Layhill Nursing And Rehabilitation Center
Inspection history, citations, penalties and survey trends for this long-term care facility in Silver Spring, Maryland.
- Location
- 3227 Bel Pre Road, Silver Spring, Maryland 20906
- CMS Provider Number
- 215168
- Inspections on file
- 19
- Latest survey
- February 18, 2026
- Citations (last 12 mo.)
- 12
Citation history
Health deficiencies cited at Layhill Nursing And Rehabilitation Center during CMS and state inspections, most recent first.
A resident identified for transfer due to a bed lock was referred by the Social Service Director to two other SNFs without prior discussion of the proposed transfer with the resident’s known medical decision maker. The Business Office Manager stated the resident was chosen because they were easygoing and reported that referrals were made in the context of opening rehab beds, while assuming Social Services had notified the representative. The resident’s representative only learned of the transfer when contacted by an outside facility, and later reported confusion and upset that another family member was called instead. The DON stated that the expectation is to discuss proposed transfers with residents or their representatives before sending referrals, and the Ombudsman reported not being notified of the bed lock or the residents referred out.
A resident with a history of organ transplant did not receive prescribed anti-rejection medications, Sirolimus and Tacrolimus, after admission due to failures in the admission process and medication reconciliation. The omission was discovered when the resident's cardiologist noted low drug levels and found the medications were not ordered or administered, resulting from multiple missed opportunities by nursing and pharmacy staff.
A resident with a history of organ transplant did not receive prescribed anti-rejection medications after admission because the facility failed to reconcile and order all medications listed on the hospital discharge summary. Confusion between the CRNP and admitting nurse regarding responsibility for medication reconciliation contributed to the omission, which was identified after the resident's drug levels were found to be low.
A resident who required anti-rejection medications after an organ transplant was re-admitted from the hospital, but the pharmacy failed to identify and include two essential immunosuppressant drugs listed on the hospital discharge summary during the admission medication review. The DON confirmed that the pharmacy overlooked these medications when reconciling the resident's medication regimen.
The facility did not inform representatives for two residents when there were significant changes in condition or treatment. One resident's G-tube feeding method was changed by the dietitian without notifying the representative, and another resident's worsening Stage 4 pressure ulcer was not communicated to their representative. Both the LPN and DON confirmed that required notifications were not made.
A resident was overcharged for Beauty Shop/Barber services due to accounting errors in the management of their personal fund account. Review of billing records and service logs revealed a discrepancy between the amount charged and the actual services received, which was confirmed by the Business Office Management.
Two residents experienced incidents involving suspected abuse or injury, but the facility did not report these allegations to the State Survey Agency within the required 24-hour period. In one case, a resident with dementia and other conditions sustained significant skin tears from an unqualified staff member, and in another, a resident's abuse allegation was delayed in being reported due to staff inaction.
A resident was discharged with an abdominal drain and on TPN, but the discharge summary provided was incomplete, missing essential nursing instructions on TPN management, drain care, patient education, and a full medication list. Staff interviews and record reviews confirmed that the nursing sections of the discharge summary were not fully completed as required by facility policy.
A resident with dementia and muscle weakness experienced a fall, after which a nurse recommended keeping the bed in a low position to prevent further incidents. However, the care plan was not updated to include this intervention, despite confirmation from the unit manager and DON that it should have been added. This deficiency was identified through record review and staff interviews.
Surveyors found that two residents' wound dressings were not labeled or initialed to indicate when dressing changes occurred, despite physician orders specifying scheduled changes. The wound nurse confirmed that standard practice required labeling, but was unable to identify who performed the changes or when they were done.
A resident admitted without pressure ulcers and assessed as mild risk developed an unstageable sacral pressure ulcer during their stay. No change in condition assessment was completed, and the family was not notified of the new ulcer, contrary to facility expectations as confirmed by the DON.
A resident with dementia and other medical conditions sustained significant skin tears on both forearms after being assisted out of a chair by a Hospitality Aide who was not qualified to provide direct care. The incident was identified by an LPN, and the resident reported the circumstances through an interpreter. Facility records and staff interviews confirmed that the aide's actions were outside their permitted duties, resulting in the resident's injuries.
The facility failed to maintain an effective system for identifying decision-makers and ensuring residents' wishes regarding CPR were documented. This led to confusion with multiple residents having conflicting MOLST forms, resulting in uncertainty about their code status. For example, a resident had two active MOLST forms with contradictory orders, and another resident's MOLST was based on a surrogate's input despite the resident being capable of making their own decisions.
The facility failed to conduct and document interdisciplinary care plan meetings effectively, resulting in outdated and incomplete care plans for several residents. Residents experienced a lack of updated care plans reflecting their current needs and conditions, with some care plans missing input from various departments. This deficiency affected the quality of care provided to the residents.
The facility did not post complete nursing staffing information, as required, during a survey. The posted lists at the reception desk included nursing staff by unit and shift but lacked the resident census and total actual nursing hours worked. The Staffing Coordinator and Nursing Home Administrator confirmed the deficiency, with no further information provided by the survey's end.
The facility failed to manage Maryland MOLST forms, crucial for documenting residents' life-sustaining treatment wishes, due to the absence of a system to void outdated forms. The Medical Director was aware but did not communicate the issue to the QUAPI program, leading to non-compliance and potential impact on all residents.
The facility did not have a medical director present at the quality assurance committee meetings for three consecutive months, which equates to one quarterly meeting. The absence was confirmed by the NHA, and no substitute medical director attended these meetings, leading to a deficiency in the facility's compliance with regulatory requirements.
The facility failed to provide communication training for nine staff members, including the NHA, DON, ADON, two social workers, the Director of Rehabilitation, two Unit Managers, and two LPN supervisors. This deficiency was identified during an extended survey triggered by an Immediate Jeopardy situation involving conflicting MOLST and resuscitation code status documents in resident records. The NHA acknowledged the lack of training during an interview.
A facility failed to create a comprehensive, resident-centered care plan for a resident on psychotropic medication for depression. The care plan lacked specific details about the resident's behaviors and did not include measurable goals or non-pharmaceutical interventions. The DON was informed but did not comment.
A facility failed to honor a resident's right to self-determination by not confirming their code status directly with them, despite the resident having the capacity to make decisions. Instead, the facility confirmed the code status through a family member, without specifying which family member was contacted. This oversight was discovered during an Immediate Jeopardy investigation into conflicting resuscitation instructions.
The facility failed to maintain a safe and clean environment, with stained carpets, missing floor planks, and damaged walls observed. Housekeeping issues included holes in bed linens and inadequate cleaning, while maintenance deficiencies involved missing emergency call light cords and cracked wheelchair padding. Despite staff acknowledgment, no corrective actions were documented.
The facility failed to provide adequate activities for residents, as evidenced by observations and lack of documentation for four residents. A resident with severe cognitive impairment was found alone without activities, and another resident's care plan was outdated and did not reflect their preferences. Two other residents had no documented participation in activities, and the Activity Director failed to gather necessary information from family members.
The facility failed to provide adequate pain management for three residents, leading to deficiencies in care. A resident did not receive their prescribed oxycodone consistently due to pharmacy and insurance issues. Another resident with a sacral ulcer had no active pain medication orders, and their pain was improperly documented by a CMA. A third resident's pain medication was administered late, and non-pharmacological interventions were not attempted as required by policy.
The facility failed to follow proper procedures for bed rail use for four residents, including not assessing risks, obtaining informed consent, or developing care plans. Observations showed bed rails were used without physician orders or documentation, and a loose bed rail was found without prior awareness by staff.
The facility failed to adhere to medication administration parameters, resulting in unnecessary drug use. A resident received Oxycontin without proper blood pressure monitoring or pain assessment, and Midodrine was given without checking blood pressure. Another resident's pain management lacked guidance on medication order, and a diuretic was administered despite low blood pressure. Additionally, a Lidocaine patch was applied without a specified removal time, leading to incomplete documentation.
The facility failed to serve residents the correct meal portions and items as indicated on their meal tickets. A resident reported not receiving a high protein diet consistently, and an observation revealed incorrect portioning practices, such as using tongs instead of a scoop for beef pepper steak. A test tray showed discrepancies, including incorrect portion sizes and missing items, which were confirmed by the Food Service Director.
The facility failed to conduct regular inspections of bed frames, mattresses, and bed rails, affecting three residents and potentially all residents. The Maintenance Director confirmed that only one audit had been conducted, limited to the first floor, and relied on reports from nursing or housekeeping to address issues. New beds did not come with rails, and there was no proactive inspection process, posing a risk of entrapment.
A facility failed to notify a resident's HCPOA of changes in treatment, including the start of a new medication and a change in the attending physician. The resident, who had significant functional limitations and was dependent on staff, was not understood well and required various therapies. The lack of documentation regarding the notification of these changes was confirmed by the DON.
A facility failed to prevent further potential abuse during an investigation due to an inaccurate assessment of a resident. The DON's pain assessment incorrectly reported no pain in the last five days, despite the resident receiving as-needed pain medication with significant pain scores. Additionally, the assessment inaccurately stated the resident had not received rehab services, which was contradicted by the Director of Rehab. The DON and NHA acknowledged these documentation errors.
A facility failed to document a resident's communication needs during a hospital transfer. The resident, who was deaf, required an ASL interpreter device, but this was not noted on the transfer form completed by an LPN. The omission was confirmed during a recertification survey, and the DON could not provide evidence that the hospital staff were informed of the resident's needs.
A deaf resident in an LTC facility was unable to communicate effectively due to the absence of a functioning video interpreter device in their room. Despite signs indicating the availability of an interpreter service, the device was not present, and no alternative communication methods were provided. The resident's care plan lacked strategies for communication, and staff interviews revealed that the device had been unavailable for an extended period, with no disruptions reported by the software company.
A facility failed to administer g-tube feedings as ordered for a resident with dysphagia, leading to significant weight loss. The resident was admitted with orders for Jevity 1.5 bolus feedings, but discrepancies in orders and documentation resulted in confusion about the nutrition provided. The resident experienced weight loss due to insufficient caloric intake, which was not addressed in a timely manner. Additionally, a new feeding order was not accurately reflected in the dietitian's assessment, leading to further confusion about the number of bolus feeds administered.
A resident with severe cognitive impairment and psychiatric diagnoses did not receive adequate behavioral health monitoring, leading to a deficiency in care. The facility failed to document a planned gradual dose reduction of Zoloft, and behavior monitoring was inaccurately recorded, despite aggressive incidents. Additionally, psychiatric medication adjustments were made without proper documentation, contributing to the deficiency.
