Laurelwood Healthcare Center
Inspection history, citations, penalties and survey trends for this long-term care facility in Elkton, Maryland.
- Location
- 100 Laurel Drive, Elkton, Maryland 21921
- CMS Provider Number
- 215111
- Inspections on file
- 21
- Latest survey
- January 30, 2026
- Citations (last 12 mo.)
- 16
Citation history
Health deficiencies cited at Laurelwood Healthcare Center during CMS and state inspections, most recent first.
Facility staff failed to protect residents’ right to religious freedom by not maintaining an accurate list of Catholic residents for an outside eucharistic minister, despite repeated requests. A eucharistic minister reported being unable to provide communion for an extended period because the lists supplied by the facility were inaccurate. Surveyors found that the list of Catholic residents did not match the most recent, signed annual activity preference forms, even though these assessments are completed at admission, with changes, at readmission, and annually, and are used to update religious preference information.
A resident who reported feeling bored had an activity assessment and care plan documenting extensive interests and dependence on staff for engagement, with interventions to encourage attendance at scheduled activities and provide preferred materials. However, review of activity logs over several months showed the resident was only offered activities on a limited number of days each month, despite the facility’s stated expectation that residents be offered all scheduled activities and that offers, attendance, and refusals be documented. The Activities Director acknowledged that the logs showed the resident had not been offered or had not attended many activities, and the DON was made aware of these findings.
A facility failed to ensure resident safety, resulting in a fall with injury for a resident who was unable to move independently, and two elopement incidents involving residents with cognitive impairments. The fall was not reported for four days, and the investigation was incomplete. One resident exited through an unsecured kitchen door, and another followed visitors out the front door. Both incidents highlight a lack of adequate supervision and safety measures.
The facility was found deficient in ensuring qualified staff for food and nutrition services. The Culinary Director lacks a Certificate in Dietary Management and is currently enrolled in a course. The Registered Dietician, who supervises the kitchen, also lacks a Certified Dietary Manager qualification and does not attend care plan meetings. This deficiency was identified through surveyor observations and staff interviews.
The facility failed to store and serve food according to professional standards, as observed by surveyors. Ice plaques and icicles were found in the freezer room, and dessert bowls with black dust particles were noted near a non-functional insect light trap. Interviews revealed that freezer temperatures were checked weekly, but issues persisted, indicating a lapse in food safety practices.
The facility did not follow its policy for labeling and dating food brought by family or visitors for residents. Observations revealed unlabeled and undated food items in the refrigerators, and staff were unsure about the storage duration for such food. This indicates a lack of adherence to the facility's guidelines for food storage.
The facility failed to provide privacy for residents sharing bathrooms with members of the opposite sex, as there were no locks on the bathroom doors. This issue affected several residents, despite the availability of unoccupied rooms. An interview confirmed that it was not the facility's practice to allow such arrangements without locks.
The facility failed to report several serious incidents to the state agency within the required timeframe. These included a resident not receiving timely care during a respiratory issue, an elopement, an allegation of verbal abuse, and an unwitnessed fall resulting in a fractured hip. Documentation issues and technical problems contributed to the lack of timely reporting.
The facility failed to thoroughly investigate multiple incidents, including elopement, neglect, and abuse allegations. In one case, a resident exited the facility without staff knowledge, and the investigation lacked documentation on how it occurred. Another incident involved a resident's alleged neglect during respiratory distress, but the investigation was incomplete. Additionally, a resident's fall resulting in a fractured hip was not properly investigated. The facility also failed to document follow-up actions and staff education in several cases.
The facility failed to maintain a homelike environment, with surveyors observing numerous deficiencies such as unpainted spackling, cracked paint, and damaged furniture in resident rooms. Shared bathrooms had missing tiles, plumbing issues, and exposed wiring. The courtyard was neglected, with overgrown weeds and broken concrete. Interviews with staff confirmed awareness of these issues, yet they remained unresolved.
The facility failed to notify physicians and responsible parties about significant incidents affecting residents, including a fall resulting in a broken hip, significant weight loss, and changes in medical condition. The DON confirmed communication lapses, and the RD noted delays in physician notification for weight issues.
The facility failed to develop comprehensive care plans for several residents, including those with legal blindness, schizophrenia, and fractures. A resident with legal blindness lacked a care plan addressing their impairment, while another with schizophrenia had no care plan for their psychiatric disorder. Additionally, a resident with a femur fracture did not have a care plan for their injury. Other deficiencies included unimplemented care plans for nutrition and ADL care refusal.
The facility failed to conduct care plan meetings and update care plans for several residents, leading to deficiencies in addressing residents' unique needs. A resident's care plan was not revised to reflect therapy refusals, another's care plan inaccurately reflected pressure ulcer status, and a third resident's care plan lacked behavior monitoring evaluation. The DON was aware of the scheduling issues.
The facility failed to accommodate the needs of two residents. One resident required a bariatric Hoyer lift for safe transfers, but the facility's lift was broken, leading staff to use multiple members for transfers against PT recommendations. Another resident, who preferred showers three times a week, received inadequate personal care, resulting in only three showers over a month and a yeast infection. These deficiencies highlight the facility's inability to meet resident needs and preferences.
A facility failed to convey funds to a resident upon discharge. The resident was admitted from another facility and discharged to a hospital, with a check for $2132.12 sent by the previous facility. The facility staff mistakenly returned the check to the previous facility instead of the resident. The Business Office Manager and Administrator acknowledged the error.
A resident with a history of inappropriate sexual behavior kissed another resident without consent. Despite being advised against entering other residents' rooms, the resident continued the behavior. The facility's response was limited to relocating the resident without further protective measures for the affected resident.
The facility failed to implement its abuse policy, as shown by two incidents: a resident's verbal abuse allegation and an unwitnessed fall resulting in a fractured hip. The investigations were incomplete, lacking documentation and thoroughness, with the DON admitting to technical issues affecting report documentation.
The facility staff failed to administer medications and treatments as ordered for several residents. A resident with diabetes had inconsistent blood sugar monitoring, leading to a hospital transfer. Another resident with convulsions did not receive prescribed medications, despite their availability. A resident with a stroke did not receive Eliquis as ordered, and a resident on oxygen therapy lacked documented management orders. These issues were identified during a survey.
The facility failed to monitor and address the nutritional needs of residents, leading to significant weight loss and malnutrition. One resident experienced an 8.6-pound weight loss that was not properly documented or addressed, while another resident on a feeding tube lost 16.7% of their body weight due to inadequate monitoring. Additionally, a third resident's eating amounts were inconsistently recorded, and no specific care plan was developed for their nutritional needs. The facility's policies for weight monitoring were not followed, and there was a lack of timely communication with physicians.
