Future Care Old Court
Inspection history, citations, penalties and survey trends for this long-term care facility in Randallstown, Maryland.
- Location
- 5412 Old Court Road, Randallstown, Maryland 21133
- CMS Provider Number
- 215118
- Inspections on file
- 14
- Latest survey
- December 23, 2024
- Citations (last 12 mo.)
- 0
Citation history
Health deficiencies cited at Future Care Old Court during CMS and state inspections, most recent first.
During a kitchen tour, a surveyor found deficiencies in food storage practices, including unlabeled and undated chicken and sausages, expired honey, and inconsistently dated sauces. The Certified Dietary Manager acknowledged the inconsistency, and the facility's food storage policy lacked guidelines for labeling and dating, potentially affecting all residents.
The facility failed to provide required annual dementia training to all geriatric nursing assistants (GNAs), with only 11 out of 43 GNAs receiving the training in 2024. The Director of Nursing noted that the annual skills fair, which includes dementia care education, did not cover all GNAs. The facility's transition from Relias to HealthStream training contributed to the non-compliance, as acknowledged by the Administrator.
A staff member at the facility misappropriated $1000 from a resident's account by cashing checks without permission. The incident was discovered during a survey, revealing that the GNA involved had outdated abuse training. The facility's investigation confirmed the misappropriation, and the resident's bank reimbursed the funds.
The facility failed to report abuse allegations involving two residents to the State Agency within the required two-hour timeframe. In one case, a resident reported abuse, but the Facility Reported Incident (FRI) form was completed the next day. In another case, a resident alleged sexual abuse by a staff member, but the initial report was submitted over a day later. Both incidents were discussed with the facility's administration.
A facility failed to ensure an agency GNA received annual abuse education, leading to a deficiency. The GNA had not completed the required training since 2021. This oversight was discovered following an incident where a resident's checks were stolen and cashed by the GNA, totaling $1000. The facility confirmed the GNA's involvement, and the resident's bank reimbursed the funds.
The facility failed to maintain resident dignity during meal assistance, as observed when a GNA stood over a resident while feeding them. Interviews revealed that agency GNAs were not informed about the importance of sitting while feeding residents, and the facility did not provide this education upon their employment.
A facility failed to develop a care plan for a resident who consistently refused showers. The resident was scheduled for showers twice a week, but records showed refusals on multiple occasions without any documented care plan or educational interventions. The lack of a care plan was confirmed by the Unit Manager and reported to the facility's administrator.
A facility failed to conduct timely care plan meetings after a resident's quarterly assessment, preventing the resident and their representative from participating in the care planning process. The interdisciplinary team is responsible for reviewing and revising care plans based on MDS assessments, but a resident did not have a care plan meeting for about seven months, with meetings only documented in February and November. The absence of a care plan meeting following the August MDS assessment was confirmed by the Social Services Director and DON.
A resident with multiple sclerosis and contractures did not receive necessary ROM exercises as part of their functional maintenance program due to complaints of pain. The restorative aide failed to communicate this to the nursing staff, and the facility's documentation showed infrequent completion of PRN ROM exercises. The Director of PT/OT and nursing staff were unaware of the resident's lack of ROM exercises, highlighting a deficiency in communication and execution of the program.
A facility failed to provide scheduled showers to a dependent resident, who expressed a desire for regular bathing. Despite being scheduled for showers twice weekly, records showed no evidence of showers being provided in November and December. Interviews with staff confirmed the oversight, and the resident was not informed of their shower schedule, highlighting a deficiency in care.
A resident experienced a delay in treatment due to a miscommunication regarding a STAT x-ray order. After sustaining an ankle injury, a physician ordered an immediate x-ray, but it was incorrectly labeled as Routine, causing a delay in the x-ray being performed and the fracture being confirmed. The resident was transferred to the hospital after the delay.
The facility failed to complete annual performance reviews for three GNAs, with one not reviewed since 2018 and another lacking any evidence of review. The HR Director tracks reviews and notifies managers, but delays occurred due to multiple responsibilities of Unit Manager. This deficiency highlights issues in staff evaluation management.
