Hebrew Home Of Greater Washington
Inspection history, citations, penalties and survey trends for this long-term care facility in Rockville, Maryland.
- Location
- 6121 Montrose Road, Rockville, Maryland 20852
- CMS Provider Number
- 215071
- Inspections on file
- 19
- Latest survey
- October 17, 2025
- Citations (last 12 mo.)
- 2
Citation history
Health deficiencies cited at Hebrew Home Of Greater Washington during CMS and state inspections, most recent first.
The facility failed to report allegations of abuse, neglect, and injuries of unknown origin to the Office of Health Care Quality (OHCQ) within the required 2-hour timeframe. This deficiency affected 18 residents and involved various allegations, including rape, physical abuse, and injuries of unknown origin. Delays were often due to internal discussions or misunderstandings of reporting requirements, with staff acknowledging the reporting failures.
The facility failed to thoroughly investigate allegations of abuse for nine residents, as investigations often lacked interviews with other residents or staff. In one case, a resident alleged rape, but no other residents from the unit were interviewed. Another resident reported being punched, yet no other residents were interviewed to assess safety concerns. Investigations were further compromised by missing documentation and incomplete interviews, undermining the reliability of the facility's response to these serious allegations.
A facility failed to maintain accurate medical records and document narcotic medication administration for several residents. Errors included incorrect uploading of a hospital transfer summary, missing documentation of narcotic administration, and incomplete medication orders lacking indications for use. These issues were confirmed by the DON and other staff during the survey.
The facility failed to maintain an effective pest control program, as evidenced by numerous reports of mice sightings and droppings in one of the two buildings reviewed. Pest activity logs and resident interviews confirmed persistent pest issues, despite regular visits from a pest control company. The deficiency was discussed with the facility's administration.
The facility failed to ensure proper labeling and dating of food items, maintain a sanitary environment in the nourishment refrigerator, and meet required temperatures for dishwashing machines. Observations revealed unlabeled food, unsanitary conditions, and malfunctioning dishwashers, leading to concerns about food safety and sanitation.
The facility staff failed to timely notify physicians and responsible parties of changes in two residents' conditions. One resident's pressure ulcer assessments and treatment changes were not communicated to the primary physician or responsible party. Another resident's physician was notified an hour after a fall with injury. These communication lapses were confirmed by the DON.
The facility failed to involve a resident with full mental capacity in their care plan meetings and did not document reasons for their absence. Additionally, the care plan for another resident was not updated after a stage 2 sacral pressure ulcer was discovered, despite the requirement to revise care plans following a change in condition.
A facility failed to provide a resident with scheduled showers twice per week, as required by their care plan. The resident, admitted for rehabilitation and strengthening, needed physical help with bathing. The shower log indicated scheduled showers on Mondays and Thursdays, but the GNA Documentation Report for January showed no documentation for these days. The DON confirmed the lack of documentation and stated that GNAs should have recorded if the resident refused or received showers.
A facility failed to provide adequate care for a resident after falls, missing required neuro checks. Another resident experienced delays in assessment and treatment for a fracture, with an X-ray and orthopedic consult delayed. A third resident did not receive a scheduled antibiotic dose due to pharmacy delays. These deficiencies highlight lapses in protocol adherence and timely medical intervention.
Two residents in the facility experienced inadequate pressure ulcer care. One resident did not receive weekly skin assessments for a sacral pressure ulcer, while another resident's worsening pressure ulcers were not properly documented or treated. The facility failed to update wound care orders and conduct necessary evaluations, leading to discrepancies in the residents' medical records.
A resident experienced significant weight loss, dropping from 210 to 192.6 pounds, without timely intervention or documentation of nutritional status. The facility's protocol required action for weight changes over 5%, but the resident's weight loss was not addressed until it reached 8%. The resident was discharged before any confirmation or intervention could be made.
A facility failed to accurately reflect a resident's oral/dental status in the MDS assessments. Despite documentation of a lower denture in the nursing admission assessment and a physician order, the MDS assessments did not indicate any oral or dental concerns. The resident reported broken dentures, which was confirmed by observation. The issue was discussed with the facility's administration.
A facility failed to implement a comprehensive care plan for a resident, leading to delayed incontinence care. The care plan did not address all medical, nursing, and psychosocial needs, and staff interviews revealed that the plan was not updated to reflect the resident's needs. The Director of Nursing acknowledged the oversight, indicating a missed review by the unit manager.