The facility failed to ensure residents were informed and involved in code status decisions when new MOLST forms were created. A resident was not consulted about their DNR status despite being cognitively intact, another had their code status changed without contacting their Health Care Agent, and a third resident's MOLST was completed without consulting their Medical POA despite incapacity certifications.
A resident reported that staff sometimes entered his room without knocking, which was confirmed when a CNA entered without knocking to deliver a lunch tray. The CNA admitted to not knowing the requirement to knock before entering. The issue was discussed with the Administrator and DON, but no further information was provided.
The facility failed to provide information on advance directives to three residents, despite their capacity to make decisions. One resident's record lacked documentation of advance directives, another's family confirmed an existing directive not discussed with the resident, and a third resident's record showed no evidence of an advance directive despite being cognitively intact. The Director of Social Services and DON acknowledged these deficiencies.
A resident with severe cognitive impairment was administered IM Haldol and Benedryl without adequate documentation of aggressive behavior. The psychiatrist ordered the medications after an emergency call, but the facility's records did not support the necessity of the injections, and they were administered hours later by a different nurse.
A facility failed to provide a resident with a notice of transfer when the resident was transferred to the hospital for abdominal pain. A review of the resident's medical record showed no Notice of Transfer documents, and an LPN confirmed the absence of the transfer notice. The DON was unable to provide evidence that a transfer notice was given.
The facility failed to provide a bed hold notice to a resident transferred to the hospital for abdominal pain. A review of the resident's medical records showed no bed hold notice, and an LPN confirmed its absence. The DON could not provide evidence of a notice being given.
A facility failed to accurately document MDS assessments for a resident, indicating an impairment in range of motion (ROM) despite the resident's ability to ambulate. Observations showed the resident walking without difficulty, contradicting the MDS documentation. The MDS nurse confirmed the error, as impaired ROM should not be coded if the resident can walk.
A facility failed to complete the PASRR form for a newly admitted resident, as required by federal mandate. The form, which was incomplete upon the resident's transfer from a hospital, lacked responses in the section concerning serious mental illness. The Social Services Director confirmed the oversight, noting that a new form should have been completed within the first week of admission.
A resident and their representative did not receive or review the baseline care plan and medication summary within 48 hours of admission, despite facility records indicating otherwise. The DON acknowledged the issue, revealing a lapse in communication and documentation by the Unit Manager.
A facility failed to ensure accurate documentation of g-tube feedings for a resident with dysphagia, leading to discrepancies in the administration records. Despite orders to hold certain feedings, staff documented them as given, resulting in inaccurate records and potential nutritional deficiencies. The resident experienced significant weight loss, indicating unmet caloric needs.
A resident in an LTC facility experienced a delay in receiving incontinent care, remaining in a soiled brief for 40 minutes despite activating the call light. The facility lacked a formal call light policy, contributing to the delay, although staff were expected to respond within 5 minutes and prevent prolonged exposure to soiled briefs.
The facility failed to assess and document pressure injuries and implement prevention therapies for two residents. One resident had a stage 2 pressure injury that was not initially documented, and another resident's heel protection boots were not used as ordered. Staff interviews revealed a lack of communication and adherence to protocols.
A facility failed to develop a care plan to maintain a resident's mobility improvements achieved during therapy. Despite significant progress in physical therapy, the care plan was not updated to reflect the resident's current capabilities, and there was a lack of communication and documentation regarding therapy recommendations. The discharge summary indicated an excellent prognosis for maintaining function, but specific guidance for staff and family was not provided.
A resident with schizophrenia and severely impaired cognition, assessed as high risk for elopement, was found unsupervised and confused in a different unit without a monitoring device. Staff interviews revealed inconsistencies in the facility's elopement prevention measures, as the resident's name was missing from the elopement list, and monitoring devices were not used unless exit-seeking behaviors were exhibited.
A facility failed to identify a resident with a critically low BMI due to inconsistent height documentation and lack of a policy for measuring height. The resident's height was inaccurately recorded, leading to a miscalculated BMI. The DON confirmed the absence of a height measurement policy, and the dietitian responsible for monitoring nutritional status was unaware of the critical BMI. The Medical Director, relying on the dietitian, was also unaware of the resident's condition, highlighting a significant oversight in nutritional monitoring.
The facility failed to ensure that irregularities identified by the pharmacist during monthly drug regimen reviews were reviewed, acted upon, and documented by the attending physician in the residents' medical records. This deficiency was evident in three residents reviewed for unnecessary medications, where recommendations for dose reductions, medication evaluations, and documentation were not addressed or recorded.
A resident with severe cognitive impairment was administered psychotropic medications without adequate justification. Despite behavior monitoring showing no concerning behaviors, the resident's Seroquel dosage was increased, and Risperdal was added and later increased. The delay in administering IM Haldol and Benedryl after an aggressive incident further highlighted the deficiency in medication management.
Failure to Notify Resident Representative and Ombudsman of Proposed Transfer
Penalty
Summary
The facility failed to ensure that a resident’s representative and the Ombudsman were notified of a proposed transfer to another SNF. A complaint was submitted to the Office of Health Care Quality alleging that the facility attempted to transfer the resident for LTC without notifying the designated medical decision maker. The Business Office Manager (BOM) stated that the resident was identified for transfer because the facility was bed locked and needed to open beds for rehab, and also described a practice she called “Quid Pro Quo,” in which facilities with low census contacted them to obtain residents. The BOM believed Social Services had notified the representative but could not confirm this. The resident’s representative, identified as the medical decision maker known to the facility, reported learning of the proposed transfer only after another facility, Kensington Rehab, contacted a family member about accepting the resident. The Social Service Director (SSD) reported receiving a list of residents to be referred out due to the bed lock and stated that her usual process was to send referrals and then contact families. She acknowledged that she did not contact this resident’s representative about the proposed transfer, explaining that she was busy and that Kensington had reached out to the representative quickly. Record review showed that the SSD sent a referral to [NAME] Grove on 01/27/26 and another referral to Kensington Rehab on 02/04/26 before any documented communication with the resident’s representative about the transfer. The DON stated that other facilities do not contact them to obtain residents and denied any “Quid Pro Quo,” and also stated that the facility’s expectation is to discuss a proposed transfer with the resident or representative before sending referrals. The Ombudsman reported not being notified of the bed lock or of residents referred out for transfer.
Failure to Administer Prescribed Anti-Rejection Medications After Admission
Penalty
Summary
A deficiency occurred when a resident with a history of organ transplant did not receive prescribed anti-rejection medications, specifically Sirolimus and Tacrolimus, following admission from a hospital. The resident's hospital discharge summary included these medications, but a review of the facility's physician orders and Medication Administration Record (MAR) for the relevant period showed no orders or administration of these drugs. The omission was discovered after the resident's cardiologist, during a routine appointment, noted low therapeutic drug levels and requested a review of the resident's active medication list, revealing the absence of the necessary anti-rejection medications. Interviews and record reviews indicated that the failure to administer these medications resulted from multiple system failures during the admission process. The admitting nurse did not enter orders for the anti-rejection medications as listed on the discharge summary, and the pharmacy's medication regimen review also failed to identify the omission. Additionally, when the cardiologist requested lab troughs for the medications, staff did not question the absence of active orders for these drugs. These oversights led to the resident not receiving essential immunosuppressive therapy for an extended period.
Failure to Reconcile and Administer Discharge Medications for Transplant Patient
Penalty
Summary
The facility failed to ensure that all medications listed on a hospital discharge summary were ordered and administered for a resident with a history of organ transplant. Upon review of facility-reported incidents and the resident's medical records, it was found that two essential anti-rejection medications, Sirolimus and Tacrolimus, were not ordered or given as prescribed following the resident's admission from the hospital. The omission was discovered after a discussion with the resident's cardiologist, who identified low therapeutic drug levels, indicating the resident had not received the necessary anti-rejection medications. Interviews with facility staff revealed confusion and lack of clarity regarding responsibility for medication reconciliation. The Certified Registered Nurse Practitioner (CRNP) stated that she reviews hospital discharge summaries but does not change or stop medications, and believed that the admitting nurse was responsible for reconciling medications. The Director of Nursing confirmed that while the admitting nurse enters medication orders, the provider is expected to reconcile the medication list. This lack of clear accountability led to the failure to order and administer critical medications as required.
Failure to Accurately Review and Reconcile Hospital Discharge Medications
Penalty
Summary
The facility failed to ensure an accurate pharmacy medication regimen review for a resident who was re-admitted following a hospital stay. Upon review of the resident's medical records, it was found that the hospital discharge summary included two essential anti-rejection medications, Sirolimus and Tacrolimus, which were not identified during the pharmacy's new admission medication review. The omission was discovered during a review of the resident's records and confirmed by the Director of Nursing, who stated that the pharmacy is responsible for reconciling the hospital discharge medication list upon admission. The deficiency was specifically related to the pharmacy's failure to recognize and include the two anti-rejection medications listed on the hospital discharge summary in the resident's medication regimen review. This oversight was evident in the documentation and was acknowledged by facility leadership during interviews. The resident's medical history included the need for immunosuppressant therapy following an organ transplant, making the accurate review and reconciliation of these medications critical at the time of re-admission.
Failure to Notify Representatives of Changes in Condition and Treatment
Penalty
Summary
The facility failed to notify residents' representatives of significant changes in condition or treatment for two residents. In the first case, a resident with a gastrostomy tube had their feeding method changed from infusion via pump to bolus administration by the dietitian to accommodate the resident's preference for being out of their room. The clinical record did not contain documentation that the resident's representative was informed of this change. Both the LPN Unit Manager and the DON confirmed that the representative should have been notified at the time of the order change, but this did not occur. In the second case, a resident with a Stage 4 pressure ulcer on the coccyx experienced a worsening of the wound, as evidenced by increased measurements in length and width. Despite this change in condition, there was no documentation in the medical record that the resident's representative was notified of the deterioration. The DON confirmed that notification was not completed for this change in the resident's condition.
Resident Overcharged Due to Inaccurate Fund Account Management
Penalty
Summary
The facility failed to accurately manage a resident's personal fund account, as evidenced by a review of billing records and interviews. The resident was charged $571 for Beauty Shop/Barber services, but a review of the Senior Salon log sheets showed that the actual charges totaled only $515. The Business Office Management (BOM) confirmed that the previous BOM had not paid for the resident's Beauty Shop/Barber services for one year, resulting in an inaccurate charge. The BOM acknowledged that accounting errors led to the resident being overcharged for these services. This deficiency was identified during a complaint survey and was based on direct record review and staff interviews, which confirmed the overcharge and the failure to properly manage the resident's fund account.
