Lorien Health Systems - Columbia
Inspection history, citations, penalties and survey trends for this long-term care facility in Columbia, Maryland.
- Location
- 6334 Cedar Lane, Columbia, Maryland 21044
- CMS Provider Number
- 215112
- Inspections on file
- 17
- Latest survey
- January 14, 2026
- Citations (last 12 mo.)
- 8
Citation history
Health deficiencies cited at Lorien Health Systems - Columbia during CMS and state inspections, most recent first.
A resident experienced severe left hip pain and was sent to a hospital, where a left hip fracture of unknown origin was diagnosed. Facility records and staff interviews showed that a charge nurse and a unit manager became aware of the severe injury the following day, and the charge nurse learned of the fracture when speaking with the resident’s family. Despite this knowledge, the facility did not submit the required Facility Reported Incident to the State Agency within the mandated two-hour timeframe after learning of the injury’s severity, instead reporting it the next day.
A resident experienced severe left hip pain and was sent to a hospital, where a left hip fracture was diagnosed. The facility’s incident file contained only one on-duty staff statement and two staff email statements, with no further documented investigative steps. A charge nurse learned of the severe fracture from the family but delayed notifying the Administrator and did not initiate additional staff or resident interviews. The Administrator later reported that a unit manager withheld information about the severe injury and confirmed that no comprehensive investigation, including interviews with staff on the involved shift and residents on the same floor, was completed.
Three residents with significant medical conditions did not receive proper pressure ulcer care due to failures in following physician orders, incorrect documentation in the electronic medical record, and inconsistent implementation of wound care protocols. In one case, daily wound treatments were missed for nearly two weeks; in another, wound care was performed more frequently than ordered due to an eMAR error; and in a third, prescribed treatments were not initiated or matched to physician instructions, as confirmed by the DON.
Outside providers performed a debridement on a resident with dementia and a right heel DTI without obtaining consent from the resident's representative. The resident's representative was informed only of a wound assessment, not a procedure, and facility staff did not ensure consent was secured before the debridement took place.
A resident reported being roughly handled by a GNA during ADL care, and several other residents voiced similar concerns about the same staff member's behavior. The facility's investigation was incomplete, lacking interviews with residents and staff regarding the care provided by another implicated staff member, resulting in a failure to thoroughly investigate the abuse allegations.
A resident with complex medical needs, including ventilator dependence and multiple wounds, did not have their care plan updated to reflect specific interventions for heel injuries. Although weekly assessments documented deep tissue injuries and a pressure ulcer, the care plan only included general skin integrity measures and omitted details such as heel elevation, heel boots, or air mattress use. The DON acknowledged the care plan should have been revised to include these interventions.
Staff failed to provide prescribed treatments for two residents, including a resident with dermatitis who did not receive Clotrimazole as ordered for a period of time, and another resident with a diabetic foot wound who missed several days of wound care per physician orders. The DON confirmed these lapses in treatment.
Surveyors found that nursing staff failed to follow physician-ordered parameters when administering blood pressure and diabetic medications for three residents with complex medical conditions. Medications were given or withheld outside of prescribed blood pressure and heart rate thresholds, and there was no documentation of physician notification or new orders. The DON confirmed these findings and acknowledged a pattern of noncompliance on the unit.
A resident with known exit-seeking behaviors eloped from the facility after removing their wanderguard, which they had a history of doing. The resident exited through the main entrance by following a visitor and was later returned by a good Samaritan. Staff interviews revealed the resident used a makeshift cutter, possibly a plastic knife, to remove the wanderguard. The facility's failure to supervise and address the resident's behavior led to the incident being classified as Immediate Jeopardy.
The facility did not complete annual performance evaluations for five GNAs, as required. A review of personnel records showed missing evaluations, and interviews with the NHA and HR Director confirmed this deficiency.
The facility failed to prevent bare hand contact with food, maintain proper hair coverings, and ensure accurate food storage and tray line accuracy. Observations included improper food labeling, unsanitary kitchen conditions, and inadequate monitoring of dishwashing temperatures, affecting all residents.
The facility failed to provide effective communication training for its staff, as revealed during a survey. Interviews with the HR Director, DON, and CEO, along with a review of training records for several GNAs, confirmed the absence of such training in the annual plan and recent materials. Additional records provided by the President of Clinical Services also lacked evidence of effective communication training.
The facility was found to lack a Behavioral Health Training Program during a recertification survey. The Human Resources Director and other staff provided training records and materials, none of which included behavioral health training. The President of Clinical Services confirmed the absence of such a program, noting the end of a previous contract with a behavioral health company.
The facility failed to provide written notification to residents and their representatives regarding hospital transfers, affecting multiple residents. Staff interviews and medical record reviews revealed a consistent practice of verbal notification without written documentation, contrary to regulatory requirements.
The facility failed to provide written notification of the bed-hold policy to residents or their representatives upon transfer to a hospital. Staff confirmed that the policy was included in the transfer packet sent to the hospital but was not given in writing to the residents or their representatives. This deficiency was identified for four residents during a survey.
The facility failed to develop comprehensive care plans for residents, leading to deficiencies in care. A resident on dialysis had a care plan lacking critical details such as dialysis access monitoring. Another resident on psychotropic medications lacked monitoring for side effects. A resident with hand contractures had no care plan addressing the issue, and a hospice resident had no hospice care plan developed. These deficiencies were confirmed by facility staff.
The facility failed to report a resident's injury of unknown origin and an alleged abuse incident within the required timeframe. In the first case, a resident's arm fracture was not reported promptly due to a delay in recognizing the incident. In the second case, an alleged abuse incident between two residents was reported more than two days late, despite the facility's investigation finding no abuse or injury.
