Green Acres Nursing And Rehab
Inspection history, citations, penalties and survey trends for this long-term care facility in La Plata, Maryland.
- Location
- 10200 La Plata Road, La Plata, Maryland 20646
- CMS Provider Number
- 215106
- Inspections on file
- 14
- Latest survey
- September 5, 2024
- Citations (last 12 mo.)
- 0
Citation history
Health deficiencies cited at Green Acres Nursing And Rehab during CMS and state inspections, most recent first.
The facility failed to protect residents from abuse and neglect, with incidents including a resident left unchanged for 23 hours, a GNA neglecting proper wheelchair use, and resident-to-resident altercations. These events highlight significant lapses in care and supervision, as well as misunderstandings about abuse definitions.
The facility failed to ensure that several residents had an Advance Directive or were offered the opportunity to create one. A resident's record lacked an Advance Directive despite a request, and there was no follow-up. Additionally, Advance Directives were not located for three other residents, and there was no documentation of them being offered. The facility acknowledged the issue and was working on the process.
Facility staff failed to ensure an accurate MDS assessment for a resident's vision. Initially, the MDS noted impaired vision without eyeglasses, despite a nursing note indicating the resident used eyeglasses. A later MDS corrected this, noting both impaired vision and eyeglass use. This discrepancy was reported to the Administrator and DON.
Facility staff failed to ensure a resident wore their eyeglasses, as identified in a complaint investigation. The resident's family expressed concern about the absence of eyeglasses, and clinical records showed discrepancies in the resident's vision care. MDS assessments noted impaired vision, with one indicating no eyeglasses and another indicating their use. There was no evidence of eyeglass use during the first four months of admission.
A facility failed to provide or obtain routine dental care for a resident. Despite a dental consult recommending x-rays and possible extractions over a year ago, no follow-up appointments or exams were documented. Interviews with staff confirmed the absence of further documentation regarding the resident's dental care.
A resident's dignity was compromised when their meal tray was removed before they finished eating. The resident was left with a breakfast casserole on the tray table, and an LPN confirmed the resident had not completed the meal. The Nursing Home Administrator was informed, and an investigation was initiated.
The facility failed to notify the local Ombudsman of resident transfers to the hospital, as required. Two residents were transferred without proper notification, and staff interviews revealed a lapse in the notification process after a change in responsibility. The facility could not provide evidence of notification during the survey.
A resident was transferred to the hospital, and the facility staff failed to provide the required bed hold policy. Despite having a transfer form, there was no evidence that the policy was communicated to the resident or their responsible party. The DON and Administrator acknowledged the oversight during a surveyor interview.
The facility failed to conduct proper care plan meetings for two residents. One resident reported not having a meeting since admission, with no evidence of meetings in their records. Another resident's meeting was attended only by Activities and Social Service staff, lacking a full team of health professionals. The facility's administration acknowledged the absence of documentation.
A resident reported right arm pain to an LPN, leading to a physician's order for an X-ray and Tylenol administration. However, the X-ray order was delayed for three days, resulting in a late diagnosis of a right proximal humerus fracture. The resident was subsequently sent to the emergency department.
A resident was not consistently wearing an ordered brace due to staff inaction, despite instructions to apply it after morning care. The resident expressed frustration over the inconsistency, and the issue was acknowledged by the facility's administration.
Two residents experienced deficiencies in G-tube care. One resident's G-tube was discolored due to medication, but the agency nurse failed to notify the physician. Another resident's G-tube was flushed with less water than ordered, as the LPN did not verify the correct amount. The Unit Manager expected staff to follow medical orders precisely.
The facility failed to maintain oxygen therapy equipment according to policy and physician orders for two residents. Observations revealed unlabeled and undated oxygen tubing and humidifier bottles, with one resident's equipment found on the floor. The DON and Unit Manager confirmed the issues, noting that the equipment should be changed and labeled weekly.
A resident received insulin despite physician's orders to hold it if blood sugar was below 150. The MAR showed insulin was administered six times when blood sugar was under the threshold, indicating a failure to follow medical directives.
