Montcare At Potomac
Inspection history, citations, penalties and survey trends for this long-term care facility in Potomac, Maryland.
- Location
- 10714 Potomac Tennis Lane, Potomac, Maryland 20854
- CMS Provider Number
- 215171
- Inspections on file
- 16
- Latest survey
- September 30, 2024
- Citations (last 12 mo.)
- 0
Citation history
Health deficiencies cited at Montcare At Potomac during CMS and state inspections, most recent first.
A facility failed to report a possible misappropriation of a resident's medication within the required 24-hour timeframe to the OHCQ. The incident involved missing Ativan tablets, and the delay in reporting was due to waiting for a pharmacy review. The DON confirmed the report was sent five days late.
A resident was observed unable to reach their call bell device, which was found draped over their wheelchair and behind a pillow, out of reach. The Unit Manager confirmed the device was not accessible and acknowledged the expectation for it to be within reach. The resident's care plan included an intervention to reinforce the need to call for assistance.
A facility failed to ensure a physician documented a resident's discharge in the medical record. An LPN noted the discharge and completed a form, but no physician documentation was found. The attending physician acknowledged the requirement to document within 30 days, but this was not done. The DON confirmed the absence of documentation.
A resident did not receive a recommended follow-up urology appointment after hospitalization for a cystoscopy with stent placement. The hospital discharge summary indicated the need for this follow-up, but no documentation was found in the medical record to show that the appointment was scheduled. The resident was later hospitalized again with a complicated UTI, suspected to be related to the stent. Facility staff confirmed the absence of any scheduled follow-up appointments.
A resident experienced a significant weight gain of 16% over 19 days, increasing from 80 to 93.4 pounds, without proper monitoring or physician notification. Despite facility policy requiring communication for significant weight changes, there was no documentation of communication between nursing staff, the dietitian, the physician, or the resident's family. The DON confirmed the oversight, acknowledging the facility's failure to adhere to its weight monitoring parameters.
A resident with chronic pain syndrome and severe cognitive impairment experienced inconsistent pain management at the facility. Despite orders to document pain scores every shift, pain medication was administered without clear parameters corresponding to these scores. Interviews and record reviews revealed frequent pain episodes and grimacing during care, highlighting the facility's failure to manage the resident's pain effectively.
A resident received unnecessary PRN pain medication when Tramadol was administered outside the prescribed parameters for moderate pain. The medication was given for pain scores of 0 and 2, contrary to the physician's order for moderate pain (score 4-6). The DON confirmed the inappropriate administration and noted that nurses sometimes gave medication based on resident requests without following orders.
A survey revealed deficiencies in medication storage and disposal of expired supplies in an LTC facility. A resident's medication was found on the floor, and expired medications and unsterile dressing supplies were discovered in medication and treatment carts.
A facility failed to document education on the benefits and side effects of influenza and pneumococcal vaccines for a resident who repeatedly refused them. Despite claims of annual and quarterly educational efforts by staff, no evidence was found in the resident's medical records. The DON acknowledged the deficiency when informed by the surveyor.
The facility failed to provide written notification to two residents and their representatives regarding the reason for their transfer to a hospital. One resident was sent to the ER for shortness of breath, weakness, and hypotension, while another was transferred to an acute care facility. In both cases, the reasons for transfer were communicated verbally but not documented in writing, as confirmed by staff and the Administrator.
A resident with a stage 4 sacrum pressure injury had incomplete medical records regarding wound care management. Despite physician's orders for daily care, documentation was missing on several dates in August and September. The DON confirmed these findings during a survey.
Failure to Timely Report Misappropriation of Resident Property
Penalty
Summary
The facility staff failed to report a possible misappropriation of resident property within the required 24-hour timeframe to the regulatory agency, the Office of Health Care Quality (OHCQ). This deficiency was identified during a recertification/complaint survey for one resident among those reviewed for abuse. Specifically, the incident involved the disappearance of 28 tablets of Ativan 0.5 mg, which were supposed to be delivered to the facility. Although the controlled substance log was found on the staff's desk, the medication itself was missing. The Director of Nursing (DON) confirmed that the initial report of the incident was sent to OHCQ five days after the incident occurred, thus failing to meet the 24-hour reporting requirement. The delay was attributed to the facility waiting for the pharmacy to review the medications delivered on the day of the incident. The DON acknowledged the reporting delay but believed it was unnecessary to self-report while awaiting the pharmacy's review.