A facility failed to thoroughly investigate an injury of unknown origin and an elopement incident involving two residents. One resident was found with a fractured arm, but the facility did not interview other residents for additional information. Another resident eloped after cutting off a wander guard, and the facility did not document how the resident returned or address the frequent cutting of the device.
A resident with a history of elopement behaviors frequently removed their Wanderguard bracelet, leading to an elopement incident. The facility's care plans and records did not include effective interventions or behavior monitoring to address the resident's actions. Staff interviews indicated the resident used plastic knives to cut the Wanderguard, but no measures were taken to prevent this.
A resident was left undressed and without assistance for an extended period, compromising their dignity and privacy. Despite expressing a preference to be dressed, the resident was observed undressed on multiple occasions. The resident's medical records indicated dependency on staff for dressing, and the DON acknowledged the need for staff to ensure privacy and dignity during care activities.
A facility failed to maintain a safe and clean environment in a resident's bathroom, where two ceiling tiles above the shower were falling, and one was heavily discolored. The Maintenance Director suggested a possible water leak from the floor above, and the DON was unaware of the issue until informed during the survey.
The facility failed to provide baseline care plans to two residents or their representatives within 48 hours of admission, as required. Documentation was missing in the residents' records, and interviews with the DON confirmed the absence of evidence that the care plans were communicated. This deficiency was identified during an annual survey and a recertification survey.
The facility failed to update care plans for two residents after significant incidents. One resident experienced a fall requiring hospitalization, but their care plan was not revised upon return. Another resident attempted to elope, yet their care plan remained unchanged since a prior update. Staff interviews confirmed that care plans should be updated after such events, but this was not done.
A facility failed to follow medical orders for a resident with pressure injuries, including not elevating heels and not changing wound dressings daily. The resident's call bell was out of reach, and staff inconsistently used PPE despite enhanced barrier precautions. There was confusion about responsibilities for dressing changes and documentation.
The facility failed to follow physician's orders and care plans for oxygen administration, and did not maintain proper labeling and timely changing of respiratory equipment for three residents. One resident received oxygen at an incorrect rate, another had unlabeled tubing and lacked required humidification, and a third had no active medical order for humidification with an incorrect oxygen setting. Staff were unaware of the prescribed settings and failed to document and monitor the respiratory care properly.
A facility agency provider failed to timely place visit notes into a resident's medical record. A pharmacist recommended a gradual dose reduction (GDR) of Seroquel, and an agency psychiatric NP was contracted to assess the resident for safety. The NP did not assess the resident due to not finding Seroquel in the medical orders, and the visit notes were entered eight days late. The DON acknowledged this delay was not timely.
The facility failed to securely store medications, properly label multidose medications with opening dates, and consistently monitor refrigerator temperatures for medication storage. An unattended and unlocked medication cart was observed, and multiple medications lacked opening dates, confirmed by staff. Additionally, the refrigerator temperature logbook had missing entries, indicating inadequate monitoring.
The facility failed to maintain accurate medical records for two residents, leading to discrepancies in dialysis access documentation, fluid intake monitoring, and enteral feeding protocols. Staff inaccurately documented a discontinued dialysis catheter and failed to record fluid intake for a resident on fluid restriction. Another resident's records lacked specific orders for water flushes during medication administration, as outlined in an outdated enteral protocol. Staff confirmed the inaccuracies, attributing them to outdated information and lack of updates in records.
The facility failed to ensure proper use of PPE for enhanced barrier precautions and timely implementation of medical orders for a resident with pressure injuries. Staff inconsistently used PPE, and the resident and their roommate were concerned about the lack of communication. Additionally, a urine collection bag for another resident was found on the floor, violating infection control practices. These issues were identified during a recertification survey.
Facility staff failed to document that a resident or their Responsible Party received education on the Influenza vaccine before refusing it. The Infection Control Preventionist confirmed that verbal education was provided but not documented, which was acknowledged by the NHA and DON.
A resident admitted with a stage two sacral pressure wound experienced worsening to a stage 4 wound over eight weeks due to inadequate pressure ulcer management. The facility failed to provide necessary wound care treatments, and specialized care was only ordered after the wound had significantly deteriorated. The DON acknowledged the deficiency in managing the resident's condition.
The facility failed to ensure proper monitoring of psychotropic medication use for residents, leading to unnecessary medication administration. A resident was prescribed psychotropic medications without comprehensive monitoring, and another resident had active orders for such medications without side effect or behavior monitoring. Additionally, a delay in implementing a recommended gradual dose reduction for a resident's medication was noted due to an oversight by an agency psychiatric NP.
The facility failed to provide timely dental services for two residents. One resident had a dental consult order that was discontinued without follow-up, and the resident expressed a desire for missing teeth replacement. Another resident's family requested a dental appointment for a cracked tooth, but no action was taken. The deficiencies were due to poor communication and inadequate processes for scheduling dental services.