The facility failed to maintain accurate medical records for two residents, leading to discrepancies in care directives. A resident's MOLST form conflicted with progress notes regarding code status, while another resident's hospice status was not properly documented, resulting in a lack of hospice care before passing away.
Deficiencies in Food Storage Practices
Penalty
Summary
The facility was found to have deficiencies in food storage practices during a kitchen tour conducted by a surveyor. The surveyor, accompanied by the Certified Dietary Manager, observed several instances of improperly labeled and dated food items. Specifically, a plastic bag of chicken breast and a bag of link sausages in the walk-in refrigerator were not labeled or dated. Additionally, a bottle of honey in the dry storage area had a prep date but was used beyond the stated date. Other items, such as graham crackers, BBQ sauce, soy sauce, and Worcestershire sauce, were either not dated or had expired dates, indicating inconsistency in labeling practices. During the tour, the Certified Dietary Manager acknowledged the inconsistency in labeling and dating food items, suggesting a need for further staff training. The facility's food storage policy, provided to the surveyor, did not include guidelines for labeling and dating food items. This lack of policy guidance contributed to the observed deficiencies, which have the potential to affect all residents in the facility. The surveyor discussed these concerns with the Nursing Home Administrator, highlighting the need for improvement in food storage practices.
Deficiency in GNA Dementia Training Compliance
Penalty
Summary
The facility failed to provide all geriatric nursing assistants (GNA) with the required annual dementia training, as evidenced by the review of employee records. Out of 43 GNAs reviewed during the survey, 32 did not have documentation of the required annual dementia training. The Director of Nursing (DON) explained that the annual competency for GNAs includes a skills fair covering dementia care, abuse prevention, and other essential topics. However, the most recent skills fair held on June 27, 2024, did not include all GNAs, as only 11 out of 43 employees received dementia training in 2024. The facility recently transitioned from Relias to HealthStream training, which contributed to the lack of compliance with the GNA training requirements. The Administrator acknowledged the deficiency and mentioned efforts to obtain the GNA dementia training records from HealthStream. Despite these efforts, the facility was not fully compliant with the training requirements for 2024, as confirmed by the Administrator. The surveyor was later provided with evidence that dementia in-service training was conducted on December 10 and 11, 2024, but these actions were not part of the initial compliance review.
Misappropriation of Resident Funds by Staff Member
Penalty
Summary
A staff member at the facility was found to have removed money from a resident's account without permission. This incident was identified during an annual recertification survey, where it was discovered that a Geriatric Nursing Assistant (GNA) had cashed two checks totaling $1000 from a resident's account. The resident's daughter reported the missing funds, and the bank confirmed that the checks were made out to GNA #32, who worked at the facility on the day the checks were cashed. The facility's investigation corroborated the misappropriation of funds, and the resident's bank subsequently blocked the account and reimbursed the resident. The Nursing Home Administrator and the staffing coordinator were interviewed regarding the incident. It was revealed that the GNA involved had outdated abuse training, with the last recorded training dated over a year before the incident. The staffing coordinator confirmed that the GNA was marked as DNR (Do Not Return) to the facility. The surveyor expressed concerns about the outdated training and the facility's failure to protect the resident from the misappropriation of property.
Failure to Timely Report Abuse Allegations
Penalty
Summary
The facility failed to report allegations of abuse involving two residents to the State Agency, the Office of Health Care Quality (OHCQ), within the required two-hour timeframe. In the first case, an allegation of abuse involving a resident was reported to the Nursing Home Administrator (NHA) by a surveyor. However, the Facility Reported Incident (FRI) form was not completed until the following day, exceeding the two-hour requirement. This delay was confirmed during an interview with the NHA and a Regional Nurse. In the second case, a resident alleged sexual abuse by a staff member during incontinence care. The facility staff became aware of the incident late in the evening, but the initial facility report was not submitted until the following night, well beyond the two-hour window. The resident, who had a Brief Interview for Mental Status (BIMS) score of 15, reported pain and alleged inappropriate contact, but no injuries were found upon examination. The surveyor noted the late submission of the FRI and discussed the concern with the facility's administration.
