Goodwill Mennonite Home, Inc.
Inspection history, citations, penalties and survey trends for this long-term care facility in Grantsville, Maryland.
- Location
- 891 Dorsey Hotel Road, Grantsville, Maryland 21536
- CMS Provider Number
- 215250
- Inspections on file
- 15
- Latest survey
- May 8, 2025
- Citations (last 12 mo.)
- 0
Citation history
Health deficiencies cited at Goodwill Mennonite Home, Inc. during CMS and state inspections, most recent first.
A resident with dementia and a known history of wandering was able to leave the facility unsupervised by following a visitor through an exit door. The care plan identified the resident as a wanderer but did not include specific monitoring interventions, resulting in the resident being outside for about 10 minutes before being found by staff.
Surveyors found that the facility did not timely report suspected abuse, neglect, or injuries of unknown origin to the state agency for several residents with cognitive and physical impairments. Multiple cases involved unexplained bruises or injuries, with no documentation of incidents to account for them and no required reports submitted. Staff interviews revealed misunderstandings of reporting requirements, and the facility's policy did not align with state regulations for timely reporting.
Two residents with cognitive and physical impairments were found with unexplained bruising, and the facility failed to conduct thorough investigations as required by policy. Staff statements were minimal, documentation was incomplete, and there was no evidence supporting the conclusions about the causes of the injuries.
The facility failed to document clinical rationales for not attempting Gradual Dose Reduction (GDR) and did not adequately monitor or record behaviors and side effects for residents receiving psychotropic medications. For example, a resident was started on Seroquel without ongoing behavioral or side effect monitoring, another continued on psychotropic drugs without documented GDR attempts or specific indications, and a third resident's side effects were rarely documented despite being on multiple psychotropic medications. These deficiencies were identified through observations, record reviews, and staff interviews.
Surveyors found that controlled substances such as Ativan, Phenobarbital, Ultram, and Xanax were not secured in a double-locked system and were not included in daily controlled substance counts, contrary to facility policy. Additionally, medication refrigerators in multiple medication rooms were maintained at temperatures below manufacturer recommendations for drugs like insulin and Trulicity, with logs and staff interviews confirming ongoing temperature deviations and lack of alignment with manufacturer guidelines.
A resident was subjected to physical abuse when a GNA pinched them, and the abuse was substantiated through an internal investigation with corroborating staff reports. The incident demonstrated a failure to protect the resident from abuse by facility staff.
Two residents did not receive appropriate care according to physician orders and their needs. One resident was found using a skin protectant cream at bedside that was not ordered by a physician, while another resident with dementia experienced multiple episodes of bruising that were not consistently documented or addressed with appropriate interventions, such as protective footwear or a clutter-free environment, despite recommendations in injury investigation reports.
Surveyors found that gaps in the drywall near pipes beneath sinks and a loose plate exposing a wall gap in two resident bathrooms were not repaired, despite regular maintenance checks and staff reporting processes. The Environmental Services Director was made aware of the issues, but repairs had not been completed at the time of follow-up.
A resident admitted to hospice care did not have a Significant Change in Status MDS assessment completed within the required 14-day period. The assessment was finalized 29 days after hospice admission, exceeding the mandated timeframe. The MDS coordinator reported being unaware of the specific deadline for this assessment.
A resident's discharge plan to an assisted living apartment was not accurately reflected on the MDS assessment, as the assessment incorrectly indicated a return to the facility was anticipated despite clear documentation and communication of the planned discharge to assisted living.
A resident with dementia and a history of wandering was admitted and identified as an elopement risk, but the baseline care plan did not include interventions for monitoring. Despite being on a locked unit, the resident was able to leave the facility unsupervised and was later found outside, confused. Staff interviews confirmed the absence of monitoring instructions in the care plan.
