Ginger Cove
Inspection history, citations, penalties and survey trends for this long-term care facility in Annapolis, Maryland.
- Location
- 4000 River Crescent Drive, Annapolis, Maryland 21401
- CMS Provider Number
- 215174
- Inspections on file
- 17
- Latest survey
- November 24, 2025
- Citations (last 12 mo.)
- 12
Citation history
Health deficiencies cited at Ginger Cove during CMS and state inspections, most recent first.
The facility failed to provide written notification of hospital transfers to residents and their representatives. In two cases, residents were transferred to the hospital without written notice being given to their representatives, despite verbal notifications being made. The DON confirmed the deficiency.
The facility failed to provide written bed hold notices to residents or their representatives within 24 hours after hospital transfers. Two residents did not receive the necessary documentation, as confirmed by the Director of Nursing. Interviews with LPNs revealed a misunderstanding of the policy, as they believed the bed hold policy was only provided to EMS staff and not directly to the resident or their representative.
A resident with progressing weakness, recurring falls, Parkinson's disease, and worsening dementia was discharged without a complete and accurate summary. The attending physician failed to document the resident's medications and the need for 24-hour supervision, despite the family's initiation of the discharge and safety concerns for independent living. The physician admitted to not always documenting all medications if the facility form does not allow it.
The facility failed to maintain a homelike environment, as observed in the rooms of three residents with black marks on walls, peeling grip strips in bathrooms, and other maintenance issues. Despite having a system for work orders and regular room checks, these deficiencies were not addressed.
The facility failed to provide baseline care plans to two residents and their representatives within 48 hours of admission. One resident's care plan was delayed by two weeks, while another's family was informed six days post-admission. The delays were partly due to weekend admissions and staff availability.
A resident receiving dialysis three times a week had a care plan that failed to include specific dietary and fluid restrictions, as well as necessary interventions for dialysis access site care. The resident was unaware of their specialized diet and fluid limits, and the care plan did not address precautions for the dialysis access site or other care needs like numbing cream application and weight assessments. These deficiencies were noted during a review with the DON.
The facility failed to measure resident-centered objectives and ensure interdisciplinary team involvement in care plan reviews for two residents. One resident's care plan evaluations lacked documentation, and the facility did not reschedule a requested meeting. Another resident did not have a quarterly care plan meeting as required.
The facility failed to implement effective pneumococcal vaccination policies, resulting in two residents not being offered or administered the appropriate vaccines. The policy lacked guidance on determining the recommended vaccine based on residents' history, leading to non-compliance with national standards. The Infection Preventionist and ADON confirmed the absence of vaccination records in both the hard chart and EMR.
The facility did not comply with federal requirements to post daily nurse staffing information, including the total number and actual hours worked by RNs, LPNs, and CNAs per shift. Observations and a review of staffing records confirmed the absence of this information in the nursing units.
Failure to Provide Written Notification of Hospital Transfers
Penalty
Summary
The facility failed to ensure that residents and their representatives received written notification of transfers to the hospital, as required. This deficiency was identified during a survey that reviewed the cases of three residents who were hospitalized. Specifically, Resident #40 was transferred to the hospital on January 9, 2024, but there was no written notification provided to the resident's representative, despite the resident having two physician certifications of incapacity. The Director of Nursing confirmed that the facility staff did not provide the necessary written notification to the resident's representative. Similarly, for Resident #246, the survey revealed that the resident was transferred to a local acute care hospital for emergent treatment, and the family was informed via a phone call. However, there was no written notice of transfer provided to either the resident or their representative. Interviews with two LPNs indicated that while a transfer form was completed and given to EMS staff, it was not provided to the resident or their representative. The Director of Nursing confirmed that the notice of transfer was not provided as required.
Failure to Provide Bed Hold Notices After Hospital Transfers
Penalty
Summary
The facility failed to provide written bed hold notices to residents or their representatives within 24 hours after a hospital transfer, as required by regulations. This deficiency was identified during an annual survey, where it was found that two residents, Resident #40 and Resident #246, did not receive the necessary documentation. Resident #40 was transferred to the hospital on January 9, 2024, and had two physician certifications of incapacity, yet there was no evidence of a bed hold notice being provided to the resident's representative. The Director of Nursing confirmed this oversight during an interview. For Resident #246, the electronic medical record did not initially show the resident, but a progress note indicated a transfer to a hospital for emergent treatment. The resident was nonresponsive at the time, and the family was informed via phone call. However, there was no documentation of a bed hold notice being given to the resident or their representative. Interviews with two LPNs revealed a misunderstanding of the policy, as they believed the bed hold policy was only provided to EMS staff and not directly to the resident or their representative, unless the resident was alert and oriented. The Director of Nursing confirmed that the policy was not provided within the required timeframe.
Incomplete Discharge Summary for Resident
Penalty
Summary
The facility failed to ensure that a discharge summary for a resident was complete and accurate. The medical record review revealed that the attending physician did not include the medications the resident was on or specify which medications should be continued after discharge. The resident had a history of progressing weakness, recurring falls, Parkinson's disease, and worsening dementia, with a treatment plan involving physical and occupational therapy, continuation of medications, and repeat labs. Despite the resident's poor prognosis and fair potential for rehabilitation, the discharge summary inaccurately stated that the resident had completed their course of treatment and was being discharged back to independent living with family. Interviews with the social worker and the DON confirmed that the discharge was initiated by the resident's family, despite safety concerns for the resident living independently due to frequent falls. The attending physician acknowledged the omission of critical information in the discharge summary, including the family's initiation of the discharge and the recommendation for 24-hour supervision. He admitted that he might not document all medications if the facility form does not accommodate this information, especially if the resident is on multiple medications.
