Glen Meadows Retirement Com.
Inspection history, citations, penalties and survey trends for this long-term care facility in Glen Arm, Maryland.
- Location
- 11630 Glen Arm Road, Glen Arm, Maryland 21057
- CMS Provider Number
- 215278
- Inspections on file
- 14
- Latest survey
- April 8, 2025
- Citations (last 12 mo.)
- 0
Citation history
Health deficiencies cited at Glen Meadows Retirement Com. during CMS and state inspections, most recent first.
Two residents with severe cognitive impairment and known elopement risk were able to leave secure areas undetected due to failures in the WanderGuard alarm system and inadequate monitoring. The alarm system did not activate when the residents exited, and staff were unaware of their absence until they were found outside or in another area. Documentation and evaluation processes were also insufficient, contributing to the lack of effective supervision.
Surveyors found expired food items in the kitchen, an overdue ice machine filtration cartridge, and inconsistent dishwashing sanitization temperatures. The CDM confirmed that expired items were not discarded as required, and the Maintenance Manager acknowledged the overdue cartridge replacement. Temperature logs and direct observation showed the dishwashing machine often failed to reach the required 180°F for final rinse, with staff not consistently monitoring the gauges.
Facility staff did not ensure an effective QAPI program was in place to identify and address quality concerns, as evidenced by the lack of discussion and corrective action for incidents such as a resident's elopement, employee-to-resident abuse, and repeated controlled medication documentation errors. The QAPI meetings and documentation failed to include detailed reviews or plans for these issues, and the NHA confirmed these deficiencies were not systematically addressed.
A resident was physically struck on the forearm by a GNA after reaching for a laundry basket, as witnessed and documented by staff. The resident confirmed the incident through gestures during an interview. Facility leadership acknowledged the event and discussed whether the act was intentional, but the smacking was confirmed to have occurred.
The facility did not submit initial reports of suspected abuse involving two residents to the State Survey Agency within the required two-hour timeframe. In both cases, staff and family members reported witnessing physical abuse by GNAs, but the reports were delayed by several hours, contrary to established protocols and staff training.
The facility did not thoroughly investigate or document three separate incidents: an alleged abuse where a resident was reportedly struck by a caregiver, an elopement where a resident left a secure area despite wearing a WanderGuard that failed to activate alarms, and a medication error involving uncounted liquid lorazepam and delayed reporting. In each case, required assessments, root cause analyses, and staff education were incomplete or missing, as confirmed by interviews and record reviews.
Nursing staff did not consistently follow professional standards for counting and documenting controlled medications, including failing to properly count liquid lorazepam and not reporting a medication discrepancy in a timely manner. Review of accountability sheets revealed multiple missing nurse signatures and incomplete documentation across several shifts, with the DON confirming these lapses in required procedures.
A resident developed new respiratory symptoms, including congestion and difficulty breathing, which led to new medical interventions such as cough medicine, a chest x-ray, and oxygen. Despite these changes, the care plan was not updated to address the resident's respiratory issues, as confirmed by staff interviews and record review.
Facility staff did not develop a baseline care plan or provide a copy of the care plan and medication list to a resident or their representative within 48 hours of admission. Review of the electronic health record and staff interviews confirmed the absence of the required documentation.
A resident was ordered to wear a WanderGuard device to prevent elopement, but staff did not update or implement a person-centered care plan addressing the device's use. Nursing documentation lacked details on the rationale, location, and care interventions for the device, and the electronic medical record did not contain an active care plan reflecting the current use of the WanderGuard.
A resident identified as at risk for pressure ulcers developed a Stage 2 pressure injury on the right heel, which progressed to an unstageable ulcer due to a lack of timely wound provider assessment and delayed implementation of new interventions. Facility staff confirmed that no new physician orders or wound care measures were initiated until several days after the ulcer was first documented, allowing the condition to worsen.
Facility staff did not have an effective system to monitor or respond to significant weight fluctuations in a resident, as evidenced by unaddressed and undocumented changes in body weight. Staff interviews confirmed that expected procedures for reweighing and reporting were not followed, and the DON acknowledged the lack of documentation and response.