The facility failed to conduct the annual performance review for a GNA, as required. A review of employee records showed no signed evidence of the GNA's performance review and in-service education for 2023 and 2024. The DON confirmed that the 2023 review was missed, and the 2024 review was not signed due to the GNA's PRN schedule. Additionally, no competency assessment was conducted in 2024.
A facility failed to monitor side effects for a resident on Escitalopram Oxalate for depression. The oversight occurred because the order for side effect monitoring was inadvertently dropped from the MAR. Staff interviews confirmed the usual process involves a separate order on the MAR to alert nurses for side effect assessments, which was missing in this case. The DON acknowledged the oversight.
A facility failed to provide adequate dental care for a resident, as evidenced by the lack of follow-up on dental consultations and inaccurate monitoring of the resident's dental status. The resident, who had broken upper and lower dentures and missing teeth, did not receive necessary dental services despite documented orders and referrals. Staff interviews revealed a lack of awareness about the resident's denture status, and the DON acknowledged the absence of follow-up on dental referrals.
Failure to Timely Report Allegations of Abuse and Neglect
Penalty
Summary
The facility failed to report allegations of abuse, neglect, and injuries of unknown origin to the Office of Health Care Quality (OHCQ) within the required 2-hour timeframe. This deficiency was identified during an annual and complaint survey, affecting 18 residents out of 60 facility-reported incidents reviewed. The incidents involved various allegations, including rape, physical abuse, and injuries of unknown origin, which were not reported promptly to the regulatory agency as required by regulations. In several cases, the facility staff delayed reporting incidents due to internal discussions or misunderstandings of the reporting requirements. For instance, in one case, a resident alleged rape, and the facility was informed by the resident's daughter, but the report to OHCQ was delayed beyond the 2-hour window. Similarly, other incidents involved residents reporting physical abuse or injuries, but the facility's initial reports to OHCQ were not submitted within the required timeframe, often due to staff waiting to discuss the incidents internally before reporting. The Director of Nursing (DON) and other staff members were interviewed and acknowledged the delays in reporting. In some instances, staff were unaware of the requirement to report within 2 hours if there were no visible injuries, leading to further delays. The facility's failure to adhere to the mandated reporting timeframe for allegations of abuse and neglect highlights a significant deficiency in their reporting processes.
Incomplete Investigations into Abuse Allegations
Penalty
Summary
The facility failed to provide thorough documentation of investigations into allegations of abuse for nine residents during a recertification/complaint survey. In several cases, the investigations lacked interviews with other residents or staff members who could provide additional context or corroborate the allegations. For instance, in the case of a resident who alleged rape, the investigation included interviews with 36 staff members but did not include interviews with other residents from the same unit. Similarly, another resident alleged being punched, but the investigation did not include interviews with other residents on the unit to assess their safety or concerns. In other instances, the investigations were incomplete due to missing interviews with relevant staff or residents. For example, a resident alleged rough treatment during incontinence care, but the investigation only included an interview with the accused GNA and lacked interviews with other residents or staff from the same assignment. Another case involved a resident who reported being slapped by staff, yet the investigation did not include interviews with other residents on the unit who might have witnessed or experienced similar incidents. The facility's investigations were further compromised by missing documentation and incomplete interviews. In one case, a resident alleged sexual assault, but the investigation did not include interviews with other residents on the unit. Additionally, a resident reported a GNA violating their rights, but the investigation lacked interviews with other staff members. These deficiencies highlight a pattern of incomplete investigations, where critical interviews and documentation were missing, undermining the thoroughness and reliability of the facility's response to serious allegations of abuse.
Deficiencies in Medical Record Accuracy and Medication Documentation
Penalty
Summary
The facility failed to maintain complete and accurate medical records in accordance with accepted professional standards, as evidenced by several deficiencies identified during a recertification/complaint survey. One significant issue involved the incorrect uploading of a hospital transfer summary for one resident into another resident's medical record. This error was confirmed by the Director of Nursing (DON) after an interview with the unit secretary responsible for the upload. Another deficiency was the failure to document the administration of narcotic medications on the Medication Administration Records (MARs) for multiple residents. The review revealed that a staff member signed out narcotic medications for several residents, but these administrations were not documented in the MARs. Interviews with the DON confirmed that the staff member failed to accurately document the administration of these medications, and some residents could not recall the number of doses received. Additionally, the survey identified incomplete medical orders for a resident, where the orders for Seroquel and Amlodipine did not include an indication for use. Despite prior recommendations from a pharmacist to include diagnoses or indications for use in medical orders, these were not reflected in the orders. The Clinical Team Manager and the DON confirmed the absence of indications in the orders, acknowledging the oversight in ensuring that the indication for use was displayed in the medical orders.
