Future Care Cold Spring
Inspection history, citations, penalties and survey trends for this long-term care facility in Baltimore, Maryland.
- Location
- 4700 Harford Road, Baltimore, Maryland 21214
- CMS Provider Number
- 215253
- Inspections on file
- 19
- Latest survey
- October 7, 2025
- Citations (last 12 mo.)
- 29
Citation history
Health deficiencies cited at Future Care Cold Spring during CMS and state inspections, most recent first.
A staff member was reported to have physically and verbally abused a resident, with a witness observing the staff member strike the resident, causing them to stumble. The resident and a roommate provided statements supporting the occurrence of the incident, while the staff member denied the physical abuse but admitted to making a threatening statement. The incident was reported for further investigation due to conflicting accounts.
Staff did not notify the state agency within the required two-hour timeframe after becoming aware of alleged incidents involving two residents. In both cases, the incidents were reported late, as confirmed by record review and staff interviews, despite facility policy requiring prompt reporting by the Administrator, DON, or ADON.
Staff did not follow professional nursing standards when a nurse delayed completing and backdated a change in condition evaluation for a resident, and an LPN failed to notify the physician after a resident repeatedly refused suprapubic catheter care. The DON and Regional Clinical Service Manager confirmed that timely documentation and physician notification are required in these situations.
Staff failed to obtain and administer medications as ordered for two residents, resulting in missed doses due to unavailable medications and improper insulin administration for a diabetic resident. Errors included not performing required blood sugar checks before meals and administering insulin at incorrect times, contrary to facility policy and physician orders.
A resident with dementia and wandering behavior exited the facility due to a malfunctioning wander guard system at the main entrance. Documentation revealed lapses in medication administration and nursing care by an LPN, and discrepancies in staff accounts regarding the incident. Post-incident logs showed errors in wander guard checks, and there was no evidence of immediate repairs following the mechanical failure.
A review of Personal Funds revealed that the facility's surety bond amount was not sufficient to cover the total amount of residents' personal funds held. The Corporate Accounts Receivable Manager indicated that residents' funds were kept in separate accounts and covered by a surety bond. However, the Trial Balance document showed a total of $172,021.92 across 75 residents, while the surety bond amount was $170,000.00. The Nursing Home Administrator confirmed the discrepancy, acknowledging that the surety bond did not cover the total amount of funds held by the facility.
The facility experienced issues with ensuring that food served to residents was palatable and at a safe, appetizing temperature. Residents reported dissatisfaction with the food's taste, temperature, and quality. Observations revealed malfunctions in food service equipment, including a broken indicator light on the steam table and a missing indicator light on the plate warmer system. Temperature testing showed a turkey burger patty at 106.7°F and cool waffle fries, with additional issues such as soggy buns and dry fries noted during palatability testing.
The facility experienced deficiencies in three key areas of its infection prevention and control program. Urinary bags for a resident were observed touching the floor multiple times, indicating improper handling. The Infection Prevention Control policy manual was outdated, with no annual reviews or updates since 2021. Additionally, staff handling dirty laundry were not using appropriate PPE, such as masks and gowns, and lacked adequate training on infection control practices related to laundry handling.
The facility failed to ensure sanitary practices and proper food storage in the kitchen. Observations included staff not wearing hair restraints, food debris in the dishwashing area, and improper storage of food items. Temperature logs for refrigerators and freezers were incomplete or inaccurate, and unlabeled food items were found. Broken kitchen equipment and inadequate monitoring of the kitchen environment were also noted.
The facility experienced issues with the accuracy of MDS assessments and coding. One resident's discharge status was incorrectly coded as a short-term general hospital instead of home. Another resident's MDS lacked an updated assessment upon discharge, with the last assessment not reflecting the discharge. Discrepancies were found in the functional limitations coding for a resident with hemiplegia and hemiparesis, showing conflicting information on upper and lower extremity impairments. Additionally, a resident's MDS assessment did not reflect the presence of pressure ulcers documented in wound and skin notes.
The report identifies several instances where care plans did not align with physician orders or resident needs. For a resident with daily wound care orders, the care plan lacked these interventions, raising concerns about pressure ulcer management. Another resident's care plan did not address their pressure ulcer at all. Specialized care plans for hospice and palliative care were found to be insufficient, lacking person-centered details. A resident with a suprapubic catheter had no care plan for surgical wound care. Infection control measures were also deficient, with no care plan for a resident on contact precautions for C-diff and inadequate details for G-tube feeding care.
Several residents, including those with recent MDS assessments, did not have documented care plan meetings. The Unit Manager indicated that the social worker, responsible for these meetings, had been inconsistent due to staffing changes. The DON acknowledged missed records for some residents due to the absence of a social worker since March 2023.
The facility failed to ensure physician responses to pharmacist recommendations for three residents, including recommendations for medication adjustments and clarifications. The DON confirmed the absence of documented responses and acknowledged ongoing efforts to improve compliance.
A resident reported losing $57 left on their bedside table. The facility's investigative report claimed the resident was provided a key to their nightstand for safekeeping, but the resident stated that their nightstand did not have a lock. Upon inspection, it was confirmed that the nightstand had a circular hole for a lock but no actual lock was present. The administrator was initially unaware of this issue and later confirmed the absence of a lock, indicating a failure to provide the promised security for the resident's belongings.
The facility failed to maintain a safe, clean, comfortable, and homelike environment, with issues such as damaged walls, broken fixtures, and unaddressed maintenance concerns observed in two nursing units. The maintenance director was unaware of these issues, which were not documented in the maintenance book.
The facility failed to provide a secure storage space for residents' belongings, as evidenced by a resident's complaint about missing or damaged items worth $2,332. Observations showed a cluttered storage room with unlabelled boxes and no security measures. The DoN confirmed the absence of a safe storage policy and tracking process.
The facility staff failed to timely report an allegation of abuse/harassment and a resident elopement to the State Agency within the required time frame. In one case, a resident was found by EMS and brought to the ER, but the self-report was delayed by over 4 hours. In another case, the facility delayed reporting harassment allegations by over 3 hours after police were notified.
The facility failed to thoroughly investigate allegations of misappropriation of resident property and a resident's elopement. Investigations lacked proper documentation, interviews, and evidence of staff training. Discrepancies in nursing care and medication administration records were also noted.
Facility staff failed to provide correct notice and ensure the safe discharge of a resident. The social worker issued a premature Notice of Medicare Non-Coverage, and the physical therapy staff ended skilled rehabilitation services abruptly without proper discharge planning. The resident's caretaker prevented an unsafe discharge.
The facility failed to maintain safety by leaving a resident's bed elevated, did not reassess a resident's fall risk after a fall, and missed follow-up appointments for another resident. Staff confirmed the bed should be lowered to prevent falls, and the DON acknowledged the missed appointments and lack of fall risk reassessment.
