Mallard Bay Nursing And Rehab
Inspection history, citations, penalties and survey trends for this long-term care facility in Cambridge, Maryland.
- Location
- 520 Glenburn Avenue, Cambridge, Maryland 21613
- CMS Provider Number
- 215191
- Inspections on file
- 19
- Latest survey
- March 30, 2026
- Citations (last 12 mo.)
- 39
Citation history
Health deficiencies cited at Mallard Bay Nursing And Rehab during CMS and state inspections, most recent first.
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.
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.
Facility staff did not ensure that State survey results and the plan of correction were readily accessible for review. An observation of the lobby showed no posted State inspection results and no sign indicating where the survey book could be found. The MDS coordinator reported that the survey book was in the Administrator’s locked office, awaiting maintenance to open it. Later, the DON produced the survey book and acknowledged that it had not been placed in an easily accessible area and that no sign had been posted to inform residents, families, or visitors of its location.
Facility staff failed to accurately code multiple MDS assessments and did not complete a required discharge assessment. Several residents’ MDSs did not correctly reflect documented falls, associated major injuries, PRN pain medication use, or administration of a Tuberculin PPD injection, as shown in the medical record and MAR. In one case, a fall with major injury was coded despite the fracture having occurred earlier from lifting a weight and not from a fall. Additionally, a resident who was discharged had no MDS discharge assessment completed, with the last assessment on file being a quarterly MDS conducted prior to discharge.
Facility staff failed to administer multiple ordered medications and supplements to a resident, including delayed and missed doses of a prescribed oral paste and several PM medications, as confirmed by leadership review of the MAR. Another resident with a history of stroke and repeated unwitnessed falls did not receive complete or consistently documented neuro checks according to the facility’s own neuro check schedule, and ordered orthostatic blood pressures were never obtained or recorded. The same resident had documented low Vitamin D levels with NP notes directing initiation of Vitamin D therapy, but no order was entered and no Vitamin D appeared on the MAR. A second resident with a surgically repaired hip fracture did not receive a timely post-op follow-up visit, had no documented order or timing for staple removal, and NP notes inaccurately continued to describe staples as present and intact after they had already been removed.
Surveyors identified that the facility failed to keep call lights within reach for two residents with impaired mobility, dementia, and documented histories of falls, despite care plans requiring access to call bells and encouraging their use when getting out of bed. One resident’s call bell was found draped behind the bed and stuck under the bed frame, making it inaccessible during an interview. Another resident’s call bell was repeatedly observed wrapped around a side rail and lying on the floor during multiple observations, even though the care plan specified that the call light should be kept within reach at all times while in the room.
Staff failed to keep resident medical information private and confidential when an electronic medical record was left open on an unattended computer atop a medication cart in a hallway. A resident’s chart remained visible on the screen, and another resident’s medications were on display, with additional information accessible in the EMR. The cart and computer were unattended until an LPN returned and acknowledged having left the screen open, resulting in resident information being exposed rather than secured.
A resident was transferred from the facility to another nursing facility without proper documentation of the transfer details. Review of the medical record showed no documented reason for the transfer, no written notice of the transfer to the resident or the resident’s representative, and no completed discharge summary. Leadership confirmed that staff failed to document the required information related to the transfer.
A resident reported being unable to see without glasses and that their glasses were broken, and an NP documented the need for glasses. Despite ongoing notes about frequent falls, dizziness, and blurred vision, and documentation that the resident’s baseline vision was poor and that no glasses were at the bedside, there was no record that vision services were arranged or that glasses were obtained. The resident later confirmed that the glasses had not been replaced and that staff had only stated they would address it, while an RN on the unit was unaware of the glasses issue. The NP stated she had informed nursing staff but could not recall whom, and the Medical Director agreed that the glasses issue and the resident’s complaints of poor vision should have been followed up on.
A resident with dementia, osteoarthritis, obsessive-compulsive disorder, repeated falls, and prior fall-related injuries had a care plan requiring the call light to be kept within reach and fall mats placed on both sides of the bed. Over multiple observations, the resident was found in bed with the call bell wrapped around a side rail and lying on the floor, out of reach, and without fall mats positioned next to the bed; one mat was instead folded by the doorway. The DON observed and acknowledged the misplaced call bell, and the Medical Director was informed of the resident’s history of falls and the missing fall-prevention measures.
A resident admitted with a history of seizures, traumatic brain injury, and chronic pain with a spinal cord stimulator was documented on the MDS and nursing admission assessment as receiving oxygen, yet there were no corresponding physician orders, MAR/TAR entries, or consistent nursing assessments reflecting oxygen therapy or respiratory status. Oxygen use appeared intermittently in vital signs and a few skilled nursing notes without details such as liter flow, tubing change schedule, or humidification, and there was no care plan addressing oxygen therapy. In interviews, the resident reported initial oxygen use but no longer needing it, while an RN described the resident as non-compliant and refusing oxygen, acknowledged that an order was required, and confirmed that no oxygen orders or comprehensive documentation existed in the medical record.
Facility staff did not timely arrange outside orthopedic services as ordered in a hospital discharge summary for a resident who had undergone open reduction internal fixation of the hip for a right femoral neck fracture. The discharge instructions required scheduling an orthopedic follow-up visit within one week, but the appointment was not made and the resident was not seen by the orthopedic physician until several weeks later. The VP of Clinical Services confirmed that staff failed to schedule the follow-up visit within the required timeframe.
The facility failed to maintain complete and accurate medical records for two residents. For one resident with a history of cerebral infarction and left-sided weakness who experienced multiple unwitnessed falls, required neuro checks were not documented in the medical record; instead, staff reported that neuro assessments were kept on separate papers in the DON’s office with fall investigation packets, making them unavailable in the record when needed. For another resident who sustained a right hip fracture and underwent ORIF, the record lacked documentation of staple removal, and NP notes continued to describe staples as clean, dry, and intact even though they had already been removed, resulting in inaccurate skin assessment documentation.
A resident with severe dementia and agitation was found physically restrained in a wheelchair with a gait belt, despite not having a care plan or physician order for restraint use. Multiple staff members observed or were informed about the restraint, and photographic evidence was shared, but there was a delay in removing the restraint and reporting the incident. The responsible individual was not identified, and the deficiency was cited for not maintaining an environment free from physical restraints.
A resident with systemic autoimmune conditions was readmitted and received several courses of IV and oral antibiotics, including treatment via a PICC line. The facility did not update the care plan to include interventions for antibiotic therapy or PICC line care while the resident was undergoing these treatments. This omission was confirmed by an LPN during record review, and the DON was notified of the findings.
Surveyors identified that two residents' medical records were incomplete and inaccurate. For one resident, several medications were marked as not given with instructions to see progress notes, but no explanations were documented. For another resident with a PICC line for IV antibiotics, the site of the catheter was not recorded in the physician's order or the TAR, contrary to standard practice confirmed by nursing staff.
A resident experienced maggots in a wound on two occasions, which was reported to nursing staff but not documented in the medical record. Despite orders for daily dressing changes, the wound dressing was not changed as required, and staff could not provide documentation or explanation for these lapses.
Surveyors found that several residents with mobility and cognitive deficits did not have their call lights within reach, as required by their care plans, and one resident was not positioned comfortably in a chair with proper leg support. These deficiencies were observed during a random tour and involved residents at risk for falls and in need of prompt assistance.
Facility staff did not notify physicians or responsible parties of significant changes in condition for several residents, including episodes of elevated heart rate, hypoglycemia, a missing tooth, and notable weight loss. These failures were confirmed by interviews with the Medical Director and DON, and there was no documentation of required notifications in the medical records.
Surveyors found that the facility did not report allegations of abuse, neglect, or injuries of unknown origin to OHCQ within the required 2-hour timeframe for four residents. In several cases, reports were delayed by more than a day or not submitted at all, and in one instance, no investigation was conducted. The DON confirmed the late or missing reports during interviews, and documentation supported these findings.
Surveyors found that the facility did not thoroughly investigate or document multiple allegations of abuse, including injuries of unknown origin, physical mistreatment by staff, and incidents involving residents with cognitive impairment. In several cases, investigation packets were incomplete or missing, and interviews with all relevant staff and residents were not conducted, as confirmed by the DON.
Surveyors identified that MDS assessments were inaccurately coded for several residents, with omissions including injections, falls with injuries, pain management, medication administration, and hospice care. These discrepancies were confirmed through medical record reviews and staff interviews, revealing that actual care provided was not consistently reflected in the MDS documentation.
Several residents dependent on staff for activities of daily living did not consistently receive or were not offered scheduled showers, with documentation often missing or incomplete. Residents and family members reported infrequent bathing and inadequate incontinent care, while staff cited insufficient GNA staffing as a barrier to providing showers as scheduled.
Multiple residents did not receive prescribed medications as ordered, including antibiotics and pain medications, and there were failures to perform and document required neuro checks after falls. Medication reconciliation and laboratory testing were not completed as directed, and some residents received incorrect medications or experienced changes in medication dosages without proper communication. In one instance, a resident with diabetes suffered repeated hypoglycemic episodes without appropriate assessment or physician notification, as confirmed by staff interviews and medical record review.
Facility staff failed to complete required quarterly nutritional assessments and did not recognize or respond to significant weight loss in three residents. In each case, there was a lack of documentation, failure to notify the dietitian or physician, and missing or incomplete nutritional care plans. Staff interviews revealed confusion about notification responsibilities, and leadership confirmed the deficiencies.
