King David Nursing And Rehabilitation Center
Inspection history, citations, penalties and survey trends for this long-term care facility in Baltimore, Maryland.
- Location
- 4204 Old Milford Mill Road, Baltimore, Maryland 21208
- CMS Provider Number
- 215022
- Inspections on file
- 16
- Latest survey
- February 26, 2026
- Citations (last 12 mo.)
- 20
Citation history
Health deficiencies cited at King David Nursing And Rehabilitation Center during CMS and state inspections, most recent first.
Staff failed to maintain sanitary food storage and kitchen conditions, including undated and outdated food items in a unit nourishment room, spilled and unclean refrigerator and freezer surfaces, and incomplete refrigerator temperature logs. In the main kitchen, surveyors found broken tiles, standing water, dusty ventilation and AC units, food and supply boxes stored directly on the floor in refrigerated, frozen, and dry storage areas, and multiple undated prepared food containers and opened juices. Dietary staff were observed preparing food without required hair and beard restraints, and the dietary manager acknowledged awareness of cleanliness and staff compliance issues but had not acted on them.
Facility staff did not properly manage outdoor waste containers, resulting in four large dumpsters being observed with open lids or doors, exposed trash bags, and waste on the ground near one container. From a dining room window, a surveyor saw multiple containers with open tops or side doors, bags of rubbish protruding or hanging over the sides, and scattered waste on the ground. The Maintenance Director reported that EVS is responsible for overseeing the dumpsters and keeping the surrounding areas clean, while the EVS Director stated that porters are responsible for recognizing when dumpsters are full and ensuring they are closed after use, even though all departments dispose of trash in them.
Staff failed to maintain multiple interior and exterior areas in a safe, clean, and homelike condition. Surveyors observed damaged drywall, a broken cabinet hinge, and water-damaged cabinetry in a nourishment room; uncapped electrical wires hanging from a box in a shower room; supplies and plumbing tools stored on a blanket under a sink in a supply room; and a broken soap dispenser in another shower room. Dining room windows had large gaps that allowed cold air to enter. Interviews with an LPN, the DON, and the Maintenance Director showed that maintenance concerns were not consistently documented in unit maintenance books, nourishment and supply rooms were not part of routine preventive checks, and there was no checklist to confirm repairs. Outside, the parking lot, tree line, and building entrance areas were littered with masks, gloves, bottles, plastic bags, and other debris, despite EVS leadership stating that housekeeping was assigned and monitored to clean these areas.
Staff failed to protect a cognitively intact resident from verbal abuse when a GNA, while assisting with care and responding to complaints about the facility, told the resident to "calm down and shut up." The incident was not reported at the time it occurred, and the GNA did not notify a nurse or supervisor about the resident’s concerns or the exchange. In subsequent interviews, the resident confirmed the statement and described another GNA in the room who witnessed it, while the involved GNA acknowledged making the remark and having prior abuse training, and the DON later characterized the situation as a cultural misunderstanding despite incomplete documentation of all witnesses in the investigation.
The facility failed to follow its abuse, neglect, and exploitation policy when a resident reported that a GNA rolled them in bed, causing their head to hit a bedrail. The policy required that any such report be treated as an abuse allegation, trigger an immediate investigation, prompt protective measures such as staffing changes, and be reported to the Administrator and state agency within 2 hours. Instead, the RN who received the report did not immediately notify the DON or Administrator, the state agency was notified well beyond the 2-hour window, and the GNA continued working the remainder of the shift with vulnerable residents.
Staff failed to follow required timeframes for reporting abuse allegations and investigation results. In one case, a resident told an RN that a GNA rolled the resident in bed and struck the resident’s head on a bedrail, but the RN waited many hours before notifying the DON, delaying the report to the state agency beyond the policy’s 2‑hour requirement. In another case, the facility submitted a 5‑day follow‑up investigation report on an abuse allegation to the state agency one working day late, despite the DON’s understanding that such reports must be submitted within 5 days.
Staff failed to thoroughly investigate multiple abuse allegations and did not consistently remove alleged abusers from resident care. In one case, a resident’s verbal abuse allegation was investigated without obtaining a written statement from a second GNA who was present, and the DON did not directly ask an LPN whether they used the specific derogatory term alleged by a resident during medication administration. In another case, a resident reported that a GNA rolled them in bed and caused their head to hit the bedrail, yet the GNA continued working for several hours after the report and returned the next morning before being suspended, contrary to the facility’s abuse policy requiring immediate investigation and protective staffing changes.
A resident with Influenza A and bacteremia did not receive ordered Tamiflu or the adjusted dose of IV Vancomycin as prescribed, and there was no documentation that the pharmacy or prescribers were notified when these medications were not available or not administered. In addition, an IV NaCl order initially lacked a specified volume, and a subsequent IV fluid order that required documentation of total volume infused each shift was not properly documented on the MAR. Interviews with an LPN, the DON, a physician, and an NP confirmed lack of awareness of missed doses and incomplete documentation, as well as failure to clarify incomplete IV fluid orders.
A resident requested to receive a turkey or tuna sandwich every day while on a regular diet for rehabilitation, but this preference was not honored. The resident’s written food preferences specified chicken salad sandwiches on certain days and turkey sandwiches on others, with no entry for tuna. The Certified Dietary Manager explained that kitchen staff could only provide turkey on meat days and tuna on dairy or meat days, and therefore could not offer the requested sandwich every day under the facility’s Jewish milk day dietary schedule.
A resident’s electronic health record showed multiple missing entries for ADL care over a two-month period, including undocumented personal hygiene, turning and repositioning, bathing, and bladder/bowel incontinence care across various shifts. An LPN unit manager confirmed that staff are expected to document ADL and incontinence care by the end of each shift and that clinical staff are responsible for ensuring completion of this documentation, but these expectations were not met for this resident.
Staff failed to follow infection prevention and control practices when linen carts were left uncovered and used as storage for personal items, and when used washcloths and a towel were left on surfaces and the floor in a shower room. An LPN unit manager acknowledged that linen carts should be covered and free of items on top, and reported that GNAs were responsible for cleaning the shower room after use while Environmental Services cleaned it daily. These observations show lapses in maintaining clean linen handling and shower room hygiene.