The facility failed to perform physician-ordered wound treatments and provide timely wound consultations for two residents. One resident's wound deteriorated due to lack of documented treatment, and another resident's wounds worsened due to incomplete and delayed assessments.
The facility staff failed to provide required care to a resident's PEG site, as the Treatment Administration Record did not include PEG site care, and there was no evidence of completed care. The Director of Nursing confirmed the oversight.
A resident went on a leave of absence (LOA) and returned the same day without a physician's order for the LOA. The DON confirmed that a new order should have been obtained for the LOA on the day the resident actually left, but this was not done, resulting in a deficiency.
The facility staff failed to follow physician orders by administering PRN pain medication outside the prescribed parameters, resulting in unnecessary medication for two residents. One resident received Oxycodone for pain scores below the prescribed range on multiple occasions, while another resident was given Oxycodone for pain scores below the prescribed range in January and February 2024. The DON confirmed these findings and acknowledged the inappropriate administration of medication.
The facility staff failed to ensure that the call system in the 3A central bathing room was fully functional. Specifically, 2 of the 3 shower stalls and the call switch wall panel for the toilet did not have cords attached to the call system. Without the cords, residents would not be able to access the call system if they were lying on the floor, potentially compromising their ability to call for help in an emergency situation.
The facility failed to document, review, and provide written responses to resident council concerns, leading to ongoing issues with laundry, linens, and shower room conditions. Residents expressed dissatisfaction with the lack of follow-up and incomplete documentation of their grievances.
The facility failed to notify two residents in writing of the bed-hold policy upon transfer to an acute care facility. Documentation was missing or incomplete, and the DON confirmed the deficiency.
The facility failed to document opioid use accurately and did not ensure a nurse had the necessary competencies for dialysis care. Two residents had multiple instances of opioid administration not recorded in the MAR, and a dialysis resident was found bleeding due to improper post-dialysis care. The DON admitted to assuming agency nurses were competent without verification.
A facility failed to provide appropriate urostomy care for a resident with bladder cancer. The resident reported that nurses did not empty, monitor, or assess the urostomy. The medical record lacked specific orders and documentation for urostomy care, and the care plan did not include detailed interventions. Interviews with an LPN and the DON confirmed these deficiencies.
The facility failed to place a physician's order for the indication of Oxygen administration and did not develop a comprehensive care plan for a resident's respiratory care, including oxygen therapy. The resident was observed using 2 liters of Oxygen via nasal cannula without a proper care plan or indication for its use in the medical record. The DON confirmed the oversight.
A nurse failed to perform a timely post-dialysis assessment on a resident, leading to a delay in identifying bleeding from the resident's Arteriovenous Fistula (AVF). Staff interviews confirmed that post-dialysis assessments should be done immediately upon the resident's return.
A facility failed to ensure that a licensed nurse was competent to care for a dialysis resident, resulting in a serious incident where a resident returned from dialysis with an arterial needle and clamp left in their access point. The issue was discovered more than two hours later when the resident was found bleeding. The LPN involved admitted to not having received training in dialysis care, and the DON acknowledged assuming agency nurses were competent without verification.
The facility staff failed to monitor and document a resident's inappropriate behavior, despite orders from the Psychologist. The LPN confirmed that behavior should be documented every shift, but records showed no checklist or progress notes. The DON acknowledged the concern but did not provide a method to validate behavior monitoring.
The facility failed to ensure proper documentation and timely administration of narcotics and antibiotics for residents. Narcotics were removed without corresponding MAR entries, and a resident did not receive prescribed antibiotics on time due to staff oversight. These issues were confirmed by staff interviews and record reviews.
The facility failed to implement a gradual dose reduction (GDR) for a resident on Seroquel despite recommendations from both a psychiatric provider and a consultant pharmacist. The resident's active medication order did not reflect the suggested dosage decrease, and there was no documented response from the physician or prescriber to the pharmacy's recommendation.
The facility failed to remove expired medications and properly store medications. Expired Intravenous Ertapenem was found in a medication storage room, and an unlabeled medication cup with 11 unidentifiable pills was found on a medication cart. Additionally, a medication cart was left unattended with a bubble pack of Diltixem ER 180 mg on it. The DON validated these concerns during interviews with the surveyor.
The facility failed to ensure that a resident received timely dental services, resulting in the resident not having dentures despite a scheduled follow-up in September 2023. Medical records indicated a missed follow-up, and staff confirmed issues with the dental service provider.
The facility failed to ensure complete documentation for a resident's medically ineffective treatment certification and made a transcription error in a sliding scale insulin order for another resident. The issues were acknowledged by the Director of Nursing and the Medical Director.
The facility failed to obtain the proper documentation for a resident who received hospice services. An order to admit the resident to hospice services was found, but no hospice documentation was present in the electronic medical record or paper chart. The DON confirmed the absence of required hospice forms.
The facility failed to maintain two bathtubs and two lift devices in safe working condition. Two bathtubs were found non-functional, and two lifts had broken parts with sharp edges, making them unsafe for use. The issues were confirmed by staff and communicated to the nursing home administrator.
The facility failed to maintain an effective training program for new and existing staff, as evidenced by incomplete training records for a GNA and a lack of training documentation for an RN since 2020. The DON and HR staff confirmed these deficiencies and acknowledged the need for follow-up.
The facility failed to ensure that all GNAs received the required 12 hours of annual education, including dementia management and resident abuse prevention training. One GNA, hired in October 2021, did not have records of the required training for 2022, as confirmed by the DON.
The facility failed to consistently post and retain nurse staffing data, including the ratio of licensed and unlicensed staff to residents, across all nursing units. The DON acknowledged the issues and confirmed that the facility was not keeping copies of the posted daily nurse staffing data as required by federal regulations.
Staff-to-Resident Physical and Verbal Abuse Incident
Penalty
Summary
A deficiency occurred when a staff member, specifically a Geriatric Nursing Assistant (GNA), was reported to have physically and verbally abused a resident. According to the facility's investigation, a Maintenance Assistant witnessed the GNA pull back their hand and strike the resident on the left shoulder with enough force to cause the resident to stumble into a wardrobe. The resident's roommate did not see the incident but heard the resident yell and a stumble. The GNA denied hitting the resident but admitted to saying, 'I'm going to bop you.' The resident later stated that the GNA hit them with a key holder because they were not dressed. The investigation also noted that the GNA had a history of tardiness and absences from work. Further interviews revealed conflicting accounts, with the Regional Director of Operations stating the investigation was inconclusive, as the resident gave differing statements about where they were struck and described the contact as a 'tap.' The Maintenance Assistant maintained that they witnessed the GNA strike the resident. The incident was reported to the Maryland Board of Nursing for further investigation. The deficiency centers on the physical and verbal abuse of a resident by a staff member, as witnessed and reported by another employee, and corroborated by the resident's statements and the roommate's account of hearing the incident.