The facility did not maintain adequate nursing staff, resulting in multiple residents missing scheduled showers, being left in soiled briefs, and not receiving timely dressing changes. Staff interviews and documentation confirmed that low staffing levels prevented GNAs and nurses from meeting residents' essential care needs, with facility records showing repeated failure to meet the required minimum hours of bedside care per resident per day.
The facility did not have a full-time licensed NHA authorized by the state during two separate periods, as confirmed by record review and administrator interview. Several individuals served as administrator without verified Maryland licensure, resulting in noncompliance with state requirements.
A facility with 160 certified beds did not employ a full-time qualified social worker as required. Instead, a full-time Social Work Assistant with a background in administration and activities, but not social work, was performing related duties under the guidance of a Regional Social Services Director. The interim NHA confirmed the absence of a qualified social worker on staff.
A resident who was fully alert and oriented was visited by a friend who used a phone to Facetime and share photos, as had been done on previous occasions. A housekeeper intervened, telling the visitor they could not use their phone, and reported the incident to the DON, despite the resident's approval of the activity and the administrator's confirmation that such use is permitted. No other residents were present during the incident.
A resident who was totally dependent on staff for care was left in a soiled brief overnight, despite using the call bell multiple times. The night shift GNAs did not respond to the resident's needs or provide required care, resulting in the resident being found in a urine-soaked bed and visibly distressed the following morning.
A resident's annual MDS assessment was not fully completed, with key sections on cognitive patterns and mood left blank, and the required resident interviews not conducted. Additionally, the assessment was not submitted within the mandated 14-day period after the ARD, with most sections completed late. The MDS Director confirmed these omissions and delays.
Facility staff did not develop a comprehensive nutritional care plan for a resident who experienced a significant weight loss of 9.4%. Despite being on a specialized diet, the resident's medical record lacked a documented nutrition plan. The dietician, citing limited hours, acknowledged the omission, and the Medical Director confirmed the absence of the required care plan.
Facility staff did not consistently hold quarterly care plan meetings or update care plans after changes in residents' conditions. One resident went nearly a year without a documented care plan meeting despite regular assessments, while another experienced multiple falls and a fracture without care plan updates. Additionally, there were lapses in social work documentation and care plan meetings, with missing staff and family participation.
A resident with a right foot wound did not receive timely dressing changes as required. Family members observed outdated dressing dates, and staff interviews revealed that a nurse was unable to change the dressing due to staffing shortages, while another nurse failed to complete the task. Additionally, a staff member admitted to incorrectly dating a dressing, contributing to the deficiency in wound care.
A resident with Alzheimer's disease and fluctuating cognitive impairment exited the facility unsupervised and was found in the community across the street. The facility had not completed an elopement risk assessment prior to the incident, and subsequent assessments contained inaccurate information. A care plan for elopement risk was not initiated until months after the event, and the incident was not reported to the regulatory agency as required.
Two residents experienced significant weight loss that was not properly evaluated or addressed by the physician or nurse practitioners. In both cases, recent weight changes were either overlooked or not acted upon, and there was no documentation of appropriate interventions or notifications to the dietician. The Medical Director confirmed that providers were expected to review and address such changes, but this did not occur.
A resident with chronic inflammatory and visual conditions did not receive prescribed ophthalmic gel for seven days after admission due to the medication being unavailable and delays in pharmacy delivery. Nursing staff documented the unavailability multiple times daily, and the DON confirmed the issue.
Two residents received antihypertensive medications without proper blood pressure monitoring as required by physician orders. In both cases, medications were administered when blood pressure readings were below the specified parameters or not documented at all, and staff confirmed that monitoring was inconsistent. The DON and Medical Director acknowledged the deficiency.
Facility staff did not provide or document dental care for a resident with a missing front tooth, despite family complaints and the issue being observable during the survey. There was no record of dental assessment or referral, and the DON and Medical Director were unaware of any related documentation or evaluation.
Facility staff did not arrange for a resident to be seen by an Infectious Disease physician as required after the resident was readmitted with an infection and inflammatory reaction related to an internal joint prosthesis. The DON confirmed that no appointment had been scheduled, despite the hospital discharge summary indicating the need for follow-up.
A resident's medical record lacked required documentation regarding a fall and subsequent hospital transfer, with no nursing assessments or discharge information recorded for the incident. The DON confirmed that nurse's notes and related documentation were missing from the 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.
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.
Failure to Provide Accessible State Survey Results and Posting Location Information
Penalty
Summary
Facility staff failed to make the results of the annual recertification survey and plan of correction readily accessible to residents, family members, and legal representatives. During an observation of the lobby at 8:05 AM on 3/24/26, there was no evidence of State inspection results displayed in an open and easily accessible area for residents, staff, and visitors to review, and no sign was posted indicating where the State survey results were located. At 8:11 AM, the MDS coordinator stated that they were waiting for maintenance to open the Administrator’s office to obtain the survey book, indicating that the survey results were kept in a locked office rather than in an accessible location. At 8:52 AM, the DON presented the survey book to the surveyor and confirmed that the survey inspection results were not placed in an area easily accessible for review and that a sign directing individuals to the location of the State survey results had not been posted. No specific residents or their medical conditions were mentioned in the report, and the deficiency centered on the facility’s failure to properly display and provide access to the State survey results and related information for review by residents, families, and legal representatives.
Inaccurate MDS Coding and Missing Discharge Assessment
Penalty
Summary
Facility staff failed to ensure Minimum Data Set (MDS) assessments were accurately coded for multiple residents and did not complete a required discharge assessment for one resident. For one resident, the admission MDS with an assessment reference date (ARD) of 11/3/25 captured only one fall without injury, despite medical record documentation of three falls on 10/28/25, 11/1/25, and 11/2/25. The same MDS coded that the resident did not receive PRN pain medication, although the November 2025 MAR showed administration of Tylenol on 11/2/25. Another resident experienced a fall in the room on 10/23/25 and was found on the floor; a nurse practitioner note documented a mildly displaced fracture of the right humerus, yet the MDS with an ARD of 11/21/25 coded zero falls with major injury. A third resident’s MDS dated 9/19/25 coded a fall with major injury within the lookback period, but the medical record showed that the resident’s right elbow fracture occurred earlier while lifting a 5‑pound weight and was not due to a fall, and that a later fall with an ordered x‑ray did not have confirmed injury because the resident refused the x‑ray. Additional MDS coding errors were identified for another resident whose November 2025 MAR documented a Tuberculin PPD injection on 11/3/25, which was not captured in Section N0300 (Medications) of the MDS with an ARD of 11/6/25. The facility also failed to complete a required MDS discharge assessment for a resident admitted in May 2025 and discharged in November 2025. The last MDS on file for this resident was a quarterly assessment dated 9/2/25, and there was no subsequent MDS, including no discharge assessment, in the medical record at the time of review. In each case, the MDS Coordinator confirmed the respective coding errors and the absence of the discharge assessment during surveyor interviews.
Failure to Follow Physician Orders, Complete Neuro Checks, and Accurately Document Post-Operative and Medication Care
Penalty
Summary
The deficiency involves multiple failures by facility staff to provide treatment and care in accordance with physician orders and professional standards of practice for several residents. For one resident, the medical record review showed that a prescribed Triamcinolone Acetonide mouth/throat paste ordered to be applied after meals and at bedtime for seven days was not started until several days after the initial order. A subsequent order for the same medication to be given twice daily for seven days was not administered for multiple AM and PM doses on specified dates. During the same period, the resident did not receive ordered PM doses of several other medications and supplements, including eye drops, fish oil, a health shake, Lactobacillus, Naprosyn, and Vitamin C. The VP of Clinical Services confirmed these missed medication administrations. Another deficiency involved a resident with a history of cerebral infarction with hemiplegia and hemiparesis who experienced multiple unwitnessed falls. The facility’s fall investigation documentation and neuro check assessment forms showed that ordered or expected neuro checks after these falls were either incomplete or entirely absent. For one fall, only two neuro checks were documented despite a form indicating a detailed schedule of frequent checks over 72 hours. For two other falls, there was no documentation of any neuro assessments. For a later fall, only nine neuro checks were documented, and the pattern did not match the expected frequency and duration, with missing four-hour checks and no continuation of neuro checks through 72 hours. The facility’s head injury policy stated that neuro checks should be performed as indicated or as specified by the physician but did not define specific timing or frequency. The same resident also had documented low Vitamin D levels, with NP progress notes indicating a plan to start Vitamin D supplementation at specified daily doses. However, there was no corresponding physician order entered into the electronic system, and review of the Medication Administration Records for several months showed no Vitamin D being administered. The NP later confirmed that the order had never been entered into the system while the NP was still learning the system. Additionally, an NP note documented an order for orthostatic blood pressure measurements in response to repeated falls and concern for hypotension related to a medication, but review of the MAR, TAR, vital signs, and nursing notes revealed no documentation that orthostatic blood pressures were ever obtained. The Director of Clinical Operations confirmed that no orthostatic blood pressures were performed. A further deficiency involved another resident who sustained a right hip fracture after a fall and underwent open reduction internal fixation of the hip in the hospital. The hospital discharge summary instructed that the resident should have a follow-up appointment with the surgeon as soon as possible within one week, but the resident was not seen until several weeks later. Wound assessments documented the presence of surgical staples at one point and a resolved surgical site at a later date, but there was no documentation in the medical record of when the staples were removed. NP notes over a period of time continued to document that the staples were clean, dry, and intact, even though the staples had been removed sometime between two documented assessment dates. There were no physician orders for staple removal and no assessment documented after the staples were removed, and leadership staff acknowledged that the timing of staple removal could not be determined from the record.