Call Bell Accessibility Deficiency
Penalty
Summary
The facility failed to ensure that a call bell device was within reach of a resident, leading to a deficiency. During an observation, a surveyor noted that a resident was lying in bed and gesturing, seemingly trying to communicate a need for assistance. Upon inquiry, the resident was observed searching for the call bell device, which was found to be plugged into the wall and draped over the resident's wheelchair, with the call device itself located behind a pillow on the wheelchair, out of the resident's reach. The Unit Manager confirmed the call bell was not accessible to the resident and acknowledged that the expectation was for residents to have their call bell within reach. The resident's care plan included an intervention to reinforce the need to call for assistance, highlighting the importance of having the call bell accessible.
Physician Discharge Documentation Deficiency
Penalty
Summary
The facility failed to ensure that a physician documented a resident's discharge in the medical record, as required. This deficiency was identified during a recertification/complaint survey for a resident who was discharged home. A progress note written by an LPN indicated the discharge, and a form titled 'My Transition Home' was completed by the LPN regarding the discharge. However, there was no documentation from the physician in the resident's medical record. The attending physician acknowledged that they should document discharges within 30 days, but upon review, no such documentation was found within the required timeframe. The Director of Nursing confirmed the absence of the physician's discharge documentation.
Failure to Schedule Follow-Up Urology Appointment
Penalty
Summary
The facility failed to ensure a resident received a recommended specialist follow-up appointment after hospitalization. The resident was discharged after a hospital stay where they underwent a cystoscopy with right ureteral stent placement. The hospital discharge summary indicated the need for a follow-up outpatient appointment with urology, as the stent was temporary and required further procedures. However, there was no documentation in the medical record indicating that the follow-up appointment was scheduled or attended. The deficiency was identified during a recertification/complaint survey, where it was found that the resident had been hospitalized again with a complicated urinary tract infection, which was suspected to be secondary to the ureteral stent. Interviews with facility staff, including the Unit Manager, Assistant Director of Nursing, and the Director of Nursing, confirmed the absence of any scheduled urology follow-up appointments. The attending physician acknowledged the lack of documentation regarding the recommended follow-up, and the facility staff could not provide evidence of attempts to schedule the necessary appointment.
Failure to Monitor and Communicate Significant Weight Gain
Penalty
Summary
The facility failed to adequately monitor and evaluate a resident's significant weight gain and did not notify the physician as required. A resident, who was receiving tube feedings upon admission, experienced a 16% weight gain over 19 days, increasing from 80 pounds to 93.4 pounds. Despite the facility's policy requiring physician notification for significant weight changes, there was no documentation of communication between nursing staff, the dietitian, the physician, or the resident's family regarding this weight gain. Interviews with staff revealed that weights were typically obtained by Geriatric Nursing Assistants and nurses, and significant changes were supposed to be communicated to the physician and dietitian. However, in this case, the process was not followed. The Director of Nursing confirmed the weight gain and acknowledged that the facility had parameters in place to notify the physician for weight changes of 3-5 pounds, which were not adhered to in this instance. The lack of weight tracking and communication contributed to the deficiency identified during the survey.
Inconsistent Pain Management for Resident with Chronic Pain Syndrome
Penalty
Summary
The facility failed to consistently evaluate and manage the pain of a resident receiving short-term rehabilitation, who was diagnosed with chronic pain syndrome and had severe cognitive impairment as indicated by a BIMS score of 0/15. Despite having an order to document pain scores every shift, the resident's pain management was inconsistent. Interviews with the resident's family member and staff revealed that the resident frequently experienced pain, grimacing during care, and that pain medication was administered without clear parameters corresponding to the documented pain scores. The resident's Medication Administration Record showed multiple instances where pain medication was given, but the administration did not align with the pain scores recorded. For example, oxyCODONE was administered for pain levels ranging from 3 to 6, but there were no specific guidelines for medication administration based on these scores. This inconsistency in pain management was confirmed during a review with the Director of Nursing, who acknowledged the lack of appropriate medication parameters corresponding to the resident's pain scores.