Failure to Timely Report Alleged Incidents to State Agency
Penalty
Summary
Facility staff failed to notify the state agency within the required two-hour timeframe after becoming aware of alleged incidents involving two residents. In the first case, staff became aware of an alleged incident at 6:50 AM and reported it to the state agency at 9:23 AM, exceeding the two-hour reporting window. In the second case, staff became aware of an alleged incident at 1:40 PM and reported it at 3:51 PM, again outside the required timeframe. These findings were confirmed through record review and staff interviews, which established that the Administrator, DON, or ADON are responsible for reporting such incidents, and that the facility's policy is to report allegations of abuse as soon as possible, within two hours.
Failure to Follow Nursing Standards for Timely Documentation and Physician Notification
Penalty
Summary
Facility staff failed to adhere to professional standards of nursing practice in two cases. In one instance, a registered nurse completed a change in condition evaluation for a resident 11 days after the change occurred and backdated the documentation. The Director of Nursing confirmed that such evaluations are expected to be completed before the end of the shift and that supervisors are responsible for ensuring timely documentation. In another case, a licensed practical nurse documented that a resident refused care of their suprapubic catheter on two separate occasions but did not notify the physician as required. The Regional Clinical Service Manager stated that staff are expected to re-offer care, involve the family, educate the resident, and notify the physician when care is refused.
Medication Administration and Insulin Sliding Scale Deficiencies
Penalty
Summary
Facility staff failed to obtain and administer medications according to procedures for two residents. For one resident, multiple medications, including Famotidine, Levothyroxine, and a nasal solution, were not administered as ordered because the pharmacy had not delivered them to the facility. Documentation in the Medication Administration Record (MAR) indicated these medications were coded as not given, with progress notes confirming the medications were ordered but unavailable. The facility's policy required medications to be administered within appropriate time frames, but this was not followed in these instances. In another case, staff did not accurately or safely conduct and apply the insulin sliding scale before meals for a resident with diabetes mellitus type 2. The nurse failed to perform a blood sugar (BS) check before breakfast and did not provide the correct insulin coverage, as the MAR had an incorrect time for the BS check that did not align with the actual meal time. The night shift nurse performed a BS check much earlier than the meal and administered insulin based on that reading, while the day shift nurse omitted the required pre-meal BS check and insulin coverage. These actions resulted in the resident not receiving insulin as ordered in relation to meal times.
Supervision and Elopement Prevention Deficiency
Penalty
Summary
The facility failed to ensure adequate supervision and prevent elopement for Resident #92, who had a history of dementia and wandering behavior, as documented in their care plan upon admission in 2021. Despite having a functional wander guard in place on the day of the incident, an equipment malfunction at the main entrance resulted in no alarm sounding as Resident #92 exited the facility on 1/26/22. The Medication Administration Audit Report for that day revealed lapses in documentation and delayed administration of medications and nursing care by Staff #63, a Licensed Practical Nurse (LPN). Staff #57, another LPN assigned to Resident #92 on the 3-11 pm shift, reported not seeing the resident and failing to notice their absence. Further investigation revealed discrepancies in staff accounts regarding the incident, with Staff #56, a Geriatric Nursing Assistant (GNA) assigned to Resident #92, denying seeing the resident on the day of elopement. The facility's documentation logs of wander guard checks post-incident showed an error in the number of days checked in February 2022. Despite upgrades made to the wander guard system after the elopement, there was no evidence of immediate repairs following the mechanical failure on 1/26/22.
Surety Bond Coverage Insufficient for Residents' Personal Funds
Penalty
Summary
The facility failed to ensure the amount of the surety bond was comparable to the total amount of residents' personal funds held, as revealed during a review of Personal Funds on 3/07/24. The Corporate Accounts Receivable Manager stated that residents' funds were kept in separate accounts and covered by a surety bond. However, a review of the Trial Balance document showed a total of $172,021.92 across 75 residents, while the surety bond amount was $170,000.00, indicating an insufficiency in coverage. The Nursing Home Administrator confirmed the discrepancy during an interview, acknowledging that the surety bond did not cover the total amount of funds held by the facility.
Food Temperature and Quality Concerns Due to Equipment Malfunctions
Penalty
Summary
The deficiency identified in the report pertains to the failure of the facility to ensure that food served to residents is palatable and at a safe, appetizing temperature. Multiple residents expressed dissatisfaction with the quality of the food, citing issues such as lack of taste, coldness upon arrival, and overall poor quality. Observations made during the survey revealed specific issues with the food service equipment, including a broken indicator light on the steam table holding turkey burgers and a missing indicator light on the plate warmer system. These equipment malfunctions likely contributed to the inconsistency in food temperature and quality experienced by the residents. Furthermore, the surveyor's temperature testing of a turkey burger patty and waffle fries from a test tray revealed that the food was not served at an appropriate temperature, with the turkey burger patty measuring at 106.7 Fahrenheit and the waffle fries being cool to the touch. The immediate testing of palatability conducted on the test tray highlighted additional issues, such as soggy buns, dry and chewy fries, and overall unappetizing food presentation.
Infection Control Deficiencies in Urinary Bag Handling, Policy Updates, and Laundry PPE Usage
Penalty
Summary
The deficiency identified during the survey pertains to three main areas within the facility's infection prevention and control program. Firstly, it was noted that the facility failed to appropriately hang a urinary bag for Resident #51, with the bag coming into contact with the bare floor on multiple occasions despite staff interventions. Secondly, the facility was found to have an outdated Infection Prevention Control program policy manual, last updated in 2021, with no evidence of annual reviews or updates. Lastly, staff handling dirty laundry were observed not using appropriate Personal Protective Equipment (PPE) such as masks and gowns, with inadequate training provided on infection control practices related to laundry handling.
Sanitary and Food Storage Deficiencies in Kitchen
Penalty
Summary
The facility failed to ensure sanitary practices were followed in accordance with professional standards for food service safety. Observations included dietary staff not wearing hair restraints, food debris in the dishwashing area, and improper storage of food items. Additionally, the soap dispenser at the staff handwashing sink was broken, and wet resident food trays were improperly stored. The ice dispenser and refrigerator in the nutrition rooms were also found to be unclean and improperly maintained. The facility also failed to store food in accordance with professional standards for food service safety. The walk-in refrigerator/freezer door was observed propped open, and temperature logs were inaccurately recorded. The temperature gauge on the walk-in refrigerator was taped over, and the thermometer inside read 60 degrees. Temperature logs for the ice cream freezer box and milk refrigerator box were incomplete or missing for several dates. Additionally, the temperature log for the reach-in snack/nourishment refrigerator had crossed-out entries. Furthermore, the facility failed to store, label, and monitor the expiration of food in accordance with professional standards for food service safety. Unlabeled and undated food items were found in the walk-in refrigerator, and staff were unsure of the expiration dates for these items. Broken and damaged kitchen equipment, such as a plastic container with a sharp edge and cook pans with scraped-away coatings, were also observed. The steam table and plate warmer system had broken indicator lights, and the facility's monitoring and oversight of kitchen equipment and environment were inadequate.
