Ingleside At King Farm
Inspection history, citations, penalties and survey trends for this long-term care facility in Rockville, Maryland.
- Location
- 701 King Farm Boulevard, Rockville, Maryland 20850
- CMS Provider Number
- 215353
- Inspections on file
- 12
- Latest survey
- March 13, 2025
- Citations (last 12 mo.)
- 0
Citation history
Health deficiencies cited at Ingleside At King Farm during CMS and state inspections, most recent first.
The facility failed to adhere to professional standards for food storage, as observed by a surveyor. Opened and unlabeled food items, uncovered containers, and expired products were found in various storage areas, including the produce refrigerator and meat/fish cooler. The Certified Food Services Manager confirmed these findings, which were contrary to the facility's policy requiring proper labeling and disposal of expired foods.
A resident's private duty aide improperly used a gait belt as a restraint to prevent the resident from getting up out of their wheelchair. This incident was identified by a nurse and confirmed through a facility investigation, which substantiated the improper use of physical restraints. The facility had policies requiring PDAs to follow its procedures, but the aide's actions were contrary to these guidelines.
A resident with cognitive impairment was found with a swollen leg and bruise, and the facility failed to report the injury within the required 2-hour timeframe and delayed submitting investigation results. The initial report was submitted 24 hours after discovery, and the investigation results were submitted 6 days later, both outside the required timeframes.
Facility staff failed to ensure a resident received routine dental care. A resident's medical record indicated an order for a dental evaluation due to a broken tooth, but there was no documentation of prior dental services. The NHA stated that the facility does not provide routine dental services, and residents are informed to arrange their own care, with the facility only arranging appointments when a concern is identified.
The facility failed to document a dental treatment plan for a resident and did not complete beneficiary notifications correctly for two residents. One resident's discharge lacked a Notice of Medicare Non-Coverage, and another's SNFABN was incomplete. The NHA and Director of Social Services acknowledged these deficiencies.
The facility staff failed to maintain a homelike environment, as evidenced by damaged drywall behind residents' beds in three rooms observed during a medication administration assessment. A surveyor noted marring on the walls, which was confirmed by an RN and an LPN. The LPN admitted not noticing the damage until it was pointed out, and the RN had been on vacation prior to the survey. The staff used an app to report maintenance issues, but the damage had not been reported before the surveyor's observation.
A facility failed to revise a resident's care plan to address communication needs, despite frequent refusal to wear hearing aids and updated recommendations from an audiologist. The resident, with dementia and hearing deficit, required visual cues for communication. The care plan did not reflect these needs or the resident's refusal to use hearing aids, as confirmed by the ADON.
The facility failed to maintain professional standards in monitoring resident weights, as two residents experienced significant weight loss without proper follow-up. A resident lost 10.17% of their weight, and another lost 6.99% within a month. The Registered Dietician identified the issues but faced delays in reweighing and lacked documentation for weekly reweigh orders. Additionally, there was no documentation of refusals or immediate reweighs to confirm weight accuracy.
A facility failed to ensure an LPN on the memory care unit completed necessary dementia training. The LPN's last documented training had expired, and the recent training lacked detailed dementia care content. The HR Director confirmed annual training assignments, but the completed training only mentioned cognitive impairment, not dementia.
The facility staff did not update the staffing sheets on two units after changes to the schedule. A GNA was documented as working but had called out, and two GNAs called in to work were not reflected on the sheets. The DON acknowledged that updates are supposed to be transcribed to the daily staffing sheet, which was not done.
A facility's pharmacy failed to administer a prescribed supplement with a dosage for a resident during a medication administration survey. The blister package containing Vitron C lacked a specified dose, although the MAR indicated it was to be given twice daily for anemia. An LPN acknowledged having called the pharmacy to verify the dose. A pharmacist confirmed that the pharmacy typically does not send medications without a dose and expressed willingness to add the strength of the supplement if needed.
Failure to Maintain Professional Standards in Food Storage
Penalty
Summary
The facility failed to store food in accordance with professional standards of food service safety, as observed during a survey of the main kitchen. The surveyor noted several instances of opened and unlabeled food items, including bags of carrots, lettuce, spinach, and chicken nuggets, as well as various containers of sauces and condiments. Additionally, there were uncovered items such as a large tub of apple cider, a pan of greens, and a tub of chicken stock. Expired items were also found, including a container of ginger garlic paste and a jar of capers. These observations were made in the produce refrigerator, meat/fish cooler, main freezer, and dry goods storage area. The surveyor confirmed these findings with the Certified Food Services Manager (CFSM) #4, who acknowledged the presence of opened, unlabeled, and expired foods. The facility's Food and Supply Storage policy requires that unused portions and open packages be covered, labeled, and dated, and that expired foods be discarded by their respective dates. The CFSM provided evidence of an in-service conducted with kitchen personnel to review proper labeling and dating procedures, although this action is not part of the deficiency itself.