Failure to Keep Call Lights Within Reach for Residents at Risk for Falls
Penalty
Summary
The deficiency involves the facility’s failure to ensure residents’ call lights were within reach as required by their individualized care plans. For one resident admitted with a cerebral infarction resulting in left-sided hemiplegia, dementia, impaired mobility, and a history of falls, the care plans directed staff to encourage the resident to use the call bell for assistance and when attempting to get out of bed. During observation, this resident was found lying in bed with the call bell hanging on the wall behind the bed, draped over sconce lights, and the cord positioned behind the headboard. When interviewed, the resident reported frequent falls and, when asked how to call the nurse, looked around for the call bell and attempted to reach behind the bed. The resident was only able to grab the cord, which was stuck behind the bed and not accessible until a GNA entered, identified that the cord was stuck under the bed, and raised the head of the bed to free it. A second resident, in the facility since 2017, had diagnoses including a non-displaced right humerus fracture, osteoarthritis, obsessive-compulsive disorder, unspecified dementia, and repeated falls, with documented falls resulting in a head hematoma with laceration and a right humerus fracture. This resident’s care plans included being at risk for falls with an intervention to keep the call light within reach at all times while in the room, and an additional plan for an actual fall with injury that included educating the resident to use the call bell when getting out of bed. On three separate observations, the resident was found lying in bed with the call bell not within reach; instead, it was wrapped around the back, bottom of the quarter side rail and lying on the floor. The DON, present during one of these observations, acknowledged that the call bell should not be on the floor and was informed of the prior similar observations.
Unsecured Electronic Medical Record and Medications Left Visible on Unattended Med Cart
Penalty
Summary
Facility staff failed to maintain the privacy and confidentiality of resident medical records when an electronic medical record was left visible on an unattended computer screen. During a complaint survey on the 200-nursing unit, a surveyor observed Resident #10’s electronic medical record displayed on an open computer screen atop an unattended medication cart positioned in the hallway outside a resident room. Resident #2’s medications were also on display on the cart, and additional information in the electronic record was accessible on the screen. The cart and computer were unattended until Staff (LPN) #21 returned to the cart, at which time the surveyor informed the LPN that the resident’s medical record had been left open and visible, and the LPN acknowledged having left the computer screen open. These observations demonstrate that staff did not ensure that electronic medical records and medication information were secured when the medication cart was left unattended in a public hallway, resulting in resident medical information being exposed and not kept private and confidential.
Failure to Document Transfer Details and Required Notices for a Transferred Resident
Penalty
Summary
Facility staff failed to document the details of a resident’s transfer to another nursing facility. Medical record review on 1/7/26 showed that Resident #9 was admitted on an unspecified date and was transferred out on 12/4/25 to another nursing facility. The resident’s chart did not contain documentation of the reason for the transfer, any written notice of transfer provided to the resident or the resident’s representative, or a completed discharge summary. In an interview on 1/7/26 at 1:17 PM, the VP of Clinical Services confirmed that staff did not document the details of this transfer. These findings were identified during a complaint survey and were evident for 1 of 3 residents reviewed for transfers, demonstrating that required documentation and notification related to the resident’s transfer, needs, appeal rights, or bed-hold policies were not present in the medical record for this resident.
Failure to Follow Up on Resident’s Need for Glasses and Vision Services
Penalty
Summary
The deficiency involves the facility’s failure to follow up on a documented need for eyeglasses for a resident who reported being unable to see properly. On 11/12/25, a Nurse Practitioner (NP #8) documented that the resident stated he/she could not see without glasses and that his/her glasses were broken. Subsequent documentation on 11/13/25 noted that staff continued to monitor the resident for falls as a safety precaution and that the resident had experienced several recent falls without injury. On 11/21/25, a note recorded that the resident was found on the ground in the courtyard, returned to his/her room, and assessed, at which time the resident complained of dizziness and blurred vision. Later on 11/21/25 at 9:08 PM, NP #8 documented that, per nursing staff, the resident fell out of his/her wheelchair onto his/her face while in the courtyard and that the resident felt dizzy and had poor baseline vision, needed to wear glasses, and did not have any glasses at the bedside. Review of the medical record showed no documentation that the resident was seen for vision services or that glasses were obtained. During interviews, the resident reported frequent falls and stated that glasses had not been replaced or found, and that staff said they would “get around to it.” A full-time RN on the unit reported not knowing anything about the glasses. NP #8 stated she had informed one of the nurses about the glasses but could not recall whom. The Medical Director acknowledged that the issue with the glasses and the resident’s complaints of dizziness and poor vision should have been followed up on and agreed with the surveyor’s findings.
Failure to Maintain Call Bell Access and Fall Mats for High-Fall-Risk Resident
Penalty
Summary
Facility staff failed to ensure that fall prevention interventions, specifically fall mats and the call bell, were properly in place for a resident with a documented history of repeated falls and prior fall-related injuries. The resident had been in the facility since 2017 and had diagnoses including a non-displaced right humerus fracture, primary osteoarthritis, obsessive-compulsive disorder, unspecified dementia, and repeated falls. The medical record showed the resident sustained a fall on 9/28/25 resulting in a head hematoma with laceration, and another fall on 10/23/25 resulting in a right humerus fracture. A 11/20/25 health status note documented that the resident was discussed in a risk management meeting related to falls and that a perimeter mattress and fall mats would be implemented. The resident’s care plan for fall risk included keeping the call light within reach at all times while in the room, educating the resident to use the call bell when getting out of bed, and placing fall mats on both sides of the bed as tolerated. Despite these documented interventions, multiple observations over several days showed that staff did not maintain the call bell within the resident’s reach and did not ensure fall mats were in place next to the bed. On 1/6/26 at 2:37 PM, 1/7/26 at 8:58 AM, and 1/8/26 at 8:38 AM, the resident was observed lying in bed with the call bell wrapped around the back, bottom of the quarter side rail and lying on the floor, not within reach. On 1/7/26 at 8:58 AM, there were no fall mats on the floor next to the resident’s bed; instead, a single fall mat was folded in half by the doorway, while the resident’s bed was by the window. The DON, present during one of the observations, acknowledged that the call bell was not supposed to be on the floor. The Medical Director was informed of the resident’s falls and the observations that the call bell was not within reach and the fall mat was not on the floor next to the bed.
Failure to Provide and Document Ordered Oxygen Therapy in Accordance With Professional Standards
Penalty
Summary
The deficiency involves the facility’s failure to provide and document respiratory services, specifically oxygen therapy, in accordance with professional standards of practice for one resident. The resident was admitted from an acute care facility with diagnoses including seizures, traumatic brain injury, and chronic pain with a spinal cord stimulator, and the admission MDS and nursing admission assessment documented that the resident was admitted with oxygen and received oxygen while in the facility. However, a review of physician orders for October 2025 through January 2026 did not show any physician order for oxygen, and there were no entries on the MAR or TAR indicating that oxygen was administered during those months. Vital sign documentation showed oxygen use on three dates in early November, but there were no nursing assessments from November 1 through November 7 documenting oxygen usage or respiratory status. Further review of skilled nursing assessments throughout November and December showed multiple assessments that did not mention oxygen use, with only a few dates documenting that the resident was on oxygen, and without specifying the number of liters, tubing change schedule, or whether humidification was required. The resident’s care plan did not include any plan for oxygen use. During interviews, the resident reported being on oxygen at admission but no longer needing it, while an RN stated the resident was non-compliant and currently refusing oxygen, acknowledged that a physician order was required, and was unable to locate such an order or any documentation of oxygen use in the medical record. The DON and VP of Operations were informed of these findings, and the Medical Director was informed that the NP’s comprehensive assessments did not address the resident’s oxygen usage.
Failure to Timely Arrange Ordered Orthopedic Follow-Up After Hip Fracture Repair
Penalty
Summary
Facility staff failed to obtain outside professional orthopedic follow-up services in a timely manner as ordered in a hospital discharge summary for one resident. The resident was originally admitted in June 2025 and was readmitted to the facility following a hospitalization for repair of a right femur fracture, during which an open reduction internal fixation of the hip for a right femoral neck fracture was performed. The hospital discharge summary dated 10/24/25 directed that an appointment with the orthopedic physician be scheduled as soon as possible for a visit in one week. Review of the medical record showed that this follow-up appointment was not scheduled and the resident was not seen by the orthopedic doctor until 12/9/25. In an interview, the VP of Clinical Services confirmed that facility staff did not schedule the orthopedic appointment within one week of discharge as ordered.
Incomplete and Inaccurate Medical Record Documentation for Neuro Checks and Post-Operative Wound Care
Penalty
Summary
The deficiency involves the facility’s failure to maintain complete and accurate medical records in accordance with accepted professional standards for two residents. For one resident admitted in October 2025 with a history of cerebral infarction and left-sided hemiplegia/hemiparesis, the medical record showed multiple unwitnessed falls on 10/28/25, 11/2/25, 11/27/25, and 12/26/25, but no neurological assessments (neuro checks) were found in the medical record following these events. During interviews, an RN stated that neuro assessments were either written on a piece of paper sent to the Interim DON’s office or sometimes entered in the vital signs section, and acknowledged uncertainty about the process. The Interim DON reported that neuro assessments were kept with the fall investigation packets in the DON’s office and confirmed they were not part of the resident’s medical record, acknowledging that they would not be accessible in the medical record if a physician requested them on a weekend. The Medical Director stated that neuro assessments should be part of the medical record and expressed disapproval that such information was kept separately. For a second resident who sustained a right hip fracture after a fall and was sent to the hospital, the hospital discharge summary documented an open reduction internal fixation of the right femoral neck fracture. Facility wound assessments documented that the surgical wound initially had staples and later that the surgical site was resolved, but there was no documentation in the medical record of when the staples were removed. Additionally, NP progress notes from 12/2/25 to 1/6/26 documented under skin assessment that the staples were clean, dry, and intact, which was inaccurate because the staples had been removed sometime between 11/11/25 and 11/24/25. These documentation gaps and inaccuracies were confirmed with the VP of Operations and discussed with the Medical Director.