Inaccurate MDS Assessments and Coding Errors Identified
Penalty
Summary
The facility failed to ensure accurate assessments for residents #128, #93, and #291, as well as accurate coding of pressure ulcers for resident #89. For Resident #128, the MDS assessment incorrectly coded the discharge status as a short-term general hospital instead of home. Resident #93's MDS lacked an updated assessment upon discharge, with the last assessment dated 10/27/23 despite documentation of discharge. Resident #291's MDS showed discrepancies in functional limitations related to hemiplegia and hemiparesis, with conflicting information on upper and lower extremity impairments. In the case of Resident #89, the MDS assessment completed on 1/22/24 did not reflect the presence of pressure ulcers documented in wound and skin notes from 12/18/23 and 2/20/24.
Care Plan Deficiencies in Addressing Resident Needs
Penalty
Summary
The report details multiple instances where deficiencies were identified in the development and implementation of comprehensive care plans for residents in the facility. In the case of Resident #57, it was noted that despite physician orders for daily wound care and dressing changes, the care plan did not include these interventions. This lack of alignment between physician orders and the care plan raised concerns about the adequacy of care provided to address the resident's pressure ulcers. Similarly, for Resident #89, the care plan did not address the resident's pressure ulcer, indicating a gap in addressing the resident's needs effectively. Furthermore, the report highlighted issues with care plans for residents receiving specialized care, such as hospice services for Resident #47 and palliative care for Resident #91. In both cases, the care plans did not reflect the specific needs associated with these services, indicating a lack of person-centered care planning. Additionally, for Resident #101 with a suprapubic catheter, the care plan did not include this important aspect of the resident's care, highlighting a gap in addressing the resident's surgical wound care needs. The deficiencies extended to infection control measures as well, as seen with Resident #302 who had a contact precaution order for C-diff, but no care plan was initiated to address this infectious disease. Similarly, for Resident #297 with a G-tube, the care plan lacked specific details regarding tube feeding care, indicating a gap in addressing the resident's nutritional needs effectively.
Inconsistent Care Plan Meetings Due to Staffing Changes
Penalty
Summary
The facility failed to ensure that care plan meetings were conducted as required for several residents, including Resident #33, #82, #91, and #98. For example, Resident #91 had a quarterly MDS assessment completed on 11/21/23, but there was no documentation of a corresponding care plan meeting. The Unit Manager indicated that the responsibility for ensuring care plan meetings fell to the social worker, who had been inconsistent due to staffing changes. Similarly, Resident #98 had multiple MDS assessments completed, but care plan meetings were not documented after November 2022, with the Director of Nursing acknowledging missed records due to a lack of a social worker since March 2023.
Failure to Act on Pharmacist Recommendations
Penalty
Summary
The facility failed to ensure that a licensed pharmacist's monthly drug regimen review recommendations were acted upon by the physician. For Resident #44, pharmacy recommendations were made on 11/06/23 and 12/08/23, but there was no documentation of the physician's response to these recommendations. The Director of Nursing (DON) confirmed the absence of physician response documentation and acknowledged that the facility was aware of the issue and working to improve compliance. Similarly, for Resident #98, multiple pharmacy recommendations from 7/14/23 to 2/09/24 were documented, but no physician responses were recorded. The DON reiterated that the Medical Regimen Review (MRR) should be reviewed by the physician, and responses should be documented and uploaded to the residents' medical records. Additionally, for Resident #37, a pharmacy recommendation made on 2/9/24 suggested a gradual dose reduction (GDR) of Seroquel or documentation if a GDR was clinically contraindicated. However, there was no physician response documented, and the DON confirmed that the GDR was not done. These deficiencies were identified during the facility's recertification survey and were evident for three of the six residents reviewed for psychiatric medications.
Failure to Provide Secure Storage for Resident's Belongings
Penalty
Summary
The facility failed to accommodate a resident's need and preferences regarding the safekeeping of personal property. Specifically, a resident reported losing $57 left on their bedside table. The facility's investigative report claimed the resident was provided a key to their nightstand for safekeeping, but the resident stated that their nightstand did not have a lock. Upon inspection, it was confirmed that the nightstand had a circular hole for a lock but no actual lock was present. The administrator was initially unaware of this issue and later confirmed the absence of a lock, indicating a failure to provide the promised security for the resident's belongings.
Facility Fails to Maintain Safe and Homelike Environment
Penalty
Summary
The facility failed to maintain a safe, clean, comfortable, and homelike environment, as evidenced by multiple deficiencies observed in two of the four nursing units reviewed. During an abbreviated tour with the maintenance director, several issues were identified, including trash and a broom in a dirty, nonfunctioning electronic jet tub, a shower stall without a light, and water puddles in another shower stall. Additionally, there were holes punctured through the wallboard in the bathing room, and an unfinished repair with white spackle and scrapes on the wall. The maintenance director was unaware of these concerns, and they were not documented in the maintenance book. In a resident's room, significant damage was observed, including a caved-in wall with missing pieces, a damaged bathroom door veneer with an opening into the hollow space of the door, and protruding screws from the wood door frame. The maintenance director confirmed the damage and mentioned that a contractor was hired to fix and repair. Other issues included a busted jagged hole in the handrail in the 3rd-floor corridor, a broken plastic corner molding strip in another room, and irregular discolorations on the walls of the shower stalls in the 2A central bathing room. These environmental concerns were confirmed by the maintenance director and reviewed with the nursing home administrator.
Failure to Provide Secure Storage for Residents' Belongings
Penalty
Summary
The facility staff failed to provide a safe and secure storage space for residents' personal belongings, as evidenced by the case of one resident out of sixteen reviewed for self-reported incidents. The resident had complained about missing or damaged items and expected reimbursement of $2,332. The facility's investigation could not clarify how the belongings went missing or were damaged. Observations revealed that the storage room was cluttered with large trash bags and unlabelled boxes, making it difficult to access. The Director of Nursing (DoN) confirmed that there was no safe storage space policy, no security cameras, and no process to track items in and out of the storage room.
Failure to Timely Report Abuse and Elopement
Penalty
Summary
The facility staff failed to timely report an allegation of abuse/harassment and a resident elopement to the State Agency within the required time frame. For the first incident, the Executive Director was notified at 5:45 PM that a resident was found by EMS walking in the facility neighborhood and brought to the emergency room. However, the self-report was not sent to the Office of Health Care Quality until 9:55 PM, approximately 4 hours and 10 minutes after the notification. Additionally, there was a lack of documentation for the resident's care and behavior monitoring during the 3-11 PM shift on the day of the incident, with some tasks being documented over 32 hours later. In the second incident, the facility staff failed to report an allegation of harassment within the required time frame. The resident's family notified the facility about harassing texts in the morning, and the local police were contacted and arrived at the facility by 10:40 AM. However, the initial self-report to the State Agency was not sent until 1:59 PM, 3 hours and 19 minutes later. The Director of Nursing confirmed the delay in reporting and was unable to provide the exact time of the initial email notification from the resident's family.
