Levindale Hebrew Ger Ctr & Hsp
Inspection history, citations, penalties and survey trends for this long-term care facility in Baltimore, Maryland.
- Location
- 2434 West Belvedere Avenue, Baltimore, Maryland 21215
- CMS Provider Number
- 215033
- Inspections on file
- 18
- Latest survey
- March 13, 2026
- Citations (last 12 mo.)
- 11 (1 serious)
Citation history
Health deficiencies cited at Levindale Hebrew Ger Ctr & Hsp during CMS and state inspections, most recent first.
A resident emailed the CAO describing that the DON and a GNA had yelled at them and explicitly requested that the facility self-report the incidents, including to CMS and the Board of Nursing. The CAO acknowledged the concerns, apologized, and indicated that appropriate action would be taken, but the Administrator later stated that leadership had no knowledge of any abuse concerns until informed by surveyors months later, at which point a report was made to OHCQ. The Administrator, who serves as abuse coordinator, confirmed that all staff must report abuse allegations within two hours and that allegations must be reported even if a resident does not want a grievance filed, yet also acknowledged that the allegation involving the DON had not been recognized or reported until the surveyor pointed to the prior correspondence. This resulted in a failure to timely report and investigate the resident’s abuse allegations involving both the GNA and the DON.
The facility failed to report alleged abuse and injuries in a timely manner for multiple residents. For one resident, a hip fracture was reported without a follow-up investigation. Another resident's abuse allegation was documented but not reported. A third resident's abuse report was delayed, and two other residents' injuries were reported late, exceeding the required timeline. The DON and NHA acknowledged these reporting failures.
The facility failed to accurately document MDS assessments for multiple residents, including incorrect discharge dates, misreported catheter and continence status, unnoted missing teeth, and inaccurate upper extremity impairment coding. These deficiencies were identified through surveyor interviews and record reviews.
A staff member recorded themselves in a clinical area of Household 5 and posted the video on TikTok, leading to their termination for Gross Misconduct. Although no residents were recorded, the act violated privacy protocols. The DON confirmed the staff had been educated on resident rights and HIPAA.
A facility failed to protect residents from abuse and aggression. One resident, under 1:1 care due to confusion and fall risk, was subjected to rough handling and verbal abuse by a CNA, witnessed by a roommate. Another resident with severe cognitive impairment was pushed by an aggressive resident, resulting in a fall. The aggressive resident had a history of behavioral issues, and interventions were in place, but the incident still occurred.
A facility failed to maintain documentation for an investigation involving a resident sent out for evaluation due to fever, tachycardia, and hypotension. A nurse incorrectly entered medications from the discharge summary, and the resident's hospital course included altered mental status, hypotension, and treatment for possible sepsis. The DON could not provide hospital records due to HIPAA concerns, but the surveyor obtained them directly.
The facility failed to evaluate the effectiveness of pain medication for a resident in a timely manner. A resident was prescribed tramadol for moderate to severe pain, but the effectiveness was assessed 7.5 and 12 hours after administration, contrary to the standard practice of 1 to 2 hours. The DON stated that reevaluation should occur 30 minutes post-administration, highlighting a gap between practice and standard care.
A resident with a high fall risk and confusion was subjected to rough care by a CNA acting outside her scope of practice. The CNA, who was supposed to monitor the resident, was reported to have physically mishandled the resident, leading to her termination. The DON confirmed that the CNA's actions were inappropriate as sitters are not allowed direct hand contact unless certified as a GNA.
A resident with multiple health conditions experienced significant medication errors upon admission due to incorrect medication orders. The facility failed to accurately reconcile medications, leading to discrepancies in dosage, frequency, and type of medication release. These errors were identified after the resident was hospitalized for confusion, tachycardia, and hypotension, with a diagnosis of Sepsis due to a UTI.
The facility failed to notify the responsible parties of two residents about changes in their care plans, resulting in a deficiency in resident rights. A resident's daughter was not informed about a new skin tear, and another resident's co-guardians were not involved in a care plan meeting. The DON confirmed the lack of documentation for these notifications.
The facility failed to maintain proper documentation of Advance Directives for two residents. One resident's MOLST certification indicated Advance Directives were selected, but no document was found. The Director of Social Service did not see the need for separate records, but the DON later provided a copy from the hospital. Another resident, capable of making decisions, had no Advance Directives on file, and it was unclear if they were offered the opportunity to create one.
A facility failed to inform a resident's primary care physician about multiple vomiting episodes and bowel movement irregularities. The resident, with a PEG tube, experienced chronic vomiting and went several days without a bowel movement, but the physician was not notified of these issues. This lack of communication and adherence to bowel management policy led to a deficiency.
The facility failed to notify the Ombudsman of two residents' transfers to the hospital, as required by regulations. One resident was transferred on two occasions, with only one instance being reported, while another resident's transfer was not reported at all. The facility acknowledged these oversights and indicated changes to ensure proper notification in the future.
A facility failed to provide a written notice of its bed hold policy to a resident's legal guardian upon transfer to a hospital. The resident was transferred twice, but there was no documentation that the policy was communicated. The DON confirmed the process involves sending the policy to the hospital and mailing it to the guardian, but there was no evidence this occurred.
The facility failed to include two residents in their care plan meetings. One resident was not invited to participate in their care plan meeting, despite being capable of expressing their needs, and decisions were made without their input. Another resident did not have a care plan meeting following their quarterly MDS assessment, with no documentation provided to confirm it was held.
A facility failed to meet a resident's needs by not providing adequate music-related activities, despite the resident's care plan emphasizing music engagement. The resident, who had a strong interest in music, was offered activities less than weekly, and the facility did not consistently incorporate music into the care plan, despite family requests and the resident's dependency on staff for emotional and social needs.
A facility failed to administer TED hose as ordered for a resident experiencing leg swelling. Despite a Nurse Practitioner's recommendation and an order for TEDs to be applied during the day, there was no documentation in the resident's medical record confirming their use. The Nursing Home Administrator acknowledged that the order did not translate to the Treatment Administration Record, leading to a lack of documentation. Observations showed the resident's feet were swollen, and the resident reported not wearing TEDs for weeks.
A resident with a hearing deficit misplaced their hearing aids, and the facility failed to ensure replacements were obtained. Despite a care plan update and discussions with the resident's brother, the resident remained without hearing aids for over three months. The Treatment Administration Order required staff to check and assist with hearing aids every shift, but notes indicated they were missing multiple times. The resident's brother did not want to pay for replacements, and guest services needed to proceed with obtaining new hearing aids.
A facility failed to provide appropriate splinting care for a resident with contracted hands. Splints were found off in the resident's room, and the family was unclear about their use. A nurse was unaware of a splinting schedule, which is typically provided by therapy. The resident had previously tolerated some splinting but was not reassessed for splinting needs after returning from the hospital, leading to a deficiency in care.