Surveyors found that the facility’s admission agreement and related forms did not disclose the facility’s kosher diet practices and improperly required residents to waive certain rights and facility liability. The admission packet lacked written information about kosher dietary restrictions, and the Hospital Liaison reported that potential residents and families were not routinely informed in writing about the kosher diet, only possibly mentioned verbally without explanation. A Risk Acknowledgement form stated the facility was not responsible for stolen, lost, or damaged personal property and not responsible for the development of pressure sores, despite regulatory requirements against such waivers and requirements to provide care to prevent pressure sores. The NHA could not provide evidence that the admission agreement had been approved at the time of a change in ownership and confirmed that residents were not consistently informed in writing about the kosher diet.
A resident's family, acting as surrogate decision makers due to the resident's lack of mental capacity, raised concerns about the resident's declining condition and requested an ambulance from an LPN, who refused and failed to check on the resident. The family submitted a formal complaint via email, but facility management did not initiate the grievance process or communicate with the family, and the incident was not documented in the grievance log.
A resident's family reported that an LPN refused to call 911 when the resident's condition worsened, argued with the family, and did not check on the resident after their request. The family called 911 themselves and submitted a formal complaint to facility management, but the allegation of neglect was not reported to the State Survey Agency as required. The DON and Administrator confirmed the incident was not reported, viewing it as a customer service issue.
A resident experienced two separate incidents where staff changed their clothing without consent, despite the resident's verbal objections and distress. Staff interviews confirmed that care was provided against the resident's wishes, and although notes were added to the care plan, no changes were made to prevent future occurrences. This resulted in repeated allegations of abuse without effective intervention.
A resident admitted with obstructive sleep apnea and acute respiratory failure did not receive timely physician orders for CPAP therapy at night or a structured plan to wean off supplemental oxygen, as specified in the hospital discharge plan. Initial orders only included oxygen via nasal cannula, and there was a significant delay before appropriate orders for CPAP and oxygen weaning were written.
A resident with OSA and acute respiratory failure did not have a comprehensive, individualized care plan addressing all respiratory needs, including oxygen weaning and CPAP use. The care plan lacked specific interventions, protocols, and staff assignments for both oxygen therapy and CPAP management, despite physician orders and facility policy requirements.
A resident with multiple chronic conditions and behavioral health concerns did not have an individualized care plan addressing their specific needs, including medication refusals, noncompliance, and behavioral issues. The care plans contained only generic interventions and lacked guidance for staff on how to provide patient-centered care, despite documented evidence of the resident's ongoing challenges and preferences. The DON was unable to provide evidence of actual care plan updates or individualized interventions.
Facility staff did not follow hospital discharge plans for a resident with respiratory conditions, failing to initiate and document both oxygen weaning and CPAP use as ordered. Nursing staff continued to provide and sign off on oxygen therapy without evidence of a coordinated weaning process or clear documentation, while rehab staff conducted isolated weaning trials during therapy sessions. The facility lacked a defined protocol for oxygen weaning and did not ensure interdisciplinary communication or documentation of the resident's response to respiratory interventions.
A resident's bed rails were found to be loose and not securely attached to the bed frame, creating a significant gap between the mattress and the rail. Multiple observations confirmed the issue over several days, and the facility was unable to provide up-to-date inspection logs, only offering an audit from the previous year. The problem was not addressed until brought to the attention of the surveyor, despite prior awareness by maintenance staff.
A resident was moved to different bed assignments on three occasions without written notice, including the reason for the room changes, being provided to the resident's representative. The NHA confirmed that while verbal notification occurred, there was no documentation of written notice for any of the bed reassignments.
A resident was not adequately protected from sexual abuse by a roommate who repeatedly engaged in sexually inappropriate behavior, including exposing themselves and inviting participation. Despite a care plan and interventions by staff, the inappropriate conduct continued, leading the affected resident to request a room change after feeling uncomfortable.
Staff did not report or investigate allegations of sexual abuse after an LPN documented that a resident exposed and touched their private parts and invited a roommate to participate. The Nursing Home Administrator was unaware of the incidents, and no report was made to regulatory agencies.
The facility did not prevent potential abuse after a resident was observed engaging in sexually inappropriate behavior toward a roommate, and failed to remove either resident from the shared room. Additionally, the facility did not complete or maintain thorough investigation records for allegations of misappropriation of funds and verbal abuse, as required, with missing resident statements and insufficient documentation.
Nursing staff did not document ADL care for a resident who was present in the facility, incorrectly noting the resident was unavailable, and a required social history assessment for another resident was missing from the medical record despite being completed by the social worker.
A resident repeatedly reported a non-working clock in their room and requested assistance from staff, but the issue was not resolved over several days. The clock remained non-functional during multiple surveyor observations, despite the NHA, DON, and Maintenance Director being informed.
Surveyors observed that staff did not provide adequate housekeeping and maintenance services, resulting in rooms with crumbs, debris, mouse droppings, makeshift repairs, accumulated dust in bathroom vents, and an uncovered thermostat with exposed wires. These deficiencies were found across two units and affected multiple residents.
The facility did not notify the Ombudsman prior to the hospital transfers of three residents following changes in condition. Record reviews and staff interviews with the NHA and DON confirmed that required notifications were not made or documented.
A resident with two Stage 4 pressure ulcers did not receive updated wound care as recommended by the wound consult physician. Instead, outdated treatment orders were followed, and the physician's instructions for specific wound cleansing and dressings were not implemented. The DON confirmed that the process for updating orders after wound consultations was not followed, resulting in the resident not receiving the intended care to promote healing.
A physician did not document a note addressing a resident's significant weight loss, despite the dietitian identifying and reporting the issue to the care team. The facility's policy requires providers to document clinical conditions contributing to weight loss, but the available provider note did not address the matter, and both the DON and Medical Director confirmed the lack of appropriate documentation.
A resident did not receive prescribed doses of metformin on several occasions because the facility ran out of the medication and was waiting for pharmacy delivery. Documentation on the MAR indicated missed doses, and in some cases, there was no explanation for the omissions. The DON confirmed the medication was not administered as ordered, and the facility's policy to ensure a sufficient medication supply was not followed.
