A GNA employed for multiple years had no recorded annual clinical skills competency training over an extended period, and an RN lacked documentation of such training for two consecutive years. The facility’s written policy addressed only annual performance evaluations and did not include requirements for annual clinical skills training for RNs, LPNs, or GNAs. During interviews, the DON and HR manager confirmed they could not provide proof of skills competency evaluations for the affected staff, and these findings were shared with surveyors at exit.
Surveyors identified that required annual performance evaluations for GNAs were not consistently completed or documented. A review of several GNA personnel files showed that one GNA had no annual evaluations on file for multiple consecutive years, and another GNA lacked evaluations for two years. These evaluations are intended to identify clinical competency skills that GNAs should improve or maintain based on the mandated annual 12-hour competency skills training. When the findings were discussed with the DON and Human Resources, leadership confirmed they could not provide evidence that the annual evaluations had been performed for the identified periods.
Surveyors found multiple sanitation and food storage deficiencies in the kitchen, including canned beverages stored directly on the floor near a floor drain, an open undated spice container, debris in a floor drain beneath the dishwasher, used plastic gloves on the floor, broken floor tiles with standing gray water, and brown stains on a wall by a handwashing sink. In a refrigerator, hard-boiled eggs and muffins were wrapped together without labels or dates, and applesauce containers were past their labeled use-by date. In dry storage, a broken floor tile partially covered a missing section of flooring, and a box of condiments lacked a received date while other items were properly dated. Staff acknowledged concerns about missing dates, expired and unlabeled food, debris in drains, and damaged flooring holding standing water.
A resident’s medical record did not accurately reflect current diagnoses in relation to a prescribed psychotropic/anticonvulsant medication. The care plan identified a potential safety risk related to a seizure disorder, and a medication order listed Lamotrigine as being given for seizures, while a psychiatric note documented Lamotrigine use for Bipolar Disorder. Despite these entries, the resident’s diagnosis list did not include a seizure disorder, and staff acknowledged there was no documentation confirming such a diagnosis, resulting in incomplete and inconsistent medical records.
The facility failed to secure and store medications safely, as observed during a survey. Insulin pens were improperly stored outside refrigeration, loose pills were found in a medication cart, and a medication cup was left at a resident's bedside. Additionally, an unlocked medication cart was left unattended in a hallway, highlighting lapses in medication security protocols.
Facility staff failed to provide necessary ADL care, such as showers and incontinence care, for a resident with advanced dementia who was dependent on them. The resident did not receive scheduled showers or bed baths, and personal hygiene was not documented on several occasions. Staff training indicated 'N/A' should not be used unless the resident was unavailable, but there was no evidence the resident was out of the facility on those days.
The facility failed to maintain accurate medical records for residents, as evidenced by discrepancies in medication administration, missing lab results, and incorrect documentation of service dates. Interviews confirmed that a resident refused Boost VHC despite records showing administration, a BMP lab was not conducted for another resident, and a physician's note contained an incorrect service date.
The facility failed to report allegations of abuse and injuries within the required timeframe for three residents. A resident's abuse allegation was reported late, another resident's injury was initially misclassified, delaying the report, and a third resident's fall with injury was not reported at all. The DON and Administrator acknowledged these reporting failures.
A resident experienced multiple falls, but the facility failed to update the care plan to reflect these incidents. The oversight was confirmed by the Regional Clinical Services Manager, who noted that the care plan had not been revised to include the falls.
A resident fell during a transfer from bed to wheelchair when a GNA improperly attempted to pull them by their pants from behind the bed, despite the resident's warning about improper leg positioning. The resident required partial/moderate assistance, and the Rehabilitation Director confirmed that the GNA should have stood in front of the resident for a safe transfer.
The facility was found to have several infection control deficiencies, including improper storage of personal items in the laundry area, lack of Enhanced Barrier Precautions (EBP) signage for two residents with specific medical needs, and a nurse eating in the clean utility room against policy.
The facility failed to maintain an effective pest control program, as evidenced by the presence of flies in the kitchen and gnats in the conference room. Despite regular pest control treatments, issues with ants, fruit flies, and roaches persisted, indicating inadequate pest management.