A facility failed to provide dental services and assessments for a resident, who had missing teeth and plaque buildup. The resident's family mentioned the need for a dental consult, but it was unclear if this was communicated to the facility. A review of the resident's medical records showed no dental consult, and the DON confirmed the lack of a dental service provider since a change in ownership.
A resident's meal preferences were not met, as their meal included bread, which they disliked, and lacked the requested coffee. A staff member confirmed the resident's preferences and acknowledged the oversight.
Facility staff failed to maintain food items in the kitchen safely. Salami deli meat was found partially wrapped with an expired use-by date, and an opened bag of mozzarella cheese was not in a sealed container. Two bags of bologna lacked date labels. The Food Service Manager confirmed the incorrect date labeling, and the Administrator acknowledged the findings.
Facility staff failed to honor resident shower preferences, as two residents reported not receiving scheduled showers. One resident stated showers only occur with sufficient staff, and records showed a significant gap since the last documented shower. Another resident reported only receiving bed baths and had a noticeable odor, with records confirming only two showers in a month. The Administrator and DON acknowledged the issue and planned to review records.
A facility failed to notify a resident's POA about a stage 2 sacrum pressure ulcer. The ulcer was documented in a wound evaluation, but there was no record of notification to the POA. An LPN claimed to have informed the POA in person but did not document it, contrary to the facility's policy requiring such notifications to be recorded.
The facility failed to report allegations of neglect and missing money to the Maryland Department of Health - Office of Healthcare Quality (OHCQ) within the required time frame. A resident was left in the same clothes for 23 hours, and the final report was delayed. Another resident reported missing money twice, with the first incident reported late and the second not reported at all. The facility did not adhere to the required reporting timelines.
The facility failed to conduct thorough investigations for two residents' allegations. One involved a sexual assault claim with insufficient interviews and no skin assessments, while the other concerned missing money with no documented interviews. The NHA provided incomplete investigation files and did not address the lack of comprehensive investigation procedures.
The facility failed to maintain the most recent survey results in an accessible location for residents and visitors, with no visible signage initially indicating the binder's location. The survey binder was eventually found but lacked documentation of Life Safety Inspections or local fire department inspections. The Nursing Home Administrator was unaware of these inspections, and the Maintenance Director was responsible for such records.
Failure to Protect Residents from Abuse and Neglect
Penalty
Summary
The facility failed to protect residents from abuse and neglect, as evidenced by several incidents involving multiple residents. In one case, a resident was left in the same clothes for 23 hours, with a full catheter bag and a urine-soaked brief, after being placed in bed by a responsible party. The Geriatric Nursing Assistant (GNA) on duty assumed the previous shift had changed the resident, leading to neglect. The Unit Manager was not informed of the incident until after the responsible party reported it to the Administrator and Director of Nursing (DON). Another incident involved a GNA who was witnessed by a maintenance worker pushing a resident in a wheelchair without foot pedals and allegedly kicking the resident's foot. The facility's investigation found evidence of neglect due to the failure to provide appropriate services, such as footrests. The resident, who had a BIMS score indicating moderate cognitive impairment, recalled the incident but could not provide details. Additionally, a resident was found soiled in urine and feces due to GNAs switching assignments, resulting in missed care. Further incidents included a resident being pulled from a wheelchair and kicked by another resident, and an unprovoked attack where one resident slapped another. Both incidents were captured on video, and the facility initially questioned whether these constituted abuse due to the mental incompetence of the perpetrators. However, the surveyor clarified that any willful act is considered abuse, regardless of mental status, emphasizing the residents' right to be free from abuse.