Failure to Timely Report Severe Injury of Unknown Origin to State Agency
Penalty
Summary
The deficiency involves the facility’s failure to timely report a severe injury of unknown origin to the State Agency, the Office of Health Care Quality (OHCQ), within the required two-hour timeframe after becoming aware of the injury’s severity. On 12/06/2025 at approximately 4:00 PM, a resident was reported to be screaming in severe pain in the left hip and was transported to a nearby hospital. The facility’s investigation file for this incident contained one on-duty staff incident statement and two staff email statements regarding the unknown origin injury. On 12/07/2025, records show that the Charge Nurse (Staff #41) and the Unit Manager (Staff #42) were informed that the hospital had diagnosed the resident with a left hip fracture. During an interview on 01/14/2026, the Charge Nurse reported that on 12/07/2025 she encountered the resident’s family picking up personal belongings and at that time learned that the resident had sustained a severe left hip fracture. In a separate interview on the same day, the Administrator confirmed that facility staff became aware of the resident’s severe injury of unknown origin on 12/07/2025. Despite this, the initial Facility Reported Incident (FRI) was not submitted to OHCQ until 12/08/2025 at 9:54 AM, which was one day after staff became aware of the severity of the injury. This delay did not comply with FRI reporting requirements that mandate immediate notification, and no later than two hours after the facility becomes aware of a severe injury.
Failure to Thoroughly Investigate Severe Injury of Unknown Origin
Penalty
Summary
The deficiency involves the facility’s failure to thoroughly investigate a severe injury of unknown origin sustained by Resident #208. According to the Facility Reported Incident file, an initial report was submitted to the State Agency on 12/08/2025 regarding an incident that occurred on 12/06/2025 at approximately 4:00 PM, when the resident was reported to be screaming in severe left hip pain and was transported to a nearby hospital. Hospital records from 12/07/2025 indicated that the resident had a left hip fracture. The facility’s investigation file contained only one on-duty staff incident statement and two staff email statements related to the event, with no further documented investigative steps. On 12/07/2025, Charge Nurse Staff #41 learned from the resident’s family, who were picking up personal belongings, that the resident had sustained a severe left hip fracture, but she did not notify the Administrator until 12/08/2025 and did not initiate further staff or resident interviews. During an interview, the Administrator reported that Unit Manager Staff #42 withheld information about the severe injury of unknown origin and acknowledged that, despite the severity of the injury, no thorough investigation was conducted. The Administrator confirmed that interviews with staff working the relevant shift and residents on the same floor were not completed, resulting in an incomplete investigation into the cause of the resident’s severe injury.
Failure to Provide and Accurately Administer Pressure Ulcer Care
Penalty
Summary
Facility staff failed to provide appropriate pressure ulcer care and prevention for three residents, as evidenced by medical record reviews and staff interviews. One resident with cerebrovascular disease, diabetes, and peripheral vascular disease was admitted with a sacral Stage IV pressure ulcer. After returning from the hospital with specific wound care instructions, the facility did not administer the required daily sacral wound treatments for nearly two weeks, a lapse confirmed by the Director of Nursing. Another resident, admitted for rehabilitation and wound care with multiple chronic conditions including cerebral palsy and diabetes, had a sacral pressure ulcer that progressed to Stage IV and extended to both buttocks. The treatment orders for this resident were incorrectly entered into the electronic medical record, resulting in wound care being performed three times daily instead of the intended once daily. Staff interviews revealed that treatments were performed according to what appeared in the eMAR, without questioning discrepancies, and the wound care physician confirmed the order was for once daily application only. A third resident, admitted for subacute rehabilitation, had deep tissue injuries (DTIs) on both heels. The treatment administration record showed that the wound care provided did not match the wound physician's orders, with incorrect dressings and delayed initiation of the prescribed treatment. The Director of Nursing acknowledged inconsistencies in following wound care orders on the unit. These findings demonstrate a failure to follow prescribed wound care protocols and ensure accurate implementation of physician orders for pressure ulcer management.
Failure to Obtain Consent for Wound Debridement by Outside Providers
Penalty
Summary
Facility staff failed to ensure that outside providers obtained consent from a resident's representative prior to performing a debridement procedure on a resident's right heel wound. The resident, who had a diagnosis of dementia and was assessed to have moderate cognitive impairment with a BIMS score of 8 out of 15, was admitted following a hospitalization and had a documented deep tissue injury (DTI) on the right heel. The facility's social worker communicated with the resident's assisted living staff and scheduled an assessment of the wound, with the resident's representative aware that an assessment would occur but not informed that a debridement would be performed or that consent would be needed for such a procedure. On the day of the incident, two nurse practitioners from the resident's assisted living arrived at the facility, identified themselves, and were escorted to the resident's room by a nurse. The nurse introduced them to the resident and informed the resident that the providers were there to assess the wound. The nurse then left the room but returned to find the providers performing a debridement without having obtained consent from the resident's representative. The nurse instructed the providers to stop the procedure and reported the incident to facility management. Interviews confirmed that consent was not obtained prior to the debridement.
Failure to Thoroughly Investigate Abuse Allegations
Penalty
Summary
The facility failed to provide documentation that allegations of abuse were thoroughly investigated for one resident who reported being mistreated by staff during activities of daily living (ADL) care. Specifically, a resident alleged to the social worker that a geriatric nursing assistant (GNA) pushed their head on the bed and that some nurses were rough during treatment, causing distress. The facility's documentation included a written statement from the social worker and a statement from one staff member, but lacked resident interviews or staff interviews regarding the care provided by the second staff member implicated in the allegation. Further review revealed that three other residents expressed concerns about the same staff member's treatment, describing her as rough, impatient, and displaying anger towards residents. Despite these concerns, the Director of Nursing (DON) was unaware of the residents' feedback, and the Nursing Home Administrator (NHA) acknowledged that the investigation focused solely on one staff member, overlooking the need to investigate the second staff member's conduct. The lack of comprehensive interviews and follow-up resulted in an incomplete investigation of the abuse allegations.
