Future Care Northpoint
Inspection history, citations, penalties and survey trends for this long-term care facility in Baltimore, Maryland.
- Location
- 1046 Old North Point Road, Baltimore, Maryland 21224
- CMS Provider Number
- 215147
- Inspections on file
- 18
- Latest survey
- October 27, 2025
- Citations (last 12 mo.)
- 32
Citation history
Health deficiencies cited at Future Care Northpoint during CMS and state inspections, most recent first.
A resident's nephrostomy drainage bag was observed resting on a towel on the floor mat and, on another occasion, hanging from the bedrail with the cap touching the floor. An LPN explained the bag was placed on the towel to prevent leaks onto the floor and did not correct its position during the survey. Unit managers confirmed that urinary drainage bags should not touch the floor, and the infection control nurse acknowledged the non-compliance with infection control protocols.
A resident's right to a clean and comfortable environment was not honored when a heavily soiled privacy curtain, marked with brown stains, remained in place despite the resident's requests for it to be changed. Both an LPN and the DON confirmed the curtain's condition and acknowledged it was inappropriate for a resident's room.
Facility staff did not report an allegation of abuse by a GNA within the required 2-hour window and failed to submit the investigation results to the State Survey Agency within 5 working days. A resident reported rough care and an inappropriate comment by a night shift aide to the night nurse, but the incident was not reported to authorities as required, and facility leadership confirmed the omission.
A resident was transferred to an acute care facility for a change in medical condition, but there was no written evidence that the required bed hold policy notification was provided to the resident or their representative at the time of transfer. Documentation and staff interviews confirmed the absence of this notification.
A resident receiving medications via gastrostomy tube did not receive their prescribed medications at the scheduled time due to staff scheduling issues, and the nurse administering the medications failed to change gloves or wash hands after touching potentially contaminated surfaces before administration.
A resident with documented impaired vision and a need for corrective lenses was observed struggling to eat without glasses and confirmed difficulty seeing. Medical records showed a missed follow-up eye exam, and the DON could not verify if the resident received the required care, with an appointment only scheduled after surveyor intervention.
Two residents experienced inconsistent pain management, with PRN pain medications administered outside of physician-ordered parameters and without documentation of non-pharmacological interventions. Both the DON and an LPN confirmed that pain medications should be given according to orders and pain scales, but staff did not consistently follow these practices or document required interventions.
A required annual performance review for a GNA was not completed or documented, as confirmed by both the HRD and DON after a review of employee files and interviews. The missing evaluation was not found in any office files or binders, resulting in a deficiency related to staff performance monitoring.
A facility did not timely implement a consulting pharmacist's recommendation to document the rationale and duration for a resident's PRN lorazepam order, despite the prescriber agreeing with the recommendation. The PRN order remained active without a specified duration or rationale in the medical record, contrary to regulatory requirements.
A resident with impaired dentition did not receive timely periodic and annual dental exams by a dentist, despite multiple notes from the dental hygienist and a care plan indicating the need for dental follow-up. The exams were not scheduled or completed as required until after surveyor intervention, and facility staff confirmed the delay in providing these routine dental services.
Surveyors found excessive ice accumulation in both the main kitchen walk-in freezer and the second-floor nourishment room refrigerator/freezer, with dietary staff unaware of the preventive maintenance schedule. Residents' snacks and outside food were stored in these affected units.
Staff did not consistently discuss or document advance directives with several residents, and current copies of these legal documents were missing from medical records. Interviews confirmed that some residents were not offered the opportunity to complete advance directives upon admission, and required documentation of these discussions was not present until after surveyor intervention.
A resident who was fully dependent on staff for bathing, due to medical conditions including seizures and muscle weakness, did not receive any showers or baths for an entire month as scheduled. There was no documentation of care provided or of any refusal by the resident, and this was confirmed by facility nursing leadership.
Staff failed to maintain accurate and complete medical records for two residents. In one case, a physician's incapacity certification for one resident was incorrectly filed in another's record. In another instance, a resident received a dose of Dilaudid that was not documented in the medical record, as confirmed by the nurse who administered it.