Failure to Maintain Annual Clinical Skills Competency Documentation for Nursing Staff
Penalty
Summary
The facility failed to ensure that nursing staff completed annual skills-based competency training, resulting in missing documentation of clinical skills competency for selected staff. During an employee record review on 02/04/2026, the surveyor found that a GNA hired on 01/28/2014 had no evidence of annual clinical skills competency training documentation in the personnel file for the years 2015 through 2024. The same review showed that an RN hired on 06/22/2022 lacked documentation of annual clinical skills training for 2023 and 2024. The facility’s performance evaluation policy, provided to the surveyor, addressed only annual performance evaluations based on job descriptions and did not reference annual clinical skills training. The facility did not provide a policy related to annual clinical training for licensed RNs, LPNs, or GNAs prior to the exit conference. In an interview on 02/04/2025 at 12:00 noon, the DON and HR manager confirmed the absence of skills competency evaluations for the identified staff and stated they were unable to provide proof of such evaluations, and these findings were discussed during the exit conference on 02/04/2026. No resident-specific medical histories or conditions were described in the report, and the deficiency centers on the lack of documented annual clinical skills competency training for nursing staff as identified through administrative record review and staff interviews.
Failure to Complete Required Annual Performance Evaluations for GNAs
Penalty
Summary
The facility failed to ensure that annual performance evaluations for Geriatric Nursing Assistants (GNAs) were completed at least every twelve months, as required. During a review of four GNA personnel files conducted between 10:00 AM and 12:00 noon on 02/04/2026, surveyors found that GNA #15, hired on 01/28/2014, had no annual performance evaluations documented for the years 2016 through 2026. In addition, GNA #9, hired on 07/26/2023, did not have annual performance evaluations present for 2024 or 2025. The annual performance evaluation is used to identify which clinical competency skills each GNA should improve or maintain based on the required annual 12-hour competency skills training. At 12:00 noon on 02/04/2026, the surveyor reviewed these findings with the Director of Nursing and the Human Resources Manager, and the Human Resources Manager confirmed that the facility could not provide evidence that the required annual performance evaluations had been completed for the identified time periods. This deficient practice was discussed with facility leadership during the exit conference on 02/04/2026.
Unsanitary Kitchen Conditions and Improper Food Storage and Labeling
Penalty
Summary
Surveyors identified a failure to maintain the kitchen and food service areas in a sanitary manner and to properly store and label food items. During observation of the main kitchen, a box containing cans of ginger ale and tomato juice was stored directly on the floor near a hand sink floor drain. A spice rack held an open, undated container of dill weed that was approximately two-thirds full. Debris was seen in the floor drain beneath the dishwasher, and a pair of used plastic foodservice gloves was found on the floor near the dishwasher. Multiple broken floor tiles were noted near the dishwasher, with standing gray water present in the crevices, and brown, dried stains were observed on the wall adjacent to the handwashing sink. Further observations revealed additional food storage and labeling deficiencies. In a freestanding refrigerator in the kitchen, two hard-boiled eggs and two muffins were wrapped together in plastic wrap without any labels or dates, and two containers of applesauce were marked with a preparation date and a use-by date that had already expired at the time of observation. In the dry storage area, a broken floor tile was partially covering the area from which it was missing, and a box of condiments was stored on a shelf without any date indicating when the items were received, while other items in the area were appropriately marked with received dates. During an interview, staff acknowledged concerns related to missing dates on food items, expired and unlabeled food, debris in floor drains, used gloves on the floor, and broken tiles collecting standing water.
Inaccurate Medical Record Diagnosis for Psychotropic/Anticonvulsant Medication
Penalty
Summary
The facility failed to maintain medical records in accordance with accepted professional standards by not accurately documenting a resident’s current medical diagnosis in relation to prescribed medication. Medical record review showed a care plan problem dated 12/15/2025 identifying a potential safety risk related to a seizure disorder, supported by a medication order dated 12/02/2025 for Lamotrigine 200 mg daily “for Seizure,” and a psychiatric note dated 01/29/2026 stating the resident was taking Lamotrigine for a diagnosis of Bipolar Disorder. However, the resident’s Diagnosis Report, which listed all active diagnoses, did not include a seizure disorder diagnosis, and staff confirmed there was no diagnosis or medical documentation in the record verifying that the resident had a seizure disorder. This inconsistency between the care plan, medication indication, psychiatric documentation, and the formal diagnosis list resulted in medical records that did not accurately reflect the resident’s current diagnoses.