The facility failed to maintain accurate medical records for a resident in hospice care and during an emergency involving another resident. Hospice documentation was missing for a resident with heart disease, and Narcan administration was not recorded for a resident found unresponsive. Staff confirmed these documentation gaps.
The facility failed to ensure nursing staff received annual training on abuse, neglect, and exploitation prevention, as well as dementia management. A review of staff records showed incomplete or missing training documentation. Additionally, a GNA was involved in an incident of alleged abuse, and their training records lacked evidence of required abuse training.
A resident was not informed about changes to their Hepatitis C treatment plan, including the cessation of a medication due to insurance authorization issues. Despite being cognitively intact, the resident was not notified of the medication hold or the need for an infectious disease consultation, leading to feelings of exclusion from their care decisions.
The facility failed to ensure that two residents or their representatives were offered the opportunity to develop advance directives and were provided with information regarding them. One resident's records lacked an advance directive despite having a MOLST form indicating CPR preference, and another resident, lacking decision-making capacity, also had no advance directive on file. Staff interviews confirmed the absence of documentation offering the opportunity to formulate advance directives.
The facility failed to issue advance written notifications to residents when Medicare Part A skilled services were no longer covered. During a survey, it was found that required notices were not provided to three residents, despite their coverage ending. Interviews with staff confirmed the oversight, and the facility's Administrator acknowledged the deficiency.
Surveyors found unsecured storage of resident records during a recertification survey. Two exterior doors were ajar, allowing access to a storage area with disorganized medical equipment and documents containing sensitive resident information. The facility's Administrator acknowledged the issue, and the Director of Maintenance confirmed the door could not be closed, indicating a lack of oversight.
The facility failed to provide written notification to two residents and their representatives regarding the reason for their transfer to the hospital. One resident was sent to the emergency department without written notice, and the staff only communicated the reason verbally. Another resident was transferred without the resident or their family being informed in writing. Interviews with staff confirmed the lack of awareness and communication regarding the requirement for written notification.
A facility failed to provide a bed-hold notice to a resident or their representative before transferring the resident to the hospital. The resident, who had unplanned hospital transfers, was not informed about the bed-hold policy. Staff interviews revealed inconsistent communication regarding the policy, and the facility's process did not meet regulatory requirements.
A facility failed to refer a resident for a required Level II PASARR evaluation, as indicated by a Level I screening form. The absence of a Level II referral was confirmed through interviews with the DON and Infection Prevention Nurse. The NHA was aware of the deficiency.
A registered nurse in an LTC facility failed to follow physician orders for medication administration, resulting in incorrect medications being given to two residents. One resident received the wrong type of laxative and probiotic, while another received an incorrect dose of Metformin and missed a dose of Topiramate due to unavailability. The nurse did not document the missed dose, leading to a medication error rate of 13.79%, exceeding the acceptable threshold.
A resident with dementia and mild cognitive impairment was not provided with individualized activities as per their care plan. Observations revealed the resident often lying in bed without activities, and the resident reported not being asked to participate in any. The care plan included music and memory programs and one-on-one visits, which were not implemented. The Activities Director confirmed infrequent one-on-one interactions, and documentation was lacking.
The facility failed to conduct competency evaluations for nursing staff upon hire, affecting two RNs and three GNAs. Training was conducted by the staffing coordinator, DON, or HR, but lacked an official educator. New hires received an orientation packet with a skills checklist, but only one staff member had a checklist on file, which was unsigned and undated. The DON confirmed the checklist should have been signed and dated.
The facility failed to conduct annual performance reviews for GNAs, as required. During a survey, it was found that the records of three GNAs lacked documented performance evaluations. Interviews with the ADON and DON confirmed that these reviews were not conducted, despite the ADON stating that nursing staff are evaluated annually by the DON. The absence of these reviews was acknowledged by the DON and ICP during the survey.
A facility's medication error rate exceeded the acceptable threshold of 5%, reaching 13.79%. Errors included administering incorrect medications and dosages to two residents. A nurse, new to the facility, acknowledged the mistakes during medication pass observations. The facility's medication administration policies were not followed.
During a survey, expired medications and supplies were found in a medication cart and central supply room. A CMA's cart contained expired Mirtazapine tablets, and various expired medical supplies were discovered in the central supply room. These findings were confirmed and the items were removed.
A resident signed an arbitration agreement despite lacking the capacity to do so, as indicated by clinical records and capacity forms. Interviews with facility staff confirmed the resident's cognitive impairment and inability to make decisions, with no evidence found to support the resident's capacity at the time of signing.
The facility failed to follow proper infection control practices, including hand hygiene during a dressing change and the use of PPE for a resident under Enhanced Barrier Precautions. A nurse did not perform hand hygiene between glove changes, and a GNA assisted a resident without wearing a gown and gloves. Additionally, the facility's infection control policies were not updated annually.
The facility failed to ensure accurate MDS assessments for two residents. One resident's MDS inaccurately indicated the use of oxygen therapy and a ventilator, despite being on room air. Another resident's significant weight loss was not captured due to discrepancies in documentation. These errors were confirmed by the DON and MDS Coordinator.
The facility failed to provide appropriate care for residents with urinary catheters, as seen in two cases. One resident did not have their catheter and drainage bag changed as ordered, nor was a follow-up urologist appointment scheduled. Another resident's urinary output was not consistently recorded. Staff interviews confirmed these lapses, which were reported to the DON and Administrator.
Failure to Maintain Accurate List of Catholic Residents for Religious Services
Penalty
Summary
Facility staff failed to protect and value residents’ right to religious freedom by not providing an accurate list of Catholic residents to an outside eucharistic minister. A complaint from the eucharistic minister stated that he or she had been unable to provide communion to Catholic residents for approximately two years because the facility did not supply an accurate list of Catholic residents. The eucharistic minister reported attempting since October 2025 to obtain an accurate list, typically emailing the Administrator and Activity Director about four days before visits, and alleged that since March 2025 the lists received were inaccurate, preventing the provision of communion. The eucharistic minister further alleged that, when the Administrator was contacted about this issue, the Administrator acknowledged seeing the email but stated that he or she did not believe the list of Catholic residents was important at the time. During the survey, the Activity Director provided a list of Catholic residents, which, upon review and comparison with the most recent annual activity preference forms, was found to be inaccurate. Residents identified on the list as Catholic did not indicate Catholicism on their most recent activity preference forms, all of which had been signed and reviewed by the Activity Director. The Activity Director stated that residents receive an assessment of activity preferences at admission, upon changes, at readmission, and annually, and that the list of Catholic residents is supposed to be updated based on changes to these forms. The Activity Director indicated that assistants normally update the list, and, after reviewing the specific residents’ preference forms presented by the surveyor, admitted that the list of Catholic residents was inaccurate. The DON and Administrator were informed by the surveyor that the list was inaccurate based on the most recent activity preference forms.