A resident with multiple diagnoses, including bipolar disorder and Parkinson's, was prescribed several psychotropic medications without corresponding physician orders for behavior or side effect monitoring. Both the DON and ECSSM confirmed that such monitoring is required, but review of the records showed it was not in place, resulting in a deficiency.
A resident receiving Oxycodone for pain management had multiple discrepancies between the controlled substance count sheet and the MAR, with several doses documented as given on one record but not the other, and inconsistencies in the timing and order of entries. Interviews with an LPN and the DON confirmed that both records should match, but this was not consistently done.
A resident receiving hospice care had elevated blood glucose levels and frequently refused fingerstick checks. The consulting pharmacist recommended changes to the insulin dose and a reduction in fingerstick frequency, but the recommendation was not addressed by a provider, as there was no response, signature, or date on the form. The DON confirmed that the facility did not review or respond to the pharmacist's recommendations within the expected timeframe.
Facility staff did not ensure consistent attendance of required QAA committee members at monthly meetings, with the Medical Director, DON, and Infection Preventionist each missing one or more meetings as confirmed by the NHA through attendance records.
Two residents were not properly offered or documented for influenza and pneumococcal vaccinations. One resident lacked records for both vaccines, and another had no documentation of being offered or educated about the pneumonia vaccine, with consent forms left incomplete and no supporting documentation in the medical record.
A review of employee health files revealed that one registered nurse's COVID-19 vaccination status was not documented. Staff interviews confirmed that the facility did not maintain COVID-19 immunization records for employees after discontinuing vaccine administration.
Surveyors found that the facility did not have a required transfer agreement with a local hospital, as confirmed by the NHA during documentation review and staff interviews.
Failure to Prevent Elopement of Cognitively Impaired Residents Due to Ineffective Monitoring and Alarm Systems
Penalty
Summary
The facility failed to maintain an effective system to prevent residents with cognitive impairments from leaving the premises without appropriate supervision. Two residents with known exit-seeking and elopement behaviors were able to leave secure areas of the facility undetected. One resident, who had a history of severe cognitive impairment and multiple prior elopement incidents, was able to exit the building after dinner and was found outside near the facility van. The WanderGuard system, which was intended to alert staff and prevent such incidents, did not trigger an alarm when the resident exited, and only recorded an event when the resident was escorted back inside. Staff documentation for this incident was also found to be mixed with records from a previous year, and no new elopement evaluation was completed after the incident. Another resident, also with severe cognitive impairment and a history of wandering, was found in the assisted living library after having previously eloped from the nursing home building. This resident had a WanderGuard bracelet in place, but the system failed to alarm when the resident passed through a monitored door. The alarm only activated when the resident was brought back through the door by staff. Interviews with facility leadership and maintenance staff revealed that the WanderGuard alarm system's audio alert was faint and not easily heard from a distance, and that the system was not integrated with staff phones, relying instead on pagers for notification. Observations confirmed that the physical environment outside the main entrance posed multiple hazards, including active roadways and parking areas. The facility's elopement evaluation process was found to be inadequate, as it was only used to determine the need for a WanderGuard and not updated after each incident. Staff interviews confirmed a lack of understanding regarding the need for post-incident evaluations. The combination of ineffective monitoring, unreliable alarm systems, and insufficient post-incident assessment contributed to the failure to provide adequate supervision and prevent accidents for residents at high risk of elopement.
Removal Plan
- A team member will be present monitoring the front entrance doors at nursing desk and the door exiting the healthcare center level of living and entering assisted level of living 24 hours a day, 7 days a week to ensure constant visual monitoring of individuals exiting the community until a mechanism is installed to create immediate notification to community staff for unauthorized exits.
- Install a mechanism to create immediate notification to community staff for unauthorized exits.
- Consult a security company to explore solutions to increase door security related to unauthorized exits and have a senior technician assess the situation.
- Educate current community staff of all disciplines on the immediate process change related to door security.