Incomplete Investigations of Misappropriation and Elopement
Penalty
Summary
The facility failed to thoroughly investigate allegations of misappropriation of resident property and elopement. For two residents who reported missing personal property, the investigations were incomplete. The interview statements did not identify the persons completing them, and there were no statements from other residents or evidence of staff training post-incident. The Director of Nursing (DON) and Nursing Home Administrator (NHA) were informed of these deficiencies but provided no additional information to address the concerns raised by the surveyor. In the case of a resident's elopement, the facility's investigation was also found to be lacking. The initial self-report indicated that the resident was found by EMS and brought to the emergency room. However, the investigation did not include documentation of the equipment malfunction that allowed the resident to exit the facility, nor did it confirm the functionality of the wander guard system. There were no interviews with maintenance staff or other relevant personnel, and no hospital records or video surveillance were included in the investigation file. The surveyor noted discrepancies in the documentation of nursing care and medication administration, with some entries being backdated. The surveyor communicated these concerns to the facility staff, including the Administrator, DON, and Corporate Director of Operations. Despite these discussions, no further clarification or additional documentation was provided to address the deficiencies in the investigation. The facility's failure to conduct thorough investigations and maintain accurate records was evident in the cases reviewed during the survey.
Improper Notice and Unsafe Discharge
Penalty
Summary
Facility staff failed to provide correct notice and ensure the safe discharge of a resident. The resident was admitted for skilled rehabilitation therapy, which was ordered four times per week for 12 weeks. However, the social worker issued a Notice of Medicare Non-Coverage (NOMNC) prematurely, indicating that the resident would be liable for their stay or had to accept discharge, despite the resident still receiving skilled rehabilitation treatment and not having achieved treatment goals. Additionally, the social worker did not secure a suitable outpatient dialysis center or arrange home health services before attempting to discharge the resident, leading to an unplanned and unsafe discharge attempt that was only prevented by the resident's caretaker's advocacy. Further review revealed that the physical therapy staff documented the resident's deterioration and need for more assistance using stairs just two days before abruptly ending skilled rehabilitation services without indicating that the resident had returned to their prior functional level. The discharge order for rehabilitative services was not obtained until six days later. The administrator acknowledged these failures, including the premature issuance of the NOMNC and the lack of proper discharge planning and continuation of skilled rehabilitation treatments.
Failure to Maintain Safety and Follow-Up on Appointments
Penalty
Summary
The facility failed to maintain safety by allowing the bed of a resident at risk for falls to be in the up position when care was not being provided. This was observed when Resident #51 was found asleep in bed elevated about 3 feet high without any care being rendered. The resident's care plan indicated that the bed should be kept in the low position except when care was being provided. Staff members, including an agency Geriatric Nursing Assistant and a Registered Nurse, confirmed that the bed should be lowered to prevent potential injury from falls. The unit manager also acknowledged that the bed should be at the lowest position to maintain safety, especially for residents at risk of falls. The facility also failed to assess a resident's fall risk after a fall incident occurred. Resident #98 had a fall resulting in a large hematoma and laceration to the face and was transferred to the hospital. Upon readmission, the resident's fall risk was not reassessed, despite the facility's policy to assess fall risk after an actual fall. Additionally, the facility did not ensure follow-up for a resident's outside consult appointments. Resident #292, admitted for amputation rehabilitation, had follow-up appointments scheduled with the Vascular Surgery Center and the Wound Healing Center, but there was no documentation of these appointments in the resident's medical records. The Director of Nursing confirmed that the appointments were missed and that the family had canceled appointments without notifying the facility.
Failure to Perform Wound Treatments and Timely Consultations
Penalty
Summary
The facility failed to ensure physician-ordered wound treatments were performed and to provide timely wound consultations for two residents. Resident #295 was admitted with a pressure injury on the buttock, and although the attending physician ordered a specific treatment, it was not transcribed to the treatment administration record (TAR), resulting in no documentation of the treatment being performed. Additionally, the initial wound evaluation by the consultant wound care physicians was conducted 17 days after the wound was identified, by which time the wound had deteriorated. The Director of Nursing confirmed the treatment was not transcribed to the TAR, indicating a lapse in care documentation and execution. Resident #293 was admitted with a new in-house acquired wound identified as Moisture Associated Skin Damage (MASD). The wound was initially assessed and treated, but subsequent evaluations were incomplete and lacked proper measurements. The wound deteriorated over time, developing into two separate wounds, one on the buttock and one on the sacrum. The attending physician and nurse practitioner failed to document or assess the wounds adequately, and the consultant wound physicians' evaluation occurred 20 days after the initial assessment, revealing a stage 4 sacrum pressure wound. The corporate nurse confirmed the lack of weekly wound assessments and the potential inaccuracies in the initial wound assessments.
Failure to Provide Required PEG Site Care
Penalty
Summary
The facility staff failed to provide required care to a resident's percutaneous endoscopic gastrostomy (PEG) site. This was evident for one resident who was admitted with diagnoses including cerebral infarction, dysphagia with PEG tube placement, and dementia. A review of the Treatment Administration Record (TAR) revealed that PEG site care was not included in the TAR form, and there was no evidence that the PEG site care had been completed for the resident from the time of admission. The Director of Nursing confirmed that the TAR should include PEG site care to ensure consistent monitoring and cleaning by the nursing staff.
Failure to Obtain Physician's Order for Leave of Absence
Penalty
Summary
The facility failed to ensure that a resident's care was directed by a physician. This was evident when a resident went on a leave of absence (LOA) and returned the same day without a physician's order for the LOA. The resident had an order for an LOA on the previous day, but did not go on that day. The Director of Nursing (DON) confirmed that a new order should have been obtained for the LOA on the day the resident actually left, but this was not done, resulting in a deficiency.
Failure to Follow Physician Orders for PRN Pain Medication
Penalty
Summary
The facility staff failed to follow physician orders by administering PRN pain medication outside the prescribed parameters, resulting in the administration of unnecessary medication. This deficiency was identified for two residents during a recertification/complaint survey. Resident #116, who was admitted with multiple medical diagnoses including chronic ulcer, pain, diabetes, and atrial fibrillation, received Oxycodone 15 mg for pain scores below the prescribed range of 5-10 on multiple occasions in February 2024. Additionally, in September 2023, Resident #116 was given Oxycodone 20 mg for pain scores below the prescribed range of 7-10. Both the LPN and the Unit Manager confirmed the inappropriate administration of Oxycodone, acknowledging that alternative pain management options should have been considered or the physician should have been contacted for further orders. Similarly, Resident #57 had an active order for Oxycodone 5 mg to be given for pain scores of 7-10. However, the medication was administered for pain scores below the prescribed range on several occasions in January and February 2024. The Director of Nursing confirmed these findings and acknowledged that the staff did not follow the physician's orders, resulting in the administration of unnecessary medication. The DON indicated that staff education on pain management and PRN medication administration would be conducted to address these issues.
