Lorien Health Systems Mt Airy
Inspection history, citations, penalties and survey trends for this long-term care facility in Mount Airy, Maryland.
- Location
- 705 Midway Avenue, Mount Airy, Maryland 21771
- CMS Provider Number
- 215335
- Inspections on file
- 16
- Latest survey
- September 3, 2025
- Citations (last 12 mo.)
- 27
Citation history
Health deficiencies cited at Lorien Health Systems Mt Airy during CMS and state inspections, most recent first.
A resident did not receive medications as ordered by the physician, with multiple doses administered several hours late or on the following day, contrary to facility policy requiring administration within one hour of the scheduled time. This deficiency was confirmed through medical record review and staff interviews.
The facility did not provide documentation that advance directives were reviewed with or information provided to two residents or their responsible representatives. In both cases, although some forms such as MOLST or POA were present, there was no evidence that AD information or education was given or discussed, as confirmed by staff interviews and record reviews.
A resident with a history of recurrent UTIs developed urinary retention after admission and required a urinary catheter and medication. Despite ongoing interventions, including voiding trials and a urology consult, staff did not update the care plan to address the resident's urinary retention and catheter care until the issue was identified by surveyors.
A resident who was dependent on a mechanical ventilator via tracheostomy was hospitalized for respiratory distress and returned to the facility. After a comprehensive assessment was completed post-hospitalization, the interdisciplinary team did not review or revise the care plan to address the resident's ongoing respiratory needs.
Surveyors found that two residents receiving supplemental oxygen had their oxygen tubing and humidifier bottles unlabeled and undated, despite physician orders requiring weekly changes and labeling. An LPN confirmed the omission, noting that night shift staff were responsible for labeling, and the DON acknowledged the issue as unacceptable.
A resident received PRN traMADol for severe pain, but documentation showed the medication was ineffective and there was no timely reassessment or additional interventions recorded. Nursing staff indicated that non-pharmacological interventions were not consistently documented, and the DON confirmed that pain reassessment was delayed.
A surveyor found an expired IV start kit in a medication cart during a review of medication storage and labeling. An RN confirmed the kit was expired and removed it immediately. The DON acknowledged the finding and stated that nurses and unit managers are responsible for checking for expired items, in accordance with facility policy.
Staff documented assessments and treatments for a resident after the individual had already been pronounced deceased and removed from the facility. The MAR and TAR reflected care activities as completed during evening and night shifts, despite the resident's death earlier that day. The DON confirmed the documentation was inaccurate, resulting in incomplete and inaccurate medical records.
Facility staff did not ensure that the social service director and medical director participated in required QAPI committee meetings, with both roles marked as on leave during certain months. No qualified designees were present for these positions, and the staff member covering for the social services director lacked appropriate training. The sign-in sheets did not show participation by a covering medical director.
Two residents in an LTC facility experienced verbal abuse from staff members. One resident, with a history of cognitive communication deficit, reported being verbally abused by a staff member, which was confirmed by a roommate. Another resident, with multiple sclerosis, reported a threatening comment from a staff member, corroborated by a witness. Both incidents were verified by the facility's investigation, leading to the termination of the involved staff members.
A medication administration error occurred when an RN prepared medications for two residents simultaneously, leading to one resident receiving medications intended for another. The affected resident, with a complex medical history, was given cardiovascular drugs and an anticoagulant not prescribed for them, resulting in a hospital transfer for monitoring. The facility's policy requiring resident identification before medication administration was not followed.
The facility failed to ensure proper care and monitoring of residents with PEG tubes, as evidenced by a complaint survey involving five residents. A resident's PEG tube became dislodged and was replaced by an RN, but the facility's policy lacked guidelines for confirming tube placement with an x-ray. Additionally, there were no documented physician orders for PEG tube size or monitoring in the medical records of several residents, highlighting inconsistencies in treatment orders and interventions for potential complications.
A medication administration error occurred when an RN prepared medications for two residents simultaneously and administered the wrong medications to a resident with a complex medical history. The resident received blood pressure-lowering drugs and an anticoagulant not intended for them, leading to hospitalization and episodes of tachycardia and bradycardia.
