Montcare At Bethesda
Inspection history, citations, penalties and survey trends for this long-term care facility in Bethesda, Maryland.
- Location
- 6530 Democracy Boulevard, Bethesda, Maryland 20817
- CMS Provider Number
- 215095
- Inspections on file
- 14
- Latest survey
- October 10, 2025
- Citations (last 12 mo.)
- 4
Citation history
Health deficiencies cited at Montcare At Bethesda during CMS and state inspections, most recent first.
A resident developed new bilateral buttocks abscesses, which were documented in progress notes and wound assessments. However, the care plan was not updated to address these new wounds, as confirmed by review of care plan revision history and staff interviews, including with the DON and a nurse practitioner.
A resident with intact cognitive function was subjected to a straight catheterization by two nurses without a physician's order or the resident's consent. Despite facility policy requiring both an order and consent for such procedures, the nurses proceeded based on their own judgment, and the DON later confirmed that no order had been obtained.
A resident with a Stage 3 pressure ulcer did not receive wound care as recommended by the wound care provider. The facility failed to enter the correct treatment orders and did not document wound care completion for several days. The wound worsened to Stage 4, and the wound care provider recommended hospital transfer. Interviews with the DON and Unit Manager confirmed the discrepancy between the provider's recommendations and the facility's actions.
A resident's medical records were inaccurately documented when staff signed off daily completion of a monthly mediport flush order, and continued to document the procedure as completed even after the mediport was removed. The DON confirmed that these sign-offs were inappropriate and did not reflect actual care provided.
The facility failed to notify the Ombudsman of a resident's transfer to an acute care facility and did not provide written notification to another resident or their representative regarding hospital transfers. The Director of Nursing acknowledged the expectation to notify the Ombudsman, and the Divisional Director of Quality Assurance stated that written notices should be provided, but no evidence was found in the records.
A facility failed to notify a resident or their representative in writing about the bed hold policy during hospital transfers. The resident's clinical record lacked documentation of this notification, and the Business Office Manager confirmed the absence of evidence. The facility could not provide documentation at the exit conference.
A resident found keys to a medication cart on the floor, indicating a lapse in medication security. Additionally, two insulin pens were improperly stored in a medication cart drawer instead of being refrigerated as required. The DON and a staff nurse acknowledged these findings.
Surveyors identified improper food storage in the kitchen, including expired Red Cooking Wine and Concord Grape Jelly without proper dating in the refrigerator. Additionally, expired Crispy Rice Cereal and Confectioners Sugar were found in the dry storage room. These items were confirmed by staff and removed for disposal.
A resident with left side paralysis and limited use of the right arm was unable to use the call bell due to its inaccessibility and inappropriate design. The resident relied on a roommate to alert staff for assistance. Despite frequent rounding, staff did not identify the issue until the survey, highlighting a failure to accommodate the resident's needs.
A facility failed to transmit MDS assessments within the required 14 days for a resident, resulting in a delay of over 120 days. The MDS Coordinator acknowledged the error, stating that assessments are usually transmitted weekly or twice a week. The President of Clinical Services was notified of the oversight.
The facility failed to revise care plans for two residents receiving specific medications. One resident's care plan lacked documentation for psychotropic medications, while another resident's care plan did not address monitoring for anticoagulant therapy. Interviews with staff confirmed the absence of these care plans, which were expected to be in place.
A facility failed to provide appropriate care for a resident with a G-tube. During a medication pass, a staff member flushed the resident's G-tube without checking for proper placement, contrary to the facility's policy. The staff member acknowledged the oversight, which was observed by a surveyor.
A resident experienced inadequate respiratory care when their oxygen tubing was found disconnected and water was observed in the tubing. The LPN was unaware of the issue, and the ADON initially attributed it to condensation. Despite attempts to resolve the problem, the resident reported not using the oxygen overnight due to water dripping from the nasal cannula. The issue was later identified as a faulty oxygen concentrator, which was replaced.
The facility failed to implement non-pharmacological pain interventions and did not adhere to physician orders for PRN pain medications for two residents. Non-pharmacological interventions were not documented, and pain medications were administered outside prescribed parameters. Staff interviews revealed inconsistencies in following pain management protocols and documentation practices.
A facility failed to deliver meals at appropriate temperatures, as observed during a survey. A resident complained about cold meals, and a test tray showed scrambled eggs and hashbrowns at 90 and 95 degrees Fahrenheit, below the expected 120 degrees. The Kitchen Manager confirmed the deficiency, and the Food Service Director noted that plate warmers were ordered.
Facility staff failed to follow infection control practices during medication administration and dressing changes. A nurse administered medications and took a resident's blood pressure without performing hand hygiene. Another staff member changed a resident's G-tube dressing without changing gloves or sanitizing hands. Both staff members acknowledged their lapses when questioned by surveyors.