Failure to Ensure Advance Directives for Residents
Penalty
Summary
The facility staff failed to ensure that several residents had an Advance Directive or were offered the opportunity to create one. This deficiency was identified for five residents out of a sample of 52 during a survey. For Resident #21, a review of the clinical record revealed the absence of an Advance Directive, despite a progress note indicating that the resident's Power of Attorney was in progress. There was no evidence of follow-up to this request. Similarly, Resident #98's record lacked an Advance Directive, although a progress note stated that the resident requested one at admission, but the facility did not follow up. Additionally, during a record review, the surveyor could not locate Advance Directives for Residents #286, #287, and #296. The facility was unable to provide documentation that Advance Directives were offered to these residents. An interview with Social Worker #6 confirmed that there was no documentation of Advance Directives being offered to these residents, and the process of following up with family members was not documented. The Director of Nursing acknowledged that the facility was working on the Advance Directives process.
Inaccurate MDS Assessment for Resident's Vision
Penalty
Summary
The facility staff failed to ensure an accurate assessment for a resident, as identified during a survey. The Minimum Data Set (MDS), a federally mandated assessment tool, was inaccurately completed for a resident. A nursing note from March 2021 indicated that the resident's sister had called about the resident's eyeglasses, which the staff had not seen. Despite this, the MDS completed in May 2021 noted the resident had impaired vision but did not use eyeglasses. However, a subsequent MDS in August 2021 correctly noted the resident's impaired vision and use of eyeglasses. This discrepancy in the MDS assessments was highlighted to the Administrator and Director of Nursing during the Exit Conference.
Failure to Ensure Resident Wore Eyeglasses
Penalty
Summary
The facility staff failed to ensure that a resident wore their eyeglasses, which was identified during an investigation of a complaint (Intake MD00166696). The complaint was initiated by the resident's family, who expressed concern that the resident was not wearing their eyeglasses. A review of the clinical record showed that on March 24, 2021, a nurse documented a phone call from the resident's sister requesting the resident's glasses, noting that the glasses had never been seen on the resident or in their room. The Minimum Data Set (MDS) assessments, which are federally mandated to guide care planning, indicated discrepancies in the resident's vision care. The MDS completed on May 21, 2021, noted impaired vision without eyeglasses, while the MDS on August 10, 2021, noted the resident used eyeglasses. There was no evidence that the resident used their eyeglasses during the first four months of their admission.
Failure to Provide Routine Dental Care
Penalty
Summary
The facility staff failed to promptly provide or obtain routine dental care or treatment for a resident, as identified during an annual survey. The deficiency was evident for one resident who was reviewed for dental services. A record review revealed that the resident's daughter reported the facility did not provide dental care. A dental consult completed over a year prior recommended x-rays and possible extractions, but no follow-up appointments or exams were documented. Interviews with the 300 Unit Manager and the Director of Nursing confirmed the lack of additional documentation regarding the resident's dental care.
Resident's Meal Tray Removed Prematurely
Penalty
Summary
The facility failed to respect a resident's dignity by removing a meal tray before the resident had finished eating. During an observation, a surveyor noted that a resident was left with a breakfast casserole directly on the tray table after the meal tray was taken away. The resident confirmed that the plate was removed, leaving them with the casserole. This incident was observed during a breakfast service, and the resident was in bed at the time. An LPN later interacted with the resident and confirmed that the resident had not finished the breakfast casserole before it was removed. The LPN acknowledged the situation and indicated they would identify the GNA responsible for removing the meal tray. The Nursing Home Administrator was informed of the incident and initiated an investigation. A grievance form later revealed that the GNA claimed the resident was holding the casserole and feeding themselves when the tray was removed, but the resident had not completed their meal.
Failure to Notify Ombudsman of Resident Transfers
Penalty
Summary
The facility staff failed to notify the local Ombudsman of facility-initiated resident discharges or transfers, as required by regulations. This deficiency was identified during an annual survey, where it was found that two residents, #19 and #108, were transferred to the hospital for further medical evaluation and treatment without the Ombudsman being notified. Resident #19 was transferred on January 15, 2024, and Resident #108 on June 7, 2024. In both cases, there was no documentation in the clinical records indicating that the Ombudsman had been informed of these transfers. Interviews with facility staff revealed that the responsibility for notifying the Ombudsman had shifted from the previous Director of Nursing (DON) to the Social Work Director in February 2024. The Social Work Director admitted that some transfer notices might have been missed since she took over this responsibility. The Nursing Home Administrator confirmed the absence of evidence showing that the Ombudsman was notified for the transfers in question. At the time of the survey exit conference, the facility was unable to provide any documentation to prove that the required notifications had been made.
