Moran Nursing And Rehabilitation Center
Inspection history, citations, penalties and survey trends for this long-term care facility in Westernport, Maryland.
- Location
- 25701 Shady Lane Southwest, Westernport, Maryland 21562
- CMS Provider Number
- 215240
- Inspections on file
- 16
- Latest survey
- March 6, 2026
- Citations (last 12 mo.)
- 4
Citation history
Health deficiencies cited at Moran Nursing And Rehabilitation Center during CMS and state inspections, most recent first.
A resident with diabetes, total incontinence, a colostomy, and risk for recurrent UTIs received incontinence care that did not follow facility policy or infection control standards. A GNA performed perineal care while repeatedly touching dirty linen, furniture, and clean linens with the same gloves, used wet towels taken from a trash bin to clean the genital area, placed used towels on clean surfaces, and continued care between the buttocks and down the legs without changing gloves. The GNA also applied prescription zinc cream and then touched room surfaces with contaminated gloves, removed PPE and exited without hand hygiene, and later re-entered, donned gloves, and washed the resident’s face without first washing hands, despite expectations from the LPN nurse manager and DON that staff follow proper front-to-back wiping, glove changes, hand hygiene, and enhanced barrier precautions.
The facility failed to follow infection prevention and control practices during incontinence care, medication administration, and catheterization. A resident with incontinence and a colostomy received perineal care from a GNA who used the same gloves for dirty and clean tasks, handled clean linens and environmental surfaces with contaminated gloves, reused wet towels taken from the trash on the genital area, placed used towels on clean surfaces, and left and re-entered the room without performing hand hygiene. Another resident with multiple chronic conditions received 11 medications from an LPN who did not perform hand hygiene before room entry, before donning gloves, between tasks, or after glove removal; when a glove tore during insulin preparation, the LPN continued with one bare hand and administered the insulin injection without subsequent handwashing. A third resident with progressive MS, paraplegia, neurogenic bladder, and recurrent UTIs reported that an RN performing straight catheterization poked near the anus while seeking the urethra, inserted the catheter into the vagina despite the resident’s objections, then into the urethra causing pain, pressed on the abdomen despite the resident’s discomfort, and later retrieved the catheter from the trash, all contrary to the facility’s stated expectations for sterile catheterization technique and infection control.
A resident with a history of drug abuse and multiple medical conditions was found unresponsive and tested positive for fentanyl, which was not prescribed. Despite this incident and documented history, the care plan was not updated to address substance abuse risks or the recent event, contrary to facility policy and staff acknowledgment.
Staff did not wear required gowns or consistently change gloves during incontinence care for a resident with a urinary catheter, despite facility policy and visible signage indicating Enhanced Barrier Precautions. Gloves were used to handle both soiled and clean items without proper hand hygiene, and staff expressed uncertainty about PPE requirements. Facility leadership confirmed the expectation for gown and glove use, but monitoring responsibilities were unclear.
A facility failed to maintain licensed nurse coverage during a night shift, as two agency LPNs left the building simultaneously to get food, leaving residents without supervision. This resulted in missed medication administration and left only GNAs to care for the residents. The incident was confirmed by geotracking data and interviews with staff and residents.
The facility failed to report abuse allegations within the required time frame for three residents. Incidents included a GNA forcefully pushing a resident, delayed reporting of an abuse incident by a resident with intact cognition, and rough handling by a GNA. Reports to the Office of Health Care Quality were made late, exceeding the mandated two-hour reporting requirement.
The facility failed to conduct thorough investigations of abuse allegations involving three residents. In one case, a GNA continued working after an abuse allegation was made, and there was no documentation of interviews with other residents. Another incident involved a GNA forcefully pushing a resident, with no interviews or abuse training conducted afterward. In a third case, investigation documentation lacked signatures and failed to document interviews with other residents.
The facility failed to ensure 24-hour supervision by licensed nursing staff and proper medication administration. A resident did not receive timely medication, and another was found deceased after not receiving necessary assessments and medications. Two agency LPNs left the facility unattended, resulting in missed medication passes. Additionally, a resident's blood sugar checks were not properly documented, indicating they were likely not performed.
The facility did not offer the current COVID-19 vaccine or document education or refusal for several residents, as confirmed by record review and staff interviews. Immunization records lacked evidence of vaccine offers, education, or refusals, and staff stated that the COVID-19 vaccine would be offered at the same time as the flu vaccine in the future.
