Future Care Sandtown-winchester
Inspection history, citations, penalties and survey trends for this long-term care facility in Baltimore, Maryland.
- Location
- 1000 North Gilmore Street, Baltimore, Maryland 21217
- CMS Provider Number
- 215271
- Inspections on file
- 16
- Latest survey
- October 21, 2025
- Citations (last 12 mo.)
- 1
Citation history
Health deficiencies cited at Future Care Sandtown-winchester during CMS and state inspections, most recent first.
A resident's abnormal urine lab results were not reviewed or communicated to a provider on the day they became available, resulting in a delay of over 25 hours before an antibiotic was ordered for a UTI. Facility staff confirmed there was no documentation of timely provider notification or intervention.
The facility failed to report an abuse allegation within the required timeframe, with discrepancies in staffing records causing confusion. Additionally, a resident's fall was not promptly communicated to relevant parties, leading to a delay in diagnosis and treatment. The facility also delayed reporting investigation results to the State Survey Agency, highlighting deficiencies in their reporting processes.
The facility failed to ensure call bells were within reach for residents, as observed during a survey. A resident with contractures had a call bell under their bed, making it difficult to use. Other residents were found with call bells on the floor or clipped to curtains, indicating a systemic issue in ensuring accessibility.
The facility failed to provide residents access to their personal funds during weekends and evenings. A complaint led to an investigation revealing that the Administrator was aware of the need for petty cash availability when the Business Office Manager was not onsite. However, no arrangements were made for fund distribution during these times, and the Administrator was rarely present after hours. Resident Statements confirmed no withdrawals occurred outside regular business hours.
The facility failed to conduct quarterly care plan meetings and did not ensure residents were invited to participate in their care planning process. In some cases, care plan meetings were not documented, and interdisciplinary team attendance was incomplete, involving only dietary, an LPN, and rehab staff.
The facility failed to store and prepare food according to professional standards, with several items lacking expiration dates and cooked meats not reaching safe temperatures. Sealed bins and refrigerated items were found without proper labeling, and cooked ground beef and pork were served at temperatures below recommended levels.
A resident experienced a fall without immediate pain or visible injury, but the facility failed to notify medical and administrative staff or the resident's representative in a timely manner. An LPN witnessed the fall but did not document a physical assessment, and the charge nurse did not communicate the incident. The resident later reported pain, and an X-ray revealed a fracture, leading to hospital transfer. The deficiency was discussed with facility leadership.
A resident was continuously receiving 3L of oxygen therapy via NC, contrary to a PRN order for oxygen when saturation fell below 95%. The facility failed to document the therapy and monitor the resident's oxygen saturation daily. A nurse confirmed the lack of documentation and monitoring during an interview.
Two residents experienced a lack of dignity and respect in their care. One resident, who is bedbound and cognitively intact, reported that staff did not respond to call bells overnight, leaving them in soiled diapers until morning. Another resident reported being spoken to disrespectfully by a GNA and having their face washed with a feces-contaminated washcloth. Despite grievances, the resident was still assigned to the same GNAs, indicating a failure to honor their preferences.
The facility staff failed to support resident choice by not offering two residents the option to get dressed and out of bed. One resident expressed a desire to get dressed, while another stated an inability to do so. The DON confirmed that staff should ask residents about their preferences and document any refusals, but no such documentation was found.
The facility failed to maintain accurate advance directives for two residents. One resident had conflicting code status information between their paper and electronic medical records, while another resident was not given the opportunity to complete an advance directive. These deficiencies were confirmed through interviews with staff and residents.
The facility failed to maintain a homelike environment in resident bathrooms, with issues such as a cracked toilet seat, cracked caulking, a hole in the wall, and missing drywall. Pest control records also recommended sealing a hole in one bathroom.
The facility staff did not thoroughly investigate an abuse allegation involving a resident. The incident occurred during a specific shift, but the alleged perpetrator's name was not on the assignment sheet for that time. The DON did not interview all staff present during the incident and acknowledged the oversight, stating an addendum would be completed.