Failure to Administer Medications as Ordered
Penalty
Summary
The facility failed to ensure that medications were administered to a resident according to physician orders and facility policy. Medical record review and interviews confirmed that multiple medications were not given at the prescribed times over several days. Specifically, medications scheduled for administration at set times, such as 7:00 AM, 8:00 PM, and 11:00 PM, were instead given several hours late, with some doses administered the following day. The facility's policy requires medications to be given within one hour before or after the scheduled time unless otherwise specified by the physician, but this standard was not met for the resident in question. The deficiency was identified during a recertification and complaint survey, which included a review of the medication administration audit report and interviews with facility staff. Both the Unit Manager and the Director of Nursing confirmed the delays in medication administration for the resident during the specified period. The findings were based on direct evidence from the medication records and staff acknowledgment of the deviations from prescribed medication times.
Failure to Document Advance Directives Review and Education
Penalty
Summary
The facility failed to provide documentation that advance directives (AD) were reviewed with, or information and education regarding ADs were provided to, residents and/or their responsible representatives. For two residents, medical record reviews revealed either the absence of AD documentation or lack of evidence that discussions about ADs had occurred. In one case, although a MOLST form and a Power of Attorney document were present in the chart, there was no documentation to support that AD information was provided to the resident or their representative. Interviews with the Director of Nursing and the social work director confirmed that the required documentation was not available and that the family was being contacted to locate the AD. In another instance, a resident's medical record included a MOLST form indicating "No CPR, Option B, Palliative and Supportive Care," but no AD was found in the records, nor was there documentation of any discussion about ADs with the resident or their responsible party. Social services progress notes also lacked any mention of ADs. Staff interviews confirmed that the topic of ADs had not been addressed with the resident or their representative, and the facility's policy requiring inquiry and documentation of ADs upon admission was not followed for these residents.
Failure to Develop Comprehensive Care Plan for Urinary Retention and Catheter Use
Penalty
Summary
The facility failed to develop a comprehensive, person-centered care plan to address a resident's urinary retention and use of a urinary catheter. The resident, who had a history of recurrent urinary tract infections (UTIs), was admitted without a urinary catheter but began experiencing difficulty urinating after admission. As a result, a urinary catheter was ordered and inserted, and the resident was placed on Flomax for urinary retention. Voiding trials were attempted but were unsuccessful, and a urology consult was ordered for ongoing urinary retention and chronic UTIs. Despite these interventions and changes in the resident's condition, there was no documented evidence that the care plan was updated to reflect the resident's urinary retention, catheter use, or the interventions being implemented, such as voiding trials. Interviews with staff confirmed that the care plan had not been updated to address these specific care needs until after the issue was identified by surveyors. The deficiency was identified through record review and staff interviews, which revealed a lack of timely and comprehensive care planning for the resident's urinary issues.
Failure to Revise Care Plan After Hospitalization and Change in Condition
Penalty
Summary
The facility failed to revise the care plan by the interdisciplinary team after each assessment for a resident who experienced a significant change in condition. Specifically, after a resident was hospitalized for respiratory distress and subsequently returned to the facility, a comprehensive assessment (MDS) was completed. However, there was no documented evidence that the care plan was reviewed and revised to address the resident's need for continuous mechanical ventilation related to respiratory insufficiency following the post-hospitalization assessment. Record review and interviews confirmed that the care plan was not updated after the resident's return from the hospital, despite the resident's dependence on a mechanical ventilator via tracheostomy. The DON acknowledged that the care plan should have been reviewed and revised as required, but this was not done after the most recent assessment.