A resident's room was found to have crumbs, debris, and mouse droppings, despite a history of reported pest issues and prior treatment. Review of pest control records showed inconsistent intervals between treatments, which were described as weekly but varied from 4 to 18 days, leading to a failure in maintaining an effective pest control program.
The facility did not complete required significant change assessments for two residents who experienced notable weight loss and declines in functional ability. Despite documentation of these changes and notification of the care team, the MDS was not updated to reflect the residents' altered conditions, as confirmed by staff interviews and record review.
A resident's room contained accident hazards due to the use of a power strip and extension cord for bed and charging needs after an outlet became inoperable, while another resident with a history of inappropriate sexual behaviors was not adequately monitored or documented by staff, despite care plan requirements and psychiatric evaluations indicating ongoing incidents.
Unsanitary Food Storage and Poor Kitchen Hygiene Practices
Penalty
Summary
Staff failed to maintain safe and sanitary dietary services in both a unit nourishment room and the main kitchen. In the Sudbrook unit nourishment room, surveyors observed an opened container of Amish Style Potato Salad and an opened container of honey uncured ham, both dated 01/26/26, still present weeks later. Vanilla ice cream was spilled in the freezer, there were multiple spills in the refrigerator, and two small containers of applesauce were unlabeled and undated. Review of the refrigerator temperature logs for Sudbrook showed multiple days in December 2025 and February 2026 when temperatures were not recorded. An LPN unit manager stated that environmental services (EVS) was responsible for cleaning the refrigerator but that all staff should monitor its contents, and indicated the temperature log was kept in a binder on the crash cart. The EVS director reported that EVS checked the refrigerator weekly, discarded outdated or undated items, and checked temperatures once a week for reporting to the administrator. In the main kitchen, surveyors observed multiple sanitation and food storage issues. There was a plastic container with water under a sink drain, broken floor tiles, a dusty exhaust fan, and a dusty, leaning window air conditioning unit. Bread crates with loaves of bread were stacked directly on the floor, and the dishwashing area had standing water on the floor. Inside the refrigerator, several containers of applesauce, fruit, Jell-O, egg salad, potato salad, chicken salad, and opened juice containers were undated, and boxes of food were stored on the floor. In the freezer, boxes were stored on the floor and fans had condensation and ice buildup on the ceiling. In the dry storage area, a bag of sugar and bags of portion cups were stored on the floor, there were lids and debris on the floor, and boxes were piled on air conditioning tubing. Dietary staff were observed preparing meals and portion cups without required hair and beard restraints. The dietary manager acknowledged responsibility for kitchen cleanliness and staff use of hair and beard nets, stated awareness of cleanliness issues and staff noncompliance with restraints, but reported he had not addressed these issues.
Improper Management of Outdoor Waste Containers
Penalty
Summary
Facility staff failed to ensure that outdoor waste refuse containers were properly closed and not overflowing with waste. During an observation from the dining room window on Mount [NAME], a surveyor observed four large waste containers, all with open lids or doors and exposed trash. Waste container #8320 had its top lid open with large bags of rubbish exposed at the top and a clear white bag hanging off the left side. Waste container #8319 had its left sliding door open with a clear waste bag hanging out of the side. Waste container #8213 had its top lid open with brown boxes and waste bags exposed. Waste container #8148 had its lid open with clear waste bags exposed and hanging over the front, and there was waste on the ground on both sides of this container. In an interview, the Maintenance Director stated that the Environmental Services (EVS) Department oversees the dumpsters, which are emptied on Monday, Wednesday, and Friday, and that EVS is responsible for keeping the areas around the dumpsters clean. In a separate interview, the EVS Director stated that porters are supposed to know when the dumpsters are full and to close them after placing trash inside, and that while all departments use the dumpsters, the porters are responsible for ensuring the dumpsters are closed.
Failure to Maintain Safe, Clean, and Well-Maintained Interior and Exterior Areas
Penalty
Summary
Facility staff failed to maintain a safe, clean, and comfortable physical environment in multiple interior areas. During complaint survey observations, damaged drywall was noted on two walls in the nourishment room, along with a cabinet door that flung open due to a broken bottom hinge and a sink cabinet with water damage and a hole in its base. In a shower room on Sudbrook, an electrical box contained two red and two black uncapped wires hanging out. In the Sudbrook supply room, a package of clear cups, a blue basket, and plumbing tools and parts were stored on a blanket under the sink. A broken soap dispenser was observed in another shower room, with the front cover placed on a shower bed inside the stall. Staff interviews revealed that although there were maintenance binders on each unit and a process to report issues during morning meetings, the identified concerns had not been documented in the binder, and no one had inspected the cabinet prior to the surveyor. The DON and LPN unit manager described reliance on unit maintenance books and verbal reporting, while the Maintenance Director reported that nourishment and supply rooms were not part of regular preventive checks, the maintenance book was not always checked daily, and there was no checklist to verify completion of repairs. Additionally, three dining room windows on Mount [NAME] had large gaps at the upper and lower sections, allowing cold air to enter the room until the surveyor demonstrated the issue to the Maintenance Director. The exterior environment was also not maintained in a clean and orderly condition. On two consecutive mornings, surveyors observed discarded face masks, gloves, water bottles, plastic cups, straws, plastic bags, paper, and other debris scattered throughout the parking lot, along the curb, in a tree line, and near the front of the building. Debris was noted in trees and bushes, lined against the building, and around the porch area at the entry door, where a trash can had debris nearby and a broken orange snow shovel and black plastic piece were present, with additional plastic bags and paper in the adjacent grass. During interviews, the EVS Director stated that housekeeping was responsible for cleaning the parking lot and that a porter was assigned daily to this task, and also stated that she personally monitored whether it was done, but acknowledged she had not checked the area since a recent snow event.