Failure to Timely Report Allegations of Abuse to State Agency
Penalty
Summary
The facility failed to report allegations of abuse to the State Survey Agency, the Office of Health Care Quality (OHCQ), within the required 24-hour timeframe for two residents. In the first instance, a resident with diagnoses including shortness of breath, dementia, and osteoarthritis of the right shoulder sustained two large skin tears on both forearms while being assisted out of a chair by a Hospitality Aide who was not qualified to provide resident care. The incident was documented in a complaint and confirmed by the aide, but a review of the clinical record and investigative notes revealed that the incident was not reported to OHCQ as required. In the second instance, another resident reported an allegation of abuse to a Unit Manager, but the Unit Manager did not inform the administration. The allegation was not reported to OHCQ until three days later, after the resident brought the matter to the attention of the DON and Administrator. These failures to report suspected abuse in a timely manner were confirmed through staff interviews and review of facility documentation.
Incomplete Discharge Summary Provided at Resident Discharge
Penalty
Summary
A deficiency was identified when a resident was discharged to a group home with an abdominal drain and receiving total parenteral nutrition (TPN). Upon review of the resident's closed medical record and discharge summary, it was found that the nursing instructions section was incomplete. Specifically, the discharge instructions lacked documentation regarding TPN management, abdominal drain care, patient education provided, and a complete list of medications. The facility's policy required that a licensed nurse complete all applicable nursing sections of the discharge instructions prior to discharge. Interviews with facility staff, including the social worker and the Director of Nursing (DON), confirmed that each discipline is responsible for their respective sections of the discharge summary, with nursing staff responsible for medication and treatment areas. The DON acknowledged that the nursing sections of the discharge summary were incomplete and did not accurately reflect the resident's status at the time of discharge, despite the resident being sent home with TPN supplies, an abdominal drain, and prescribed medications.
Failure to Update Care Plan with Fall Prevention Intervention
Penalty
Summary
The facility failed to review and revise the interdisciplinary care plan to accurately reflect interventions for a resident with diagnoses including dementia, generalized muscle weakness, and cognitive communication deficit. The resident experienced a fall in their room while attempting to retrieve an item from a drawer. Following the fall, a licensed nurse assessed the resident, performed neuro checks, and documented that there were no injuries. The nurse's post-fall documentation included a recommendation for the bed to be kept in a low position as an intervention to prevent further falls. Upon review, it was found that the resident's care plan for falls, which had been initiated and revised prior to and after the fall, did not include the intervention of keeping the bed in a low position, despite this being documented in the nurse's note. Both the unit manager and the DON confirmed that the care plan should have been updated to include this intervention, as it is a standard measure for fall prevention. The deficiency was identified through record review and staff interviews, which confirmed that the care plan did not accurately reflect the interventions in place for the resident.
Failure to Label Wound Dressings with Change Date and Shift
Penalty
Summary
Surveyors determined that the facility failed to ensure wound dressings were properly labeled to indicate when dressing changes occurred, as required by facility protocol. During observations, two residents receiving wound care for a skin tear and a knee wound, respectively, were found to have dressings that were not initialed, dated, or labeled to show when the last dressing change took place or on which shift it was performed. Review of clinical records confirmed that physician orders specified scheduled dressing changes, but the actual dressings lacked the required labeling. Interviews with the wound nurse confirmed that the standard practice was for licensed nurses to initial, date, and label dressings after each change. However, the nurse was unable to identify who performed the most recent dressing changes or on which shift they occurred. The deficiency was acknowledged by both the wound nurse and the nurse educator during the survey process.
Failure to Provide Timely Pressure Ulcer Assessment and Notification
Penalty
Summary
A deficiency was identified when a resident, admitted without pressure ulcers and assessed as having a mild risk for pressure sore development using the Braden Scale, developed an unstageable pressure ulcer to the sacral area while residing in the facility. The medical record review showed that the resident was admitted with diagnoses of morbid obesity and type 2 diabetes mellitus, and had no pressure ulcers at admission. Despite the resident's risk factors and the development of a new pressure ulcer, there was no documentation of a change in condition assessment being completed at the time the ulcer was identified. Further review revealed that the family representative was not notified of the change in the resident's condition, as confirmed by the DON. The wound continued to progress in size over time, as documented in subsequent wound assessments. The DON acknowledged that the facility's expectation is for nurses to complete a change in condition assessment and notify residents or their representatives of any change, but this was not done in this case.
Resident Injured by Unqualified Staff Member During Transfer
Penalty
Summary
A deficiency occurred when a resident with diagnoses including shortness of breath, dementia, and osteoarthritis of the right shoulder sustained two large skin tears on both forearms while being assisted out of a chair to go to the bathroom. The assistance was provided by a Hospitality Aide who was not qualified or permitted to provide direct care to residents. The incident was discovered when an LPN was called to the resident's room and observed the injuries. The resident, who was non-English speaking, communicated through an interpreter that the injuries occurred during the transfer. The LPN documented the incident but did not measure the skin tears at the time. Further investigation revealed that the Hospitality Aide admitted to assisting the resident, which was outside the scope of their job responsibilities as outlined in the facility's job description. The Director of Nursing confirmed that Hospitality Aides are not allowed to provide direct care or assist residents physically. The facility's documentation and staff interviews confirmed that the resident was injured due to the actions of an unqualified staff member, and there was inconsistency in the facility's communication with the resident's representative regarding the incident.
Failure to Maintain Accurate MOLST Documentation
Penalty
Summary
The facility failed to maintain an effective system for identifying the appropriate decision-maker regarding healthcare decisions and ensuring that residents' wishes regarding CPR were clearly documented in their medical records. This deficiency was evident in four residents who had conflicting MOLST forms, leading to confusion about their code status. For instance, one resident had two active MOLST forms with contradictory orders, one indicating a DNR status and the other a full code status. The staff was unsure which order to follow, and the resident's wishes were not accurately reflected in the medical records. Another resident's MOLST form was completed based on information from a surrogate, despite the resident being cognitively intact and capable of making their own healthcare decisions. The medical director confirmed the resident's capacity, yet the MOLST form did not reflect the resident's actual wishes, which were to receive CPR. This discrepancy highlights the facility's failure to ensure that residents' current wishes were accurately documented and followed. Additionally, a resident with severe cognitive impairment had multiple active MOLST forms with conflicting orders, and there was no documentation of attempts to consult the resident's healthcare agent. The physician completed a new MOLST form without verifying the resident's decision-making capacity or consulting the healthcare agent, resulting in a full code order that contradicted the resident's previous DNR status. These failures put residents at risk of not receiving the correct orders for life-sustaining treatments.
Deficiencies in Care Plan Meetings and Documentation
Penalty
Summary
The facility failed to ensure that interdisciplinary care plan meetings were conducted and documented effectively for several residents. For Resident #30, the medical record showed a lack of care plan meetings since October 2023, despite the resident's complex medical conditions, including severe cognitive impairment. The Multidisciplinary Care Conference note was incomplete, lacking input from various departments, and there was no evidence of a scheduled care plan meeting as indicated in a previous note. Resident #23's care plan was not updated to reflect the resident's progress in therapy, and there was no documentation of interdisciplinary team involvement in care plan meetings. The care plan still included outdated interventions, such as the use of a hoyer lift, despite the resident's improved mobility. Similarly, Resident #95's care plan did not reflect the resident's preferences for activities, and there was no evidence of care plan meetings since December 2023. Other residents, such as Resident #78, #55, #84, #10, and #100, also experienced deficiencies in care plan meetings and updates. These residents either did not have care plan meetings after assessments or had care plans that were not revised to reflect their current needs and conditions. The facility's failure to conduct regular and comprehensive care plan meetings led to outdated and incomplete care plans, impacting the quality of care provided to the residents.
Incomplete Nursing Staffing Information Posting
Penalty
Summary
The facility failed to post complete nursing staffing information, as required, during the recertification survey. On the morning of the survey, the survey team observed a staffing list at the reception desk, which included nursing staff by unit and shift. However, upon further review and interviews with the Staffing Coordinator and the Nursing Home Administrator, it was confirmed that the posted documents did not include the resident census or the total actual nursing hours worked. The Staffing Coordinator explained that the lists were signed by staff upon arrival and included orientee staff names, but acknowledged the absence of the required information. The Nursing Home Administrator also confirmed the deficiency and indicated an intention to seek more information, but no additional details were provided by the end of the survey.
Failure to Manage MOLST Forms
Penalty
Summary
The facility failed to address issues with the Maryland MOLST forms, which are crucial for documenting residents' wishes regarding life-sustaining treatments, including CPR. The annual survey identified non-compliance due to the absence of a system to properly void outdated MOLST forms, ensuring only one active form per resident in their electronic health record. The Medical Director was aware of these concerns but did not communicate them effectively to the facility's quality assurance and performance improvement (QUAPI) program. Consequently, the issue was not discussed or addressed in QUAPI meetings, which focused on other concerns such as pressure ulcer reduction and re-hospitalization. Further investigation revealed that the Medical Director did not attend three consecutive QUAPI meetings, and no substitute was present to address the MOLST concerns. Despite being informed of the issue, the Facility Administrator and Director of Nursing were unaware of the MOLST-related deficiencies until the survey. This lack of communication and oversight contributed to the facility's failure to ensure that residents' resuscitative wishes were accurately recorded and managed, potentially affecting all residents in the facility.
Absence of Medical Director in QA Meetings
Penalty
Summary
The facility failed to establish a quality assurance committee that included a medical director at every quarterly meeting. Upon review of the attendance sheets from September 2023 through August 2024, it was found that the medical director did not attend the quality assurance committee meetings in May, June, and July 2024. This absence was confirmed by the Facility Administrator (NHA) during an interview, who also reported that there was no substitute medical director present at these meetings. This resulted in the facility not meeting the requirement of having a medical director present at each quarterly meeting.
Lack of Communication Training for Staff
Penalty
Summary
The facility failed to ensure that staff received training in interpersonal communication, as evidenced by a review of training records during an extended survey. This deficiency was identified for nine out of ten staff members whose records were reviewed, including the Nursing Home Administrator, Director of Nursing, Assistant Director of Nursing, two Social Workers, the Director of Rehabilitation, two Unit Managers, and two LPN nursing supervisors. The lack of communication training was discovered during an extended survey triggered by an Immediate Jeopardy situation related to conflicting Medical Orders for Life Sustaining Treatment (MOLST) and resuscitation code status documents in resident records. The Director of Human Resources was unable to provide evidence of communication training for these staff members, and the Nursing Home Administrator acknowledged the finding during an interview.