A resident with a history of skin tears and a care plan requiring Geri Gloves to prevent injury was repeatedly observed without the prescribed gloves. Despite provider orders and documentation in the care plan, staff interviews confirmed the intervention was not implemented, resulting in the resident being unprotected against skin injury.
Two residents were found to have bed rails in use without proper assessment for entrapment risk, and the facility's bed rail assessments did not include evaluation for entrapment. Staff interviews revealed confusion over responsibility for safety checks, and documentation was lacking for ongoing assessment or reevaluation of side rail need, despite policy requirements.
An LPN presigned and dated the controlled substance log count for a future shift on a medication cart, indicating a completed count that had not yet occurred. This action resulted in an inaccurate inventory of controlled medications, as confirmed by the DON.
A resident with hypertension received antihypertensive medication on several occasions despite having a pulse below the threshold specified in the physician's order. Staff confirmed that the medication was administered when it should have been held, and the facility's retrospective review process had not yet identified these errors.
Staff failed to properly label and remove expired food items, including an unlabeled container of coleslaw dressing and expired thickened lemon-flavored water, from facility refrigerators. Both dietary and nursing staff missed these items during their routine checks.
A medication cart was left unattended with an unlocked computer displaying resident information, including a photo and personal data, near the nurse's station. Two individuals walked past the cart before an Infection Control Nurse noticed and locked the screen. The nurse confirmed the computer had been left unattended with resident data visible but could not identify which resident's information was exposed.
Two residents who were dependent on staff for bed mobility did not have their beds inspected or assessed for entrapment risks, despite having side rails. Bed rail assessments were performed multiple times but did not include safety or entrapment checks. The DON confirmed that current assessments do not monitor for entrapment, and the facility's policy lacks guidance on this issue.
Surveyors found that daily staffing information was not posted in a prominent, publicly accessible location. The NHA confirmed that only unit-specific staffing ratios were available at nursing stations, and consolidated facility-wide staffing data was not posted at the main entrance as required.
Failure to Prevent Elopement of Cognitively Impaired Resident
Penalty
Summary
The facility failed to implement an effective system to prevent cognitively impaired residents from leaving the premises without appropriate supervision. A resident with dementia, who had a documented history of wandering and elopement, was admitted to the facility and identified as a wanderer in both clinical documentation and the baseline care plan. However, the care plan did not specify interventions to monitor the resident, despite clear evidence of cognitive impairment and inability to make informed decisions as certified by two providers. On the day of the incident, the resident was able to exit the building unsupervised by following another resident's family member through an exit door at the end of a hallway. The resident traveled outside, down a steep hill to a parking lot near a public road and a large pond, and was found outside by housekeeping staff after being unsupervised for approximately 10 minutes. The lack of specific monitoring interventions and inadequate supervision directly contributed to the resident's ability to elope from the facility.
Failure to Timely Report Suspected Abuse and Injuries of Unknown Origin
Penalty
Summary
The facility failed to comply with regulatory requirements for timely reporting of suspected abuse, neglect, or injuries of unknown origin to the State Survey Agency. Multiple instances were identified where residents with cognitive and physical impairments, including those with severe dementia and total care needs, were found with unexplained bruises or injuries. In several cases, there was no documentation of a fall or incident to account for the injuries, and the facility did not submit required incident reports to the state agency. For example, one resident with severe cognitive impairment was found with multiple bruises aligning with equipment and furniture, but no report was made to the state agency. In another case, a resident who required substantial staff assistance for transfers was found with a new bruise, but the facility's investigation did not determine the cause, and the injury was not reported to the state agency. Interviews with staff revealed a misunderstanding of reporting requirements, with some staff believing that if a plausible explanation could be found, reporting was unnecessary, even without corroborating evidence. The facility's social service coordinator confirmed that no reportable injuries had been submitted to the state agency for an extended period. Additional deficiencies included late reporting of an abuse allegation and failure to report injuries of unknown origin for other residents, despite facility policy requiring prompt reporting. The facility's policy did not align with state regulations, as it did not require all injuries of unknown origin to be reported within two hours. Interviews with nursing leadership confirmed a lack of documentation and reporting for these incidents, and the Director of Nursing acknowledged that the required reports had not been made.