Failure to Protect Resident From Verbal Abuse by GNA
Penalty
Summary
Facility staff failed to ensure a resident was free from verbal abuse when a GNA told Resident #1 to "shut up." The incident occurred during the 3:00 pm–11:00 pm shift on 10/02/25, but was not reported until 10/05/25 during the 7:00 am–7:00 pm shift, when Resident #1 informed an LPN Unit Manager. At the time of the incident, the GNA was working but assigned to a different unit than where the resident was located, and the alleged perpetrator was allowed to complete the shift. Resident #1, who had a BIMS score of 15/15 as of 09/30/25, later provided a statement to the Administrator confirming that a GNA told them to shut up, adding that the GNA apologized and that the resident did not think it was meant in a harmful way, though they were surprised. During the survey, review of the GNA’s employee record showed she had completed abuse and dementia training and had an active GNA certificate with a clear background check. In an interview, the GNA confirmed she told the resident to "calm down and shut up" while the resident was complaining about the facility, acknowledging that, based on the resident’s reaction, it was verbal abuse. She stated she did not intend it in a bad way and attributed her wording partly to her culture, explaining she was encouraging the resident to calm down and look inward. She did not report the resident’s concerns or the incident to a nurse or supervisor. The DON later stated they learned of the allegation via a supervisor’s phone call and described the situation as a cultural misunderstanding, but the investigation documentation did not include mention or a statement from another GNA who, according to both the DON and the resident, was present in the room during the incident and observed the exchange.
Failure to Implement Abuse Policy for Timely Reporting and Resident Protection
Penalty
Summary
The deficiency involves the facility’s failure to implement its abuse, neglect, and exploitation policy as written, specifically regarding timely identification, reporting, and protection of residents following an abuse allegation. The facility’s policy, last reviewed/revised in 11/2023, stated that any report by a resident, staff, or family was to be considered an abuse allegation, that an immediate investigation was warranted when there was suspicion of abuse, that room or staffing changes were to be made if necessary to protect residents from an alleged perpetrator, and that all alleged violations were to be reported to the Administrator, state agency, adult protective services, and other required agencies immediately, but no later than 2 hours after the allegation was made. Record review of a facility-reported incident showed that a resident reported to an RN that a GNA rolled the resident over in bed, causing the resident’s head to hit the bedrail. This allegation was made at 8:30 PM, but the Administrator was not informed until approximately 11 hours later, at 7:30 AM the following day, and the DON was not informed until about 7:00 AM. The report to the state agency was submitted at 9:25 AM, exceeding the policy’s 2-hour reporting requirement. During interview, the DON stated that the RN reported she was unsure whether this was an abuse allegation and did not call immediately, despite staff being aware they could contact the DON at any time. Additionally, the alleged perpetrator GNA continued to work the remainder of the shift until 11:00 PM with vulnerable residents, contrary to the policy’s requirement to make staffing changes as necessary to protect residents from the alleged perpetrator.
Failure to Timely Report Abuse Allegations and Investigation Results
Penalty
Summary
Facility staff failed to report allegations of abuse within the required timeframes as outlined in the facility’s Abuse, Neglect, and Exploitation policy and federal requirements. The policy, last revised in 11/2023, required that all alleged violations reported by a resident, staff, or family be reported to the Administrator, state agency, adult protective services, and other required agencies immediately, but no later than 2 hours after the allegation is made. For one incident, a resident reported to an RN that a GNA rolled the resident over in bed and hit the resident’s head on the bedrail. The RN did not report this allegation of abuse to the DON until approximately 11 hours later, and the DON then reported the allegation to the State Agency after she became aware of it. The DON stated that the nurse was unsure it was an allegation of abuse and confirmed that her expectation was that staff report allegations as soon as possible. In a separate incident involving another resident, the facility submitted an initial allegation of abuse to the State Agency and was required to submit the final investigation results within 5 working days. The final 5‑day report was submitted one working day late, beyond the required 5‑day timeframe. During an interview, the DON acknowledged that the timeframe for submitting follow‑up investigation results to the State Agency is 5 days. These failures to report the initial allegation within 2 hours and to submit the final investigation report within 5 working days constituted noncompliance with the facility’s own policy and reporting requirements.
Failure to Thoroughly Investigate Abuse Allegations and Remove Alleged Abusers from Resident Care
Penalty
Summary
Facility staff failed to conduct thorough investigations into multiple resident abuse allegations and did not consistently remove alleged perpetrators from resident care during investigations. In one incident, a resident reported verbal abuse that allegedly occurred during a prior shift; the DON stated that staff and residents were interviewed and that another GNA had been present in the room during the alleged verbal abuse. However, the investigation file contained no written statement from that GNA, despite the DON acknowledging having spoken with the aide. In another case involving an allegation that an LPN called a resident a derogatory name during medication administration, the DON reported using open-ended questions with the nurse but did not directly ask whether the LPN had used the specific expletive alleged by the resident. The LPN later denied the allegation when directly questioned by the surveyor, and also stated they had not been aware of any problem with that resident. The facility’s abuse, neglect, and exploitation policy defined any report by a resident, staff, or family as an abuse allegation requiring immediate investigation and indicated that room or staffing changes should be made as needed to protect residents from alleged perpetrators. In a separate incident, a resident reported to an RN that a GNA rolled them in bed and caused their head to hit the bedrail. The GNA’s timesheet showed that the aide continued working for approximately 2.5 hours after the allegation and returned to work the next morning before being suspended. The DON later stated that the RN had failed to notify her of the allegation immediately, which resulted in the GNA continuing to work with residents after the abuse allegation was made.
Failure to Clarify and Follow Medication and IV Fluid Orders
Penalty
Summary
Facility staff failed to ensure that physician orders were clarified, followed, and that ordered medications and treatments were administered to a resident diagnosed with Influenza A and bacteremia. The resident was diagnosed with Influenza A and had an order entered for Tamiflu 30 mg PO BID for 5 days, which was discontinued the same day and re-entered later that night; however, the medication was never administered according to the MAR. Documentation showed the physician was notified late in the evening on the day of the order that the medication was not received, but there was no documentation that the pharmacy was contacted or that the physician was notified when the medication was still not received the following day. During interviews, the LPN Unit Manager stated that medications are typically received within 24 hours or within a 4-hour window for STAT orders, and the physician and NP later reported they were not aware that the Tamiflu had not been administered. The same resident had a critical blood culture result positive for gram-positive cocci, and was ordered Vancomycin 750 mg IV BID for 14 days for bacteremia. The resident received three doses, and a Vancomycin trough level was reported as high, leading to a dose reduction to Vancomycin 500 mg IV BID for 14 days. The resident did not receive any doses of the reduced Vancomycin prior to being sent to the emergency room, and there was no documentation that the physician or pharmacy were notified that the lower dose was not administered. Additionally, the resident had an order for 0.9% NaCl IV q shift that did not specify the volume in milliliters to be infused each shift, and this incomplete order was not clarified. A later order for 1 liter NaCl IV on specific evenings at 100 ml/hr directed nurses to document the total amount of IV fluid given each shift, but the MAR showed that nurses were not documenting the volume administered. The DON acknowledged that the amount of fluids given should be written in the notes, and the LPN Unit Manager stated that if a medication is not available on site, they would obtain an equivalent and call the pharmacy for a STAT dose.