Failure to Provide Activities Consistent With Resident’s Assessed Interests
Penalty
Summary
Surveyors identified a deficiency in the facility’s failure to provide activities to meet a resident’s needs and interests as outlined in the comprehensive care plan. An anonymous complaint reported that Resident #32 felt bored at the facility. Record review showed that the resident was admitted in 2025 and had an Activity Preferences Interview dated 7/12/2025 indicating interest in a wide range of activities, including animals, group activities, sports, religion, cards, bingo, games, audio books, reading, writing, music, TV, movies, outdoor activities, talking, and parties. The resident’s comprehensive care plan, initiated on 7/15/2025, documented that the resident was dependent on staff for activities and engagement, with interventions to encourage attendance, invite the resident to scheduled activities, and provide activity materials of interest such as books, puzzles, and magazines. Despite these documented interests and care plan interventions, review of the resident’s activity logs from July 2025 through January 2026 showed that the resident was offered activities on relatively few days each month. Specifically, the logs showed the resident was offered an activity on 10 of 31 days in July, 7 of 31 days in August, 7 of 30 days in September, 9 of 30 days in November, 8 of 31 days in December, and 5 of 28 days in January (as of the review date). During interview, the Activities Director stated that the expectation was that residents would be offered all scheduled activities and that offers, attendance, and refusals would be documented on the activity log, and acknowledged awareness that the resident’s activity log reflected that the resident had not been offered nor attended many activities during the reviewed months. The DON was informed of these findings and indicated understanding.
Deficiencies in Resident Safety and Supervision
Penalty
Summary
The facility failed to provide a safe environment for Resident #102, who was unable to walk or move out of bed, resulting in a fall and a broken hip. The incident occurred when an agency aide and a geriatric nursing assistant were repositioning the resident in bed. The fall was not reported to the nursing administration until four days later, and the investigation into the incident was incomplete. The resident experienced severe pain following the fall, which was not adequately assessed or associated with the fall until the x-ray confirmed a fracture. The facility also failed to prevent an elopement incident involving Resident #18, who was found outside in the facility's parking lot by family members. The resident, who had severe cognitive impairment, exited the building without staff knowledge, likely through an unsecured kitchen exit door. The facility did not have video footage of the incident, and the door lock system was changed after the elopement. The resident had no prior history of wandering or exit-seeking behavior, and a wanderguard was ordered after the incident. Another elopement incident involved Resident #106, who was found in the facility's adjacent parking lot. The resident, diagnosed with Alzheimer's disease, was able to leave the facility by following visitors out the front door, which was supposed to be locked. The receptionist did not notice the resident leaving with the visitors. This was the only known elopement incident for this resident, and the facility staff failed to provide adequate supervision to prevent it.
Deficiency in Qualified Food and Nutrition Staff
Penalty
Summary
The facility failed to ensure that it had qualified staff with the appropriate competencies and skill sets to carry out food and nutrition services. This deficiency was identified through observations and interviews conducted by the surveyor. The Culinary Director, who has been in the position for two years, does not possess a Certificate in Dietary Management (CDM) and is currently enrolled in a CDM course. The Registered Dietician (RD), who supervises the kitchen and works four days a week, also lacks a Certified Dietary Manager qualification. The RD assists with tray line temperatures, checks residents' food preferences, and attends risk meetings but does not participate in care plan meetings. The surveyor noted that the Culinary Director's lack of a CDM certificate does not meet the facility's requirement for qualified staff in food and nutrition services.
Food Safety Deficiency in Kitchen Operations
Penalty
Summary
The facility failed to ensure that food was stored and served in accordance with professional standards for food safety requirements. During the surveyor's initial observation of the kitchen food service operations, ice plaques were found on plastic freezer curtain strips, icicles were noted on the black cord connecting the freezer and freezer door, and icy spots were observed on the floor and ceiling of the freezer room. These conditions were identified as not meeting food safety requirements. Additionally, a pile of dessert bowls was observed on the countertop near the dishwashing area, with black dust particles noted in the top bowl. Above these bowls, a non-functional wall-mounted insect light trap was present, indicating potential contamination. Interviews with the dietary staff and the Culinary Director revealed that the freezer temperatures were checked once a week, and any issues identified were reported to environmental services for maintenance. However, the presence of icicles and icy spots in the freezer room suggests that these checks were insufficient to prevent the formation of ice, which poses a risk to food safety. The collection of black dust particles in the dessert bowls, located under the insect light trap, further indicates a lapse in maintaining cleanliness and preventing contamination in the food preparation area.
Failure to Label and Date Resident Food Brought by Visitors
Penalty
Summary
The facility failed to adhere to its policy regarding the storage and labeling of food brought in by family members or visitors for residents. During the survey, it was observed that the refrigerator in the nourishment room next to the Nurses' station was used to store supplements, sandwiches, and food brought by residents' families or visitors. However, the food was not consistently labeled with dates, as required by the facility's policy. Specifically, a paper bag with a resident's name but no date, an unlabeled container with a smoothie-like drink, and an unlabeled open water bottle were found in the refrigerator. Additionally, another refrigerator in unit B was found to be full of food items like pepperoni slices and cheese sticks, with a beef stew pack labeled with a resident's name but lacking a date. Staff interviews revealed uncertainty about the duration for which residents' food could be stored, indicating a lack of awareness or training regarding the facility's food storage policy.
Lack of Privacy in Shared Bathrooms
Penalty
Summary
The facility staff failed to honor the residents' right to a dignified existence by not providing adequate privacy in shared bathrooms. During a recertification/complaint survey, it was found that nine residents, including Resident #121, were forced to share bathrooms with members of the opposite sex without any mechanism to lock the bathroom doors. This lack of privacy was confirmed through medical record reviews, observations, and interviews. The issue was highlighted by a complaint from Resident #121's responsible party, who reported that the resident was sharing a bathroom with a member of the opposite sex. Observations on the A wing revealed that several residents were in similar situations, despite the availability of unoccupied rooms that could potentially alleviate the issue. An interview with the Infection Preventionist confirmed that it was not the facility's practice to have residents of opposite sexes share a bathroom without locks.