Medication Storage and Security Deficiencies
Penalty
Summary
The facility failed to ensure that medications were secured and stored safely, as evidenced by multiple observations during the recertification survey. In one instance, an unopened Lispro Kwikpen insulin pen for a resident was found in a medication cart, dated and labeled to be refrigerated until opened, but was not stored in a refrigerator. This was confirmed by the RN responsible for the cart, who acknowledged that the pharmacy instructions were not followed. Similarly, another insulin pen for a different resident was found in a similar condition in another LPN's medication cart. Additionally, loose pills were discovered in the bottom of the same LPN's medication cart drawer. Further deficiencies were noted when a medication cup with a pink tablet was found at a resident's bedside, contrary to the facility's expectations that medications should not be left unattended. The Assistant Director of Nursing confirmed the medication was PreserVision, as per the resident's physician orders. Moreover, an unlocked medication cart was observed unattended in a hallway, with several staff members and a resident passing by before a nurse eventually locked it. These observations indicate lapses in medication storage and security protocols within the facility.
Failure to Provide ADL Care for Resident with Advanced Dementia
Penalty
Summary
Facility staff failed to provide necessary activities of daily living (ADL) care, such as showers, dressing, and toileting, for a resident who was dependent on them for this care. The resident, who had advanced dementia and was previously on hospice care, was admitted to the facility for therapy after a fall and a broken arm. During the 15 days at the facility, the resident did not receive scheduled showers, with documentation marked as 'N/A' or 'no' on multiple occasions. Additionally, the resident did not receive bed baths on specific dates, and incontinence care and personal hygiene were not documented as provided on several occasions. An interview with a geriatric nursing assistant (GNA) revealed that staff were trained to document care provided, and 'N/A' should not be used unless the resident was unavailable. However, there was no evidence that the resident was out of the facility on the days marked 'N/A' for care. The Director of Nursing (DON) stated that 'N/A' was acceptable if the resident was not available, but the medical record did not support this claim.
Inaccurate Medical Records in LTC Facility
Penalty
Summary
The facility failed to ensure the accuracy of residents' medical records, as evidenced by discrepancies found during a recertification survey. For one resident, the Medication Administration Record (MAR) inaccurately documented the administration of Boost VHC, despite the resident's refusal to consume it, preferring chocolate milk instead. This discrepancy was confirmed through interviews with the resident and their assigned Geriatric Nursing Assistant (GNA). Another resident's medical records lacked a Basic Metabolic Panel (BMP) lab result, which was supposed to be drawn due to concerns about the resident's declining oral intake and potential dehydration. The Nursing Home Administrator confirmed that the lab test was not conducted after contacting the laboratory company. Additionally, an error was found in the documentation of a Facility Reported Incident (FRI) involving another resident. The physician's note inaccurately recorded the date of service, which was later corrected by the Director of Nursing after consulting with the physician. The physician admitted to documenting the wrong date, which led to inaccuracies in the investigation timeline of the FRI. These findings highlight the facility's failure to maintain accurate and reliable medical records for its residents.
Failure to Timely Report Allegations of Abuse and Injuries
Penalty
Summary
The facility failed to report allegations of abuse to the state agency within the required timeframe for three residents. For Resident #100, an allegation of abuse was reported to facility staff on 10/6/23 at 12:15 PM, but the report was not sent to the state agency until 3:14 PM, exceeding the 2-hour reporting requirement. The Director of Nursing (DON) admitted that the facility lacked a process to ensure timely submission of such reports, which was confirmed by the Nursing Home Administrator (NHA). Resident #69 had an x-ray on 10/25/23 revealing an acute fracture, and was transferred to the ER. The injury was initially thought to be from a previous fall, but later considered an injury of unknown origin. Despite this, the report was not submitted to the Office of Health Care Quality (OHCQ) until 10/31/23, well beyond the 2-hour requirement for serious bodily injuries. For Resident #2, a fall occurred on 9/9/22, resulting in a head injury, but there was no evidence that the state agency was notified. The Administrator confirmed the incident was not reported.
Failure to Revise Care Plan After Resident Falls
Penalty
Summary
The facility failed to ensure that a resident's care plan was revised in a timely manner following multiple falls. During a review of the medical records for a resident, it was discovered that the resident experienced falls on three separate occasions. Despite these incidents, the care plan for falls had not been updated to reflect these events. This oversight was confirmed during an interview with the Regional Clinical Services Manager, who acknowledged that the care plan had not been revised to include the falls that occurred on the specified dates.