A resident with impaired mobility fell while attempting to transfer to a bedside commode after a GNA left them unattended. The resident's care plan required assistance with toileting, which was not followed, leading to the incident. The DON confirmed the protocol breach.
A resident with a G-tube was not provided appropriate tube feeding treatment and site care. The feeding pump was turned off, but the tubing remained connected without proper labeling or dating. The G-tube site dressing was not changed as ordered, showing signs of oozing drainage. The on-duty nurse failed to label the Nepro container, disconnect the tubing on time, and change the dressing twice daily. These issues were reported to the Nurse Manager and DON.
A facility failed to conduct a bed rail assessment and obtain informed consent for a resident with hemiplegia and muscle weakness. The resident was observed with all bed rails raised, but no documentation of evaluation or consent was found. The NHA confirmed the absence of an assessment, and the facility's clinical engineering did not evaluate entrapment risks. The Specialty Bed Instruction manual emphasized the need for such assessments, which were not performed.
A provider failed to implement a pharmacist's recommendation to discontinue Novolog and check a resident's A1C levels. Despite agreeing to the recommendation, the provider did not update the orders, leaving Novolog active and no A1C lab ordered. The DON confirmed that providers should write orders when agreeing with pharmacist recommendations.
The facility failed to maintain accurate medical records, as evidenced by conflicting bed rotation orders for a resident and discrepancies in code status documentation for two residents. The Director of Nursing acknowledged the error in bed rotation orders, while nursing staff corrected the code status inconsistencies after surveyor intervention.
A resident, assessed as cognitively intact, communicated refusal of ADL care, but a GNA proceeded with the care against the resident's wishes, citing instructions from other staff. The resident resisted by holding the covers tightly, but the GNA attempted to perform the care regardless. The DON confirmed the incident and acknowledged the GNA's failure to respect the resident's rights.
A resident, assessed as cognitively intact, was physically restrained by a GNA during care despite expressing refusal. The GNA, following instructions from other staff, held the resident down to check for incontinence. The incident was confirmed by the resident and acknowledged by the Director of Nursing.
A resident with behavior problems pushed another resident, causing a fall, due to ineffective implementation of a care plan. The resident had previously warned staff about harming wandering residents entering their room. The care plan, which included interventions like increased supervision, was not followed, resulting in the incident.
The facility failed to provide timely behavioral health services to three residents. One resident with dementia and mood disturbances experienced gaps in psychiatric follow-up, while another resident's psychiatric consultation was delayed due to communication issues. A third resident requiring antipsychotic medications also faced a delay in receiving a psychiatric consult. These deficiencies highlight the facility's failure to meet the behavioral health needs of its residents.
Failure to Timely Report and Investigate Resident Abuse Allegations
Penalty
Summary
The facility failed to ensure that allegations of abuse were timely reported to the proper authorities after a resident made specific abuse-related complaints about staff. On 11/17/25 at 3:12 AM, the resident sent an email to the Chief Administrative Officer (CAO) describing that the DON had previously come into the resident’s room and yelled at them, which the resident perceived as unacceptable behavior in what they considered their home. In the same correspondence, the resident alleged that a Geriatric Nursing Assistant (GNA) had also yelled at them, and explicitly requested that the facility self-report, including requests to report the GNA to the Board of Nursing and to self-report to CMS without retaliation. Later that same day, the CAO responded by email, apologizing for what the resident described, stating that culinary leaders were included for one concern, and indicating that they would follow up with leaders on the GNA and that appropriate action would be taken. Despite these explicit allegations and requests, the Administrator reported during interview on 3/11/26 that the facility had no knowledge of the resident’s abuse concerns until surveyor notification on 2/5/26, at which time a self-report was made to the Office of Health Care Quality (OHCQ). The Administrator confirmed that only one initial report on 2/5/26 and one follow-up report on 2/12/26 had been made regarding this resident, and also stated that all staff are responsible for timely reporting of abuse allegations within two hours, even if information does not reach leadership promptly. The CAO told the surveyor that the resident’s care concerns had been handled through normal processes, were investigated, and found unsubstantiated, and acknowledged receiving multiple emails from the resident prior to discharge at the end of November 2025. During interview, the Administrator, who identified as the abuse coordinator, acknowledged that abuse allegations must be reported even if a resident does not want a grievance filed, yet also stated they were unaware of the abuse allegation involving the DON until the surveyor directed them to the 11/17/25 correspondence. This sequence of events shows that the facility did not timely report or investigate the resident’s abuse allegations involving both the GNA and the DON as required.
Failure to Timely Report Alleged Abuse and Injuries
Penalty
Summary
The facility failed to report alleged violations of abuse as required, affecting five residents. For Resident #11, the facility did not submit a final investigation or follow-up report to the Office of Healthcare Quality (OHCQ) after an initial report of a hip fracture was made. The Nursing Home Administrator (NHA) was unable to provide the final report and acknowledged the oversight. Similarly, for Resident #217, an allegation of abuse was documented in the resident's medical record, but no facility reported incidents (FRI) were found, and the NHA was unaware of the documented allegation. In another case, Resident #195 alleged abuse by a Geriatric Nursing Assistant (GNA), and the facility sent both the initial and final reports to OHCQ together, which was not in compliance with the required reporting timeline. For Resident #39, the facility reported a change in condition related to knee pain and swelling nine hours after the event, exceeding the two-hour reporting requirement. The Director of Nursing (DON) acknowledged the delay in reporting. Additionally, for Resident #147, a GNA reported multiple bruises, which should have been reported immediately to OHCQ. However, the facility's initial report was sent almost 16 hours later. The DON confirmed the delay in reporting. These incidents highlight the facility's failure to adhere to timely reporting requirements for suspected abuse, neglect, or injury of unknown origin, as mandated by regulations.
Inaccurate MDS Documentation for Multiple Residents
Penalty
Summary
The facility failed to accurately document resident assessments on the Minimum Data Set (MDS) for four residents. For one resident, the MDS assessment inaccurately recorded the discharge date to the hospital, which was corrected after the surveyor's review. Another resident's MDS assessment inaccurately coded the presence of an indwelling catheter and urinary continence, as well as bowel continence, which was acknowledged by the Director of Clinical Reimbursement. Additionally, a resident's MDS assessment failed to note missing front teeth, despite the resident's statement and visible evidence of missing teeth. Another resident with bilateral contracted hands was observed without splints, and the MDS assessments inaccurately reflected the resident's upper extremity impairments. These inaccuracies were confirmed by the Clinical Director of Reimbursement during the surveyor's investigation.