Failure to Honor Resident’s Daily Sandwich Preference Due to Jewish Dietary Schedule
Penalty
Summary
Facility staff failed to honor a resident’s stated food preference for a daily turkey or tuna sandwich due to restrictions related to Jewish dietary observance. A complaint review on 02/19/26 showed the resident, who was on a regular diet and in the facility for rehabilitation, requested to receive a turkey or tuna sandwich every day, but this request was not honored during the stay. Review of the resident’s food preference record on 02/26/26 showed scheduled sandwiches at lunch: chicken salad sandwiches on Sunday, Tuesday, Thursday, and Saturday, and turkey sandwiches on Monday, Wednesday, and Friday, with no documented preference for a tuna sandwich. In an interview on 02/26/26, the Certified Dietary Manager stated that if a resident requested a turkey or tuna sandwich daily, the kitchen could provide turkey during a meat meal and tuna during a dairy or meat meal, but not every day, indicating the resident’s daily preference could not be accommodated within the facility’s Jewish milk day meal structure.
Failure to Document ADL and Incontinence Care for a Resident
Penalty
Summary
Facility staff failed to document activities of daily living (ADL) assistance for one resident in accordance with accepted professional standards. Review of the electronic health record on 02/25/26 at 8:39 am for Resident #6’s ADL tasks for December 2025 and January 2026 showed multiple GNA tasks not completed in the record. On 12/24 and 12/25 during the 11 pm–7 am shift, 12/26 during the 7 am–3 pm shift, and 12/31 during the 11 pm–7 am shift, there was no documentation to verify whether the resident received personal hygiene care. On those same dates and shifts (12/24, 12/25, 12/26, and 12/31), there was also no documentation to verify that the resident was turned and repositioned. Further review of January 2026 documentation revealed additional gaps. On 01/03 during the 3 pm–11 pm shift, there was no documentation to verify that the resident was turned and repositioned. On 01/03, 01/11, and 01/18 during the 11 pm–7 am shift, there was no documentation to verify that the resident was bathed. On those same dates during the 3 pm–11 pm shift, there was no documentation to verify whether the resident had episodes of bladder or bowel incontinence or whether personal hygiene was provided. During an interview on 02/25/26 at 9:42 am, the LPN Unit Manager stated that staff were expected to document ADL care each shift, either at the time the task was completed or by the end of the shift, and that incontinence episodes should be documented. The LPN Unit Manager also stated that clinical staff are responsible for ensuring completion of documentation and that chart reviews are done the day after care is provided.
Failure to Maintain Infection Control for Linen Carts and Shower Room
Penalty
Summary
Facility staff failed to maintain infection prevention and control practices related to linen handling and shower room cleanliness. During observation rounds, a surveyor observed a linen cart outside a resident room with personal items, including a tube of cream, shower gel, a fan, and a bag of washcloths, placed on top of the cart. On another occasion, an uncovered linen cart was observed outside a resident room. When these issues were brought to the attention of an LPN unit manager, the manager acknowledged that the linen cart should have been covered and that items should not have been placed on top of it. In a separate observation in the Sudbrook shower room with the same LPN unit manager, the surveyor observed a used washcloth on the grab bar in a shower stall and two used washcloths and a towel on the floor in front of the first shower stall. The LPN unit manager stated that GNAs were supposed to clean up after using the shower room and that, to their knowledge, Environmental Services cleaned the shower room daily. These observations demonstrate failures in staff actions to follow established infection control practices for maintaining clean linen carts and properly cleaning and maintaining the shower room environment.
Noncompliant Admission Agreement and Failure to Disclose Kosher Diet Requirements
Penalty
Summary
The deficiency involves the facility’s admission agreement and related documents failing to disclose special service limitations related to the facility’s kosher diet and improperly requiring residents to waive certain rights and facility liability. Record review of the admission packet showed that the Admission Agreement did not contain information about the facility’s kosher dietary practices, despite the facility following a kosher diet. A separate welcome packet included an “Always Available Menu” listing items such as tuna salad, egg salad, turkey, bologna, and pastrami sandwiches, with a note that any alternate chosen must reflect a kosher-appropriate option (dairy for dairy meal, meat for meat meal), but there was no other mention of special dietary considerations. The Hospital Liaison, who speaks with potential residents in the hospital, stated that residents and families are not informed in writing prior to admission that the facility follows a kosher diet, and that she may only casually mention it without explaining what it means unless specifically asked. Further review of the admission documents revealed that the Admission Agreement required the resident and sponsor to agree not to hold the facility responsible for injury or harm that could have been avoided if they had hired a private duty nurse. A separate Risk Acknowledgement form stated that the facility was not responsible for stolen, lost, or damaged personal property and was not responsible for the development of pressure sores, despite regulatory requirements prohibiting waiver of potential facility liability for personal property losses and requiring the facility to provide quality care, including treatment and services to prevent pressure sores. When requested, the NHA was unable to provide proof that the admission agreement had been approved at the time of the change in ownership in 2017 and confirmed that residents were not informed in writing prior to admission that the facility followed a kosher diet. The NHA could not verify that any brochure describing the kosher diet was consistently provided to residents and offered no rationale for the noncompliant admission agreement and risk acknowledgement language.
Failure to Promptly Address and Resolve Resident Grievance
Penalty
Summary
Facility staff failed to make prompt efforts to resolve a grievance and did not keep the resident's representative informed of progress toward resolution. A resident, who had been determined by two physicians to lack mental capacity, had their children acting as surrogate decision makers. On the evening in question, one of the resident's children expressed concern about the resident's deteriorating condition and requested that an LPN call an ambulance. The LPN refused, instructed the family to call themselves, argued with the family, and did not check on the resident after the request. The family sent an email complaint to facility management and the Social Work Director that night, but received no response. Review of the facility's grievance logs showed no record of this complaint, and the Administrator initially denied knowledge of any grievance related to the resident. Upon further inquiry, it was revealed that the Social Work Director had forwarded the family's email to the Administrator, who confirmed receipt but did not initiate the grievance process or follow up with the resident's representative. The Administrator stated that no action was taken because the resident had been discharged, despite being the designated Grievance Officer for the facility.