- Audit the front entry door monitoring and door between assisted living and nursing home daily by NHA or designee.
- Submit audit results for review and recommendation to the Quality Assurance Performance Improvement Committee.
Deficiencies in Food Storage, Ice Machine Maintenance, and Dishwashing Sanitization
Penalty
Summary
Surveyors identified several deficiencies in the facility's food service operations during an inspection. Expired food items, including various spices, pork, and frozen cookies, were found in the kitchen with labels indicating they were past their use-by dates. The Certified Dietary Manager (CDM) confirmed that these items should have been discarded according to facility policy, which requires opened items to be labeled and disposed of once expired. The CDM acknowledged responsibility for ensuring compliance with these procedures and disposed of the expired items during the surveyor's observation. Additionally, the ice machine's filtration cartridge was found to be overdue for replacement. The label on the cartridge indicated it should have been replaced six months after installation, but both the CDM and the Maintenance Manager confirmed it had not been replaced as required. The Maintenance Manager, whose initials were on the installation label, acknowledged that the replacement was overdue. The facility also failed to consistently maintain required temperature levels for dishwashing sanitization. Observations showed that the dishwashing machine's final rinse temperature did not always reach the required 180°F, with several loads registering below this threshold. Review of the dishwasher temperature logs revealed that a significant number of final rinse temperatures documented over the past month were below the required level. Neither the CDM nor the dishwasher staff were observed monitoring the temperature gauges during operation, and the CDM confirmed that staff had been trained to do so but were not consistently following this practice.
Failure to Implement Effective QAPI Program for Quality Concerns
Penalty
Summary
Facility staff failed to maintain an effective Quality Assurance Performance and Improvement (QAPI) program capable of identifying and correcting quality concerns. During the recertification and complaint survey, surveyors found that the facility's QAPI meetings, while held monthly, did not address specific incidents such as resident elopement, employee-to-resident abuse, or issues with controlled medication documentation. The QAPI binder contained only general incident counts without detailed discussions or corrective action plans for these events. When questioned, the Nursing Home Administrator (NHA) was unable to provide evidence that these incidents were reviewed or addressed through the QAPI process. Specific incidents were cited, including a resident's elopement, an employee-to-resident abuse case, and repeated failures in controlled medication documentation by nursing staff. The NHA confirmed that these issues were either not discussed or not documented in the QAPI process, despite being self-reported and noted in follow-up reports. The lack of a systematic approach to identifying and correcting these deficiencies demonstrated the facility's failure to ensure an effective QAPI program was in place.
Failure to Protect Resident from Physical Abuse by Staff
Penalty
Summary
A deficiency occurred when a geriatric nursing assistant (GNA) was observed by another staff member to have open-hand smacked a resident on the left forearm after the resident reached for and would not let go of a laundry basket. The incident took place in the hallway outside a resident room, and was documented in the facility's investigation file, including a signed interview with the witnessing staff member. The resident, when interviewed, demonstrated a swiping motion and indicated through gestures that they had been hit, further corroborating the account of the incident. The facility's policy defines physical abuse as including actions such as hitting and slapping, and the incident was discussed by facility leadership, who acknowledged the smacking occurred. Interviews with the DON and NHA revealed a focus on whether the act was intentional, but both confirmed the event took place as described. The report does not mention any relevant medical history or specific condition of the resident at the time of the incident, but it is clear that the resident was in a wheelchair and able to communicate non-verbally about the event.
Failure to Timely Report Allegations of Abuse to State Agency
Penalty
Summary
The facility failed to timely report allegations of abuse to the State Survey Agency, specifically the Office of Health Care Quality (OHCQ), as required. In the first incident, a staff member observed a geriatric nursing assistant (GNA) allegedly smacking a resident on the forearm. The incident was observed at approximately 7:30 AM, but the initial report to OHCQ was not submitted until almost four hours later, exceeding the required two-hour reporting timeframe. Interviews with the Director of Nursing (DON), Assistant Director of Nursing (ADON), and Extended Care Services Support Manager (ECSSM) confirmed that the report was not submitted within the mandated period, despite staff being educated on immediate reporting protocols. In the second incident, a family member reported witnessing a male caregiver push and hit another resident. The facility became aware of this allegation at 9:50 AM, but the initial report was not submitted to OHCQ until 4:25 PM, approximately 6.5 hours later. The DON confirmed during an interview that this report was also not submitted within the required two-hour timeframe. Both incidents demonstrate a failure to adhere to state-mandated timelines for reporting suspected abuse, as evidenced by documentation and staff interviews.
