Keswick Multi-care Center
Inspection history, citations, penalties and survey trends for this long-term care facility in Baltimore, Maryland.
- Location
- 700 West 40th Street, Baltimore, Maryland 21211
- CMS Provider Number
- 215037
- Inspections on file
- 16
- Latest survey
- March 3, 2026
- Citations (last 12 mo.)
- 1
Citation history
Health deficiencies cited at Keswick Multi-care Center during CMS and state inspections, most recent first.
The facility failed to ensure accurate completion of MDS assessments for two residents. One resident with atrial fibrillation had an active order and care plan for the anticoagulant Xarelto, but the admission and 5-day Medicare MDS (Section N – Medications) did not code the use of an anticoagulant. Another resident’s progress notes documented a discharge to the hospital, while the Discharge – return not anticipated MDS incorrectly coded a discharge home under home health services. These discrepancies show that MDS coding did not accurately reflect the residents’ actual medication regimen and discharge status.
A resident with intact cognition and a history of depression, who was dependent on staff for toileting, was subjected to verbal abuse by a GNA during incontinence care. The GNA used inappropriate and expletive language, causing the resident to become embarrassed and cry. The incident was confirmed through interviews and documentation, revealing a failure to protect the resident from verbal abuse.
A resident with severe cognitive impairment and multiple comorbidities was found to have a left shoulder fracture of unknown origin. After x-ray results confirmed the injury, the facility did not report the incident to state authorities within the required two-hour window, as mandated by policy. The delay occurred because the supervisor did not complete the initial report after being notified of the injury.
Surveyors identified deficiencies in the facility's kitchen, including a dietary aide not wearing a hair restraint, uncovered and unlabeled food items, and a dishwasher operating below the recommended temperature. The CDM confirmed these issues and acknowledged the concerns raised by the surveyors.
The facility failed to report allegations of abuse within the required timeframes, as identified in incidents MD#00188565, MD#00200867, and MD#00181354. The Administrator misunderstood the reporting requirements, believing that allegations not involving serious bodily injury could be reported within 24 hours. This misunderstanding was reflected in the facility's policies, which did not ensure timely reporting to the appropriate authorities.
The facility failed to report a resident's missing funds to law enforcement and delayed reporting abuse allegations to the Office of Health Care Quality (OHCQ) within the required 2-hour timeframe. A resident's missing money was not reported to the police, and abuse allegations involving two residents were reported late to OHCQ due to a misunderstanding of reporting requirements by the Nursing Home Administrator.
A resident reported abuse involving a male perpetrator over two nights. Despite the facility being informed, no immediate protective measures were taken. Two male staff members continued working during the investigation without being removed from assignment. The facility's ADON confirmed no staff were placed on leave during the investigation.
The facility failed to develop comprehensive care plans for three residents, including one with prostheses, another with denture issues, and a third with ESRD requiring dialysis. The care plans lacked specific interventions and goals, as confirmed by nursing staff and management.
A resident experienced repeated removal of a g-tube, requiring multiple replacements over five months. The care plan was revised but lacked effective interventions. Staff acknowledged the issue, and the DON was informed.
A facility failed to provide scheduled showers for a resident who was dependent on staff for ADL care. Despite a physician's order for showers twice a week, the resident only received bed baths due to scheduling conflicts with dialysis days. Staff interviews confirmed the oversight, and the ADON acknowledged the issue.
A resident experienced a fall and reported severe pain, but the facility delayed administering pain medication for over two hours. A STAT X-ray was ordered but not conducted until the next day, and despite a physician's order, the resident was not promptly sent to the hospital. Staff interviews confirmed these delays and previous issues with the X-ray company's response times.
A facility failed to provide appropriate care for a resident with a urostomy, as there were no specific orders for stoma care, site assessment, or urine output documentation. The resident experienced issues with a leaking urine bag and prolonged periods without emptying. The DON confirmed the absence of necessary orders, indicating a deficiency in the facility's management process.
A resident's call device was found inaccessible during a survey, as it was attached to a bed rail in the down position and resting on the floor, obstructed by a bedside table. An LPN confirmed the device should be within reach, aligning with the resident's care plan, which was not followed.