Improper Transfer Technique Leads to Resident Fall
Penalty
Summary
The facility failed to ensure the safety of a resident during a transfer from the bed to an electric wheelchair. On the specified date, a Geriatric Nursing Assistant (GNA) attempted to assist the resident in transferring from a lying position to a sitting position on the side of the bed. The resident informed the GNA that their legs were not properly positioned against the mattress, which was necessary for a safe transfer using a transfer board. Despite this, the GNA proceeded to pull the resident by their pants from behind the bed, resulting in the resident sliding off the bed and onto the floor. A review of the resident's Minimum Data Set (MDS) mobility assessment indicated that the resident required partial/moderate assistance for moving from lying to sitting on the side of the bed without back support. The Rehabilitation Director confirmed that the resident required one-person assistance when using the transfer board and that the GNA should have stood in front of the resident to perform the transfer safely. The incident highlights a failure in following proper transfer protocols, leading to the resident's fall.
Infection Control Deficiencies in Facility
Penalty
Summary
The facility failed to adhere to proper infection prevention and control practices during the annual recertification survey. During an initial tour of the laundry department, a surveyor observed an employee's personal backpack on the floor underneath the clean laundry folding table, which was acknowledged by the Housekeeping Floor Technician and the Laundry Aide as against the facility's expectations. Additionally, on Nursing Unit 1, the surveyor noted the absence of Enhanced Barrier Precautions (EBP) signage on the doors of two residents' rooms, despite physician orders for such precautions. The Assistant Director of Nursing/Infection Preventionist confirmed the lack of signage, which is required for residents with specific medical conditions such as catheters and enteral feedings. Further observations on Nursing Unit 3 revealed a Registered Nurse eating lunch in the clean utility room, which was against the facility's policy as stated by the Unit Manager. The Licensed Practical Nurse present also reminded the Registered Nurse of this policy. These incidents highlight lapses in maintaining infection control protocols, including the improper storage of personal items in clean areas and the failure to post necessary precautionary signage for residents requiring enhanced infection control measures.
Ineffective Pest Control Program
Penalty
Summary
The facility failed to maintain an effective pest control program, as evidenced by observations in the kitchen and conference room. During an initial tour of the kitchen, a surveyor observed a fly near the top shelf of the food storage rack in the dry storage room. The Certified Food Service Manager (CFSM) acknowledged the presence of the fly and mentioned that the pest control company is scheduled for service and treatment every other week. Additionally, on a separate occasion, surveyors observed gnats flying around in the conference room, and the Nursing Home Administrator (NHA) was seen swatting at a gnat while delivering documents to the surveyors. The review of ORKIN Pest Control Service Reports from March 2024 through August 2024 revealed multiple instances of pest issues, including ants, fruit flies, and roaches, in various areas of the facility. The reports indicated that treatments were conducted throughout the kitchen, storage areas, and office areas, with specific mentions of sanitation issues in the kitchen, such as drains and trash cans needing cleaning. Despite these treatments, the presence of pests during the survey indicates that the pest control measures in place were not effective in preventing or addressing the pest issues in the facility.
Latest citations in Maryland
The facility did not ensure that its Infection Preventionist (IP) met required qualifications for managing the Infection Prevention and Control Program. The DON reported serving as the IP but acknowledged lacking the specialized infection control training required for the role, and confirmed that no other staff member was currently qualified. Records showed that the previously qualified IP left several months earlier, and the Administrator and DON confirmed they were still seeking a replacement, leaving the infection control program without a properly trained leader.
Staff failed to consistently secure medications and medical supplies across three units, including an oxygen tank left on the floor behind a resident’s bed without a supporting device, a treatment cart with Collagenase Santyl cream left on top while two residents in power wheelchairs passed by, an unattended and unlocked treatment cart at a nursing station, and another treatment cart with Diclofenac gel and dressings left on top, indicating repeated lapses in maintaining locked and secure storage for drugs, biologicals, and related supplies.
The facility failed to provide sufficient dietitian coverage and timely nutritional assessments for several residents with significant dietary needs. A resident admitted for diabetic management with a high A1C was placed on a regular diet instead of the recommended carb-controlled diet and had only one weight taken in the first two weeks, with no dietitian review of the record. Another resident with prior significant weight loss had no documented dietitian follow-up despite continued weight loss, and a resident admitted with severe protein-calorie malnutrition experienced further significant weight loss without any dietitian assessment. The dietitian reported working limited hours and prioritizing certain high-risk cases, resulting in delayed or missed evaluations for new admissions and residents with ongoing nutritional concerns.