Failure to Investigate and Document Abuse, Elopement, and Medication Error Incidents
Penalty
Summary
The facility failed to thoroughly investigate and document three separate incidents involving residents. In the first incident, a family member reported that a male caregiver allegedly pushed and struck a resident. Although the facility's initial self-report stated that the resident was immediately assessed and had no injuries, there was no evidence of any assessment or related progress notes in the resident's medical record during the investigation period. Interviews with the DON and NHA confirmed that the required assessment was not completed or documented as indicated in the self-report. In the second incident, a resident eloped from the secure area of the healthcare building while wearing a WanderGuard bracelet, which failed to activate the door alarms. The facility's investigation records did not include documentation of a root cause analysis or an audit of other residents' WanderGuard devices. Additionally, education regarding the elopement incident was not provided to all required staff, as only a portion of the nursing staff received in-service training. The third incident involved a medication error where a controlled substance (liquid lorazepam) was not properly counted by nursing staff, and a discrepancy was not reported in a timely manner. The facility's investigation revealed that not all nurses involved received the required education, and the DON did not conduct a thorough audit of controlled medications, nor was there an audit form available. These failures demonstrate a lack of comprehensive investigation and follow-through on corrective actions for reported incidents.
Failure to Follow Professional Standards for Controlled Medication Counts
Penalty
Summary
Facility nursing staff failed to adhere to professional standards of nursing practice regarding the counting and documentation of controlled medications. Specifically, on one occasion, liquid lorazepam for a resident was not properly counted by an LPN and an RN, and a discrepancy in the medication amount was not reported in a timely manner by another RN. The facility's investigation revealed that during a shift change, the required process of two nurses verifying and counting controlled medications, including those stored in the medication refrigerator, was not followed. When a discrepancy of 15ml was discovered, the appropriate reporting protocol was not immediately followed, as the nurse contacted another staff member by phone instead of notifying the Director of Nursing (DON) as required. Further review of the facility's controlled medication accountability signature sheets for two medication carts over a two-week period showed multiple instances where required nurse signatures and total item counts were missing. These omissions occurred across various shifts and dates, indicating a pattern of incomplete documentation and lack of adherence to established procedures for controlled medication accountability. The DON confirmed that the expectation was for two nurses to verify and document the counts with signatures at each shift change, and acknowledged the deficiencies identified during the review.
Failure to Update Care Plan for New Respiratory Issues
Penalty
Summary
The facility failed to revise the interdisciplinary care plan to address a resident's new respiratory issues. Medical record review showed that the resident returned from an outing in stable condition but subsequently developed congestion and a dry cough, which led to the ordering of cough medicine and a chest x-ray. Progress notes documented that the resident was unable to clear mucus and required oral suctioning. Later, the resident experienced difficulty breathing, prompting the application of oxygen and a call to 911. The resident, who had a DNR order, expired before emergency services arrived. Despite these significant changes in the resident's respiratory status and the initiation of new interventions, the care plan was not updated to reflect the resident's recent respiratory issues. Interviews with facility staff confirmed that the expectation was for the care plan to be revised in response to such changes, but documentation showed the care plan had not been updated since before the onset of the respiratory symptoms.
