Maryland Baptist Aged Home
Inspection history, citations, penalties and survey trends for this long-term care facility in Baltimore, Maryland.
- Location
- 2801 Rayner Avenue, Baltimore, Maryland 21216
- CMS Provider Number
- 215360
- Inspections on file
- 15
- Latest survey
- July 17, 2025
- Citations (last 12 mo.)
- 9
Citation history
Health deficiencies cited at Maryland Baptist Aged Home during CMS and state inspections, most recent first.
Surveyors identified that staff failed to properly label, date, and track expiration of food items, with several expired or unlabeled products found in kitchen storage areas. Additionally, staff did not consistently maintain the required concentration of Quaternary Ammonium Compounds (QACs) for dish sanitization, with logs showing levels below the manufacturer-recommended range and staff unaware of the correct standards.
The facility did not have an RN on duty for 24 hours on multiple weekends and holidays, as confirmed by staffing records and the Administrator, who stated that RN coverage could not be secured for these periods.
A facility-wide assessment was found to be inaccurate, with errors in reported admission numbers, incomplete information on the facility's ability to care for residents with infectious diseases, and missing details about care for residents with tracheostomies and assistance with showers. The DON and Administrator confirmed inaccuracies and lack of staff competency verification for specialized care.
The facility's leadership failed to ensure effective oversight and implementation of the QAPI program. The QAPI plan lacked a systematic approach for identifying and analyzing problems, and the governing body did not provide adequate oversight. The DON confirmed the absence of governing body involvement, and the CFO was unaware of key issues identified by the QAPI committee, such as staff lacking CPR certification.
Facility staff did not ensure that call devices were installed in shower areas and that strings were attached to call systems in toilet stalls. Observations revealed that both the long and short hall bathrooms lacked call devices in the shower areas, and several toilet stalls were missing the necessary strings for the call systems.
Two residents were not provided with showers or opportunities to get out of bed, despite expressing a desire for these choices. Documentation in the EMR was lacking, and staff confirmed there was no way to record showers, resulting in the residents remaining in bed and not receiving showers since admission.
Staff did not provide a copy of the Notice of Medicare Non-Coverage to a resident's representative before discharge. The form lacked the representative's signature, and there was no verification that the notice was mailed or received, as confirmed by the social worker.
A resident with multiple psychiatric and behavioral diagnoses was administered several psychotropic medications without proper documentation of behavioral and mood monitoring, as required by their care plan. Staff were unable to provide the necessary monitoring records, and a pharmacy consultant's recommendation for a gradual dose reduction of one medication was not addressed. This resulted in a deficiency related to the justification and monitoring of psychotropic medication use.
Staff did not provide a resident's representative with written notification of the reasons for hospital transfers, nor did they supply a copy of the bed-hold policy at the time of hospitalization. Documentation showed only telephone notification, and staff confirmed the bed-hold policy was only given at admission.
A resident was admitted to hospice, representing a significant change in condition, but the required MDS assessment was not completed within the mandated 14-day period. The assessment was started late and remained incomplete beyond the required timeframe, as confirmed by the MDS Coordinator.
Staff did not complete and transmit a resident's MDS assessment within the required 14-day window due to delays in completing specific assessment sections. The MDS Coordinator reported that the DON and Administrator were not made aware of the issue.
Staff did not complete a narcotic count when an RN assumed control of the nursing assignment, as shown by discrepancies in the Controlled Drug Count Verification form and inability of the DON to verify completion. This resulted in a failure to meet professional standards for controlled substance management.
A resident with a left-hand contracture and hemiplegia did not receive the prescribed hand splint as outlined in the care plan, and there was no documentation of supportive device use or recent occupational therapy evaluation, despite ongoing limitations in range of motion.
Staff did not consistently provide activities to two bedbound residents who could not participate in group activities. One resident reported that in-room activities ceased after a staff member left, and activity logs showed no recent sessions for either resident. The Activities Director could not explain the lack of regular activities.
Surveyors found that medications and biologicals were not properly labeled or dated after opening, and expired medications were not removed from medication carts. Examples included undated eye drops, Nystatin powder, Duoderm gel, and blood glucose strips, as well as an expired tube of Nystatin cream, with staff confirming these deficiencies.
A resident with hemiplegia and a left-hand contracture did not receive a required Occupational Therapy evaluation or ongoing interventions after a previous course of therapy ended. The care plan called for supportive devices and splints, but no such interventions were documented or observed, and the resident reported ongoing difficulty with hand movement.
Facility staff did not have an effective system to identify, report, track, investigate, or analyze adverse events, as shown by the lack of documentation and data in the QAPI plan. The DON confirmed that while the team met monthly and discussed staffing concerns, there was no evidence of monitoring or analysis. Additionally, the facility could not provide records regarding the discovery or resolution of issues such as incomplete CPR certification among nursing staff.
Facility staff did not include the Infection Preventionist in QAPI meetings as required, with sign-in sheets lacking their name or signature and no documentation of attendance by phone. The IP could not recall their last participation, and the DON was made aware of the attendance requirement.