A survey identified a deficiency in a call system within a shower room, where a call bell device lacked a necessary cord for activation. This issue was confirmed by the Maintenance Technician and the NHA during a facility tour.
Failure to Update Care Plan for New Wounds
Penalty
Summary
A deficiency was identified when the facility failed to update the comprehensive care plan for a resident who developed new wounds. Record review showed that the resident developed abscesses on the bilateral buttocks, as documented in a Skin and Wound Note and a wound assessment. Despite these findings, the resident's care plan was not updated to address the new wounds. The care plan revision history confirmed that no new interventions or goals were added after the wounds were identified. Interviews with facility staff, including a nurse practitioner and the Director of Nursing (DON), confirmed that the wounds were present and that the care plan had not been updated accordingly. The DON acknowledged that the responsibility for updating care plans at the time belonged to a wound treatment nurse, who failed to make the necessary updates. The lack of timely care plan revision was confirmed by both documentation review and staff interviews.
Catheterization Performed Without Physician Order or Consent
Penalty
Summary
A deficiency occurred when nursing staff performed a straight catheterization on a resident without obtaining a physician's order or the resident's consent. The incident involved two nurses who, during the early morning hours, inserted a catheter to collect a urine sample after the resident declined to walk to the bathroom. The resident, who was cognitively intact as indicated by a BIMS score of 15, reported that the procedure was done without explanation or consent, leading the resident to feel violated and contact local authorities. Review of the medical record showed that while there was a physician's order for laboratory tests including urinalysis, there was no specific order for straight catheterization. Facility policy required a physician's order for all catheterizations, and staff interviews confirmed that both an order and resident consent were necessary for the procedure. The DON acknowledged that the catheterization was performed based on nursing judgment rather than a physician's directive, in direct contradiction to facility policy.
Failure to Follow Wound Care Provider Recommendations for Pressure Ulcer Treatment
Penalty
Summary
A deficiency occurred when the facility failed to provide appropriate wound care for a resident with a Stage 3 pressure ulcer in the sacral area. The wound care provider made specific recommendations for wound treatment, including the use of Collagen and later Dakins solution with fluffed gauze, zinc oxide paste, and transparent film, to be applied twice daily. However, these recommendations were not entered into the resident's treatment orders or the Treatment Administration Record (TAR). Instead, the facility ordered a different treatment regimen, including cleansing with normal saline instead of Dakins solution and applying the treatment only once daily on certain days, which did not match the wound care provider's instructions. Further review revealed that wound care was not documented as completed for several days, and when it was documented, it was not done according to the recommended frequency. Interviews with the DON and the Unit Manager confirmed that the wound care provider's recommendations were not followed and that the orders in the TAR differed from those recommendations. The resident's wound worsened from Stage 3 to Stage 4, and the wound care provider ultimately recommended hospital transfer for further management.
Inaccurate Medical Record Documentation for Mediport Care
Penalty
Summary
The facility failed to ensure the accuracy of medical records for one resident who had a mediport in place. Medical record review showed that there was an order to flush the resident's implanted port monthly, which was incorrectly documented as completed daily over several months, rather than only on the scheduled date. Additionally, after the mediport was surgically removed, staff continued to sign off the order as completed for several days, despite the port no longer being present. The Director of Nursing confirmed that the order should not have been signed off unless the procedure was actually performed and that documentation should have ceased after the port's removal.
Failure to Notify Ombudsman and Provide Written Transfer Notices
Penalty
Summary
The facility failed to notify the Ombudsman of a resident's transfer to an acute care facility and did not provide written notification to another resident or their representative regarding hospital transfers. Specifically, the facility did not inform the Ombudsman about the transfer of a resident to a hospital emergency room on a specified date. This omission was discovered during a review of the Ombudsman notification records, which lacked documentation of the transfer. The Director of Nursing acknowledged that the facility's expectation is to notify the Ombudsman of all resident transfers. Additionally, the facility did not provide written notification to a resident or their representative for multiple hospital transfers. The clinical record review revealed no documentation of written notices for transfers on specific dates. The Divisional Director of Quality Assurance stated that the nursing staff is expected to notify residents or their representatives verbally and provide a written hospital transfer/discharge form. However, a review of the binder where these forms are kept showed no evidence of written notices for the resident's transfers. At the time of the exit conference, the facility could not provide evidence of written notification for these transfers.
Failure to Notify Resident of Bed Hold Policy
Penalty
Summary
The facility failed to notify a resident or the resident's representative in writing about the bed hold policy when the resident was transferred to an acute care facility. This deficiency was identified during the annual survey for one of the three residents reviewed for hospitalizations. Specifically, the clinical record of the resident showed transfers to the hospital on two occasions, but there was no documentation that the bed hold policy was communicated in writing to the resident or their representative. An interview with the Business Office Manager confirmed the absence of evidence that the bed hold policy was provided in writing for the hospital transfers. At the time of the exit conference, the facility was unable to present any documentation to show compliance with the requirement to notify the resident or their representative about the bed hold policy.
