Lorien Mays Chapel
Inspection history, citations, penalties and survey trends for this long-term care facility in Timonium, Maryland.
- Location
- 12230 Round Wood Road, Timonium, Maryland 21093
- CMS Provider Number
- 215351
- Inspections on file
- 14
- Latest survey
- October 7, 2025
- Citations (last 12 mo.)
- 1
Citation history
Health deficiencies cited at Lorien Mays Chapel during CMS and state inspections, most recent first.
The facility failed to secure residents' medical records, as four charts were left unattended on a filing cabinet in a hallway, with physician orders visible to the public. A staff member acknowledged the issue and removed the charts, explaining that new orders were usually flagged and placed for nurse review, leading to the oversight.
The facility failed to properly label and monitor expiration dates for stored food items, as observed during a survey. Expired and undated food items were found in the kitchen and walk-in refrigerator. Staff was unable to clarify expiration dates for these items.
The facility's policy on abuse, neglect, exploitation, and misappropriation was found deficient during a survey, as it lacked accurate reporting timeframes and did not include necessary procedures for investigation. The Administrator confirmed the absence of additional policies and the non-use of occurrence reports, despite the policy's requirements.
The facility did not provide written notification to a resident and their representative regarding the resident's transfer or discharge. A resident was hospitalized on three occasions in 2024, and no written notifications were given. The DON confirmed that the facility only provides verbal or phone notifications, which was identified as a concern.
A facility failed to provide a baseline care plan summary for a resident within the required timeframe, as identified during a survey. The baseline care plan was found to be 78 days overdue, with no documentation in the resident's progress notes. The DON acknowledged the oversight and was unsure why it was missed, noting the resident's admission occurred on a Friday after staff had left for the day.
A resident with a left leg fracture was improperly transferred without a Hoyer lift, as required by their care plan, resulting in pain and a deficiency. The resident was non-weight bearing and required total assist, but the aide transferred them manually, causing their leg to jam and heel to hit the floor.
A facility failed to monitor a resident's medication parameters for Metoprolol Succinate ER, as staff did not document required vital signs despite administering the medication. Interviews revealed that an LPN lacked access to an automated link for inputting values, while an RN confirmed that vital signs should always be recorded. The DON acknowledged the expectation for documentation, even if the medication was not held.
A facility failed to monitor a psychotropic medication for a resident, as a pharmacy recommendation for side effect monitoring of Seroquel was not documented or implemented until identified by a surveyor. The DON confirmed the oversight, and behavior monitoring was being conducted by GNAs, but specific side effect monitoring was not in place until the surveyor's intervention.
A resident received medication not prescribed to them, leading to weakness and body aches. A family member found an unrecognized pill on the resident's bed, which was identified as belonging to the resident's roommate. The nursing supervisor confirmed the error and reported it to the DON and NHA for further investigation.
A facility failed to secure medications properly, leading to a resident ingesting a lancet left in a medicine cup and a medication cart being found unlocked and unattended. The resident was sent to the ER for evaluation, and the facility's staff acknowledged the security lapses.
The facility failed to maintain adequate medical records for two residents. One resident's records lacked a thorough assessment after a gastrostomy tube dislodgement and hospital transfer, while another resident's records did not document a timely pain reassessment after a fall. The DON acknowledged the missing documentation, which led to inaccuracies in the residents' medical records.
The facility failed to maintain accurate infection control signage and up-to-date employee immunization records. Surveyors found inconsistent signage for COVID-19 precautions and missing immunization documentation for several GNAs. The DON acknowledged the discrepancies, and the facility's policy did not include Tdap as a required immunization.
A facility failed to offer a pneumococcal vaccine to a resident, as required by its immunization policy. The resident's medical records lacked documentation of being offered, receiving, or refusing the vaccine. The DON confirmed the oversight during an interview, despite providing evidence of the resident receiving an influenza vaccine.
A facility failed to educate a resident about the COVID-19 vaccine, including its benefits, risks, and side effects, and did not offer the vaccine to the resident. The DON confirmed the lack of documentation and education, which was against the facility's policy that emphasizes the importance of vaccination for LTC residents.
A resident was subjected to verbal and physical abuse by a GNA, who was observed on video screaming and pushing the resident. The facility's investigation confirmed the abuse, leading to the GNA's termination.