Failure to Provide Required Abuse Training to Agency GNA
Penalty
Summary
The facility failed to ensure that an agency Geriatric Nursing Assistant (GNA) received the required annual abuse education necessary for working with long-term care residents. This deficiency was identified during a survey when it was discovered that GNA #32, one of the three GNAs reviewed, had not completed the annual abuse training. The training record provided by the facility showed that the last abuse training for GNA #32 was signed and dated on 5/19/2021, indicating that the training was overdue. The facility staffing coordinator confirmed that there were no additional training records for GNA #32 prior to the incident. The deficiency was further highlighted by an incident involving the misappropriation of funds from a resident. The resident's daughter reported that two checks were stolen and cashed by GNA #32, totaling $1000. The facility's investigation confirmed that GNA #32 had worked on the day the checks were cashed, and the bank verified that the checks were made out to GNA #32. Although the resident's bank reimbursed the funds, the incident underscored the importance of ensuring that all staff, including agency staff, receive the necessary training to prevent such occurrences.
Failure to Maintain Resident Dignity During Feeding
Penalty
Summary
The facility failed to ensure that residents were treated with respect and dignity during meal assistance, as observed with one resident. On December 10, 2024, a surveyor noted that a Geriatric Nursing Assistant (GNA), identified as Staff #46, was standing over a resident while feeding them. This practice was confirmed through interviews with two agency GNAs, Staff #46 and Staff #45, who both stated they were unaware that standing while feeding residents was inappropriate. Further interviews with the Staffing Coordinator and the Nursing Home Administrator revealed that agency GNAs were not educated on maintaining resident dignity in relation to feeding when they began working at the facility. The Staffing Coordinator mentioned that GNAs are expected to have learned these skills during their training to obtain their GNA license.
Failure to Develop Care Plan for Resident Refusing Showers
Penalty
Summary
The facility failed to develop and implement a comprehensive care plan for a resident who consistently refused showers. During the survey, it was found that the resident was scheduled to receive showers twice a week, specifically on Mondays and Thursdays during the 3 PM to 11 PM shift. However, documentation indicated that the resident either did not receive or refused showers on these scheduled days throughout November and December 2024. Additionally, the surveyor noted that there were no shower sheets available for the resident in the binder, and upon further review, it was confirmed that the resident refused showers on several Wednesdays as well. The surveyor's review of the resident's electronic medical record revealed a lack of documentation regarding a care plan addressing the resident's refusal of showers. There was no evidence of any actions taken by the nursing staff to educate the resident or any alternatives provided to meet the resident's hygiene needs. The Unit Manager confirmed that a care plan should have been developed for the resident's refusal of showers, but none was found in the records. This oversight was communicated to the facility's administrator, highlighting the deficiency in care planning for the resident's needs.
Failure to Conduct Timely Care Plan Meetings
Penalty
Summary
The facility failed to facilitate timely care plan meetings after a resident's quarterly assessment, which hindered the resident and their representative's ability to participate in the care planning process. This deficiency was identified for one resident during the survey. The interdisciplinary team (IDT) is responsible for developing, reviewing, and revising care plans based on the Minimum Data Set (MDS) assessments, which are conducted quarterly. However, it was discovered that the resident had not had a care plan meeting for approximately seven months, with meetings documented only in February and November of the same year. During the survey, it was revealed that the facility's standard practice is to hold care plan meetings quarterly, typically within days of the MDS assessment. Despite this, there was no documentation of a care plan meeting following the resident's MDS assessment in August. The Social Services Director and the Director of Nursing confirmed the absence of a care plan meeting in August, although they provided documentation for a meeting held in May. This lapse in scheduling and documenting care plan meetings led to the identified deficiency.
Failure to Provide Necessary ROM Exercises
Penalty
Summary
The facility failed to provide necessary Range of Motion (ROM) exercises for a resident in the functional maintenance program, specifically for a resident with a history of multiple sclerosis and contractures. The resident reported that staff did not provide ROM exercises to their wrist and hands. The restorative aide, responsible for carrying out orders from the Physical Therapist (PT) or Occupational Therapist (OT), confirmed that the resident was listed for ROM exercises but had not received them for several months due to complaints of pain. This lack of communication about the resident's pain and the absence of ROM exercises contributed to the deficiency. The Director of PT/OT and the nursing staff were unaware that the resident was not receiving ROM exercises due to pain. The facility's documentation showed that PRN ROM was only completed on three occasions over several months. The Director of Nursing and the regional nurse acknowledged the need to clarify the PRN ROM order, which did not specify when or under what conditions it should be performed. The deficiency was further highlighted by the lack of communication between staff members regarding the resident's condition and the execution of the functional maintenance program.