Unauthorized Recording in Clinical Area
Penalty
Summary
The facility failed to protect residents' private space from unauthorized photographs and recordings, as evidenced by an incident involving Staff #19. On a specific date, Staff #19 recorded themselves in a common care area within Household 5 and posted the video on the social media platform TikTok. Although Staff #19 claimed that no residents were recorded, the act of recording in a clinical area was deemed inappropriate. The employee file review revealed that Staff #19 was terminated for Gross Misconduct due to this incident. Interviews with the Director of Nursing confirmed that Staff #19 had received education on resident rights and HIPAA during orientation. The incident was reported anonymously to the administration, and no specific resident was involved in the recording.
Failure to Protect Residents from Abuse and Aggression
Penalty
Summary
The facility failed to protect a resident from physical and verbal abuse, as evidenced by an incident involving a resident who was under 1:1 care due to confusion and high fall risk. A Registered Nurse reported hearing a 1:1 sitter shouting from the resident's room, where the resident was found in a precarious position. The facility's investigation revealed that a Certified Nursing Assistant (CNA) was accused of providing rough care, including hitting the resident with a flashlight and yelling. A witness corroborated the rough handling but not the flashlight incident, describing the CNA's actions as grabbing the resident and slamming them into a wheelchair, causing distress to the resident and fear in a roommate who witnessed the event. Another incident involved a resident with severe cognitive impairment who was pushed by another resident, resulting in a fall. The aggressor admitted to pushing a linen cart that knocked the resident to the floor, motivated by frustration over wandering residents entering their room. The facility's investigation noted that the aggressive resident had a history of behavioral issues, including threats to harm others, and interventions were in place to manage these behaviors. However, the incident highlighted a failure to prevent the aggressive behavior and protect the vulnerable resident from harm.
Failure to Document Investigation of Resident Incident
Penalty
Summary
The facility failed to maintain pertinent documentation of a reported investigation for a facility-reported incident involving a resident. The incident involved a resident who was sent out for further evaluation due to fever, tachycardia, and hypotension. The facility identified an error where a nurse incorrectly entered medications from the discharge summary. The resident's hospital course included altered mental status and hypotension requiring pressor support, ongoing leukocytosis, and treatment with empiric meropenem for possible sepsis. The Director of Nursing was unable to provide hospital records, citing HIPAA concerns, although the surveyor was able to obtain these records directly from the hospital.
Inadequate Evaluation of Pain Medication Effectiveness
Penalty
Summary
The facility failed to adequately evaluate the effectiveness of pain medication for a resident, as evidenced by the review of records and staff interviews. A complaint was made regarding a resident who did not receive medications, including tramadol, as ordered. The resident had an order for tramadol, an opiate pain relief medication, to be administered as needed for moderate to severe pain. However, the administration notes revealed that the effectiveness of the medication was evaluated 7 hours and 30 minutes after one administration and approximately 12 hours after another, which is not in line with the standard practice of evaluating effectiveness between 1 to 2 hours after administration. During an interview, the Director of Nursing stated that the expectation was to reevaluate pain 30 minutes after administration, indicating a discrepancy between the facility's practice and the standard of care. This deficiency was evident for one resident out of fourteen reviewed for pain management.
Inappropriate Care by CNA Leads to Deficiency
Penalty
Summary
The facility failed to provide a resident with an employee who practiced the appropriate skill set according to their education, leading to a deficiency in care. Resident #201, who was readmitted to the facility due to multiple falls and was very confused at baseline with impaired gait and a high fall risk, was ordered to have a 1:1 sitter. However, the sitter, identified as CNA #32, allegedly provided rough care to Resident #201, as reported by the resident and witnessed by the roommate, Resident #46. The roommate described CNA #32 as grabbing Resident #201 by the wrists, ankles, and feet, and slamming the resident into a wheelchair. The Director of Nursing (DON) clarified that the role of a sitter is to monitor and communicate the needs of the resident with nursing staff and that direct hand contact is not allowed unless the sitter is a Certified Geriatric Nursing Assistant (GNA). CNA #32 acted outside of her scope of practice by having direct hand contact with Resident #201, which led to the termination of her employment. This incident highlights the facility's failure to ensure that staff members have the appropriate competencies to care for residents, particularly those with high fall risks and confusion.
Medication Errors on Admission Lead to Deficiency
Penalty
Summary
The facility failed to protect a resident from significant medication errors by inaccurately ordering medications upon admission. This deficiency was identified for a resident with a diagnosis of Heart Failure, Chronic Kidney Disease, and Peripheral Vascular Disease. Upon admission, the nurse incorrectly entered medications from the discharge summary into the resident's chart as active medications. The medications involved included Lasix (Furosemide), Quetiapine Fumarate, Metoprolol Tartrate, and Sacubitril-Valsartan. These medications were administered in dosages and frequencies that differed from those prescribed during the resident's hospital stay. The discrepancies in medication orders included differences in dosage, frequency, and type of medication release. For instance, Metoprolol Tartrate was given instead of Metoprolol Succinate, and Quetiapine Fumarate was scheduled daily rather than as needed. These errors were discovered after the resident was sent to the hospital for evaluation due to confusion, tachycardia, and hypotension. The hospital records indicated that the resident was admitted with a diagnosis of Sepsis due to a UTI, which was treated successfully, resolving the symptoms. The facility's medication reconciliation process, as explained by a staff member, involves reviewing the discharge summary and consulting with the provider, but this process failed in this instance.
Failure to Notify Resident Representatives of Care Plan Changes
Penalty
Summary
The facility failed to notify the Responsible Party (RP) of a change in the care plan for two residents, leading to a deficiency in resident rights. For Resident #51, the facility did not inform the RP, who was the resident's daughter, about a new skin tear documented on 8/20/24. Despite the Director of Nursing (DON) acknowledging that the RP should have been notified, there was no documentation to confirm that this notification occurred. Similarly, for Resident #40, the facility did not ensure the involvement of the resident's co-guardians in the care planning process. Although a care plan meeting was documented on 7/17/24, there was no evidence that the family was invited or attended. The DON confirmed the lack of documentation regarding the family's involvement in the care plan meeting held in July 2024, further highlighting the facility's failure to uphold the resident's rights.
Failure to Maintain and Offer Advance Directives
Penalty
Summary
The facility failed to maintain proper documentation of Advance Directives for two residents during an annual survey. For one resident, the Medical Orders for Life-Sustaining Treatment (MOLST) certification indicated that Advance Directives were selected, but no document was found in the medical record. The Director of Social Service stated that Advance Directives information was integrated into the facility's internal system and did not see the need to maintain separate records. However, the Director of Nursing acknowledged the deficiency and later provided a copy of the Advance Directives from the hospital's record. For another resident, the surveyor found that the resident was capable of making medical decisions but did not have Advance Directives on file. A psychosocial assessment noted the absence of Advance Directives, and a progress note indicated that the resident had requested information about Advance Directives to be sent to a family member. The Director of Social Service admitted that there was no specific area in the psychosocial assessment to indicate if the resident was offered the opportunity to create Advance Directives, leading to uncertainty about whether the resident was given this option.