The facility failed to maintain adequate linen and incontinence supplies and did not keep resident care areas in good repair, resulting in delays and alterations in incontinence care and substandard environmental conditions. Staff reported that towels and washcloths were used instead of wipes and then discarded due to heavy soiling, and that linen deliveries to units were late, leaving residents waiting for care. Observations showed very limited numbers of clean washcloths and other linens on units and in the laundry, with no stock of disposable wipes or backup washcloth supply despite repeated reports to housekeeping. Additional observations revealed recliner chairs blocking a dining-area handwashing sink and kitchenette, multiple resident and shared bathrooms with unfinished spackle, chipped paint, musty odors, black substances near showers, missing threshold molding, exposed cracks and nails, and eroded, rusted baseboard heaters. Hallway handrails on both units were worn, chipped, and splintered, and a shower room contained fecal odors, dried brown stains on the toilet, and deteriorated fixtures, all contributing to a failure to provide a safe, clean, and homelike environment.
Facility staff did not thoroughly investigate two separate abuse allegations involving a resident and an injury of unknown origin involving another resident. In both cases, investigations focused on the directly affected resident and included staff interviews, but there were no interviews of other residents on the unit or documented assessments of those residents for signs of abuse or injuries of unknown origin, including residents unable to communicate due to cognitive status.
Two residents who were dependent on staff for oral care, including one with a tracheostomy, were observed with thick, white or milky substances coating their mouths and teeth, indicating inadequate oral hygiene. One resident communicated that staff did not brush their teeth and that staff "need to." In another case, despite oral care supplies being present in the room, the resident’s mouth and teeth remained unclean on multiple observations, with a thick milky substance caking the teeth and stringing between them when the resident tried to open their mouth. These findings showed that staff did not consistently provide oral care to residents who relied on them for this ADL.
Staff failed to maintain complete and accurate medical records for multiple residents, including missing and inconsistent documentation of wound care, delayed pain assessment after discovery of an injury of unknown origin in a cognitively impaired resident, and inaccurate recording of a PPD test result that was documented as negative despite no evidence the injection was administered and no supporting nurse’s note. Residents reported not receiving certain treatments, while MAR entries either lacked signatures for completion or contained conflicting information about whether care was provided.
Surveyors found that the facility failed to consistently implement and communicate correct transmission-based precautions and PPE use. One resident with a Foley catheter related to wounds had no precaution signage posted, while another resident in a double room had a contact precautions sign at the door, yet the NP entered without PPE and the GNA provided high-contact care wearing only gloves. Staff in that room stated the resident was not on contact precautions and later reversed the sign to show no PPE requirement. Therapy staff reported they rely solely on posted signs to determine PPE, and surveyors identified broader issues with inaccurate signage and staff awareness of which residents required contact precautions.
Surveyors found that MDS assessments were inaccurately coded for two residents. In one case, a resident sustained a femoral neck fracture after a fall, but the subsequent significant change MDS did not code the fall as a major injury and failed to capture prn Tylenol use documented on the MAR within the look-back period. In the other case, a quarterly MDS indicated opioid use for a resident, but the MAR for the same period showed no prescribed opioid, indicating incorrect coding of high-risk drug classes.
A resident who had recently been admitted and experienced a fall received multiple doses of the narcotic analgesic Tramadol, but the facility failed to accurately document all administered doses on the Medication Administration Record (MAR). Review showed only one Tramadol dose recorded on the MAR, while the Controlled Drug Receipt/Record/Disposition Form on the med cart reflected three doses given over two days. In interview, the DON stated staff are expected to document narcotic administration on the MAR and confirmed that two administered doses were not recorded there, resulting in an incomplete and inaccurate medical record.
Unqualified Infection Preventionist Overseeing Infection Control Program
Penalty
Summary
The facility failed to ensure that its designated Infection Preventionist (IP) met the mandatory qualifications for overseeing the Infection Prevention and Control Program. During an interview on 3/24/26 at 10:00 AM, the DON confirmed that she/he was serving as the facility’s IP but had not completed the specialized training in infection control required for the position. The DON further stated that no other staff member currently met the qualifications to serve as IP. Record review showed that the previously qualified IP left the facility in October 2025, and as of the survey date, the position remained unfilled by a qualified individual. At 1:30 PM on the same day, the Administrator and DON confirmed they were still in the process of finding a qualified IP for the facility, leaving the Infection Prevention and Control Program without a properly trained and qualified leader. No specific residents, medical histories, or clinical conditions were described in relation to this deficiency.