Failure to Develop Comprehensive Care Plan for Resident on Psychotropic Medication
Penalty
Summary
The facility staff failed to develop and implement a comprehensive, resident-centered care plan for a resident receiving psychotropic medications. The resident, who was admitted at the end of June 2024, had a diagnosis of depression and was prescribed Escitalopram Oxalate (Lexapro), an antidepressant, to be taken once daily. The medication was administered consistently from the beginning of September 2024 until mid-September 2024. However, the care plan for this resident, initiated in mid-August 2024, was not comprehensive and did not include specific details about the resident's behaviors for which the psychotropic medication was prescribed. The care plan lacked measurable goals and interventions, including non-pharmaceutical interventions, to assist the resident with their behaviors. The existing care plan only included general interventions such as administering medications as ordered, physician review of medications as needed, and removing the resident from the environment. The Director of Nurses was informed of these concerns but did not provide any comments at the time.
Failure to Honor Resident's Right to Self-Determination in Code Status Confirmation
Penalty
Summary
The facility failed to honor a resident's right to self-determination, specifically regarding the Medical Orders for Life Sustaining Treatments (MOLST) documentation. During an Immediate Jeopardy investigation, it was found that there were conflicting resuscitation instructions for a resident, prompting an audit of all residents' code status choices. The audit revealed that a resident, who was determined by the Medical Director to have the capacity to make decisions, had their code status confirmed through a family member rather than directly with the resident. The documentation showed that the Regional Social Work Director contacted the resident's family to confirm the code status, but did not specify which family member was contacted, despite the resident having two listed family members. The Medical Director confirmed that the resident should have been asked directly about their code status choice, and there was no evidence that this was done. This oversight in confirming the resident's code status choice directly with the resident, despite their capacity to make decisions, led to the deficiency.
Deficiencies in Facility Maintenance and Housekeeping
Penalty
Summary
The facility failed to maintain a safe, clean, comfortable, and homelike environment, as evidenced by multiple deficiencies observed by surveyors. On both floors of the nursing facility, the carpet in the hallways was stained, and several rooms had missing or loose floor planks, particularly around HVAC units. Despite the Maintenance Director's acknowledgment of the flooring issues and a plan to address them, no documentation was provided to indicate that new carpets or flooring had been ordered by the time of the survey exit. Additionally, the facility's housekeeping practices were found lacking. Surveyors observed holes in bed linens and a lack of appropriately sized sheets for bariatric beds, with the Housekeeping Supervisor confirming issues with laundry processes. Resident complaints about room cleaning delays and observations of unclean conditions, such as brown smudges on walls and damaged furniture, further highlighted the inadequacies in maintaining a clean environment. The Housekeeping Supervisor acknowledged these issues but indicated that some maintenance concerns had not been reported to her. The facility also exhibited maintenance deficiencies, including damaged walls, missing emergency call light cords, and cracked wheelchair padding. Observations of ceiling tiles with brown stains and damaged shower room flooring were noted, with the Maintenance Director attributing some issues to condensation from the air conditioner. Despite staff acknowledging these problems, there was a lack of evidence that corrective actions had been initiated or completed by the survey's conclusion.
Failure to Provide Adequate Resident Activities
Penalty
Summary
The facility failed to provide adequate activities to meet the needs of its residents, as evidenced by the cases of four residents during the survey. Resident #30, who has severe cognitive impairment and a history of major depressive disorder and dementia, was observed alone in a wheelchair without any music or activity. The resident's care plan indicated a preference for group activities and 1:1 activities, but there was no documentation of participation in these activities or any interdisciplinary care plan meetings since October 2023. The Activity Director was unable to provide documentation of activity participation, except for a single 1:1 visit documented in April 2024. Resident #95, diagnosed with dementia and lung disease, was observed sitting alone in a wheelchair in the hallway on multiple occasions. The resident's care plan, which had not been updated since August 2023, failed to reflect the resident's preference for listening to music and participating in religious activities. The Activity Director could not provide documentation of the resident's participation in activities or 1:1 visits, and the resident's responsible party confirmed the lack of recent care plan meetings. Resident #13, with diagnoses including dementia, heart disease, and diabetes, was not documented to have participated in any activities, despite a care plan indicating a preference for group activities and religious services. The Activity Director could not locate documentation of 1:1 activities for this resident. Similarly, Resident #109, a long-term resident, reported a lack of interaction with staff and had no documented 1:1 activities since admission. The Activity Director admitted to not interviewing the resident's family to obtain information about activity preferences, despite their frequent visits.
Deficiencies in Pain Management for Residents
Penalty
Summary
The facility failed to provide adequate pain management for three residents, leading to deficiencies in care. Resident #31 did not receive their prescribed oxycodone medication consistently due to issues with pharmacy delivery and insurance coverage. The medication was administered only 42 out of 62 scheduled times, with no documentation explaining the missed doses. Both the LPN and the DON acknowledged the problem, citing insurance issues as the reason for the delay in medication delivery. Resident #57, who had a sacral ulcer, did not have any active pain medication orders despite experiencing pain. The resident's pain was documented by a Certified Medicine Aide, which is against the facility's protocol as pain assessment should be conducted by a licensed nurse. The DON confirmed that the CMA should not have documented pain monitoring, and the Medical Director was unaware of the lack of pain medication orders for the resident. Resident #50 expressed the importance of timely pain medication administration to manage their pain effectively. However, the facility failed to implement non-pharmacological interventions before administering pain medication, as required by their policy. Additionally, the resident's narcotic pain medication was administered late on multiple occasions, with discrepancies in documentation noted by the LPN responsible. The DON acknowledged these concerns, highlighting a lack of adherence to the facility's pain management policy.
Deficiencies in Bed Rail Use and Documentation
Penalty
Summary
The facility failed to ensure proper procedures were followed before the installation and use of bed rails for four residents. Observations and medical record reviews revealed that the facility did not identify and use appropriate alternatives to bed rails, assess the residents' risk of injury or entrapment, or discuss the risks and benefits of bed rails with the residents or their representatives. Additionally, informed consent was not obtained, and there was no documentation of monitoring and supervision during the use of bed rails. Care plans with measurable objectives and specific interventions for the use of bed rails were also not developed for these residents. For Resident #78, the medical record indicated that bed rails were not needed as a mobility enabler, yet they were installed without a physician's order or documentation of risk assessment and informed consent. Similarly, Resident #380's records showed no need for bed rails as a mobility enabler, but they were used without proper documentation or consent. Resident #13, who had severe cognitive impairment, had a bed rail installed based on preference, but there was no documentation of a risk-benefit discussion or a care plan. The facility also failed to assess the risk of entrapment for this resident. Resident #57 was observed with a loose bed rail, which was acknowledged by an LPN and the Maintenance Director, who was unaware of the issue despite regular checks. The Director of Nursing was also unaware of the loose bed rail and could not provide additional evidence to address the observation. These deficiencies highlight a lack of adherence to protocols for bed rail use, posing potential safety risks to residents.
Failure to Adhere to Medication Administration Parameters
Penalty
Summary
The facility failed to maintain a resident's drug regimen free from unnecessary drugs by not adhering to physician-ordered blood pressure parameters for medication administration. For Resident #78, the facility did not document blood pressure monitoring before administering Oxycontin, nor did it assess the resident's pain level or the medication's effectiveness. Additionally, Midodrine was administered without documenting blood pressure checks to ensure it was within the prescribed parameters. These issues were discussed with the Director of Nurses, who did not provide a response. For Resident #380, the facility did not provide adequate parameters for administering as-needed pain medications. The orders for Acetaminophen and Percocet lacked guidance on which medication to administer first for pain management. This concern was acknowledged by the Director of Nurses without further comments. Similarly, Resident #24 received a diuretic despite having a systolic blood pressure below the threshold specified in the physician's order, and Resident #50 was given a narcotic pain medication despite having a pain score of zero. Furthermore, the facility did not ensure that the attending provider's orders for Resident #78's topical anesthetic medication included a time for removal. The Lidocaine patch was applied daily without documentation of its removal, as the order did not specify a removal time. This oversight was confirmed by the Director of Nursing, who acknowledged the lack of documentation for the patch's removal.
Failure to Serve Correct Meal Portions and Items
Penalty
Summary
The facility failed to provide residents with the correct portions and items as indicated on their meal tickets, which was evident during a survey. On a specific date, a resident reported not consistently receiving a high protein diet as advised by their physician. During an observation of the tray line, it was noted that a 1/2 cup scoop was used for portions, except for the beef pepper steak, which was served using tongs by a staff member who claimed the portion was three ounces. This practice was not in line with the expected use of a scoop for portion control. A test tray was randomly selected from the food cart, and discrepancies were found between the meal ticket and the actual items on the tray. The meal ticket for a resident indicated specific items, including a grilled cheese sandwich, sugar snap peas, mashed potatoes, a dinner roll, margarine, tossed salad with dressing, chocolate pudding parfait, and hot tea. However, the test tray had only half a cup of sugar snap peas, no dinner roll, and a chocolate cream pie instead of the chocolate pudding parfait. The Food Service Director confirmed these discrepancies and acknowledged the use of incorrect portion sizes and items.
Failure to Conduct Regular Bed Safety Inspections
Penalty
Summary
The facility failed to conduct regular inspections of bed frames, mattresses, and bed rails, which is a part of their regular maintenance program. This deficiency was identified during observations and interviews with staff. Specifically, three residents were observed with bed rails attached to their beds, but the facility did not have a routine audit process in place to ensure the safety and proper maintenance of these items. The Maintenance Director, who had been in the position for about a year, confirmed that only one audit had been conducted, and it only included beds on the first floor. The second floor beds had not been audited, and maintenance relied on reports from nursing or housekeeping to address any issues with beds, mattresses, or side rails. The Maintenance Director also indicated that new beds purchased for the facility did not come with rails, and rails could not be added to these beds. If a bed rail broke, the facility might have a spare to replace it, but there was no proactive inspection process in place. The Director of Nurses was informed of these concerns, acknowledging the issues without further comment. The lack of regular inspections and maintenance of bed frames, mattresses, and bed rails had the potential to affect all residents, posing a risk of entrapment.
Failure to Notify HCPOA of Treatment Changes
Penalty
Summary
The facility failed to notify a resident's Health Care Power of Attorney (HCPOA) of changes in the resident's treatment, which was identified during a survey. The resident, who was admitted in June 2024 after a hospitalization, was rarely or never understood, had functional limitations in range of motion in both upper extremities, and impairment in one lower extremity. The resident was dependent on staff for activities of daily living and was receiving occupational, speech, and physical therapy. The medical record review revealed that a new medication, Metoprolol, was started on June 26, 2024, for high blood pressure, but there was no documentation indicating that the HCPOA was informed of this change. Additionally, the attending physician for the resident changed on July 1, 2024, as noted in a Medical Discharge Summary progress note. However, there was no documentation to show that the HCPOA was notified of this change in the primary care provider. The Director of Nursing reported that the healthcare organization should contact the other provider when there is a change in the primary care provider, and the prior primary care provider should inform the family of the change. The lack of documentation regarding the notification of the HCPOA about the medication and physician changes was confirmed during discussions with the Director of Nursing.