Failure to Timely Report Incidents to State Agency
Penalty
Summary
The facility failed to report allegations of abuse, neglect, exploitation, injuries of unknown origin, an elopement, and an unwitnessed fall to the state agency within the required timeframe. This deficiency was identified in several incidents involving different residents. One resident alleged not receiving timely care during a respiratory issue, with the incident being reported to the Office of Health Care Quality (OHCQ) several days late. Another resident eloped from the facility, and the documentation of the incident report was missing due to technical issues with the Director of Nursing's computer, which resulted in a lack of proof of timely reporting. Additionally, a resident alleged verbal abuse by a staff member, but the facility's investigation did not document when the report was sent to OHCQ. Furthermore, an unwitnessed fall resulting in a fractured hip was not reported to OHCQ. These incidents highlight the facility's failure to adhere to the required reporting timelines for serious incidents, as confirmed by interviews with the Nursing Home Administrator and the Director of Nursing.
Inadequate Investigation and Documentation of Incidents
Penalty
Summary
The facility failed to thoroughly investigate multiple incidents involving residents, including allegations of abuse, neglect, and elopement. In one case, a resident exited the facility without staff knowledge and was found outside by a family member. The facility's investigation did not document how the resident managed to leave the building, and there was no video footage to support the staff's assumptions. Another incident involved a resident who alleged neglect during a respiratory distress episode, but the investigation lacked proper documentation, including dates and statements from the resident involved. In another case, a resident reported an alleged assault, but the facility could not provide documentation of the investigation, as the files were missing. Similarly, an incident involving a resident who was excessively sleepy and treated with Narcan was not thoroughly documented, lacking staff interviews and a final report to the Office of Health Care Quality. Additionally, a resident's fall resulting in a fractured hip was not properly investigated, with only a few witness statements and no comprehensive review of the incident. The facility also failed to document follow-up actions and education provided to staff in several cases. For instance, a resident alleged verbal abuse by a staff member, but the investigation lacked documentation of other resident interviews and staff education. Another resident's unwitnessed fall was not investigated, with no staff interviews conducted. These deficiencies highlight a pattern of inadequate investigation and documentation of incidents, compromising the facility's ability to address and prevent future occurrences.
Facility Fails to Maintain Homelike Environment
Penalty
Summary
The facility failed to ensure a homelike environment for its residents, as evidenced by numerous deficiencies observed during the surveyor's environmental tour. The surveyor noted multiple instances of disrepair and neglect in resident rooms, including unpainted spackling, cracked and peeling paint, missing or broken ceiling tiles, and damaged furniture. In several rooms, the surveyor observed issues such as broken window blinds, missing trim molding, and exposed wallboard, which contributed to an overall unkempt and uncomfortable living space for the residents. Additionally, the surveyor identified specific concerns related to the shared bathrooms in the facility. These included missing or broken tiles, stained ceiling tiles, and plumbing issues such as non-draining sinks and backed-up plumbing. The presence of foul odors, exposed wiring, and loose fixtures further highlighted the lack of maintenance and attention to detail in ensuring a safe and comfortable environment for the residents. Interviews with residents revealed that the state of disrepair negatively impacted their well-being, with one resident expressing feelings of being put down by the condition of their room. The facility's courtyard, which was accessible to residents, was also found to be in a state of neglect, with overgrown weeds, broken concrete, and empty planter pots. Interviews with facility staff, including the Director of Maintenance and the Environmental Services Director, confirmed awareness of these issues, yet they remained unresolved at the time of the survey. The surveyor's findings were shared with the facility's Administrator, who acknowledged the concerns, indicating a systemic failure to maintain a homelike environment for the residents.
Communication Failures in Resident Care Notification
Penalty
Summary
The facility staff failed to notify the physician and responsible parties in a timely manner regarding significant incidents affecting residents. In one case, a resident experienced a fall resulting in a broken hip, but the incident was not reported to the physician or responsible party until four days later. The Director of Nursing (DON) confirmed that the fall was not reported to administration, the physician, or the responsible party until they became aware of it days later. In another instance, a resident experienced significant weight loss shortly after admission, but there was no documentation that the responsible party was notified. The DON acknowledged issues with weight monitoring. Similarly, another resident on a feeding tube experienced a significant weight loss, but the physician and responsible party were not promptly informed. The Registered Dietitian (RD) mentioned that weight issues were discussed in weekly risk meetings, but there was no immediate notification to the physician. Additionally, a resident had a change in medical condition, resulting in new treatments and medications being ordered, but the family was not notified. The DON stated that families should be informed of any change in condition, regardless of their status as Power of Attorney. The report highlights a pattern of communication failures regarding significant changes in residents' conditions and treatments.
Deficiencies in Comprehensive Care Planning
Penalty
Summary
The facility staff failed to develop and implement comprehensive person-centered care plans for several residents, as identified during a recertification and complaint survey. Resident #35, who was legally blind, did not have a care plan addressing their visual impairment, despite documentation indicating the need for assistance with reading. The B-Wing Unit Manager confirmed the care plan was not comprehensive and failed to capture the resident's diagnosis of legal blindness. Resident #30, diagnosed with schizophrenia, also lacked a care plan addressing their psychiatric disorder. The Director of Nursing acknowledged the absence of a care plan for schizophrenia and stated that unit managers, MDS nurses, and staff nurses were responsible for ensuring comprehensive care plans. Similarly, Resident #92, with a displaced fracture of the left femur neck, did not have a care plan addressing the fracture, despite the Director of Nursing's expectation that such information should be present. Additional deficiencies were noted for other residents. Resident #247's care plan for altered nutrition was not implemented, as there was no documentation of notifying the responsible party of weight loss. Resident #125, who was on a feeding tube, experienced significant weight loss without timely physician notification. Lastly, Resident #113 did not have a care plan for ADL care refusal, despite documentation of refusal and the Director of Nursing's expectation for such situations to be addressed in the care plan.