Unsecured Medications, Treatment Carts, and Oxygen Equipment
Penalty
Summary
Facility staff failed to ensure that drugs, biologicals, and related medical supplies were securely stored and properly maintained on multiple units. On one unit, an oxygen tank assigned to a resident was observed sitting on the floor behind the resident’s bed without any supporting device. On another unit, a treatment cart was observed with a tube of Collagenase Santyl cream labeled for a specific resident left on top of the cart, while residents in power wheelchairs passed by and staff were present at the nursing station. These observations showed that medications and oxygen equipment were not consistently secured as required. Further observations on additional units revealed an unattended and unlocked treatment cart at a nursing station, and on a separate occasion, a treatment cart with Diclofenac gel labeled for a resident left on top along with multiple packs of dressings. These incidents occurred across three units and on more than one date, demonstrating repeated failures to keep medications and treatment supplies in locked compartments or otherwise secured from unauthorized access.
Insufficient Dietitian Coverage and Delayed Nutritional Assessments
Penalty
Summary
The deficiency involves the facility’s failure to employ sufficient food and nutrition staff, including adequate dietitian coverage, to ensure timely assessment and appropriate diets for residents with significant nutritional and diabetic needs. A resident admitted over two weeks earlier with multiple comorbidities and an A1C of 11.5% had a hospital discharge recommendation for a carbohydrate-controlled diet, but was placed on a regular diet at admission with no acknowledgment of the recommended diet until one week later, when the resident requested larger portions. As of the survey date, the dietitian had not yet seen or reviewed this resident’s medical record, and the resident reported not having seen a dietitian and being very frustrated with the meals. During the first two weeks after admission, only one weight was obtained for this resident, despite physician notes stating the resident’s weight was “stable.” Further review of other residents showed additional failures in timely dietitian assessment and follow-up. One resident, readmitted in January and previously seen by the dietitian in September for a 6.4 lb weight loss over 30 days, had no documented follow-up despite continued weight loss totaling 22 lbs since the last dietitian review. Another resident admitted at the end of February with severe protein-calorie malnutrition had not been seen by the dietitian after about a month in the facility, despite a documented 14 lb (7%) weight loss over two weeks. The dietitian reported working only 12 hours per week at the facility and stated that she must prioritize which residents to see, focusing first on residents with tube feedings and those identified in risk meetings, resulting in delayed or absent assessments for new admissions and residents with ongoing weight loss and malnutrition diagnoses.
Linen Shortages and Poor Environmental Maintenance Compromise Resident Care and Comfort
Penalty
Summary
The deficiency involves the facility’s failure to maintain an adequate supply of clean linens and appropriate incontinence wipes, resulting in delays and alterations in residents’ incontinence care, as well as the use of towels and washcloths in place of disposable wipes. During the initial tour, the surveyor observed that the linen supply on one nursing unit hallway was low. Complaint reviews included concerns about delays in incontinence care and bed linens not being changed regularly, with residents left without clean bedding. A complainant reported that there was not enough clean linen available for residents. Staff interviews confirmed that towels, sheets, and washcloths were being used to wipe residents for incontinence care due to the absence of wipes, and that many of these linens were being thrown away when soiled. Staff also reported a shortage of linen, that linen deliveries to the units were late, and that residents who preferred to get up before breakfast had to wait for care when linen was delayed. Further observations showed that the clean supply room contained no disposable wipes or cloths for incontinence care, and a resident reported that staff did not use wipes, that the resident had to purchase their own, and that heavily soiled towels or washcloths were discarded. A tour of all nursing unit linen carts and closets revealed only six clean washcloths and limited supplies of towels, gowns, and bed linens. In the laundry room, only three washcloths were present, and the laundry assistant stated that there were only three washcloths available for each nursing unit that morning, that the facility was short on linen supply, and that these concerns had been repeatedly reported to the Director of Housekeeping over the preceding month and again that morning. The laundry assistant confirmed there was no additional laundry in process. The DON stated that wipe squares should be used for incontinence care, but no such wipes were found in the clean medical supply room, and no backup supply of washcloths was present in the emergency linen supply. The Director of Housekeeping confirmed there was no backup supply of washcloths. The deficiency also includes environmental and maintenance issues affecting resident bathrooms, handrails, and common areas. In the main dining area, a recliner chair was observed positioned directly in front of the handwashing sink, and two recliner chairs were stored in front of the nutrition area kitchenette. Multiple resident bathrooms and shared bathrooms were repeatedly observed over several days with unfinished spackle on walls that needed resurfacing and painting, chipped paint around sinks, uneven boards nailed to walls under sinks that appeared to partially cover holes, musty odors, black substances between shower bases and walls, missing threshold transition molding exposing cracks, missing tiles, and a nail, as well as eroded and chipped paint on baseboard heaters with exposed dark brown metal and rust-like material. Hallway handrails on both nursing units were observed to be worn, with chips, splintering, holes, and areas where the wood finish had worn off. A shower room was observed with a foul fecal odor, dried brown stains on the back of the toilet seat and in the toilet bowl, and a baseboard heater with eroded, chipped paint and rust-like material, along with chipped paint on the handrail. These conditions were acknowledged by the Director of Maintenance and other leadership, and some areas were noted to be in the process of renovation, but the observed deficiencies remained present during the survey period. Overall, the facility did not maintain a safe, clean, comfortable, and homelike environment in good repair across both nursing units and the dining area. The lack of adequate linen and incontinence supplies, combined with the poor condition of resident bathrooms, handrails, and certain common areas, constituted the basis for the cited deficiency. The observations and staff and resident reports consistently described shortages of essential hygiene supplies, delayed care related to linen availability, and multiple unresolved environmental and maintenance issues in resident care areas and shared spaces.