Failure to Inform Physician of Resident's Condition Changes
Penalty
Summary
The facility failed to inform the primary care physician of a resident's need to alter treatment, specifically regarding episodes of vomiting and bowel movement irregularities. The resident, who was admitted in early 2021 with a percutaneous endoscopic gastrostomy (PEG) tube for feeding, experienced multiple episodes of vomiting throughout October and early November 2024. Despite these occurrences, orders to hold or restart the tube feeding were only documented on two specific days. Additionally, the resident went several days without a documented bowel movement on two separate occasions, which was not communicated to the physician as per the facility's bowel management policy. The physician, upon a follow-up visit, noted the resident's chronic vomiting and the lack of bowel movements, which led to the prescription of a new bowel regimen. However, the physician was not informed of the full extent of the vomiting episodes or the frequency of tube feeding interruptions. This lack of communication and failure to adhere to the facility's policy on bowel management contributed to the deficiency identified by the surveyor.
Failure to Notify Ombudsman of Resident Transfers to Hospital
Penalty
Summary
The facility failed to provide timely notification to the Ombudsman regarding the transfer of residents to the hospital, as required by regulations. This deficiency was identified during a survey, which revealed that the facility did not notify the Ombudsman of Resident #191's transfer to the hospital on 7/20/2024. The Nursing Home Administrator (NHA) acknowledged that the notification was not done for this transfer because the resident was expected to return to the facility. Although the NHA provided documentation of an email sent to the Ombudsman on 8/5/2024, it did not include the transfer on 7/20/2024, only the transfer on 7/29/2024. Similarly, the facility failed to notify the Ombudsman of Resident #30's transfer to the hospital on 4/20/2024. During an interview, the Administrator admitted that the resident was not included in the report of discharges and transfers sent to the Ombudsman for April. Resident #30 had a history of UTIs and was hospitalized for sepsis from a UTI. The facility acknowledged the oversight and indicated that changes were made to ensure proper notification in the future.
Failure to Provide Bed Hold Policy Notification
Penalty
Summary
The facility failed to provide a written notice of its bed hold policy to the resident's legal guardian upon the resident's transfer to an acute care facility. This deficiency was identified during a review of the medical records and interviews conducted by the surveyor. Specifically, the medical record review revealed that the resident was transferred to the hospital on two occasions, but there was no documentation indicating that the bed hold policy was communicated to the legal guardian. The Director of Nursing confirmed that the facility's process involved sending the bed hold policy in a packet to the hospital and mailing it to the responsible party or guardian, but acknowledged that there was no documentation to support that these actions were taken for the resident's transfers.
Failure to Include Residents in Care Plan Meetings
Penalty
Summary
The facility staff failed to ensure that residents were able to participate in their care plan meetings, as required. Specifically, Resident #147 was not invited to participate in their care plan meeting, despite being capable of making their needs known. The care plan meeting was conducted without the resident or their family, and decisions were made by the care team alone. This pattern of exclusion was noted in previous care plan meetings as well, where neither the resident nor their family were involved in the decision-making process. Staff #6 admitted to not discussing the care plan meeting with the resident, leaving it up to the family, which resulted in the resident being excluded from the process. Additionally, the facility failed to conduct a care plan meeting following Resident #51's quarterly Minimum Data Set (MDS) assessment. While a care plan meeting was held after the July MDS assessment, there was no documentation of a care plan meeting following the October assessment. The Director of Nursing acknowledged that a meeting should have been held and attempted to locate documentation, but none was provided by the time of the survey exit. This oversight indicates a failure to adhere to the required care planning process after each MDS assessment.
Failure to Provide Music Activities for Resident
Penalty
Summary
The facility failed to provide an activities program tailored to meet the interests and needs of a resident, as evidenced by the case of a resident who had a strong interest in music. Despite the resident's family bringing in a music player and requesting music therapy, the facility did not adequately incorporate music into the resident's care plan. The resident's care plan indicated a dependency on staff for emotional, intellectual, physical, and social needs, with music engagement listed as an intervention. However, the facility did not consistently offer music-related activities to the resident. Interviews and record reviews revealed that the resident's activity log showed infrequent music-related activities, with only a few documented instances over several months. The therapeutic recreational re-assessment initially did not include music listening as an activity, although it was later checked in a subsequent assessment. Despite the care plan's emphasis on music engagement, the resident was offered activities less than weekly, indicating a failure to meet the resident's documented needs and preferences.
Failure to Administer TED Hose as Ordered
Penalty
Summary
The facility failed to provide treatments according to a resident's plan of care, specifically for skin care. Resident #77 reported swelling in both lower legs and was recommended by a Nurse Practitioner to use Thrombo-Embolic Deterrent (TED) hose to prevent blood clots and swelling. An order was placed for TEDs to be applied during the day and removed at night. However, there was no documentation in the resident's medical record indicating that the TEDs were applied as ordered. The Nursing Home Administrator confirmed that the order for TEDs did not translate to the Treatment Administration Record (TAR), resulting in a lack of documentation that the treatment was provided. Observations revealed that the resident's feet were swollen, and the resident reported that the TEDs had not been worn for weeks.
Failure to Replace Missing Hearing Aids for Resident
Penalty
Summary
The facility failed to ensure that a resident in need of hearing aids received services to obtain replacements after misplacing them. The resident, who had a documented communication problem related to a hearing deficit in both ears, lost their hearing aids on October 29, 2023. Despite a care plan update on December 29, 2023, indicating that the resident's brother would order new hearing aids with insurance coverage, the resident remained without hearing aids for over three months. The Treatment Administration Order required staff to check and assist with the application of hearing aids every shift, but notes indicated that the hearing aids were missing 13 out of 62 times. The facility's social worker assistant documented a care plan meeting with the resident's brother on July 10, 2024, and a follow-up on October 9, 2024, to discuss the missing hearing aids. However, it was confirmed during an interview on November 12, 2024, that the resident's brother did not want to pay for replacements, and guest services needed to proceed with obtaining new hearing aids. This lack of resolution resulted in the resident being without necessary hearing aids for an extended period, impacting their ability to communicate effectively.