The facility failed to review background check results for a GNA, who was employed for a year despite a background check revealing a second-degree assault offense. The Administrator and HR Director were unaware of the results, leading to an audit of other employees' background checks.
The facility failed to report injuries of unknown origin and abuse allegations in a timely manner. A resident sustained head trauma, allegedly from a male aide, but the incident was reported to OHCQ over a month later. Another resident's arm bruise was not reported immediately, and a serious injury was reported 51 hours after x-ray results were received. An abuse allegation was also reported late. The facility's Administrator acknowledged these delays.
A facility failed to protect a resident during an abuse investigation and did not thoroughly investigate the allegation. A resident reported abuse by a male nurse in a blue uniform, matching an LPN's description. Despite this, the facility did not take immediate protective measures, allowing the alleged perpetrator to continue working and conduct an interview with the resident. The investigation file contained inconsistencies, and the facility administrator could not confirm any protective actions taken.
A facility failed to update a resident's care plan after multiple G-tube dislodgements, despite discussing the issue in a care plan meeting. The resident experienced four dislodgements between July and October 2024, with two requiring emergency room transfers. The care plan was not updated until October 2024, as staff typically update plans quarterly or as needed, but the dislodgement issue was overlooked until then.
Confidentiality Breach of Residents' Medical Records
Penalty
Summary
The facility failed to maintain the confidentiality of residents' medical records, as observed during a recertification/complaint survey on the second floor nursing unit. Four residents' charts were found unattended on top of a wide filing cabinet in the hallway, with physician orders visible to the public. The charts, belonging to Residents #8, #25, #53, and #56, had physician order pages flagged and sticking out, making them easily accessible and visible. Staff #17, when interviewed, acknowledged the issue and removed the charts. She indicated that the person responsible for writing the rehab orders typically flagged new orders and placed them next to the computer station for nurse review, leading to the oversight in securing the charts.
Deficiency in Food Storage and Labeling
Penalty
Summary
The facility failed to ensure proper labeling and monitoring of expiration dates for stored food items, as observed during the recertification/complaint survey. During a kitchen tour, surveyors found a 3 lbs can of strawberry topping with an expired 'used by' date, a 6 lbs can of navy beans with an unknown expiration date, and several undated open bags of cinnamon swirl bread with raisins and hamburger buns. Additionally, in the walk-in refrigerator, there were undated open bags of mixed salad, turkey breast deli meat, and a large open plastic container of cherry topping prepared on a specific date but lacking an expiration date. Staff #15 was unable to clarify the expiration dates for these items and mentioned that the undated bread was typically used within the day, with no leftovers usually remaining.
Deficiency in Abuse and Neglect Policy Reporting Timeframes
Penalty
Summary
The facility was found to have a deficiency in its abuse, neglect, exploitation, and misappropriation policy during a recertification/complaint survey. The surveyor identified that the policy lacked the necessary reporting and response timeframes required by regulations. Specifically, the policy contained inaccurate reporting timeframes for allegations of abuse, exploitation, neglect, or unknown injury. It stated that reports should be faxed or emailed within 24 hours to the Office of Health Care Quality, and in cases of reasonable suspicion of a crime, the facility must notify OHCQ and law enforcement agencies. However, the policy did not clearly delineate the required timeframes for reporting allegations of sexual abuse or serious bodily injury, leading to confusion and potential non-compliance. During the survey, the facility's Administrator confirmed that the policy in question was the only one in place and that there were no additional policies or procedures related to the investigation of abuse, neglect, or misappropriation. The Administrator also acknowledged that the facility did not use occurrence reports to document allegations, despite the policy indicating otherwise. The surveyor expressed concerns about these deficiencies, which were acknowledged by the facility's Administrator and Director of Nursing during the exit conference.
Failure to Provide Written Notification for Resident Transfers
Penalty
Summary
The facility failed to provide written notification to a resident and their representative regarding the resident's transfer or discharge and the reasons for the move. This deficiency was identified during a recertification/complaint survey for a resident who was hospitalized on three separate occasions in 2024. The medical records review revealed that there was no written notification provided for the hospitalizations on 1/16/24, 8/25/24, and 10/12/24. During an interview, the Director of Nursing stated that families are notified verbally or by phone, and staff are required to document these notifications. However, she confirmed that the facility does not send written notifications, which was identified as a concern.