Failure to Maintain Environment Free of Physical Restraints
Penalty
Summary
A deficiency was identified when a resident with severe cognitive impairment and a diagnosis of severe dementia with agitation was found physically restrained in a wheelchair using a gait belt. The resident, who had a Brief Interview for Mental Status (BIMS) score of 0 indicating severe cognitive impairment, was observed by staff with a gait belt wrapped around their waist and the wheelchair, effectively restraining them. Multiple staff members, including GNAs, LPNs, and an occupational therapist, observed or were informed about the restraint, and photographic evidence was taken and shared among staff. Medical record review confirmed that the resident was not care planned for restraint use, and there was no physician order authorizing the use of restraints. Witness statements revealed that the gait belt was left on the resident for an extended period, and several staff members became aware of the situation but did not immediately remove the restraint or report the incident to appropriate supervisory personnel. The occupational therapist and other staff acknowledged in hindsight that the restraint should have been removed sooner. The incident was further substantiated by text messages and emails among staff and administration, including photographic documentation of the resident restrained in the wheelchair. Despite multiple staff being aware of the restraint, there was a delay in action, and the individual responsible for applying the restraint could not be identified. The resident was later observed without the restraint, but the deficiency was established based on the failure to maintain an environment free from physical restraints as required.
Failure to Update Care Plan for Antibiotic Therapy and PICC Line Care
Penalty
Summary
The facility failed to review and revise the interdisciplinary care plan to include accurate interventions for a resident who was receiving intravenous antibiotics and had a peripherally inserted central catheter (PICC) line. The resident, who had diagnoses including Systemic Lupus Erythematosus and Rheumatoid Arthritis, was readmitted in May 2025 and received multiple courses of antibiotics, including Vancomycin and Daptomycin via PICC line, and Amoxicillin-Pot Clavulanate by mouth. Upon review of the clinical record, there was no care plan addressing antibiotic therapy or PICC line care during the periods when the resident was receiving these treatments. The Unit Manager confirmed the absence of updated care plan interventions for these clinical needs and could not provide a reason for the omission. The Director of Nursing was informed of these findings during the survey.
Incomplete and Inaccurate Medical Record Documentation
Penalty
Summary
The facility failed to ensure that medical records were complete and accurate for two residents. For one resident, multiple medications were documented in the Medication Administration Record (MAR) as not given, with the reason coded as 'Other/See Progress Notes.' However, upon review, there was no corresponding documentation in the progress notes explaining why these medications were not administered. Both a registered nurse and the Director of Nursing confirmed that it was expected for such documentation to be present, and that it was missing for the dates in question. The facility's own policy requires documentation to be accurate, relevant, and complete, containing sufficient details about the resident's care and responses to care. For another resident, who had a peripherally inserted central catheter (PICC) line in place for intravenous antibiotic treatment, the physician's order and Treatment Administration Record (TAR) did not specify the site or location of the PICC line. The Unit Manager and the Director of Nursing both confirmed that it was standard practice to document the site of the PICC line in the physician's order and on the TAR, but this information was not present in the resident's clinical record.
Failure to Document and Provide Wound Care per Standards
Penalty
Summary
A deficiency was identified when a resident experienced the presence of maggots in their wound on two separate occasions during their stay. The first incident occurred about a week after the resident's admission, and the second incident happened the week prior to the survey. The resident reported both occurrences to nursing staff, including a nurse and the unit manager. Despite these reports, there was no documentation in the resident's medical record or progress notes regarding the presence of maggots or the incidents themselves. The facility's Unit Manager and DON both acknowledged awareness of the situation but were unable to provide any documentation or explanation for the lack of records. Further review of the resident's treatment orders showed that daily and PRN dressing changes were required, with instructions to date and time each dressing. However, during a wound dressing change observed by the surveyor, the dressing was found to have last been changed three days prior, contrary to the documented daily changes on the Treatment Administration Record. The nurse present did not respond when this discrepancy was pointed out, and the ADON later acknowledged understanding of the issue. The lack of documentation and failure to follow wound care protocols led to the identified deficiency.
Failure to Ensure Call Lights Within Reach and Proper Resident Positioning
Penalty
Summary
Surveyors observed that the facility failed to ensure that call lights were within reach for multiple residents, as required by their individualized care plans. During a random tour, six residents were found with their call bells either on the floor, under the bed, draped over wall lights, or otherwise out of reach. These residents had documented care plans indicating self-care performance deficits, muscle weakness, cognitive deficits, dementia, deconditioning, and high risk for falls, with specific interventions requiring that call lights be kept within reach and residents encouraged to use them for assistance. In each case, the call bell was not accessible to the resident at the time of observation. Additionally, one resident was observed sitting in a semi-reclining wheelchair with legs bent and unsupported, despite having a reclining chair available in the room that would have provided proper leg support. This resident's call bell was also found out of reach. The care plans for these residents consistently included interventions to keep call lights accessible and to encourage their use, particularly due to their risk for falls and limited mobility. The observations demonstrated a failure to follow these care plan interventions, resulting in residents not having access to assistance when needed and not being positioned comfortably.
Failure to Notify Physician and Responsible Parties of Changes in Condition
Penalty
Summary
Facility staff failed to notify physicians and/or responsible parties of significant changes in residents' conditions, as evidenced by multiple incidents. One resident was admitted in November 2024 and experienced several episodes of elevated heart rate prior to being transferred to the hospital, but there was no documentation that the physician was notified of these abnormal vital signs. The Medical Director confirmed that the physician was not informed of the elevated heart rates on the specified dates. Another resident, admitted with a history of stroke and diabetes, experienced multiple episodes of hypoglycemia, with blood sugar readings as low as 53 and 59 mg/dL, and eventually 36 mg/dL, which led to respiratory distress and transfer to the emergency room. There was no documentation that the physician or responsible party was notified of the low blood sugar incidents prior to the emergency event, a fact confirmed by the DON. Additional deficiencies included a resident with a missing front tooth, where there was no documentation that the responsible party was notified, and a significant weight loss in two residents without evidence that the dietician, physician, or responsible party were informed. Interviews with facility leadership confirmed the lack of notification and documentation regarding these changes in condition.
Failure to Timely Report Alleged Abuse and Injuries of Unknown Origin
Penalty
Summary
The facility failed to report allegations of abuse, neglect, or injury of unknown origin to the regulatory agency, the Office of Health Care Quality (OHCQ), within the required 2-hour timeframe for four residents. In one instance, a resident reported to a family member that a nurse caused injury resulting in swelling to the right hand, but the incident was not reported to OHCQ until more than 24 hours after the facility was notified. Another case involved an allegation related to a staff meeting recording, with the initial report to OHCQ submitted nearly two weeks after the incident. For a third resident, bruising of unknown origin was discovered while the resident was in the emergency room, but the incident was not reported to OHCQ, nor was an investigation conducted. In the fourth case, a resident alleged that an aide threw water in their face after administering medication, but the report to OHCQ was delayed by several days. Interviews with the Director of Nursing (DON) confirmed the late reporting or lack of reporting in these cases. Documentation reviewed by surveyors, including email confirmations and investigative packets, substantiated that the facility did not adhere to the required reporting timelines for suspected abuse or injuries of unknown origin. The findings were based on reviews of facility-reported incidents, complaint investigations, and staff interviews.
Failure to Thoroughly Investigate and Document Abuse Allegations
Penalty
Summary
The facility failed to provide documentation that allegations of abuse were thoroughly investigated for seven residents out of thirteen facility-reported incidents reviewed during a complaint survey. In several cases, such as when a resident was found with bruising of unknown origin and another resident alleged physical abuse by a staff member, there was either no formal investigation conducted or the investigation documentation was incomplete or missing. In one instance, the Director of Nursing confirmed that an injury of unknown origin was not formally investigated and no documentation could be provided to the surveyor. Other incidents included allegations of staff physically mistreating residents, such as smacking, poking, or throwing water, as well as reports of residents not feeling safe due to staff actions. In these cases, the facility's investigation packets were either void of any investigation, lacked interviews with all relevant staff and residents, or failed to assess cognitively impaired residents who may have been affected. The Director of Nursing acknowledged that investigations were incomplete or not conducted, and in some cases, stated she was not employed at the facility during the time of the incidents. Additionally, there were incidents involving residents with severe cognitive impairment, including one where a resident was found in a compromising situation with another resident, and law enforcement was contacted. However, the documentation lacked details such as staff interviews, case numbers, or confirmation of when the incident was reported to the appropriate authorities. Across all reviewed incidents, the facility did not consistently follow through with comprehensive investigations or maintain adequate documentation as required.