Deficiency in Call System Accessibility
Penalty
Summary
The facility staff failed to ensure that the call system in the 3A central bathing room was fully functional. Specifically, 2 of the 3 shower stalls and the call switch wall panel for the toilet did not have cords attached to the call system. This deficiency was observed on 3/5/24 at 2:26 PM. The maintenance director confirmed the findings on 03/08/24 at 10:39 AM. The nursing home administrator was informed of these observations on 03/11/24 at 1:30 PM. Without the cords, residents would not be able to access the call system if they were lying on the floor, potentially compromising their ability to call for help in an emergency situation.
Failure to Document and Address Resident Council Concerns
Penalty
Summary
The facility failed to ensure that grievances and concerns from the resident council were documented, reviewed, and responses provided to the group in writing. This was evident in a review of 9 resident council meeting minutes, which did not reveal the actual concerns or if previous concerns were reviewed. The resident council president and other members indicated that there was no real follow-up or review of previous concerns, and multiple residents expressed ongoing issues with laundry, linens, and the condition of shower rooms. The facility's process for addressing these concerns was found to be incomplete and lacking proper documentation and follow-up with the residents. Interviews with the resident council president and a group of residents revealed dissatisfaction with the facility's handling of their concerns. Issues such as missing or untimely returned personal laundry, poor quality and insufficient linens, and unclean shower rooms were repeatedly brought up in meetings but not adequately addressed. The residents also reported that staff were sometimes disrespectful when asked for basic necessities like towels and washcloths. The facility's concern forms often lacked complete information, such as the staff person receiving the concern, the results of the investigation, and whether the resident council was satisfied with the resolution. The nursing home administrator and activities staff acknowledged the deficiencies in the documentation and follow-up process. The activities director admitted that previous concerns were not properly reviewed, leading to residents having to restart the complaint process. The nursing home administrator confirmed that the appropriate department is supposed to respond to concern forms and review them at the next meeting, but several forms were found to be incomplete or lacking signatures and dates. This failure to properly document, review, and resolve resident council concerns led to ongoing dissatisfaction and unresolved issues among the residents.
Failure to Notify Residents of Bed-Hold Policy
Penalty
Summary
The facility failed to notify the resident or the resident's representative in writing of the bed-hold policy upon transfer to an acute care facility. This deficiency was identified for two residents during the recertification/complaint survey. Resident #118 was sent to the hospital in November 2023, but there was no documentation that the bed-hold notification form was signed by the resident or staff, nor was there any indication that the resident received a copy. The Director of Nursing (DON) confirmed that the bed-hold notification form was not signed and that there was no proof the resident received it. Similarly, Resident #12 was hospitalized on two occasions, but there was no documentation in the resident's physical chart or electronic medical records indicating that the bed-hold policy was provided. Staff indicated that the bed-hold policy should be given prior to transfer, but the DON was unable to provide proof that the policy was given to Resident #12. The emergency room checklist form did not show that the bed-hold agreement was provided on either transfer date. The DON acknowledged the concern and mentioned that the bed-hold notification process was being revamped.
Deficiencies in Documentation and Dialysis Care Competency
Penalty
Summary
The facility failed to meet professional standards of practice by not ensuring proper documentation and competency in two critical areas. Firstly, the nursing staff did not consistently document opioid use on the Medication Administration Record (MAR) and Controlled Drug Administration Record. This was evident for two residents, where multiple instances of opioid administration were not recorded in the MAR, leading to discrepancies in the narcotic count sheets. Specifically, one resident had nine instances of Oxycodone administration not documented, and another had nine instances of Tramadol administration not recorded in the MAR, despite being pulled from the medication cart multiple times within the review period. Secondly, the facility failed to ensure that a licensed nurse had the necessary competencies and skill sets to care for a dialysis resident. An incident occurred where a resident returned from dialysis with an arterial needle and clamp left in their access point, which was not discovered until over two hours later when the resident was found bleeding. The nurse responsible for the resident did not recognize the issue or take appropriate action, as she was not trained in dialysis care. The Director of Nursing admitted that there was an assumption that agency nurses were competent to care for dialysis patients, which was proven incorrect in this case. The deficiency in documentation and lack of proper training for dialysis care led to significant risks for the residents involved. The failure to document opioid administration accurately could result in medication errors and potential abuse, while the lack of competency in dialysis care led to a serious incident of bleeding that required emergency intervention. These findings highlight critical gaps in the facility's adherence to professional standards of practice and the need for improved training and documentation protocols.
Failure to Provide Appropriate Urostomy Care
Penalty
Summary
The facility failed to provide appropriate treatment and services for a resident with a urostomy upon admission. Resident #88, who had a urostomy due to bladder cancer diagnosed in 2022, reported that the facility nurses did not empty, monitor, or assess the urostomy. A review of the resident's medical record revealed an order to change the urostomy per physician order within 24 hours as needed, but there was no specific order or documentation for urostomy care, including monitoring and assessment. Additionally, the resident's care plan did not include resident-centered and measurable interventions for urostomy care. Interviews with an LPN and the DON confirmed that there should have been an order for urostomy care and that the care plan should have detailed its specifics.
Failure to Develop Comprehensive Care Plan for Oxygen Therapy
Penalty
Summary
The facility failed to place a physician's order for the indication of Oxygen administration and did not develop and implement a person-centered comprehensive care plan for a resident's respiratory care, including oxygen therapy. This deficiency was observed for one resident who had an Oxygen nasal cannula prepared at the bedside but was not using it initially. Later, the resident was observed using 2 liters of Oxygen via nasal cannula. A review of the resident's medical record revealed an order for Oxygen therapy that lacked an indication for its use, and no care plan was developed for the resident's Oxygen therapy. The Director of Nursing confirmed the need for an Oxygen order with an indication and a corresponding care plan.
Failure to Perform Timely Post-Dialysis Assessment
Penalty
Summary
The nurse failed to perform a timely assessment on a resident post dialysis. On 02/22/24, a complaint was reviewed alleging that Resident #82 was not assessed immediately upon return from dialysis, with an hour delay before the assessment was completed. The nurse's note documented that the resident returned from dialysis at 12 PM on 11/29/23, but the blood pressure was not obtained until 12:48 PM, and medication was administered at 12:49 PM. The resident was then assisted back to bed at 12:51 PM. Later, at 2:30 PM, the nurse found the resident's Arteriovenous Fistula (AVF) bleeding, with a needle and a white clamp on the resident's lap in bed. The bleeding was controlled, and the physician was notified for follow-up interventions. Staff interviews revealed that the post-dialysis process requires immediate vital signs and dialysis port checks upon the resident's return. Both Staff #18, an LPN, and the unit manager, Staff #12, confirmed that post-dialysis assessments should be done immediately. The Director of Nursing (DON) stated that the expectation is for the resident to be assessed within 10-15 minutes of return if there are no emergent issues. The DON was made aware of the concern for Resident #82.