Inaccurate Assessment During Abuse Investigation
Penalty
Summary
The facility failed to prevent further potential abuse while an investigation was in progress due to an inaccurate immediate assessment of an alleged victim. The deficiency was identified in a resident who had been in the facility for 20 days and was involved in a facility-reported incident of alleged abuse. The Director of Nursing (DON) conducted a pain assessment, which inaccurately indicated that the resident had no pain in the last five days, despite the resident receiving as-needed pain medication with pain scores ranging from 4/10 to 10/10 during that period. Additionally, the assessment inaccurately documented that the resident had not received rehabilitation services in the past five days, although the Director of Rehab confirmed that the resident was on their caseload for four weeks. The DON and the Nursing Home Administrator acknowledged the inaccuracies in the documentation, which included the failure to specify that the assessment focused solely on the resident's shoulder. These inaccuracies in the immediate assessment of the alleged victim contributed to the facility's failure to prevent further potential abuse.
Failure to Document Communication Needs During Resident Transfer
Penalty
Summary
The facility failed to provide essential information to emergency department staff when a resident was transferred to the hospital. Specifically, the transfer form for a resident who was experiencing abdominal pain and required an emergency room transfer did not include critical information about the resident's communication needs. The resident, who was deaf, had a device for ASL interpretation, but this was not documented on the transfer form completed by an LPN. This omission was discovered during a review of the resident's medical records and confirmed through interviews with the LPN and the Director of Nursing. The deficiency was identified during a recertification survey, where it was noted that the section of the transfer form regarding the resident's communication needs was left blank. Despite the presence of a sign above the resident's bed indicating the need for an ASL interpreter device, this information was not conveyed to the hospital staff. The Director of Nursing was unable to provide any additional evidence that the hospital staff were informed of the resident's communication needs, highlighting a lapse in the facility's protocol for ensuring comprehensive communication during resident transfers.
Failure to Meet Communication Needs of Deaf Resident
Penalty
Summary
The facility failed to ensure that the communication needs of a deaf resident were met, as observed during a recertification survey. The resident was unable to communicate effectively with staff due to the absence of a functioning video interpreter device in their room. Although signs were posted indicating the availability of an interpreter service via a tablet, the device was not present, and the resident had no alternative means of communication, such as pen and paper, readily available. The resident's care plan did not include any strategies for communication, such as using a live video interpreter, a whiteboard, or written notes. Interviews with staff revealed that the video interpreter device had been removed from the resident's room due to technical issues, and no alternative communication methods were provided. The Director of Nursing acknowledged the resident's non-compliance with the video interpreter device but did not address why communication strategies were absent from the care plan. The Admissions Director and Assistant Admissions Director confirmed that the device had been unavailable for an extended period, contradicting their initial claim of a shorter duration. A follow-up with the software company revealed no disruptions in service, indicating a lack of proper communication support for the resident.
Failure to Administer G-Tube Feedings as Ordered and Address Weight Loss
Penalty
Summary
The facility failed to ensure that feedings via a g-tube were administered as ordered and did not establish a plan to restore oral eating for a resident with dysphagia. The resident was admitted with a g-tube for nutrition and had orders for bolus feedings of Jevity 1.5 four times a day. However, there were discrepancies in the orders and documentation, with two different enteral feed orders in effect simultaneously, leading to confusion about the actual amount of nutrition being provided. The medical record lacked documentation of the actual amount of Jevity administered during each bolus feed, and there was a significant weight loss noted for the resident, which was not addressed in a timely manner. The resident experienced a significant weight loss from 132 lbs to 125 lbs over a month, which was unfavorable and unplanned. The dietitian noted that the tube feeding was providing insufficient calories, leading to the weight loss. Despite the resident's estimated caloric needs being between 1710-2000 calories per day, the tube feeding regimen was only providing 1600 calories per day. A recommendation was made to change the tube feeding regimen to provide 2130 calories per day, but there was no documentation indicating that the weight loss was addressed by the dietitian before the recommendation was made. Further issues arose when a new g-tube order was put in place, and the resident was supposed to receive six bolus feeds per day. However, there was an order to hold the 10 AM feeding to promote oral intake, which was not reflected in the dietitian's assessment. The resident was only receiving five bolus feeds per day, contrary to the dietitian's note. The nursing staff confirmed that the 10 AM feeding was held, and the resident was receiving lunch only and bolus feeds for all other meals. The discrepancy in the number of bolus feeds being administered was not addressed in the dietitian's assessment, leading to further confusion and potential nutritional inadequacy for the resident.
Inadequate Behavioral Health Monitoring and Medication Management
Penalty
Summary
The facility failed to provide adequate behavioral health monitoring for a resident, leading to a deficiency in ensuring the resident's highest practicable mental and psychosocial well-being. The resident, who had severe cognitive impairment and diagnoses including major depressive disorder and dementia, was receiving psychiatric medications such as Seroquel and Zoloft. However, there was a lack of documentation regarding the gradual dose reduction (GDR) of Zoloft, which was discontinued without clear documentation of a planned GDR. This oversight was evident when the resident exhibited aggressive behavior, resulting in the administration of IM Haldol and Benadryl. Further investigation revealed that the facility's behavior monitoring documentation was inadequate. The Medication Administration Record (MAR) showed only check marks for each shift, indicating no behaviors of concern, despite the resident's aggressive incidents. Interviews with nursing staff confirmed that the check marks were meant to indicate the absence of behaviors, but this was not an accurate assessment of the resident's condition. The lack of proper documentation and monitoring contributed to the failure to address the resident's behavioral health needs effectively. Additionally, there were inconsistencies in the management of the resident's psychiatric medications. The resident's Seroquel dosage was increased following aggressive behavior, but this change occurred after a significant delay and without adequate documentation of the need for the increase. Similarly, the dose of Risperdal was doubled without documented justification. These actions, combined with the inadequate behavior monitoring, highlight the facility's failure to provide necessary behavioral health care and services to the resident.
Failure to Ensure Resident Involvement in Code Status Decisions
Penalty
Summary
The facility failed to ensure that residents were fully informed and involved in discussions regarding their code status when new Medical Orders for Life-Sustaining Treatment (MOLST) forms were created. This deficiency was identified in three residents during the survey. For Resident #97, the MOLST form indicated a Do Not Resuscitate (DNR) order, but the resident, who was cognitively intact, was not consulted about their wishes. Instead, the physician communicated only with the resident's representative. It was later discovered that the resident's wishes differed from those of the representative, as the resident wanted resuscitative treatment. Resident #30, who had severe cognitive impairment, had a MOLST form completed upon readmission to the facility that indicated a full code status. However, there was no documentation that the resident's Health Care Agent was contacted to discuss this change from the previous DNR status. The physician responsible for completing the MOLST did not recall the resident and indicated that a new MOLST was required for each readmission, defaulting to full code if the resident could not make decisions and no Power of Attorney was available. For Resident #23, who was rarely understood and dependent on staff for daily activities, the MOLST was completed without consulting the resident's Medical Power of Attorney, despite certifications of the resident's incapacity. The physician did not document any assessment or examination of the resident in the months leading up to the MOLST completion. The facility's Director of Nursing confirmed that the MOLST from the hospital should remain in place until updated by a practitioner, who must review it with the family if the resident is incapable of making decisions.
Failure to Ensure Resident Dignity
Penalty
Summary
The facility failed to ensure that a resident received services with dignity, as evidenced by the actions of a certified nursing assistant (CNA). During an interview with Resident #42, the resident reported that facility staff sometimes entered his room without knocking. This was confirmed during an observation when Staff #10, a CNA, entered the resident's room to deliver a lunch tray without knocking. Staff #10 later admitted during an interview that she did not knock before entering and was unaware of the requirement to do so. The issue was discussed with the Administrator and Director of Nursing, but no additional information was provided.
Failure to Provide Advance Directive Information
Penalty
Summary
The facility failed to provide residents with information to formulate an advance directive, as evidenced by the cases of three residents. Resident #37's clinical record lacked documentation related to advance directives, despite a care plan meeting discussing the resident's code status. The Director of Social Work confirmed that advance directive information was typically offered at admission but not during care plan meetings, and there was no evidence of discussions with the resident or their family regarding advance directives. Resident #24's medical records did not reveal an advance directive, although the resident was certified as having decision-making capacity. The Social Services Coordinator indicated that the Director of Social Services, who was on vacation, usually handled advance directives. A Discharge Planning Psychosocial Assessment was overdue, and the resident's family later confirmed the existence of an advance directive, but it had not been discussed with the resident prior to the surveyor's inquiry. Resident #55's electronic medical record showed no evidence of an advance directive, despite the resident being cognitively intact and having resided in the facility since 2020. The Director of Social Services confirmed the lack of documentation and discussion regarding the resident's right to formulate an advance directive. The Director of Nursing acknowledged the concerns for all three residents.
Inadequate Justification for IM Antipsychotic Administration
Penalty
Summary
The facility administered an intramuscular injection of an antipsychotic medication, Haloperidol (Haldol), and an antihistamine, Diphenhydramine (Benedryl), to a resident without adequate indication. The resident, who had severe cognitive impairment and a history of major depressive disorder and dementia, was reported to have exhibited aggressive behavior towards a roommate. However, documentation did not support the continued aggressive behavior after the resident was separated from the roommate, raising concerns about the necessity of the medication. The psychiatrist involved was contacted and initially ordered the resident to be transferred to a hospital, but the resident refused. Subsequently, the psychiatrist gave a STAT order for the IM medications. Despite this, there was no documentation indicating that the resident was attacking staff or others after being removed from the shared room, which was the basis for the psychiatrist's emergency order. Furthermore, the medications were not administered until several hours after the order was given, and by a different nurse than the one who obtained the order. The facility's documentation practices were called into question, as the behavior monitoring sheets did not reflect any aggressive behavior during the night shift when the medications were administered. The psychiatrist confirmed that oral medication would typically be offered before an IM injection, but due to the emergency nature of the situation, the IM was ordered. However, the lack of documentation supporting the emergency and the delay in administration highlighted deficiencies in the facility's medication administration process.