A facility failed to protect residents from verbal and physical abuse by a GNA, as reported by multiple residents. One resident felt the GNA was rough and inattentive, while others described similar experiences, including rough handling and lack of attentiveness. The incident was reported, but the night shift LPN did not recognize it as abuse, highlighting a deficiency in resident care.
A resident's MDS assessment was inaccurately coded, failing to reflect a fall that occurred in February 2024. The RN Assessment Coordinator admitted to missing the fall during the assessment period review. The DON was informed of the error, highlighting a deficiency in the facility's assessment process.
A resident with a history of pressure ulcers and dementia, requiring two staff for bed mobility, was bathed by a single GNA, leading to a fall and injuries. Despite the care plan's requirements, the GNA routinely bathed the resident alone, and another GNA confirmed similar practices. The DON stated staff should follow the care plan and check the resident profile for assistance needs.
A facility failed to follow physician orders and lacked a comprehensive policy for chest tube care, resulting in undocumented drainage and site care for a resident. Interviews revealed reliance on a nursing manual without specific guidance, and the need for physician contact for site care orders was acknowledged.
Surveyors found a ceiling tile in a 3rd floor shower/bathroom covered with a black and fuzzy white substance, indicating a failure to maintain a clean and sanitary environment. The issue was confirmed by nursing and administrative staff, with conflicting reports about whether the tile had been replaced after a recent pipe repair. The Maintenance Director was not previously informed of the current condition.
The facility did not ensure that the walk-in refrigerator door in the kitchen would routinely close, as observed during multiple staff entries and exits. The Certified Dietary Manager confirmed the door had ongoing issues, requiring staff to monitor it closely and check temperatures more frequently. The deficiency was confirmed through direct observation and staff interviews.
Failure to Provide Clean and Safe Incontinence Care and Follow Infection Control Practices
Penalty
Summary
The deficiency involves failure to provide clean and safe incontinence and perineal care in accordance with facility policy and infection control practices for one resident. Facility policy required staff to perform hand hygiene, gather necessary supplies before care, use gloves and other PPE per standard precautions, and clean the perineal area from front to back using clean sections of the washcloth, followed by rinsing and drying. The resident involved had type 2 diabetes, needed help with personal care, was always incontinent, had a colostomy, and was at risk for repeated urinary tract infections. The care plan documented scheduled bathing and that the resident required substantial to maximal assistance with perineal hygiene. During an observed incontinence care episode, a GNA touched the bedside table, resident’s blanket, dirty linen, closet handles, and clean linen without changing gloves. The GNA handled clean towels, clean sheets, and the faucet with the same gloves used for dirty items and was unsure whether the resident remained on enhanced barrier precautions, despite the resident being on such precautions due to a colostomy. The GNA used wet towels removed from the trash bin to clean the resident’s genital area and placed used towels on clean surfaces, including a clean sheet next to the resident. The GNA continued wiping between the buttocks and washing the thighs and knees without changing gloves, and after applying prescription zinc cream, touched the bedside table with contaminated gloves. The GNA then removed gloves and gown, discarded them, left the room without performing hand hygiene, and later re-entered the room, donned gloves, and washed the resident’s face without prior handwashing. Interviews with the nurse manager and DON confirmed that staff were expected to know and follow proper incontinence care steps, including front-to-back wiping, glove changes between dirty and clean tasks, hand hygiene, and adherence to clean-to-dirty procedures.