Failure to Ensure Competency in Dialysis Care
Penalty
Summary
The facility failed to ensure that a licensed nurse was competent to care for a dialysis resident, leading to a serious incident. On 11/30/23, a resident returned from a dialysis session with an arterial needle and clamp left in their dialysis access point. This was not discovered until more than two hours later when the resident was found bleeding from the access site with the needle and clamp pulled out. The nurse's notes indicated that the resident returned to the unit at 12 PM, and the issue was discovered at 2:30 PM during rounds. The nurse controlled the bleeding, notified the physician, and implemented follow-up interventions. However, the dialysis communication form had already noted that the dressing was not clean, dry, and intact, and that the needle and clamp were still attached to the patient upon return from dialysis. An interview with the Registered Nurse (RN) revealed that the expectation was to assess the resident's vital signs and the AV fistula site immediately upon return from dialysis. However, the Agency Licensed Practical Nurse (LPN) who was caring for the resident at the time of the incident admitted to not having received any training in caring for dialysis patients and did not think there was anything wrong with the needle and clamp being left in place. The Director of Nursing (DON) acknowledged that she had assumed agency nurses were competent to care for dialysis residents and was unaware that this was a concern. This lack of proper training and assessment led to the resident's bleeding incident, highlighting a significant deficiency in staff competency and oversight.
Failure to Monitor and Document Resident's Inappropriate Behavior
Penalty
Summary
The facility staff failed to monitor and document a resident's inappropriate behavior related to mental health. This was evident for one resident who exhibited behaviors such as entering other residents' rooms, taking their food, and hitting them. Despite the Psychologist's orders to monitor and document the resident's mood, sleep, appetite, and behavior, the medical records lacked the necessary documentation. The Licensed Practical Nurse (LPN) confirmed that behavior should be documented in the electronic medical record system every shift, but a review of the records showed no checklist or progress notes regarding the resident's behavior monitoring. During an interview, the Director of Nursing (DON) stated that behavior issues would only be documented if an incident was identified. When asked about the lack of documentation, the DON acknowledged the concern but did not provide a method to validate that behavior monitoring was being conducted. This failure to document and monitor the resident's behavior as ordered by the Psychologist led to the identified deficiency.
Medication Administration and Documentation Deficiencies
Penalty
Summary
The facility staff failed to ensure that narcotics removed from the resident's supply were administered to the resident, as evidenced by the lack of documentation of the need for the narcotic or its administration. This was evident for three residents reviewed for controlled drug administration. Specifically, the count sheets for two residents showed multiple instances where narcotics were removed, but the corresponding Medication Administration Records (MAR) did not document the administration of these medications. Interviews with the LPN and DON confirmed that the facility's protocol requires documentation in both the count sheet and MAR, which was not followed in these cases. Additionally, the facility failed to timely provide medication to meet the needs of a resident who had recently undergone spinal surgery and required both IV and oral antibiotics. The resident reported not receiving the prescribed antibiotics on time. A review of the resident's physician orders and MAR revealed that the IV antibiotic Cefepime was not administered at all on the day it was ordered to start, and the first dose of oral Metronidazole was delayed. The DON confirmed that the orders for the antibiotics were not entered promptly due to oversight by the evening shift supervisor and the unit manager. The deficiencies highlight significant lapses in medication administration and documentation protocols within the facility. The failure to document narcotic administration and the delay in providing critical antibiotics to a resident post-surgery were confirmed by staff interviews and record reviews. These lapses were acknowledged by the DON, who identified specific staff members responsible for the oversights.
Failure to Implement Gradual Dose Reduction for Psychotropic Medication
Penalty
Summary
The facility failed to implement a gradual dose reduction (GDR) for a resident receiving a psychotropic medication, specifically Seroquel. The resident's active medical order indicated a dosage of 25mg twice a day. A psychiatry note dated 2/21/24 recommended a GDR due to the resident's stable mood and lack of psychotic symptoms or agitation. Despite this recommendation, the resident's active medication order did not reflect the suggested dosage decrease. Additionally, a pharmacy recommendation made on 2/9/24 also suggested a GDR or documentation if it was clinically contraindicated, but there was no documented response from the physician or prescriber on this recommendation form. During an interview, the Director of Nursing (DON) stated that the response time for implementing a psychiatric provider's recommendation for a GDR should be within one day. However, the GDR for the resident had not been initiated. The DON confirmed that the GDR was not done, indicating a failure to follow through on the psychiatric and pharmacy recommendations for the resident's medication management.
Failure to Remove Expired Medications and Properly Store Medications
Penalty
Summary
The facility failed to remove expired medications and properly store medications, as observed by the surveyor. In the medication storage room on unit 3B, two bags of 100ml Intravenous Ertapenem were found expired, labeled with a use-by date of 2/15/24. The attending LPN confirmed the medications were expired. Additionally, on the 3A unit medication cart, an unlabeled medication cup containing 11 unidentifiable pills was found. The LPN responsible for the cart admitted that the pills were for a resident who had reported an upset stomach but confirmed that no label was written for the medication. The Director of Nursing validated the concerns regarding the unlabeled medication during an interview with the surveyor. Furthermore, a medication cart was observed unattended in front of a resident's room, with a bubble pack of Diltixem ER 180 mg left on the cart. The charge nurse acknowledged the issue and stated that the medication should not have been left there. The Director of Nursing also validated the concerns about medication storage during a subsequent interview with the surveyor.
Failure to Provide Timely Dental Services
Penalty
Summary
The facility failed to ensure that residents received needed dental services, as evidenced by the case of one resident who did not have any teeth and had not received follow-up dental care for dentures. The resident was supposed to have a follow-up dental appointment in September 2023, but this did not occur. Medical records showed that the resident had a dental visit in July 2023 with impressions made for dentures and a follow-up scheduled for August 2023, which was not documented as completed. Interviews with the Unit Manager and the Director of Nursing confirmed that there were issues with the dental service provider and that the resident had not received the necessary dental care in a timely manner.
Incomplete Documentation and Transcription Error in Medical Orders
Penalty
Summary
The facility failed to ensure the completeness and accuracy of medical documentation for two residents. For Resident #102, a form certifying the medical ineffectiveness of treatment was found incomplete, as it did not specify which treatments were deemed ineffective. This form was signed by a physician who was no longer with the facility, and the issue was acknowledged by both the Director of Nursing and the Medical Director upon review by the surveyor. For Resident #39, an active medical order for sliding scale insulin administration contained a transcription error. The order incorrectly directed zero units of insulin for blood glucose levels above 400, whereas the previous order had specified 10 units. This error was confirmed by the Director of Nursing, who acknowledged that the incorrect order had been followed, resulting in the administration of 10 units of insulin on nine occasions in January 2024 for blood glucose levels above 400.