Failure to Conduct Thorough Investigations of Injuries of Unknown Origin
Penalty
Summary
The facility failed to ensure that injuries of unknown origin were thoroughly investigated for two out of five residents reviewed for potential abuse. One resident with severe Alzheimer's dementia and significant physical care needs was found with multiple bruises on her legs and wrist. Although staff noted that the bruises appeared to align with equipment and furniture, the investigation documentation lacked detailed staff interviews and did not provide evidence supporting the conclusions about the source of the bruising. Statements from staff were minimal, and there was no documentation indicating that staff were asked about possible events leading to the injuries. Another resident with dementia and total care needs was found to have a new bruise on the right eyelid. The investigation report attributed the bruise to a transfer with a hoyer lift, but staff statements were limited, with most reporting they did not notice the bruise and no further details provided. The Assistant Director of Nursing, who completed the final investigation note, confirmed that there was no additional documentation to support the determination of the cause of the injury. The investigation did not include evidence or documentation of interviews with other residents or a thorough assessment of possible causes. Facility policy requires that injuries of unknown source be classified and investigated when the source is not observed or explained, and that written statements be obtained from all relevant staff. The policy also requires attempts to contact staff from previous shifts and tracking of such incidents by Quality Assurance. However, the investigations reviewed did not meet these requirements, as documentation was incomplete and lacked evidence of a comprehensive investigation process.
Failure to Document and Monitor Psychotropic Medication Use and GDR
Penalty
Summary
The facility failed to properly document and monitor the use of psychotropic medications for several residents, specifically neglecting to record why Gradual Dose Reduction (GDR) was contraindicated and not providing specific indications for administering these medications. For one resident, Seroquel was initiated due to increased agitation, but there was no ongoing documentation of behavioral monitoring or side effects before and after starting the medication. Nursing notes indicated the resident was frequently sleepy, yet there was no evidence of continued assessment or documentation as required by the facility's own policy. Another resident was observed sleeping frequently, with both staff and the resident's representative noting excessive drowsiness. The pharmacy had recommended a GDR for this resident's psychotropic medications, but the attending physician did not provide a clinical rationale for declining the reduction and failed to follow up on a stated plan to attempt a GDR. Additionally, the physician's notes did not specify the ongoing indication for the medication, nor was there documentation of any GDR attempts after the first year of use, as confirmed by the DON and the physician. A third resident was prescribed multiple psychotropic medications, including antipsychotics, anti-anxiety, and antidepressants, but the facility did not have orders in place to monitor or document side effects. Review of the resident's behavior monitoring sheets revealed that side effects were only documented on one day out of an entire month, despite daily documentation of behaviors. The DON confirmed the lack of orders and documentation for monitoring side effects, and the pharmacist had not identified this gap. These deficiencies were identified through observations, record reviews, and staff interviews.
Controlled Substances Not Double-Locked and Improper Medication Refrigerator Temperatures
Penalty
Summary
Surveyors identified that controlled substances, including Ativan, Phenobarbital, Ultram, and Xanax, were not stored in accordance with facility policy and federal regulations. In three medication storage rooms, these Schedule IV drugs were kept in stock medication boxes on top of medication carts, sealed only with colored zip ties rather than being secured under a double-lock system as required. Nurses explained that the zip ties indicated whether drawers had been opened, and that two signatures were required when removing medications. However, no daily counts of these controlled substances were performed, and the inventory was managed by the pharmacy during restocking. The Director of Nursing confirmed that controlled substances should be locked and included in daily counts, but this was not being done for the stock medications. Additionally, surveyors observed that medication refrigerators in all three medication rooms were not maintained at appropriate temperatures for medication storage. Nurses reported that the night shift was responsible for logging refrigerator temperatures, but logs and direct readings showed temperatures as low as 32°F, which is below the manufacturer's recommended range for medications such as insulin and Trulicity. The posted temperature guidelines in the medication rooms did not align with manufacturer instructions, and the facility's insulin storage policy did not specify the required temperature range. Nurses stated that if temperatures were out of range, they would notify the DON or maintenance, but logs showed repeated instances of temperatures below the acceptable range without clear evidence of corrective action. The surveyors found that the facility's practices for storing controlled substances and maintaining proper medication storage temperatures did not comply with professional standards, facility policy, or manufacturer guidelines. These deficiencies were confirmed through staff interviews, direct observation, and review of facility documentation, with both the Director of Nursing and Assistant Director of Nursing acknowledging the issues.