Failure to Provide Transfer Notice to Resident
Penalty
Summary
The facility failed to provide a resident with a notice of transfer when the resident was transferred to the hospital. This deficiency was identified for one resident who was reviewed for hospitalization. On September 10, 2024, a review of the resident's medical record revealed a physician order for an emergency room transfer due to abdominal pain on September 4, 2024. However, there were no Notice of Transfer documents present in the resident's record. An interview with an LPN confirmed the absence of the transfer notice. Additionally, the Director of Nursing was unable to provide any evidence that a transfer notice was given to the resident when transferred to the hospital.
Failure to Provide Bed Hold Notice During Hospital Transfer
Penalty
Summary
The facility failed to provide a bed hold notice to a resident when the resident was transferred to the hospital. This deficiency was identified during a review of the medical records of a resident who had a physician's order for an emergency room transfer due to abdominal pain. The review revealed that there was no bed hold notice in the resident's chart. An interview with an LPN confirmed the absence of the bed hold notice in the resident's records. Additionally, the Director of Nursing was unable to provide any evidence that a bed hold notice was given to the resident at the time of the hospital transfer.
Inaccurate MDS Documentation for Resident's ROM
Penalty
Summary
The facility failed to ensure that Minimum Data Set (MDS) assessments were accurately documented for a resident reviewed for behavior. The resident, admitted in April 2024, had four MDS assessments indicating an impairment in range of motion (ROM) to both sides of the lower extremities. However, an observation on September 16, 2024, showed the resident lying in bed with knees bent and later ambulating around the bedside without difficulty. A licensed practical nurse confirmed the resident's ability to walk, contradicting the documented impairment. The MDS nurse acknowledged that the MDS assessments were documented in error, as impaired ROM should not be coded if the resident is able to ambulate.
Incomplete PASRR Form for Newly Admitted Resident
Penalty
Summary
The facility failed to ensure the completion of the Preadmission Screening and Resident Review (PASRR) form for a newly admitted resident. This deficiency was identified during a review of the medical records for a resident who was admitted in late 2024. The PASRR form, which is federally mandated for all nursing facility applicants, was found to be incomplete. Specifically, the section concerning serious mental illness contained four unanswered questions, and the form was not completed upon the resident's admission to the facility. The Social Services Director confirmed that the incomplete PASRR form originated from the hospital and acknowledged that the facility did not complete a new form during the resident's admission. The director noted that while residents transferred from hospitals typically arrive with a PASRR form, a new one should be completed within the first week of admission if the existing form is incomplete. Despite this protocol, the facility did not fulfill this requirement for the resident in question, leading to the identified deficiency.
Failure to Provide Baseline Care Plan to Resident
Penalty
Summary
The facility staff failed to provide a resident and their representative with a copy of the baseline care plan, including a summary of the resident's medications, within 48 hours of admission. This deficiency was identified during an interview with the resident and their representative, who confirmed that they had not received the baseline care plan or had it reviewed with them. Despite the facility's documentation indicating that the care plan had been initiated, reviewed, and provided to the resident or their representative, the resident and their representative reported otherwise. Further investigation revealed that the Unit Manager was responsible for ensuring the resident or their representative received and reviewed the baseline care plan. However, the Director of Nurses acknowledged the concerns raised by the resident and their representative, indicating a lapse in communication and documentation practices. The discrepancy between the facility's records and the statements from the resident and their representative highlighted a failure in the facility's process for ensuring residents and their representatives are informed about the care plan and medications upon admission.
Inaccurate Documentation of G-Tube Feedings
Penalty
Summary
The facility failed to ensure accurate documentation of g-tube feedings for a resident with dysphagia who was admitted with orders for Jevity 1.5 bolus feedings four times a day. The medical record review revealed discrepancies in the documentation of the g-tube feedings, with two different orders in effect simultaneously from early June to late July. The Medication Administration Record (MAR) indicated that the feedings were documented as administered as ordered, despite evidence of significant weight loss and a dietitian's recommendation to adjust the feeding regimen. The resident's weight dropped from 132 lbs to 125 lbs, indicating a significant weight loss, and the tube feeding was not meeting the resident's caloric needs. Further investigation revealed that after a new order was placed in late July for Jevity 1.5 bolus six times a day, there was an order to hold the 10 AM bolus feed, which was not consistently followed. Despite the order to hold the 10 AM feeding, the MAR showed that staff documented administering the feedings, including the 10 AM dose, which was supposed to be held. Interviews with nursing staff confirmed that the 10 AM and 1 PM bolus feeds were not being administered, yet they were documented as given. The unit nurse manager confirmed the discrepancy, acknowledging that the staff were signing for feedings that were not provided, leading to inaccurate documentation and potential nutritional deficiencies for the resident.
Delayed Incontinent Care for Resident
Penalty
Summary
The facility staff failed to provide timely incontinent care to a resident, leading to a deficiency in meeting the resident's personal hygiene needs. On the morning of September 17, 2024, a resident activated their call light at 5:10 AM, requesting assistance for incontinent care. A nurse responded shortly after, turned off the call light, and informed the resident that a CNA would be sent to assist. However, the resident remained unattended for approximately 40 minutes, during which time the Assistant Director of Nursing (ADON) entered the room, turned off the call light again, and promised to send help. The resident, who was fully aware and had no cognitive decline, reported sitting in a soiled brief for 40 minutes before receiving care. The facility's nighttime nurse supervisor eventually provided the necessary care at 6:20 AM, confirming the resident's incontinence of bowel and bladder. The resident's medical records indicated a consistent need for staff assistance with toileting due to complete incontinence. Interviews with the ADON revealed that the facility's goal was to respond to call lights within 5 minutes and to ensure residents do not remain in soiled briefs for more than 10 minutes to prevent skin breakdown. Despite these expectations, the facility lacked a formal call light policy, contributing to the delay in care for the resident.
Failure to Implement Pressure Ulcer Prevention and Care
Penalty
Summary
The facility failed to accurately assess and document the presence of pressure injuries and implement appropriate pressure prevention therapies for two residents. Resident #328 was admitted for rehabilitation following a hospital stay, and initial assessments did not reveal any pressure injuries. However, subsequent documentation by the wound nurse identified a stage 2 pressure injury on the sacrum, which was later documented as a stage 3 pressure injury by a nurse practitioner. Despite the presence of the injury, there were no orders for pressure prevention interventions until several days after admission. Resident #109, a long-term resident, had an order for heel protection boots to prevent pressure injuries. Observations revealed that the boots were consistently not applied, and the resident's heels were left against the bed. The resident's family confirmed that the boots were not used, and staff were unaware of the order. When the boots were eventually located in the resident's closet, the resident refused to wear them, but there was no documentation of this refusal or any alternative interventions attempted. Interviews with staff, including the wound care nurse, highlighted a lack of communication and adherence to pressure injury prevention protocols. The wound care nurse expected nursing staff to identify and document skin integrity concerns and to notify her of any resident refusals of pressure injury prevention therapies. Despite these expectations, the facility failed to implement and document necessary interventions, leading to deficiencies in pressure ulcer care and prevention.
Failure to Maintain Resident's Mobility Improvements
Penalty
Summary
The facility failed to develop a care plan to maintain the mobility improvements achieved by a resident during therapy. The resident, admitted in June 2024, had functional limitations in both upper and lower extremities and was dependent on staff for daily activities. Despite completing physical therapy with significant progress, including walking 125 feet with assistance and transferring with contact guard, the facility did not document a care plan to sustain these improvements. The care plan still indicated the use of a hoyer lift for transfers, which contradicted the resident's current capabilities. Interviews with the unit nurse manager and the Rehab Director revealed a lack of communication and documentation regarding the resident's therapy recommendations. The Rehab Director admitted that information was conveyed verbally and occasionally through inservice, but there was no restorative nursing aide or documented restorative program in place. The unit nurse manager was unable to provide details on therapy recommendations, and the care plan meeting documentation lacked input from the interdisciplinary team, including therapy personnel. The physical therapy discharge summary indicated an excellent prognosis for maintaining the resident's current level of function with strong family and staff support. However, the discharge recommendations did not include specific guidance for the family or staff to assist the resident in maintaining mobility. The facility's failure to update the care plan and ensure consistent communication between therapy and nursing staff contributed to the deficiency in maintaining the resident's mobility improvements.
Failure to Monitor High-Risk Resident for Elopement
Penalty
Summary
The facility failed to implement a system for monitoring residents identified as high risk for elopement, as evidenced by the case of Resident #59. This resident, diagnosed with schizophrenia and severely impaired cognition, was assessed as above high risk for elopement due to a history of exit-seeking behavior. Despite this, the resident was observed off their designated unit without a monitoring device and was found in a confused state, unable to recall their room number or the facility's name. The resident expressed a desire to go home, indicating a lack of supervision and monitoring. Interviews with staff revealed inconsistencies in the facility's elopement prevention measures. A certified nurse aide acknowledged the resident's high risk for elopement, yet the unit manager and director of nursing indicated that monitoring devices were only used for residents actively exhibiting exit-seeking behaviors. Furthermore, the resident's name and picture were missing from the elopement list at the front desk, highlighting a gap in the facility's monitoring system. This deficiency in monitoring and supervision contributed to the resident's unsupervised movement within the facility.
Failure to Accurately Monitor Resident's BMI Due to Height Measurement Discrepancy
Penalty
Summary
The facility failed to identify a resident with a critically low BMI and did not have a policy in place for measuring residents' height. This deficiency was identified during a recertification survey and involved a resident whose height was inconsistently documented over time. The resident's height was recorded as 61 inches in 2024, a significant discrepancy from the 72 inches recorded in 2016. The Director of Nursing (DON) was unaware of the process used to measure height and confirmed that the facility lacked a policy for this procedure. Upon re-measurement, the resident's height was found to be 70 inches, leading to a recalculated BMI of 15, which is critically low. The dietitian responsible for the resident's nutritional status had documented a BMI of 20, based on incorrect height data. The dietitian was not present during the survey, and the facility's hybrid policy did not clarify whether dietitians made in-person visits to residents. The Medical Director, who relied on the dietitian for nutritional monitoring, was unaware of the resident's critical BMI. The lack of accurate height measurement and monitoring contributed to the oversight of the resident's nutritional needs, potentially affecting all residents in the facility.