Failure to Provide Scheduled Showers to Dependent Resident
Penalty
Summary
The facility failed to provide showers to a dependent resident, identified as Resident #103, twice per week as required. During an interview, the resident expressed a desire for a shower and indicated that it had been a long time since they had one. The facility's policy mandates that residents receive a shower or tub bath twice weekly, yet a review of the resident's care records for November and December 2024 showed no evidence of showers being provided. The resident was scheduled for showers on Wednesdays and Saturdays, but there were no records of showers being given on these days, and the resident confirmed not being offered showers. Interviews with facility staff, including a Geriatric Nursing Assistant and the Unit Manager, corroborated the lack of showers provided to the resident. The resident's Minimum Data Set (MDS) assessment highlighted the importance of choosing between different bathing options, and it was noted that the resident was dependent on staff for activities of daily living (ADL) care. Despite the resident's dependency and expressed preference, the facility did not adhere to the scheduled shower days, and the resident was not informed of their shower schedule. The deficiency was confirmed during the survey, and the facility's failure to provide the required care was communicated to the Administrator.
Delay in STAT X-ray Order Leads to Treatment Delay
Penalty
Summary
The facility failed to ensure a physician's order for a STAT x-ray was performed in a timely manner, resulting in a delay in treatment for a resident. The resident, who sustained an injury to the left ankle while being weighed on a wheelchair scale, reported the incident and subsequent pain. A physician's order for a STAT x-ray was placed on the same day, but the x-ray was not completed until later that evening, and the results confirming a fracture were not reviewed until the following morning. The delay was attributed to the x-ray order being incorrectly labeled as Routine instead of STAT when called into the radiology company by a registered nurse. This miscommunication led to the x-ray being assigned as a same-day request rather than an immediate priority. The resident was eventually transferred to the hospital after the fracture was confirmed, but the delay in obtaining the x-ray and subsequent treatment was a significant concern identified during the survey.
Deficiency in Timely Completion of Nursing Aide Performance Reviews
Penalty
Summary
The facility staff failed to complete annual performance reviews for three out of seven Geriatric Nursing Assistants (GNAs) whose records were reviewed during the survey. Specifically, GNA #28 had not received a performance review since 2018, and there was no evidence of a performance review for GNA #31. The Human Resource Director (HR) #47 explained that she tracks all employees' annual performance reviews and submits the necessary documentation to the employee's manager one month prior to the review due date. Despite these procedures, the performance appraisals for GNA #28, GNA #31, and GNA #53 were not completed in a timely manner. The HR Director #47 stated that two of the three outstanding performance appraisals were completed during the survey, with the remaining appraisal pending due to the employee's weekend work schedule. Unit Manager #26 acknowledged being behind on several employee performance reviews due to multiple job responsibilities. This lack of timely performance reviews indicates a deficiency in the facility's management of staff evaluations, which is crucial for maintaining the quality of care provided to residents.
Inaccurate Medical Records and Hospice Documentation
Penalty
Summary
The facility failed to maintain accurate medical records for two residents, leading to discrepancies in their care directives. For Resident #51, there was a conflict between the paper MOLST form, which indicated a Full Code status, and the electronic medical record progress notes, which documented the resident as DNR/DNI. This inconsistency was identified during a review by the surveyor and the Nursing Home Administrator, highlighting a significant error in the resident's documented code status. For Resident #129, the facility did not accurately document the resident's hospice status. Although the hospice care consent was signed, the MDS did not reflect this status due to incomplete documentation regarding the court order of care guardian. Despite the presence of hospice nurse documentation and progress notes indicating communication with hospice nurses, the facility staff insisted that hospice care was not initiated due to the lack of confirmation from the court. This resulted in the resident not receiving hospice care before passing away, as confirmed by the Director of Nursing.
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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