Inappropriate Administration of PRN Pain Medication
Penalty
Summary
The facility staff failed to adhere to physician orders by administering PRN pain medication outside the prescribed parameters, resulting in the resident receiving unnecessary medication. This deficiency was identified during a recertification/complaint survey for one of the five residents reviewed for unnecessary medications. The resident involved was admitted to the facility with multiple medical diagnoses, including disorders of muscle, infection due to cardiac valve, pneumonia, type 2 diabetes mellitus, presence of a cardiac pacemaker, and spondylosis lumbar region. The physician's order specified Tramadol HCL 25 mg to be given every 4 hours as needed for moderate pain, defined as a pain score of 4-6 on a scale of 0-10. Upon reviewing the resident's Medication Administration Record (MAR) for September 2024, it was found that Tramadol was administered on two occasions when the resident's pain score was below the prescribed threshold. Specifically, the medication was given for a pain score of 0 and 2, which did not meet the criteria for moderate pain as per the physician's order. The Director of Nursing confirmed the inappropriate administration of Tramadol and acknowledged that nurses sometimes administered medication based on resident requests without adhering to the prescribed parameters.
Medication Storage and Expired Supplies Deficiency
Penalty
Summary
During a recertification and complaint survey, it was observed that the facility staff failed to safely store a resident's medication and dispose of expired medications and dressing supplies. On the 2nd floor unit, a surveyor found a labeled plastic bag containing an Atenolol 50 mg tablet on the floor near a resident's bedside table. The medication was identified as belonging to the roommate of the resident in the room, although the Director of Nursing later confirmed that the resident was not currently prescribed Atenolol. The pharmacy associated with the facility did not recognize the packaging, suggesting it may have been brought in from the hospital with the resident's personal belongings. Additionally, on the 1st floor unit, expired medications and unsterile dressing supplies were found in the medication and treatment carts. A bottle of Pro-Stat protein supplement was found to be expired, and expired Iodoform Packing Strip and opened, unsterile Xeroform Petrolatum dressing were discovered in the treatment cart. These findings were confirmed by the registered nurses present during the observations, who immediately removed the expired and unsterile items from the carts.
Deficiency in Vaccine Education Documentation
Penalty
Summary
The facility failed to provide education regarding the benefits and potential side effects of the influenza and pneumococcal vaccines to Resident #29, as evidenced during a recertification/complaint survey. The medical record review revealed that Resident #29, who had been residing at the facility since March 2020, refused the influenza vaccine in 2020 and 2022, with no documentation for 2021 and 2023. There was no evidence in the resident's records to support that education on the vaccine's risks and benefits was provided. Similarly, the pneumococcal vaccine records showed refusals in 2020 and March 2024, again without documentation of educational efforts. Interviews with the Infection Control Preventionist (Staff #22) indicated that the facility claimed to provide annual influenza education and quarterly and yearly education for the pneumococcal vaccine to residents who refused. However, this was not documented in the Electronic Medical Record for Resident #29. The Director of Nursing (DON) acknowledged the concern when it was shared by the surveyor, validating the deficiency in providing necessary education to the resident.
Failure to Provide Written Notification for Hospital Transfers
Penalty
Summary
The facility failed to provide written notification to residents and their representatives regarding the reason for transfer or discharge to a hospital. This deficiency was identified during a recertification/complaint survey for two residents who were hospitalized. Resident #136 was sent to the emergency room on 8/1/2024 for shortness of breath, weakness, and hypotension. Although the reason for transfer was documented in the change in condition form and verbally communicated to the resident and their representative, there was no written notification provided. The Licensed Practical Nurse confirmed that the reason for transfer was communicated verbally but not in writing. Similarly, Resident #70 was transferred to an acute care facility on 8/19/2024, and there was no documentation in the medical record indicating that the resident or their responsible party received written notice of the reason for the transfer. The Administrator acknowledged the absence of written documentation and confirmed the findings during the survey. The lack of written notification for both residents constitutes a failure to comply with regulatory requirements for resident transfer and discharge notifications.