Failure to Provide Appropriate Splinting Care for a Resident
Penalty
Summary
The facility failed to provide appropriate treatment to prevent further decreased range of motion for a resident. During an observation, splints intended for the resident were found off and placed in the corner of the room. The resident's family member was unclear about the usage of the splints, and the resident had contracted hands. A registered nurse was interviewed and stated that the resident was being trialed for splint tolerance by therapy before a hospital visit. However, the nurse was not aware of any splinting schedule for the resident, which is typically provided by therapy once the resident tolerates the splints for a certain duration. Further review of the resident's occupational therapy notes revealed that the resident had previously tolerated passive range of motion exercises and was able to wear a resting hand splint for a limited time on one hand. However, there was no current splinting schedule in place after the resident's return from the hospital. The rehab manager confirmed that the resident was not on the schedule for splinting needs assessment after returning from the hospital, although the resident would benefit from it. This lack of coordination and communication between therapy and nursing staff led to the deficiency in care.
Inadequate Supervision During ADL Care Leads to Resident Fall
Penalty
Summary
The facility failed to adequately supervise and assist a dependent resident during Activities of Daily Living (ADL) care, leading to an accident. On 10/22/24, a progress note by a Nurse Practitioner documented that a resident sustained a fall after attempting to transfer themselves to a bedside commode. The Geriatric Nursing Assistant (GNA) had assisted the resident to the edge of the bed and helped them stand up but left the room before the resident completed the transfer to the commode. The resident had a care plan initiated on 10/21/24, indicating a self-care deficit related to impaired mobility, with an intervention requiring assistance with toileting. The Director of Nursing confirmed that the GNA did not follow protocol, and the resident should not have been left alone.
Deficient Tube Feeding and G-tube Care
Penalty
Summary
The facility staff failed to adhere to appropriate tube feeding treatment and gastrostomy tube (G-tube) site care for a resident with a history of hemiplegia after a stroke, dysphagia, and dementia. Observations revealed that the resident's feeding pump was turned off, yet the feeding tubing remained connected to the G-tube without proper labeling or dating of the formula bottle. This was observed on multiple occasions, indicating a lack of compliance with the facility's tube feeding treatment policy. Additionally, the G-tube site dressing was not changed as per the physician's orders, which required it to be cleaned and dressed twice daily. The dressing was found to be dated with the previous day and showed signs of oozing drainage. The on-duty nurse failed to ensure the Nepro container was labeled, the feeding tubing was disconnected at the appropriate time, and the G-tube site dressing was changed as required. These deficiencies were communicated to the Nurse Manager and the Director of Nursing as concerns.
Failure to Conduct Bed Rail Assessment and Obtain Consent
Penalty
Summary
The facility failed to conduct a bed rail assessment and obtain informed consent prior to the use of bed rails for a resident. The resident, who had a medical history of hemiplegia affecting the left side and muscle weakness, was observed with all four bed rails raised while grabbing onto one of them. Despite the care plan indicating the need to discuss concerns regarding diagnoses or treatments with the resident or their family, there was no documentation of a bed rail evaluation or consent in the resident's medical record. During interviews, the Nursing Home Administrator (NHA) acknowledged the absence of a bed rail assessment and mentioned that the resident was in a specialty bed that required the bed rails to be up for proper functioning. The facility's clinical engineering, shared with a hospital on campus, was not involved in evaluating the risk of entrapment. The Corporate Director of Clinical Operations confirmed that their department only serviced the beds when malfunctioning and did not assess for entrapment risks. The Specialty Bed Instruction for Use manual emphasized the need for assessing entrapment risks and obtaining appropriate medical personnel's determination for siderail usage, which was not adhered to in this case.
Failure to Implement Pharmacist's Recommendation
Penalty
Summary
The provider failed to follow through with a pharmacist's recommendation after a medication regimen review for a resident. During a pharmacy medication review, the pharmacist recommended discontinuing Novolog and checking the resident's A1C levels. The provider agreed to this recommendation and signed the documentation. However, upon review, it was found that Novolog remained an active order, and there was no order for an A1C lab test. The Director of Nursing confirmed that the expectation is for providers to write orders at the time of signing the recommendation if they agree with it.
Discrepancies in Medical Records and Code Status Documentation
Penalty
Summary
The facility failed to maintain medical records in accordance with acceptable professional standards and practices, as evidenced by discrepancies in the medical records of three residents. For one resident, there were two conflicting bed rotation orders in the medical record. The first order specified a 50% turn to the right and left for 5 minutes, while the second order specified a 40% turn with a 0.5-minute pause. Both orders were marked as completed, indicating a lack of clarity and potential confusion in care delivery. The Director of Nursing acknowledged the error, noting that the first order was a standard one, while the second was placed by the treatment team. Additionally, discrepancies were found in the code status documentation for two other residents. The paper charts indicated a 'No CPR' status, while the electronic records stated 'Full Code' with a reference to the MOLST form. Interviews with nursing staff revealed that the expectation was to use the most up-to-date MOLST in the paper chart to determine code status. However, the inconsistency between paper and electronic records was only corrected after surveyor intervention, highlighting a failure in maintaining accurate and consistent medical records.
Failure to Respect Resident's Right to Refuse Care
Penalty
Summary
The facility failed to honor and respect a resident's wishes regarding Activities of Daily Living (ADL) care, resulting in a deficiency related to resident rights. A resident, identified as cognitively intact with a Brief Interview for Mental Status (BIMS) score of 15, communicated that a Geriatric Nursing Assistant (GNA) held them down and performed care against their expressed wishes. The resident was able to communicate their refusal through nodding, mouthing answers, and using electronic devices. Despite the resident's clear refusal, the GNA proceeded with the care, citing instructions from other staff members to check for incontinence even if the resident refused. The facility's investigation revealed that the GNA attempted to perform the care by pulling the covers from the foot of the bed and holding the resident's arm across them, despite the resident's resistance. The Director of Nursing (DON) confirmed the incident and acknowledged that the GNA should have respected the resident's right to refuse care. The GNA involved was subsequently suspended and placed on the facility's do-not-return list.
Resident Restrained by GNA Against Their Will
Penalty
Summary
The facility failed to protect a resident from being physically restrained by an employee, which was evident in the case of one resident reviewed for abuse. The incident involved a Geriatric Nursing Assistant (GNA) who restrained the resident during care. The resident, who was assessed as cognitively intact with a Brief Interview for Mental Status (BIMS) score of 15, communicated that the GNA held them down and performed care that they had expressed was not wanted or needed. The resident confirmed the incident during an interview with the surveyor. The GNA involved in the incident stated that they were instructed by other staff to check the resident for incontinence even if the resident refused. Despite the resident's clear communication of refusal, the GNA proceeded to pull the covers from the foot of the bed and held the resident's arm across their body to perform the check. The Director of Nursing confirmed the GNA's actions and acknowledged that the resident should not have been restrained in this manner.
Failure to Implement Behavior Management Care Plan
Penalty
Summary
The facility failed to implement interventions in a care plan for a resident with behavior problems, which led to an incident involving physical aggression. On March 14, 2024, a resident pushed another resident, causing them to fall. The incident occurred because the resident felt their privacy was invaded by another resident wandering into their room. The resident had previously communicated to staff that they would harm wandering residents if they entered their room. Despite this, the care plan initiated on July 12, 2023, which identified the resident's triggers for aggression and outlined interventions such as removing other residents from their room and increasing supervision, was not effectively implemented, leading to the incident.