Failure to Maintain Proper Positioning of Nephrostomy Drainage Bag
Penalty
Summary
Clinical staff failed to follow infection control protocols regarding the proper positioning of a nephrostomy drainage bag for a resident with urinary drainage needs. During a survey, it was observed that the resident's nephrostomy bag was placed on a towel on top of a floor mat next to the bed, rather than being hung off the floor as required. An LPN explained that the bag was placed on the towel to prevent urine from leaking onto the floor, and indicated that the bag had been properly hung at the end of her previous shift, suggesting the night shift may have moved it. The LPN did not correct the positioning of the bag during the observation. Further observations revealed that, on a subsequent day, the nephrostomy bag was hanging from the bedrail but the cap of the bag was touching the floor. Unit managers confirmed that urinary drainage bags should not be in contact with the floor. The infection control nurse was later notified of the issue and acknowledged the non-compliance with infection control policies regarding the proper hanging of nephrostomy drainage bags.
Failure to Maintain Clean and Homelike Resident Environment Due to Soiled Privacy Curtain
Penalty
Summary
The facility failed to provide a clean, comfortable, and homelike environment for a resident, as evidenced by a heavily soiled privacy curtain in the resident's room. The resident reported that the curtain was dirty and had requested it be changed, noting that in a previous room, a similarly soiled curtain was not changed for months despite staff being aware of its condition. During an interview and observation, both the Regional Mobile Director of Nursing and an LPN confirmed the curtain was dirty and soiled with brown marks, and the LPN acknowledged that this was not appropriate for a resident's environment. These findings were based on direct resident interviews and staff observations, with staff verifying the presence of the soiled curtain and acknowledging its unsuitability for the resident's living space.
Failure to Timely Report Alleged Abuse and Investigation Results
Penalty
Summary
Facility staff failed to report an allegation of abuse involving a resident within the required 2-hour timeframe and did not submit the results of the investigation to the State Survey Agency within 5 working days, as mandated by regulation. The incident began when a resident reported to a surveyor that a night shift Geriatric Nursing Assistant (GNA) was rough while providing care and made an inappropriate comment. The resident stated that this concern was reported to the night nurse. However, the Unit Manager (UM) was not aware of the allegation until informed by the surveyor and subsequently indicated she would follow up. Further interviews revealed that neither the initial self-report nor the final investigation report was submitted to the Office of Health Care Quality (OHCQ) as required. The DON confirmed that the facility did not report the allegation within the specified timeframes, citing the resident's later statement that the GNA's actions were not intentional. A review of facility records corroborated that the required reports were not made to the appropriate agencies, and no additional information was provided by facility leadership to validate that reporting occurred.
Failure to Provide Written Bed Hold Policy Notification Upon Hospital Transfer
Penalty
Summary
The facility failed to provide written notification of the bed hold policy to a resident and/or the resident's representative when the resident was transferred to an acute care facility due to a change in medical condition. Medical record review showed that the resident was admitted to the facility and later sent to an acute care hospital, but there was no written evidence in the medical record that the bed hold policy was given at the time of transfer. Documentation reviewed, including the change in condition transfer form, nurse's progress notes, and the eINTERACT SBAR Summary, did not indicate that the required notification was provided. Staff interviews confirmed that while the bed hold policy is typically signed and sent with the resident, no documentation could be produced to verify that this occurred for the resident in question.
Failure to Administer G-Tube Medications as Ordered and Lapse in Hand Hygiene
Penalty
Summary
A deficiency was identified when a registered nurse failed to administer medications to a resident with a gastrostomy tube according to the physician's orders and scheduled times. The resident, who was receiving long-term care and required multiple medications via G-tube, did not receive their medications at the scheduled 9 AM time. The delay in administration was attributed to the absence of a Certified Medicine Aide, which resulted in the nurse administering the medications later than ordered. Additionally, the nurse did not follow proper infection control procedures during medication administration. The nurse was observed touching the bathroom faucet and the resident's bed control without changing gloves or washing hands before administering the medications. The nurse acknowledged these lapses in both medication timing and hand hygiene during an interview with the surveyor.
Failure to Ensure Timely Vision Services for Resident
Penalty
Summary
A deficiency was identified when a resident was observed eating breakfast with their eyes closed, not wearing glasses, and using their hands to locate food items. During an interview, the resident confirmed difficulty seeing and was noted to have impaired vision on their most recent MDS assessment, with corrective lenses indicated as being used. The medical record showed an order for ophthalmology evaluation and treatment as needed, and a prior eye exam recommended a comprehensive follow-up in March 2024. Despite these documented needs and recommendations, there was no evidence that the required follow-up eye exam was provided as scheduled. The DON was unable to confirm whether the resident had received the necessary follow-up care, relying instead on a service provider's list of upcoming appointments. It was only after surveyor intervention that the resident was scheduled for an eye appointment, indicating a lapse in ensuring timely access to vision services as required by the resident's care plan and medical orders.