The facility failed to transmit MDS assessments within the required 14 days for two residents and did not complete a discharge assessment for another. An MDS nurse confirmed the oversight, stating assessments were transmitted weekly but without specific days. The DON and ADON were informed of these deficiencies.
A facility failed to accurately document a resident's oral assessment, leading to incorrect MDS coding. The resident, who had no natural teeth and used dentures, was inaccurately recorded as having natural teeth in both the admission assessment and baseline care plan. Interviews with staff revealed that the MDS assessment did not capture the resident's edentulous status correctly, indicating a lapse in documentation and assessment processes.
A resident received medications improperly when an LPN punctured soft gel capsules, contrary to facility policy, and administered Docusate Sodium in capsule form instead of the prescribed tablet. The DON and ADON acknowledged the errors during a follow-up discussion.
A resident with chronic pain and prostate cancer experienced inconsistent pain management due to the facility's failure to adhere to professional standards. PRN pain medication orders lacked parameters for pain scores, leading to inappropriate administration of Oxycodone and Acetaminophen. Interviews with staff confirmed the absence of pain score parameters and acknowledged the inconsistency in medication administration.
A resident was administered Docusate Sodium in a soft gel capsule form instead of the ordered tablet form. An LPN prepared and administered the medication by cutting the capsules and mixing the contents with applesauce. The error was confirmed upon review of the resident's medical records, and the DON and ADON were notified.
A resident with COVID-19 was unnecessarily administered Azithromycin, an antibiotic, despite it not being a standard treatment for the virus. The order was created by an RN and later signed by a physician, although both the Infection Preventionist and the physician expressed confusion over the necessity of the antibiotic. The facility's antibiotic stewardship program flagged the order, but no documented communication with the physician was found.
The facility failed to post Enhanced Barrier Precaution (EBP) signs in front of residents' rooms, which are necessary to prevent infection transmission. During a survey, it was found that two residents' rooms lacked the required EBP signs, and another resident had an incorrect sign posted. This deficiency affected residents with specific medical needs, such as tube feeding, highlighting a lapse in the facility's infection control measures.
The facility failed to document the vaccination status of influenza and pneumococcal vaccines for three residents. A resident admitted in September 2024 had no documented flu vaccination status, another admitted in June 2024 lacked pneumococcal vaccine documentation, and a third resident did not have their annual flu vaccine status documented for 2022. The unit manager was responsible for assessing vaccination status, but the required documentation was missing from the electronic medical records. The DON acknowledged these findings.
A facility failed to document COVID-19 vaccine education for a resident who refused the vaccine upon admission. Despite the facility's routine of providing education at admission, no evidence was found in the resident's records. The deficiency was acknowledged by the DON during a survey.
Inaccurate MDS Coding for Medications and Discharge Status
Penalty
Summary
The deficiency involves the facility’s failure to accurately complete Minimum Data Set (MDS) assessments for two residents, despite having clear clinical documentation to support correct coding. For one resident with atrial fibrillation, the medical record showed an active physician order for the anticoagulant Xarelto and a current care plan problem for anticoagulant therapy. However, the admission and Medicare 5-Day MDS assessments, specifically Section N – Medications, did not reflect that the resident was taking an anticoagulant. This discrepancy was identified during surveyor review of the resident’s medical record and comparison of the MDS with the physician orders and care plan. For another resident, review of a closed medical record showed that progress notes documented a discharge to the hospital on a specific date. In contrast, the Discharge – return not anticipated MDS assessment coded that the resident was discharged home under the care of an organized home health service organization. During an interview, the LNHA confirmed that the resident had in fact been discharged to the hospital, not home with home health services. These inconsistencies between the MDS assessments and the residents’ actual medication regimen and discharge destination demonstrate that the facility did not ensure accurate completion of MDS assessments for the residents reviewed.