Inaccurate MDS Assessment Coding for Multiple Residents
Penalty
Summary
Facility staff failed to ensure that Minimum Data Set (MDS) assessments were accurately coded for multiple residents, as evidenced by discrepancies between medical records and MDS documentation. In several cases, injections, falls, fractures, pain management, medication administration, and hospice care were not properly recorded in the MDS, despite being documented elsewhere in the residents' medical records. For example, one resident received a prescribed injection for diabetes, but the MDS assessment indicated no injections were given during the relevant period. Another resident experienced an unwitnessed fall resulting in a fracture, but the MDS failed to document both the fall and the injury. Additional errors included the omission of falls and related injuries for other residents, as well as the failure to record the administration of anti-convulsant and opioid medications. In one instance, a resident was on hospice care, but this was not captured in the MDS assessments. Pain management was also inaccurately documented, with residents receiving scheduled or PRN pain medications that were not reflected in the MDS coding. These inaccuracies were confirmed through interviews with the MDS Coordinator, who acknowledged the errors in assessment coding. The deficiencies were identified during a complaint survey, with six residents specifically noted as having inaccurate MDS assessments. The errors spanned various sections of the MDS, including medication administration, falls, fractures, pain management, and hospice care, indicating a pattern of incomplete or incorrect documentation that did not align with the residents' actual care and medical records.
Failure to Provide and Document Scheduled Showers and Incontinent Care
Penalty
Summary
The facility failed to ensure that residents who were unable to perform activities of daily living independently were consistently offered and/or received showers on their assigned shower days. Multiple residents reported not receiving showers for extended periods, with some stating they had only received bed baths and never refused showers. Documentation for several residents showed either a lack of showers provided, missing records of showers being offered or refused, or entries marked as 'not applicable' on scheduled shower days. In some cases, residents' care plans indicated significant self-care deficits, such as paraplegia and impaired mobility, further emphasizing their dependence on staff for personal hygiene. Interviews with residents and staff revealed that staffing shortages directly impacted the ability to provide showers as scheduled. Staff reported that when the number of geriatric nursing assistants (GNAs) on shift was insufficient, showers could not be given, especially for residents requiring assistance from two GNAs. Documentation inconsistencies were noted, with some residents receiving only bed baths for months and others having sporadic or undocumented shower provision. Residents expressed dissatisfaction, stating they were not offered showers or were told by staff that there was not enough time to provide them. Additionally, there were documented instances of residents not receiving timely incontinent care, as evidenced by bowel and bladder records showing missed care on multiple shifts. Family members also reported finding their loved ones soiled during visits. These findings collectively demonstrate a pattern of inadequate assistance with activities of daily living, specifically related to bathing and personal hygiene, due to both documentation failures and staffing issues.
Failure to Provide Care and Administer Medications as Ordered
Penalty
Summary
The facility failed to provide appropriate treatment and care according to physician orders, resident preferences, and goals, as evidenced by multiple incidents involving eight residents. In several cases, residents did not receive prescribed medications as ordered. For example, one resident was prescribed Macrobid for a urinary tract infection but only received the medication for four days instead of the five days ordered, despite the medication being available in the facility's stock. Another resident did not receive several medications, including antibiotics and pain medications, upon admission and after hospital discharge, as documented in the Medication Administration Record and confirmed by the Director of Nursing. There were also failures in post-fall care and documentation. Two residents experienced unwitnessed falls, and although neuro checks and vital signs were ordered and noted as necessary, there was no documentation that these assessments were performed after the incidents. In one case, a resident was found unresponsive and expired after a fall, with no evidence of neuro checks being conducted between the fall and the discovery of the resident's condition. Another resident's representative reported a lack of information regarding the resident's fall and subsequent transfer to the hospital, and the medical record lacked documentation of neuro checks or assessments following the fall. Additional deficiencies included failures in medication reconciliation and laboratory testing. One resident's medication list was not fully reconciled after readmission, and laboratory tests recommended by a nurse practitioner were not ordered until after surveyor intervention. There were also instances where residents received incorrect medications, missed doses of IV antibiotics, and changes in medication dosages without proper communication or documentation. In one case, a resident with diabetes experienced multiple episodes of hypoglycemia, including a critical event requiring emergency intervention, but there was no documentation of daily skilled assessments, vital signs, or physician notification of low blood sugars. These findings were confirmed through interviews with facility staff and review of medical records.
Failure to Complete Nutritional Assessments and Address Significant Weight Loss
Penalty
Summary
Facility staff failed to complete required quarterly nutritional assessments for multiple residents and did not recognize or respond appropriately to significant weight loss. For one resident with a diagnosis of malnutrition, the last nutritional assessment was completed over a year before discharge, with no subsequent dietitian notes or follow-up. The dietitian confirmed the lack of documentation and attributed it to limited contracted hours, stating she could not complete all necessary assessments within her allotted time. Another resident experienced a 9.4% weight loss over several months, but there was no evidence in the medical record that the dietitian, physician, or responsible party were notified. The resident's care plan lacked a nutritional component, and staff interviews revealed confusion about who was responsible for notifying the dietitian. The medical director and DON acknowledged that the weight loss should have been addressed and that dietary assessments were missing from the record. A third resident had a documented 7.1% weight loss in one month, with no documentation that the dietitian or physician were notified. Subsequent medical notes referenced the resident's weight but did not address the loss or initiate a nutritional consult. The DON confirmed that no notifications were made regarding the weight losses, and the medical director concurred with the findings.
Failure to Provide Sufficient Nursing Staff and Essential Resident Care
Penalty
Summary
The facility failed to provide sufficient nursing staff to meet the needs of its residents, as evidenced by multiple complaints, staff interviews, and documentation reviews. Sixteen out of forty-two complaints reviewed by the Office of Health Care Quality (OHCQ) alleged inadequate staffing, resulting in essential care such as showers, toileting, and changing not being provided. Several residents reported not receiving scheduled showers for extended periods, with documentation confirming missed or unoffered showers over several months. Staff interviews corroborated these findings, with geriatric nursing assistants (GNAs) stating that when staffing levels were low, they were unable to provide showers or complete other necessary care tasks. Further review revealed that the lack of adequate staffing also impacted other aspects of resident care. In one instance, a nurse was unable to change a resident's dressing due to being the only nurse for 40 residents, resulting in the dressing not being changed as scheduled. Additional complaints and grievance logs documented residents being left in soiled briefs for extended periods, with staff confirming that high resident-to-staff ratios made it impossible to provide timely care, including answering call bells and performing regular rounds. Staff consistently reported that when there were call outs or insufficient GNAs, care tasks such as showers and meal service could not be completed as required. Analysis of staffing schedules and records showed that the facility repeatedly failed to meet the state-mandated minimum of 3.0 hours of bedside care per resident per day (PPD). For multiple periods reviewed, the facility's staffing hours fell below this threshold, with some days as low as 2.31 PPD. The staffing coordinator acknowledged ongoing difficulties in maintaining adequate staffing levels, particularly after the facility stopped using agency staff, and noted frequent challenges in securing registered nurses for night shifts. These deficiencies had the potential to affect all residents in the facility.
Failure to Employ Licensed Nursing Home Administrator
Penalty
Summary
The facility failed to employ a full-time licensed Nursing Home Administrator (NHA) authorized by the State of Maryland during two distinct periods. Record review and interviews revealed that from November 9, 2022, until November 15, 2023, and again from February 4, 2024, until March 4, 2024, the facility did not have an NHA with a valid Maryland license. The surveyor was unable to verify the licensure status of several individuals listed as administrators during these periods, and the current administrator confirmed the absence of a licensed NHA for the specified times. This deficiency was identified during an investigation into an anonymous complaint regarding the facility's operation without a full-time licensed NHA.
Failure to Employ Full-Time Qualified Social Worker in Facility Exceeding 120 Beds
Penalty
Summary
The facility failed to employ a full-time qualified social worker despite having more than 120 certified beds, as required. At the time of the survey, the facility was licensed for 160 certified beds. An interview with the Social Work Assistant revealed that she was employed full-time but was not a licensed or certified social worker; her background included administration, medical assisting, and activities, but not social work. She reported being trained by the Regional Social Services Director, who was available on call, but confirmed that there was no full-time qualified social worker on staff. The interim Nursing Home Administrator also confirmed the absence of a full-time qualified social worker at the facility.
Failure to Respect Resident Privacy During Visitor Interaction
Penalty
Summary
Facility staff failed to respect the privacy of a resident who was fully alert and oriented, as evidenced by a BIMS score of 15 out of 15. The incident occurred when a housekeeper observed a visitor in the resident's room using a phone, which the resident stated was for the purpose of Facetiming the visitor's mother and sharing family photos, activities that had occurred multiple times before without issue. The housekeeper approached the visitor, told them they could not use their phone, and then reported the situation to the Director of Nursing after the visitor responded dismissively. The resident expressed that they did not see any problem with the visitor's actions and felt that the staff member should not have intervened. The housekeeper stated that she tells everyone not to have their cell phone out, but did not observe the visitor taking pictures outside the resident's room. The administrator confirmed that residents have the right to Facetime with visitors in their rooms. At the time of the incident, the resident was alone with the visitor and no other residents were present.
Resident Left Unattended in Soiled Brief Due to Staff Neglect
Penalty
Summary
A resident with quadriplegia, depression, anxiety disorder, and chronic pain, who was totally dependent on staff for all activities of daily living, was left unattended in a soiled brief for an extended period. The resident was last changed at approximately 10:30 PM by the evening shift GNA and was not changed again until 8:00 AM the following morning, despite ringing the call bell several times during the night. The night shift GNA entered the room, turned off the call bell, but did not provide care. Both GNAs assigned to the unit that night reported not answering any call bells or providing care to the resident during their shift. When the morning staff arrived, the resident was found visibly upset, crying, and lying in a bed soaked with urine. The resident was alert and oriented, with a BIMS score of 15, and clearly communicated the lack of care received overnight. Staff interviews confirmed that the resident did not receive the required care and that there was a history of issues with night shift aides not performing their duties. The facility's documentation and witness statements corroborated the resident's account of neglect.