Failure to Report Allegation of Neglect to State Survey Agency
Penalty
Summary
Facility staff failed to report an allegation of neglect to the State Survey Agency after a resident's family expressed concerns about the resident's deteriorating condition. On the evening in question, the family requested that an LPN call an ambulance for the resident, but the LPN refused, instructed the family to call 911 themselves, argued with them, and did not check on the resident after the request. The family subsequently called 911 and sent an email to facility management and the Social Work Director, formally complaining about the LPN's refusal to assist and lack of concern for the resident's well-being. The email complaint was forwarded to the facility Administrator, but the allegation was not reported to the State Survey Agency as required. The Director of Nursing and Administrator confirmed during interviews that they did not report the incident, considering it a customer service issue rather than a reportable allegation of neglect. Medical record review confirmed that the family, not the nurse, called 911 following the change in the resident's condition. The failure to report the allegation of neglect constituted a deficiency in the facility's compliance with reporting requirements.
Failure to Prevent Recurrence of Abuse Allegations
Penalty
Summary
The facility failed to implement interventions to prevent the recurrence of abuse and neglect allegations for a resident who reported two separate incidents within a two-week period. The first incident involved the resident alleging that staff changed and dressed them without permission, despite the resident verbally refusing and expressing distress. The resident reported being held down by the wrists and forced to change their shirt, which they described as a violation of their rights. The second incident occurred under similar circumstances, with another staff member changing the resident's shirt without consent, even after the resident became combative and verbally objected. Interviews with staff confirmed that care was provided despite the resident's refusal, and the staff continued with the task after the resident expressed their wishes. The Director of Nursing acknowledged that while notes were added to the resident's care plan regarding these events, there were no actual adjustments made to the plan of care to address the resident's needs or to prevent future occurrences. This lack of intervention contributed to repeated allegations of abuse by the same resident.
Failure to Implement Hospital Discharge Plan for Respiratory Care
Penalty
Summary
Upon admission of a resident with diagnoses including obstructive sleep apnea and acute respiratory failure with hypercapnia, the attending physician did not address the hospital discharge plan that specified the need for CPAP therapy at night and a plan to wean the resident off supplemental oxygen. The initial physician orders only included oxygen inhalation via nasal cannula at 2 liters per minute, with no mention of CPAP use or a structured oxygen weaning protocol as directed by the hospital discharge summary. Subsequent physician documentation referenced the resident's history of obstructive sleep apnea and the need to continue CPAP, but no formal order for CPAP was written at that time, nor was there documentation addressing the plan to wean off oxygen or a rationale for not following the discharge plan. It was not until several days after admission that an order to wean off oxygen was written, and this order did not specify a target oxygen saturation level. An order for nighttime CPAP use was not written until approximately one month after admission. Interviews with the DON revealed uncertainty regarding the reconciliation of hospital discharge plans at admission, and no further clarification was provided to the surveyor before the survey exit. These actions and omissions resulted in a failure to implement the hospital's post-discharge respiratory care plan for the resident.
Failure to Develop and Implement Comprehensive Respiratory Care Plan
Penalty
Summary
The facility failed to develop and implement a comprehensive, person-centered care plan to address all of a resident's respiratory needs. The resident, who had diagnoses including obstructive sleep apnea (OSA) and acute respiratory failure with hypercapnia, was admitted from the hospital with discharge instructions to continue weaning off supplemental oxygen and to use CPAP at night. Although a care plan was created shortly after admission, it did not initially address the resident's altered respiratory status or difficulty breathing related to COPD until several weeks later. The care plan also lacked individualized interventions for the resident's use of supplemental oxygen and did not include a protocol or designate staff responsible for oxygen weaning, despite a physician's order for oxygen weaning being present. Additionally, the care plan was not updated to include specific, resident-centered interventions for the use of the CPAP machine, such as mask type, humidification, cleaning schedules, supply provision, or staff responsibilities. Facility policies reviewed did not provide a protocol for oxygen weaning, and the DON was unable to explain the omissions in the care plan or provide further information before the survey concluded. These deficiencies were identified through record review and staff interviews, and the administrator was made aware of the concerns.
Failure to Individualize and Revise Care Plan for Resident with Complex Needs
Penalty
Summary
The facility failed to revise and individualize the care plan for a resident with multiple comorbidities, including chronic pain, mood and adjustment disorder, cancer, and a history of respiratory failure. The resident had recent allegations of abuse related to ADL care, and the care plans reviewed did not contain interventions tailored to the resident's specific mental health, behavioral, or ADL needs. Instead, the care plans included generic interventions such as administering medications, referring to psychiatric services, and monitoring mood, without addressing the resident's established patterns of medication refusal, noncompliance, or specific behavioral concerns. The care plans also lacked descriptions of the resident's confabulatory statements or hallucinations, and did not provide staff with individualized strategies to address these behaviors. Despite documentation in the medical record of the resident's refusals and noncompliance, the interventions remained non-specific and did not guide staff on how to provide patient-centered care. During interviews, the DON stated that care plans were updated, but only care plan progress notes and evaluations were provided, not actual updates to the care plan itself. The DON also asserted that no interventions could be put in place for this resident, and there was no care plan addressing the resident's verbalized preferences or specific needs related to ADL care. This lack of individualized care planning was evident despite ongoing concerns and repeated refusals by the resident.