Failure to Protect Resident from Verbal Abuse During Incontinence Care
Penalty
Summary
A resident with a history of cerebrovascular disease, depression, dementia, and chronic kidney disease, who was dependent on staff for toileting hygiene and was always incontinent of bowel and bladder, was subjected to verbal abuse by a Geriatric Nursing Assistant (GNA) during incontinence care. The resident had intact cognition, as indicated by a BIMS score of 13, and was known to experience feelings of depression and low energy. The care plan documented the resident's dependence on staff for incontinence care and noted behavioral concerns related to depression and anxiety. The incident occurred when the resident's family member, while on the phone with the resident, overheard the GNA use inappropriate and expletive language directed at the resident during incontinence care. The GNA questioned the resident in a derogatory manner about their incontinence, which caused the resident to become embarrassed, upset, and cry. The resident later confirmed to the social worker that the GNA used inappropriate language and expletives during care, and this was corroborated by behavioral health notes documenting the resident's distress over the interaction. The GNA denied using inappropriate language but admitted to making comments about the resident's actions during care. Facility documentation, including interviews with the resident, family member, and staff, as well as behavioral health progress notes, confirmed that the resident experienced verbal abuse during care. The incident was substantiated by the facility, and the resident reported feeling embarrassed and upset as a result of the GNA's comments. The facility's policy stated zero tolerance for abuse, but the actions of the GNA failed to protect the resident from verbal abuse during a vulnerable moment.
Failure to Timely Report Injury of Unknown Source
Penalty
Summary
The facility failed to report an injury of unknown source within two hours of being informed that a resident sustained a serious bodily injury, as required by their abuse and neglect policy. The policy mandates that allegations of abuse, neglect, exploitation, or injury of unknown origin resulting in serious bodily injury must be reported to state agencies within two hours. In this case, a resident with severe cognitive impairment, dementia, and a history of osteoarthritis and osteoporosis was found to have a minimally angulated fracture of the proximal neck of the left humerus. The injury was identified after the resident exhibited swelling and pain in the left shoulder, prompting an x-ray ordered by the physician. The x-ray results, which indicated a fracture, were received and sent to the physician between 6:30 PM and 7:00 PM, with the physician responding around 9:30 PM. Despite the facility becoming aware of the injury upon receipt of the x-ray results, the initial two-hour report to the state agency was not completed within the required timeframe. The Executive Director confirmed that the supervisor did not complete the initial two-hour report after being notified of the injury. The facility ultimately notified the state survey agency at 10:45 PM, which was outside the two-hour window from when the x-ray results were received and the injury was identified. This delay constituted a failure to comply with regulatory reporting guidelines for suspected abuse or injury of unknown source.
Kitchen Deficiencies in Food Safety and Equipment Maintenance
Penalty
Summary
The facility was found to have several deficiencies in its kitchen operations. During an initial tour, a dietary aide was observed plating food without a hair restraint, which was against the facility's expectations. The Certified Dietary Manager (CDM) confirmed that staff were expected to wear hair restraints and acknowledged the concern. Additionally, surveyors observed uncovered and unlabeled food items in the produce walk-in refrigerator, including cups of mandarin oranges and diced pears, as well as salads without labeling. The CDM acknowledged that these items should have been dated and labeled, confirming the surveyor's concerns. The facility's dishwasher was also found to be operating below the manufacturer's recommended minimum wash temperature of 160°F. Observations showed the dishwasher's temperature at 148°F, and previous logs indicated temperatures of 154°F on two separate occasions. The CDM was unaware of the correct minimum temperature and had not documented any corrective actions or managerial reviews for the dishwasher's temperature logs. The CDM acknowledged the issue after being shown the manufacturer's placard and confirmed understanding of the surveyor's concerns.
Deficiency in Abuse Reporting Timeframes
Penalty
Summary
The facility failed to accurately address reporting timeframes for allegations of abuse in their policies, as identified during a surveyor's review of a facility-reported incident, MD#00188565. The incident involved an allegation of abuse that was not reported to the Office of Health Care Quality (OHCQ) within the required timeframe. The facility's Administrator believed that allegations not involving serious bodily injury could be reported within 24 hours, contrary to the requirement for immediate reporting or within two hours if serious bodily injury is involved. This misunderstanding was evident in additional facility-reported incidents, MD#00200867 and MD#00181354, which also involved delayed reporting of abuse allegations. The surveyor reviewed two facility policies related to abuse reporting, which outlined different reporting timeframes based on the seriousness of bodily injury. However, the policies did not ensure timely reporting to the appropriate authorities as required. During interviews, the Administrator acknowledged the misunderstanding and confirmed that the policies were reviewed annually and updated as needed. Despite this, the surveyor noted that no changes had been made to the abuse policies in response to the current understanding of reporting timeframes, highlighting a deficiency in the facility's compliance with abuse reporting requirements.