The facility did not maintain an adequate emergency water supply and lacked oversight of its internal water system, including failure to test for Legionella and other pathogens. Staff were unaware of their responsibilities regarding water testing and emergency preparedness, and the available water supply was significantly below recommended levels for residents and staff.
Facility staff did not apply for a required waiver for rooms that were less than the minimum square footage, despite being aware of the deficiency. When asked, the DON indicated a waiver existed, but documentation review revealed that no such waiver was available for the undersized rooms. The Administrator stated they were told not to apply for a waiver unless requested by surveyors, resulting in noncompliance.
Deficient Food Labeling and Dish Sanitization Practices Identified
Penalty
Summary
The facility failed to maintain proper labeling, dating, and expiration practices for food items, as well as to ensure correct sanitization procedures in the kitchen. During a kitchen tour, staff were unable to identify correct expiration dates on several food items, including a box of hot sauce with conflicting dates and cereal dispensers with unclear labeling. Expired spices were found, and staff could not consistently identify or date items in the freezer, with some frozen goods and a container of potato salad lacking proper labeling. Unlabeled bags of spreadable butter were also found in a freezer, and staff acknowledged the need for improved labeling practices. Additionally, the facility did not consistently meet the manufacturer-recommended range for Quaternary Ammonium Compounds (QACs) used for dish sanitization. Staff were unsure of the correct QAC concentration range, and logs showed readings below the required 200-400 ppm, with staff not recognizing that 100 ppm was insufficient for proper sanitization. These deficiencies were identified during the initial kitchen visit of the annual recertification survey.
Failure to Provide 24-Hour RN Coverage
Penalty
Summary
The facility failed to have a Registered Nurse (RN) on duty for 24 hours a day over a period of seven consecutive days, as evidenced by staff interviews and review of the PBJ Staffing Data Report. The report identified specific dates on which there were no RNs present for the full 24-hour period, including multiple Saturdays, Sundays, and a holiday. The Administrator confirmed during an interview that there was no RN coverage on these dates, citing an inability to secure RN staff for weekends and holidays, either from facility staff or agency sources. Additionally, review of two weeks of staffing schedules showed a consistent lack of RN coverage on weekends.
Inaccurate Facility Assessment Documentation
Penalty
Summary
A facility-wide assessment failed to accurately reflect the services provided, as discovered during a recertification survey. The assessment incorrectly documented an average of 10 resident admissions during the weekday and did not include the facility's capacity to admit residents with infectious diseases such as COVID-19, MRSA, or Clostridium Difficile. Additionally, the section regarding care for residents with conditions not listed was incomplete, and while the assessment stated the facility could care for residents with a tracheostomy, there were no current residents with this condition. The assessment also omitted showers as a form of assistance provided for activities of daily living. During interviews, the DON acknowledged that it had been some time since nurses participated in a skills lab, and there were no competencies to verify staff training for tracheostomy or gastrostomy tube care. The Administrator confirmed that the reported average of 10 admissions per week was an error.
Failure of Governing Body to Oversee and Implement Effective QAPI Program
Penalty
Summary
The facility's governing body and executive leadership failed to ensure that the Quality Assurance Performance Improvement (QAPI) program effectively identified and prioritized problems related to organizational processes, functions, and services provided to residents. During the recertification survey, it was found that the QAPI plan lacked a systematic approach for identifying, tracking, investigating, and analyzing data. The Director of Nursing (DON) confirmed that there was no oversight of the QAPI processes by the governing body. Additionally, the Administrator stated that the Chief Financial Officer (CFO) provided oversight, but could not confirm the CFO's participation or input in QAPI meetings. Further interviews revealed that the CFO was only kept informed about the QAPI process by the Administrator and DON and occasionally attended morning calls. The CFO was unable to provide details about the most recent QAPI meeting and had not reviewed the QAPI documentation. When asked about specific issues identified by the QAPI committee, such as nursing staff lacking CPR certification, the CFO was unaware of these findings. These actions and inactions demonstrate a lack of effective oversight and engagement by the facility's leadership in the QAPI process.
Missing Call Devices and Strings in Resident Bathrooms and Shower Areas
Penalty
Summary
Facility staff failed to ensure that a functioning call system was available in each resident's bathroom and bathing area. During an annual survey, it was observed that the bathroom on the long hall did not have a call device in the shower area, and the call device in the toilet stall was missing its string. Additionally, the shared bathroom on the short hall was found to be without a call device in the shower area, and two out of three toilet stalls lacked strings attached to the call devices. These deficiencies were confirmed during both the initial and subsequent tours of the facility with facility leadership.