Deficiencies in Care Plan Meetings and Updates
Penalty
Summary
The facility staff failed to hold care plan meetings for several residents and their representatives, as well as to revise and update the residents' comprehensive care plans. This deficiency was identified during a recertification/complaint survey, affecting five out of 87 residents reviewed. The care plan meetings, which are essential for addressing the unique needs of each resident, were not conducted as required. For instance, Resident #38 had not had a care plan meeting in 2024, and the social services designee admitted to being behind on scheduling these meetings. Additionally, the facility did not update the care plans to reflect significant changes in residents' conditions. Resident #14's care plan was not revised to indicate the resident's refusal to participate in physical and occupational therapy, despite the therapy staff acknowledging the resident's refusal. Similarly, Resident #72's care plan inaccurately reflected the status of pressure ulcers, as the resident no longer had open areas, but the care plan had not been updated to reflect this change. Furthermore, Resident #15's care plan lacked evidence of evaluation for behavior monitoring, despite the resident having severe cognitive impairments and a history of behavioral issues. The facility also failed to document and schedule quarterly and significant change care plan meetings for this resident. The Director of Nursing was aware of the issue with care plan meeting scheduling, as confirmed by the social worker's statement that they were behind in scheduling these meetings.
Failure to Accommodate Resident Needs and Preferences
Penalty
Summary
The facility failed to provide reasonable accommodation for Resident #6's needs and preferences regarding mobility assistance. Resident #6 required a bariatric Hoyer lift for safe transfers from a wheelchair to a bed, as recommended by physical therapy (PT). However, the facility's bariatric Hoyer lift had been broken since May 2023, and no suitable replacement was available. Despite PT's recommendation, staff resorted to using multiple staff members for transfers, which was not in line with the prescribed method. Interviews with various staff members, including the Area Manager for Therapy, Unit Manager, Maintenance Director, and Director of Nursing (DON), confirmed the lack of a suitable lift and the ongoing attempts to find a solution, but no effective resolution had been implemented. Resident #134 experienced a deficiency in personal care services, specifically regarding showering preferences. Upon admission, Resident #134 expressed a preference for showers three times a week, as documented in the Nursing Admission Evaluation. However, the facility failed to provide the requested number of showers, resulting in the resident receiving only three showers from January 15, 2024, to February 13, 2024. The resident reported not receiving a shower for approximately two weeks after admission, leading to a yeast infection due to inadequate hygiene. The facility's documentation confirmed the lack of showers provided, and the Infection Preventionist corroborated the resident's account. These deficiencies highlight the facility's failure to accommodate the specific needs and preferences of its residents, as evidenced by the lack of appropriate equipment for Resident #6's transfers and the failure to adhere to Resident #134's showering preferences. The facility's inability to provide necessary resources and services resulted in compromised care and unmet resident needs, as confirmed by staff interviews and documentation reviews.
Failure to Convey Resident Funds at Discharge
Penalty
Summary
The facility staff failed to convey resident funds to a resident at discharge, which was identified during an annual survey. Resident #104 was admitted to the facility from another facility and later discharged to the hospital, not returning afterward. Prior to discharge, the previous facility sent a check for $2132.12 payable to the resident, and the resident's RFMS account was closed. However, the facility staff sent the check back to the previous facility instead of returning it to the resident. The Business Office Manager explained that they had not opened a new RFMS account for the resident and assumed the previous facility could reopen the account and deposit the funds. The Administrator confirmed the error in handling the resident's funds.
Failure to Prevent Unwanted Sexual Advances
Penalty
Summary
The facility failed to prevent an incident of abuse involving a resident who was kissed by another resident without consent. This incident was reported by the facility and involved Resident #98, who was known to have a history of inappropriate sexual behavior. Despite being alert and oriented, Resident #98 had previously been advised not to enter other residents' rooms and had been warned about the consequences of such behaviors. On May 14, 2024, Resident #98 entered Resident #16's room and kissed them on the lips, which was unwanted and non-consensual. The facility's social worker documented that Resident #16 had expressed discomfort with Resident #98's behavior, indicating a pattern of unwanted advances. The facility's response to the incident was inadequate, as they only moved Resident #98 to a different room at the end of the hall without implementing additional interventions to protect Resident #16. The Director of Nursing confirmed that no further precautions were taken to prevent Resident #98 from entering Resident #16's room or to address the unwanted touching. The facility's lack of action in providing adequate protection and intervention for Resident #16 after the incident was a significant factor in the deficiency identified by the surveyors.
Failure to Implement Abuse Policy and Incomplete Incident Investigations
Penalty
Summary
The facility failed to implement its abuse policy effectively, as evidenced by two incidents. In the first incident, a resident alleged verbal abuse by a staff member. The facility's investigation was inadequate, lacking documentation of when the incident was reported to the state agency and missing additional resident interviews. The Director of Nursing (DON) admitted to issues with self-reports due to technical problems, resulting in a lack of documentation. There was no evidence of staff suspension or education related to the incident, and the investigation packet provided to the surveyor was incomplete. In the second incident, a resident suffered a fractured hip from an unwitnessed fall during a transfer by staff. The facility failed to report this incident to the Office of Health Care Quality (OHCQ). The investigation was incomplete, with only three witness statements and no comprehensive documentation of the incident. The DON confirmed that no further information was available, and the Corporate Nurse acknowledged the lack of a thorough investigation. These deficiencies highlight the facility's failure to adhere to its policies for timely reporting and thorough investigation of incidents.
Medication and Treatment Administration Failures
Penalty
Summary
The facility staff failed to provide medication and treatment in accordance with professional standards of practice for several residents. Resident #110, who was admitted with uncontrolled diabetes, had their blood sugar levels monitored inconsistently. Despite hospital instructions to check blood sugar before meals and at bedtime, the facility only monitored it twice a day. This led to a situation where the resident's blood sugar reached critically high levels, necessitating a hospital transfer. Additionally, Resident #120, admitted with convulsions, did not receive prescribed medications, Dexamethasone and Levetiracetam, as ordered by the physician. The facility had these medications in stock, yet they were not administered on the specified dates. Furthermore, Resident #134, who was admitted with a diagnosis of cerebral infarction, did not receive the prescribed medication Eliquis on the day it was ordered to start. The medication was available in the facility's inventory but was not administered. Additionally, Resident #133, who was on oxygen therapy, did not have an order for the management of oxygen documented in their records. The DON confirmed that the order was missed during the admission process, and there were no care and management orders for the oxygen therapy. These deficiencies were identified during a recertification/complaint survey.