Failure to Provide Timely Baseline Care Plan
Penalty
Summary
The facility failed to provide a baseline care plan summary for a resident within the required timeframe. This deficiency was identified during a recertification/complaint survey, where it was found that the baseline care plan for a resident was 78 days overdue. The review of the resident's progress notes did not reveal any documentation related to the baseline care plan. During an interview, the Director of Nursing (DON) acknowledged the absence of the baseline care plan and was unsure why it was missed, noting that the resident was admitted on a Friday after staff had left for the day, and the oversight was not corrected the following Monday.
Failure to Use Assistive Device for Resident Transfer
Penalty
Summary
The facility failed to provide and utilize an assistive device as ordered for a resident during a transfer, leading to a deficiency. On the night of May 6, 2024, a resident who had a left leg fracture and was non-weight bearing due to a fall was supposed to be transferred using a Hoyer lift, as per their care plan and physical therapist evaluation. However, the aide attempted to transfer the resident from the bed to a wheelchair without the Hoyer lift, causing the resident's left leg to jam into the bed and their heel to hit the floor hard, resulting in pain. The Director of Nursing confirmed that the resident was a total assist and should not have been transferred without the Hoyer lift.
Failure to Monitor Medication Parameters
Penalty
Summary
The facility failed to ensure proper monitoring of a medication for a resident, identified as Resident #4, during a recertification/complaint survey. The medical record review revealed that the medication administration record (MAR) for January 2025 documented an order for Metoprolol Succinate ER Tablet 25mg, to be given daily for hypertension, with specific parameters to hold the medication if the pulse was less than 60 or systolic blood pressure was less than 100 mmHg. However, from January 1 to January 16, 2025, the fields for recording blood pressure and pulse were not completed, despite staff signing off on the daily administration of the medication. Interviews with facility staff, including an LPN and an RN, indicated a lack of proper documentation for vital signs associated with the medication order. The LPN mentioned that an automated link for inputting values was not present, while the RN stated that there should always be a box to input vital signs for medications with parameters. The Director of Nursing confirmed the expectation for staff to document vital signs in the medical record, even if the medication was not held. The concern was acknowledged by the Director of Nursing and the Unit Manager.
Failure to Monitor Psychotropic Medication
Penalty
Summary
The facility failed to ensure proper monitoring of a psychotropic medication for a resident, as identified during a recertification/complaint survey. The issue was discovered when a surveyor reviewed the medical record of a resident and found that a recommendation made by the pharmacy in November 2024 for side effect monitoring of Seroquel, an antipsychotic medication, was not documented in the resident's medical record. The Director of Nursing (DON) confirmed that the recommendation was not on the 'no recommendations made' list and was unable to locate the recommendation initially. Upon further investigation, the DON provided the missing recommendation, which indicated the need for side effect monitoring on the medication administration record (MAR). However, it was revealed that no side effect or behavior monitoring was present on the MAR until the surveyor's intervention on January 16, 2025. The DON acknowledged the oversight and confirmed that behavior monitoring was being conducted by Geriatric Nursing Assistants (GNAs), but the specific side effect monitoring was not implemented until the surveyor's findings were shared. The concern was communicated to the Unit Manager and the DON, who both acknowledged the issue.
Medication Error Involving Resident and Roommate
Penalty
Summary
The facility failed to ensure that a resident was free from significant medication errors, as evidenced by an incident involving a resident who received medication not prescribed to them. A family member of the resident discovered an unrecognized pill on the resident's bed and reported it to the evening shift supervisor. The resident had previously reported feeling weak and experiencing body aches after being given 14 pills, which was inconsistent with their prescribed medication regimen of 3 pills in the morning and 1 at night. Investigation revealed that the pill found belonged to the resident's roommate, who was prescribed multiple medications. The nursing supervisor confirmed the error and reported it to the Director of Nursing and the Nursing Home Administrator for further investigation.
Medication Security Lapses in Facility
Penalty
Summary
The facility failed to properly secure residents' medications, leading to two significant incidents. In the first incident, a nurse left a lancet in a medicine cup with a resident's medications and placed it unsupervised at the bedside. The resident ingested the lancet along with their pills, mistaking it for a medication. This resulted in the resident being sent to the emergency room for evaluation, where a foreign object was confirmed in their gastrointestinal tract via x-ray. Fortunately, the resident did not suffer any adverse effects following the incident. In the second incident, a medication cart on the second floor was found unlocked and unattended during a surveyor's initial tour. The surveyor was able to access the cart's drawers, which contained various resident medications. An LPN confirmed that the facility's expectation was for medication carts to be closed and locked when not in use. The surveyor shared this concern with the facility's Administrator and Director of Nursing, who acknowledged the issue.