Incomplete Medical Record for Wound Care Management
Penalty
Summary
The facility staff failed to maintain a complete and accurate medical record for a resident, as identified during a recertification/complaint survey. The resident, who had a stage 4 sacrum pressure injury, was discharged to acute care and later readmitted to the facility. Physician's orders dated April 20, 2024, specified daily wound care management for the pressure injury. However, the Electronic Medical Record and Treatment Administration Record lacked documentation of wound care management on several specified dates in August and September 2024. The Director of Nursing confirmed these findings during the survey.
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The facility did not ensure that its Infection Preventionist (IP) met required qualifications for managing the Infection Prevention and Control Program. The DON reported serving as the IP but acknowledged lacking the specialized infection control training required for the role, and confirmed that no other staff member was currently qualified. Records showed that the previously qualified IP left several months earlier, and the Administrator and DON confirmed they were still seeking a replacement, leaving the infection control program without a properly trained leader.
Staff failed to consistently secure medications and medical supplies across three units, including an oxygen tank left on the floor behind a resident’s bed without a supporting device, a treatment cart with Collagenase Santyl cream left on top while two residents in power wheelchairs passed by, an unattended and unlocked treatment cart at a nursing station, and another treatment cart with Diclofenac gel and dressings left on top, indicating repeated lapses in maintaining locked and secure storage for drugs, biologicals, and related supplies.
The facility failed to provide sufficient dietitian coverage and timely nutritional assessments for several residents with significant dietary needs. A resident admitted for diabetic management with a high A1C was placed on a regular diet instead of the recommended carb-controlled diet and had only one weight taken in the first two weeks, with no dietitian review of the record. Another resident with prior significant weight loss had no documented dietitian follow-up despite continued weight loss, and a resident admitted with severe protein-calorie malnutrition experienced further significant weight loss without any dietitian assessment. The dietitian reported working limited hours and prioritizing certain high-risk cases, resulting in delayed or missed evaluations for new admissions and residents with ongoing nutritional concerns.
The facility failed to maintain adequate linen and incontinence supplies and did not keep resident care areas in good repair, resulting in delays and alterations in incontinence care and substandard environmental conditions. Staff reported that towels and washcloths were used instead of wipes and then discarded due to heavy soiling, and that linen deliveries to units were late, leaving residents waiting for care. Observations showed very limited numbers of clean washcloths and other linens on units and in the laundry, with no stock of disposable wipes or backup washcloth supply despite repeated reports to housekeeping. Additional observations revealed recliner chairs blocking a dining-area handwashing sink and kitchenette, multiple resident and shared bathrooms with unfinished spackle, chipped paint, musty odors, black substances near showers, missing threshold molding, exposed cracks and nails, and eroded, rusted baseboard heaters. Hallway handrails on both units were worn, chipped, and splintered, and a shower room contained fecal odors, dried brown stains on the toilet, and deteriorated fixtures, all contributing to a failure to provide a safe, clean, and homelike environment.
Facility staff did not thoroughly investigate two separate abuse allegations involving a resident and an injury of unknown origin involving another resident. In both cases, investigations focused on the directly affected resident and included staff interviews, but there were no interviews of other residents on the unit or documented assessments of those residents for signs of abuse or injuries of unknown origin, including residents unable to communicate due to cognitive status.
Two residents who were dependent on staff for oral care, including one with a tracheostomy, were observed with thick, white or milky substances coating their mouths and teeth, indicating inadequate oral hygiene. One resident communicated that staff did not brush their teeth and that staff "need to." In another case, despite oral care supplies being present in the room, the resident’s mouth and teeth remained unclean on multiple observations, with a thick milky substance caking the teeth and stringing between them when the resident tried to open their mouth. These findings showed that staff did not consistently provide oral care to residents who relied on them for this ADL.