Failure to Follow Infection Control Practices During Incontinence Care, Medication Administration, and Catheterization
Penalty
Summary
The deficiency involves the facility’s failure to follow its own infection prevention and control practices, including hand hygiene, glove use, separation of clean and dirty items, safe medication administration, and safe catheterization technique. For a resident with type 2 diabetes, incontinence, a colostomy, and a history of recurrent UTIs, a GNA provided incontinence care without changing gloves between dirty and clean tasks and without maintaining separation between contaminated and clean surfaces. During a partial bed bath, the GNA touched the bedside table, resident’s blanket, dirty linen, closet handles, and clean linen with the same pair of gloves. The GNA handled clean towels, clean sheets, and the faucet with gloves that had already been used on dirty items, and used wet towels taken from the trash bin to clean the resident’s genital area, then placed used towels on clean surfaces, including a clean sheet next to the resident. After applying prescription zinc cream, the GNA touched the bedside table with contaminated gloves, then removed gloves and gown, discarded them, and exited the room without performing hand hygiene, later re-entering the room and donning gloves without prior handwashing to wash the resident’s face. For another resident with spinal stenosis, bilateral lower-extremity weakness, vertigo, muscle weakness, neuropathy, and a bone disorder, an LPN failed to perform hand hygiene during medication administration. The LPN did not sanitize hands before entering the room or before donning gloves and administered 11 medications without performing hand hygiene between tasks. While preparing and administering insulin, the LPN’s right glove ripped, and the LPN continued the procedure with only the left hand gloved. Using a bare hand, the LPN wiped the injection site with alcohol and administered the insulin injection, then did not wash or sanitize hands after removing the remaining glove. These actions were inconsistent with the facility’s hand hygiene policy, which required handwashing or sanitizing before resident contact, before donning gloves, after glove removal, and after contact with potentially contaminated items. For a resident with active progressive multiple sclerosis, paraplegia, a history of recurrent UTIs, neurogenic bladder, and complete urinary incontinence, the facility’s practices around straight catheterization raised infection control and procedural concerns. Documentation showed repeated catheterizations for urine samples and a resident report that fecal matter was seen on the tip of a catheter used for urine collection. In a grievance and related complaint, the resident reported that during a straight catheterization, an RN touched the wrong area and poked near the anus while trying to locate the urethral opening, inserted the catheter into the vagina despite the resident shouting that it was the wrong place, then inserted the catheter into the urinary tract, causing pain. The resident also reported that the RN pressed on the abdomen to obtain more urine despite the resident stating it hurt, and that the catheter came out and the procedure was ended. The resident, who was alert and oriented with a BIMS score of 15, consistently described these events to facility staff. The DON acknowledged that catheterization is a sterile procedure and that the expectation was to keep the procedure as clean and sterile as possible with clean gloves and careful technique, and also acknowledged awareness that the RN later returned to the resident’s room to retrieve the catheter from the trash, which was not consistent with the DON’s expectations for handling the procedure and related supplies. Interviews with facility leadership and the infection preventionist confirmed that staff were expected to follow specific infection control practices that were not observed in these cases. The nurse manager stated that staff were expected to wipe front-to-back, change gloves between dirty and clean tasks, wash hands, and gather all supplies before starting care, and confirmed that the resident with a colostomy was on enhanced barrier precautions. The infection preventionist described prior in-services on perineal care, hand sanitizing, working from outer to inner areas, changing gloves after dirty care and between new briefs, and performing hand hygiene before and after glove use, as well as expectations for hand hygiene during medication passes. The DON stated that catheterization was a sterile procedure and that the facility expected clean gloves and careful technique. Despite these stated expectations and policies, the observed care and documented events for the three residents showed failures to adhere to infection prevention and control practices during incontinence care, medication administration, and catheterization.
Failure to Revise Care Plan After Resident Drug Abuse Incident
Penalty
Summary
The facility failed to revise the care plan for a resident with a known history of drug abuse after an incident in which the resident was found unresponsive and tested positive for fentanyl, a medication not prescribed to them. The resident had multiple medical diagnoses, including hemiplegia, hepatic encephalopathy, dysphagia, aphasia, and vascular dementia, and was assessed as having moderate cognitive impairment and short-term memory problems. Despite documentation in the resident's medical records and emergency room notes indicating a history of drug abuse and a previous overdose, the care plan was not updated to reflect these significant risk factors or the recent incident involving fentanyl. Interviews with facility staff, including the MDS Coordinator, ADON, and DON, confirmed that the resident's care plan was not revised to address the history of drug abuse or the fentanyl incident. The facility's own policy required the interdisciplinary team to review and revise care plans after each assessment and when a resident's clinical status or condition changes. However, the care plan review conducted after the incident did not include any updates related to the resident's substance abuse history or the unresponsive episode, despite clear evidence and staff acknowledgment that these issues should have been addressed.