Deficiencies in Medical Record Documentation for Two Residents
Penalty
Summary
The facility failed to maintain adequate medical records for two residents, leading to deficiencies in documenting the care provided. For one resident, the medical records did not include a thorough assessment following the dislodgement of a gastrostomy tube and subsequent transfer to the emergency room. Additionally, there was no documentation indicating that the resident's representative was notified of the hospital transfer. The Director of Nursing acknowledged that the required SBAR communication tool was not completed in a timely manner, and it was too late to enter a late entry assessment. For another resident, the facility's records failed to document a timely reassessment of pain following the administration of Tylenol after an unwitnessed fall. The resident was found with multiple fractures, and although there was a reassessment conducted, it was not recorded in the medical records. The Director of Nursing confirmed that the reassessment should have been documented within an hour of medication administration, but the records did not reflect this. The lack of documentation meant that the resident's medical records did not accurately reflect all interventions provided during their care.
Inaccurate Infection Control Signage and Incomplete Employee Immunization Records
Penalty
Summary
The facility failed to ensure the accuracy of infection control signage and the up-to-date status of employee immunizations, leading to deficiencies in infection prevention and control. During the survey, it was observed that the signage for infection control precautions was inconsistent and inaccurate. Specifically, rooms with COVID-19 positive residents had varying signage, with some rooms lacking appropriate signage altogether. The Director of Nursing (DON) acknowledged the discrepancies and indicated that the typical Infection Preventionist was on leave, which may have contributed to the oversight. Additionally, the facility did not maintain up-to-date immunization records for its employees. A review of employee files revealed that several Geriatric Nursing Assistants (GNAs) lacked documentation for required immunizations, including Tdap, influenza, and MMR. The facility's policy on employee medical records did not mention Tdap as a required immunization, and the DON was unaware of its necessity until questioned by the survey team. Despite requests for documentation, the facility was unable to provide evidence of the missing immunizations for the employees in question. The surveyor's findings highlighted a lack of adherence to infection control protocols and incomplete employee immunization records, which are critical components of infection prevention and control in the facility. The facility's Administrator and DON were informed of these concerns during the survey and exit conference, acknowledging the issues identified by the survey team.
Failure to Offer Pneumococcal Vaccine to Resident
Penalty
Summary
The facility failed to ensure that each resident was offered a pneumococcal vaccine, as evidenced by the case of Resident #19. During a review of electronic medical records for five residents, it was found that there was no documentation indicating that Resident #19 was offered, received, or refused the pneumococcal vaccine. Although the Director of Nursing (DON) provided evidence that Resident #19 had received an influenza vaccine, there was no documentation for the pneumococcal vaccine. The DON confirmed in an interview that Resident #19 was not offered the pneumococcal vaccine, which is a requirement according to the facility's policy on immunization of residents.
Failure to Educate and Offer COVID-19 Vaccine to Resident
Penalty
Summary
The facility failed to provide necessary education to a resident regarding the COVID-19 vaccine, including its benefits, risks, and potential side effects. This deficiency was identified during a review of electronic medical records for five residents, where it was found that one resident had not been offered or educated about the COVID-19 vaccination. The Director of Nursing (DON) was unable to provide documentation to show that the resident had been informed about the vaccine, confirming that no such education or offer had been made. The facility's policy on immunization emphasizes the importance of vaccination for long-term care residents due to their higher risk for complications from illnesses like COVID-19. However, the DON admitted that the resident in question was not educated on or offered the COVID-19 vaccine. The facility's expectation is to offer the vaccine and document consent or refusal, but this process was not followed for the resident, leading to the deficiency noted by the surveyors.