Failure to Complete and Timely Submit Comprehensive MDS Assessment
Penalty
Summary
The facility failed to complete the Comprehensive Minimum Data Set (MDS) assessments for a resident both thoroughly and within the required timeframe. Specifically, the annual MDS assessment for the resident, with an Assessment Reference Date (ARD) of 10/12/24, was missing critical sections, including Section C (Cognitive Patterns) and Section D (Mood), which were not completed as indicated by blank entries. The MDS Director confirmed that these sections, which include the Brief Interview for Mental Status (BIMS) and the Resident Mood Interview, were not done, and attributed responsibility for one section to social work. The absence of these completed sections meant that the resident's participation in required interviews and assessments was not documented as mandated. Additionally, the MDS assessment was not completed within the regulatory timeframe. The RN Assessment Coordinator verified the assessment completion on 11/27/24, which exceeded the 14-day requirement following the ARD. Most sections of the MDS, except for Section F (Activities), were completed more than two weeks after the ARD, with some sections finalized as late as 11/27/24. The MDS Director acknowledged that the assessment was not submitted in a timely manner, confirming the deficiency in both the thoroughness and timeliness of the resident's assessment process.
Failure to Develop Comprehensive Nutritional Care Plan
Penalty
Summary
Facility staff failed to develop a comprehensive, resident-centered care plan addressing the nutritional needs of a resident who experienced significant weight loss. Medical record review showed that the resident's weight dropped from 183.8 lbs. to 166.6 lbs., a loss of 17.2 lbs. or 9.4% over a short period. Despite this notable weight loss and the resident being on a specialized diet, there was no nutritional care plan documented in the resident's medical record. During interviews, the facility's dietician acknowledged responsibility for creating nutritional care plans but admitted that due to limited contracted hours, she prioritized high-risk cases and was unable to address all needs. The dietician could not provide an explanation for the absence of a nutritional care plan for this resident. The Medical Director confirmed the lack of a nutritional care plan after reviewing the medical record.
Failure to Hold Timely Care Plan Meetings and Update Care Plans After Changes in Condition
Penalty
Summary
Facility staff failed to conduct timely quarterly care plan meetings and did not update care plans following changes in residents' conditions. For one resident admitted in June 2024, there was only one documented care plan meeting since admission, despite quarterly MDS assessments being completed. The Director of Nursing confirmed that required quarterly care plan meetings were not held for this resident until nearly a year after admission. Another resident experienced multiple falls, including an unwitnessed fall resulting in a left humerus fracture, but the care plan was not updated with new interventions after these incidents. The Director of Nursing acknowledged that the care plan should have been revised to include additional fall prevention measures. Additionally, for a third resident, there were significant gaps in social work documentation and care plan meetings, with periods where no meetings were held and instances where required staff or family participation was lacking. The Social Work Assistant confirmed the absence of a full-time social worker and irregular care plan meeting practices.
Failure to Provide Timely Wound Dressing Changes
Penalty
Summary
A deficiency occurred when a resident with wounds on the right foot did not have their wound dressing changed as scheduled. The resident's family member observed that the date on the dressing was not current, indicating it had not been changed as required. The unit manager initially suggested the wrong date may have been written, but the family member reported that a nurse had previously stated she was unable to change the dressing due to being the only nurse on duty for 40 residents without a medication aide, and that the evening nurse, who was advised to perform the dressing change, failed to do so. Additionally, another staff member admitted to incorrectly dating a dressing, stating she did not work on the date written and may have put the wrong date on the dressing. These actions and inactions resulted in the failure to provide timely wound care for the resident.
Failure to Prevent Elopement of Cognitively Impaired Resident
Penalty
Summary
A deficiency occurred when a resident with a history of Alzheimer's disease, depression, and anxiety, and fluctuating cognitive impairment, was able to exit the facility unsupervised. The resident was not located during staff rounds, prompting a search of the building and grounds, and a 911 call. The resident was eventually found by staff in the community across the street and was returned to the facility. The resident stated they were fine and had just been out walking. The incident was reported by a complainant, who stated that the police were called and brought the resident back, although 911 later indicated that no officer responded. Review of the resident's medical record revealed that, despite multiple BIMS scores indicating moderate to severe cognitive impairment, there was no elopement risk evaluation completed until after the elopement event. When the elopement risk assessment was eventually completed, it inaccurately indicated that the resident did not have cognitive impairment or behaviors associated with elopement, despite evidence to the contrary. Subsequent assessments continued to document incorrect information, failing to recognize the resident's history of leaving the premises unsupervised. Additionally, the care plan addressing elopement risk and wandering was not initiated until six months after the resident's elopement. Interviews with facility leadership confirmed that the incident was not reported to the regulatory agency as required. The facility's front entrance was secured with a coded lock, and staff stated that residents needed permission to go outside, with staff supervision provided when residents were out front. However, these measures were not effective in preventing the resident's unsupervised exit.
Failure to Address Significant Weight Loss in Two Residents
Penalty
Summary
The facility failed to ensure that a physician supervised the care of two residents by not properly evaluating and addressing significant weight loss. For one resident with multiple psychiatric diagnoses, the medical record showed a 17.2 lb. (9.4%) weight loss over several months. The physician, during a progress note, referenced an outdated weight and did not review or address the recent weight loss. Nurse practitioners also saw the resident multiple times but did not mention or intervene regarding the weight loss, resulting in a lack of timely response to the resident's change in condition. For another resident with a history of cerebral infarction, depression, and repeated falls, the medical record indicated a 9 lb. (7.1%) weight loss in one month, with no documentation that the physician or dietician was notified. The physician's notes acknowledged the weight but did not address the loss, and a nurse practitioner noted poor intake and failure to thrive without initiating a nutritional consult. The Medical Director confirmed that the expectation was for providers to review and address pertinent information such as weight changes, which did not occur in these cases.
Failure to Provide Timely Medication Delivery
Penalty
Summary
The facility failed to provide timely pharmaceutical services to meet the needs of a resident who was admitted with diagnoses including Ankylosing spondylitis and visual loss. Upon admission, the resident had a hospital discharge order for Biolle Gel Tears Ophthalmic Gel 1%, to be administered as one drop in both eyes three times daily for dry eyes. Review of the resident's medical record and Medication Administration Record (MAR) showed that the prescribed eye drops were not available for administration for six consecutive days following admission. Nursing notes documented three times daily that the medication was unavailable and that the facility was awaiting pharmacy delivery. After three days without the medication, the Nurse Practitioner was notified, but the medication remained unavailable for an additional three days. It was not until the seventh day after admission that the medication was delivered and administered to the resident. The Director of Nursing (DON) confirmed the findings regarding the unavailability of medications from the pharmacy. The documentation shows that the facility did not ensure the resident received the ordered medication in a timely manner, as required to meet the resident's pharmaceutical needs.
Failure to Monitor Blood Pressure Prior to Antihypertensive Medication Administration
Penalty
Summary
The facility failed to ensure that residents' drug regimens were free from unnecessary drugs by not adhering to physician orders regarding blood pressure monitoring prior to administering antihypertensive medications. For one resident with an order for Losartan Potassium to be held if systolic blood pressure (SBP) was less than 110, the medication was administered on two occasions when the SBP was 104, as documented in the Medication Administration Record (MAR), with no notes indicating the medication was held or any justification for administration outside of parameters. A nurse practitioner later ordered the medication to be stopped due to hypotension. For another resident prescribed Metoprolol Tartrate with instructions to hold for SBP less than 110 or heart rate less than 60, blood pressure was not consistently monitored or documented prior to administration. Review of the MARs over several months showed that blood pressure was only checked a small fraction of the times the medication was given, and the medication was administered at least once when the SBP was below the ordered threshold. Staff interviews confirmed that blood pressure was not always documented before medication administration, and the DON and Medical Director acknowledged the issue.
Failure to Provide Dental Care for Resident with Missing Tooth
Penalty
Summary
Facility staff failed to provide dental care for a resident who had a missing front tooth. The issue was first brought to the facility's attention in December 2023 when the Ombudsman relayed a complaint from the resident's family regarding the missing tooth and lack of communication from the facility. A review of the resident's medical record revealed no documentation regarding the missing tooth, no evidence that the resident had been seen by a dentist, and no nutritional assessments that included information about the resident's oral health. The resident had been in the facility since November 2022, and the missing tooth was still present at the time of the survey. During the survey, the resident was observed to have a missing front tooth, confirming the family's report. Interviews with the Medical Director and DON revealed that they were unaware of any documentation or assessments related to the missing tooth. The Medical Director expressed concern and stated that residents should be screened and evaluated for dental treatment, and that dental services should be offered if problems are identified. However, there was no evidence that such actions had been taken for this resident.
Failure to Arrange Timely Infectious Disease Follow-Up
Penalty
Summary
Facility staff failed to obtain outside professional services in a timely manner for a resident who was readmitted following a hospitalization with an infection and inflammatory reaction due to an internal joint prosthesis. Medical record review showed that the hospital discharge summary required the resident to have a follow-up with an Infectious Disease physician. However, there was no evidence in the medical record that the resident had been seen by, or had an appointment scheduled with, the Infectious Disease physician. This was confirmed during an interview with the Director of Nursing, who acknowledged that staff did not schedule the necessary appointment.
Incomplete Medical Record Documentation Following Resident Fall and Hospital Transfer
Penalty
Summary
The facility failed to maintain complete and accurate medical records for a resident who was admitted following orthopedic surgery for rehabilitation and later discharged. Review of the resident's medical record revealed a lack of documentation regarding a fall and subsequent transfer to the hospital on the day of discharge. The last nurse's note and evaluation prior to the incident was recorded the previous day, and the only note on the day of the fall referenced a call from the resident's representative about the hospital transfer, with no nursing assessment or discharge information related to the fall documented. The Director of Nursing confirmed that the required nurse's notes, assessments, and discharge information were missing from the resident's medical record.