Failure to Thoroughly Investigate Abuse Allegations and Injuries of Unknown Origin
Penalty
Summary
Facility staff failed to thoroughly investigate allegations of potential abuse involving one resident and an injury of unknown origin involving another resident. For one resident, there were two separate allegations of abuse occurring on different days in early February. The facility’s investigation packets included interviews with staff who cared for or were scheduled to work with this resident on the days of the alleged incidents, and the investigations focused solely on this resident. However, there were no interviews conducted with other residents on the unit to inquire about abusive or neglectful treatment by the staff who were working during the times of the allegations. The surveyors noted that, although the allegations were not validated, there was no documentation that other residents were interviewed, if able, or assessed for signs or symptoms of injury. In a separate incident, another resident was identified on March 4 with a new bruise on the right eye, documented as a change in condition at 4:09 AM. This resident had a BIMS score of 99, indicating the resident was unable to complete an interview and therefore could not report how the injury occurred. The facility’s investigation identified a potential cause of the injury but did not reach a definitive resolution. Additionally, there were no interviews of other residents on the unit regarding possible abuse, nor were there documented assessments of other residents for injuries of unknown origin, particularly for those unable to speak for themselves, as in this resident’s case.
Failure to Provide Oral Care to Dependent Residents
Penalty
Summary
The deficiency involves the facility’s failure to provide oral care to residents who were dependent on staff for activities of daily living, specifically oral hygiene. One resident with a tracheostomy was observed with a thick, sticky white substance in the mouth and was noted to intermittently chew on nearby bedding. This resident made good eye contact and, when asked if staff brushed their teeth, shook their head no and mouthed that staff “need to.” According to the resident’s Minimum Data Set (MDS) dated 2/11/26, the resident was dependent on staff for oral care. Another resident, also dependent on staff for oral care per the 3/11/26 MDS, was observed sitting propped up in bed and able to respond with smiles. During the initial observation, the inside of this resident’s lips and upper and lower teeth had a thick, clear, white milky substance visible when the resident tried to open their mouth to smile. Oral care supplies were present in the nightstand, but the resident’s mouth and teeth were not clean. On a subsequent observation with the DON, NHA, and Corporate VP of clinical services, the same resident again had a thick, clear, milky substance between the lips and caking the teeth, which would string between the teeth when the resident attempted to open their mouth, demonstrating a lack of consistent oral care for residents dependent on staff for this ADL.
Incomplete and Inaccurate Medical Record Documentation for Treatments and Assessments
Penalty
Summary
Facility staff failed to maintain complete and accurate medical records and documentation for multiple residents. For one resident with wound care needs, review of the MAR showed that wound care and related treatments were signed as completed on the dates initially reported, despite the resident’s ongoing complaints that wound dressings were not being changed. When additional dates were reviewed, there were missing staff signatures for wound care on two specific dates, as well as three instances where application of A&D ointment to the resident’s feet was not signed off out of 24 days reviewed. Another resident with severe cognitive impairment, as evidenced by a BIMS score of 00, was found to have an injury of unknown origin (a bruise on the left hand). Documentation showed that a change in condition was initiated late in the morning, but a formal pain evaluation was not initiated and completed until that night, and the resident was unable to explain how the injury occurred or verbalize pain using a standard pain scale. For a third resident, documentation related to the admission PPD test was inconsistent and incomplete. The MAR contained an entry indicating “9” for the administration date, meaning “see nurse’s note,” but there was no corresponding nurse’s note. Despite the absence of a signed administration of the PPD injection, staff documented the PPD result as “negative” on the scheduled read date. The resident reported never receiving the PPD injection, and the DON confirmed that the facility had been out of PPD solution at the time, so the test would not have been administered. These findings demonstrate failures in accurate documentation of treatments and assessments, including wound care, pain assessment, and TB screening, as well as missing or incomplete supporting notes in the medical record.