Failure to Update Care Plan with Accurate Interventions for Skin Integrity
Penalty
Summary
Facility staff failed to review and revise the interdisciplinary care plan to accurately reflect interventions for a resident with significant medical needs. The resident, admitted with diagnoses including cardiac arrest resulting in anoxic brain damage, asthma, and ventilator dependence, developed a deep tissue injury (DTI) to the left heel, as documented in weekly skin assessments from late December through January. Additional wounds, including a Stage 2 pressure ulcer to the left ischium and a DTI to the right buttock, were also noted during this period. Despite these findings, the care plan created for the resident only included general interventions for skin integrity, such as incontinence checks, use of barrier cream, daily skin inspections, and weekly wound monitoring. The care plan was not updated to include specific interventions for the resident's heels, such as elevation or floating of heels, use of heel boots, application of skin prep to heels, or provision of an air mattress. The Director of Nursing confirmed during an interview that the care plan should have been updated to reflect these interventions.
Failure to Administer Physician-Ordered Treatments
Penalty
Summary
Facility staff failed to administer prescribed treatments according to physician orders for two residents. One resident was admitted with dermatitis and was prescribed Clotrimazole by the wound physician. Although the resident received the medication initially, there was a lapse in administration from the end of July through mid-August, despite ongoing physician orders and documentation that the rash had not resolved until later in August. The Director of Nursing confirmed that the treatment should have continued during this period. Another resident with a history of cerebrovascular disease, diabetes, and peripheral vascular disease was admitted with a right foot wound and later underwent a partial foot amputation. The wound physician provided specific treatment orders for the resident's right lateral foot wound. However, review of the treatment administration records revealed that staff failed to provide the ordered wound care during several periods over multiple months. The Director of Nursing acknowledged these lapses in treatment provision.
Failure to Follow Physician-Ordered Medication Parameters
Penalty
Summary
Surveyors identified that the facility failed to ensure residents' drug regimens were free from unnecessary drugs by not adhering to physician-ordered parameters for administering blood pressure and diabetic medications. For one resident with multiple complex diagnoses, including heart failure and diabetes, nursing staff administered Carvedilol even when the resident's heart rate was below the physician-ordered threshold, and failed to administer insulin as ordered when blood sugar was elevated, without documentation of physician notification or new orders. The Medication Administration Records (MAR) and nursing notes confirmed these deviations from prescribed parameters. Similar deficiencies were found for two other residents with significant medical histories, including neurological and cardiovascular conditions. In these cases, medications such as Propranolol, Hydralazine, and Metoprolol were administered or withheld contrary to specific physician orders based on blood pressure and heart rate readings. The Director of Nursing (DON) confirmed these findings during record reviews and acknowledged a recurring issue with staff not following physician-ordered medication parameters on the affected unit.
Failure to Prevent Resident Elopement Due to Inadequate Supervision
Penalty
Summary
The facility failed to provide adequate supervision and intervention for a resident known to have exit-seeking and elopement behaviors. This deficiency was identified during a survey when it was discovered that the resident, who had a history of wandering and removing their wanderguard, managed to elope from the facility. The resident had been displaying wandering behaviors since their admission, and despite having a wanderguard applied, they frequently removed it, including on the day of the elopement. On the day of the incident, the resident cut off their wanderguard and exited the facility through the main entrance by following a visitor. The resident was later returned to the facility by a good Samaritan. Interviews with facility staff revealed that the resident had been using a makeshift cutter, possibly a plastic knife from a food tray, to remove the wanderguard. The facility's staff were aware of the resident's behavior but failed to implement effective measures to prevent the elopement. The facility's failure to adequately supervise the resident and address the known risk of elopement led to the incident being classified as Immediate Jeopardy. The resident's ability to remove the wanderguard and exit the facility without detection highlighted a significant lapse in the facility's safety protocols and monitoring systems.
Removal Plan
- Assessment of the resident for injury on return and documented.
- Notified the Responsible Party and provider.
- The resident was placed on 1:1 sitter.
- Completed wandering/elopement risk assessment, pain, fall, Patient Health Questionnaire 9(PHq9), and Brief Interview of Mental Status(BIMS) assessment.
- Social work evaluation completed.
- The resident was started on plastic silverware.
- The room was changed to be on the other side of the nurse's station.
- Check the wanderguard system to ensure door alarms when the wanderguard is present.
- All wanderguards in the facility were checked for placement and tested.
- Elopement assessments for all residents will be reviewed to ensure accuracy and completion.
- Staff members received education on elopement policy and expectations. Staff will receive education on hire, annually, and as needed.
- Drills will serve as education and competency assessments.
- Education to families regarding signing out.
- Front desk drills for alertness.
- Photos of residents at risk of elopement are posted on the left upper wall inside the front desk station and photos of residents at risk of elopement posted at the nurses' station.
- Elopement binder located at the front desk.
Failure to Conduct Annual Performance Evaluations for GNAs
Penalty
Summary
The facility failed to conduct performance evaluations for five Geriatric Nursing Assistants (GNAs) within the required 12-month period. This deficiency was identified during a review of staff personnel records on July 3, 2024, which revealed that GNAs #26, #27, #28, #29, and #30 did not have any performance evaluations on file. An interview with the Nursing Home Administrator and the HR Director confirmed the absence of these evaluations and acknowledged the deficiency. The facility staff understood that this oversight constituted a failure to comply with regulatory requirements for regular performance reviews of nurse aides.