Improper Use of Gait Belt as Restraint by Private Duty Aide
Penalty
Summary
The facility failed to maintain an environment free of physical restraints, as evidenced by an incident involving a resident's private duty aide (PDA) improperly using a gait belt as a restraint. The incident was identified when a nurse observed the PDA using the gait belt to prevent the resident from getting up out of their wheelchair. This action was contrary to the intended use of a gait belt, which is meant to assist with mobility and not to restrict movement. The facility conducted an investigation and substantiated the improper use of physical restraints by the PDA. Interviews with staff confirmed that there were no other instances of physical restraint use. The PDA was contracted by the resident's family, and the facility had policies in place that required PDAs to adhere to the facility's procedures, including those related to nursing care. The incident was one of four facility-reported incidents reviewed during the survey.
Failure to Timely Report Injury of Unknown Origin
Penalty
Summary
The facility failed to report an injury of unknown origin within the required 2-hour timeframe and did not submit the results of the investigation within 5 days to the Office of Health Care Quality. This deficiency was identified during a review of a facility reported incident involving a resident who was found with a swollen left leg and a bruise on the left shin during activities of daily living care. The Director of Nursing was informed of the incident shortly after it was discovered and initiated an investigation. The resident involved had a BIMS score of 2, indicating significant cognitive impairment, and was unable to provide information about the injury. The facility was unable to determine the cause or timing of the incident. The initial report to the Office of Health Care Quality was submitted approximately 24 hours after the incident was discovered, and the investigation results were submitted 6 days later, both outside the required reporting timeframes.
Failure to Provide Routine Dental Care
Penalty
Summary
Facility staff failed to ensure a resident received routine dental care, as evidenced by the case of a resident who was reviewed for dental services during the survey. The resident's medical record showed a progress note from November 2021 indicating an order for a dental evaluation due to a broken tooth. However, there was no documentation in the medical record to confirm that the resident received any dental services prior to the incident of the broken tooth. During an interview, the Nursing Home Administrator (NHA) stated that the facility does not provide routine dental services and that residents are informed to arrange their own dental care, with the facility only arranging appointments when a concern is identified.
Deficiencies in Medical Record Documentation and Beneficiary Notification
Penalty
Summary
The facility staff failed to ensure that a resident's medical record included all necessary documentation related to dental treatment. Specifically, for one resident, a progress note indicated an order for a dental evaluation due to a broken tooth. However, the documentation of the treatment plan following the dental visit was missing, even after the Power of Attorney was contacted. The Nursing Home Administrator (NHA) was unable to provide the required documentation when requested by the surveyor. Additionally, the facility did not correctly complete beneficiary notification documentation for two residents. One resident was discharged without receiving a Notice of Medicare Non-Coverage (NOMNC) due to a lack of notice about the discharge, and there was no documentation to support that the discharge was requested by the resident. For another resident, the Skilled Nursing Facility Advance Beneficiary Notice of Non-coverage (SNFABN) was incomplete, as the resident did not select one of the required options regarding Medicare and payment. The Director of Social Services acknowledged the oversight.
Failure to Maintain a Homelike Environment Due to Wall Damage
Penalty
Summary
The facility staff failed to maintain a homelike environment, as evidenced by damaged drywall behind residents' beds in three of the six rooms observed during a medication administration assessment. Specifically, the surveyor noted marring on the walls behind the beds of three residents. During the observations, both a Registered Nurse (RN) and a Licensed Practical Nurse (LPN) confirmed the surveyor's findings. The LPN acknowledged that the resident's bed might have caused the damage, despite having a stopper. However, the LPN admitted not noticing the damage until it was pointed out by the surveyor. Additionally, the RN had been on vacation for two weeks prior to the survey and had not reported the damage before that day. The staff used a computer-generated app named Worxhub Links to report maintenance issues, but the damage had not been reported prior to the surveyor's observation.