Failure to Ensure Safe and Consistent Pain Management
Penalty
Summary
Facility staff failed to provide safe and appropriate pain management for two residents, as evidenced by inconsistent administration of pain medications and lack of adherence to physician orders. One resident, who had a history of surgical amputation, diabetes, bacteremia, and atrial fibrillation, reported severe pain rated at 10/10 and stated that pain medications were not given regularly and were delayed. Review of clinical records showed that PRN Oxycodone was administered without clear parameters or pain scale, and was sometimes given for a pain score of 0, contrary to the intended use for moderate to severe pain. Additionally, there was no documentation of non-pharmacological interventions being attempted prior to administering PRN pain medications. A second resident, with diagnoses including urinary tract infection, aseptic necrosis of the femur, low back pain, atrial fibrillation, muscle weakness, and legal blindness, also reported chronic, severe pain that was not well managed. Clinical record review revealed that PRN pain medications, including Oxycodone and Acetaminophen, were administered without consistent use of pain scales or parameters, and were sometimes given for pain scores outside the ordered range, including for a pain score of 0. Again, there was no documentation of non-pharmacological interventions prior to medication administration. Interviews with the DON confirmed that PRN pain medications should be administered according to physician orders and that non-pharmacological interventions are expected to be attempted and documented prior to PRN medication use. However, the DON acknowledged that staff did not consistently document these interventions. An LPN also stated that pain medications should be given based on ordered parameters and pain scores, but records showed this was not consistently followed.
Failure to Complete Annual Performance Review for GNA
Penalty
Summary
The facility failed to conduct annual performance reviews for Geriatric Nursing Assistants (GNAs) as required. During a recertification survey, a review of two randomly selected GNA employee files revealed that one GNA, hired in April 2022, did not have a documented performance evaluation for the 2023 calendar year. The absence of this required evaluation was confirmed through examination of employee files and interviews with the Human Resources Director (HRD) and the Director of Nursing (DON). Both the HRD and DON were unable to locate the 2023 performance review for the GNA in question, despite searching through office files and binders. The HRD acknowledged that some performance reviews had not been filed and were possibly misplaced, but after a thorough search, neither the 2022, 2023, nor 2024 performance reviews for the GNA could be found. The DON also confirmed that she did not have copies of the missing performance reviews and only had access to a binder from the previous DON containing 2022 reviews. The lack of a documented performance review for the specified period was acknowledged by both the HRD and DON during the survey process.
Failure to Implement Pharmacist's PRN Psychotropic Medication Recommendations
Penalty
Summary
The facility failed to respond in a timely manner to recommendations made by the consulting pharmacist and agreed upon by the medical director regarding a resident's PRN lorazepam order. The pharmacist's monthly medication regimen review identified that the PRN lorazepam order lacked a specified duration, as required by CMS regulations, and recommended that the prescriber document both the rationale for continued use and the duration of the PRN order in the medical record. The prescriber agreed with the pharmacist's recommendation and signed the form, but did not document the required rationale or specify the duration in the resident's medical record. Subsequent review of the resident's medical orders showed that the PRN lorazepam order remained active with an indefinite end date and no documented rationale or duration in the medical record. Interviews with the DON and Regional Director of Operations confirmed that, prior to surveyor intervention, there was no documentation in the medical record addressing the pharmacist's recommendation. The deficiency was identified for one resident reviewed for unnecessary medications during the facility's recertification survey.
Failure to Provide Timely Routine Dental Services
Penalty
Summary
Facility staff failed to ensure that a resident received routine dental services in a timely manner. The resident, who reported having bad teeth and a need to see the dentist, had multiple notes from the facility's dental hygienist indicating that periodic and annual dental exams were due. However, there was no documentation that the resident had been seen by a dentist for these required exams. The medical record showed only an initial dental exam by the dentist, with subsequent recommendations for periodic and annual exams, but no evidence that these were completed as scheduled. Interviews with facility staff, including the DON and the medical scheduler, confirmed that annual and periodic dental exams are to be performed by a dentist, not a hygienist. Despite this, the resident was not scheduled for these exams until after surveyor intervention. The resident's care plan also identified impaired dentition and included an approach to consult with a dentist and follow up with recommendations, but this was not carried out in a timely manner. The deficiency was confirmed when the DON acknowledged that the resident was not seen for the required exams until prompted by the surveyor.