Failure to Support Resident Choice for Showers and Mobility
Penalty
Summary
Facility staff failed to honor and facilitate resident self-determination by not providing opportunities for residents to receive showers or get out of bed, as evidenced by observations and interviews with two residents. One resident reported not getting out of bed despite wanting to, and it was observed that the only available chair in the room was used by the roommate. Both residents were observed in bed over a two-day period, and one resident confirmed not having had a shower since admission in October 2023. A review of the electronic health records and shower schedules revealed no documentation verifying that either resident had received a shower. The scheduled care indicated complete bed baths for both residents on specific days and shifts, but there was no place in the electronic medical record for staff to document showers. Staff confirmed the lack of documentation options, and the Director of Nursing was made aware of the situation, with both residents verifying the lack of showers and opportunities to get out of bed.
Failure to Provide Notice of Medicare Non-Coverage Prior to Discharge
Penalty
Summary
Facility staff failed to provide a copy of the Notice of Medicare Non-Coverage (NOMNC) to a resident's representative prior to the resident's discharge. During the recertification survey, it was found that the NOMNC form for the resident was dated and included a typed note stating that the responsible party was notified by telephone, but there was no signature from the representative to confirm receipt. Additionally, although an envelope addressed to the responsible party was presented, staff could not verify when the letter was mailed or if it was actually received. The social worker confirmed that the facility had not received a signed copy from the responsible party.
Failure to Document and Monitor Psychotropic Medication Use
Penalty
Summary
The facility failed to ensure that psychotropic medications administered to a resident were necessary and justified, as staff did not complete required behavioral and mood monitoring documentation for the conditions these medications were prescribed to treat. A resident with diagnoses including Paranoid Schizophrenia, Major Depressive Disorder, unspecified anxiety disorder, and dementia with behavioral disturbance was receiving multiple psychotropic medications, such as Quetiapine, Valproic acid, Trazodone, and Lorazepam. There was no documented indication for Quetiapine in the physician's order, and no behavior and mood monitoring documentation was found in the resident's medical record, despite care plan interventions requiring behavior monitoring every shift and documentation of behaviors and interventions. During interviews, the DON stated that behavior monitoring was done on paper and kept in the medication administration binder, but staff were unable to produce the behavior monitoring flowsheet when requested, providing only the Treatment Administration Record instead. Additionally, a pharmacy consultant had recommended a gradual dose reduction of Trazodone, but there was no documentation that this recommendation was addressed by the psychiatry provider. These findings indicate a lack of proper documentation and follow-through regarding the use and monitoring of psychotropic medications for the resident.
Failure to Provide Written Notification and Bed-Hold Policy During Resident Hospitalization
Penalty
Summary
Facility staff failed to provide written notification to a resident's representative regarding the reasons for the resident's transfers to the hospital, as required. Medical record review showed that while telephone notifications were documented for two separate hospitalizations, there was no evidence of written communication explaining the reasons for these transfers. Additionally, the facility did not provide a copy of the bed-hold policy to the resident's representative at the time of hospitalization, as confirmed by staff interviews, with the policy only being given upon admission. These deficiencies were identified during a recertification survey through review of both electronic and paper medical records, as well as staff interviews, and were specific to one resident whose records were examined for transfer and discharge practices.
Failure to Complete Timely MDS Assessment After Significant Change
Penalty
Summary
The facility failed to complete a Minimum Data Set (MDS) assessment within 14 days following a significant change in a resident's condition. Specifically, a resident was admitted to hospice services, which constitutes a significant change requiring an updated MDS assessment. Record review showed that the MDS significant change assessment was initiated ten days after the resident's admission to hospice but remained incomplete more than three weeks after the significant change occurred. During a phone interview, the MDS Coordinator confirmed both the resident's admission to hospice and that the significant change assessment was still in process well past the required timeframe. The Coordinator acknowledged that the MDS assessment should have been updated within 14 days of the significant change, and that the electronic records had not been updated in a timely manner. Facility leadership and relevant staff were informed of these findings during the exit conference.
Failure to Complete and Transmit MDS Assessment Within Required Timeframe
Penalty
Summary
Facility staff failed to complete and transmit a Minimum Data Set (MDS) assessment for one resident within the required 14-day timeframe. Record review showed that the assessment reference date was 04/05/25, but the assessment was not signed until 04/25/25, which exceeded the allowed window for completion and transmission. During an interview, the MDS Coordinator explained that the delay occurred because staff responsible for completing Section E and Section Q did not do so in a timely manner. The MDS Coordinator also stated that neither the Director of Nursing nor the Administrator were informed about the difficulties in obtaining timely completion from staff.
Failure to Complete Narcotic Count During Shift Change
Penalty
Summary
Facility staff failed to complete a narcotic count when a registered nurse assumed control over the nursing assignment, as evidenced by a review of the Controlled Drug Count Verification form. On multiple shifts, the signatures of incoming and outgoing nurses did not match, and it could not be verified that the narcotic count was completed when a different nurse took over the shift. During an interview, the Director of Nursing was unable to confirm that the narcotic count was performed when a nurse assumed control of the assignment, indicating a lapse in following professional standards of practice for controlled substance accountability. No specific residents or patient medical histories were mentioned in relation to this deficiency.