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The facility did not ensure that its Infection Preventionist (IP) met required qualifications for managing the Infection Prevention and Control Program. The DON reported serving as the IP but acknowledged lacking the specialized infection control training required for the role, and confirmed that no other staff member was currently qualified. Records showed that the previously qualified IP left several months earlier, and the Administrator and DON confirmed they were still seeking a replacement, leaving the infection control program without a properly trained leader.
Staff failed to consistently secure medications and medical supplies across three units, including an oxygen tank left on the floor behind a resident’s bed without a supporting device, a treatment cart with Collagenase Santyl cream left on top while two residents in power wheelchairs passed by, an unattended and unlocked treatment cart at a nursing station, and another treatment cart with Diclofenac gel and dressings left on top, indicating repeated lapses in maintaining locked and secure storage for drugs, biologicals, and related supplies.
The facility failed to provide sufficient dietitian coverage and timely nutritional assessments for several residents with significant dietary needs. A resident admitted for diabetic management with a high A1C was placed on a regular diet instead of the recommended carb-controlled diet and had only one weight taken in the first two weeks, with no dietitian review of the record. Another resident with prior significant weight loss had no documented dietitian follow-up despite continued weight loss, and a resident admitted with severe protein-calorie malnutrition experienced further significant weight loss without any dietitian assessment. The dietitian reported working limited hours and prioritizing certain high-risk cases, resulting in delayed or missed evaluations for new admissions and residents with ongoing nutritional concerns.
The facility failed to maintain adequate linen and incontinence supplies and did not keep resident care areas in good repair, resulting in delays and alterations in incontinence care and substandard environmental conditions. Staff reported that towels and washcloths were used instead of wipes and then discarded due to heavy soiling, and that linen deliveries to units were late, leaving residents waiting for care. Observations showed very limited numbers of clean washcloths and other linens on units and in the laundry, with no stock of disposable wipes or backup washcloth supply despite repeated reports to housekeeping. Additional observations revealed recliner chairs blocking a dining-area handwashing sink and kitchenette, multiple resident and shared bathrooms with unfinished spackle, chipped paint, musty odors, black substances near showers, missing threshold molding, exposed cracks and nails, and eroded, rusted baseboard heaters. Hallway handrails on both units were worn, chipped, and splintered, and a shower room contained fecal odors, dried brown stains on the toilet, and deteriorated fixtures, all contributing to a failure to provide a safe, clean, and homelike environment.
Facility staff did not thoroughly investigate two separate abuse allegations involving a resident and an injury of unknown origin involving another resident. In both cases, investigations focused on the directly affected resident and included staff interviews, but there were no interviews of other residents on the unit or documented assessments of those residents for signs of abuse or injuries of unknown origin, including residents unable to communicate due to cognitive status.
Two residents who were dependent on staff for oral care, including one with a tracheostomy, were observed with thick, white or milky substances coating their mouths and teeth, indicating inadequate oral hygiene. One resident communicated that staff did not brush their teeth and that staff "need to." In another case, despite oral care supplies being present in the room, the resident’s mouth and teeth remained unclean on multiple observations, with a thick milky substance caking the teeth and stringing between them when the resident tried to open their mouth. These findings showed that staff did not consistently provide oral care to residents who relied on them for this ADL.
Staff failed to maintain complete and accurate medical records for multiple residents, including missing and inconsistent documentation of wound care, delayed pain assessment after discovery of an injury of unknown origin in a cognitively impaired resident, and inaccurate recording of a PPD test result that was documented as negative despite no evidence the injection was administered and no supporting nurse’s note. Residents reported not receiving certain treatments, while MAR entries either lacked signatures for completion or contained conflicting information about whether care was provided.
Surveyors found that the facility failed to consistently implement and communicate correct transmission-based precautions and PPE use. One resident with a Foley catheter related to wounds had no precaution signage posted, while another resident in a double room had a contact precautions sign at the door, yet the NP entered without PPE and the GNA provided high-contact care wearing only gloves. Staff in that room stated the resident was not on contact precautions and later reversed the sign to show no PPE requirement. Therapy staff reported they rely solely on posted signs to determine PPE, and surveyors identified broader issues with inaccurate signage and staff awareness of which residents required contact precautions.
Surveyors found that MDS assessments were inaccurately coded for two residents. In one case, a resident sustained a femoral neck fracture after a fall, but the subsequent significant change MDS did not code the fall as a major injury and failed to capture prn Tylenol use documented on the MAR within the look-back period. In the other case, a quarterly MDS indicated opioid use for a resident, but the MAR for the same period showed no prescribed opioid, indicating incorrect coding of high-risk drug classes.
A resident who had recently been admitted and experienced a fall received multiple doses of the narcotic analgesic Tramadol, but the facility failed to accurately document all administered doses on the Medication Administration Record (MAR). Review showed only one Tramadol dose recorded on the MAR, while the Controlled Drug Receipt/Record/Disposition Form on the med cart reflected three doses given over two days. In interview, the DON stated staff are expected to document narcotic administration on the MAR and confirmed that two administered doses were not recorded there, resulting in an incomplete and inaccurate medical record.
Unqualified Infection Preventionist Overseeing Infection Control Program
Penalty
Summary
The facility failed to ensure that its designated Infection Preventionist (IP) met the mandatory qualifications for overseeing the Infection Prevention and Control Program. During an interview on 3/24/26 at 10:00 AM, the DON confirmed that she/he was serving as the facility’s IP but had not completed the specialized training in infection control required for the position. The DON further stated that no other staff member currently met the qualifications to serve as IP. Record review showed that the previously qualified IP left the facility in October 2025, and as of the survey date, the position remained unfilled by a qualified individual. At 1:30 PM on the same day, the Administrator and DON confirmed they were still in the process of finding a qualified IP for the facility, leaving the Infection Prevention and Control Program without a properly trained and qualified leader. No specific residents, medical histories, or clinical conditions were described in relation to this deficiency.
Unsecured Medications, Treatment Carts, and Oxygen Equipment
Penalty
Summary
Facility staff failed to ensure that drugs, biologicals, and related medical supplies were securely stored and properly maintained on multiple units. On one unit, an oxygen tank assigned to a resident was observed sitting on the floor behind the resident’s bed without any supporting device. On another unit, a treatment cart was observed with a tube of Collagenase Santyl cream labeled for a specific resident left on top of the cart, while residents in power wheelchairs passed by and staff were present at the nursing station. These observations showed that medications and oxygen equipment were not consistently secured as required. Further observations on additional units revealed an unattended and unlocked treatment cart at a nursing station, and on a separate occasion, a treatment cart with Diclofenac gel labeled for a resident left on top along with multiple packs of dressings. These incidents occurred across three units and on more than one date, demonstrating repeated failures to keep medications and treatment supplies in locked compartments or otherwise secured from unauthorized access.
Insufficient Dietitian Coverage and Delayed Nutritional Assessments
Penalty
Summary
The deficiency involves the facility’s failure to employ sufficient food and nutrition staff, including adequate dietitian coverage, to ensure timely assessment and appropriate diets for residents with significant nutritional and diabetic needs. A resident admitted over two weeks earlier with multiple comorbidities and an A1C of 11.5% had a hospital discharge recommendation for a carbohydrate-controlled diet, but was placed on a regular diet at admission with no acknowledgment of the recommended diet until one week later, when the resident requested larger portions. As of the survey date, the dietitian had not yet seen or reviewed this resident’s medical record, and the resident reported not having seen a dietitian and being very frustrated with the meals. During the first two weeks after admission, only one weight was obtained for this resident, despite physician notes stating the resident’s weight was “stable.” Further review of other residents showed additional failures in timely dietitian assessment and follow-up. One resident, readmitted in January and previously seen by the dietitian in September for a 6.4 lb weight loss over 30 days, had no documented follow-up despite continued weight loss totaling 22 lbs since the last dietitian review. Another resident admitted at the end of February with severe protein-calorie malnutrition had not been seen by the dietitian after about a month in the facility, despite a documented 14 lb (7%) weight loss over two weeks. The dietitian reported working only 12 hours per week at the facility and stated that she must prioritize which residents to see, focusing first on residents with tube feedings and those identified in risk meetings, resulting in delayed or absent assessments for new admissions and residents with ongoing weight loss and malnutrition diagnoses.