Failure to Follow Enhanced Barrier Precautions and Hand Hygiene During Incontinence Care
Penalty
Summary
Staff failed to follow the facility's infection prevention and control program by not donning all required personal protective equipment (PPE) and not adhering to hand hygiene protocols during incontinence care for a resident with an indwelling urinary catheter. Facility policy required Enhanced Barrier Precautions (EBP), including the use of gloves and gowns, for residents with catheters during high-contact care activities. Despite visible signage and available gowns outside the resident's room, staff only donned gloves and did not wear gowns while providing care. During the observed care, two staff members assisted the resident, who had a history of infection and required assistance with personal care. Both staff members performed incontinence care without changing gloves between dirty and clean tasks, and handled personal items and clean clothing with soiled gloves. Hand hygiene was not performed at appropriate intervals, and gloves were only changed after multiple care steps had been completed. The staff members acknowledged during interviews that they should have worn gowns and changed gloves more frequently, but cited uncertainty and nervousness as reasons for their actions. Interviews with facility leadership, including the QA/Infection Prevention Nurse, ADON, DON, and Administrator, confirmed that the expectation was for staff to wear gowns and gloves for residents on EBP and to change gloves when soiled or before handling clean items. Monitoring of staff compliance was described as a responsibility of the QA/IP Nurse and nursing leadership, but there was uncertainty about who specifically monitored incontinence care. The deficiency was identified through direct observation, interviews, and review of facility policy.
Lack of Licensed Nurse Coverage During Night Shift
Penalty
Summary
The facility failed to ensure licensed nurse coverage was present throughout the entire night shift on February 21, 2025. This deficiency was identified during a survey following a complaint from a resident who felt unsafe due to the absence of licensed nurses. The resident reported that agency staff left the building unattended to get food, resulting in missed medication administration. The staffing schedule confirmed that two agency LPNs were the only licensed nurses on duty that night, and both left the facility simultaneously, leaving the residents and GNAs without supervision. Interviews and record reviews revealed that the agency LPNs left the facility for approximately 1-2 hours during their shift, which was corroborated by geotracking data. The absence of licensed nurses during this time meant that the facility's residents were left without proper supervision and care, as only four GNAs were present. The facility administrator confirmed the incident, acknowledging that the LPNs took an excessively long break and left the facility without a designated charge nurse in place.
Delayed Reporting of Abuse Allegations
Penalty
Summary
The facility failed to report allegations of abuse within the mandated time frame for three residents. In the first case, a Geriatric Nursing Assistant (GNA) was observed forcefully pushing a resident into a wheelchair, witnessed by the facility social worker. The incident occurred in the dining room and was reported to the Office of Health Care Quality more than four hours later, which was acknowledged as a deficiency by the Nursing Home Administrator (NHA). In the second case, a resident with intact cognition reported an abuse incident to a GNA, which was then communicated to the NHA. However, the initial report to the State Agency was delayed, being sent over nine hours after the incident was first reported to the facility staff. In the third case, a resident's representative informed a nurse about an abuse allegation involving rough handling by a GNA. The nurse notified the Director of Nursing and the NHA, but the report to the Office of HealthCare Quality was not made until the following day, exceeding the two-hour reporting requirement. The facility's policy requires immediate reporting, but the surveyor found that the staff did not adhere to this policy, resulting in late reporting of the abuse allegations.
Failure to Conduct Thorough Abuse Investigations
Penalty
Summary
The facility failed to ensure thorough investigations of abuse allegations for three residents. In the first case, a resident's representative reported that a Geriatric Nursing Assistant (GNA) was rough and slapped the resident's hand. Despite the facility's policy to suspend the accused staff during investigations, the GNA continued to work until the following day. Additionally, there was no documentation of interviews with other residents or the representative to verify the allegation. In the second case, a GNA was observed forcefully pushing a resident into a wheelchair. The facility's investigation did not include interviews with other residents who were present during the incident, nor did it assess if other residents had experienced similar abuse. Furthermore, there was no evidence of abuse training provided to staff following the incident. The third case involved a resident who confirmed an abuse incident that occurred previously. The investigation documentation lacked signatures from interviewed residents and the staff conducting the interviews. The Director of Nursing and the Nursing Home Administrator were unsure if other residents were interviewed, and the Registered Nurse responsible for the documentation admitted to failing to document interviews with other residents assigned to the alleged perpetrator.