Failure to Protect Resident from Abuse
Penalty
Summary
The facility failed to protect a resident's right to be free from abuse, as evidenced by an incident involving a Geriatric Nursing Assistant (GNA) and a resident. During the facility's recertification/complaint survey, it was found that a nurse aide, GNA #23, was observed on video footage screaming at and calling a resident 'stupid' while pushing the resident back into a wheelchair. This incident was reported in the facility's investigative report MD00204294, which confirmed the abuse through video evidence. The resident involved is a Korean-speaking individual who can understand and respond with limited English. During the initial pool selection, the resident did not express any concerns when asked. However, the investigation revealed that the abuse occurred on a previous date, and the GNA involved was initially suspended and later terminated. The Director of Nursing and the Nursing Home Administrator confirmed that the investigation followed the facility's policy and procedures, including interviews with staff, the resident, and review of camera footage, which substantiated the abuse allegation.
Failure to Review Background Check Results for GNA
Penalty
Summary
The facility failed to ensure a thorough review of background check results during the hiring process for a geriatric nursing assistant (GNA) who had been employed for approximately one year. During a recertification/complaint survey, it was discovered that the employment file for GNA #16 lacked a background check. Upon further investigation, it was revealed that a background check completed on 12/11/23 showed a second-degree assault offense with a guilty disposition and sentencing details. The facility Administrator was initially unaware of these results and could not provide further information about the hiring process for GNA #16. The Human Resources Director confirmed that they were not informed of the background check results by the Human Resources Recruiter, who was no longer in the role. After the surveyor's intervention, the Human Resources Director began an audit to ensure no other employees had similar issues with their background checks. The concern was discussed with the facility's Administrator and Director of Nursing during the exit conference.
Delayed Reporting of Injuries and Abuse Allegations
Penalty
Summary
The facility failed to ensure timely reporting of a serious injury of unknown source and an allegation of abuse, as evidenced by several incidents involving residents. In one case, a resident sustained a blunt force head trauma, allegedly from a male aide, but the facility reported the incident to the Office of Health Care Quality (OHCQ) over a month later. The Nursing Home Administrator (NHA) stated that the injury was believed to be from bedrails, and thus, they did not report it as required. However, the injury was unwitnessed, and the delay in reporting was acknowledged by the NHA. Another incident involved a resident who had a bruise on their arm, which was initially not reported by a GNA who thought it was old. The bruise was later reported to a nurse, and subsequently to the administrator, but the notification to OHCQ was delayed. The LPN involved could not recall the incident, and the NHA was informed of the failure to report in a timely manner. Additionally, a resident's serious injury was not reported to OHCQ until more than 51 hours after the facility received the x-ray results. The facility's Administrator confirmed the late reporting. In another case, an allegation of abuse was made by a resident to a social worker, but the initial report to OHCQ was delayed. The facility's Administrator acknowledged the concern, and no further documentation was provided before the surveyor's exit.
Failure to Protect Resident During Abuse Investigation
Penalty
Summary
The facility failed to ensure protective measures were taken for a resident during an investigation of an abuse allegation and did not thoroughly investigate the allegation. A resident reported an allegation of staff-to-resident abuse to an LPN, who documented the complaint and notified the Director of Nursing. The resident identified the alleged perpetrator as a male nurse in a blue uniform, which matched the description of another LPN. Despite this, the facility did not take immediate action to protect the resident, allowing the alleged perpetrator to continue working and even conduct an interview with the resident. The facility's investigation file contained inconsistencies, including two similar statements from the alleged perpetrator with different dates and differing descriptions of the alleged perpetrator. The facility administrator could not confirm any protective measures taken regarding the alleged perpetrator, who was the only male nurse on the unit during the alleged timeframe. The facility's failure to act promptly and thoroughly investigate the allegation resulted in a deficiency identified during the survey.
Failure to Update Care Plan for G-tube Dislodgement
Penalty
Summary
The facility failed to ensure that the care plan for a resident with a gastrostomy tube (G-tube) was reviewed and updated by the interdisciplinary team after a care plan meeting. The resident experienced four separate incidents of G-tube dislodgement between July 2024 and October 2024, with two incidents requiring transfer to the emergency room for further evaluation. Despite the dislodgement being discussed in a care plan meeting in July 2024, the facility did not update the resident's care plan to address the issue and prevent future occurrences until October 2, 2024. Interviews with staff revealed that the responsibility for updating the care plan typically falls on the unit manager or the Director of Nursing, and updates are usually done quarterly with the Minimum Data Set (MDS) assessment or as needed. However, the G-tube dislodgement was not addressed in the care plan until it was realized by a staff member in October 2024.
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.
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