Linen Shortages and Poor Environmental Maintenance Compromise Resident Care and Comfort
Penalty
Summary
The deficiency involves the facility’s failure to maintain an adequate supply of clean linens and appropriate incontinence wipes, resulting in delays and alterations in residents’ incontinence care, as well as the use of towels and washcloths in place of disposable wipes. During the initial tour, the surveyor observed that the linen supply on one nursing unit hallway was low. Complaint reviews included concerns about delays in incontinence care and bed linens not being changed regularly, with residents left without clean bedding. A complainant reported that there was not enough clean linen available for residents. Staff interviews confirmed that towels, sheets, and washcloths were being used to wipe residents for incontinence care due to the absence of wipes, and that many of these linens were being thrown away when soiled. Staff also reported a shortage of linen, that linen deliveries to the units were late, and that residents who preferred to get up before breakfast had to wait for care when linen was delayed. Further observations showed that the clean supply room contained no disposable wipes or cloths for incontinence care, and a resident reported that staff did not use wipes, that the resident had to purchase their own, and that heavily soiled towels or washcloths were discarded. A tour of all nursing unit linen carts and closets revealed only six clean washcloths and limited supplies of towels, gowns, and bed linens. In the laundry room, only three washcloths were present, and the laundry assistant stated that there were only three washcloths available for each nursing unit that morning, that the facility was short on linen supply, and that these concerns had been repeatedly reported to the Director of Housekeeping over the preceding month and again that morning. The laundry assistant confirmed there was no additional laundry in process. The DON stated that wipe squares should be used for incontinence care, but no such wipes were found in the clean medical supply room, and no backup supply of washcloths was present in the emergency linen supply. The Director of Housekeeping confirmed there was no backup supply of washcloths. The deficiency also includes environmental and maintenance issues affecting resident bathrooms, handrails, and common areas. In the main dining area, a recliner chair was observed positioned directly in front of the handwashing sink, and two recliner chairs were stored in front of the nutrition area kitchenette. Multiple resident bathrooms and shared bathrooms were repeatedly observed over several days with unfinished spackle on walls that needed resurfacing and painting, chipped paint around sinks, uneven boards nailed to walls under sinks that appeared to partially cover holes, musty odors, black substances between shower bases and walls, missing threshold transition molding exposing cracks, missing tiles, and a nail, as well as eroded and chipped paint on baseboard heaters with exposed dark brown metal and rust-like material. Hallway handrails on both nursing units were observed to be worn, with chips, splintering, holes, and areas where the wood finish had worn off. A shower room was observed with a foul fecal odor, dried brown stains on the back of the toilet seat and in the toilet bowl, and a baseboard heater with eroded, chipped paint and rust-like material, along with chipped paint on the handrail. These conditions were acknowledged by the Director of Maintenance and other leadership, and some areas were noted to be in the process of renovation, but the observed deficiencies remained present during the survey period. Overall, the facility did not maintain a safe, clean, comfortable, and homelike environment in good repair across both nursing units and the dining area. The lack of adequate linen and incontinence supplies, combined with the poor condition of resident bathrooms, handrails, and certain common areas, constituted the basis for the cited deficiency. The observations and staff and resident reports consistently described shortages of essential hygiene supplies, delayed care related to linen availability, and multiple unresolved environmental and maintenance issues in resident care areas and shared spaces.
Failure to Thoroughly Investigate Abuse Allegations and Injuries of Unknown Origin
Penalty
Summary
Facility staff failed to thoroughly investigate allegations of potential abuse involving one resident and an injury of unknown origin involving another resident. For one resident, there were two separate allegations of abuse occurring on different days in early February. The facility’s investigation packets included interviews with staff who cared for or were scheduled to work with this resident on the days of the alleged incidents, and the investigations focused solely on this resident. However, there were no interviews conducted with other residents on the unit to inquire about abusive or neglectful treatment by the staff who were working during the times of the allegations. The surveyors noted that, although the allegations were not validated, there was no documentation that other residents were interviewed, if able, or assessed for signs or symptoms of injury. In a separate incident, another resident was identified on March 4 with a new bruise on the right eye, documented as a change in condition at 4:09 AM. This resident had a BIMS score of 99, indicating the resident was unable to complete an interview and therefore could not report how the injury occurred. The facility’s investigation identified a potential cause of the injury but did not reach a definitive resolution. Additionally, there were no interviews of other residents on the unit regarding possible abuse, nor were there documented assessments of other residents for injuries of unknown origin, particularly for those unable to speak for themselves, as in this resident’s case.
Failure to Provide Oral Care to Dependent Residents
Penalty
Summary
The deficiency involves the facility’s failure to provide oral care to residents who were dependent on staff for activities of daily living, specifically oral hygiene. One resident with a tracheostomy was observed with a thick, sticky white substance in the mouth and was noted to intermittently chew on nearby bedding. This resident made good eye contact and, when asked if staff brushed their teeth, shook their head no and mouthed that staff “need to.” According to the resident’s Minimum Data Set (MDS) dated 2/11/26, the resident was dependent on staff for oral care. Another resident, also dependent on staff for oral care per the 3/11/26 MDS, was observed sitting propped up in bed and able to respond with smiles. During the initial observation, the inside of this resident’s lips and upper and lower teeth had a thick, clear, white milky substance visible when the resident tried to open their mouth to smile. Oral care supplies were present in the nightstand, but the resident’s mouth and teeth were not clean. On a subsequent observation with the DON, NHA, and Corporate VP of clinical services, the same resident again had a thick, clear, milky substance between the lips and caking the teeth, which would string between the teeth when the resident attempted to open their mouth, demonstrating a lack of consistent oral care for residents dependent on staff for this ADL.
Incomplete and Inaccurate Medical Record Documentation for Treatments and Assessments
Penalty
Summary
Facility staff failed to maintain complete and accurate medical records and documentation for multiple residents. For one resident with wound care needs, review of the MAR showed that wound care and related treatments were signed as completed on the dates initially reported, despite the resident’s ongoing complaints that wound dressings were not being changed. When additional dates were reviewed, there were missing staff signatures for wound care on two specific dates, as well as three instances where application of A&D ointment to the resident’s feet was not signed off out of 24 days reviewed. Another resident with severe cognitive impairment, as evidenced by a BIMS score of 00, was found to have an injury of unknown origin (a bruise on the left hand). Documentation showed that a change in condition was initiated late in the morning, but a formal pain evaluation was not initiated and completed until that night, and the resident was unable to explain how the injury occurred or verbalize pain using a standard pain scale. For a third resident, documentation related to the admission PPD test was inconsistent and incomplete. The MAR contained an entry indicating “9” for the administration date, meaning “see nurse’s note,” but there was no corresponding nurse’s note. Despite the absence of a signed administration of the PPD injection, staff documented the PPD result as “negative” on the scheduled read date. The resident reported never receiving the PPD injection, and the DON confirmed that the facility had been out of PPD solution at the time, so the test would not have been administered. These findings demonstrate failures in accurate documentation of treatments and assessments, including wound care, pain assessment, and TB screening, as well as missing or incomplete supporting notes in the medical record.
Failure to Implement and Communicate Correct Transmission-Based Precautions
Penalty
Summary
Surveyors identified a deficiency in the facility’s infection prevention and control program related to inconsistent and incorrect implementation of transmission-based precautions and PPE use. During a complaint investigation focused on residents on transmission-based precautions, one resident with a visible Foley catheter was observed in the room with physical therapy, but there were no signs posted indicating any need for PPE, despite the resident being a new admission with a Foley catheter placed related to wounds. In another double-occupancy room, a contact precautions sign was posted at the doorway, but the nurse practitioner was in the room on a personal phone with no PPE, and the assigned GNA was repositioning the resident in bed while wearing only gloves. When questioned, the NP, RN, and GNA all stated that the resident in the room was not on contact precautions, and the GNA reported that signs were hanging at all doors and that this particular resident’s sign was “just wrong.” The surveyor observed the GNA later return to the room and turn the sign around to indicate no PPE requirement. Subsequent interviews revealed that therapy staff relied on posted signage to determine PPE use and that if the sign was wrong, the PPE used would be wrong. Overall, surveyors found problems with signage accuracy and staff awareness of which residents required contact precautions, as well as observed failures to follow appropriate PPE use for residents who should have been on contact precautions.
Inaccurate MDS Coding for Falls, Pain Management, and High-Risk Medications
Penalty
Summary
Facility staff failed to ensure Minimum Data Set (MDS) assessments were accurately coded for two residents reviewed during a complaint survey. For one resident, a facility-reported incident showed that the resident was found seated on the floor beside the bed and was diagnosed with a non-displaced femoral neck impaction fracture of the left hip following an x-ray. Despite this fall with a major injury, the subsequent significant change MDS dated 11/4/25 did not code the fall with major injury in Section J1900C. Review of the resident’s Medication Administration Records for October and November 2025 showed administration of Tylenol on 10/31/25 at 9:30 PM, which fell within the 5-day look-back period for the MDS, but Section J0100 (prn pain) of the same significant change MDS did not capture the use of Tylenol. For another resident, review of a quarterly MDS with an assessment reference date of 10/15/25 showed that Section N0415 (High-Risk Drug Classes) documented the use of an opioid medication. However, review of the resident’s October 2025 Medication Administration Record did not show that the resident had been prescribed an opioid during that period. In both cases, MDS staff later confirmed that these were errors in MDS coding, demonstrating that the assessments did not accurately reflect the residents’ clinical status and medication use as documented in their medical records.
Incomplete Documentation of Narcotic Administration on MAR
Penalty
Summary
The facility failed to maintain complete and accurate medical records in accordance with accepted professional standards for one resident receiving narcotic medication. The resident, admitted in March 2026, had a fall on 3/6/26 and was sent to the hospital on 3/9/26. Review of the March 2026 Medication Administration Record (MAR) showed documentation of a single 25 mg dose of Tramadol administered on 3/8/26 at 9:23 AM. However, review of the resident’s Controlled Drug Receipt/Record/Disposition Form, kept on the nurse’s medication cart and not in the medical record, showed that Tramadol 25 mg was administered three times between 3/8/26 and 3/9/26: at 11:00 AM and 9:00 PM on 3/8/26, and at 9:00 AM on 3/9/26. In interview, the DON stated that staff are expected to document narcotic administration on the MAR and confirmed that only one of the three Tramadol doses reflected on the controlled drug record was documented on the resident’s MAR. This discrepancy between the controlled substance record and the MAR, with missing documentation of two administered doses of Tramadol on the official medical record, constituted the failure to maintain a complete and accurate medical record for the resident.
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