Failure to Timely Report Abuse and Misappropriation
Penalty
Summary
The facility staff failed to report the misappropriation of a resident's funds to local law enforcement. Resident #75 reported missing $200 from his wallet after returning from a hospital visit. Although the facility conducted an investigation and reported the incident to the Office of Health Care Quality (OHCQ), they did not notify the police, which was acknowledged as a lapse by the Director of Nursing (DON). The facility also failed to report allegations of abuse within the required 2-hour timeframe to the regulatory agency, OHCQ. Resident #310 reported an abuse allegation to dialysis staff, which was communicated to the facility's DON and other officials. However, the initial self-report to OHCQ was made more than 27 hours later. Similarly, Resident #69's allegation of being pushed by a staff member was reported to the police but not to OHCQ within the required timeframe. The Nursing Home Administrator (NHA) misunderstood the reporting requirements, believing that incidents not involving serious bodily injury could be reported within 24 hours. Another incident involved Resident #93, who expressed discomfort with a Geriatric Nursing Assistant (GNA) being rough. This was reported to the House Supervisor, but the initial self-report to OHCQ was delayed beyond the 2-hour requirement. The NHA again cited a misunderstanding of the reporting timeframe for incidents not involving serious bodily injury, leading to a failure to meet the regulatory requirements.
Failure to Protect Resident During Abuse Investigation
Penalty
Summary
The facility failed to take appropriate measures to protect a resident during an abuse investigation. A resident reported an allegation of abuse to dialysis staff, who then informed the facility's Director of Nursing, Assistant Director of Nursing, and the President of Clinical Services. The facility was aware of the allegation shortly after it was reported. The resident expressed fear for their safety, and the alleged abuse involved a male perpetrator over two consecutive nights. Despite this, the facility did not take immediate action to protect the resident from potential harm by male staff members during the investigation. The investigation file revealed that two male staff members, who were working during the alleged timeframe, continued to work their shifts without being removed from assignment or placed on administrative leave. The facility's Assistant Director of Nursing confirmed that no staff had been removed from assignment during the investigation. The surveyor noted that the psych consult for the resident occurred the day after the allegation was reported. The facility's failure to take precautionary measures during the investigation was acknowledged by the Assistant Director of Nursing during an interview with the surveyor.
Deficiencies in Comprehensive Care Planning for Residents
Penalty
Summary
The facility failed to develop and implement comprehensive and person-centered care plans for three residents during a recertification/complaint survey. For Resident #50, the care plan did not include the use of lower extremity prostheses, despite the resident having medical diagnoses of acquired absence of both legs below the knee and using prostheses daily. The absence of a medical order or care plan for the prostheses was confirmed by both a registered nurse and a unit manager, who acknowledged the oversight. Resident #12's care plan lacked pertinent goals and interventions related to denture use, despite the resident having no upper or lower teeth and experiencing issues with ill-fitting lower dentures. The resident's admission assessment incorrectly documented natural teeth, and no orders were placed for denture care and storage. The unit manager was unaware of the missing denture care plan until informed by the surveyor. For Resident #312, the facility did not develop a care plan addressing the resident's End Stage Renal Disease (ESRD) and dependence on hemodialysis. Although the resident's medical records and physician orders indicated the need for dialysis and monitoring of an AV fistula, the care plan failed to include specific interventions and approaches for these needs. The Director of Nursing and Assistant Director of Nursing confirmed the deficiency upon review.