Failure to Develop and Provide Baseline Care Plan Upon Admission
Penalty
Summary
Facility staff failed to develop a baseline care plan and did not provide the resident or their representative with a copy of the baseline care plan and medication list within 48 hours of admission, as required. Medical record review on 3/31/25 revealed that the resident did not have a baseline care plan documented in the electronic health record. During interviews, the DON confirmed that no baseline care plan was present and was unable to provide a copy, stating that the nurse is responsible for completing and having the care plan signed, after which it should be scanned into the electronic record. Further interviews with the ADON and Administrator confirmed that there was no documentation of a completed baseline care plan for the resident.
Failure to Update Care Plan for Resident with WanderGuard Device
Penalty
Summary
Facility staff failed to update and implement a person-centered care plan for a resident who was ordered to wear a WanderGuard safety device to prevent elopement. The medical record review showed that an order for the WanderGuard was written, but there was no nursing documentation explaining the rationale for the device, its location, or an active care plan guiding staff on how to care for the resident while the device was in use. The treatment administration record indicated that staff signed off on the device's presence but did not document its site of application. Further review of the resident's care plan in the electronic medical record system revealed there was no active care plan addressing the use of the WanderGuard. The DON confirmed during interview that a care plan should have been in place for the safety device. An inactive behavioral care plan was provided, but it did not reflect the current use of the WanderGuard or include updated interventions. Previous documentation noted the device's placement on the resident's wheelchair, but this information was not current or incorporated into an active care plan.
Failure to Timely Assess and Intervene for Pressure Ulcer Development
Penalty
Summary
The facility failed to implement timely and appropriate measures to prevent the development and worsening of a pressure ulcer for a resident who was at risk due to decreased mobility and occasional incontinence. Upon admission, the resident was identified as being at risk for pressure ulcers, and a care plan was established to maintain skin integrity. Despite this, the resident developed an open blister on the right heel, which was documented as a Stage 2 pressure ulcer within two days. There was no evidence of wound provider assessment or new physician orders for wound care interventions until ten days after the initial identification of the pressure injury. During this period, the resident's condition progressed from a Stage 2 pressure ulcer to an unstageable pressure ulcer, as confirmed by the wound nurse practitioner's first assessment. Facility staff confirmed that the resident was not seen by the wound provider and did not receive new interventions until after the ulcer had worsened. The lack of timely assessment and intervention was acknowledged by facility leadership as a significant concern.
Failure to Monitor and Respond to Significant Weight Changes
Penalty
Summary
Facility staff failed to have a system in place to monitor and respond to significant changes in a resident's weight. Medical record review showed that a resident experienced notable fluctuations in body weight over a short period, including an 8.3% loss within nine days and a subsequent 23% gain, with no documentation or follow-up regarding these changes. The dietitian noted suspected errors in weight entries but there was no evidence in the medical record that these discrepancies were investigated or addressed in a timely manner. Interviews with staff confirmed that while there was an expectation to reweigh and report significant weight changes, there was no documentation that this process was followed for the resident in question. The DON verified that the facility did not document monitoring or response to the resident's weight fluctuations, confirming the deficiency in the facility's system for managing residents' nutritional status.
Failure to Provide Required Behavioral Health Monitoring for Resident on Psychotropic Medications
Penalty
Summary
The facility failed to provide necessary behavioral health monitoring for a resident who was prescribed multiple psychotropic medications. Medical record review revealed that the resident, who had diagnoses including bipolar disorder, Parkinson's disorder, a history of falls, muscle weakness, and unsteadiness, was receiving Seroquel, Divalproex sodium ER, and Mirtazapine. Despite these medications, there were no physician orders for behavior or side effect monitoring documented in the resident's records. During interviews, both the Director of Nursing (DON) and the Extended Care Services Support Manager (ECSSM) confirmed that behavior monitoring is required for any resident on psychotropic medications and that such orders should be present and documented in the medication administration record. Upon review of the resident's physician orders, both staff members acknowledged that the required behavior monitoring order was missing for this resident, confirming the deficiency.