Failure to Obtain Proper Hospice Documentation
Penalty
Summary
The facility failed to obtain the proper documentation for a resident who received hospice services. Specifically, for Resident #47, there was an order to admit the resident to hospice services, but no hospice documentation was found in the electronic medical record. Further review of the resident's paper chart revealed the absence of Hospice Certification or Recertification forms, hospice election form, and hospice plan of care. The Director of Nursing confirmed that the hospice documentation should be in the resident's paper chart but was unable to locate these documents.
Failure to Maintain Essential Equipment in Safe Working Condition
Penalty
Summary
The facility failed to maintain essential equipment in working condition, specifically two bathtubs and two lift devices. During environmental rounds, it was observed that two out of four bathtubs were not operational. The Bather 2001 electronic jet tubs in the 3A and 2A central bathing rooms were found to be non-functional, with one tub containing trash and a broom. The maintenance director confirmed that both tubs were not in working order. This issue was communicated to the nursing home administrator on 3/12/24. Additionally, the facility failed to ensure that lift equipment used for resident care was maintained in a safe condition. A Hoyer lift (Ultralift 3500x) was observed with a cracked plastic covering and sharp edges, making it unsafe for use. The Unit Manager acknowledged the unsafe condition and removed the lift from use. Another lift (Steady Aid Lift) was found with a broken plastic base cover and exposed sharp edges. The Director of Maintenance was unaware of this issue and reported that no records were kept of repairs made by the facility maintenance staff. The Ultralift 3500x was taken out of commission due to difficulty in acquiring parts for the old equipment.
Failure to Maintain Effective Staff Training Program
Penalty
Summary
The facility failed to maintain an effective training program for new and existing staff, as evidenced by the incomplete training records for a Geriatric Nursing Assistant (GNA) and a Registered Nurse (RN). The review of GNA #50's training records revealed that several critical care areas, such as nail care, suprapubic care, ostomy care, and others, were not completed or signed off. The Director of Nursing (DON) acknowledged that GNA #50 should not be working without completing the orientation form, validating the surveyor's concerns about the incomplete training documentation. Additionally, the review of RN #53's employee file showed a lack of training records since 2020, despite the requirement for annual training on abuse, neglect, and exploitation. The DON and HR staff confirmed that RN #53 had not completed the required training since the implementation of a new training program in 2020. The HR staff admitted that this was the first instance of an employee not receiving timely training and promised to follow up with the Nursing Home Administrator. The DON validated the surveyor's concerns regarding the RN's training deficiencies.
Failure to Provide Required Annual Training for GNAs
Penalty
Summary
The facility failed to ensure that all Geriatric Nursing Assistants (GNAs) received no less than 12 hours of education per year, including mandatory annual training in dementia management and resident abuse prevention. This deficiency was identified during a review of five randomly selected GNA employee files, where it was found that one GNA, hired in October 2021, did not have any records of the required annual training for the year 2022. The Director of Nursing (DON) confirmed that the corporate office assigns annual training through a computer-based program and in-person sessions as needed, but acknowledged that the required training for this GNA was not completed in 2022.
Failure to Post and Retain Nurse Staffing Data
Penalty
Summary
The facility failed to consistently post the nurse staffing data at the beginning of each shift, the ratio of licensed and unlicensed staff to residents, and failed to retain the posted daily nurse staffing data for a minimum of 18 months. This deficiency was observed across all four nursing units and in the facility lobby during the recertification/complaint survey. Specific instances included missing titles of nurses on the staffing sheets, undated staffing sheets, and missing staffing sheets for several dates. For example, on Unit 3B, the staffing sheets for the 11-7 shift on 12/4/2023 and 12/5/2023 were missing, and on Unit 3A, there were no staffing sheets for multiple dates in February 2024. Additionally, some staffing sheets had dates written in pencil with question marks, indicating uncertainty about the exact dates. The Director of Nursing (DON) acknowledged the issues and stated that the facility was not keeping copies of the posted daily nurse staffing data as required. The DON was unaware that the scheduler was not retaining these records and confirmed that the facility was supposed to keep the posted daily nurse staffing data for at least 18 months following federal regulations. The surveyor's review of the provided staffing data revealed further deficiencies, such as the absence of ratios for licensed and unlicensed staff to residents and missing room assignments for licensed staff. The DON confirmed the surveyor's findings and acknowledged the lack of compliance with the posting and retention requirements.
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The facility did not ensure that its Infection Preventionist (IP) met required qualifications for managing the Infection Prevention and Control Program. The DON reported serving as the IP but acknowledged lacking the specialized infection control training required for the role, and confirmed that no other staff member was currently qualified. Records showed that the previously qualified IP left several months earlier, and the Administrator and DON confirmed they were still seeking a replacement, leaving the infection control program without a properly trained leader.
Staff failed to consistently secure medications and medical supplies across three units, including an oxygen tank left on the floor behind a resident’s bed without a supporting device, a treatment cart with Collagenase Santyl cream left on top while two residents in power wheelchairs passed by, an unattended and unlocked treatment cart at a nursing station, and another treatment cart with Diclofenac gel and dressings left on top, indicating repeated lapses in maintaining locked and secure storage for drugs, biologicals, and related supplies.
The facility failed to provide sufficient dietitian coverage and timely nutritional assessments for several residents with significant dietary needs. A resident admitted for diabetic management with a high A1C was placed on a regular diet instead of the recommended carb-controlled diet and had only one weight taken in the first two weeks, with no dietitian review of the record. Another resident with prior significant weight loss had no documented dietitian follow-up despite continued weight loss, and a resident admitted with severe protein-calorie malnutrition experienced further significant weight loss without any dietitian assessment. The dietitian reported working limited hours and prioritizing certain high-risk cases, resulting in delayed or missed evaluations for new admissions and residents with ongoing nutritional concerns.
The facility failed to maintain adequate linen and incontinence supplies and did not keep resident care areas in good repair, resulting in delays and alterations in incontinence care and substandard environmental conditions. Staff reported that towels and washcloths were used instead of wipes and then discarded due to heavy soiling, and that linen deliveries to units were late, leaving residents waiting for care. Observations showed very limited numbers of clean washcloths and other linens on units and in the laundry, with no stock of disposable wipes or backup washcloth supply despite repeated reports to housekeeping. Additional observations revealed recliner chairs blocking a dining-area handwashing sink and kitchenette, multiple resident and shared bathrooms with unfinished spackle, chipped paint, musty odors, black substances near showers, missing threshold molding, exposed cracks and nails, and eroded, rusted baseboard heaters. Hallway handrails on both units were worn, chipped, and splintered, and a shower room contained fecal odors, dried brown stains on the toilet, and deteriorated fixtures, all contributing to a failure to provide a safe, clean, and homelike environment.
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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