Failure to Protect Resident from Physical Abuse by Staff
Penalty
Summary
A facility failed to protect a resident from abuse, as evidenced by an incident in which a Geriatric Nursing Assistant (GNA) pinched a resident. The abuse was substantiated following an internal investigation, which included reports from another GNA who was present during the incident. The facility's Abuse Coordinator and Director of Nursing acknowledged the occurrence and the failure to prevent the abuse. Documentation confirmed that the abuse was reported to the appropriate state board. The resident involved had been admitted to the facility in 2021. The deficiency was identified through record reviews and staff interviews, which confirmed that the resident was not adequately protected from physical abuse by facility staff.
Failure to Administer Correct Topical Treatment and Prevent Recurrent Injuries
Penalty
Summary
The facility failed to ensure that a resident received the correct topical treatment as ordered by a physician. One long-term resident in the dementia care unit reported using a cream for an itchy back, and a tube of Dimethicone skin protectant was observed at the bedside. However, a review of the resident's physician orders did not reveal an order for Dimethicone, and the Assistant Director of Nursing confirmed that a different cream had been ordered for the resident. This indicates that the resident was using a topical product not prescribed by the physician, contrary to facility policy and physician orders. Additionally, the facility failed to protect another resident from injury related to multiple episodes of bruising. This resident, also with dementia, was noted to have bruising on several occasions, as documented in treatment administration notes. Despite these findings, subsequent skin assessments did not consistently document the presence of bruising. The resident was found to have significant bruises on both feet on separate occasions, with injury investigation reports attributing the injuries to contact with a tray table and noting the resident's use of anticoagulant medication, which increased the risk of bruising. Although the injury investigation reports recommended interventions such as applying protective footwear and keeping the area around the resident's feet clear, there was no evidence in the physician orders that these interventions were implemented. The Assistant Director of Nursing and Director of Nursing both confirmed that these interventions should have been ordered and documented, but this was not done, resulting in a failure to implement measures to prevent further injury.
Failure to Repair Drywall Gaps in Resident Bathrooms
Penalty
Summary
Surveyors observed that the facility failed to maintain a safe and homelike environment by not repairing holes and gaps in the drywall in two resident bathroom areas. Specifically, there were visible gaps in the drywall near the pipes beneath the sinks in bathrooms shared by residents in multiple rooms, as well as a loose plate exposing a gap in the drywall where a toilet pipe entered the wall. These deficiencies were noted during facility observations and were confirmed through interviews with the Environmental Services Director, who acknowledged the issues after being informed by the surveyor. Despite regular maintenance rounds and staff reporting protocols, the necessary repairs had not been completed by the time of follow-up observation.
Late Completion of Significant Change MDS Assessment After Hospice Admission
Penalty
Summary
The facility failed to complete a Significant Change in Status Minimum Data Set (MDS) assessment within the required 14-day timeframe for a resident who was admitted to hospice care. Record review showed that the resident had been in the facility since May 2023 and was admitted to hospice on 1/22/25. The Significant Change in Status MDS assessment was not completed and signed until 2/19/25, which was 29 days after hospice admission and 15 days past the required deadline. During staff interview, the MDS coordinator acknowledged being unaware of the required timeframe for completing the assessment following a resident's admission to hospice care.