Failure to Provide Timely Behavioral Health Services
Penalty
Summary
The facility failed to provide necessary behavioral health services according to the identified individual needs in the care plans of three residents. Resident #105, who had a care plan for altered thought processes and mood disturbances related to dementia and major depressive disorder, was observed exhibiting hallucinations and disruptive behavior. Despite documentation indicating that psychiatric services were closely monitoring the resident, there were significant gaps in psychiatric visits, with no documented services from January to October 2024. This lack of consistent psychiatric follow-up contributed to the deficiency in care. Resident #245 was observed to be restless and anxious, with behaviors such as pulling at medical equipment. Although a psychiatric consultation was ordered due to agitation, the consultation was delayed because the provider was not informed in a timely manner. Similarly, Resident #214, who exhibited behaviors requiring multiple antipsychotic medications, experienced a delay in receiving a psychiatric consultation. The need for the consult was identified on May 17, 2024, but the order was not placed until nine days later. These delays in providing necessary psychiatric services highlight the facility's failure to meet the behavioral health needs of its residents.
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The facility did not ensure that its Infection Preventionist (IP) met required qualifications for managing the Infection Prevention and Control Program. The DON reported serving as the IP but acknowledged lacking the specialized infection control training required for the role, and confirmed that no other staff member was currently qualified. Records showed that the previously qualified IP left several months earlier, and the Administrator and DON confirmed they were still seeking a replacement, leaving the infection control program without a properly trained leader.
Staff failed to consistently secure medications and medical supplies across three units, including an oxygen tank left on the floor behind a resident’s bed without a supporting device, a treatment cart with Collagenase Santyl cream left on top while two residents in power wheelchairs passed by, an unattended and unlocked treatment cart at a nursing station, and another treatment cart with Diclofenac gel and dressings left on top, indicating repeated lapses in maintaining locked and secure storage for drugs, biologicals, and related supplies.
The facility failed to provide sufficient dietitian coverage and timely nutritional assessments for several residents with significant dietary needs. A resident admitted for diabetic management with a high A1C was placed on a regular diet instead of the recommended carb-controlled diet and had only one weight taken in the first two weeks, with no dietitian review of the record. Another resident with prior significant weight loss had no documented dietitian follow-up despite continued weight loss, and a resident admitted with severe protein-calorie malnutrition experienced further significant weight loss without any dietitian assessment. The dietitian reported working limited hours and prioritizing certain high-risk cases, resulting in delayed or missed evaluations for new admissions and residents with ongoing nutritional concerns.
The facility failed to maintain adequate linen and incontinence supplies and did not keep resident care areas in good repair, resulting in delays and alterations in incontinence care and substandard environmental conditions. Staff reported that towels and washcloths were used instead of wipes and then discarded due to heavy soiling, and that linen deliveries to units were late, leaving residents waiting for care. Observations showed very limited numbers of clean washcloths and other linens on units and in the laundry, with no stock of disposable wipes or backup washcloth supply despite repeated reports to housekeeping. Additional observations revealed recliner chairs blocking a dining-area handwashing sink and kitchenette, multiple resident and shared bathrooms with unfinished spackle, chipped paint, musty odors, black substances near showers, missing threshold molding, exposed cracks and nails, and eroded, rusted baseboard heaters. Hallway handrails on both units were worn, chipped, and splintered, and a shower room contained fecal odors, dried brown stains on the toilet, and deteriorated fixtures, all contributing to a failure to provide a safe, clean, and homelike environment.
Facility staff did not thoroughly investigate two separate abuse allegations involving a resident and an injury of unknown origin involving another resident. In both cases, investigations focused on the directly affected resident and included staff interviews, but there were no interviews of other residents on the unit or documented assessments of those residents for signs of abuse or injuries of unknown origin, including residents unable to communicate due to cognitive status.
Two residents who were dependent on staff for oral care, including one with a tracheostomy, were observed with thick, white or milky substances coating their mouths and teeth, indicating inadequate oral hygiene. One resident communicated that staff did not brush their teeth and that staff "need to." In another case, despite oral care supplies being present in the room, the resident’s mouth and teeth remained unclean on multiple observations, with a thick milky substance caking the teeth and stringing between them when the resident tried to open their mouth. These findings showed that staff did not consistently provide oral care to residents who relied on them for this ADL.
Staff failed to maintain complete and accurate medical records for multiple residents, including missing and inconsistent documentation of wound care, delayed pain assessment after discovery of an injury of unknown origin in a cognitively impaired resident, and inaccurate recording of a PPD test result that was documented as negative despite no evidence the injection was administered and no supporting nurse’s note. Residents reported not receiving certain treatments, while MAR entries either lacked signatures for completion or contained conflicting information about whether care was provided.
Surveyors found that the facility failed to consistently implement and communicate correct transmission-based precautions and PPE use. One resident with a Foley catheter related to wounds had no precaution signage posted, while another resident in a double room had a contact precautions sign at the door, yet the NP entered without PPE and the GNA provided high-contact care wearing only gloves. Staff in that room stated the resident was not on contact precautions and later reversed the sign to show no PPE requirement. Therapy staff reported they rely solely on posted signs to determine PPE, and surveyors identified broader issues with inaccurate signage and staff awareness of which residents required contact precautions.
Surveyors found that MDS assessments were inaccurately coded for two residents. In one case, a resident sustained a femoral neck fracture after a fall, but the subsequent significant change MDS did not code the fall as a major injury and failed to capture prn Tylenol use documented on the MAR within the look-back period. In the other case, a quarterly MDS indicated opioid use for a resident, but the MAR for the same period showed no prescribed opioid, indicating incorrect coding of high-risk drug classes.
A resident who had recently been admitted and experienced a fall received multiple doses of the narcotic analgesic Tramadol, but the facility failed to accurately document all administered doses on the Medication Administration Record (MAR). Review showed only one Tramadol dose recorded on the MAR, while the Controlled Drug Receipt/Record/Disposition Form on the med cart reflected three doses given over two days. In interview, the DON stated staff are expected to document narcotic administration on the MAR and confirmed that two administered doses were not recorded there, resulting in an incomplete and inaccurate medical record.