Failure to Label and Date Oxygen Equipment for Residents Receiving Respiratory Care
Penalty
Summary
Surveyors observed that two residents receiving supplemental oxygen therapy had oxygen equipment, including humidifier bottles and oxygen tubing, that were not labeled or dated to indicate when they were last changed. Both residents had physician orders specifying that the oxygen tubing, nasal cannula, and humidifier bottles should be changed weekly and labeled with the date of change. During the survey, the equipment in both residents' rooms lacked any such labeling, and in one instance, the oxygen tubing was found lying on the floor. Staff interviews confirmed that the labeling had not been completed as required. An LPN acknowledged the omission and stated that the night shift was responsible for labeling the oxygen tubing, regardless of whether the oxygen was administered as needed. The DON was also informed of the issue and agreed that the lack of labeling was unacceptable. The deficiency was identified based on direct observation, record review, and staff interviews.
Failure to Timely Assess and Address Ineffective Pain Management
Penalty
Summary
A deficiency was identified when a resident with an order for PRN traMADol for pain was administered the medication for a reported pain level of 7 out of 10. Documentation showed that the medication was not effective in relieving the resident's pain. However, there was no evidence in the Medication Administration Record (MAR) or Treatment Administration Record (TAR) that additional interventions were implemented or that the effectiveness of the pain medication was reassessed within the professional standard of one hour after administration. Interviews with nursing staff revealed that while non-pharmacological interventions such as ice packs might be offered, these were not consistently documented unless there was a physician's order. The Director of Nursing acknowledged that, based on available documentation, the reassessment of the pain medication's effectiveness was completed late, and additional interventions were not offered until several hours after the initial administration.
Expired IV Start Kit Found in Medication Cart
Penalty
Summary
During a recertification survey, facility staff failed to remove expired supplies from a medication cart. Specifically, an IV start kit with an expired date was found in the bottom drawer of Medication Cart #1 on the Prospect Unit. This was observed by a surveyor in the presence of a registered nurse, who confirmed the kit was expired and acknowledged it should not have been in the cart. The nurse immediately removed the expired kit upon discovery. The Director of Nursing (DON) was informed of the finding and confirmed awareness of the expired IV start kit. According to the facility's policy and procedure for storage of medications, no discontinued, outdated, or deteriorated drugs or biologicals should be available for use, and all such items are to be destroyed. The responsibility for checking medication carts for expired items was stated to rest with the nurses and unit managers.
Inaccurate Post-Mortem Documentation in Medical Records
Penalty
Summary
The facility failed to maintain complete and accurate medical records in accordance with accepted professional standards for one resident. A review of the closed medical record for a resident who had died revealed that staff documented assessments and treatments as having been performed during the evening and night shifts on the date of the resident's death, despite the resident having already been pronounced deceased and released to the funeral home earlier that day. Documentation included administration of medications, completion of assessments for pain, oxygen monitoring, bleeding/bruising precautions, and other routine care tasks, all recorded after the resident was no longer present in the facility. Further review of the nurses' progress notes confirmed the resident experienced a change in condition, was assessed by EMTs, and was pronounced dead in the early afternoon. The Director of Nursing verified that the documentation by evening and night shift staff was inaccurate, as the resident was not in the facility at the time the care was recorded as provided. This discrepancy demonstrates that the medical records did not accurately reflect the resident's status or the care provided, constituting a failure to safeguard resident-identifiable information and maintain records according to professional standards.
Failure to Ensure Required QAPI Committee Participation by Key Staff
Penalty
Summary
Facility staff failed to ensure that both the social service director and the medical director participated in the required monthly Quality Assessment Performance Improvement (QAPI) committee meetings. Review of QAPI sign-in sheets revealed that the medical director was on a leave of absence for certain months, and the social service director was also marked as on leave for other months. During these absences, there was no designated person for the medical director, and the only social services worker, who also served as the director, was absent. Staff stated that information from the QAPI meetings was shared with absent members during risk management meetings, but the sign-in roster did not reflect participation by a covering medical director. Additionally, the staff member who acted as the designee for the social services director did not have training in social services, and there was no qualified designee for the medical director during the periods of absence.