Ice Buildup in Kitchen and Nourishment Room Cold Storage
Penalty
Summary
Surveyors observed significant ice buildup in two cold storage areas within the facility's kitchen. In the main kitchen's walk-in freezer, ice was found on the floor and covering approximately 75% of the ceiling. Dietary staff present during the observation was unaware of the preventive maintenance schedule for the freezer room. Additionally, in the second-floor nourishment room, the refrigerator/freezer used to store residents' outside food had more than an inch of ice accumulation around the freezer. Residents' snacks were also stored in this refrigerator. These findings were based on direct observations and staff interviews during the survey period. No information about the medical history or condition of residents was provided in relation to the deficiency.
Failure to Ensure Advance Directives Are Discussed and Documented
Penalty
Summary
Facility staff failed to ensure that advance directives were discussed with residents or their responsible representatives and did not maintain current copies of residents' advance directives in the medical records. This deficiency was identified for six residents out of forty-seven reviewed during the recertification survey. Surveyor review of the medical records for these residents did not reveal any advance directives on file. Interviews with the Unit Manager confirmed that not all residents had advance directives and that, if available, they should be located in both the paper chart and the electronic medical record (PCC). Further interviews with the Social Services Director (SSD) revealed that, while the process requires offering advance directives at admission and quarterly for LTC residents, there was no documentation of these discussions for several residents. The SSD acknowledged that for some residents, there was no record of advance directive discussions or copies in the medical record. Additionally, it was confirmed that some residents were not offered the opportunity to formulate an advance directive upon admission, and documentation of these discussions was lacking until prompted by the surveyor.
Failure to Provide Bathing Assistance for Dependent Resident
Penalty
Summary
A deficiency was identified when a resident, who was dependent on staff for bathing due to a history of seizures, muscle weakness, and osteoarthritis, did not receive the required assistance with activities of daily living (ADL). The resident's admission Minimum Data Set (MDS) assessment documented total dependence on staff for bathing, and the geriatric nursing assistant (GNA) Kardex indicated that the resident was scheduled to receive showers twice weekly. However, a review of the resident's ADL documentation revealed that no showers were provided throughout the entire month of January, and there was no record of a bed bath or any documentation indicating that the resident had refused bathing or showering during this period. This deficiency was further substantiated by staff interview, where the Corporate Director of Nurses confirmed that the resident did not receive a shower or bath in January and that there was no documentation of refusal. The lack of both care provision and documentation demonstrated a failure to meet the resident's individualized care needs as identified in the assessment and care plan.
Failure to Maintain Accurate and Complete Medical Records
Penalty
Summary
Facility staff failed to maintain complete and accurate medical records in accordance with accepted professional standards for two residents. In one instance, a review of a closed medical record revealed that a physician certification of incapacity for one resident was incorrectly filed in another resident's record. The certification, which documented incapacity due to dementia, was signed and dated by the physician, but a second certificate in the same record pertained to a different resident entirely. The facility administrator was unaware of this error until it was identified by the surveyor. In another case, a complaint alleged improper administration of pain medication to a resident who had been admitted following lower extremity surgery. Physician orders directed nursing staff to administer pain medication as needed. Medication administration records showed three documented doses of Dilaudid on a specific date, but a printout from the interim medication dispensing machine indicated an additional dose was administered that was not documented in the resident's medical record. The nurse involved confirmed that the medication was given but admitted to forgetting to document the administration.
Latest citations in Maryland
The facility did not ensure that its Infection Preventionist (IP) met required qualifications for managing the Infection Prevention and Control Program. The DON reported serving as the IP but acknowledged lacking the specialized infection control training required for the role, and confirmed that no other staff member was currently qualified. Records showed that the previously qualified IP left several months earlier, and the Administrator and DON confirmed they were still seeking a replacement, leaving the infection control program without a properly trained leader.
Staff failed to consistently secure medications and medical supplies across three units, including an oxygen tank left on the floor behind a resident’s bed without a supporting device, a treatment cart with Collagenase Santyl cream left on top while two residents in power wheelchairs passed by, an unattended and unlocked treatment cart at a nursing station, and another treatment cart with Diclofenac gel and dressings left on top, indicating repeated lapses in maintaining locked and secure storage for drugs, biologicals, and related supplies.
The facility failed to provide sufficient dietitian coverage and timely nutritional assessments for several residents with significant dietary needs. A resident admitted for diabetic management with a high A1C was placed on a regular diet instead of the recommended carb-controlled diet and had only one weight taken in the first two weeks, with no dietitian review of the record. Another resident with prior significant weight loss had no documented dietitian follow-up despite continued weight loss, and a resident admitted with severe protein-calorie malnutrition experienced further significant weight loss without any dietitian assessment. The dietitian reported working limited hours and prioritizing certain high-risk cases, resulting in delayed or missed evaluations for new admissions and residents with ongoing nutritional concerns.