Failure to Implement and Communicate Correct Transmission-Based Precautions
Penalty
Summary
Surveyors identified a deficiency in the facility’s infection prevention and control program related to inconsistent and incorrect implementation of transmission-based precautions and PPE use. During a complaint investigation focused on residents on transmission-based precautions, one resident with a visible Foley catheter was observed in the room with physical therapy, but there were no signs posted indicating any need for PPE, despite the resident being a new admission with a Foley catheter placed related to wounds. In another double-occupancy room, a contact precautions sign was posted at the doorway, but the nurse practitioner was in the room on a personal phone with no PPE, and the assigned GNA was repositioning the resident in bed while wearing only gloves. When questioned, the NP, RN, and GNA all stated that the resident in the room was not on contact precautions, and the GNA reported that signs were hanging at all doors and that this particular resident’s sign was “just wrong.” The surveyor observed the GNA later return to the room and turn the sign around to indicate no PPE requirement. Subsequent interviews revealed that therapy staff relied on posted signage to determine PPE use and that if the sign was wrong, the PPE used would be wrong. Overall, surveyors found problems with signage accuracy and staff awareness of which residents required contact precautions, as well as observed failures to follow appropriate PPE use for residents who should have been on contact precautions.
Inaccurate MDS Coding for Falls, Pain Management, and High-Risk Medications
Penalty
Summary
Facility staff failed to ensure Minimum Data Set (MDS) assessments were accurately coded for two residents reviewed during a complaint survey. For one resident, a facility-reported incident showed that the resident was found seated on the floor beside the bed and was diagnosed with a non-displaced femoral neck impaction fracture of the left hip following an x-ray. Despite this fall with a major injury, the subsequent significant change MDS dated 11/4/25 did not code the fall with major injury in Section J1900C. Review of the resident’s Medication Administration Records for October and November 2025 showed administration of Tylenol on 10/31/25 at 9:30 PM, which fell within the 5-day look-back period for the MDS, but Section J0100 (prn pain) of the same significant change MDS did not capture the use of Tylenol. For another resident, review of a quarterly MDS with an assessment reference date of 10/15/25 showed that Section N0415 (High-Risk Drug Classes) documented the use of an opioid medication. However, review of the resident’s October 2025 Medication Administration Record did not show that the resident had been prescribed an opioid during that period. In both cases, MDS staff later confirmed that these were errors in MDS coding, demonstrating that the assessments did not accurately reflect the residents’ clinical status and medication use as documented in their medical records.
Incomplete Documentation of Narcotic Administration on MAR
Penalty
Summary
The facility failed to maintain complete and accurate medical records in accordance with accepted professional standards for one resident receiving narcotic medication. The resident, admitted in March 2026, had a fall on 3/6/26 and was sent to the hospital on 3/9/26. Review of the March 2026 Medication Administration Record (MAR) showed documentation of a single 25 mg dose of Tramadol administered on 3/8/26 at 9:23 AM. However, review of the resident’s Controlled Drug Receipt/Record/Disposition Form, kept on the nurse’s medication cart and not in the medical record, showed that Tramadol 25 mg was administered three times between 3/8/26 and 3/9/26: at 11:00 AM and 9:00 PM on 3/8/26, and at 9:00 AM on 3/9/26. In interview, the DON stated that staff are expected to document narcotic administration on the MAR and confirmed that only one of the three Tramadol doses reflected on the controlled drug record was documented on the resident’s MAR. This discrepancy between the controlled substance record and the MAR, with missing documentation of two administered doses of Tramadol on the official medical record, constituted the failure to maintain a complete and accurate medical record for the resident.
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Every citation, penalty and Plan of Correction is sourced from public CMS records (latest release May 27, 2026) and official state health department websites — never guesswork.
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