Failure to Maintain Homelike Environment
Penalty
Summary
The facility failed to ensure a homelike environment for residents, as evidenced by observations of rooms with multiple black marks on walls and peeling grip strips in bathrooms. Specifically, Resident #21's room had black marks on the hallway walls and partially peeled grip strips in the shower stall. Resident #34's room had black marks on the hallway walls, holes in the bathroom door, and peeling grip strips in the shower stall. Resident #39's room had black marks on walls, exposed metal corner pieces, and peeling grip strips in the bathroom, along with tiles with peeled-off coating. Interviews with the Director of Maintenance and the Chief Engineer revealed that the facility uses a computer-based system for staff to submit work orders and conducts weekly rounds to check rooms. They also reported that rooms are painted and new carpet installed when residents are discharged. However, the issues in the rooms of Residents #21, #34, and #39 had not been addressed, indicating a lapse in maintaining a homelike environment for the residents.
Failure to Provide Timely Baseline Care Plans
Penalty
Summary
The facility failed to provide a baseline care plan to residents and their representatives within 48 hours of admission, as required. For Resident #40, the baseline care plan was developed but not signed by the resident's representative, and it was not provided to them until two weeks after completion. The resident was admitted from the hospital and had two physician certifications of incapacity, indicating the need for a representative's involvement. The facility did not offer a summary of the baseline care plan, including initial goals and services, within the required timeframe. For Resident #42, the family reported not being informed of the care plan until six days after admission. The baseline care plan was signed by dietary, nursing, and rehab staff, but there was no indication of the resident or their agent's participation in the review. The Unit Manager, who works Monday to Friday, acknowledged the delay, attributing it to the resident's weekend admission. The Director of Nursing confirmed the facility's failure to meet the 48-hour requirement and mentioned that weekend supervisors could ensure compliance.
Deficient Care Plan for Dialysis Resident
Penalty
Summary
The facility staff failed to ensure that the care plan for a resident receiving dialysis included all necessary individual care needs and interventions. The resident, who undergoes dialysis three times a week, was unaware of the specifics of their specialized diet and fluid restrictions, which were crucial for their renal health. The medical record review revealed that the care plan did not incorporate the resident's dietary restrictions, such as avoiding certain foods and limiting fluid intake, as ordered by the physician. Additionally, the care plan omitted the provision of ice chips, which was part of the physician's orders. Furthermore, the care plan lacked detailed interventions related to the resident's dialysis access site and potential complications from hemodialysis. It did not specify the precautions staff should take, such as avoiding blood pressure measurements and blood draws from the arm with the access site, or the prohibition of tub baths. The plan also failed to include necessary assessments of the access site for patency, infection, or complications other than bleeding. Other care needs, such as the application of numbing cream and weight assessments before dialysis, were also not reflected in the care plan. These omissions were identified during a review of the care plan with the Director of Nursing.
Deficiencies in Care Plan Development and Review
Penalty
Summary
The facility staff failed to measure resident-centered objectives to determine the effectiveness of care plan interventions for Resident #10. The care plan evaluations were not documented comprehensively, and the most recent evaluation notes did not reflect how the treatment team concluded that the approaches were appropriate. Additionally, there was no evidence that resident-specific objectives were measured and evaluated to determine the resident's progress. Furthermore, the facility did not ensure that Resident #10's care plan reviews were completed by an interdisciplinary team, including the attending physician, a registered nurse, a nurse aide, a member of the food and nutrition services staff, and the resident or their representative. Resident #10, who receives dialysis three times a week, was unaware of the specifics of their specialized diet and fluid restriction. The medical record review revealed no evaluations of the effectiveness of Resident #10's Nutrition Care Plan interventions or any revisions made to assist the resident in better meeting their goals. The facility also failed to reschedule a care plan meeting as requested by the resident's representative, and there was no documentation of the interdisciplinary team members who attended the meeting. For Resident #40, the facility staff failed to hold a quarterly care plan meeting. The resident was admitted to the facility, and a quarterly MDS assessment was completed, but no care plan meeting was held since January 2024. The Director of Nursing confirmed that the facility staff did not conduct the required quarterly care plan meeting for Resident #40 in April 2024.
Failure to Implement Effective Pneumococcal Vaccination Policies
Penalty
Summary
The facility failed to develop and implement effective policies and procedures for pneumococcal vaccinations, as evidenced by the lack of appropriate vaccination records and offers for two residents. The facility's policy lacked specific guidance on determining which pneumococcal vaccine was recommended based on residents' immunization history, medical conditions, and age. This resulted in confusion and non-compliance with national standards, as the policy incorrectly suggested offering the vaccine only to residents over a certain age, which did not align with the CDC and ACIP guidelines. For one resident, there was no evidence of a pneumococcal vaccination being offered or administered since their admission in 2023. The Infection Preventionist (IP) and Assistant Director of Nursing (ADON) confirmed the absence of vaccination records in both the hard chart and electronic medical record (EMR). Another resident, admitted in 2022, also lacked documentation of a pneumococcal vaccination offer or administration, despite having a previous PPSV23 vaccination in 1997. The IP was unaware of the need for additional vaccinations according to national standards, and the ADON confirmed that the vaccination history was not properly documented in the EMR.
Failure to Post Daily Nurse Staffing Information
Penalty
Summary
The facility failed to comply with federal requirements for posting daily nurse staffing information. Observations made on June 4th at 10:30 AM revealed that the facility did not display the total number and actual hours worked by Registered Nurses, Licensed Practical Nurses, and Certified Nursing Aides per shift in any part of the nursing units. An interview with the Director of Nursing at 11 AM on the same day confirmed that the current staffing record did not document the total number of hours worked by these categories of staff. This deficiency was identified through observations, a review of daily staffing records, and staff interviews.
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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