The facility staff failed to follow professional nursing standards by not completing and signing the narcotic count sheet as required. An LPN initially stated they completed the count with a Unit Manager but later corrected themselves, indicating it was with an RN. The narcotic sign-off sheet only had the signatures of the LPN and the RN. Additionally, an RN stated they completed the count with another RN on different units, but the second RN did not sign the form. The Director of Nursing was informed of these discrepancies.
A cognitively intact resident, dependent on staff for daily living activities, was not offered daily activity opportunities or documented participation. Despite the resident's interest in various activities, they reported not being offered activities daily and faced delays in being returned to their room. The Activities Director confirmed the lack of recent participation and one-on-one visits, with records showing minimal activity offerings over several months.
A facility failed to ensure a resident who smokes did not have readily available cigarettes, as observed by a surveyor who found cigarettes on the floor in the resident's room. The resident's care plans included smoking policies but lacked interventions for monitoring smoking paraphernalia. A nurse confirmed the resident was care planned for having cigarettes, and the administrator acknowledged residents should not have cigarettes on hand.
The facility failed to provide adequate care for residents with indwelling urinary catheters. One resident had no physician orders for catheter care despite a urology consult, and another had a catheter with cloudy tubing and sediment, with no record of recent changes. Staff were unable to verify when the catheter was last changed.
The facility staff failed to accurately complete and document the controlled substance count on two medication carts. Discrepancies were found in the narcotic count process, with staff providing conflicting accounts of who completed the counts and failing to sign the required forms. The facility's policy mandates that both incoming and outgoing nurses sign the narcotic count sheet, which was not followed.
Facility staff failed to store medications properly and discard expired supplies in Unit #5. Medications requiring refrigeration, such as Lorazepam for a resident, were found in a cabinet. An LPN confirmed the presence of an opened vial of Lorazepam, an opened gastrostomy tube package, and expired COVID-19 Rapid Test Kits and IV tubing kits. The LPN was unsure who was responsible for checking these items, and the DON was informed of the deficiencies.
A resident was found to have poor dentition with only two teeth remaining, and it was discovered that they had not received dental care since admission. Despite a referral process for dental care being in place, it was not effectively implemented for this resident, resulting in a deficiency identified during the survey.
A resident expressed dissatisfaction with their meal, stating it did not align with their preferences. The lunch tray included items the resident disliked, such as zucchini squash and cranberry juice, and lacked requested condiments. The Director of Food Services confirmed that the resident's dietary preferences were not honored, as the dietary slips were used only for tray delivery, not for ensuring preferences.
The facility failed to maintain medical records according to professional standards, as evidenced by a surveyor finding a resident's Anticoagulation Record form in another resident's paper medical record. The Unit Manager was unable to explain the error but corrected it by placing the document in the correct record.
Delay in Provider Notification and Treatment Following Abnormal Lab Results
Penalty
Summary
The facility failed to ensure timely physician notification of laboratory results for a resident, resulting in a delay in treatment. Specifically, a urine analysis and culture were ordered to rule out a urinary tract infection (UTI). The lab specimen was collected and resulted, but the results were not reviewed until the following day. There was no documentation that the provider was notified of the abnormal results on the day they became available. The medical record did not show any provider notification or action on the day the lab results were reported. Further review revealed that an antibiotic was not ordered until more than 25 hours after the lab results were available. Progress notes and provider documentation addressing the urine results were dated the day after the results were reported. Interviews with facility staff confirmed that there was no evidence or documentation of timely provider notification or intervention on the day the lab results were received.
Deficiencies in Timely Reporting of Abuse and Fall Incidents
Penalty
Summary
The facility staff failed to report an allegation of abuse involving a resident within the required 2-hour timeframe. The incident allegedly occurred during the 3:00 pm - 11:00 pm shift, but discrepancies in the staffing sheet and time records indicated confusion about the exact timing. The resident reported the incident on the morning of the following day, but the facility's administrator only became aware of the correct date after the surveyor's intervention. This delay in reporting was a significant deficiency in the facility's handling of abuse allegations. In another case, the facility did not promptly notify the resident representative, physician, or administrative staff about a resident's fall. The fall occurred, and the resident was later diagnosed with a fractured left hip. The facility's documentation revealed that the fall was not reported immediately, and there was a delay in conducting a physical assessment and notifying relevant parties. This lack of timely communication and documentation was a clear breach of the facility's policy and procedures regarding fall incidents. Additionally, the facility failed to report the results of investigations within the required five working days for two separate incidents. In one case, the results were submitted beyond the five-day window, and in another, the facility confirmed the delay during an interview. These delays in reporting investigation results to the State Survey Agency further highlight the deficiencies in the facility's reporting processes.