Failure to Provide Bed Hold Policy
Penalty
Summary
The facility staff failed to provide a bed hold policy to a resident upon their hospitalization. This deficiency was identified during a review of the clinical record of a resident who was transferred to the hospital. Although a transfer form was present, there was no evidence that the bed hold policy was communicated to the resident or their responsible party. The Director of Nursing and the Administrator acknowledged the oversight during an interview with the surveyor.
Deficiency in Care Plan Meetings for Residents
Penalty
Summary
The facility staff failed to ensure that care plan meetings were held for two residents, as required. Resident #4 reported not having a care plan meeting since admission, and a review of their clinical record suggested a meeting might have been held on February 14, 2024, but there was no evidence, such as a sign-in sheet, to confirm the resident's invitation or attendance. A subsequent meeting, due in May, also lacked documentation. Interviews with the Administrator and Director of Nursing confirmed the absence of evidence for these meetings. Resident #21 also experienced a deficiency in care plan meetings. Although a meeting was recorded on January 31, 2024, it was attended only by staff from the Activities and Social Service Departments, lacking a comprehensive team of health professionals. A meeting noted for May 1, 2024, was marked as 'in progress,' with no clear indication that it occurred. The Administrator and Director of Nursing acknowledged the issue and intended to search the electronic health records for evidence of these meetings.
Delayed X-ray Order Leads to Fracture Diagnosis
Penalty
Summary
The facility failed to ensure timely care for a resident who reported pain in their right arm. The resident informed an LPN about the pain, and the physician was notified, resulting in a new order for an X-ray and administration of Tylenol. However, the staff delayed placing the order for the X-ray for three days. Consequently, the resident only received the X-ray three days later, which revealed a fracture of the right proximal humerus. Following the X-ray results, the resident was sent to the emergency department as per physician orders. The Unit Manager confirmed that the facility's expectation is for the nurse who obtains an order to follow through and place it. The Unit Manager recalled the incident and mentioned that staff were educated on following physician orders.
Failure to Ensure Consistent Use of Ordered Brace
Penalty
Summary
The facility staff failed to ensure that a resident consistently wore an ordered brace, which was necessary to maintain or improve the resident's range of motion. During an interview, the resident indicated that not all staff members applied the brace as required, despite a sign above the bed instructing that the brace should be put on after morning care. On multiple occasions, the resident was observed without the brace, including during meals, and expressed frustration that some staff did not apply it, leading to the resident's resignation to the situation. The facility's Administrator and Director of Nursing were informed of these observations and interviews, acknowledging the issue but not detailing any immediate corrective actions.
Failure to Follow G-Tube Orders and Notify Physician
Penalty
Summary
The facility staff failed to administer additional water flushes via gastrostomy tube (G-tube) according to the prescriber's orders and did not notify the physician of a change in the color of the tubing for two residents. For Resident #73, a nursing note indicated that the G-tube was black in color, raising concerns about a potential infection. However, the Unit Manager confirmed that the tube was not being used for feeding, only for administering medications like Ferrous Sulfate, which caused the discoloration. The agency nurse who noted the change did not inform anyone or contact the doctor, delaying necessary medical consultation. For Resident #78, the treatment administration record specified that the G-tube should be flushed with 250 ml of water every 4 hours. However, an agency LPN flushed the tube with only 120 ml of water without verifying the correct order. The LPN admitted to not reviewing the physician's orders before administering the flush. The Unit Manager expressed that it was expected for staff to follow medical orders precisely, highlighting a lapse in adherence to protocol.