The facility failed to maintain adequate linen and incontinence supplies and did not keep resident care areas in good repair, resulting in delays and alterations in incontinence care and substandard environmental conditions. Staff reported that towels and washcloths were used instead of wipes and then discarded due to heavy soiling, and that linen deliveries to units were late, leaving residents waiting for care. Observations showed very limited numbers of clean washcloths and other linens on units and in the laundry, with no stock of disposable wipes or backup washcloth supply despite repeated reports to housekeeping. Additional observations revealed recliner chairs blocking a dining-area handwashing sink and kitchenette, multiple resident and shared bathrooms with unfinished spackle, chipped paint, musty odors, black substances near showers, missing threshold molding, exposed cracks and nails, and eroded, rusted baseboard heaters. Hallway handrails on both units were worn, chipped, and splintered, and a shower room contained fecal odors, dried brown stains on the toilet, and deteriorated fixtures, all contributing to a failure to provide a safe, clean, and homelike environment.
Facility staff did not thoroughly investigate two separate abuse allegations involving a resident and an injury of unknown origin involving another resident. In both cases, investigations focused on the directly affected resident and included staff interviews, but there were no interviews of other residents on the unit or documented assessments of those residents for signs of abuse or injuries of unknown origin, including residents unable to communicate due to cognitive status.
Two residents who were dependent on staff for oral care, including one with a tracheostomy, were observed with thick, white or milky substances coating their mouths and teeth, indicating inadequate oral hygiene. One resident communicated that staff did not brush their teeth and that staff "need to." In another case, despite oral care supplies being present in the room, the resident’s mouth and teeth remained unclean on multiple observations, with a thick milky substance caking the teeth and stringing between them when the resident tried to open their mouth. These findings showed that staff did not consistently provide oral care to residents who relied on them for this ADL.
Staff failed to maintain complete and accurate medical records for multiple residents, including missing and inconsistent documentation of wound care, delayed pain assessment after discovery of an injury of unknown origin in a cognitively impaired resident, and inaccurate recording of a PPD test result that was documented as negative despite no evidence the injection was administered and no supporting nurse’s note. Residents reported not receiving certain treatments, while MAR entries either lacked signatures for completion or contained conflicting information about whether care was provided.
Surveyors found that the facility failed to consistently implement and communicate correct transmission-based precautions and PPE use. One resident with a Foley catheter related to wounds had no precaution signage posted, while another resident in a double room had a contact precautions sign at the door, yet the NP entered without PPE and the GNA provided high-contact care wearing only gloves. Staff in that room stated the resident was not on contact precautions and later reversed the sign to show no PPE requirement. Therapy staff reported they rely solely on posted signs to determine PPE, and surveyors identified broader issues with inaccurate signage and staff awareness of which residents required contact precautions.
Surveyors found that MDS assessments were inaccurately coded for two residents. In one case, a resident sustained a femoral neck fracture after a fall, but the subsequent significant change MDS did not code the fall as a major injury and failed to capture prn Tylenol use documented on the MAR within the look-back period. In the other case, a quarterly MDS indicated opioid use for a resident, but the MAR for the same period showed no prescribed opioid, indicating incorrect coding of high-risk drug classes.
A resident who had recently been admitted and experienced a fall received multiple doses of the narcotic analgesic Tramadol, but the facility failed to accurately document all administered doses on the Medication Administration Record (MAR). Review showed only one Tramadol dose recorded on the MAR, while the Controlled Drug Receipt/Record/Disposition Form on the med cart reflected three doses given over two days. In interview, the DON stated staff are expected to document narcotic administration on the MAR and confirmed that two administered doses were not recorded there, resulting in an incomplete and inaccurate medical record.
Unqualified Infection Preventionist Overseeing Infection Control Program
Penalty
Summary
The facility failed to ensure that its designated Infection Preventionist (IP) met the mandatory qualifications for overseeing the Infection Prevention and Control Program. During an interview on 3/24/26 at 10:00 AM, the DON confirmed that she/he was serving as the facility’s IP but had not completed the specialized training in infection control required for the position. The DON further stated that no other staff member currently met the qualifications to serve as IP. Record review showed that the previously qualified IP left the facility in October 2025, and as of the survey date, the position remained unfilled by a qualified individual. At 1:30 PM on the same day, the Administrator and DON confirmed they were still in the process of finding a qualified IP for the facility, leaving the Infection Prevention and Control Program without a properly trained and qualified leader. No specific residents, medical histories, or clinical conditions were described in relation to this deficiency.