Failure to Ensure Call Bells Within Reach for Residents
Penalty
Summary
The facility failed to ensure that call bells were kept within reach for residents, as observed during a survey. In one instance, a resident with arm and hand contractures had a call bell placed under their bed, making it difficult to use. A Geriatric Nursing Assistant (GNA) retrieved the call bell and attached it to the resident's bed sheet, despite acknowledging that the resident could not communicate or use it effectively. This indicates a lack of appropriate accommodation for the resident's specific needs. Additionally, during observation rounds, several other residents were found without accessible call bells. One resident's call bell was on the floor, another's was under a bed wheel, and others had their call bells clipped to privacy curtains or otherwise out of reach. The Assistant Director of Nursing (ADON) confirmed that the expectation is for call bells to always be within reach, highlighting a systemic issue in ensuring residents have access to call bells as needed.
Failure to Provide Resident Access to Personal Funds
Penalty
Summary
The facility failed to allow five residents to access their personal funds, as required by regulations. A complaint was submitted to the Office of Health Care Quality regarding this issue. During the investigation, it was found that the facility did not provide access to personal funds during weekends and evenings. The Business Office Manager confirmed that the Administrator was aware of the need for petty cash availability when she was not onsite. However, the Administrator admitted that there was no one available to distribute funds during these times unless he was present, which was rare. The Resident Statements showed no withdrawals during weekends or evenings, indicating a lack of access to funds outside regular business hours.
Deficiencies in Care Plan Meetings and Resident Participation
Penalty
Summary
The facility staff failed to conduct quarterly care plan meetings and did not ensure that residents were offered the opportunity to participate in their care planning process. This was evident in the cases of two residents, where one resident was not having care plan meetings, and another resident had not had a documented care plan meeting since their admission. Additionally, there was a lack of documentation to verify that scheduled care plan meetings occurred, and residents were not receiving the required quarterly care plan meetings. Furthermore, the facility did not ensure that care plan meetings were attended by the entire interdisciplinary team. In one instance, a resident's care plan meeting was attended only by dietary, an LPN, and rehab staff, without the presence of other typical interdisciplinary team members such as nursing and activities. This lack of comprehensive team involvement and failure to include residents in their care planning process highlights deficiencies in the facility's care planning procedures.
Food Safety and Temperature Control Deficiencies
Penalty
Summary
The facility failed to adhere to professional standards for food service safety, as observed during inspection rounds. In the kitchen's dry goods storage room, sealed bins of flour, sugar, rice, and food thickener, along with canned beets, banana pudding, and bags of croutons, were found without expiration dates labeled on them. Additionally, the kitchen's refrigerator contained nine Imperial chocolate shake cartons that also lacked expiration or use-by dates. The facility's policy for manufactured food without provided use-by dating requires labeling and dating products to establish a baseline use-by date, which was not followed in these instances. Further observations revealed issues with food temperature control during meal preparation. The kitchen's food serving line and preparation station for the resident's lunchtime meal had cooked ground beef measured at 140 degrees Fahrenheit and cooked pork at 130 degrees Fahrenheit, both of which were below the recommended safe temperatures for serving. These deficiencies indicate a failure to maintain proper food safety standards, potentially compromising the safety and quality of meals served to residents.
Failure to Notify and Assess Resident Post-Fall
Penalty
Summary
The facility failed to protect a resident's right to be free from neglect by not notifying medical staff, administrative staff, and the resident's representative of a change in condition in a timely manner. This deficiency was identified during an investigation into a complaint regarding a resident's fall. On September 8, the resident fell, and although there were no immediate complaints of pain or visible injuries, the incident was not reported to the necessary parties. The LPN who witnessed the fall did not document a physical assessment in the electronic medical record, and the charge nurse failed to notify the resident's representative, medical director, nurse practitioner, or facility administrative staff. The resident later complained of pain, and an X-ray revealed a left proximal femur fracture. The results were reported to the facility two days after the fall, and the resident was sent to the hospital. The delay in notification and assessment post-fall was discussed with the facility's administrator, DON, and regional nursing manager prior to the exit conference. The lack of immediate action and communication following the fall led to the deficiency being cited.