Food Safety and Sanitation Deficiencies
Penalty
Summary
The facility staff failed to prevent bare hand contact with ready-to-eat food, as observed during an in-room interview with a resident. A GNA was seen handling toast with bare hands while buttering it for the resident, which she later acknowledged was against protocol. This incident was discussed with the unit manager and the director of nursing. In the kitchen, several issues were noted, including improper use of hair coverings by staff, with some not covering their beard hair or wearing any hair covering at all. Additionally, there were concerns about the dating and storage of food items, with some items left unrefrigerated and others improperly labeled or stored. The kitchen equipment was not well-maintained, with broken thermometers and ice accumulation in cold storage areas, creating unsanitary conditions. The surveyor also observed inaccuracies in the tray line, with missing food items on residents' trays, and personal items on food prep surfaces. Furthermore, there was a lack of monitoring of required dishwashing sanitization temperature levels, with several instances of unrecorded temperatures. These practices potentially affected all residents in the facility.
Lack of Effective Communication Training for Staff
Penalty
Summary
The facility failed to ensure that all staff received training in effective communication, as identified during the Extended Survey investigation portion of the recertification survey. An interview with the Human Resources Director revealed that the annual training plan required by the corporate office for nurses and Geriatric Nursing Assistants (GNAs) did not include any training on effective communication. Training records for four GNAs were reviewed, and none showed evidence of such training. Further interviews with the Director of Nursing and the Chief Executive Officer confirmed that recent training materials also lacked effective communication content. Additional training records provided by the President of Clinical Services did not include evidence of effective communication training, and it was confirmed that the facility had no such training for any staff.
Lack of Behavioral Health Training Program
Penalty
Summary
The facility failed to implement a Behavioral Health Training Program, as required by regulations, which was identified during the Extended Survey portion of the recertification survey. On July 5, 2024, the Human Resources Director provided the annual training plan and training records for four Geriatric Nursing Assistants (GNAs), which lacked any information or evidence of a Behavioral Health Training Program. Further interviews with the Director of Nursing and the Chief Executive Officer, as well as a review of training materials from a recent skills day, confirmed the absence of such a program. On July 10, 2024, a review of the training records for the four GNAs again showed no evidence of behavioral health training. Despite additional training records being provided by the President of Clinical Services on July 11, 2024, there was still no evidence of a Behavioral Health Training Program. The President of Clinical Services confirmed that the facility did not have a Behavioral Health Training Program at that time, noting that a previous arrangement with a contracted behavioral health company had ended.
Failure to Provide Written Notification for Hospital Transfers
Penalty
Summary
The facility failed to provide written notification to residents and their representatives regarding transfers or discharges to the hospital, as required by regulations. This deficiency was identified during a recertification and complaint survey, affecting four out of six residents reviewed for hospitalization. The survey revealed that the facility's staff, including Licensed Practical Nurses and Unit Managers, consistently provided verbal notifications but did not follow up with written documentation, which is a regulatory requirement. For Resident #131, the surveyor found that the resident was transferred to the hospital for a change in mental status without receiving written notification. Interviews with the staff, including the LPN and Unit Manager, confirmed that the practice was to verbally inform residents and their representatives, with documentation only in the transfer packet sent to the hospital. The Director of Nursing also acknowledged the lack of written notification, despite verbal communication being documented in the change in condition form (SBAR). Similarly, Resident #49 was transferred to the hospital without written notification to the responsible party, as confirmed by interviews and medical record reviews. The same issue was noted for Residents #74 and #99, where medical records did not show evidence of written notification for hospital transfers. Staff interviews consistently revealed a practice of verbal notification only, with no written documentation provided to residents or their representatives, highlighting a systemic issue within the facility's transfer notification process.
Failure to Provide Written Bed-Hold Policy Notification
Penalty
Summary
The facility failed to notify residents or their representatives in writing of the bed-hold policy upon transfer to an acute care facility. This deficiency was identified during a recertification/complaint survey for four out of six residents reviewed for hospitalization. The bed-hold policy, which outlines the facility's procedure for reserving a resident's bed during therapeutic leave or hospitalization, was not provided in writing to the residents or their representatives, as required. For Resident #131, the facility staff confirmed that the bed-hold policy was included in the transfer packet sent to the hospital but was not given to the resident or their representative. The Licensed Practical Nurse (LPN) and Unit Manager (UM) both stated that they verbally informed the resident and their family about the bed-hold policy, but no written notification was provided. Similarly, for Resident #49, the facility staff did not provide written notification of the bed-hold policy, although it was included in the transfer packet sent to the hospital. The Director of Nursing (DON) confirmed that the facility did not send any written notification to the residents or their representatives. The same issue was observed for Residents #74 and #99, where there was no documentation of written notification of the bed-hold policy being provided to the residents or their representatives upon transfer to the hospital. Staff interviews revealed that the facility's practice was to verbally inform residents and their families about the bed-hold policy and include it in the transfer packet sent to the hospital, but not to provide a written copy to the residents or their representatives.
Deficiencies in Comprehensive Care Planning
Penalty
Summary
The facility staff failed to develop and initiate comprehensive person-centered care plans for several residents, leading to deficiencies in care. For Resident #131, who was dependent on renal dialysis due to End Stage Renal Disease, the care plan lacked critical details such as the type and location of dialysis access, specific dialysis days, and necessary monitoring instructions for the access site. Despite having physician orders for monitoring the AV fistula, these were not reflected in the care plan, which focused primarily on infection control without addressing other essential aspects of dialysis care. Resident #163, who was on psychotropic medications including Lorazepam and Seroquel, did not have a care plan that included monitoring for medication side effects or behavioral changes. The absence of medical orders for such monitoring was confirmed by both the resident's assigned nurse and the facility Administrator, indicating a gap in ensuring the safe administration of these medications. The care plan only included general instructions to administer medications as ordered and monitor for effects, without specific orders for side effect monitoring. For Resident #83, who had visible contractures in both hands, the care plan did not address the issue of contractures or include interventions such as the use of hand splints or palm protectors, despite these being listed in the resident's task list. Additionally, Resident #109, who was admitted to hospice care, did not have a hospice care plan developed since the start of hospice care. The facility staff, including the unit manager and DON, confirmed the absence of a hospice care plan, highlighting a failure to address the resident's change in condition and care needs.