Staff failed to maintain complete and accurate medical records for multiple residents, including missing and inconsistent documentation of wound care, delayed pain assessment after discovery of an injury of unknown origin in a cognitively impaired resident, and inaccurate recording of a PPD test result that was documented as negative despite no evidence the injection was administered and no supporting nurse’s note. Residents reported not receiving certain treatments, while MAR entries either lacked signatures for completion or contained conflicting information about whether care was provided.
Surveyors found that the facility failed to consistently implement and communicate correct transmission-based precautions and PPE use. One resident with a Foley catheter related to wounds had no precaution signage posted, while another resident in a double room had a contact precautions sign at the door, yet the NP entered without PPE and the GNA provided high-contact care wearing only gloves. Staff in that room stated the resident was not on contact precautions and later reversed the sign to show no PPE requirement. Therapy staff reported they rely solely on posted signs to determine PPE, and surveyors identified broader issues with inaccurate signage and staff awareness of which residents required contact precautions.
Surveyors found that MDS assessments were inaccurately coded for two residents. In one case, a resident sustained a femoral neck fracture after a fall, but the subsequent significant change MDS did not code the fall as a major injury and failed to capture prn Tylenol use documented on the MAR within the look-back period. In the other case, a quarterly MDS indicated opioid use for a resident, but the MAR for the same period showed no prescribed opioid, indicating incorrect coding of high-risk drug classes.
A resident who had recently been admitted and experienced a fall received multiple doses of the narcotic analgesic Tramadol, but the facility failed to accurately document all administered doses on the Medication Administration Record (MAR). Review showed only one Tramadol dose recorded on the MAR, while the Controlled Drug Receipt/Record/Disposition Form on the med cart reflected three doses given over two days. In interview, the DON stated staff are expected to document narcotic administration on the MAR and confirmed that two administered doses were not recorded there, resulting in an incomplete and inaccurate medical record.
Unqualified Infection Preventionist Overseeing Infection Control Program
Penalty
Summary
The facility failed to ensure that its designated Infection Preventionist (IP) met the mandatory qualifications for overseeing the Infection Prevention and Control Program. During an interview on 3/24/26 at 10:00 AM, the DON confirmed that she/he was serving as the facility’s IP but had not completed the specialized training in infection control required for the position. The DON further stated that no other staff member currently met the qualifications to serve as IP. Record review showed that the previously qualified IP left the facility in October 2025, and as of the survey date, the position remained unfilled by a qualified individual. At 1:30 PM on the same day, the Administrator and DON confirmed they were still in the process of finding a qualified IP for the facility, leaving the Infection Prevention and Control Program without a properly trained and qualified leader. No specific residents, medical histories, or clinical conditions were described in relation to this deficiency.
Unsecured Medications, Treatment Carts, and Oxygen Equipment
Penalty
Summary
Facility staff failed to ensure that drugs, biologicals, and related medical supplies were securely stored and properly maintained on multiple units. On one unit, an oxygen tank assigned to a resident was observed sitting on the floor behind the resident’s bed without any supporting device. On another unit, a treatment cart was observed with a tube of Collagenase Santyl cream labeled for a specific resident left on top of the cart, while residents in power wheelchairs passed by and staff were present at the nursing station. These observations showed that medications and oxygen equipment were not consistently secured as required. Further observations on additional units revealed an unattended and unlocked treatment cart at a nursing station, and on a separate occasion, a treatment cart with Diclofenac gel labeled for a resident left on top along with multiple packs of dressings. These incidents occurred across three units and on more than one date, demonstrating repeated failures to keep medications and treatment supplies in locked compartments or otherwise secured from unauthorized access.