Failure to Reconcile Controlled Substance Administration Records
Penalty
Summary
The facility failed to maintain drug records in a manner that allowed for reconciliation of dispensed and administered medication for a resident who was admitted for recovery from a right digital radial fracture and was prescribed Oxycodone 2.5mg every 6 hours as needed for pain. A review of the resident's Medication Administration Record (MAR) and controlled substance records for March 2025 revealed multiple instances where the controlled substance records indicated that Oxycodone was administered, but there was no corresponding documentation in the MAR. Specific dates and times were identified where this discrepancy occurred, and there were also inconsistencies in the documentation for a particular day, with times and doses not matching between the two records and not being recorded chronologically. Interviews with facility staff, including an LPN and the Director of Nursing, confirmed that the expectation was for nurses to document administration of controlled medications on both the MAR and the controlled substance count sheet. The DON acknowledged the discrepancies and agreed that the two records should match, validating the surveyor's findings of incomplete and inconsistent documentation for the administration of a controlled substance.
Failure to Timely Respond to Pharmacist Medication Recommendations
Penalty
Summary
The facility failed to respond in a timely manner to recommendations made by the consulting pharmacist for a resident reviewed for unnecessary medication use. The pharmacist had recommended adjustments to the resident's insulin regimen and frequency of fingerstick blood glucose monitoring, noting that the resident's blood sugar levels were elevated and that the resident, who was on hospice care, often refused fingersticks. The recommendation form in the resident's medical record lacked any physician response, signature, or date, indicating that the recommendations were not addressed as required. During review with the Director of Nursing, it was confirmed that the facility did not review and respond to the Monthly Recommendation Report within the expected timeframe.
Failure to Ensure Required QAA Committee Member Attendance
Penalty
Summary
Facility staff failed to ensure that all required members of the Quality Assessment and Assurance (QAA) committee consistently attended the monthly QAA meetings. Review of facility records from February 2024 to February 2025 showed that the Medical Director missed one meeting, the Director of Nursing missed two meetings, and the Infection Preventionist missed three meetings. These attendance lapses were confirmed by the Nursing Home Administrator during an interview and review of the QAA committee attendance sheets. No information regarding specific residents, their medical history, or their condition at the time of the deficiency was provided in the report.
Failure to Offer and Document Flu and Pneumococcal Vaccinations
Penalty
Summary
The facility failed to ensure that all residents were properly offered and documented for influenza and pneumococcal vaccinations. Specifically, one resident admitted in February 2025 did not have records of receiving the flu vaccine for the current season, nor any documentation regarding the pneumococcal vaccine. Interviews with the Assistant Director of Nursing (ADON) and a corporate support manager revealed that delays in updating vaccination status were attributed to difficulties in reaching responsible parties for consent, but there was no documentation in the resident's medical record to reflect these efforts or the resident's vaccination status. Additionally, another resident's medical record lacked documentation of the pneumonia vaccination status. Although the responsible party had provided telephone consent for the flu vaccine, there was no evidence that education or an offer for the pneumococcal vaccine was provided, as indicated by the incomplete consent form. The ADON confirmed that the pneumonia vaccine status was not updated and that there was no documentation supporting that education regarding the pneumococcal vaccine had been given.
Failure to Document Employee COVID-19 Vaccination Status
Penalty
Summary
The facility failed to ensure proper documentation of employees' COVID-19 vaccination status, as evidenced by the absence of a COVID-19 vaccination record for one registered nurse hired in November 2024. During a review of five randomly selected employee health files, it was found that the immunization record for this nurse did not include any documentation of COVID-19 vaccination. Interviews with the ADON and corporate supporting manager confirmed that the facility did not maintain this documentation, with the ADON stating that records were not kept since the facility no longer offered the COVID-19 vaccine. The lack of documentation was validated by staff during the survey.
Lack of Required Hospital Transfer Agreement
Penalty
Summary
The facility failed to maintain a transfer agreement with a local hospital as required by federal regulations. During an extended survey, the surveyor requested documentation of a transfer agreement, and the Nursing Home Administrator confirmed that no such agreement existed between the facility and a local hospital. This deficiency was identified through review of documentation and staff interviews. No information about specific residents, their medical history, or their condition at the time of the deficiency was provided in the report.
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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