Failure to Monitor and Document Oxygen Therapy
Penalty
Summary
The facility staff failed to monitor a resident's oxygen saturation as ordered and did not follow a physician's order for oxygen therapy. The deficiency was identified during a survey when it was observed that a resident was continuously receiving 3 liters of oxygen therapy via nasal cannula, despite the order specifying that oxygen should be administered as needed (PRN) for shortness of breath and when the resident's oxygen saturation fell below 95%. The resident's electronic medical record did not contain documentation to support the administration of oxygen therapy, and the resident's oxygen saturation levels were not being checked daily as required. The surveyor noted that the last documented oxygen saturation was recorded on January 29, 2025, with a result of 98%, and the previous documentation was on January 22, 2025, also showing a result of 98%. During an interview, a registered nurse confirmed that oxygen therapy should be documented on the treatment administration record and acknowledged the lack of documentation and monitoring for the resident receiving continuous oxygen therapy. This oversight in documentation and monitoring led to the deficiency being cited during the survey.
Failure to Ensure Resident Dignity and Respect
Penalty
Summary
The facility failed to provide an environment that promotes resident respect and dignity, as evidenced by the experiences of two residents. Resident #10, who is cognitively intact with a BIMS score of 15 and is dependent on nursing staff for activities of daily living due to being bedbound with bilateral hand and feet contractures, reported that the nursing staff did not check on them or respond to call bells overnight. The resident had to remain in soiled diapers until morning rounds, as confirmed by the GNA Point of Care documentation, which showed significant gaps in incontinent care during the night shift. Resident #34 reported feeling disrespected by GNA #50, who spoke to them in a demeaning manner, and expressed a desire not to be assigned to this GNA. Additionally, Resident #34 reported an incident where GNA #51 washed their face with a feces-contaminated washcloth. Despite filing grievances and the facility's assurance that these GNAs would no longer be assigned to them, Resident #34 was still assigned to both GNAs on multiple occasions. This indicates a failure in the facility's system to honor the resident's preferences and ensure their dignity.
Failure to Support Resident Choice in Daily Activities
Penalty
Summary
The facility staff failed to honor the residents' right to self-determination by not providing them with the option to get dressed and out of bed. During observation rounds, Resident #37 was found in bed wearing a gown and expressed a desire to get dressed and out of bed. Similarly, Resident #50 was observed in bed and stated an inability to get out of bed and get dressed. The Director of Nursing (DON) acknowledged that staff are expected to ask residents if they wish to get dressed and out of bed, and if a resident refuses, it should be documented. However, there was no documentation to support that the residents refused these options, indicating a failure in promoting and facilitating resident choice.
Failure to Maintain Accurate Advance Directives
Penalty
Summary
The facility failed to ensure that a current copy of a resident's advance directive was in the resident's medical record and that every resident had the opportunity to execute an advance directive. For Resident #7, there was a discrepancy between the paper medical record and the electronic medical record regarding the resident's code status. The paper medical record contained a Maryland Medical Orders for Life-Sustaining Treatment (MOLST) form indicating 'No CPR', while the electronic medical record had an Oral Advanced Directive form indicating 'FULL CODE'. This inconsistency was confirmed during an interview with the Interim Social Work Director and the Regional Clinical Services Registered Nurse, highlighting a failure to maintain accurate medical records reflecting the resident's current medical wishes. For Resident #46, the facility did not have an advance directive in place, nor was there any documentation indicating that the resident was given the opportunity to complete one. During an interview, the resident confirmed that the facility did not ask if they wanted to complete an advance directive. The Regional Clinical Services Manager also confirmed the absence of an advance directive and a progress note for this resident, indicating a failure to provide the resident with the opportunity to execute an advance directive.