Failure to Implement and Document Oxygen Weaning and CPAP Orders
Penalty
Summary
Facility staff failed to implement hospital discharge treatment plans for a resident requiring supplemental oxygen weaning and CPAP use upon admission. The resident, who had diagnoses including obstructive sleep apnea and acute respiratory failure with hypercapnia, was admitted with specific hospital instructions to continue weaning off oxygen and to use CPAP at night. However, the admission physician orders only included oxygen therapy at 2 liters per minute via nasal cannula, with no orders for oxygen weaning or CPAP use as directed by the hospital discharge plan. The baseline care plan documented oxygen therapy but did not address oxygen weaning or CPAP use. Although a physician order to wean off oxygen was written later, it did not specify a target SpO2 level, and there was no clear documentation of how or if the weaning was being carried out. The comprehensive care plan was updated to include altered respiratory status and CPAP use, but still lacked details on oxygen therapy, weaning protocols, goals, or responsible staff. Nursing staff continued to sign off on oxygen therapy and weaning orders every shift, but there was no evidence they were involved in or aware of the weaning process, and documentation of the resident's response to weaning was absent. Rehab staff reported conducting oxygen weaning trials during therapy sessions and documenting these in the rehab record, but these efforts were not coordinated with nursing staff, who were responsible for ongoing care outside of therapy hours. The facility's policy for oxygen administration did not include a protocol for oxygen weaning or designate responsible staff. Interviews with the DON and other staff revealed a lack of clarity and communication regarding the implementation and documentation of the oxygen weaning process, and the DON was unable to provide further information before the survey concluded.
Failure to Secure Bed Rails and Maintain Inspection Documentation
Penalty
Summary
The facility failed to ensure that bed rails were securely affixed to the bed frame, resulting in loose rails that created a gap of approximately 4-5 inches between the mattress and the rail for one resident. During observations on multiple dates, the bed rails were found to be unstable and easily tilted away from the mattress. The facility was unable to provide current bed rail inspection logs when requested, only producing a single audit from the previous year and indicating that audits were conducted annually. Despite being informed of the issue, the loose bed rails were not addressed for several days until surveyor intervention. The Maintenance Director confirmed the rails were loose during a joint observation with the surveyor, acknowledging that he had previously attempted to tighten them, but the problem persisted.
Failure to Provide Written Notice for Room Changes
Penalty
Summary
The facility failed to provide written notice, including the reason for room changes, to the resident's representative for three separate bed reassignments involving Resident #23. Record review showed that the resident was relocated to different bed assignments on three occasions. When the surveyor requested documentation of written notice for these changes, the Nursing Home Administrator confirmed that, although the resident or their representative was verbally informed, there was no documentation to validate that written notice with the reason for the room changes was provided for any of the bed reassignments.
Failure to Protect Resident from Sexual Abuse by Roommate
Penalty
Summary
A deficiency was identified when the facility failed to protect a resident from sexual abuse by another resident. The incident involved a resident who was observed by an LPN exposing and touching their private parts and inviting their roommate to participate in the inappropriate behavior. Progress notes indicated that this behavior was ongoing, with the resident continuing to grab and expose their private area to anyone entering the room. A care plan was initiated addressing the resident's sexually inappropriate behavior, with interventions to protect others, but the inappropriate conduct persisted. The roommate of the resident confirmed during an interview that they experienced an incident where the resident explicitly exposed themselves, causing discomfort. The roommate subsequently requested a room change. The facility's failure to effectively intervene and prevent further exposure to the inappropriate behavior resulted in the resident not being adequately protected from abuse.
Failure to Report and Investigate Alleged Sexual Abuse
Penalty
Summary
Facility staff failed to report an allegation of abuse to regulatory agencies and the Office of Health Care Quality (OHCQ) after a complaint was made regarding a resident sexually harassing a roommate. Medical record review revealed that an LPN documented multiple incidents where the resident exposed and touched their private parts, inviting the roommate to participate, and continued to display this behavior to anyone entering the room. Despite these documented observations, no investigation was initiated, and the Nursing Home Administrator confirmed he was unaware of the incidents and that no report or investigation had been conducted.
Failure to Prevent Abuse and Incomplete Investigations
Penalty
Summary
The facility failed to prevent potential abuse and did not complete thorough investigations or maintain proper records following documented incidents. In one case, a resident was observed by staff engaging in sexually inappropriate behavior toward a roommate, including exposing and touching private parts and inviting the roommate to participate. Despite staff awareness of these behaviors, neither the resident exhibiting the behavior nor the roommate was removed from the shared room, and no immediate protective measures were documented. Additionally, the facility did not conduct or document comprehensive investigations into allegations of misappropriation of funds and verbal abuse involving another resident. Investigation files lacked statements from the affected resident and did not include documentation or notations demonstrating that the facility reviewed relevant evidence, such as bank account transactions. When questioned, the Nursing Home Administrator was unable to provide complete investigation records or resident statements, and only a minimal, one-sentence statement was later produced. No evidence was provided to show that a statement was taken regarding the verbal abuse allegation.
Failure to Maintain Accurate and Complete Medical Records
Penalty
Summary
The facility failed to maintain accurate and complete medical records in accordance with accepted professional standards for two residents. For one resident, nursing staff did not document Activities of Daily Living (ADL) care after 7:00 AM on a specific date, instead recording that the resident was not available for care, despite evidence that the resident was present in the facility all day. For another resident, the required social history assessment was missing from the medical record, even though the responsible social worker stated that the assessment had been completed. These deficiencies were identified through medical record review and staff interviews during a complaint survey.
Failure to Accommodate Resident's Request for Clock Repair
Penalty
Summary
The facility failed to provide reasonable accommodation for a resident's need regarding a non-functioning clock in the resident's room. Over the course of several days, the resident reported to staff that the clock was not working and requested assistance to have it fixed. Despite these requests, the clock remained non-functional during three separate observations by the surveyor. Both the Nursing Home Administrator and the Director of Nursing were made aware of the issue, and the Maintenance Director acknowledged the need for repair, but the deficiency persisted as the clock was not fixed during the survey period.
Failure to Maintain Safe and Clean Resident Environment
Penalty
Summary
Facility staff failed to maintain a safe, clean, and homelike environment as evidenced by multiple observations across two of four units during the annual survey. In one resident's room, crumbs, debris, and mouse droppings were found along the back corner wall, and these remained present on a follow-up visit the next day. In another unit, a room was observed to have a makeshift cardboard plank covering cracked drywall and a wooden board above the air conditioning unit. Additionally, a gap at the top of an air conditioner allowed outside light to enter, and a rough notch was protruding from the metal edging of the unit. Bathroom vents in two rooms were found to have accumulated dust, indicating a lack of regular cleaning. Further deficiencies included an uncovered thermostat with exposed wires and coils in a resident room. The Maintenance Director confirmed that these thermostats were non-functional and should not have been present in resident rooms. The presence of these issues demonstrates a failure to provide necessary housekeeping and maintenance services to ensure a safe, clean, and comfortable environment for residents.