Unqualified Infection Preventionist Overseeing Infection Control Program
Penalty
Summary
The facility failed to ensure that its designated Infection Preventionist (IP) met the mandatory qualifications for overseeing the Infection Prevention and Control Program. During an interview on 3/24/26 at 10:00 AM, the DON confirmed that she/he was serving as the facility’s IP but had not completed the specialized training in infection control required for the position. The DON further stated that no other staff member currently met the qualifications to serve as IP. Record review showed that the previously qualified IP left the facility in October 2025, and as of the survey date, the position remained unfilled by a qualified individual. At 1:30 PM on the same day, the Administrator and DON confirmed they were still in the process of finding a qualified IP for the facility, leaving the Infection Prevention and Control Program without a properly trained and qualified leader. No specific residents, medical histories, or clinical conditions were described in relation to this deficiency.
Unsecured Medications, Treatment Carts, and Oxygen Equipment
Penalty
Summary
Facility staff failed to ensure that drugs, biologicals, and related medical supplies were securely stored and properly maintained on multiple units. On one unit, an oxygen tank assigned to a resident was observed sitting on the floor behind the resident’s bed without any supporting device. On another unit, a treatment cart was observed with a tube of Collagenase Santyl cream labeled for a specific resident left on top of the cart, while residents in power wheelchairs passed by and staff were present at the nursing station. These observations showed that medications and oxygen equipment were not consistently secured as required. Further observations on additional units revealed an unattended and unlocked treatment cart at a nursing station, and on a separate occasion, a treatment cart with Diclofenac gel labeled for a resident left on top along with multiple packs of dressings. These incidents occurred across three units and on more than one date, demonstrating repeated failures to keep medications and treatment supplies in locked compartments or otherwise secured from unauthorized access.
Insufficient Dietitian Coverage and Delayed Nutritional Assessments
Penalty
Summary
The deficiency involves the facility’s failure to employ sufficient food and nutrition staff, including adequate dietitian coverage, to ensure timely assessment and appropriate diets for residents with significant nutritional and diabetic needs. A resident admitted over two weeks earlier with multiple comorbidities and an A1C of 11.5% had a hospital discharge recommendation for a carbohydrate-controlled diet, but was placed on a regular diet at admission with no acknowledgment of the recommended diet until one week later, when the resident requested larger portions. As of the survey date, the dietitian had not yet seen or reviewed this resident’s medical record, and the resident reported not having seen a dietitian and being very frustrated with the meals. During the first two weeks after admission, only one weight was obtained for this resident, despite physician notes stating the resident’s weight was “stable.” Further review of other residents showed additional failures in timely dietitian assessment and follow-up. One resident, readmitted in January and previously seen by the dietitian in September for a 6.4 lb weight loss over 30 days, had no documented follow-up despite continued weight loss totaling 22 lbs since the last dietitian review. Another resident admitted at the end of February with severe protein-calorie malnutrition had not been seen by the dietitian after about a month in the facility, despite a documented 14 lb (7%) weight loss over two weeks. The dietitian reported working only 12 hours per week at the facility and stated that she must prioritize which residents to see, focusing first on residents with tube feedings and those identified in risk meetings, resulting in delayed or absent assessments for new admissions and residents with ongoing weight loss and malnutrition diagnoses.
Linen Shortages and Poor Environmental Maintenance Compromise Resident Care and Comfort
Penalty
Summary
The deficiency involves the facility’s failure to maintain an adequate supply of clean linens and appropriate incontinence wipes, resulting in delays and alterations in residents’ incontinence care, as well as the use of towels and washcloths in place of disposable wipes. During the initial tour, the surveyor observed that the linen supply on one nursing unit hallway was low. Complaint reviews included concerns about delays in incontinence care and bed linens not being changed regularly, with residents left without clean bedding. A complainant reported that there was not enough clean linen available for residents. Staff interviews confirmed that towels, sheets, and washcloths were being used to wipe residents for incontinence care due to the absence of wipes, and that many of these linens were being thrown away when soiled. Staff also reported a shortage of linen, that linen deliveries to the units were late, and that residents who preferred to get up before breakfast had to wait for care when linen was delayed. Further observations showed that the clean supply room contained no disposable wipes or cloths for incontinence care, and a resident reported that staff did not use wipes, that the resident had to purchase their own, and that heavily soiled towels or washcloths were discarded. A tour of all nursing unit linen carts and closets revealed only six clean washcloths and limited supplies of towels, gowns, and bed linens. In the laundry room, only three washcloths were present, and the laundry assistant stated that there were only three washcloths available for each nursing unit that morning, that the facility was short on linen supply, and that these concerns had been repeatedly reported to the Director of Housekeeping over the preceding month and again that morning. The laundry assistant confirmed there was no additional laundry in process. The DON stated that wipe squares should be used for incontinence care, but no such wipes were found in the clean medical supply room, and no backup supply of washcloths was present in the emergency linen supply. The Director of Housekeeping confirmed there was no backup supply of washcloths. The deficiency also includes environmental and maintenance issues affecting resident bathrooms, handrails, and common areas. In the main dining area, a recliner chair was observed positioned directly in front of the handwashing sink, and two recliner chairs were stored in front of the nutrition area kitchenette. Multiple resident bathrooms and shared bathrooms were repeatedly observed over several days with unfinished spackle on walls that needed resurfacing and painting, chipped paint around sinks, uneven boards nailed to walls under sinks that appeared to partially cover holes, musty odors, black substances between shower bases and walls, missing threshold transition molding exposing cracks, missing tiles, and a nail, as well as eroded and chipped paint on baseboard heaters with exposed dark brown metal and rust-like material. Hallway handrails on both nursing units were observed to be worn, with chips, splintering, holes, and areas where the wood finish had worn off. A shower room was observed with a foul fecal odor, dried brown stains on the back of the toilet seat and in the toilet bowl, and a baseboard heater with eroded, chipped paint and rust-like material, along with chipped paint on the handrail. These conditions were acknowledged by the Director of Maintenance and other leadership, and some areas were noted to be in the process of renovation, but the observed deficiencies remained present during the survey period. Overall, the facility did not maintain a safe, clean, comfortable, and homelike environment in good repair across both nursing units and the dining area. The lack of adequate linen and incontinence supplies, combined with the poor condition of resident bathrooms, handrails, and certain common areas, constituted the basis for the cited deficiency. The observations and staff and resident reports consistently described shortages of essential hygiene supplies, delayed care related to linen availability, and multiple unresolved environmental and maintenance issues in resident care areas and shared spaces.
Failure to Thoroughly Investigate Abuse Allegations and Injuries of Unknown Origin
Penalty
Summary
Facility staff failed to thoroughly investigate allegations of potential abuse involving one resident and an injury of unknown origin involving another resident. For one resident, there were two separate allegations of abuse occurring on different days in early February. The facility’s investigation packets included interviews with staff who cared for or were scheduled to work with this resident on the days of the alleged incidents, and the investigations focused solely on this resident. However, there were no interviews conducted with other residents on the unit to inquire about abusive or neglectful treatment by the staff who were working during the times of the allegations. The surveyors noted that, although the allegations were not validated, there was no documentation that other residents were interviewed, if able, or assessed for signs or symptoms of injury. In a separate incident, another resident was identified on March 4 with a new bruise on the right eye, documented as a change in condition at 4:09 AM. This resident had a BIMS score of 99, indicating the resident was unable to complete an interview and therefore could not report how the injury occurred. The facility’s investigation identified a potential cause of the injury but did not reach a definitive resolution. Additionally, there were no interviews of other residents on the unit regarding possible abuse, nor were there documented assessments of other residents for injuries of unknown origin, particularly for those unable to speak for themselves, as in this resident’s case.