Failure to Monitor and Address Nutritional Needs
Penalty
Summary
The facility failed to adequately address and monitor the nutritional needs of several residents, leading to significant weight loss and malnutrition. Resident #247 experienced a weight loss of 8.6 pounds within a week, which was not properly documented or addressed by the dietician. The dietician struck out a weight entry three weeks later without providing an explanation or obtaining an updated weight, and there was no follow-up documentation after the initial weight loss was noted. The Director of Nursing acknowledged issues with weight monitoring, but no corrective actions were documented. Resident #125, who was on a feeding tube, was found to be extremely malnourished. The resident's weight dropped from 82.6 pounds to 68.8 pounds within a short period, indicating a significant weight loss of 16.7%. The dietician requested a reweigh, but the facility's policy of obtaining weekly weights for new admissions was not followed, as evidenced by missing weight documentation. The dietician admitted to process issues and a lack of timely physician notification, which contributed to the delay in addressing the resident's nutritional needs. Resident #103's nutritional status was not adequately monitored, as evidenced by incomplete documentation of the resident's eating amounts and a lack of a resident-centered care plan. The resident's eating amounts were inconsistently recorded, with several days missing documentation entirely. Despite a care plan addressing behavioral issues related to weight monitoring, there was no specific plan for the resident's nutritional needs. The Director of Nursing confirmed the lack of documentation and monitoring, acknowledging the failure to report concerns to dietitians and physicians.
Deficiencies in Medical Record Documentation for Hospice and Emergency Care
Penalty
Summary
The facility failed to maintain complete and accurate medical records for residents receiving hospice care and during emergency situations. For one resident admitted to hospice care due to heart disease, the medical record lacked documentation from hospice, including progress notes and assessments. Despite the resident's admission to hospice, there were no hospice notes available in either the electronic or paper medical records for a specified period. This deficiency was confirmed by a staff member who acknowledged the absence of hospice documentation. In another incident involving a self-reported case, a resident was found unresponsive and without respiration or pulse. The facility's nursing staff administered Narcan twice and initiated CPR. However, the medical record for this resident did not contain documentation of the Narcan order or its administration in the Medication Administration Record (MAR). The Director of Nursing confirmed the absence of this critical documentation, despite the expectation that such emergency interventions should be recorded in the MAR.
Deficiency in Staff Training on Abuse Prevention
Penalty
Summary
The facility failed to provide evidence that nursing staff received annual education on abuse, neglect, exploitation prevention, and dementia management. This deficiency was identified during a recertification/complaint survey, where records of five randomly selected nursing staff were reviewed. The review revealed that none of the selected staff had complete records of the required annual training. Specifically, Registered Nurses and Geriatric Nurse Assistants had either incomplete or missing records of training on abuse, neglect, and exploitation prevention. The Director of Nursing confirmed the inconsistency in training records and acknowledged that some staff did not receive the necessary training upon hire or annually. Additionally, an incident involving a Geriatric Nursing Aide (GNA) was reported, where a resident alleged that the GNA slapped their hand. The facility's investigation confirmed the incident, and the GNA was removed from the resident's care. However, a review of the GNA's training records showed no evidence of abuse training upon hire or after the incident. The Director of Nursing verified the absence of the GNA's attendance in abuse training sessions, highlighting a significant gap in the facility's training and education processes.
Failure to Inform Resident of Treatment Plan Changes
Penalty
Summary
The facility failed to inform a resident about changes to their treatment plan, specifically regarding a medication for Hepatitis C. The resident, who was cognitively intact with a BIMS score of 14 out of 15, expressed concern about not being notified of laboratory test results and the cessation of a medication. The medication was ordered by a Nurse Practitioner but was never administered due to a lack of prior authorization from the insurance company. Despite the medication being on hold, there was no documentation indicating that the resident was informed of these changes. Interviews with facility staff, including a Registered Nurse, the Nurse Practitioner, and the Director of Nursing, revealed that the resident was not notified about the medication hold or the need for an infectious disease consultation. The appointment scheduler confirmed that attempts to arrange a consultation were unsuccessful, and there was no documentation of these efforts in the resident's medical records. The lack of communication and documentation led to the resident feeling uninformed and excluded from decision-making regarding their care.
Failure to Offer Advance Directives to Residents
Penalty
Summary
The facility failed to ensure that residents or their representatives were offered the opportunity to develop advance directives and were provided with information regarding advance directives. This deficiency was identified for two residents during a review of their medical records. For one resident, there was no evidence of an advance directive in either the electronic or paper medical records, despite the presence of a Maryland Order for Life Sustaining Treatment (MOLST) form indicating a preference for CPR. Interviews with staff confirmed that the resident did not have an advance directive on file, and there was no documentation showing that the resident or their representative had been given the opportunity to formulate one. For another resident, admitted in July 2023, there was similarly no evidence of an advance directive in the medical records. The resident's capacity form, signed by two physicians, indicated a lack of adequate decision-making capacity, yet there was no documentation of an advance directive or evidence that the resident or their representative had been offered the opportunity to create one. The Director of Nursing was informed of these findings, and the social services department had previously identified the issue during an interview with a surveyor.
Failure to Provide Advance Beneficiary Notices
Penalty
Summary
The facility failed to provide advance written notification to residents when it determined that they no longer qualified for Medicare Part A skilled services. This deficiency was identified during a recertification survey, where the surveyor reviewed the cases of three residents. The surveyor requested the completion of Skilled Nursing Facility Beneficiary Protection Notification Review forms for these residents, but the facility did not have the necessary documentation. Interviews with the facility's staff, including the Director of Nursing and the Social Services Designee, confirmed that the required advanced beneficiary notices of non-coverage had not been issued. The surveyor's review revealed that for one resident, the last covered day of Part A service was in early April, yet no notice was issued, and the resident remained in the facility. Another resident's coverage ended in late June, with a phone call made to the family but no written notice sent until the day coverage ended. Similarly, a third resident's coverage ended in mid-June without the issuance of the required notice. The facility's Administrator acknowledged the oversight, confirming that the advanced beneficiary notices should have been provided to the residents.
Insecure Storage of Resident Records
Penalty
Summary
The facility failed to ensure the secure storage of resident records and personal information, as observed during a recertification survey. During an exterior environmental tour, surveyors found two exterior doors ajar and unlocked, providing open access to a storage area. This area contained therapy-related medical equipment in disarray, a two-drawer metal filing cabinet, and two oversized cardboard banker boxes filled with various medical documents. These documents included sensitive information such as Medicare debt documents, resident names, social security numbers, room numbers, letters, audit documents, and financial documents related to resident insurance information. The storage area was completely accessible from the outside environment, posing a risk to the confidentiality of resident information. Upon notification, the facility's Administrator acknowledged the issue and contacted the Director of Maintenance to remove the documents. The Director of Maintenance confirmed that the door to the storage area could not be closed and was unsure how long the documents had been there. They also reported not having used the storage area recently, indicating a lack of oversight and control over the storage of sensitive documents. This oversight led to the exposure of confidential resident information, violating privacy regulations.