Facility Fails to Maintain Homelike Environment in Resident Bathrooms
Penalty
Summary
The facility failed to provide residents with a homelike environment in good repair, as evidenced by several deficiencies observed in resident bathrooms. During observation rounds, a cracked toilet seat was found in one bathroom, while another bathroom had cracked caulking around the sink where it meets the wall. Additionally, a third bathroom had a hole in the wall behind the toilet, with the cove base separated and peeling from the wall, and large pieces of drywall missing from the wall directly in front of the toilet. Furthermore, the facility's pest control records indicated that Orkin Pest Control recommended sealing the hole in the wall during their service visit.
Incomplete Investigation of Abuse Allegation
Penalty
Summary
The facility staff failed to conduct a thorough investigation of an allegation of abuse involving a resident. The incident reportedly occurred during the 3:00 pm to 11:00 pm shift on Unit #5, but the alleged perpetrator's name was not on the assignment sheet for that shift. However, the alleged perpetrator's name appeared on the staffing sheet for the 7:00 am to 3:00 pm shift, and the time sheet indicated they clocked out at 4:24 pm. The Director of Nursing (DON) #2, who was responsible for the investigation, did not interview all staff who worked during the alleged incident. During an interview, DON #2 acknowledged that not all relevant staff were interviewed and mentioned that an addendum to the investigation would be completed, as they were off duty when the incident occurred.
Failure to Properly Document Narcotic Count
Penalty
Summary
The facility staff failed to adhere to professional nursing standards by not completing and signing the narcotic count sheet as required. During the survey, it was discovered that an LPN initially stated they completed the narcotic count with a Unit Manager, but later corrected themselves, indicating they completed it with an RN. However, the narcotic sign-off sheet only had the signatures of the LPN and the RN, with no mention of the Unit Manager. This inconsistency in the narcotic count process was further highlighted when the RN stated they completed the count with another RN on different units, but the second RN did not sign the controlled substance form. The Director of Nursing was informed of the discrepancies, and it was confirmed that the narcotic count was completed by the two RNs on two different units. The failure to properly document and sign off on the narcotic count sheet before the shift began indicates a lapse in following established procedures for controlled substances, as acknowledged by the Director of Nursing. This deficiency was identified during the survey, pointing to a lack of compliance with professional standards of quality in handling narcotics.
Failure to Provide Daily Activity Opportunities for Resident
Penalty
Summary
The facility failed to ensure that a resident had the opportunity to participate in daily activity programs and maintain documentation of resident participation. This deficiency was identified for one resident who was investigated for activities during the survey. The resident, who was cognitively intact with a BIMS score of 15, was dependent on nursing staff for activities of daily living and required a mechanical lift for transfers due to bilateral hand and feet contractures. Despite the resident's interest in activities such as word search puzzles, music, group activities, and religious services, they reported not being offered activities daily and expressed dissatisfaction with the time it took staff to return them to their room after activities. The Activities Director confirmed that the resident had not participated in activities recently and had not been visited for one-on-one room activities. A review of the resident's participation record revealed that the resident was offered activities on only a few days over several months, with no documented offers in February 2025. The lack of daily activity offerings and documentation of participation contributed to the deficiency, as the resident was not provided with adequate opportunities to engage in activities that they enjoyed and required assistance with.
Failure to Monitor Resident's Access to Cigarettes
Penalty
Summary
The facility staff failed to ensure that a resident who smokes did not have readily available cigarettes, which was a deficiency observed during the survey. On February 6, 2025, at 1:17 pm, a surveyor noticed cigarettes on the floor in a resident's room on Unit #5. The cigarettes were found next to a bed and in the walking path, indicating that the resident had access to them. Upon inquiry, Registered Nurse #37 confirmed that the resident was care planned for having their cigarettes, but the care plans did not include interventions for monitoring smoking paraphernalia. Later, at 2:50 pm, the surveyor reported the presence of multiple cigarettes in the resident's room to Administrator #1, who acknowledged that residents should not have cigarettes on hand. The deficiency was identified as the facility's failure to adhere to its smoking policy and ensure proper supervision and monitoring of the resident's access to smoking materials.