Inaccurate MDS Discharge Documentation
Penalty
Summary
The facility failed to accurately document a resident's discharge plan on the Minimum Data Set (MDS) assessment. Review of the resident's care plan and progress notes indicated that the resident wished to be discharged to their home, specifically to their assisted living apartment. Multiple entries in the medical record, including nursing, social services, and restorative program notes, confirmed that the discharge to assisted living was planned and communicated to the resident and their family. The resident's therapy was concluded, and a home exercise program was provided in preparation for the discharge. Despite this clear discharge plan, Section A of the MDS assessment completed on the discharge date was marked as 'return anticipated,' indicating the resident was expected to return to the facility. During an interview, the MDS Coordinator acknowledged responsibility for completing this section and, upon review, admitted that 'return not anticipated' should have been selected based on the resident's actual discharge plan. The coordinator explained that she often selects 'return anticipated' for residents who frequently return, but recognized this was not appropriate in this case.
Failure to Develop Baseline Care Plan with Elopement Interventions
Penalty
Summary
Facility staff failed to develop a person-centered baseline care plan with specific interventions for monitoring a resident identified as an elopement risk. The resident, who had dementia and a history of wandering and elopement attempts at home, was admitted to the facility and assessed as a wanderer. Although the baseline care plan noted the resident's wandering behavior, it did not include any interventions or instructions for staff to monitor the resident, despite the known risk. A few days after admission, the resident was found outside the building by housekeeping staff and was noted to be very confused at the time. Interviews with MDS coordinators confirmed that the baseline care plan did not contain monitoring interventions because the resident was on a locked unit. However, the resident was still able to leave the facility unsupervised, demonstrating that the lack of specific monitoring interventions contributed to the incident.
Failure to Implement Care Plan Interventions to Prevent Skin Injury
Penalty
Summary
The facility failed to implement a resident-centered care plan for a resident with a known risk for skin injury. Despite having a documented care plan and provider order for the application of Geri Gloves to both arms each morning and removal each evening to prevent skin injury, observations on two consecutive days showed the resident was not wearing the prescribed Geri Gloves. The resident was observed with a wound dressing on the right elbow, and the resident's representative reported that the resident sometimes sustains skin tears from falls. Further review of the resident's records confirmed the care plan included the intervention of Geri Gloves, yet staff interviews revealed that the gloves had not been seen in use for over a year. The geriatric nurse aide specifically stated never having seen the resident with Geri Gloves, indicating a failure to implement the care plan intervention as ordered and documented.
Failure to Assess and Monitor Bed Rail Entrapment Risk
Penalty
Summary
The facility failed to properly assess and monitor the risk of entrapment associated with side rail use for two residents. For one resident, repeated observations showed a significant gap between the mattress and the side rail, but the facility's bed rail assessments did not include evaluation for entrapment risk. Interviews with the DON, Environmental Services Director, and Therapy Director revealed confusion over which department was responsible for conducting safety checks, and it was acknowledged that entrapment assessments were not being performed. The facility's policy also did not address the need to assess for entrapment risk or ongoing safety monitoring. For the second resident, side rails were in use per physician order to assist with bed mobility, and the care plan included monitoring for injury or entrapment. However, the facility's bed rail assessments did not include evaluation for entrapment risk. Documentation indicated that the resident was not using the side rails for mobility and that removal would be attempted, but there was no evidence of follow-up or reevaluation after this recommendation. The resident continued to have orders for side rail use, and the facility was unable to provide documentation of ongoing assessment or reevaluation regarding the need for side rails. The facility's policy required completion of a side rail assessment form before use and periodic reassessment, but the assessments conducted did not address entrapment risk. There was also a lack of clear documentation and follow-through when recommendations for removal of side rails were made. These deficiencies were identified through observations, record reviews, and staff interviews.