Delayed Reporting of Injury and Alleged Abuse Incidents
Penalty
Summary
The facility failed to report allegations of injury of unknown origin and alleged abuse to the state agency within the required timeframe. In the first case, a resident was found with swelling and discoloration on the left arm, which was later diagnosed as an acute fracture. The incident was initially observed by a nurse, and an X-ray was ordered. However, there was a significant delay between the time the X-ray results were reported and when the facility staff became aware of the incident, leading to a delayed submission of the initial incident report to the state agency. In the second case, an alleged abuse incident occurred between two residents, but the facility did not report it to the Office of Health Care Quality within the required 2-hour timeframe. The incident was reported more than two days later, which was not compliant with the reporting requirements. The facility's investigation concluded that no abuse or injury occurred, but the delay in reporting was confirmed by the Assistant Administrator.
Failure to Investigate Injury and Elopement Incidents
Penalty
Summary
The facility failed to thoroughly investigate an injury of unknown origin involving a resident who was found with a bluish discoloration and swelling on the left arm, later diagnosed as an acute fracture. Despite notifying the physician and conducting staff education on safe transfers and positioning, the facility did not interview other residents to gather additional information about the incident. The administrator acknowledged the lack of interviews with other residents and mentioned that this practice was only recently adopted based on recommendations from a sister facility. In a separate incident, the facility did not adequately investigate an elopement involving a resident who cut off their wander guard and left the facility. Although the resident was returned by a good Samaritan without injury, the facility's investigation did not address how the resident managed to cut the wander guard or document the details of their return. The administrator admitted to the surveyor that the situation was a "perfect storm" and validated the concern about the lack of documentation and investigation into the resident's actions.
Failure to Address Resident's Elopement Risk
Penalty
Summary
The facility failed to provide appropriate behavioral health care and services to a resident with a history of exit-seeking and elopement behaviors. The resident, who had been residing in the facility since December 2023, was known to frequently remove or cut off their Wanderguard bracelet, a device intended to prevent elopement. Despite the resident's repeated actions of removing the Wanderguard, the facility did not implement effective interventions to address this behavior. The resident successfully eloped from the facility on one occasion, following a visitor out of the main entrance, and was returned an hour later. The facility's care plans and physician's progress notes did not adequately address the resident's behavior of cutting the Wanderguard. The care plans were updated but lacked specific interventions to prevent the resident from removing the device. Additionally, the Treatment Administration Record (TAR) did not include behavior monitoring after the first elopement incident. Interviews with staff revealed that the resident likely used plastic knives from food trays to cut the Wanderguard, yet no effective measures were taken to prevent access to these knives or to ensure the Wanderguard remained in place.
Failure to Maintain Resident Dignity and Privacy
Penalty
Summary
The facility staff failed to treat a resident with dignity and respect by leaving them undressed and without assistance for an extended period. During a survey, it was observed that the resident was not appropriately dressed, with only a gown placed on their chest, and reported waiting for staff assistance for 40 minutes. The resident expressed a preference to be dressed and mentioned discomfort with the possibility of an opposite-gender resident entering the room. Despite this, an opposite-gender resident attempted to enter the room during the survey. Further observations revealed that the resident was again found undressed, covered only with a sheet and towel, and expressed a desire to be dressed but had not received assistance. The resident's medical records indicated a high cognitive status and a dependency on staff for dressing. The Director of Nursing acknowledged the importance of maintaining residents' privacy and dignity, stating that staff should knock, introduce themselves, and ensure privacy by closing curtains during care activities.
Ceiling Tile Disrepair in Resident Bathroom
Penalty
Summary
The facility failed to maintain a safe, clean, and well-repaired environment, as evidenced by the condition of the bathroom in a room on the Renaissance 1 Medical Surgical Unit. During an initial observation, two ceiling tiles above the shower were found to be falling down, with one tile showing brown discoloration over 75% of its surface around the ceiling fan. This issue was first noted on 6/20/24. On 7/03/24, the Maintenance Director acknowledged the problem, suggesting a possible water leak from the shower on the floor above. The Director of Nursing was also unaware of the issue until informed during the survey, validating the concern upon inspection.
Failure to Provide Baseline Care Plans to Residents
Penalty
Summary
The facility failed to provide a baseline care plan to residents or their representatives within 48 hours of admission, as required. This deficiency was identified during an annual survey and a recertification survey. Specifically, for one resident, there was no documentation that the baseline care plan was provided on three separate occasions, despite the Director of Nursing (DON) being aware of the issue and unable to provide evidence of compliance. Similarly, another resident's record showed no indication that the baseline care plan was shared with the resident or their representative, and the DON confirmed the absence of documentation. Interviews with the DON and the President of Clinical Services revealed acknowledgment of the deficiency, but no evidence was found to support that the baseline care plans were communicated to the residents or their representatives. The lack of documentation in the residents' records highlights the facility's failure to meet regulatory requirements for timely communication of care plans, which is essential for informing residents and their representatives about the care they will receive.