Failure to Prevent Repeated G-Tube Removal
Penalty
Summary
The facility failed to implement an effective interdisciplinary care plan to prevent the repeated removal of a gastronomy tube (g-tube) for a resident. The resident experienced five incidents of g-tube removal over approximately five months, requiring multiple replacements. Despite the care plan being revised in August 2024, no additional effective interventions were added to address the issue. The care plan initially stated that the resident would have fewer episodes of g-tube removal, but this goal was not achieved. Interviews with staff revealed that an abdominal binder was ordered to prevent the resident from removing the g-tube, but no further measures were considered. The unit manager acknowledged the care plan's ineffectiveness and the need for updates. The Director of Nursing was informed of these findings and acknowledged the deficiency.
Failure to Provide Scheduled Showers for Resident
Penalty
Summary
The facility failed to provide adequate Activities of Daily Living (ADL) care for a dependent resident, as identified during a recertification and complaint survey. The deficiency was noted for a resident who had been in the facility for over 45 days without receiving a full shower or bath, as reported by the resident's family. The physician's order specified that the resident was to have skin assessments and baths on Monday and Thursday evenings, but a review of the GNA task sheet from July to October 2024 showed that the resident only received bed baths and not showers on the assigned days. Interviews with staff revealed that the resident's shower days coincided with their dialysis days, and the night shift staff, responsible for preparing the resident for dialysis, did not provide showers. The GNA confirmed that the resident never received showers since admission, and the Assistant Director of Nursing acknowledged the oversight. This failure to adhere to the prescribed bathing schedule resulted in the resident not receiving the necessary ADL care as ordered by the physician.
Delayed Pain Management and Hospital Transfer After Resident Fall
Penalty
Summary
The facility failed to provide timely treatment and care to a resident who sustained a fall, resulting in severe pain. The resident fell on 09/03/23 around 8 PM and reported a pain level of 9/10. Despite the resident's escalating pain, which reached a level of 10/10, the facility staff delayed administering pain medication until 10:30 PM, over two hours after the fall. This delay in pain management was a significant oversight in providing care according to professional standards. Additionally, a STAT X-ray was ordered for the resident's left hip following the fall, but the X-ray was not conducted until the next day at 10:30 AM. Furthermore, despite a physician's order to send the resident to the hospital at 8:59 PM on the day of the fall, the facility staff delayed this action. Interviews with facility staff, including a Registered Nurse and the Director of Nursing, confirmed these delays and highlighted previous issues with the X-ray company's response times, which contributed to the delay in sending the resident to the hospital for evaluation.
Failure to Provide Urostomy Care and Management
Penalty
Summary
The facility failed to provide appropriate care and management for a resident with a urostomy, as evidenced by the lack of specific orders for urostomy care. The resident, who was admitted with a urostomy, experienced issues with her urine bag leaking near the surgical wound and being left full of waste for extended periods. This situation was reported during a complaint investigation, where it was found that the resident's records did not include necessary orders for stoma care, site assessment, or documentation of urine output. During an interview, the Director of Nursing (DON) explained that residents with urostomies should have specific orders in the electronic record system, POINT CLICK CARE, to guide nursing staff in assessing and monitoring the urostomy site. However, it was confirmed that no such orders were present for the resident in question, leading to inadequate care and management of the urostomy. The DON acknowledged the absence of these orders as a concern, highlighting a deficiency in the facility's process for managing residents with urostomies.
Resident's Call Device Inaccessibility
Penalty
Summary
During a recertification survey, it was observed that a resident's call device was not accessible, leading to a deficiency in accommodating the resident's needs. The resident was found sitting on the side of their bed with the call device attached to the bed's side rail, which was in the down position, causing the device to rest on the floor underneath the bed. The bedside table was positioned between the resident and the call device, making it unreachable for the resident. A Licensed Practical Nurse (LPN) confirmed the issue and acknowledged that the call device should be within the resident's reach when staff leave the room. The resident's care plan included an intervention to ensure the call light was within reach and to encourage its use for assistance, highlighting the facility's failure to adhere to this plan.