Failure to Address Pharmacist-Identified Medication Irregularities
Penalty
Summary
The facility failed to ensure that irregularities identified by the pharmacist during monthly drug regimen reviews were reviewed, acted upon, and documented by the attending physician in the residents' medical records. This deficiency was evident in three out of five residents reviewed for unnecessary medications. For Resident #30, a pharmacist's recommendation for a gradual dose reduction of Seroquel was not addressed by the primary care or psychiatric provider, and no documentation was found in the medical record to indicate any response to the recommendation. For Resident #78, multiple clinically significant irregularities were identified by the pharmacist, including the concurrent use of CNS-active medications, the need for a stop date for Enoxaparin, and the absence of Amlodipine Besylate in the facility orders despite prior home use. Additionally, the pharmacist recommended evaluating the use of Aspirin and Enoxaparin together and advised that Metformin should be taken with food. However, there was no documentation in the medical record to indicate that the attending physician reviewed or responded to these recommendations. Resident #50's medical record also lacked documentation of the attending physician's response to identified irregularities. The Director of Nursing (DON) confirmed that the physician had not documented their response to the pharmacy recommendations. The facility's process for handling medication regimen reviews involved the pharmacist sending reports to the DON, who would then pass them to the physician for a response. However, this process was not followed, leading to the deficiency.
Inadequate Justification for Psychotropic Medication Use
Penalty
Summary
The facility failed to ensure that a resident was free from unnecessary psychotropic medications. The resident, who had severe cognitive impairment and multiple diagnoses including major depressive disorder and dementia, was involved in an incident where they became highly agitated and aggressive. The psychiatrist ordered IM Haldol and Benedryl for aggressive behavior, but these medications were not administered until several hours later by a different nurse who was not present when the order was given. This delay in administration raised concerns about the appropriateness and timeliness of the medication use. Further review of the resident's medical record revealed that behavior monitoring documentation did not indicate any concerning behaviors from June to September. Despite this, the resident's Seroquel dosage was increased from 25 mg to 100 mg twice a day over a period of time, and Risperdal was added and later increased without documented justification. The psychiatrist and psychiatric nurse practitioner documented plans to adjust medications based on staff reports of aggression, but there was no consistent documentation of such behaviors in the behavior monitoring sheets. The surveyor noted that the increase in antipsychotic medication lacked adequate indication, as the behavior monitoring sheets did not support the need for such increases. The facility's failure to document the necessity for increased dosages and the lack of timely administration of medications contributed to the deficiency. The surveyor requested additional documentation to address these concerns, highlighting the need for proper documentation and justification for psychotropic medication use.
Latest citations in Maryland
The facility did not ensure that its Infection Preventionist (IP) met required qualifications for managing the Infection Prevention and Control Program. The DON reported serving as the IP but acknowledged lacking the specialized infection control training required for the role, and confirmed that no other staff member was currently qualified. Records showed that the previously qualified IP left several months earlier, and the Administrator and DON confirmed they were still seeking a replacement, leaving the infection control program without a properly trained leader.
Staff failed to consistently secure medications and medical supplies across three units, including an oxygen tank left on the floor behind a resident’s bed without a supporting device, a treatment cart with Collagenase Santyl cream left on top while two residents in power wheelchairs passed by, an unattended and unlocked treatment cart at a nursing station, and another treatment cart with Diclofenac gel and dressings left on top, indicating repeated lapses in maintaining locked and secure storage for drugs, biologicals, and related supplies.
The facility failed to provide sufficient dietitian coverage and timely nutritional assessments for several residents with significant dietary needs. A resident admitted for diabetic management with a high A1C was placed on a regular diet instead of the recommended carb-controlled diet and had only one weight taken in the first two weeks, with no dietitian review of the record. Another resident with prior significant weight loss had no documented dietitian follow-up despite continued weight loss, and a resident admitted with severe protein-calorie malnutrition experienced further significant weight loss without any dietitian assessment. The dietitian reported working limited hours and prioritizing certain high-risk cases, resulting in delayed or missed evaluations for new admissions and residents with ongoing nutritional concerns.
The facility failed to maintain adequate linen and incontinence supplies and did not keep resident care areas in good repair, resulting in delays and alterations in incontinence care and substandard environmental conditions. Staff reported that towels and washcloths were used instead of wipes and then discarded due to heavy soiling, and that linen deliveries to units were late, leaving residents waiting for care. Observations showed very limited numbers of clean washcloths and other linens on units and in the laundry, with no stock of disposable wipes or backup washcloth supply despite repeated reports to housekeeping. Additional observations revealed recliner chairs blocking a dining-area handwashing sink and kitchenette, multiple resident and shared bathrooms with unfinished spackle, chipped paint, musty odors, black substances near showers, missing threshold molding, exposed cracks and nails, and eroded, rusted baseboard heaters. Hallway handrails on both units were worn, chipped, and splintered, and a shower room contained fecal odors, dried brown stains on the toilet, and deteriorated fixtures, all contributing to a failure to provide a safe, clean, and homelike environment.
Facility staff did not thoroughly investigate two separate abuse allegations involving a resident and an injury of unknown origin involving another resident. In both cases, investigations focused on the directly affected resident and included staff interviews, but there were no interviews of other residents on the unit or documented assessments of those residents for signs of abuse or injuries of unknown origin, including residents unable to communicate due to cognitive status.
Two residents who were dependent on staff for oral care, including one with a tracheostomy, were observed with thick, white or milky substances coating their mouths and teeth, indicating inadequate oral hygiene. One resident communicated that staff did not brush their teeth and that staff "need to." In another case, despite oral care supplies being present in the room, the resident’s mouth and teeth remained unclean on multiple observations, with a thick milky substance caking the teeth and stringing between them when the resident tried to open their mouth. These findings showed that staff did not consistently provide oral care to residents who relied on them for this ADL.
Staff failed to maintain complete and accurate medical records for multiple residents, including missing and inconsistent documentation of wound care, delayed pain assessment after discovery of an injury of unknown origin in a cognitively impaired resident, and inaccurate recording of a PPD test result that was documented as negative despite no evidence the injection was administered and no supporting nurse’s note. Residents reported not receiving certain treatments, while MAR entries either lacked signatures for completion or contained conflicting information about whether care was provided.
Surveyors found that the facility failed to consistently implement and communicate correct transmission-based precautions and PPE use. One resident with a Foley catheter related to wounds had no precaution signage posted, while another resident in a double room had a contact precautions sign at the door, yet the NP entered without PPE and the GNA provided high-contact care wearing only gloves. Staff in that room stated the resident was not on contact precautions and later reversed the sign to show no PPE requirement. Therapy staff reported they rely solely on posted signs to determine PPE, and surveyors identified broader issues with inaccurate signage and staff awareness of which residents required contact precautions.
Surveyors found that MDS assessments were inaccurately coded for two residents. In one case, a resident sustained a femoral neck fracture after a fall, but the subsequent significant change MDS did not code the fall as a major injury and failed to capture prn Tylenol use documented on the MAR within the look-back period. In the other case, a quarterly MDS indicated opioid use for a resident, but the MAR for the same period showed no prescribed opioid, indicating incorrect coding of high-risk drug classes.
A resident who had recently been admitted and experienced a fall received multiple doses of the narcotic analgesic Tramadol, but the facility failed to accurately document all administered doses on the Medication Administration Record (MAR). Review showed only one Tramadol dose recorded on the MAR, while the Controlled Drug Receipt/Record/Disposition Form on the med cart reflected three doses given over two days. In interview, the DON stated staff are expected to document narcotic administration on the MAR and confirmed that two administered doses were not recorded there, resulting in an incomplete and inaccurate medical record.
Unqualified Infection Preventionist Overseeing Infection Control Program
Penalty
Summary
The facility failed to ensure that its designated Infection Preventionist (IP) met the mandatory qualifications for overseeing the Infection Prevention and Control Program. During an interview on 3/24/26 at 10:00 AM, the DON confirmed that she/he was serving as the facility’s IP but had not completed the specialized training in infection control required for the position. The DON further stated that no other staff member currently met the qualifications to serve as IP. Record review showed that the previously qualified IP left the facility in October 2025, and as of the survey date, the position remained unfilled by a qualified individual. At 1:30 PM on the same day, the Administrator and DON confirmed they were still in the process of finding a qualified IP for the facility, leaving the Infection Prevention and Control Program without a properly trained and qualified leader. No specific residents, medical histories, or clinical conditions were described in relation to this deficiency.
Unsecured Medications, Treatment Carts, and Oxygen Equipment
Penalty
Summary
Facility staff failed to ensure that drugs, biologicals, and related medical supplies were securely stored and properly maintained on multiple units. On one unit, an oxygen tank assigned to a resident was observed sitting on the floor behind the resident’s bed without any supporting device. On another unit, a treatment cart was observed with a tube of Collagenase Santyl cream labeled for a specific resident left on top of the cart, while residents in power wheelchairs passed by and staff were present at the nursing station. These observations showed that medications and oxygen equipment were not consistently secured as required. Further observations on additional units revealed an unattended and unlocked treatment cart at a nursing station, and on a separate occasion, a treatment cart with Diclofenac gel labeled for a resident left on top along with multiple packs of dressings. These incidents occurred across three units and on more than one date, demonstrating repeated failures to keep medications and treatment supplies in locked compartments or otherwise secured from unauthorized access.
Insufficient Dietitian Coverage and Delayed Nutritional Assessments
Penalty
Summary
The deficiency involves the facility’s failure to employ sufficient food and nutrition staff, including adequate dietitian coverage, to ensure timely assessment and appropriate diets for residents with significant nutritional and diabetic needs. A resident admitted over two weeks earlier with multiple comorbidities and an A1C of 11.5% had a hospital discharge recommendation for a carbohydrate-controlled diet, but was placed on a regular diet at admission with no acknowledgment of the recommended diet until one week later, when the resident requested larger portions. As of the survey date, the dietitian had not yet seen or reviewed this resident’s medical record, and the resident reported not having seen a dietitian and being very frustrated with the meals. During the first two weeks after admission, only one weight was obtained for this resident, despite physician notes stating the resident’s weight was “stable.” Further review of other residents showed additional failures in timely dietitian assessment and follow-up. One resident, readmitted in January and previously seen by the dietitian in September for a 6.4 lb weight loss over 30 days, had no documented follow-up despite continued weight loss totaling 22 lbs since the last dietitian review. Another resident admitted at the end of February with severe protein-calorie malnutrition had not been seen by the dietitian after about a month in the facility, despite a documented 14 lb (7%) weight loss over two weeks. The dietitian reported working only 12 hours per week at the facility and stated that she must prioritize which residents to see, focusing first on residents with tube feedings and those identified in risk meetings, resulting in delayed or absent assessments for new admissions and residents with ongoing weight loss and malnutrition diagnoses.