Failure to Maintain Oxygen Therapy Equipment
Penalty
Summary
The facility failed to maintain oxygen therapy equipment according to its policy and physician orders for two residents during the annual survey. For one resident, the surveyor observed that the oxygen tubing and humidifier bottle were not labeled or dated, and the oxygen was found lying on the floor. The Unit Manager confirmed the lack of labeling and stated that the tubing is supposed to be changed, labeled, and dated every Sunday. The Director of Nursing (DON) acknowledged the issue, explaining that the resident had just been admitted and the tubing had not yet been labeled. For another resident, the oxygen tubing was not labeled, and the humidification bottle was dated several days prior, with a low water level observed. The clinical record review showed physician orders for weekly changes of the humidification bottle and oxygen tubing, which were not followed. The facility's Oxygen Administration Policy did not provide guidelines on changing or dating the equipment. The Unit Manager confirmed the discrepancy and noted that the equipment should have been changed according to the physician's orders.
Failure to Administer Medications According to Physician's Orders
Penalty
Summary
The facility staff failed to administer medications according to physician's orders for a resident. The resident's primary physician had ordered Novolog pen 100 unit/ml, 16 units before meals, with instructions to hold the insulin if the resident's blood sugar was less than 150. However, a review of the resident's Medication Administration Record (MAR) revealed that the insulin was administered on six occasions when the resident's blood sugar was below 150. Specifically, the blood sugar levels were recorded as 143, 145, 117, 140, 143, and 142 on different days, yet the insulin was still given. This deficiency was identified during a clinical record review and staff interview, which included discussions with the Administrator and Director of Nursing. The facility acknowledged the findings and indicated they would review the MARs.
Failure to Provide Dental Services
Penalty
Summary
The facility failed to provide necessary dental services and assessments for a resident, as evidenced by the case of a resident who was reviewed for dental care. During a phone interview, the resident's family mentioned that the resident had missing teeth and required a dental consult, although it was unclear if this concern had been communicated to the facility. An observation of the resident revealed missing teeth and apparent plaque buildup on the bottom front teeth. A review of the resident's medical records showed no evidence of a dental consult. The Director of Nursing acknowledged that the facility had not secured a dental service provider since a change in ownership earlier in the year.
Failure to Meet Resident Meal Preferences
Penalty
Summary
The facility staff failed to ensure that a resident's meals matched their preferences, as observed during a survey. The deficiency was identified for one resident out of a sample of 52. During an observation in the dining room, the resident showed the surveyor a plate of food that included bread, which was listed as a dislike on the meal slip. Additionally, the resident had requested coffee with every meal, but it was not provided on the tray. A staff member confirmed the resident's preferences and acknowledged that the incorrect meal upset the resident.
Improper Food Storage and Labeling in Kitchen
Penalty
Summary
The facility staff failed to maintain food items in the kitchen in a safe and appropriate manner. During a kitchen tour, several slices of salami deli meat were found partially wrapped in plastic wrap with a label indicating it was opened on 7/26/24 and had a use-by date of 8/2/24, which had already passed. Additionally, an opened bag of shredded mozzarella cheese was not stored in a sealed container, and two bags of bologna lacked date labels. The Food Service Manager confirmed that lunchmeat is considered good for 7 days and acknowledged that the wrong date was written on the label. The Administrator was informed of these findings and acknowledged them.
Failure to Honor Resident Shower Preferences
Penalty
Summary
The facility staff failed to honor resident choices regarding showering, as evidenced by interviews and clinical record reviews for two residents. One resident reported not receiving the scheduled two showers per week, stating that showers only occur if there are four or more geriatric nursing aides on duty. A review of the electronic health record showed the last documented shower was nearly a year ago. Another resident reported only receiving bed baths and exhibited a distinct odor, indicating a lack of proper bathing. Clinical records confirmed that this resident only received two showers in a 30-day period, with no refusals documented. The Administrator and Director of Nursing acknowledged the findings and indicated they would review the records and shower sheets.