Facility Fails to Maintain Effective Pest Control Program
Penalty
Summary
The facility failed to maintain an effective pest control program, as evidenced by numerous reports of mice sightings and droppings in one of the two buildings reviewed during the recertification/complaint survey. The pest activity logs from September 2024 to February 2025 revealed frequent entries of mouse sightings and droppings in various patient care areas, including resident rooms, dining rooms, and common areas. Despite the facility's pest control company visiting three times a week, the logs indicated persistent pest activity, with multiple entries each month documenting the presence of mice. Interviews conducted with residents and staff corroborated the findings in the pest activity logs. Several residents reported seeing mice in their rooms and common areas, with some residents experiencing daily sightings. A geriatric nursing assistant also confirmed seeing a mouse in the resident hallway and reported it to the housekeeping staff. These interviews highlighted the ongoing issue of mice presence within the facility, affecting the residents' living conditions. The findings were discussed with the facility's Vice President of Building Services and the Administrator, who acknowledged the pest control logs and resident reports. The surveyor's investigation and interviews confirmed the facility's failure to effectively address the pest control issue, leading to a deficiency in maintaining a safe and sanitary environment for the residents.
Deficiencies in Food Safety and Dishwashing Practices
Penalty
Summary
The facility failed to ensure proper labeling, dating, and expiration of nourishment items in one of its kitchens. During an initial tour, a surveyor observed a reach-in refrigerator containing various food items such as orange slices, cold salad sandwiches, and containers of fruit and cottage cheese without any labeling or dates to indicate preparation or expiration. A tray of cheese sandwiches was also found with an expired label, leading to its disposal by the Certified Dietary Manager (CDM). The CDM acknowledged the issue but was unable to confirm when the foods had been prepared or were to expire. Additionally, the facility did not maintain a sanitary environment in the nourishment refrigerator. The surveyor found a cardboard box with condiment packets and tea bags showing visible spots of black, brown, and green matter. A container of soymilk was also found with an expired label. The Project Manager, overseeing the kitchen temporarily, confirmed the unsanitary conditions and disposed of the items. The Senior Dining Director and CDM were made aware of these concerns and acknowledged the issues. The facility's dishwashing machines also failed to meet the required manufacturer temperatures for sanitization. Observations revealed that the dishwashing machines in both the main and additional kitchens were not reaching the necessary temperatures for wash and final rinse cycles. Maintenance staff identified issues with the machines, such as a malfunctioning sensor and blown fuses, which prevented the machines from sustaining the required temperatures. Despite attempts to address these issues, the machines continued to operate below the recommended temperatures, leading to concerns about their effectiveness in sanitizing dishware.
Failure to Timely Notify Physicians and Responsible Parties
Penalty
Summary
The facility staff failed to notify a resident's physician and responsible party for changes in the resident's condition in a timely manner. For Resident #630, the staff did not inform the primary physician about the assessments of a sacral pressure ulcer when the wound care doctor was unavailable. Additionally, there was no documentation indicating that the resident's responsible party was notified of changes in wound care orders, despite multiple changes occurring over several months. This lack of communication was confirmed by the Director of Nursing during an interview. In another instance, the facility staff delayed notifying Resident #643's physician after the resident experienced a fall with injury. The fall occurred at 5:45 PM, but the physician was not informed until an hour later. The resident sustained an injury to the right elbow and hit their head, necessitating a hospital transfer for further assessment and treatment. The Director of Nursing confirmed the delay in notification during an interview.
Failure to Involve Resident in Care Plan Meetings and Update Care Plan for Pressure Ulcer
Penalty
Summary
The facility failed to involve a resident with the capacity to attend their own care plan meetings and did not document the reasons for their absence. Resident #96, who had a perfect BIMS score indicating full mental capacity, reported never being informed about care plan meetings. The Director of Social Work claimed the resident often declined to attend due to personal issues, but there was no documentation to support this claim. Upon review, it was confirmed that there was no record of the resident being invited or the reasons for their non-attendance. Additionally, the facility did not update the care plan for Resident #963 after a significant change in condition. Initially, the resident's skin was noted as normal upon admission, but a stage 2 sacral pressure ulcer was discovered five days later. Despite this change, the care plan was not revised to address the new condition. The Director of Nursing confirmed that the care plan had not been updated following the discovery of the pressure ulcer, which was a requirement when there is a change in a resident's condition.