Failure to Apply Prescribed Hand Splint for Resident with Contracture
Penalty
Summary
Facility staff failed to ensure the use of a hand splint for a resident with a left-hand contracture and hemiplegia, as specified in the resident's care plan. The care plan, which was last revised in October 2024, required staff to assist with the application of supportive devices, including splints, and to perform skin checks every shift. However, during multiple observations, the resident was seen without a splint or any supportive device on the affected hand, and there was no documentation of such interventions in the Treatment Administration Record (TAR). Additionally, the resident had not received any occupational therapy screening or evaluation since August 2024, despite ongoing limitations in range of motion as documented in the Minimum Data Set (MDS) assessment. The lack of follow-up therapy and absence of the prescribed supportive device indicate that the facility did not implement the care plan interventions intended to maintain the resident's ability to perform activities of daily living.
Failure to Provide Activities to Bedbound Residents
Penalty
Summary
Facility staff failed to consistently provide activities to residents who were unable to participate in communal activities, as evidenced by record review and interviews. Two residents who were bedbound did not receive regular in-room activities; one resident reported that a staff member previously provided activities in their room, but this stopped when the staff member left. Activity logs for both residents showed no documented activity sessions for several weeks prior to the survey. The Activities Director was unable to explain why these residents were not receiving regular activities.
Improper Medication Labeling and Storage
Penalty
Summary
Surveyors identified that medications and biologicals were not properly labeled or dated once opened, and expired medications were not removed from medication carts. During observation, two eye drop medications for one resident and another eye drop for a second resident were found opened without dates on one medication cart. On another cart, two bottles of Nystatin powder and two tubes of Duoderm Hydroactive gel for a resident were also found without labels or dates. Additionally, a canister of blood glucose strips was found without an opening date. Further review revealed an expired tube of Nystatin cream for another resident still present in the medication cart. These findings were confirmed by staff present during the observations.
Failure to Provide Required Occupational Therapy Evaluation and Interventions
Penalty
Summary
A deficiency was identified when a resident with hemiplegia affecting the left non-dominant side and a left-hand contracture did not receive an Occupational Therapy (OT) evaluation as required. The resident was previously seen by OT from April to August of the prior year for activities of daily living and fall risk, but there was no documentation of any further OT screening or evaluation after that period. The Minimum Data Set (MDS) quarterly assessment indicated a limitation in the range of motion of the upper and lower extremity on one side, and the care plan included interventions such as the use of supportive devices and splints for the left hand contracture. Despite these documented needs, there was no evidence in the medical record or Treatment Administration Record (TAR) of ongoing treatment or intervention for the contracture after August of the previous year. Observations confirmed that the resident was not using a splint or any supportive device on the affected hand, and the resident reported being unable to completely open the hand. The lack of follow-up OT evaluation and absence of prescribed interventions contributed to the facility's failure to provide specialized rehabilitative services as required.
Failure to Implement Effective QAPI System for Adverse Event Monitoring
Penalty
Summary
Facility staff failed to implement an effective system for identifying, reporting, tracking, investigating, and analyzing adverse events, as determined during a recertification survey. The QAPI plan was found to lack a systematic approach for problem identification and data analysis. During interviews, the DON stated that the QAPI team met monthly and focused on staffing concerns, but could not provide documentation or data to demonstrate monitoring or analysis of staffing issues. Additionally, when asked about the process for addressing the lack of CPR certification among nursing staff, the facility was unable to provide documentation regarding when the issue was discovered, how it was being monitored, or what actions were taken to address it. Requested data and records were not available for review in the QAPI documentation.
Infection Preventionist Not Documented as Attending QAPI Meetings
Penalty
Summary
Facility staff failed to include the Infection Preventionist (IP) in the Quality Assurance Performance Improvement (QAPI) meetings as required. Record review of QAPI meeting sign-in sheets for several dates showed that the IP's name or signature was not present. During a telephone interview, the IP confirmed not attending the meetings in person but stated they participated via telephone, although there was no documentation of their attendance either in person or by phone. When asked, the IP could not recall the last time they participated in a meeting. The Director of Nursing was informed of the requirement for the IP to attend QAPI meetings and acknowledged understanding of this requirement.
Failure to Maintain Emergency Water Supply and Water System Oversight
Penalty
Summary
The facility failed to maintain an adequate infection prevention and control program by not ensuring an appropriate emergency water supply and by lacking knowledge and oversight of the building's water system. During interviews, the Director of Maintenance was unaware that the facility was responsible for testing the internal water system for Legionella and other waterborne pathogens, stating that no such testing had been conducted during his two-year tenure. Additionally, he reported that aerators in residents' rooms had not been changed and that plumbing maintenance was only performed in response to emergencies, not as part of routine preventive measures. Observation in the basement revealed only 11 five-gallon containers of water and 4 empty containers, which was significantly below the recommended emergency water supply of one gallon per person per day for three days, given the facility's capacity of 29 residents and 10 staff per day. The Director of Maintenance confirmed that the emergency water supply was used for daily operations and that recent deliveries from the contracted water supplier were insufficient. Staff were unaware of the required emergency water supply amount, and no documentation or diagrams of the water system were available.