Failure to Notify Ombudsman of Resident Transfers
Penalty
Summary
The facility failed to notify the Ombudsman prior to the transfer of three residents who were sent to the hospital following changes in their conditions. Record reviews and staff interviews confirmed that, for each of these residents, there was no documentation or evidence that the Ombudsman had been informed of their transfers. The Nursing Home Administrator and the Director of Nursing both acknowledged during interviews that they were unable to provide proof of such notifications for the relevant hospitalizations. This deficiency was identified through the review of medical records and direct questioning of facility leadership regarding the required notifications.
Failure to Update and Implement Physician-Recommended Wound Care Orders
Penalty
Summary
A deficiency was identified when a resident with two Stage 4 pressure ulcers, one on the right hip and one in the sacral area, did not receive updated wound care treatment as recommended by the in-house wound consult physician. The physician's recommendations, made after a debridement procedure, included specific instructions for cleansing and dressing both wounds using Dakin solution, santyl with calcium alginate, and appropriate dressings. However, these recommendations were not incorporated into the resident's treatment orders. Instead, the resident continued to receive wound care based on outdated orders from several weeks prior, which did not reflect the physician's updated recommendations. Documentation showed that the older orders were followed for an extended period, and the Director of Nursing confirmed that the process for updating orders after wound consultations was not followed in this instance. The failure to update and implement the recommended wound care regimen resulted in the resident not receiving treatment intended to promote healing of the pressure ulcers.
Physician Failed to Document Significant Weight Loss
Penalty
Summary
A physician failed to document a note addressing a significant weight loss in a resident, as identified during a review of medical records and staff interviews. The resident experienced a weight decrease from 135.8 lbs to 109 lbs over a six-month period, amounting to a 19.73% loss. The dietitian recognized the weight loss as significant and documented that the interdisciplinary team, Medical Director, and resident representative were informed. However, a review of the physician's notes revealed no documentation addressing the weight loss following the notification. The facility's weight monitoring policy states that providers should document diagnoses or clinical conditions contributing to significant weight loss. Despite this, the only provider note available after the weight loss did not address the issue. Interviews with the DON and Medical Director confirmed that the physician did not document an updated plan of care or address the significant weight loss in the resident's medical record, even though the expectation was for such documentation to occur.
Failure to Administer Prescribed Medication Due to Unavailable Supply
Penalty
Summary
The facility failed to ensure that medications were administered to a resident as ordered, specifically regarding the administration of metformin, a medication used to treat type 2 diabetes. Record reviews and interviews revealed that the resident did not receive prescribed doses of metformin on multiple occasions over a two-month period. On certain dates, the medication was not available due to the facility waiting for pharmacy delivery, despite the medication not being new. Documentation on the Medication Administration Records (MAR) indicated missed doses, with some entries referencing progress notes for further explanation. Interviews with the resident confirmed that there were several occasions when the prescribed metformin was not provided because the facility had run out. The Director of Nursing (DON) verified that on specific dates, the medication was not administered due to delays in pharmacy delivery, and in some instances, there was no documentation explaining the missed doses. The facility's policy required established procedures to ensure a sufficient supply of medications for residents, but these procedures were not followed, resulting in the resident missing prescribed doses.
Failure to Maintain Effective Pest Control Program
Penalty
Summary
The facility failed to maintain an effective pest control program, as evidenced by the presence of crumbs, debris, and mouse droppings observed in a resident's room on the [NAME] View Unit. The issue was first identified by a surveyor and subsequently confirmed by the Nursing Home Administrator (NHA) during a follow-up visit. Review of the pest problem log book indicated that the same room had previously been reported for mice concerns in September 2024 and was treated at that time. Examination of pest management treatment invoices for 2025 revealed that although the facility described its pest control services as weekly, the actual intervals between treatments were inconsistent, ranging from 4 to 18 days. The recurrence of mouse droppings in a room with a known history of pest issues, combined with irregular pest control service intervals, contributed to the deficiency.
Failure to Complete Significant Change Assessments for Residents with Weight Loss and Functional Decline
Penalty
Summary
The facility failed to comprehensively assess two residents who experienced significant changes in condition, specifically regarding weight loss and functional ability, using the CMS-specified Resident Assessment Instrument (RAI) process. For one resident, medical record review revealed significant weight loss and a decline in feeding ability from independent to dependent, but the Minimum Data Set (MDS) was not updated to reflect these changes at any point during the resident's stay. Interviews with the MDS Coordinator and Administrator confirmed that the MDS record was not updated as required. Another resident experienced a weight loss of 19.73% over six months, which was documented as significant by the dietitian, and the interdisciplinary team, Medical Director, and Resident Representative were notified. However, review of the MDS showed that while changes in self-care ability were coded in subsequent assessments, there was no significant change of status assessment conducted in the MDS to reflect the weight loss and changes in activities of daily living. The MDS Coordinator acknowledged that the significant change of status assessment was missed after reviewing the resident's chart.
Failure to Prevent Accident Hazards and Inadequate Behavioral Monitoring
Penalty
Summary
The facility failed to ensure that a resident's room was free from accident hazards and did not provide adequate supervision to prevent accidents. Specifically, one resident's bed was plugged into an outlet across the room using a power strip and an extension cord, both of which were resting on the floor. The resident reported that the outlet on their side of the room had not worked for approximately four months, necessitating the use of the extension cord and power strip for charging needs. The power strip, which had previously been secured to the wall, was found on the floor during the surveyor's observation. The situation persisted until the time of the survey, with the resident relying on this setup due to the inoperable outlet. Additionally, the facility did not adequately monitor and document the behaviors of a resident with known inappropriate sexual behaviors. The care plan for this resident included monitoring and documenting behavior episodes, but a review of the treatment administration record and progress notes revealed inconsistent or absent documentation of the resident's sexual behaviors, despite psychiatric evaluations noting ongoing incidents. The lack of detailed documentation and monitoring was confirmed during interviews with facility staff, who acknowledged that the expected behavioral documentation was not present in the resident's records.
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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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