Failure to Provide Scheduled Showers
Penalty
Summary
The facility failed to ensure that a resident who required assistance received showers twice per week, as was the established care plan. This deficiency was identified during a recertification/complaint survey for a resident admitted in December 2022 from an acute care hospital for rehabilitation and strengthening. The resident's medical record indicated a need for physical help with bathing, and the shower log specified that showers were to be provided on Mondays and Thursdays. However, the GNA Documentation Report for January 2023 showed blank spaces for all scheduled shower days, indicating that the showers were not documented as given. During an interview, the Director of Nursing confirmed the lack of documentation and stated that GNAs should have recorded whether the resident refused or received showers.
Deficiencies in Resident Care and Treatment
Penalty
Summary
The facility failed to provide adequate care for Resident #614 following two falls on the same day. After the first fall, the staff did not complete the required neuro checks according to the facility's 72-hour assessment protocol, missing checks at 4:15 PM and 5:15 PM. After the second fall, the staff failed to restart the neuro check protocol, missing several checks that were supposed to occur every 15 minutes and hourly thereafter. This lack of adherence to protocol was confirmed by the Director of Nursing. Resident #131 experienced a delay in receiving appropriate medical assessment and treatment for a left arm fracture. Despite the resident's daughter requesting an assessment for soreness, the initial assessment was not thorough, focusing only on the hand. An X-ray was not ordered until several days later, after the resident exhibited significant pain. The Occupational Therapy evaluation was also delayed, occurring five days after the order was given, and the resident did not receive an orthopedic consult until being sent to the ER, where the fracture was confirmed. Resident #913 did not receive a scheduled dose of Daptomycin for endocarditis due to a delay in medication delivery from the pharmacy. The resident was admitted to the facility with orders to continue antibiotic therapy, but the medication was not administered until two days later. Despite multiple calls to the pharmacy, the medication was not delivered on time, resulting in a delay in treatment. The Director of Nursing and Clinical Team Manager acknowledged the delay in administering the medication.
Failure to Provide Adequate Pressure Ulcer Care
Penalty
Summary
The facility staff failed to provide adequate treatment and services to prevent and heal pressure ulcers for two residents. Resident #630 was assessed to have a Stage II sacral pressure ulcer, but the facility staff did not conduct weekly skin assessments, including measurements, on several occasions. Specifically, there were no assessments from 6/26/23 to 7/13/23, a gap of 17 days. The Director of Nursing confirmed the failure to perform these assessments during an interview. Resident #660 was admitted with a Stage II pressure ulcer on the right buttock, and the condition of the resident's wounds worsened over time. The facility's documentation showed discrepancies in the wound's status, and there were no additional orders or evaluations despite the worsening condition. The wound consultant's notes were not updated weekly, and there was a lack of follow-up assessments and order changes when the resident's wounds deteriorated. The Director of Nursing confirmed the absence of additional documentation to support evaluations during the worsening of the resident's condition.
Failure to Address Significant Weight Loss in Resident
Penalty
Summary
The facility failed to address appropriate care for a resident experiencing significant weight loss. The deficiency was identified during a recertification survey, where it was found that a resident had lost a substantial amount of weight over a short period. The resident's initial weight was recorded at 210 pounds, and over the course of several weeks, the weight decreased to 192.6 pounds, marking an 8% loss from the initial weight. Despite this significant weight loss, there was no documentation of any follow-up nutrition assessment or intervention after the initial assessment upon admission. Interviews with facility staff revealed a lack of timely response to the resident's weight changes. The clinical nutrition manager stated that weight changes were only addressed if they exceeded a 5% difference, and the resident's weight loss was not acted upon until it reached 8%. The Director of Nursing confirmed that nursing staff were expected to re-check weights with more than a 5-pound difference and notify providers, but this protocol was not followed. The resident was discharged before any confirmation or intervention could be made regarding the weight loss, and there was no documentation of the resident's nutritional status or any actions taken to address the weight loss trend.