Deficient Catheter Care for Residents
Penalty
Summary
The facility staff failed to provide adequate care and treatment for residents with indwelling urinary catheters, as evidenced by the cases of two residents. For one resident, the surveyor observed a catheter bag with cloudy urine and found no physician orders for the indwelling catheter or its care in the electronic medical record. Despite a urology consultation recommending specific catheter management steps, there were no orders implemented following the consult. The Director of Nursing confirmed the absence of necessary physician orders for catheter care, and it was only after the surveyor's review that new orders were placed. In another case, a resident was observed with an indwelling catheter that had cloudy tubing with sediment. The electronic medical record showed an order for catheter changes, but there was no documentation of any changes being made in the preceding months. A registered nurse was unable to verify when the catheter was last changed, and upon inspection, the catheter tubing was found to be cloudy with sediment, and the drainage bag was soiled. The nurse acknowledged the need for a catheter change.
Inaccurate Narcotic Count Documentation
Penalty
Summary
The facility staff failed to ensure the controlled substance count was completed accurately, as evidenced by discrepancies in the narcotic count process on two medication carts. On one occasion, an LPN initially stated that the narcotic count was completed with a Unit Manager, but later corrected themselves, indicating it was done with an RN. However, the RN reported completing the count with another RN on different floors, and the controlled substance form was not signed by the RN who supposedly completed the count. The Director of Nursing acknowledged that the nurses are required to complete and sign the narcotic count sheet before their shift, which was not adhered to in this instance. In another instance, a review of a medication cart revealed that the shift-to-shift narcotic count was inaccurately documented. The dayshift RN reported completing the count with a Unit Manager, not the nightshift RN as recorded. The Unit Manager confirmed this but admitted to not signing the narcotic count sheet, contrary to the facility's policy that requires both incoming and outgoing nurses to sign the form. A review of the facility's punch logs showed discrepancies in the timing of the shift changes, further indicating a lack of adherence to the narcotic counting policy.
Improper Medication Storage and Expired Supplies Found
Penalty
Summary
The facility staff failed to adhere to proper medication storage protocols in Unit #5, as observed by the surveyor. Medications requiring refrigeration, such as Lorazepam prescribed for Resident #37, were improperly stored in a cabinet instead of a refrigerator. Additionally, the surveyor found an opened and nearly empty vial of Lorazepam, an opened gastrostomy tube package, and expired COVID-19 Rapid Test Kits and intravenous tubing kits in the medication storage room. Licensed Practical Nurse #30 confirmed these findings but was unsure who was responsible for checking the medications and other items in the storage room. The Director of Nursing was informed of these deficiencies by the surveyor.
Failure to Provide Dental Care to Resident
Penalty
Summary
The facility staff failed to ensure that a resident received necessary dental care, as evidenced by the surveyor's observations and interviews. During an interaction with the resident, the surveyor noticed that the resident had poor dentition, with only two teeth remaining, one in each lower quadrant. Upon inquiry, it was revealed that the resident had not received dental care since being admitted to the facility. The Assistant Director of Nursing mentioned a referral process for dental care, but it was not effectively implemented for this resident, leading to the deficiency being identified during the survey.
Failure to Honor Resident's Dietary Preferences
Penalty
Summary
The facility failed to provide food in accordance with a resident's preferences, as determined by a surveyor's interview and observation. The resident expressed dissatisfaction with their lunch tray, stating that they never received meals according to their preferences. Although the resident had initially communicated their likes and dislikes upon arrival, the food served did not align with these preferences. The lunch tray included a small hot dog on plain bread without condiments, zucchini squash instead of the requested steamed broccoli, and a plain unfrosted cake instead of cranberry swirl cake. Additionally, the resident received cranberry juice, which they disliked, and hot tea without the desired condiments. The Director of Food Services acknowledged that the menu and alternatives were posted on the unit but admitted that not all residents could view them. The dietary slips were used solely for tray delivery, not for ensuring that residents' preferences were honored. The Director confirmed that the resident's dislikes, as noted on the lunch menu slip, were not respected, leading to the deficiency identified during the survey.
Medical Record Mismanagement
Penalty
Summary
The facility failed to maintain medical records in accordance with accepted professional standards and practices. During a survey, it was discovered that the paper medical record of one resident contained an Anticoagulation Record form belonging to another resident. This error was identified when a surveyor reviewed the medical records and found the misplaced document. The Unit Manager was informed of the discrepancy but was unable to explain how the document was incorrectly filed. The Unit Manager subsequently removed the incorrect document and placed it in the correct resident's medical record.
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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