Unsecured Medications, Treatment Carts, and Oxygen Equipment
Penalty
Summary
Facility staff failed to ensure that drugs, biologicals, and related medical supplies were securely stored and properly maintained on multiple units. On one unit, an oxygen tank assigned to a resident was observed sitting on the floor behind the resident’s bed without any supporting device. On another unit, a treatment cart was observed with a tube of Collagenase Santyl cream labeled for a specific resident left on top of the cart, while residents in power wheelchairs passed by and staff were present at the nursing station. These observations showed that medications and oxygen equipment were not consistently secured as required. Further observations on additional units revealed an unattended and unlocked treatment cart at a nursing station, and on a separate occasion, a treatment cart with Diclofenac gel labeled for a resident left on top along with multiple packs of dressings. These incidents occurred across three units and on more than one date, demonstrating repeated failures to keep medications and treatment supplies in locked compartments or otherwise secured from unauthorized access.
Insufficient Dietitian Coverage and Delayed Nutritional Assessments
Penalty
Summary
The deficiency involves the facility’s failure to employ sufficient food and nutrition staff, including adequate dietitian coverage, to ensure timely assessment and appropriate diets for residents with significant nutritional and diabetic needs. A resident admitted over two weeks earlier with multiple comorbidities and an A1C of 11.5% had a hospital discharge recommendation for a carbohydrate-controlled diet, but was placed on a regular diet at admission with no acknowledgment of the recommended diet until one week later, when the resident requested larger portions. As of the survey date, the dietitian had not yet seen or reviewed this resident’s medical record, and the resident reported not having seen a dietitian and being very frustrated with the meals. During the first two weeks after admission, only one weight was obtained for this resident, despite physician notes stating the resident’s weight was “stable.” Further review of other residents showed additional failures in timely dietitian assessment and follow-up. One resident, readmitted in January and previously seen by the dietitian in September for a 6.4 lb weight loss over 30 days, had no documented follow-up despite continued weight loss totaling 22 lbs since the last dietitian review. Another resident admitted at the end of February with severe protein-calorie malnutrition had not been seen by the dietitian after about a month in the facility, despite a documented 14 lb (7%) weight loss over two weeks. The dietitian reported working only 12 hours per week at the facility and stated that she must prioritize which residents to see, focusing first on residents with tube feedings and those identified in risk meetings, resulting in delayed or absent assessments for new admissions and residents with ongoing weight loss and malnutrition diagnoses.
Linen Shortages and Poor Environmental Maintenance Compromise Resident Care and Comfort
Penalty
Summary
The deficiency involves the facility’s failure to maintain an adequate supply of clean linens and appropriate incontinence wipes, resulting in delays and alterations in residents’ incontinence care, as well as the use of towels and washcloths in place of disposable wipes. During the initial tour, the surveyor observed that the linen supply on one nursing unit hallway was low. Complaint reviews included concerns about delays in incontinence care and bed linens not being changed regularly, with residents left without clean bedding. A complainant reported that there was not enough clean linen available for residents. Staff interviews confirmed that towels, sheets, and washcloths were being used to wipe residents for incontinence care due to the absence of wipes, and that many of these linens were being thrown away when soiled. Staff also reported a shortage of linen, that linen deliveries to the units were late, and that residents who preferred to get up before breakfast had to wait for care when linen was delayed. Further observations showed that the clean supply room contained no disposable wipes or cloths for incontinence care, and a resident reported that staff did not use wipes, that the resident had to purchase their own, and that heavily soiled towels or washcloths were discarded. A tour of all nursing unit linen carts and closets revealed only six clean washcloths and limited supplies of towels, gowns, and bed linens. In the laundry room, only three washcloths were present, and the laundry assistant stated that there were only three washcloths available for each nursing unit that morning, that the facility was short on linen supply, and that these concerns had been repeatedly reported to the Director of Housekeeping over the preceding month and again that morning. The laundry assistant confirmed there was no additional laundry in process. The DON stated that wipe squares should be used for incontinence care, but no such wipes were found in the clean medical supply room, and no backup supply of washcloths was present in the