Failure to Update Care Plans After Incidents
Penalty
Summary
The facility failed to update or revise care plans for two residents following significant incidents. Resident #154, who was initially admitted in December 2023, experienced a fall on March 21, 2024, which required hospitalization. Upon readmission, the resident's care plan, which included interventions for fall risk, was not updated to reflect the new incident. Observations noted the resident's anxious behavior and attempts to get out of a geriatric chair, yet no additional interventions were documented. Interviews with nursing staff, including the Director of Nursing (DON), confirmed that care plans should be updated after such incidents, but it was revealed that the care plan for Resident #154 was not revised after the fall. Similarly, Resident #89 attempted to elope from the facility on October 31, 2022, but the care plan was not updated to address this incident. The last update to the resident's elopement care plan was on July 19, 2022, which included an intervention to engage the resident in purposeful activities. Despite prior elopement attempts, the care plan remained unchanged after the October incident. The DON confirmed the lack of updates to the care plan and acknowledged the surveyor's concerns about this deficiency.
Failure to Follow Medical Orders and Inconsistent Use of PPE
Penalty
Summary
The facility failed to ensure that medical orders were followed and that appropriate care interventions were in place for a resident with pressure injuries. The surveyor observed that the resident's feet were resting directly on the bed surface, contrary to the medical order to elevate or float the heels to prevent skin breakdown. Additionally, the resident's call bell was out of reach, and the resident reported needing assistance with repositioning, which was not addressed promptly. The facility also failed to communicate the reason for enhanced barrier precautions to the resident and their roommate, leading to confusion and concern. The surveyor noted inconsistencies in the use of personal protective equipment (PPE) for a resident on enhanced barrier precautions. Although a sign indicated the need for such precautions, staff did not consistently wear gowns during wound care and repositioning, as required. The resident's wound dressings were not changed daily as ordered, with one dressing observed to be two days old. The facility also failed to obtain a medical order for heel protector boots, despite a hospital discharge recommendation for their use. Interviews with staff revealed a lack of clarity regarding responsibilities for dressing changes and documentation. The wound nurse was performing dressing changes on certain days, but there was no clear process for ensuring all residents were seen or for documenting these changes. The Assistant Director of Nursing reported that precautions were implemented by whoever entered the orders first, indicating a lack of coordination between the Infection Control Nurse and Unit Managers.
Deficiencies in Respiratory Care Management
Penalty
Summary
The facility failed to adhere to physician's orders and care plans for the administration of oxygen to residents, as well as to maintain proper labeling and timely changing of respiratory equipment. Resident #49 was observed receiving oxygen at a rate of 4 liters per minute, contrary to the prescribed 2 liters per minute. The nurse on duty was unaware of the prescribed rate and confirmed that the oxygen order was not documented in the treatment administration record, leading to a lack of proper monitoring. Additionally, the oxygen tubing was not labeled with the date of the last change, indicating a failure in following the facility's policy for changing oxygen tubing. Resident #81 was found using unlabeled oxygen tubing and without the required humidification in place. The medical record indicated that the oxygen equipment should be changed weekly, and humidification should be used continuously. However, the tubing was overdue for a change, and the humidification bottle was not set up until the surveyor's intervention. The RN Unit Manager confirmed these discrepancies and acknowledged the oversight in maintaining the respiratory equipment as per the facility's protocol. Resident #163's oxygen setup lacked labeling on both the tubing and humidification bottle, and there was no active medical order for the humidification. The oxygen liter setting was observed to be at zero, and the family expressed concerns about the respiratory equipment. The LPN and RN involved were unaware of the last change of the tubing and the correct oxygen setting, highlighting a lack of communication and adherence to medical orders. The surveyor's observations and interviews with staff revealed significant lapses in the facility's management of respiratory care for these residents.
Delayed Entry of Visit Notes in Resident's Medical Record
Penalty
Summary
A facility agency provider failed to timely place visit notes into a resident's medical record, which was identified during a recertification survey investigating facility-reported incidents and complaints. The deficiency involved a resident for whom a pharmacist consultant recommended a gradual dose reduction (GDR) of Seroquel (Quetiapine Fumarate). The facility contracted an agency psychiatric nurse practitioner (NP) to assess the resident to ensure the GDR was safe. However, the NP did not assess the resident for a GDR because they could not locate Seroquel in the resident's medical orders. The NP's visit notes were not entered into the resident's chart until eight days after the visit, which the Director of Nursing (DON) acknowledged was not timely.
Medication Storage and Labeling Deficiencies
Penalty
Summary
The facility was found to have several deficiencies related to the storage and labeling of medications during a recertification survey. Firstly, a medication cart on the 2 South Nursing Unit was observed to be unattended and unlocked, allowing access to all medications within. This was confirmed by an LPN who acknowledged that the cart should have been locked when not in use. Additionally, multiple medication carts were found with multidose medications that lacked opening dates, which is necessary to determine their expiration. This was observed on both the first and second floors, with staff confirming the absence of opening dates on medications such as Fluticasone Propionate nasal spray, Acetaminophen solution, and various insulin injections. Furthermore, the facility failed to consistently monitor and document the refrigerator temperatures where residents' medications were stored. The temperature logbook for the first-floor refrigerator showed missing entries for several days in April 2024, indicating a lack of proper monitoring to ensure medication integrity. The unit manager acknowledged that the night shift nurses were responsible for maintaining the logbooks and recognized the need for re-education on this process.