Insufficient Dietitian Coverage and Delayed Nutritional Assessments
Penalty
Summary
The deficiency involves the facility’s failure to employ sufficient food and nutrition staff, including adequate dietitian coverage, to ensure timely assessment and appropriate diets for residents with significant nutritional and diabetic needs. A resident admitted over two weeks earlier with multiple comorbidities and an A1C of 11.5% had a hospital discharge recommendation for a carbohydrate-controlled diet, but was placed on a regular diet at admission with no acknowledgment of the recommended diet until one week later, when the resident requested larger portions. As of the survey date, the dietitian had not yet seen or reviewed this resident’s medical record, and the resident reported not having seen a dietitian and being very frustrated with the meals. During the first two weeks after admission, only one weight was obtained for this resident, despite physician notes stating the resident’s weight was “stable.” Further review of other residents showed additional failures in timely dietitian assessment and follow-up. One resident, readmitted in January and previously seen by the dietitian in September for a 6.4 lb weight loss over 30 days, had no documented follow-up despite continued weight loss totaling 22 lbs since the last dietitian review. Another resident admitted at the end of February with severe protein-calorie malnutrition had not been seen by the dietitian after about a month in the facility, despite a documented 14 lb (7%) weight loss over two weeks. The dietitian reported working only 12 hours per week at the facility and stated that she must prioritize which residents to see, focusing first on residents with tube feedings and those identified in risk meetings, resulting in delayed or absent assessments for new admissions and residents with ongoing weight loss and malnutrition diagnoses.
Linen Shortages and Poor Environmental Maintenance Compromise Resident Care and Comfort
Penalty
Summary
The deficiency involves the facility’s failure to maintain an adequate supply of clean linens and appropriate incontinence wipes, resulting in delays and alterations in residents’ incontinence care, as well as the use of towels and washcloths in place of disposable wipes. During the initial tour, the surveyor observed that the linen supply on one nursing unit hallway was low. Complaint reviews included concerns about delays in incontinence care and bed linens not being changed regularly, with residents left without clean bedding. A complainant reported that there was not enough clean linen available for residents. Staff interviews confirmed that towels, sheets, and washcloths were being used to wipe residents for incontinence care due to the absence of wipes, and that many of these linens were being thrown away when soiled. Staff also reported a shortage of linen, that linen deliveries to the units were late, and that residents who preferred to get up before breakfast had to wait for care when linen was delayed. Further observations showed that the clean supply room contained no disposable wipes or cloths for incontinence care, and a resident reported that staff did not use wipes, that the resident had to purchase their own, and that heavily soiled towels or washcloths were discarded. A tour of all nursing unit linen carts and closets revealed only six clean washcloths and limited supplies of towels, gowns, and bed linens. In the laundry room, only three washcloths were present, and the laundry assistant stated that there were only three washcloths available for each nursing unit that morning, that the facility was short on linen supply, and that these concerns had been repeatedly reported to the Director of Housekeeping over the preceding month and again that morning. The laundry assistant confirmed there was no additional laundry in process. The DON stated that wipe squares should be used for incontinence care, but no such wipes were found in the clean medical supply room, and no backup supply of washcloths was present in the emergency linen supply. The Director of Housekeeping confirmed there was no backup supply of washcloths. The deficiency also includes environmental and maintenance issues affecting resident bathrooms, handrails, and common areas. In the main dining area, a recliner chair was observed positioned directly in front of the handwashing sink, and two recliner chairs were stored in front of the nutrition area kitchenette. Multiple resident bathrooms and shared bathrooms were repeatedly observed over several days with unfinished spackle on walls that needed resurfacing and painting, chipped paint around sinks, uneven boards nailed to walls under sinks that appeared to partially cover holes, musty odors, black substances between shower bases and walls, missing threshold transition molding exposing cracks, missing tiles, and a nail, as well as eroded and chipped paint on baseboard heaters with exposed dark brown metal and rust-like material. Hallway handrails on both nursing units were observed to be worn, with chips, splintering, holes, and areas where the wood finish had worn off. A shower room was observed with a foul fecal odor, dried brown stains on the back of the toilet seat and in the toilet bowl, and a baseboard heater with eroded, chipped paint and rust-like material, along with chipped paint on the handrail. These conditions were acknowledged by the Director of Maintenance and other leadership, and some areas were noted to be in the process of renovation, but the observed deficiencies remained present during the survey period. Overall, the facility did not maintain a safe, clean, comfortable, and homelike environment in good repair across both nursing units and the dining area. The lack of adequate linen and incontinence supplies, combined with the poor condition of resident bathrooms, handrails, and certain common areas, constituted the basis for the cited deficiency. The observations and staff and resident reports consistently described shortages of essential hygiene supplies, delayed care related to linen availability, and multiple unresolved environmental and maintenance issues in resident care areas and shared spaces.