emergency linen supply. The Director of Housekeeping confirmed there was no backup supply of washcloths. The deficiency also includes environmental and maintenance issues affecting resident bathrooms, handrails, and common areas. In the main dining area, a recliner chair was observed positioned directly in front of the handwashing sink, and two recliner chairs were stored in front of the nutrition area kitchenette. Multiple resident bathrooms and shared bathrooms were repeatedly observed over several days with unfinished spackle on walls that needed resurfacing and painting, chipped paint around sinks, uneven boards nailed to walls under sinks that appeared to partially cover holes, musty odors, black substances between shower bases and walls, missing threshold transition molding exposing cracks, missing tiles, and a nail, as well as eroded and chipped paint on baseboard heaters with exposed dark brown metal and rust-like material. Hallway handrails on both nursing units were observed to be worn, with chips, splintering, holes, and areas where the wood finish had worn off. A shower room was observed with a foul fecal odor, dried brown stains on the back of the toilet seat and in the toilet bowl, and a baseboard heater with eroded, chipped paint and rust-like material, along with chipped paint on the handrail. These conditions were acknowledged by the Director of Maintenance and other leadership, and some areas were noted to be in the process of renovation, but the observed deficiencies remained present during the survey period. Overall, the facility did not maintain a safe, clean, comfortable, and homelike environment in good repair across both nursing units and the dining area. The lack of adequate linen and incontinence supplies, combined with the poor condition of resident bathrooms, handrails, and certain common areas, constituted the basis for the cited deficiency. The observations and staff and resident reports consistently described shortages of essential hygiene supplies, delayed care related to linen availability, and multiple unresolved environmental and maintenance issues in resident care areas and shared spaces.
Failure to Thoroughly Investigate Abuse Allegations and Injuries of Unknown Origin
Penalty
Summary
Facility staff failed to thoroughly investigate allegations of potential abuse involving one resident and an injury of unknown origin involving another resident. For one resident, there were two separate allegations of abuse occurring on different days in early February. The facility’s investigation packets included interviews with staff who cared for or were scheduled to work with this resident on the days of the alleged incidents, and the investigations focused solely on this resident. However, there were no interviews conducted with other residents on the unit to inquire about abusive or neglectful treatment by the staff who were working during the times of the allegations. The surveyors noted that, although the allegations were not validated, there was no documentation that other residents were interviewed, if able, or assessed for signs or symptoms of injury. In a separate incident, another resident was identified on March 4 with a new bruise on the right eye, documented as a change in condition at 4:09 AM. This resident had a BIMS score of 99, indicating the resident was unable to complete an interview and therefore could not report how the injury occurred. The facility’s investigation identified a potential cause of the injury but did not reach a definitive resolution. Additionally, there were no interviews of other residents on the unit regarding possible abuse, nor were there documented assessments of other residents for injuries of unknown origin, particularly for those unable to speak for themselves, as in this resident’s case.
Failure to Provide Oral Care to Dependent Residents
Penalty
Summary
The deficiency involves the facility’s failure to provide oral care to residents who were dependent on staff for activities of daily living, specifically oral hygiene. One resident with a tracheostomy was observed with a thick, sticky white substance in the mouth and was noted to intermittently chew on nearby bedding. This resident made good eye contact and, when asked if staff brushed their teeth, shook their head no and mouthed that staff “need to.” According to the resident’s Minimum Data Set (MDS) dated 2/11/26, the resident was dependent on staff for oral care. Another resident, also dependent on staff for oral care per the 3/11/26 MDS, was observed sitting propped up in bed and able to respond with smiles. During the initial observation, the inside of this resident’s lips and upper and lower teeth had a thick, clear, white milky substance visible when the resident tried to open their mouth to smile. Oral care supplies were present in the nightstand, but the resident’s mouth and teeth were not clean. On a subsequent observation with the DON, NHA, and Corporate VP of clinical services, the same resident again had a thick, clear, milky substance between the lips and caking the teeth, which would string between the teeth when the resident attempted to open their mouth, demonstrating a lack of consistent oral care for residents dependent on staff for this ADL.