Failure to Maintain Accurate Controlled Substance Inventory
Penalty
Summary
The facility failed to maintain an accurate inventory of controlled medications on one of three medication carts observed, specifically on the Memory Lane unit. During a surveyor's observation, a pharmacy service delivered medications to the nurses station, and an LPN signed for the delivery. When asked to show the medication storage, the LPN was found to have presigned and dated the controlled substance log count for a future shift, indicating the count had already been completed when it had not. The LPN acknowledged this action, stating they had gotten ahead of themselves. This deficiency was confirmed by the Director of Nursing.
Failure to Hold Antihypertensive Medication for Low Pulse
Penalty
Summary
A resident with a diagnosis of high blood pressure was prescribed antihypertensive medication to be administered twice daily, with specific instructions from the attending provider to hold the medication if the resident's pulse was less than 70. Record review revealed that the resident received the antihypertensive medication on multiple occasions when their pulse was below the specified threshold, including instances where the pulse was recorded as 63, 66, and 64. Staff interviews confirmed that the medication was administered contrary to the physician's order on these dates. The facility's process for reviewing medication administration records was retrospective, and the errors had not been identified prior to the surveyor's review.
Failure to Properly Store and Label Food Items
Penalty
Summary
The facility failed to store food in accordance with professional standards, as evidenced by multiple observations. In the walk-in refrigerator, an opened container of coleslaw dressing was found without an open date or use-by date, despite staff stating that all opened food items should be labeled with the opening date. In the Memory care unit snack refrigerator, an opened carton of thickened lemon-flavored water was found with an open date that indicated it had expired, and staff confirmed it was past its best by date. Interviews with staff revealed that both dietary and nursing staff were responsible for checking and discarding expired items, but the expired thickened water was missed during routine checks.
Unattended Computer Exposes Resident Data
Penalty
Summary
A deficiency occurred when a medication cart was left unattended on the south wing near the nurse's station, with an unlocked computer displaying visible resident information, including a photo and personal data. The surveyor observed two individuals walking past the unattended cart during this time. The Infection Control Nurse later noticed the situation and locked the computer screen. Upon interview, the nurse acknowledged the computer had been left unattended with resident data visible but was unable to identify which resident's information had been exposed, as the screen was closed too quickly to determine this. This incident was observed on one out of three nursing units and was based on direct observation and staff interview.
Failure to Inspect Beds and Assess Entrapment Risks
Penalty
Summary
The facility failed to inspect beds and identify risks for entrapment for two residents who were dependent on staff for bed mobility. Observations revealed that one resident had a one-half side rail on their bed, and reviews of both residents' care plans and bed rail assessments showed that inspections of the beds or assessments for entrapment risks were not included during evaluations. The bed rail assessments were conducted on multiple occasions, but none addressed bed inspection or entrapment risk. Interviews with the DON confirmed that monthly bed assessments were performed, but these did not include monitoring for entrapment. The Environmental Services Director was unable to provide documentation of bed inspections or entrapment risk assessments, and the facility's Bed/Side-Rail policy did not address these safety concerns. The DON acknowledged that bed assessments for safety were not currently being conducted.
Failure to Post Daily Facility-Wide Staffing Information
Penalty
Summary
Surveyors observed that the facility failed to post daily staffing information in a prominent and publicly accessible location, such as the main visitor entrance. During the recertification survey, it was noted that no staffing posting was present at the main entrance. In an interview, the Nursing Home Administrator (NHA) acknowledged being unaware of the requirement to display consolidated daily staffing information for the entire facility in a central area. Instead, the NHA stated that staffing ratios were only available at individual nursing stations for each unit, and not in a general or central location accessible to the public. As a result, consolidated daily staffing information was unavailable and not posted as required. The NHA confirmed this deficiency. 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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