Failure to Provide Oral Care to Dependent Residents
Penalty
Summary
The deficiency involves the facility’s failure to provide oral care to residents who were dependent on staff for activities of daily living, specifically oral hygiene. One resident with a tracheostomy was observed with a thick, sticky white substance in the mouth and was noted to intermittently chew on nearby bedding. This resident made good eye contact and, when asked if staff brushed their teeth, shook their head no and mouthed that staff “need to.” According to the resident’s Minimum Data Set (MDS) dated 2/11/26, the resident was dependent on staff for oral care. Another resident, also dependent on staff for oral care per the 3/11/26 MDS, was observed sitting propped up in bed and able to respond with smiles. During the initial observation, the inside of this resident’s lips and upper and lower teeth had a thick, clear, white milky substance visible when the resident tried to open their mouth to smile. Oral care supplies were present in the nightstand, but the resident’s mouth and teeth were not clean. On a subsequent observation with the DON, NHA, and Corporate VP of clinical services, the same resident again had a thick, clear, milky substance between the lips and caking the teeth, which would string between the teeth when the resident attempted to open their mouth, demonstrating a lack of consistent oral care for residents dependent on staff for this ADL.
Incomplete and Inaccurate Medical Record Documentation for Treatments and Assessments
Penalty
Summary
Facility staff failed to maintain complete and accurate medical records and documentation for multiple residents. For one resident with wound care needs, review of the MAR showed that wound care and related treatments were signed as completed on the dates initially reported, despite the resident’s ongoing complaints that wound dressings were not being changed. When additional dates were reviewed, there were missing staff signatures for wound care on two specific dates, as well as three instances where application of A&D ointment to the resident’s feet was not signed off out of 24 days reviewed. Another resident with severe cognitive impairment, as evidenced by a BIMS score of 00, was found to have an injury of unknown origin (a bruise on the left hand). Documentation showed that a change in condition was initiated late in the morning, but a formal pain evaluation was not initiated and completed until that night, and the resident was unable to explain how the injury occurred or verbalize pain using a standard pain scale. For a third resident, documentation related to the admission PPD test was inconsistent and incomplete. The MAR contained an entry indicating “9” for the administration date, meaning “see nurse’s note,” but there was no corresponding nurse’s note. Despite the absence of a signed administration of the PPD injection, staff documented the PPD result as “negative” on the scheduled read date. The resident reported never receiving the PPD injection, and the DON confirmed that the facility had been out of PPD solution at the time, so the test would not have been administered. These findings demonstrate failures in accurate documentation of treatments and assessments, including wound care, pain assessment, and TB screening, as well as missing or incomplete supporting notes in the medical record.
Failure to Implement and Communicate Correct Transmission-Based Precautions
Penalty
Summary
Surveyors identified a deficiency in the facility’s infection prevention and control program related to inconsistent and incorrect implementation of transmission-based precautions and PPE use. During a complaint investigation focused on residents on transmission-based precautions, one resident with a visible Foley catheter was observed in the room with physical therapy, but there were no signs posted indicating any need for PPE, despite the resident being a new admission with a Foley catheter placed related to wounds. In another double-occupancy room, a contact precautions sign was posted at the doorway, but the nurse practitioner was in the room on a personal phone with no PPE, and the assigned GNA was repositioning the resident in bed while wearing only gloves. When questioned, the NP, RN, and GNA all stated that the resident in the room was not on contact precautions, and the GNA reported that signs were hanging at all doors and that this particular resident’s sign was “just wrong.” The surveyor observed the GNA later return to the room and turn the sign around to indicate no PPE requirement. Subsequent interviews revealed that therapy staff relied on posted signage to determine PPE use and that if the sign was wrong, the PPE used would be wrong. Overall, surveyors found problems with signage accuracy and staff awareness of which residents required contact precautions, as well as observed failures to follow appropriate PPE use for residents who should have been on contact precautions.
Inaccurate MDS Coding for Falls, Pain Management, and High-Risk Medications
Penalty
Summary
Facility staff failed to ensure Minimum Data Set (MDS) assessments were accurately coded for two residents reviewed during a complaint survey. For one resident, a facility-reported incident showed that the resident was found seated on the floor beside the bed and was diagnosed with a non-displaced femoral neck impaction fracture of the left hip following an x-ray. Despite this fall with a major injury, the subsequent significant change MDS dated 11/4/25 did not code the fall with major injury in Section J1900C. Review of the resident’s Medication Administration Records for October and November 2025 showed administration of Tylenol on 10/31/25 at 9:30 PM, which fell within the 5-day look-back period for the MDS, but Section J0100 (prn pain) of the same significant change MDS did not capture the use of Tylenol. For another resident, review of a quarterly MDS with an assessment reference date of 10/15/25 showed that Section N0415 (High-Risk Drug Classes) documented the use of an opioid medication. However, review of the resident’s October 2025 Medication Administration Record did not show that the resident had been prescribed an opioid during that period. In both cases, MDS staff later confirmed that these were errors in MDS coding, demonstrating that the assessments did not accurately reflect the residents’ clinical status and medication use as documented in their medical records.
Incomplete Documentation of Narcotic Administration on MAR
Penalty
Summary
The facility failed to maintain complete and accurate medical records in accordance with accepted professional standards for one resident receiving narcotic medication. The resident, admitted in March 2026, had a fall on 3/6/26 and was sent to the hospital on 3/9/26. Review of the March 2026 Medication Administration Record (MAR) showed documentation of a single 25 mg dose of Tramadol administered on 3/8/26 at 9:23 AM. However, review of the resident’s Controlled Drug Receipt/Record/Disposition Form, kept on the nurse’s medication cart and not in the medical record, showed that Tramadol 25 mg was administered three times between 3/8/26 and 3/9/26: at 11:00 AM and 9:00 PM on 3/8/26, and at 9:00 AM on 3/9/26. In interview, the DON stated that staff are expected to document narcotic administration on the MAR and confirmed that only one of the three Tramadol doses reflected on the controlled drug record was documented on the resident’s MAR. This discrepancy between the controlled substance record and the MAR, with missing documentation of two administered doses of Tramadol on the official medical record, constituted the failure to maintain a complete and accurate medical record for the resident.
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