Failure to Obtain Waiver for Undersized Resident Rooms
Penalty
Summary
Facility staff failed to apply for a required waiver for resident rooms that were less than the minimum square footage mandated by regulations. During the annual survey, the surveyor inquired about existing waivers at the entrance conference, and the DON stated that a waiver existed for undersized rooms. However, upon review of documentation, it was found that certain rooms did not meet the required square footage, and no waiver was available for these rooms. The Administrator explained that they were instructed not to apply for a waiver unless specifically requested by the survey team, resulting in the waiver not being available prior to the survey and leading to noncompliance.
Latest citations in Maryland
The facility did not ensure that its Infection Preventionist (IP) met required qualifications for managing the Infection Prevention and Control Program. The DON reported serving as the IP but acknowledged lacking the specialized infection control training required for the role, and confirmed that no other staff member was currently qualified. Records showed that the previously qualified IP left several months earlier, and the Administrator and DON confirmed they were still seeking a replacement, leaving the infection control program without a properly trained leader.
Staff failed to consistently secure medications and medical supplies across three units, including an oxygen tank left on the floor behind a resident’s bed without a supporting device, a treatment cart with Collagenase Santyl cream left on top while two residents in power wheelchairs passed by, an unattended and unlocked treatment cart at a nursing station, and another treatment cart with Diclofenac gel and dressings left on top, indicating repeated lapses in maintaining locked and secure storage for drugs, biologicals, and related supplies.
The facility failed to provide sufficient dietitian coverage and timely nutritional assessments for several residents with significant dietary needs. A resident admitted for diabetic management with a high A1C was placed on a regular diet instead of the recommended carb-controlled diet and had only one weight taken in the first two weeks, with no dietitian review of the record. Another resident with prior significant weight loss had no documented dietitian follow-up despite continued weight loss, and a resident admitted with severe protein-calorie malnutrition experienced further significant weight loss without any dietitian assessment. The dietitian reported working limited hours and prioritizing certain high-risk cases, resulting in delayed or missed evaluations for new admissions and residents with ongoing nutritional concerns.
The facility failed to maintain adequate linen and incontinence supplies and did not keep resident care areas in good repair, resulting in delays and alterations in incontinence care and substandard environmental conditions. Staff reported that towels and washcloths were used instead of wipes and then discarded due to heavy soiling, and that linen deliveries to units were late, leaving residents waiting for care. Observations showed very limited numbers of clean washcloths and other linens on units and in the laundry, with no stock of disposable wipes or backup washcloth supply despite repeated reports to housekeeping. Additional observations revealed recliner chairs blocking a dining-area handwashing sink and kitchenette, multiple resident and shared bathrooms with unfinished spackle, chipped paint, musty odors, black substances near showers, missing threshold molding, exposed cracks and nails, and eroded, rusted baseboard heaters. Hallway handrails on both units were worn, chipped, and splintered, and a shower room contained fecal odors, dried brown stains on the toilet, and deteriorated fixtures, all contributing to a failure to provide a safe, clean, and homelike environment.
Facility staff did not thoroughly investigate two separate abuse allegations involving a resident and an injury of unknown origin involving another resident. In both cases, investigations focused on the directly affected resident and included staff interviews, but there were no interviews of other residents on the unit or documented assessments of those residents for signs of abuse or injuries of unknown origin, including residents unable to communicate due to cognitive status.
Two residents who were dependent on staff for oral care, including one with a tracheostomy, were observed with thick, white or milky substances coating their mouths and teeth, indicating inadequate oral hygiene. One resident communicated that staff did not brush their teeth and that staff "need to." In another case, despite oral care supplies being present in the room, the resident’s mouth and teeth remained unclean on multiple observations, with a thick milky substance caking the teeth and stringing between them when the resident tried to open their mouth. These findings showed that staff did not consistently provide oral care to residents who relied on them for this ADL.
Staff failed to maintain complete and accurate medical records for multiple residents, including missing and inconsistent documentation of wound care, delayed pain assessment after discovery of an injury of unknown origin in a cognitively impaired resident, and inaccurate recording of a PPD test result that was documented as negative despite no evidence the injection was administered and no supporting nurse’s note. Residents reported not receiving certain treatments, while MAR entries either lacked signatures for completion or contained conflicting information about whether care was provided.
Surveyors found that the facility failed to consistently implement and communicate correct transmission-based precautions and PPE use. One resident with a Foley catheter related to wounds had no precaution signage posted, while another resident in a double room had a contact precautions sign at the door, yet the NP entered without PPE and the GNA provided high-contact care wearing only gloves. Staff in that room stated the resident was not on contact precautions and later reversed the sign to show no PPE requirement. Therapy staff reported they rely solely on posted signs to determine PPE, and surveyors identified broader issues with inaccurate signage and staff awareness of which residents required contact precautions.