Medication Security and Storage Deficiencies
Penalty
Summary
The facility failed to maintain a secure system for medication management, as evidenced by an incident involving a resident who found a set of keys belonging to a medication cart on the hallway floor. The keys were handed over to the surveyor by the resident, who stated they were found on the 1st floor nursing unit. During an interview, the Nursing Home Administrator and the Director of Nursing were informed about the missing keys, and it was confirmed that they were unaware of the situation. An observation of the medication cart revealed that the narcotic counts were accurate and matched the narcotic log, indicating no discrepancies in the medication inventory. Additionally, the facility did not store medications properly, as observed during a medication storage check on the Embassy Unit. Two insulin pens, one for Humalog Kwik Pen and another for Glargine Solostar, were found in a basket in the 3rd drawer of the medication cart, despite having pharmacy labels indicating they should be refrigerated until opened. The Director of Nursing and a staff nurse acknowledged the surveyor's findings, confirming the improper storage of these medications.
Improper Food Storage in Kitchen
Penalty
Summary
During a recertification survey, surveyors observed deficiencies in the storage of food items in the kitchen of the facility. On the initial tour of the kitchen, surveyors found a bottle of Red Cooking Wine with an open date of 8/15/24 and a dispose date of 9/15/24, as well as an opened 48 oz glass container of Concord Grape Jelly without any open or dispose date in the food prep refrigerator. These items were confirmed by a cook to be improperly stored and were subsequently removed for disposal. Further observations in the dry storage room revealed two unopened bags of Crispy Rice Cereal with a use-by date of 10/2/24 and five unopened boxes of Confectioners Sugar with a use-by date of 2/1/22. The Kitchen Manager confirmed these items were past their use-by dates and removed them from the shelf for disposal.
Inadequate Call Bell Accessibility for Resident
Penalty
Summary
The facility failed to reasonably accommodate the needs and preferences of a resident by not ensuring that a call bell was kept within reach and by not providing the appropriate type of call bell device for the resident's use. During the annual survey, it was observed that a resident with left side paralysis and severe limited use of the right arm was unable to use the call bell. The resident had to rely on a roommate to activate the call bell for assistance. The call bell was found resting on the resident's chest but tucked under the blanket, making it inaccessible. Further observations revealed that the call bell was placed on the headboard, out of the resident's reach. The resident's LPN confirmed that the resident was unable to activate the call bell and that the roommate often alerted staff when assistance was needed. Despite frequent rounding by nursing staff, the issue was not identified until the survey. The deficiency was evident as the resident was dependent for all care, and the facility did not provide a suitable call bell device to accommodate the resident's needs.
Failure to Transmit MDS Assessments Timely
Penalty
Summary
The facility failed to transmit Minimum Data Set (MDS) assessments within the required 14 days of completion for a resident. Specifically, the MDS assessment for a resident with a discharge date was completed but not transmitted to the Centers for Medicare and Medicaid Services' (CMS) Internet Quality Improvement and Evaluation System (iQIES) for over 120 days. This delay was identified during a record review conducted as part of the annual survey. During an interview, the MDS Coordinator acknowledged the requirement to transmit MDS assessments within 14 days and confirmed that the assessment in question was not submitted due to an error. The coordinator stated that assessments were typically transmitted weekly or twice a week, but this particular assessment was overlooked. The President of Clinical Services was informed of the oversight, confirming the deficiency in the facility's process for timely transmission of MDS assessments.
Failure to Revise Care Plans for Medications
Penalty
Summary
The facility failed to ensure that care plans were revised for two residents who were receiving specific medications. For one resident, the Medication Administration Record indicated the use of psychotropic medications, including busPIRone HCl and Seroquel. However, a review of the resident's care plan revealed that there was no care plan in place for these psychotropic medications. The Divisional Director of Quality Assurance confirmed that it was the facility's expectation to have a care plan with a focus, goal, and interventions for psychotropic medications. Another resident was receiving Heparin Sodium injections for Deep Vein Thrombosis prophylaxis, but there was no care plan developed to monitor for bruising and bleeding related to anticoagulant therapy. Interviews with an LPN and a Unit Manager revealed that the care plan for blood thinners should have been in the electronic system, but they were unable to locate it. The Assistant Director of Nursing confirmed that a care plan should have been initiated for residents on blood thinners, and it was the responsibility of the Unit Managers to develop these care plans.