Incomplete and Inaccurate Medical Record Documentation for Treatments and Assessments
Penalty
Summary
Facility staff failed to maintain complete and accurate medical records and documentation for multiple residents. For one resident with wound care needs, review of the MAR showed that wound care and related treatments were signed as completed on the dates initially reported, despite the resident’s ongoing complaints that wound dressings were not being changed. When additional dates were reviewed, there were missing staff signatures for wound care on two specific dates, as well as three instances where application of A&D ointment to the resident’s feet was not signed off out of 24 days reviewed. Another resident with severe cognitive impairment, as evidenced by a BIMS score of 00, was found to have an injury of unknown origin (a bruise on the left hand). Documentation showed that a change in condition was initiated late in the morning, but a formal pain evaluation was not initiated and completed until that night, and the resident was unable to explain how the injury occurred or verbalize pain using a standard pain scale. For a third resident, documentation related to the admission PPD test was inconsistent and incomplete. The MAR contained an entry indicating “9” for the administration date, meaning “see nurse’s note,” but there was no corresponding nurse’s note. Despite the absence of a signed administration of the PPD injection, staff documented the PPD result as “negative” on the scheduled read date. The resident reported never receiving the PPD injection, and the DON confirmed that the facility had been out of PPD solution at the time, so the test would not have been administered. These findings demonstrate failures in accurate documentation of treatments and assessments, including wound care, pain assessment, and TB screening, as well as missing or incomplete supporting notes in the medical record.
Failure to Implement and Communicate Correct Transmission-Based Precautions
Penalty
Summary
Surveyors identified a deficiency in the facility’s infection prevention and control program related to inconsistent and incorrect implementation of transmission-based precautions and PPE use. During a complaint investigation focused on residents on transmission-based precautions, one resident with a visible Foley catheter was observed in the room with physical therapy, but there were no signs posted indicating any need for PPE, despite the resident being a new admission with a Foley catheter placed related to wounds. In another double-occupancy room, a contact precautions sign was posted at the doorway, but the nurse practitioner was in the room on a personal phone with no PPE, and the assigned GNA was repositioning the resident in bed while wearing only gloves. When questioned, the NP, RN, and GNA all stated that the resident in the room was not on contact precautions, and the GNA reported that signs were hanging at all doors and that this particular resident’s sign was “just wrong.” The surveyor observed the GNA later return to the room and turn the sign around to indicate no PPE requirement. Subsequent interviews revealed that therapy staff relied on posted signage to determine PPE use and that if the sign was wrong, the PPE used would be wrong. Overall, surveyors found problems with signage accuracy and staff awareness of which residents required contact precautions, as well as observed failures to follow appropriate PPE use for residents who should have been on contact precautions.
Inaccurate MDS Coding for Falls, Pain Management, and High-Risk Medications
Penalty
Summary
Facility staff failed to ensure Minimum Data Set (MDS) assessments were accurately coded for two residents reviewed during a complaint survey. For one resident, a facility-reported incident showed that the resident was found seated on the floor beside the bed and was diagnosed with a non-displaced femoral neck impaction fracture of the left hip following an x-ray. Despite this fall with a major injury, the subsequent significant change MDS dated 11/4/25 did not code the fall with major injury in Section J1900C. Review of the resident’s Medication Administration Records for October and November 2025 showed administration of Tylenol on 10/31/25 at 9:30 PM, which fell within the 5-day look-back period for the MDS, but Section J0100 (prn pain) of the same significant change MDS did not capture the use of Tylenol. For another resident, review of a quarterly MDS with an assessment reference date of 10/15/25 showed that Section N0415 (High-Risk Drug Classes) documented the use of an opioid medication. However, review of the resident’s October 2025 Medication Administration Record did not show that the resident had been prescribed an opioid during that period. In both cases, MDS staff later confirmed that these were errors in MDS coding, demonstrating that the assessments did not accurately reflect the residents’ clinical status and medication use as documented in their medical records.
Incomplete Documentation of Narcotic Administration on MAR
Penalty
Summary
The facility failed to maintain complete and accurate medical records in accordance with accepted professional standards for one resident receiving narcotic medication. The resident, admitted in March 2026, had a fall on 3/6/26 and was sent to the hospital on 3/9/26. Review of the March 2026 Medication Administration Record (MAR) showed documentation of a single 25 mg dose of Tramadol administered on 3/8/26 at 9:23 AM. However, review of the resident’s Controlled Drug Receipt/Record/Disposition Form, kept on the nurse’s medication cart and not in the medical record, showed that Tramadol 25 mg was administered three times between 3/8/26 and 3/9/26: at 11:00 AM and 9:00 PM on 3/8/26, and at 9:00 AM on 3/9/26. In interview, the DON stated that staff are expected to document narcotic administration on the MAR and confirmed that only one of the three Tramadol doses reflected on the controlled drug record was documented on the resident’s MAR. This discrepancy between the controlled substance record and the MAR, with missing documentation of two administered doses of Tramadol on the official medical record, constituted the failure to maintain a complete and accurate medical record for the resident.
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Every citation, penalty and Plan of Correction is sourced from public CMS records (latest release May 27, 2026) and official state health department websites — never guesswork.
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