Failure to Transmit MDS Assessments Timely
Penalty
Summary
The facility failed to transmit Minimum Data Set (MDS) assessments within the required 14 days of completion and did not create a discharge assessment for three residents. Specifically, Resident #64's MDS assessment was completed on 6/5/24 but was not transmitted to CMS' IQIES for over 120 days. Similarly, Resident #146's MDS assessment was completed on 6/6/24 and also not transmitted for over 120 days. Additionally, a discharge assessment for Resident #148 was never completed as required. During an interview, MDS nurse #5 stated that assessments were transmitted weekly to CMS but without specific days, and confirmed that all assessments are required to be transmitted regardless of the payer source. The nurse acknowledged the oversight in transmitting the assessments. The Director of Nursing (DON) and the Assistant Director of Nursing (ADON) were informed of the deficiencies, which included two resident MDS assessments not being transmitted and one resident assessment not being completed and transmitted for over 120 days.
Inaccurate Oral Assessment Documentation and MDS Coding
Penalty
Summary
The facility failed to accurately document the oral assessment of a resident, leading to an inaccurate coding of the resident's oral status on the Minimum Data Set (MDS) assessment. During the recertification/complaint survey, it was observed that a resident had no upper or lower teeth and used dentures, which was not accurately reflected in their medical records. The resident's admission assessment incorrectly indicated that they had their own teeth, and the baseline care plan also inaccurately noted natural teeth. This discrepancy was evident despite multiple dental consultations confirming the presence of dentures. Interviews with facility staff revealed that the oral assessments were completed by nurses upon admission and documented in the admission packet. However, the Unit Manager and MDS nurse acknowledged the inaccuracies in the documentation and coding. The MDS nurse confirmed that the MDS assessment did not capture the resident's edentulous status accurately, as it was coded incorrectly. The Director of Nursing and Assistant Director of Nursing were informed of these inaccuracies, highlighting a failure in the facility's documentation and assessment processes.
Improper Medication Administration and Form Discrepancy
Penalty
Summary
The facility failed to adhere to professional standards of nursing practice during medication administration for Resident #318. On the morning of October 16, 2024, an LPN was observed preparing medications for the resident, who required medications to be crushed. The LPN improperly handled soft gel capsules by cutting them open and mixing the contents with applesauce, despite the known risks of altering drug absorption when capsules are punctured. This practice was contrary to the facility's policy, which prohibits the crushing or puncturing of non-crushable medications, such as soft gel capsules. Additionally, there was a discrepancy in the form of medication administered to Resident #318. The resident was prescribed Docusate Sodium in tablet form, but the LPN administered it in a soft gel capsule form instead. This error was confirmed by the LPN and acknowledged by the Director of Nursing (DON) and Assistant Director of Nursing (ADON) during a follow-up discussion. The facility's policy and in-service education documents were provided to the surveyor, highlighting the expectation that nurses should contact a physician to change medication forms when necessary.
Inconsistent Pain Management for Resident
Penalty
Summary
The facility staff failed to provide appropriate pain management for a resident, as evidenced by inconsistent administration of pain medication and lack of adherence to professional standards of practice. The resident, who was readmitted to the facility with chronic pain syndrome, unspecified abdominal pain, and prostate cancer, reported being in constant pain and experiencing delays in receiving pain medication. A review of the resident's clinical records revealed that PRN pain medication orders lacked parameters corresponding to pain scores, leading to inconsistent administration. For instance, Oxycodone was administered for a pain score of 0, and Acetaminophen was given for a pain score of 0, indicating a lack of adherence to appropriate pain management protocols. Interviews with facility staff, including an LPN and the DON, confirmed the absence of pain score parameters for PRN medications and acknowledged the inconsistency in medication administration. The DON noted that Oxycodone should not have been given for a pain score of 0 and recognized that the resident's pain was never truly at zero. Additionally, a review of the resident's September MAR showed that Oxycodone was administered outside the ordered parameters, further highlighting the deficiency in pain management practices. The facility staff acknowledged these discrepancies and the need for proper adherence to pain management protocols.