Failure to Verify G-Tube Placement Before Flushing
Penalty
Summary
The facility failed to provide appropriate treatment and services to a resident receiving tube feedings. During a medication pass, a surveyor observed a staff member flushing a resident's gastrostomy tube (G-tube) with water without first checking for proper placement. The staff member admitted to not verifying the G-tube placement by aspirating the stomach contents before administering the flush, which is against the facility's policy. The facility's policy, revised earlier in the year, mandates that the placement and functioning of a feeding tube be verified before any feeding, flushing, or medication administration.
Failure to Provide Proper Respiratory Care
Penalty
Summary
The facility failed to provide appropriate respiratory care for a resident, as observed by a surveyor. The deficiency was identified when the surveyor noticed the resident's oxygen tubing and nasal cannula disconnected and lying on the floor, with water droplets moving inside the tubing. The resident's son reported that water had backed up from the oxygen concentrator. The humidifier bottle and tubing were not dated, indicating a lack of adherence to proper procedures. An LPN was unaware of the issue, as she had not yet conducted her morning assessment. The Assistant Director of Nursing (ADON) was informed of the situation and observed the water in the tubing, attributing it to condensation from the concentrator being near a room heater. Despite moving the concentrator and changing the tubing, the problem persisted, as the resident reported not using the oxygen overnight due to water dripping from the nasal cannula. The ADON later determined the issue was with the oxygen concentrator itself, which was subsequently replaced. The surveyor later confirmed that the new equipment was correctly dated, but the initial failure to provide proper respiratory care was evident.
Deficiency in Pain Management and Documentation
Penalty
Summary
The facility failed to develop and implement non-pharmacological interventions for pain management and did not ensure that pain medication was administered in accordance with professional standards of practice. This deficiency was identified during an annual survey for two residents who were reviewed for pain management. The records for these residents showed that non-pharmacological interventions were not documented in the Medication Administration Record (MAR), Treatment Administration Record (TAR), progress notes, or care plans. Interviews with staff, including Licensed Practical Nurses (LPNs), Unit Managers (UMs), and the Assistant Director of Nursing (ADON), revealed a lack of clarity and consistency in documenting and implementing non-pharmacological interventions. Additionally, the facility staff did not adhere to the pain parameters specified in the physician orders for administering PRN pain medications. For one resident, Oxycodone was administered despite a pain level of 3, which did not meet the criteria for moderate pain as per the physician's order. Similarly, another resident received Acetaminophen and Tramadol for pain levels that did not align with the prescribed parameters for moderate and severe pain. The MAR and nursing progress notes indicated discrepancies between the recorded pain levels and the administration of pain medications. Interviews with nursing staff, including Registered Nurses (RNs) and UMs, highlighted inconsistencies in following the facility's pain management protocols. The ADON confirmed that a standard pain scale was used, but the pain parameters in the physician orders were not consistently followed by the nurses. The facility's process for documenting pain levels and the effectiveness of pain medications was not adequately implemented, leading to the administration of pain medications outside the prescribed parameters.
Failure to Deliver Meals at Appropriate Temperature
Penalty
Summary
The facility failed to ensure that food was delivered to residents at an appropriate and palatable temperature. This deficiency was identified during a surveyor's observation and interviews with residents and facility staff. A complaint was reviewed where a resident alleged that all meals were delivered cold. During a breakfast tray observation, it was noted that the plates on the meal cart did not have bottom plate warmers to maintain warmth. The surveyor, along with the Kitchen Manager, observed the meal cart delivery process, and it was found that the scrambled eggs and hashbrowns on the test tray were at temperatures of 90 and 95 degrees Fahrenheit, respectively, which were below the expected 120 degrees Fahrenheit for hot foods. The Food Service Director later confirmed that 24 plate warmers had been ordered.
Infection Control Lapses in Medication Administration and Dressing Changes
Penalty
Summary
The facility staff failed to adhere to infection control practices during medication administration and dressing changes, as observed by surveyors. In the first instance, a Registered Nurse, identified as Staff #8, administered medications to a resident in a semi-private room without performing hand hygiene afterward. The nurse then proceeded to take another resident's blood pressure without sanitizing hands, despite acknowledging the usual practice of wearing gloves. In the second instance, Staff #9, while wearing gloves, removed a contaminated dressing from a resident's G-tube site and immediately reached for a clean dressing without changing gloves or performing hand hygiene. This oversight was acknowledged by Staff #9 during an interview with the surveyor.
Deficiency in Call System Functionality in Shower Room
Penalty
Summary
During a recertification survey, it was observed that the facility staff failed to ensure that a call system in a shower room was fully functional. Specifically, a call bell device mounted on the wall within one of the shower stalls in the first-floor central shower room was missing a cord. This cord is essential for residents to activate or deactivate the call light, particularly in situations where a resident might fall and be unable to reach the button on the mounted device. The deficiency was confirmed during an initial tour by surveyors and further verified by the Maintenance Technician and the Nursing Home Administrator.
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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