Failure to Provide Written Notification for Hospital Transfers
Penalty
Summary
The facility failed to provide written notification to residents and their representatives regarding the reason for transfer or discharge to the hospital. This deficiency was identified during a recertification/complaint survey for two residents who were hospitalized. Resident #38 was sent to the emergency department without receiving written notification of the transfer reason. Interviews with LPN #3 and the B-Wing Unit Manager revealed that they were unaware of the requirement to provide written notification, and the reason for transfer was only communicated verbally and documented in the resident's chart and transfer form. Similarly, Resident #4 was transferred to the hospital without written notification to the resident or their family about the reason for the transfer. An interview with LPN Staff #23 confirmed that while they assisted with sending documents to the hospital, they did not communicate the reason for the transfer to the resident or their family. The Director of Nursing and the Nursing Home Administrator acknowledged the lack of written notification for both residents during discussions with the surveyor.
Failure to Provide Bed-Hold Notice Before Hospital Transfer
Penalty
Summary
The facility failed to provide a bed-hold notice to a resident or the resident's representative before transferring the resident to the hospital. This deficiency was identified during a recertification/complaint survey for one of the four resident records reviewed for hospitalization. The resident, who experienced unplanned hospital transfers in January and April 2024, confirmed that they were not informed about the bed-hold policy by the facility. A review of the medical records, including the INTERACT transfer assessment and progress notes, revealed that the bed-hold policy was not discussed with the resident or documented prior to the hospital transfer. Interviews with facility staff, including an LPN and the social worker designee, indicated a lack of consistent communication regarding the bed-hold policy. The LPN mentioned that another department is responsible for sending the bed-hold notification to the family, and sometimes nurses read the policy to the resident. The social worker designee and the DON acknowledged that the current process does not meet the required regulation, as the bed-hold policy is not consistently communicated to residents or their families. The facility's practice of mailing a bed-hold authorization letter to the family if the resident is still hospitalized, or providing a copy upon the resident's return, was found to be inadequate.
Failure to Conduct Required PASARR Level II Evaluation
Penalty
Summary
The facility failed to refer a resident to the appropriate state-designated authority for a Level II Preadmission Screening and Resident Review (PASARR) evaluation and determination. This deficiency was identified during an annual survey for one resident out of two reviewed for PASARR compliance. The records of the resident in question showed a Level I PASARR screening form dated March 10, 2022, which indicated the need for a Level II evaluation. However, there was no documentation of a Level II PASARR referral in the resident's records. Interviews conducted with the Director of Nursing and the Infection Prevention Nurse confirmed the absence of a Level II referral for the resident. The Nursing Home Administrator was also informed of the deficiency and acknowledged awareness of the issue.
Medication Administration Errors in LTC Facility
Penalty
Summary
The facility failed to meet professional standards of practice by not ensuring staff followed physician orders for medication administration and documentation. During a recertification/complaint survey, it was observed that a registered nurse (RN) administered incorrect medications to two residents. For one resident, the RN gave Senna Plus instead of the prescribed Sennosides 8.6 mg tablet and Acidophilus probiotic instead of the prescribed Probiotic Capsule 250 mg (Saccharomyces boulardii). For another resident, the RN administered only one tablet of Metformin 500 mg instead of the prescribed two tablets and failed to administer Topiramate 25 mg because it was not available. The RN did not document the missed dose of Topiramate in the Medication Administration Record (MAR). The facility's policies and procedures for medication administration were not adhered to, as evidenced by the RN's failure to administer medications as prescribed, observe the five rights of medication administration, and document medication errors. The RN, who was new to the facility and still in training, acknowledged the errors and stated that the Topiramate was not available at the time of administration. The medication error rate for the observed medication passes was calculated to be 13.79%, which is above the acceptable threshold of 5%. These findings were reviewed with the Unit Manager and Director of Nursing, highlighting the facility's failure to ensure proper medication administration and documentation practices.
Failure to Provide Individualized Activities for Resident
Penalty
Summary
The facility failed to implement an ongoing program of activities tailored to the abilities, interests, and treatment needs of a resident with dementia and mild cognitive impairment. During a recertification/complaint survey, it was observed that the resident was often found lying in bed without any activities provided, and the television was off. The resident expressed that they had not been asked to participate in any activities. The care plan for the resident included interventions such as ensuring activities were compatible with the resident's capabilities, encouraging participation in music and memory programs, and conducting one-on-one room visits if the resident was unable to attend out-of-room events. However, these interventions were not followed, as there were no music or memory programs or one-on-one visits observed. The Activities Director confirmed that the resident did not like to participate in group activities but enjoyed conversation. Despite this, documentation showed that the resident was only seen for activities on two occasions between January and July 2024. The Activities Director and Aide, both new to their positions, acknowledged that they were not providing one-on-one activities as frequently as needed. The lack of documentation and failure to offer or document group activities or one-on-one interactions contributed to the deficiency in meeting the resident's activity needs.
Failure to Conduct Competency Evaluations for Nursing Staff
Penalty
Summary
The facility failed to ensure that nursing staff had competency evaluations upon hire, as evidenced by a review of employee records and interviews. This deficiency was identified for five randomly selected nursing staff members, including two registered nurses and three geriatric nursing assistants. The American Nurses Association defines nursing competence as an expected level of performance that integrates knowledge, skills, abilities, and judgment. However, the facility did not have an official educator, and training was conducted by the staffing coordinator, Director of Nursing (DON), or Human Resources. An orientation packet, including a skills checklist, was provided to new hires, but the competency training was only conducted yearly. Interviews with the staffing coordinator, Assistant Director of Nursing (ADON), and DON revealed that competency training was a team effort involving unit managers, the infection preventionist nurse, DON, and ADON. New hires were expected to complete a skills checklist while shadowing a preceptor, with both the trainee and preceptor signing and dating the form. However, the review of nursing employee records showed that only one of the five selected staff members had a skills checklist on file, which was not signed and dated. The DON confirmed that the checklist should have been signed and dated, indicating a lapse in the facility's process for verifying new nursing staff skills upon hire.
Failure to Conduct Annual Performance Reviews for GNAs
Penalty
Summary
The facility staff failed to conduct annual performance reviews for Geriatric Nursing Assistants (GNAs) as required. During a recertification/complaint survey, it was discovered that the records of three randomly selected GNAs did not contain any annual performance reviews. Specifically, GNA #16, hired in January 2022, GNA #48, hired in March 2013, and GNA #49, hired in May 2020, all lacked documented performance evaluations. Interviews with the Assistant Director of Nursing (ADON) and the Director of Nursing (DON) confirmed that these reviews were not conducted, despite the ADON stating that nursing staff are evaluated annually by the DON. The absence of these reviews was acknowledged by the DON and the Infection Control Preventionist (ICP) during the survey process.