Medication Administration Error: Incorrect Form Given
Penalty
Summary
The facility failed to administer the correct form of medication to a resident, as observed during a recertification/complaint survey. A Licensed Practical Nurse (LPN) was seen preparing medications for a resident who required medications to be crushed. The LPN used a PAXIT system to obtain an Omega 3 capsule and a house stock bottle for Docusate Sodium, both of which were in soft gel capsule form. The LPN cut the tips of these capsules, squeezed the contents into a medication cup, and mixed them with applesauce before administering them to the resident. Upon reviewing the resident's medical records, it was found that the order specified Docusate Sodium in tablet form, not as a soft gel capsule. The LPN confirmed the error, acknowledging that the medication administered was not in the ordered form. The Director of Nursing (DON) and the Assistant Director of Nursing (ADON) were informed of this discrepancy, highlighting a failure in adhering to the prescribed medication form for the resident.
Unnecessary Antibiotic Use for COVID-19
Penalty
Summary
The facility failed to ensure that a resident was free from unnecessary antibiotic use, specifically Azithromycin, which was administered to a resident diagnosed with COVID-19. The resident had reported sinus pressure, and the attending physician noted mild upper respiratory infection and ordered COVID-19 and flu tests. Despite the positive COVID-19 test result, a registered nurse created an order for Azithromycin to treat postnasal drip and COVID-19, which was later signed by the attending physician. The medication was administered over several days, although antibiotics are not typically used to treat COVID-19. The facility's antibiotic stewardship program flagged the Azithromycin order with a question mark, indicating a concern. The Infection Preventionist RN acknowledged the issue, stating that antibiotics were not used to treat COVID-19 and was unsure why the order was placed. The attending physician also expressed confusion over the order, stating that she did not place it and that it did not make sense to treat COVID-19 with antibiotics. The Director of Nursing was informed of these findings, acknowledging the issues discussed.
Failure to Post Enhanced Barrier Precaution Signs
Penalty
Summary
The facility failed to implement an effective infection prevention and control program by not posting Enhanced Barrier Precaution (EBP) signs in front of residents' rooms, which are necessary to prevent the transmission of infections. This deficiency was identified during a recertification/complaint survey, where it was observed that two residents' rooms did not have the required EBP signs, despite having orders for such precautions. Additionally, another resident had a contact isolation sign posted instead of the required EBP sign. The deficiency was evident for three residents who were reviewed for infection precaution signs. One resident had tube feeding equipment at the bedside, indicating a need for EBP, yet no sign was posted. The facility's infection preventionist acknowledged the issue, and the Director of Nursing was informed of the findings. The lack of proper signage failed to communicate the necessary precautions to individuals entering and exiting the rooms, which is crucial for infection control.
Deficiency in Documenting Vaccination Status
Penalty
Summary
The facility failed to document the vaccination status of influenza and pneumococcal vaccines for three residents during a recertification/complaint survey. Resident #127, admitted in September 2024, had no documented evidence of flu vaccination status upon admission, despite a previous vaccination in October 2019. Resident #152, admitted in June 2024, lacked documentation of pneumococcal vaccine status. Additionally, Resident #16, admitted in July 2019, did not have documentation of their annual flu vaccine status for the year 2022. The surveyor's review of the residents' records and interviews with the Infection Preventionist RN revealed that the facility's unit manager was responsible for assessing vaccination status and providing education at admission. However, the required documentation was missing from the electronic medical records. The Director of Nursing acknowledged these findings when informed by the surveyor, and no additional documentation was provided to support that the facility completed the necessary vaccination assessments.
Deficiency in Documenting COVID-19 Vaccine Education
Penalty
Summary
The facility failed to document that COVID-19 vaccine education was provided to a resident, leading to a deficiency identified during a recertification/complaint survey. Specifically, for one resident, upon admission in March 2023, the resident refused the COVID-19 vaccine. However, the electronic medical record indicated that no vaccination education was documented as provided to the resident or their representative. This lack of documentation was noted during a review of the resident's vaccination records. Interviews with the Infection Preventionist Nurse revealed that the facility's routine included offering vaccination and providing education at the time of admission assessment. Despite this, the facility could not provide documented evidence to support that COVID-19 vaccine education was given to the resident or their representative. The Director of Nursing acknowledged these findings during the surveyor's review.
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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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Every citation, penalty and Plan of Correction is sourced from public CMS records (latest release May 27, 2026) and official state health department websites — never guesswork.
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