Failure to Thoroughly Investigate Abuse Allegations and Injuries of Unknown Origin
Penalty
Summary
Facility staff failed to thoroughly investigate allegations of potential abuse involving one resident and an injury of unknown origin involving another resident. For one resident, there were two separate allegations of abuse occurring on different days in early February. The facility’s investigation packets included interviews with staff who cared for or were scheduled to work with this resident on the days of the alleged incidents, and the investigations focused solely on this resident. However, there were no interviews conducted with other residents on the unit to inquire about abusive or neglectful treatment by the staff who were working during the times of the allegations. The surveyors noted that, although the allegations were not validated, there was no documentation that other residents were interviewed, if able, or assessed for signs or symptoms of injury. In a separate incident, another resident was identified on March 4 with a new bruise on the right eye, documented as a change in condition at 4:09 AM. This resident had a BIMS score of 99, indicating the resident was unable to complete an interview and therefore could not report how the injury occurred. The facility’s investigation identified a potential cause of the injury but did not reach a definitive resolution. Additionally, there were no interviews of other residents on the unit regarding possible abuse, nor were there documented assessments of other residents for injuries of unknown origin, particularly for those unable to speak for themselves, as in this resident’s case.
Failure to Provide Oral Care to Dependent Residents
Penalty
Summary
The deficiency involves the facility’s failure to provide oral care to residents who were dependent on staff for activities of daily living, specifically oral hygiene. One resident with a tracheostomy was observed with a thick, sticky white substance in the mouth and was noted to intermittently chew on nearby bedding. This resident made good eye contact and, when asked if staff brushed their teeth, shook their head no and mouthed that staff “need to.” According to the resident’s Minimum Data Set (MDS) dated 2/11/26, the resident was dependent on staff for oral care. Another resident, also dependent on staff for oral care per the 3/11/26 MDS, was observed sitting propped up in bed and able to respond with smiles. During the initial observation, the inside of this resident’s lips and upper and lower teeth had a thick, clear, white milky substance visible when the resident tried to open their mouth to smile. Oral care supplies were present in the nightstand, but the resident’s mouth and teeth were not clean. On a subsequent observation with the DON, NHA, and Corporate VP of clinical services, the same resident again had a thick, clear, milky substance between the lips and caking the teeth, which would string between the teeth when the resident attempted to open their mouth, demonstrating a lack of consistent oral care for residents dependent on staff for this ADL.
Incomplete and Inaccurate Medical Record Documentation for Treatments and Assessments
Penalty
Summary
Facility staff failed to maintain complete and accurate medical records and documentation for multiple residents. For one resident with wound care needs, review of the MAR showed that wound care and related treatments were signed as completed on the dates initially reported, despite the resident’s ongoing complaints that wound dressings were not being changed. When additional dates were reviewed, there were missing staff signatures for wound care on two specific dates, as well as three instances where application of A&D ointment to the resident’s feet was not signed off out of 24 days reviewed. Another resident with severe cognitive impairment, as evidenced by a BIMS score of 00, was found to have an injury of unknown origin (a bruise on the left hand). Documentation showed that a change in condition was initiated late in the morning, but a formal pain evaluation was not initiated and completed until that night, and the resident was unable to explain how the injury occurred or verbalize pain using a standard pain scale. For a third resident, documentation related to the admission PPD test was inconsistent and incomplete. The MAR contained an entry indicating “9” for the administration date, meaning “see nurse’s note,” but there was no corresponding nurse’s note. Despite the absence of a signed administration of the PPD injection, staff documented the PPD result as “negative” on the scheduled read date. The resident reported never receiving the PPD injection, and the DON confirmed that the facility had been out of PPD solution at the time, so the test would not have been administered. These findings demonstrate failures in accurate documentation of treatments and assessments, including wound care, pain assessment, and TB screening, as well as missing or incomplete supporting notes in the medical record.