Inaccurate Medical Records and Documentation Errors
Penalty
Summary
The facility failed to maintain complete and accurate medical records for two residents during a recertification and complaint survey. For one resident, there were discrepancies in the documentation of dialysis access sites. The medical record inaccurately indicated the presence of a right jugular tunneled dialysis catheter, which had been discontinued once the left arteriovenous fistula became functional. Additionally, there was a lack of documentation regarding the resident's fluid intake, despite an order for a 1.5 L/day fluid restriction. Furthermore, an audiology consult order remained active in the records even after the appointment had been scheduled, leading to inaccurate staff documentation. For another resident, the facility's records failed to include specific orders for water flushes during medication administration, as required by the resident's enteral feeding protocol. The active orders and the Medication Administration Record (MAR) and Treatment Administration Record (TAR) did not reflect the necessary water flushes during medication pass, which were outlined in an outdated enteral protocol form. The protocol form in the resident's paper chart was not updated to match the current tube feeding orders, leading to inconsistencies in the documentation. Interviews with staff, including unit managers and the Director of Nursing, confirmed the inaccuracies and omissions in the medical records. Staff acknowledged that the documentation did not accurately reflect the residents' current medical orders and protocols. The discrepancies in the records were attributed to outdated information and a lack of proper updates in the electronic and paper records, which resulted in staff following incorrect procedures.
Infection Control Deficiencies in PPE Use and Catheter Maintenance
Penalty
Summary
The facility failed to ensure staff donned appropriate personal protective equipment (PPE) for enhanced barrier precautions and did not timely implement and follow the medical order for these precautions. This was evident for a resident with pressure injuries. The resident was admitted with wounds, and the medical order for enhanced barrier precautions was implemented approximately nine days later. During this period, staff inconsistently used PPE, with some staff not wearing gowns during wound care and repositioning, despite the facility's expectations. The resident and their roommate expressed concerns about the lack of communication and inconsistent use of PPE. Additionally, the facility did not use appropriate infection control practices during urinary catheter maintenance for another resident. The urine collection bag for this resident was observed on the floor, which is against standard infection control practices. The Director of Nursing acknowledged that this was unacceptable. These deficiencies were identified during a recertification survey, highlighting lapses in infection prevention and control practices at the facility.
Failure to Document Flu Vaccine Education
Penalty
Summary
The facility staff failed to document that residents and/or their Responsible Parties (RPs) were provided education on the Influenza vaccine before requesting consent. This deficiency was identified during a survey when reviewing the immunization records of five randomly selected residents. Specifically, for one resident, who had been residing at the facility since December 2023 and refused the Flu vaccine, there was no documentation to support that the resident or their RP received education regarding the flu vaccine. During an interview, the Infection Control Preventionist (Staff #15) stated that they provide education on the Flu and Pneumonia vaccines and obtain consents, documenting these actions in the electronic medical record under the immunization tab. However, it was confirmed that for the resident in question, although verbal education was provided to a family member, it was not documented. This lack of documentation was acknowledged by the Nursing Home Administrator (NHA) and Director of Nursing (DON) when the surveyor shared the concern.
Inadequate Pressure Ulcer Management
Penalty
Summary
The facility failed to provide adequate pressure ulcer management for a resident who was admitted with a stage two sacral pressure wound. Over approximately eight weeks, the resident's condition worsened to a stage 4 sacral pressure wound. The medical record review revealed that the facility did not provide the necessary wound care treatments to prevent the deterioration of the resident's condition. The attending provider only ordered specialized wound care treatment after the wound had progressed to stage 4. An interview with the Director of Nursing confirmed the facility's failure to provide preventative wound care, acknowledging the deficiency in managing the resident's pressure wound.
Failure to Monitor Psychotropic Medication Use
Penalty
Summary
The facility failed to ensure residents remained free from unnecessary medications, as observed during a recertification survey. Resident #138 was found to have been prescribed psychotropic medications without comprehensive monitoring for side effects or behavior. The surveyor noted that the resident had been on trazodone, a psychotropic medication, with PRN orders not limited to 14 days, contrary to recommendations. The Director of Nursing (DON) and other staff acknowledged the lack of monitoring and the oversight in reordering monitoring upon the resident's readmission. Resident #163 was also found to have active orders for psychotropic medications, including Lorazepam and Seroquel, without corresponding orders for monitoring side effects or behavior. The resident's assigned nurse and the facility Administrator confirmed that such monitoring should have been in place but was not ordered. The facility's process for ensuring monitoring was described by the DON, but it was evident that the process was not effectively implemented for this resident. Additionally, Resident #545's case revealed a delay in implementing a recommended gradual dose reduction (GDR) for Seroquel. The facility's contracted agency psychiatric nurse practitioner failed to assess the resident for the GDR due to an oversight in locating the medication in the resident's orders. Consequently, the resident continued to receive the higher dose until the attending provider ordered the reduction. The DON acknowledged the delay and the surveyor expressed concern over the facility's handling of the GDR recommendation.
Failure to Provide Timely Dental Services
Penalty
Summary
The facility failed to ensure timely dental services for residents requiring routine or emergent care, as evidenced by the cases of two residents. One resident had a dental consult order for a loose tooth placed in April 2023, which was discontinued in February 2024 due to a hospital readmission. The resident expressed a desire to have missing teeth replaced, but there was no record of a dental appointment or consult being scheduled. The Unit Manager and Nursing Home Administrator were unaware of the resident's dental concerns until the surveyor's inquiry, and the resident had not been seen by a dentist since the initial order. Another resident's family member had requested a dental appointment for a cracked tooth and decay in March 2024, but no appointment was arranged. The social worker responsible for the Long-Term Care Unit was not aware of the request, as it was not communicated by the previous social worker or nursing staff. The family member reported multiple attempts to arrange the appointment through various staff members, including the administrator, but no action was taken. The deficiencies highlight a lack of communication and follow-through in scheduling necessary dental services for residents. The facility's processes for handling dental consults and appointments were inadequate, leading to delays in care and unmet needs for the residents involved.
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.