Failure to Revise Care Plan for Resident's Communication Needs
Penalty
Summary
The facility failed to ensure that a resident-centered care plan was revised to meet the needs of a resident, specifically in response to current interventions related to communication and sensory needs. The deficiency was identified for a resident with diagnoses including dementia, anxiety, hearing deficit, and major depressive disorder. The resident had physician orders to use bilateral hearing aids and required visual cues for effective communication. However, the resident frequently refused to wear the hearing aids, citing discomfort and excessive noise, and this refusal was documented multiple times over several months. Despite an audiology visit that adjusted the hearing aids to a comfortable volume and provided updated recommendations for communication, the care plan was not revised to reflect these changes or the resident's refusal to wear the hearing aids. The care plan, initially created in October 2023 and revised in January 2024, did not include the resident's refusal to wear hearing aids or the updated communication strategies recommended by the audiologist. This oversight was confirmed during an interview with the Assistant Director of Nursing, who acknowledged the resident's inconsistent use of hearing aids and the lack of updated documentation in the care plan.
Failure to Monitor Resident Weight Loss
Penalty
Summary
The facility failed to maintain professional standards of practice regarding the monitoring of resident weights, as evidenced by the cases of two residents. Resident #7 experienced a significant weight loss of 10.17% within approximately one month, dropping from 108.2 lbs to 97.2 lbs. The Registered Dietician (Staff #23) identified the weight loss and suspected a scale error, requesting a reweigh on 01/06/25, which was not conducted until 01/08/25. Despite recognizing the significant weight loss, there was no documentation of an order for weekly reweighs for four weeks, and Staff #23 did not report the delay in reweighing to her supervisor. Similarly, Resident #21 experienced a 6.99% weight loss within about a month, from 146.0 lbs to 135.8 lbs. The Registered Dietician noted the significant weight loss but faced difficulties in reweighing the resident and could not find documentation of a refusal to be reweighed. There was also no documentation of an order for weekly reweighs for four weeks. The Registered Nurse (Staff #5) indicated that significant weight differences should prompt immediate reweighing to confirm accuracy and that any refusal to be weighed should be documented, which was not evident in this case.
Deficiency in Dementia Training for LPN
Penalty
Summary
The facility staff failed to ensure that a Licensed Practical Nurse (LPN) working on the memory care unit had completed the necessary competency training to effectively care for residents with dementia. During the Medicare/Medicaid survey, it was found that the LPN's last documented dementia training had expired, and the training they completed did not provide detailed information on caring for residents with dementia. The Director of Human Resources confirmed that annual training assignments are given to staff, and a report is sent to supervisors to track completion. However, the training completed by the LPN only mentioned cognitive impairment without specific focus on dementia care, which is not equivalent to a diagnosis of dementia.
Failure to Update Staffing Sheets in LTC Facility
Penalty
Summary
The facility staff failed to update the staffing sheets on two units in the Long-Term Care Wing after changes were made to the staffing schedule. On the day of the survey, the surveyor reviewed the Daily Nursing Schedule log and found discrepancies in the staffing documentation. Specifically, on one unit, a Geriatric Nursing Assistant (GNA) was documented as working, but had called out, and this was not reflected on the staffing sheet. Additionally, two GNAs were called in to work that day, but their presence was not updated on the staffing sheets. The Director of Nursing acknowledged that sometimes staff call the scheduler directly when unable to work, and updates are supposed to be transcribed to the daily staffing sheet, which was not done in this instance.
Pharmacy Fails to Administer Prescribed Supplement Dosage
Penalty
Summary
The facility's pharmacy failed to administer a prescribed supplement with a dosage for Resident #19, who was observed during a medication administration survey. On February 14, 2025, at 9:41 AM, during the observation of Resident #19's medication administration, the surveyor noticed that the blister package containing Vitron C did not have a specified dose. The medication administration record (MAR) indicated that Vitron C 65-125 MG (Iron -Vitamin C) was to be administered by mouth twice a day for anemia. Licensed Practical Nurse #8, who was preparing the medications, acknowledged having previously called the pharmacy to verify the dose. On February 18, 2025, the surveyor interviewed Pharmacist #17, who confirmed that the pharmacy typically does not send medications or supplements without a dose. Later, Pharmacist #12 explained that it was not feasible to list all ingredients in a supplement and that the dose might be written on the MAR, but the medication only comes in one form. Pharmacist #12 also stated that the pharmacy would be willing to add the strength of the supplement or medication if needed.
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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