Surveyors found that MDS assessments were inaccurately coded for two residents. In one case, a resident sustained a femoral neck fracture after a fall, but the subsequent significant change MDS did not code the fall as a major injury and failed to capture prn Tylenol use documented on the MAR within the look-back period. In the other case, a quarterly MDS indicated opioid use for a resident, but the MAR for the same period showed no prescribed opioid, indicating incorrect coding of high-risk drug classes.
A resident who had recently been admitted and experienced a fall received multiple doses of the narcotic analgesic Tramadol, but the facility failed to accurately document all administered doses on the Medication Administration Record (MAR). Review showed only one Tramadol dose recorded on the MAR, while the Controlled Drug Receipt/Record/Disposition Form on the med cart reflected three doses given over two days. In interview, the DON stated staff are expected to document narcotic administration on the MAR and confirmed that two administered doses were not recorded there, resulting in an incomplete and inaccurate medical record.
Unqualified Infection Preventionist Overseeing Infection Control Program
Penalty
Summary
The facility failed to ensure that its designated Infection Preventionist (IP) met the mandatory qualifications for overseeing the Infection Prevention and Control Program. During an interview on 3/24/26 at 10:00 AM, the DON confirmed that she/he was serving as the facility’s IP but had not completed the specialized training in infection control required for the position. The DON further stated that no other staff member currently met the qualifications to serve as IP. Record review showed that the previously qualified IP left the facility in October 2025, and as of the survey date, the position remained unfilled by a qualified individual. At 1:30 PM on the same day, the Administrator and DON confirmed they were still in the process of finding a qualified IP for the facility, leaving the Infection Prevention and Control Program without a properly trained and qualified leader. No specific residents, medical histories, or clinical conditions were described in relation to this deficiency.
Unsecured Medications, Treatment Carts, and Oxygen Equipment
Penalty
Summary
Facility staff failed to ensure that drugs, biologicals, and related medical supplies were securely stored and properly maintained on multiple units. On one unit, an oxygen tank assigned to a resident was observed sitting on the floor behind the resident’s bed without any supporting device. On another unit, a treatment cart was observed with a tube of Collagenase Santyl cream labeled for a specific resident left on top of the cart, while residents in power wheelchairs passed by and staff were present at the nursing station. These observations showed that medications and oxygen equipment were not consistently secured as required. Further observations on additional units revealed an unattended and unlocked treatment cart at a nursing station, and on a separate occasion, a treatment cart with Diclofenac gel labeled for a resident left on top along with multiple packs of dressings. These incidents occurred across three units and on more than one date, demonstrating repeated failures to keep medications and treatment supplies in locked compartments or otherwise secured from unauthorized access.
Insufficient Dietitian Coverage and Delayed Nutritional Assessments
Penalty
Summary
The deficiency involves the facility’s failure to employ sufficient food and nutrition staff, including adequate dietitian coverage, to ensure timely assessment and appropriate diets for residents with significant nutritional and diabetic needs. A resident admitted over two weeks earlier with multiple comorbidities and an A1C of 11.5% had a hospital discharge recommendation for a carbohydrate-controlled diet, but was placed on a regular diet at admission with no acknowledgment of the recommended diet until one week later, when the resident requested larger portions. As of the survey date, the dietitian had not yet seen or reviewed this resident’s medical record, and the resident reported not having seen a dietitian and being very frustrated with the meals. During the first two weeks after admission, only one weight was obtained for this resident, despite physician notes stating the resident’s weight was “stable.” Further review of other residents showed additional failures in timely dietitian assessment and follow-up. One resident, readmitted in January and previously seen by the dietitian in September for a 6.4 lb weight loss over 30 days, had no documented follow-up despite continued weight loss totaling 22 lbs since the last dietitian review. Another resident admitted at the end of February with severe protein-calorie malnutrition had not been seen by the dietitian after about a month in the facility, despite a documented 14 lb (7%) weight loss over two weeks. The dietitian reported working only 12 hours per week at the facility and stated that she must prioritize which residents to see, focusing first on residents with tube feedings and those identified in risk meetings, resulting in delayed or absent assessments for new admissions and residents with ongoing weight loss and malnutrition diagnoses.