Verbal Abuse Incidents in LTC Facility
Penalty
Summary
The facility failed to protect residents from verbal abuse, affecting two residents. Resident #3, who had a history of pulmonary embolism, cognitive communication deficit, hypertension, and a history of falling, reported an incident where a staff member, Staff #110, used derogatory language towards them. The incident was corroborated by Resident #3's roommate, who confirmed hearing the abusive language. Despite the resident's attempt to engage with the staff member, the staff member repeated the abusive statement. The staff member involved refused to cooperate with the facility's investigation and was subsequently terminated. Another incident involved Resident #5, who had a medical history of multiple sclerosis and spinal stenosis. Resident #5 reported that Staff #111 made a threatening comment about pushing them out of their wheelchair. This incident was overheard by another resident, who confirmed the statement. The staff member involved denied making the comment but was reassigned pending investigation and later terminated. The facility's investigation verified the resident's report based on witness statements and the staff member's lack of cooperation. Both incidents were confirmed as verbal abuse by the facility's Director of Nursing and other staff members involved in the investigation. The facility's policy on abuse, which maintains zero tolerance for any form of abuse or neglect, was not adhered to in these cases, leading to the substantiation of the allegations. The facility took steps to investigate and address the incidents, but the deficiency was identified due to the initial failure to protect the residents from verbal abuse.
Medication Administration Error Due to Policy Violation
Penalty
Summary
The facility failed to administer medications according to its policy and standard nursing practice, specifically concerning the medication rights of residents. An incident occurred involving an RN who prepared medications for two different residents simultaneously, which led to a medication error. The RN mistakenly administered medications intended for one resident to another. This error was discovered when the RN realized she still had the medication for the first resident after leaving the room of the second resident. The facility's policy requires identification of the resident before medication administration, which was not followed in this instance. The affected resident, who had a complex medical history including diastolic congestive heart failure, atrial fibrillation, and diabetes mellitus, received medications intended for another resident. These medications included cardiovascular drugs and an anticoagulant, which were not appropriate for the resident's condition. The resident's vital signs prior to the medication administration indicated that a blood pressure medication should have been withheld, but due to the error, the resident received additional medications that could lower blood pressure. As a result, the resident was transferred to the hospital for monitoring and stayed for four days. The facility's Director of Nursing and Nursing Home Administrator were informed of these findings during the survey.
Deficiency in PEG Tube Care and Monitoring
Penalty
Summary
The facility failed to ensure proper processes were in place for the daily care and monitoring of residents with percutaneous endoscopic gastrostomy (PEG) tubes, as evidenced by a complaint survey involving five residents. The deficiency was highlighted by an incident involving a resident whose PEG tube became dislodged and was replaced by a staff RN. The replacement process included inflating the balloon with 15ml of water, as per the SBAR form, and confirming placement through aspiration and auscultation. However, the facility's policy lacked specific guidelines regarding the need for an x-ray to confirm tube placement, and there were no documented physician orders for the size of the PEG tube or directions for placement and monitoring in the resident's medical record. Further investigation revealed that other residents relying on PEG tubes for nutrition and medication administration also lacked documented orders for PEG tube replacement and monitoring. One resident had conflicting orders noting two different sizes of PEG tubes. Interviews with staff confirmed that physician orders should be in place for residents with PEG tubes, but the medical records reviewed did not reflect this. The deficiency was discussed with the facility's Director of Nursing, highlighting the inconsistency and lack of treatment orders and interventions for potential complications related to PEG tube care.
Medication Administration Error in LTC Facility
Penalty
Summary
The facility failed to administer medications to residents without significant medication errors, as evidenced by an incident involving a registered nurse (RN) who prepared medications for two different residents simultaneously. The RN mistakenly administered the medications intended for one resident to another. Specifically, the RN prepared medications for Resident #8 and Resident #12 at the same time and inadvertently gave Resident #12's medications, including three blood pressure-lowering drugs and an anticoagulant, to Resident #8. This error occurred despite the fact that Resident #8's vital signs indicated that blood pressure medication should have been withheld. Resident #8, who had a complex medical history including diastolic congestive heart failure, atrial fibrillation, and diabetes mellitus, was adversely affected by the medication error. Following the administration of the incorrect medications, Resident #8 was transferred to the hospital for monitoring, where they experienced episodes of tachycardia and bradycardia. The hospital recommended the placement of a pacemaker, but the family declined due to the resident's age. The incident was reviewed with the facility's Director of Nursing (DON) and Nursing Home Administrator (NHA) during the survey.