Linen Shortages and Poor Environmental Maintenance Compromise Resident Care and Comfort
Penalty
Summary
The deficiency involves the facility’s failure to maintain an adequate supply of clean linens and appropriate incontinence wipes, resulting in delays and alterations in residents’ incontinence care, as well as the use of towels and washcloths in place of disposable wipes. During the initial tour, the surveyor observed that the linen supply on one nursing unit hallway was low. Complaint reviews included concerns about delays in incontinence care and bed linens not being changed regularly, with residents left without clean bedding. A complainant reported that there was not enough clean linen available for residents. Staff interviews confirmed that towels, sheets, and washcloths were being used to wipe residents for incontinence care due to the absence of wipes, and that many of these linens were being thrown away when soiled. Staff also reported a shortage of linen, that linen deliveries to the units were late, and that residents who preferred to get up before breakfast had to wait for care when linen was delayed. Further observations showed that the clean supply room contained no disposable wipes or cloths for incontinence care, and a resident reported that staff did not use wipes, that the resident had to purchase their own, and that heavily soiled towels or washcloths were discarded. A tour of all nursing unit linen carts and closets revealed only six clean washcloths and limited supplies of towels, gowns, and bed linens. In the laundry room, only three washcloths were present, and the laundry assistant stated that there were only three washcloths available for each nursing unit that morning, that the facility was short on linen supply, and that these concerns had been repeatedly reported to the Director of Housekeeping over the preceding month and again that morning. The laundry assistant confirmed there was no additional laundry in process. The DON stated that wipe squares should be used for incontinence care, but no such wipes were found in the clean medical supply room, and no backup supply of washcloths was present in the emergency linen supply. The Director of Housekeeping confirmed there was no backup supply of washcloths. The deficiency also includes environmental and maintenance issues affecting resident bathrooms, handrails, and common areas. In the main dining area, a recliner chair was observed positioned directly in front of the handwashing sink, and two recliner chairs were stored in front of the nutrition area kitchenette. Multiple resident bathrooms and shared bathrooms were repeatedly observed over several days with unfinished spackle on walls that needed resurfacing and painting, chipped paint around sinks, uneven boards nailed to walls under sinks that appeared to partially cover holes, musty odors, black substances between shower bases and walls, missing threshold transition molding exposing cracks, missing tiles, and a nail, as well as eroded and chipped paint on baseboard heaters with exposed dark brown metal and rust-like material. Hallway handrails on both nursing units were observed to be worn, with chips, splintering, holes, and areas where the wood finish had worn off. A shower room was observed with a foul fecal odor, dried brown stains on the back of the toilet seat and in the toilet bowl, and a baseboard heater with eroded, chipped paint and rust-like material, along with chipped paint on the handrail. These conditions were acknowledged by the Director of Maintenance and other leadership, and some areas were noted to be in the process of renovation, but the observed deficiencies remained present during the survey period. Overall, the facility did not maintain a safe, clean, comfortable, and homelike environment in good repair across both nursing units and the dining area. The lack of adequate linen and incontinence supplies, combined with the poor condition of resident bathrooms, handrails, and certain common areas, constituted the basis for the cited deficiency. The observations and staff and resident reports consistently described shortages of essential hygiene supplies, delayed care related to linen availability, and multiple unresolved environmental and maintenance issues in resident care areas and shared spaces.
Failure to Thoroughly Investigate Abuse Allegations and Injuries of Unknown Origin
Penalty
Summary
Facility staff failed to thoroughly investigate allegations of potential abuse involving one resident and an injury of unknown origin involving another resident. For one resident, there were two separate allegations of abuse occurring on different days in early February. The facility’s investigation packets included interviews with staff who cared for or were scheduled to work with this resident on the days of the alleged incidents, and the investigations focused solely on this resident. However, there were no interviews conducted with other residents on the unit to inquire about abusive or neglectful treatment by the staff who were working during the times of the allegations. The surveyors noted that, although the allegations were not validated, there was no documentation that other residents were interviewed, if able, or assessed for signs or symptoms of injury. In a separate incident, another resident was identified on March 4 with a new bruise on the right eye, documented as a change in condition at 4:09 AM. This resident had a BIMS score of 99, indicating the resident was unable to complete an interview and therefore could not report how the injury occurred. The facility’s investigation identified a potential cause of the injury but did not reach a definitive resolution. Additionally, there were no interviews of other residents on the unit regarding possible abuse, nor were there documented assessments of other residents for injuries of unknown origin, particularly for those unable to speak for themselves, as in this resident’s case.
Failure to Provide Oral Care to Dependent Residents
Penalty
Summary
The deficiency involves the facility’s failure to provide oral care to residents who were dependent on staff for activities of daily living, specifically oral hygiene. One resident with a tracheostomy was observed with a thick, sticky white substance in the mouth and was noted to intermittently chew on nearby bedding. This resident made good eye contact and, when asked if staff brushed their teeth, shook their head no and mouthed that staff “need to.” According to the resident’s Minimum Data Set (MDS) dated 2/11/26, the resident was dependent on staff for oral care. Another resident, also dependent on staff for oral care per the 3/11/26 MDS, was observed sitting propped up in bed and able to respond with smiles. During the initial observation, the inside of this resident’s lips and upper and lower teeth had a thick, clear, white milky substance visible when the resident tried to open their mouth to smile. Oral care supplies were present in the nightstand, but the resident’s mouth and teeth were not clean. On a subsequent observation with the DON, NHA, and Corporate VP of clinical services, the same resident again had a thick, clear, milky substance between the lips and caking the teeth, which would string between the teeth when the resident attempted to open their mouth, demonstrating a lack of consistent oral care for residents dependent on staff for this ADL.
Incomplete and Inaccurate Medical Record Documentation for Treatments and Assessments
Penalty
Summary
Facility staff failed to maintain complete and accurate medical records and documentation for multiple residents. For one resident with wound care needs, review of the MAR showed that wound care and related treatments were signed as completed on the dates initially reported, despite the resident’s ongoing complaints that wound dressings were not being changed. When additional dates were reviewed, there were missing staff signatures for wound care on two specific dates, as well as three instances where application of A&D ointment to the resident’s feet was not signed off out of 24 days reviewed. Another resident with severe cognitive impairment, as evidenced by a BIMS score of 00, was found to have an injury of unknown origin (a bruise on the left hand). Documentation showed that a change in condition was initiated late in the morning, but a formal pain evaluation was not initiated and completed until that night, and the resident was unable to explain how the injury occurred or verbalize pain using a standard pain scale. For a third resident, documentation related to the admission PPD test was inconsistent and incomplete. The MAR contained an entry indicating “9” for the administration date, meaning “see nurse’s note,” but there was no corresponding nurse’s note. Despite the absence of a signed administration of the PPD injection, staff documented the PPD result as “negative” on the scheduled read date. The resident reported never receiving the PPD injection, and the DON confirmed that the facility had been out of PPD solution at the time, so the test would not have been administered. These findings demonstrate failures in accurate documentation of treatments and assessments, including wound care, pain assessment, and TB screening, as well as missing or incomplete supporting notes in the medical record.
Failure to Implement and Communicate Correct Transmission-Based Precautions
Penalty
Summary
Surveyors identified a deficiency in the facility’s infection prevention and control program related to inconsistent and incorrect implementation of transmission-based precautions and PPE use. During a complaint investigation focused on residents on transmission-based precautions, one resident with a visible Foley catheter was observed in the room with physical therapy, but there were no signs posted indicating any need for PPE, despite the resident being a new admission with a Foley catheter placed related to wounds. In another double-occupancy room, a contact precautions sign was posted at the doorway, but the nurse practitioner was in the room on a personal phone with no PPE, and the assigned GNA was repositioning the resident in bed while wearing only gloves. When questioned, the NP, RN, and GNA all stated that the resident in the room was not on contact precautions, and the GNA reported that signs were hanging at all doors and that this particular resident’s sign was “just wrong.” The surveyor observed the GNA later return to the room and turn the sign around to indicate no PPE requirement. Subsequent interviews revealed that therapy staff relied on posted signage to determine PPE use and that if the sign was wrong, the PPE used would be wrong. Overall, surveyors found problems with signage accuracy and staff awareness of which residents required contact precautions, as well as observed failures to follow appropriate PPE use for residents who should have been on contact precautions.
Inaccurate MDS Coding for Falls, Pain Management, and High-Risk Medications
Penalty
Summary
Facility staff failed to ensure Minimum Data Set (MDS) assessments were accurately coded for two residents reviewed during a complaint survey. For one resident, a facility-reported incident showed that the resident was found seated on the floor beside the bed and was diagnosed with a non-displaced femoral neck impaction fracture of the left hip following an x-ray. Despite this fall with a major injury, the subsequent significant change MDS dated 11/4/25 did not code the fall with major injury in Section J1900C. Review of the resident’s Medication Administration Records for October and November 2025 showed administration of Tylenol on 10/31/25 at 9:30 PM, which fell within the 5-day look-back period for the MDS, but Section J0100 (prn pain) of the same significant change MDS did not capture the use of Tylenol. For another resident, review of a quarterly MDS with an assessment reference date of 10/15/25 showed that Section N0415 (High-Risk Drug Classes) documented the use of an opioid medication. However, review of the resident’s October 2025 Medication Administration Record did not show that the resident had been prescribed an opioid during that period. In both cases, MDS staff later confirmed that these were errors in MDS coding, demonstrating that the assessments did not accurately reflect the residents’ clinical status and medication use as documented in their medical records.
Incomplete Documentation of Narcotic Administration on MAR
Penalty
Summary
The facility failed to maintain complete and accurate medical records in accordance with accepted professional standards for one resident receiving narcotic medication. The resident, admitted in March 2026, had a fall on 3/6/26 and was sent to the hospital on 3/9/26. Review of the March 2026 Medication Administration Record (MAR) showed documentation of a single 25 mg dose of Tramadol administered on 3/8/26 at 9:23 AM. However, review of the resident’s Controlled Drug Receipt/Record/Disposition Form, kept on the nurse’s medication cart and not in the medical record, showed that Tramadol 25 mg was administered three times between 3/8/26 and 3/9/26: at 11:00 AM and 9:00 PM on 3/8/26, and at 9:00 AM on 3/9/26. In interview, the DON stated that staff are expected to document narcotic administration on the MAR and confirmed that only one of the three Tramadol doses reflected on the controlled drug record was documented on the resident’s MAR. This discrepancy between the controlled substance record and the MAR, with missing documentation of two administered doses of Tramadol on the official medical record, constituted the failure to maintain a complete and accurate medical record for the resident.
Trusted data from CMS and state health departments
Every citation, penalty and Plan of Correction is sourced from public CMS records (latest release May 27, 2026) and official state health department websites — never guesswork.
Trusted by long-term care providers and associations.