Failure to Notify POA of Pressure Ulcer
Penalty
Summary
The facility failed to notify the Power of Attorney (POA) of a resident's medical condition, specifically a stage 2 sacrum pressure ulcer. This deficiency was identified during a survey where it was found that the POA of Resident #29 was not informed about the pressure ulcer, which was acquired prior to the resident's re-admission to the facility. The pressure ulcer was documented in a wound evaluation, but there was no record of notification to the POA. During interviews, the POA confirmed not being notified about the pressure ulcer, while an LPN claimed to have informed the POA in person but admitted that this notification was not documented in the resident's medical record. The facility's policy requires that any change in a resident's condition be communicated to the Resident Representative and documented in the medical record, which was not adhered to in this case.
Failure to Timely Report Allegations of Neglect and Missing Money
Penalty
Summary
The facility failed to report allegations of neglect and missing money to the Maryland Department of Health - Office of Healthcare Quality (OHCQ) within the required time frame. In the first incident, a responsible party (RP) reported that a resident was left in the same clothes for 23 hours, with a full catheter bag and a urine-soaked brief. The initial report was submitted to OHCQ on the day the RP reported it, but the final report was delayed and not sent until 22 days later, exceeding the 5-day requirement. Interviews with the Unit Manager, Director of Nursing (DON), and Administrator revealed a lack of communication and awareness among staff regarding the incident. In the second incident, a resident reported missing money on two separate occasions. The facility initially reported the first allegation of missing money in August 2023 to OHCQ, but the final report was submitted late, beyond the required timeframe. Furthermore, the second allegation of missing money in November 2023 was not reported to OHCQ at all. The Nursing Home Administrator (NHA) confirmed the oversight during interviews with the surveyor and acknowledged the absence of a complaint form for the November incident. The facility is required to submit initial self-reports for abuse, neglect, injury of unknown origin, and misappropriation of resident property within 2 hours if serious bodily harm resulted, or within 24 hours for all other cases, and to forward investigation results within 5 business days. The failure to adhere to these reporting timelines for both incidents indicates a deficiency in the facility's reporting procedures.
Inadequate Investigation of Alleged Violations
Penalty
Summary
The facility failed to conduct thorough investigations for alleged violations involving two residents. For one resident, an allegation of sexual assault was reported, and the facility's investigation included only three resident interviews and three employee interviews, with no documentation of skin assessments for other residents. The Nursing Home Administrator (NHA) initially provided an incomplete investigation file, which lacked a fourth employee interview statement and an investigation summary report. The NHA later acknowledged the limited number of staff interviews due to the number of staff on the unit but did not address the lack of additional resident interviews or skin assessments. In another case, a resident reported missing money, initially $100, later changed to $160. The facility's investigation file for this incident lacked any documentation of resident or employee interviews. The NHA confirmed the file was complete but did not provide any additional documentation when questioned by the surveyor. These deficiencies highlight the facility's failure to ensure comprehensive investigations into reported incidents, as required by regulatory standards.
Inaccessible and Incomplete Survey Binder
Penalty
Summary
The facility staff failed to have the most recent survey results readily accessible to residents, family members, and legal representatives, which has the potential to affect all residents and visitors. Initially, the survey team could not locate the survey binder in the lobby, and there was no visible signage indicating its location. The receptionist was unaware of its whereabouts, and the Director of Nursing (DON) had to search for it. Eventually, the binder was found and provided to the surveyors, but it was not in the lobby as claimed by the DON. A new sign was posted indicating the binder's availability from the receptionist, but the receptionist was not on duty during the surveyor's visit, limiting access to the binder. Additionally, the survey binder lacked documentation of Life Safety Inspections or local fire department inspections. When questioned, the Nursing Home Administrator (NHA) stated that no such inspections had occurred since her tenure and that the Maintenance Director was responsible for these records. This lack of documentation further contributed to the deficiency, as the facility could not provide evidence of compliance with safety inspections. The surveyor later observed a new survey binder in the lobby, but the initial failure to maintain accessible and complete survey records was a significant issue.
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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