Linen Shortages and Poor Environmental Maintenance Compromise Resident Care and Comfort
Penalty
Summary
The deficiency involves the facility’s failure to maintain an adequate supply of clean linens and appropriate incontinence wipes, resulting in delays and alterations in residents’ incontinence care, as well as the use of towels and washcloths in place of disposable wipes. During the initial tour, the surveyor observed that the linen supply on one nursing unit hallway was low. Complaint reviews included concerns about delays in incontinence care and bed linens not being changed regularly, with residents left without clean bedding. A complainant reported that there was not enough clean linen available for residents. Staff interviews confirmed that towels, sheets, and washcloths were being used to wipe residents for incontinence care due to the absence of wipes, and that many of these linens were being thrown away when soiled. Staff also reported a shortage of linen, that linen deliveries to the units were late, and that residents who preferred to get up before breakfast had to wait for care when linen was delayed. Further observations showed that the clean supply room contained no disposable wipes or cloths for incontinence care, and a resident reported that staff did not use wipes, that the resident had to purchase their own, and that heavily soiled towels or washcloths were discarded. A tour of all nursing unit linen carts and closets revealed only six clean washcloths and limited supplies of towels, gowns, and bed linens. In the laundry room, only three washcloths were present, and the laundry assistant stated that there were only three washcloths available for each nursing unit that morning, that the facility was short on linen supply, and that these concerns had been repeatedly reported to the Director of Housekeeping over the preceding month and again that morning. The laundry assistant confirmed there was no additional laundry in process. The DON stated that wipe squares should be used for incontinence care, but no such wipes were found in the clean medical supply room, and no backup supply of washcloths was present in the emergency linen supply. The Director of Housekeeping confirmed there was no backup supply of washcloths. The deficiency also includes environmental and maintenance issues affecting resident bathrooms, handrails, and common areas. In the main dining area, a recliner chair was observed positioned directly in front of the handwashing sink, and two recliner chairs were stored in front of the nutrition area kitchenette. Multiple resident bathrooms and shared bathrooms were repeatedly observed over several days with unfinished spackle on walls that needed resurfacing and painting, chipped paint around sinks, uneven boards nailed to walls under sinks that appeared to partially cover holes, musty odors, black substances between shower bases and walls, missing threshold transition molding exposing cracks, missing tiles, and a nail, as well as eroded and chipped paint on baseboard heaters with exposed dark brown metal and rust-like material. Hallway handrails on both nursing units were observed to be worn, with chips, splintering, holes, and areas where the wood finish had worn off. A shower room was observed with a foul fecal odor, dried brown stains on the back of the toilet seat and in the toilet bowl, and a baseboard heater with eroded, chipped paint and rust-like material, along with chipped paint on the handrail. These conditions were acknowledged by the Director of Maintenance and other leadership, and some areas were noted to be in the process of renovation, but the observed deficiencies remained present during the survey period. Overall, the facility did not maintain a safe, clean, comfortable, and homelike environment in good repair across both nursing units and the dining area. The lack of adequate linen and incontinence supplies, combined with the poor condition of resident bathrooms, handrails, and certain common areas, constituted the basis for the cited deficiency. The observations and staff and resident reports consistently described shortages of essential hygiene supplies, delayed care related to linen availability, and multiple unresolved environmental and maintenance issues in resident care areas and shared spaces.
Failure to Thoroughly Investigate Abuse Allegations and Injuries of Unknown Origin
Penalty
Summary
Facility staff failed to thoroughly investigate allegations of potential abuse involving one resident and an injury of unknown origin involving another resident. For one resident, there were two separate allegations of abuse occurring on different days in early February. The facility’s investigation packets included interviews with staff who cared for or were scheduled to work with this resident on the days of the alleged incidents, and the investigations focused solely on this resident. However, there were no interviews conducted with other residents on the unit to inquire about abusive or neglectful treatment by the staff who were working during the times of the allegations. The surveyors noted that, although the allegations were not validated, there was no documentation that other residents were interviewed, if able, or assessed for signs or symptoms of injury. In a separate incident, another resident was identified on March 4 with a new bruise on the right eye, documented as a change in condition at 4:09 AM. This resident had a BIMS score of 99, indicating the resident was unable to complete an interview and therefore could not report how the injury occurred. The facility’s investigation identified a potential cause of the injury but did not reach a definitive resolution. Additionally, there were no interviews of other residents on the unit regarding possible abuse, nor were there documented assessments of other residents for injuries of unknown origin, particularly for those unable to speak for themselves, as in this resident’s case.
Failure to Provide Oral Care to Dependent Residents
Penalty
Summary
The deficiency involves the facility’s failure to provide oral care to residents who were dependent on staff for activities of daily living, specifically oral hygiene. One resident with a tracheostomy was observed with a thick, sticky white substance in the mouth and was noted to intermittently chew on nearby bedding. This resident made good eye contact and, when asked if staff brushed their teeth, shook their head no and mouthed that staff “need to.” According to the resident’s Minimum Data Set (MDS) dated 2/11/26, the resident was dependent on staff for oral care. Another resident, also dependent on staff for oral care per the 3/11/26 MDS, was observed sitting propped up in bed and able to respond with smiles. During the initial observation, the inside of this resident’s lips and upper and lower teeth had a thick, clear, white milky substance visible when the resident tried to open their mouth to smile. Oral care supplies were present in the nightstand, but the resident’s mouth and teeth were not clean. On a subsequent observation with the DON, NHA, and Corporate VP of clinical services, the same resident again had a thick, clear, milky substance between the lips and caking the teeth, which would string between the teeth when the resident attempted to open their mouth, demonstrating a lack of consistent oral care for residents dependent on staff for this ADL.