Failure to Implement and Communicate Correct Transmission-Based Precautions
Penalty
Summary
Surveyors identified a deficiency in the facility’s infection prevention and control program related to inconsistent and incorrect implementation of transmission-based precautions and PPE use. During a complaint investigation focused on residents on transmission-based precautions, one resident with a visible Foley catheter was observed in the room with physical therapy, but there were no signs posted indicating any need for PPE, despite the resident being a new admission with a Foley catheter placed related to wounds. In another double-occupancy room, a contact precautions sign was posted at the doorway, but the nurse practitioner was in the room on a personal phone with no PPE, and the assigned GNA was repositioning the resident in bed while wearing only gloves. When questioned, the NP, RN, and GNA all stated that the resident in the room was not on contact precautions, and the GNA reported that signs were hanging at all doors and that this particular resident’s sign was “just wrong.” The surveyor observed the GNA later return to the room and turn the sign around to indicate no PPE requirement. Subsequent interviews revealed that therapy staff relied on posted signage to determine PPE use and that if the sign was wrong, the PPE used would be wrong. Overall, surveyors found problems with signage accuracy and staff awareness of which residents required contact precautions, as well as observed failures to follow appropriate PPE use for residents who should have been on contact precautions.
Inaccurate MDS Coding for Falls, Pain Management, and High-Risk Medications
Penalty
Summary
Facility staff failed to ensure Minimum Data Set (MDS) assessments were accurately coded for two residents reviewed during a complaint survey. For one resident, a facility-reported incident showed that the resident was found seated on the floor beside the bed and was diagnosed with a non-displaced femoral neck impaction fracture of the left hip following an x-ray. Despite this fall with a major injury, the subsequent significant change MDS dated 11/4/25 did not code the fall with major injury in Section J1900C. Review of the resident’s Medication Administration Records for October and November 2025 showed administration of Tylenol on 10/31/25 at 9:30 PM, which fell within the 5-day look-back period for the MDS, but Section J0100 (prn pain) of the same significant change MDS did not capture the use of Tylenol. For another resident, review of a quarterly MDS with an assessment reference date of 10/15/25 showed that Section N0415 (High-Risk Drug Classes) documented the use of an opioid medication. However, review of the resident’s October 2025 Medication Administration Record did not show that the resident had been prescribed an opioid during that period. In both cases, MDS staff later confirmed that these were errors in MDS coding, demonstrating that the assessments did not accurately reflect the residents’ clinical status and medication use as documented in their medical records.
Incomplete Documentation of Narcotic Administration on MAR
Penalty
Summary
The facility failed to maintain complete and accurate medical records in accordance with accepted professional standards for one resident receiving narcotic medication. The resident, admitted in March 2026, had a fall on 3/6/26 and was sent to the hospital on 3/9/26. Review of the March 2026 Medication Administration Record (MAR) showed documentation of a single 25 mg dose of Tramadol administered on 3/8/26 at 9:23 AM. However, review of the resident’s Controlled Drug Receipt/Record/Disposition Form, kept on the nurse’s medication cart and not in the medical record, showed that Tramadol 25 mg was administered three times between 3/8/26 and 3/9/26: at 11:00 AM and 9:00 PM on 3/8/26, and at 9:00 AM on 3/9/26. In interview, the DON stated that staff are expected to document narcotic administration on the MAR and confirmed that only one of the three Tramadol doses reflected on the controlled drug record was documented on the resident’s MAR. This discrepancy between the controlled substance record and the MAR, with missing documentation of two administered doses of Tramadol on the official medical record, constituted the failure to maintain a complete and accurate medical record for the resident.
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