Inaccurate MDS Assessment of Oral/Dental Status
Penalty
Summary
The facility failed to ensure that the Comprehensive Minimum Data Set (MDS) assessments accurately reflected a resident's oral and dental status. This deficiency was identified during a recertification/complaint survey for one of the four residents reviewed. The resident in question was initially admitted to the facility after abdominal surgery and was readmitted following a hospitalization for high ostomy output. Despite the presence of a lower denture being documented in the nursing admission assessment and a physician order, the MDS assessments conducted on two separate occasions did not reflect any oral or dental concerns. The MDS manager, responsible for conducting the assessments, acknowledged the oversight. She confirmed that the assessments included a record review, resident interview, and physical assessment, yet failed to code any oral or dental issues in the relevant section of the MDS. The resident, during an interview, reported having broken upper and lower dentures, which was corroborated by a surveyor's observation. The discrepancy between the documented presence of dentures and the MDS coding was discussed with the facility's Administrator and Director of Nursing during the exit conference.
Failure to Implement Comprehensive Care Plan
Penalty
Summary
The facility failed to develop and implement a comprehensive person-centered care plan for a resident, as identified during a recertification/complaint survey. The deficiency was evident for one resident whose care plan did not address all medical, nursing, and psychosocial needs identified in the admission comprehensive assessment. Specifically, the resident experienced an episode of incontinence, and the care was delayed for several hours despite staff being notified. The Geriatric Nursing Assistant (GNA) task list showed incontinence care was documented only once on the day of the incident. Interviews with staff revealed that the care plan was not updated to reflect the resident's needs. RN #55 confirmed that the care plan needed updating and that all nurses could update it as needed. The unit manager, RN #70, stated that care plans should be updated initially within 30 days, as needed with any change, and every 90 days with the admission assessment. However, the care plan for the resident did not reflect personal care needs or active diagnoses and interventions. The Director of Nursing acknowledged the oversight, indicating that the unit manager was responsible for the care plan review, which was missed.
Failure to Conduct Annual Performance Review for GNA
Penalty
Summary
The facility failed to conduct the required annual performance review for a Geriatric Nursing Assistant (GNA), identified as GNA #71, during the recertification/complaint survey process. The surveyor's review of three GNA employee records revealed that there was no signed documented evidence of GNA #71's performance review and in-service education for the years 2023 and 2024. During a telephone interview, the Director of Nursing (DON) acknowledged that the performance review and competency assessment for GNA #71 were missed in 2023. Although the 2024 performance review was documented, it was not signed due to GNA #71's PRN (as needed) work schedule. Furthermore, the DON confirmed that no competency assessment was conducted in 2024, as it is typically done alongside the performance review.
Failure to Monitor Side Effects of Psychotropic Medication
Penalty
Summary
The facility failed to ensure proper monitoring for side effects of a psychotropic medication for a resident, which was identified during a recertification/complaint survey. The resident was receiving Escitalopram Oxalate for depression, starting from early January. However, the medical record review revealed that side effect monitoring was not instituted for this medication, which is a necessary step in managing psychotropic medications. Interviews with facility staff, including an LPN and the Clinical Team Manager, confirmed that the usual process for monitoring side effects involves a separate order on the medication administration record (MAR). This order alerts nurses to complete and document assessments for side effects. It was discovered that the order for side effect monitoring was inadvertently dropped from the MAR in late December, leading to the oversight. The Director of Nursing acknowledged the oversight, confirming that the medications had been reviewed but the monitoring order was missed.
Failure to Provide Adequate Dental Care
Penalty
Summary
The facility failed to provide appropriate dental care for Resident #269, as evidenced by the lack of accurate monitoring of the resident's dental status and failure to follow up on dental services. The resident was admitted to the facility in February 2024 and readmitted in mid-April 2024 after hospitalization. The nursing admission assessment documented the presence of partial lower dentures, but subsequent oral health assessments indicated significant dental issues, including decayed or broken teeth. Despite a physician's order for assistance with the resident's partial lower denture, there was no follow-up documentation for dental consultations requested in August and October 2024. Interviews and medical record reviews revealed that the resident's dental needs were not adequately addressed. The resident reported having broken upper and lower dentures and missing teeth, which was confirmed by the surveyor. Staff interviews indicated a lack of awareness regarding the resident's denture status, and the social worker confirmed that the resident's insurance did not cover new dentures. The Director of Nursing acknowledged the absence of follow-up on the dental referral, highlighting a deficiency in the facility's dental care provision.
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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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