Medication Error Rate Exceeds Acceptable Threshold
Penalty
Summary
The facility failed to maintain a medication error rate below 5%, as evidenced by errors during medication administration for two residents. On the A-Wing Unit, a registered nurse (RN #8) administered incorrect medications to one resident, giving Senna Plus instead of Sennosides and Acidophilus instead of the prescribed Probiotic Capsule 250 mg. Additionally, the nurse administered only one tablet of Metformin instead of the prescribed two tablets to another resident and failed to provide Topiramate due to its unavailability. These errors were identified during medication pass observations conducted by surveyors. The medication error rate was calculated to be 13.79%, significantly exceeding the acceptable threshold. The errors were confirmed through interviews with the involved nurse and a review of the Medication Administration Records (MAR). The nurse acknowledged the mistakes, attributing them to being new to the facility and still in training. The facility's policies and procedures for medication administration, which emphasize the importance of following the five rights and documenting any medication errors, were not adhered to in these instances.
Expired Medications and Supplies Found During Survey
Penalty
Summary
During a recertification and complaint survey, it was observed that the facility staff failed to remove expired medications and patient supplies. On one of the nursing units, a Certified Medicine Aide's medication cart was found to contain a blister pack of Mirtazapine 15 mg tablets that had expired on July 16, 2024, for a resident. This was confirmed by an RN present during the observation, who then showed the expired medication to the Regional Director of Clinical Operations, who removed it from the cart. Additionally, in the central supply room, several expired medical supplies were found, including blood collection needles, various gauge needles, a 3-way stopcock, and vacutainer items, with expiration dates ranging from 2017 to 2023. These findings were verified by the central supplies staff and the A-Wing Unit Manager, who then disposed of the expired items in a sharps container. The Director of Nursing was informed of these observations and stated an intention to follow up.
Failure to Ensure Resident Understanding of Arbitration Agreement
Penalty
Summary
The facility failed to ensure that residents understood the arbitration agreement, as evidenced by the case of a resident who signed an agreement despite lacking the capacity to do so. During the recertification/complaint survey, it was found that the arbitration agreement for a resident was electronically signed, even though clinical records indicated that the resident had a cognitive impairment and lacked the capacity to make decisions or sign documents. This was confirmed by a certification of capacity form dated over a year prior to the signing of the agreement, as well as a second capacity form that reiterated the resident's inability to make decisions. Interviews conducted with the Admissions Director and the Nursing Home Administrator revealed that there was no evidence to support that the resident had the capacity to sign the arbitration agreement at the time it was signed. The Admissions Director confirmed the resident's lack of capacity and expressed uncertainty as to why the agreement was signed. The Nursing Home Administrator acknowledged the deficiency after reviewing the signed arbitration agreement and capacity forms, and confirmed that no evidence was found to indicate the resident had the capacity to sign the document.
Infection Control Deficiencies in Hand Hygiene and PPE Use
Penalty
Summary
The facility failed to adhere to proper infection prevention and control practices, as evidenced by multiple deficiencies observed during the survey. One significant issue involved improper hand hygiene by a wound nurse during a dressing change for a resident. The nurse removed soiled gloves and donned clean gloves without performing hand hygiene in between, which was confirmed through interviews with the nurse, the Director of Nursing, and the Infection Preventionist Nurse. This lapse in protocol was acknowledged by the facility's administration. Additionally, the facility did not comply with Enhanced Barrier Precautions (EBP) for a resident requiring such measures. A Geriatric Nursing Assistant assisted the resident to the shower without wearing the required gown and gloves, and there was a lack of PPE supplies in the shower room. This was confirmed through interviews with the involved staff and the Infection Preventionist Nurse, who acknowledged the oversight. Furthermore, the facility's infection control policies and procedures were not updated annually, with several key policies lacking revisions for multiple years. This was confirmed by the Infection Preventionist Nurse and acknowledged by the facility's administrator.
Inaccurate MDS Assessments for Two Residents
Penalty
Summary
The facility staff failed to ensure that Minimum Data Set (MDS) assessments were accurately coded for two residents during a recertification/complaint survey. For Resident #38, the MDS inaccurately indicated the use of oxygen therapy and a ventilator, despite observations and interviews confirming that the resident was on room air and had never used such equipment while in the facility. The Director of Nursing and the MDS Coordinator both confirmed the inaccuracies in the MDS coding, acknowledging that the resident was not on a ventilator or oxygen therapy, and that the coding errors were due to mistakes in the assessment process. For Resident #125, there was a discrepancy in the recorded weight, which led to an inaccurate MDS assessment. The admission MDS documented a weight of 83 lbs, while subsequent records showed a significant weight loss that was not captured in the MDS. The MDS Coordinator attributed the error to a discrepancy in documentation, as the hospital weight upon admission was different from what was initially recorded. This resulted in the failure to accurately document a significant weight loss in the MDS, which was not addressed until the error was identified during the survey.
Deficiencies in Urinary Catheter Care and Monitoring
Penalty
Summary
The facility staff failed to provide appropriate care for residents with urinary catheters, as evidenced by the case of Resident #48. This resident had a urinary catheter placed in the emergency room, with orders to have it changed every three months and the drainage bag every 30 days. However, there was no documentation of these changes being made since the resident returned to the facility. Additionally, the facility did not arrange for a follow-up appointment with a urologist as per the discharge orders from the hospital. Interviews with staff, including the Unit Manager and Registered Nurse, confirmed the lack of documentation and follow-up, and the Appointment Scheduler admitted that no urologist appointment was scheduled. Another deficiency was identified with Resident #70, who also had a urinary catheter. The facility failed to monitor and record the urinary output as ordered by the physician. The Treatment Administration Records for May, June, and July showed multiple instances where the urinary output was not recorded. Interviews with Geriatric Nursing Assistants revealed inconsistencies in the frequency of emptying urinary bags, with some staff admitting that bags were occasionally not emptied by the previous shift. These deficiencies were brought to the attention of the Director of Nursing and the Administrator, highlighting the facility's failure to adhere to physician orders and maintain proper catheter care. The lack of documentation and follow-up appointments, along with inconsistent monitoring of urinary output, contributed to the identified deficiencies during the recertification/complaint survey.
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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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