Incomplete and Inaccurate Medical Record Documentation for Treatments and Assessments
Penalty
Summary
Facility staff failed to maintain complete and accurate medical records and documentation for multiple residents. For one resident with wound care needs, review of the MAR showed that wound care and related treatments were signed as completed on the dates initially reported, despite the resident’s ongoing complaints that wound dressings were not being changed. When additional dates were reviewed, there were missing staff signatures for wound care on two specific dates, as well as three instances where application of A&D ointment to the resident’s feet was not signed off out of 24 days reviewed. Another resident with severe cognitive impairment, as evidenced by a BIMS score of 00, was found to have an injury of unknown origin (a bruise on the left hand). Documentation showed that a change in condition was initiated late in the morning, but a formal pain evaluation was not initiated and completed until that night, and the resident was unable to explain how the injury occurred or verbalize pain using a standard pain scale. For a third resident, documentation related to the admission PPD test was inconsistent and incomplete. The MAR contained an entry indicating “9” for the administration date, meaning “see nurse’s note,” but there was no corresponding nurse’s note. Despite the absence of a signed administration of the PPD injection, staff documented the PPD result as “negative” on the scheduled read date. The resident reported never receiving the PPD injection, and the DON confirmed that the facility had been out of PPD solution at the time, so the test would not have been administered. These findings demonstrate failures in accurate documentation of treatments and assessments, including wound care, pain assessment, and TB screening, as well as missing or incomplete supporting notes in the medical record.
Failure to Implement and Communicate Correct Transmission-Based Precautions
Penalty
Summary
Surveyors identified a deficiency in the facility’s infection prevention and control program related to inconsistent and incorrect implementation of transmission-based precautions and PPE use. During a complaint investigation focused on residents on transmission-based precautions, one resident with a visible Foley catheter was observed in the room with physical therapy, but there were no signs posted indicating any need for PPE, despite the resident being a new admission with a Foley catheter placed related to wounds. In another double-occupancy room, a contact precautions sign was posted at the doorway, but the nurse practitioner was in the room on a personal phone with no PPE, and the assigned GNA was repositioning the resident in bed while wearing only gloves. When questioned, the NP, RN, and GNA all stated that the resident in the room was not on contact precautions, and the GNA reported that signs were hanging at all doors and that this particular resident’s sign was “just wrong.” The surveyor observed the GNA later return to the room and turn the sign around to indicate no PPE requirement. Subsequent interviews revealed that therapy staff relied on posted signage to determine PPE use and that if the sign was wrong, the PPE used would be wrong. Overall, surveyors found problems with signage accuracy and staff awareness of which residents required contact precautions, as well as observed failures to follow appropriate PPE use for residents who should have been on contact precautions.
Inaccurate MDS Coding for Falls, Pain Management, and High-Risk Medications
Penalty
Summary
Facility staff failed to ensure Minimum Data Set (MDS) assessments were accurately coded for two residents reviewed during a complaint survey. For one resident, a facility-reported incident showed that the resident was found seated on the floor beside the bed and was diagnosed with a non-displaced femoral neck impaction fracture of the left hip following an x-ray. Despite this fall with a major injury, the subsequent significant change MDS dated 11/4/25 did not code the fall with major injury in Section J1900C. Review of the resident’s Medication Administration Records for October and November 2025 showed administration of Tylenol on 10/31/25 at 9:30 PM, which fell within the 5-day look-back period for the MDS, but Section J0100 (prn pain) of the same significant change MDS did not capture the use of Tylenol. For another resident, review of a quarterly MDS with an assessment reference date of 10/15/25 showed that Section N0415 (High-Risk Drug Classes) documented the use of an opioid medication. However, review of the resident’s October 2025 Medication Administration Record did not show that the resident had been prescribed an opioid during that period. In both cases, MDS staff later confirmed that these were errors in MDS coding, demonstrating that the assessments did not accurately reflect the residents’ clinical status and medication use as documented in their medical records.
Incomplete Documentation of Narcotic Administration on MAR
Penalty
Summary
The facility failed to maintain complete and accurate medical records in accordance with accepted professional standards for one resident receiving narcotic medication. The resident, admitted in March 2026, had a fall on 3/6/26 and was sent to the hospital on 3/9/26. Review of the March 2026 Medication Administration Record (MAR) showed documentation of a single 25 mg dose of Tramadol administered on 3/8/26 at 9:23 AM. However, review of the resident’s Controlled Drug Receipt/Record/Disposition Form, kept on the nurse’s medication cart and not in the medical record, showed that Tramadol 25 mg was administered three times between 3/8/26 and 3/9/26: at 11:00 AM and 9:00 PM on 3/8/26, and at 9:00 AM on 3/9/26. In interview, the DON stated that staff are expected to document narcotic administration on the MAR and confirmed that only one of the three Tramadol doses reflected on the controlled drug record was documented on the resident’s MAR. This discrepancy between the controlled substance record and the MAR, with missing documentation of two administered doses of Tramadol on the official medical record, constituted the failure to maintain a complete and accurate medical record for the resident.
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