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.
Surveyors found that the facility failed to develop and implement comprehensive care plans for two residents. One resident used a motorized wheelchair and had a documented safety assessment and an ED note describing a leg injury that occurred while using the device, yet the care plan contained no documentation or interventions related to motorized wheelchair use. Another resident had a documented diagnosis of PTSD and a history of childhood sexual abuse, and while the care plan noted trauma as a focus, it listed no specific interventions to address PTSD or the trauma history.
Surveyors identified that the facility failed to revise person-centered care plans after significant changes in two residents’ conditions. For one resident, the MOLST and paper chart were updated from Full Code to DNR-B with No CPR and palliative/supportive care orders, but the care plan continued to list the resident as Full Code. For another resident who sustained a fall with injuries and was sent to the ER, the existing fall-prevention care plan was not updated to reflect the incident or any new interventions, and no timely review was documented. During interviews, the rehab director reported that therapy provides recommendations after falls but does not revise care plans, and the DON and regional administrator confirmed that no care plan revisions or fall investigation documentation were available.
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.
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.
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 Develop Comprehensive Care Plans for Motorized Wheelchair Use and PTSD
Penalty
Summary
Surveyors identified a failure to develop and implement comprehensive care plans for two residents. For one resident who used a motorized wheelchair, interviews with the DON, Administrator, and Occupational Therapist confirmed that the resident had a power mobility device and that a safety assessment for its use had been completed by therapy. The resident’s medical record included an Emergency Department physician note documenting the resident’s report that they were in their motorized wheelchair when they sustained a leg skin tear or laceration after running into their bed. The facility’s matrix and records showed the resident had been admitted and later discharged, and a power mobility indoor driving assessment dated several months prior was provided. Despite this information and the confirmed use of a motorized wheelchair, review of the resident’s care plan showed no documentation addressing the resident’s use of a motorized wheelchair. For another resident, record review showed documentation in the facility matrix and in a Quarterly MDS that the resident had a medical diagnosis of post-traumatic stress disorder (PTSD) and a history of trauma related to childhood sexual abuse. The resident’s care plan focus reflected this trauma history; however, the only listed intervention for that focus was the word “trauma,” with no specific interventions identified to address the PTSD diagnosis or trauma history. During an interview, the Nursing Home Administrator was informed that the resident had a PTSD diagnosis, but the surveyor could not locate any detailed interventions in the care plan beyond the generic trauma notation.
Failure to Revise Care Plans After Code Status Change and Resident Fall
Penalty
Summary
The deficiency involves the facility’s failure to ensure person-centered care plans were timely updated and revised by the interdisciplinary team following significant changes in residents’ status and events. For one resident, a social services note documented that the Maryland MOLST was reviewed and changed from Full Code to DNR-B on a specified date, and the paper chart contained a MOLST form with orders for No CPR, Option B, Palliative and Supportive Care. However, the resident’s care plan still contained a focus stating that the resident’s Full Code MOLST would remain in place through the review date, and this care plan was not revised to reflect the updated code status. During record review with the Nursing Home Administrator, it was confirmed that the MOLST had been updated but the care plan had not been revised accordingly. The deficiency also includes the facility’s failure to revise a resident’s care plan after a fall event. A progress note by an LPN documented that another resident experienced a fall, sustained several injuries, and was transferred to the emergency room. Review of this resident’s care plan showed that no revisions were made to the existing fall interventions in response to the fall, and the care plan was not documented as reviewed and revised until a later date. During interviews, the Director of Rehabilitation stated that therapy makes recommendations and sees residents after falls but does not revise the care plan and was unsure if nursing was responsible for care plan revisions. The DON and Regional Administrator confirmed that no care plan revisions had been made in response to the fall and that there was no recollection or documentation of a fall investigation.
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.
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.
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