Failure in Supervision and Medication Administration
Penalty
Summary
The facility staff failed to ensure 24-hour supervision by licensed nursing staff and proper medication administration for residents. Resident #68, admitted for alcohol dependence and other health issues, had medications administered late by an agency LPN. Similarly, Resident #409, admitted for potential hospice care, did not receive necessary assessments and medications, including morphine for pain management. The resident was found unresponsive and later pronounced deceased. It was reported that agency LPNs left the facility unattended during their shift, leaving residents without proper care and supervision. An anonymous complaint and interviews revealed that two agency LPNs left the facility during their shift to purchase food, leaving the facility without licensed nursing coverage. This resulted in missed medication passes and lack of supervision for the residents. The facility's staffing schedule confirmed the absence of licensed nurses during this period, and the DON and NHA acknowledged the incident. The facility did not report the incident to the state agency or the Maryland Board of Nursing, and no investigation was conducted to verify the events with the GNAs present that night. Additionally, Resident #8, who had been residing in the facility since 2022 and required insulin for diabetes management, had an order for weekly blood sugar checks that were not properly documented. The eMAR indicated that the checks were marked as done, but no actual blood sugar values were recorded. Interviews with the LPN assigned to the resident and the DON confirmed the lack of documentation, indicating that the blood sugar checks were likely not performed as ordered.
Failure to Offer or Document COVID-19 Vaccination for Residents
Penalty
Summary
The facility failed to offer the current COVID-19 vaccination or provide documentation of vaccine education or refusal for four out of five residents reviewed for immunization status. Medical record reviews on 3/04/25 revealed no evidence that these residents had been offered or educated about the current COVID-19 vaccine, nor was there documentation of any refusals. During interviews, the Infection Preventionist confirmed that these residents had not received the COVID vaccine, had not been educated about it, and that there was no documentation of refusal. The Infection Preventionist also stated that the facility planned to offer the COVID vaccine alongside the flu vaccine in the fall. The administrator confirmed this plan and did not provide further documentation prior to the end of the survey.
Failure to Protect Residents from Abuse
Penalty
Summary
The facility failed to protect a vulnerable resident from verbal and physical abuse, as evidenced by an incident involving a resident and a GNA. The incident occurred when the resident reported feeling that the GNA was rough during care and not attentive to their needs. The day shift nurse reported the allegation to the administrator, prompting an investigation. However, the night shift LPN did not report the incident as abuse, as the resident only described the GNA as 'rude.' Interviews conducted with other residents revealed similar concerns about the GNA's behavior, including rough handling and lack of attentiveness. Multiple residents reported negative experiences with the same GNA, including one who felt the GNA was not listening and insisted on actions despite the resident's pain. Another resident mentioned the GNA's inattentiveness while on the phone, and others described the GNA as rough and argumentative. These accounts indicate a pattern of behavior that compromised the residents' dignity and safety, leading to the deficiency noted in the survey.
Inaccurate MDS Assessment Coding for Resident Fall
Penalty
Summary
The facility failed to ensure comprehensive assessments were coded accurately for a resident who had been residing in the facility since 2022. The deficiency was identified during a review of the resident's medical records and interviews. The resident experienced an unwitnessed fall resulting in a fracture, which was reported in October 2024. However, during a subsequent review of the Minimum Data Set (MDS) assessment conducted with an Assessment Reference Date (ARD) of March 5, 2024, it was found that the resident was incorrectly coded as having no falls since the last assessment. This error was confirmed by the Registered Nurse Assessment Coordinator, who acknowledged missing the fall that occurred on February 15, 2024. The Registered Nurse Assessment Coordinator admitted to the oversight during an interview and indicated that the period reviewed for the MDS assessment was between March 5, 2024, and the day after the ARD of the previous assessment, December 8, 2023. The Director of Nursing was informed of the error, acknowledging the concern regarding the inaccurate coding of the MDS assessment. The failure to accurately code the resident's fall history in the MDS assessment highlights a deficiency in the facility's assessment process, impacting the accuracy of resident care planning decisions.
Inadequate Supervision During Resident Care
Penalty
Summary
Facility staff failed to provide adequate supervision for a resident during care, leading to an accident. The resident, identified as having a potential for skin breakdown and a history of pressure ulcers, was care planned for self-care deficit and falls related to dementia. The care plan specified the need for two staff members to assist with bed mobility. However, a review of documentation revealed that on most days, only one geriatric nursing assistant (GNA) was involved in bathing the resident. On a specific occasion, a GNA was bathing the resident alone when the resident slid from the bed, resulting in bruising and an abrasion. The GNA admitted to routinely bathing the resident without assistance, despite having access to the resident's care plan, which indicated the need for two staff members. Another GNA also reported occasionally bathing the resident alone, noting that the resident's ability to assist varied. The Director of Nursing confirmed that staff were expected to follow the care plan and check the resident profile for the required level of assistance before providing care.
Deficiency in Chest Tube Care Documentation and Policy
Penalty
Summary
The facility failed to provide appropriate respiratory care for a resident requiring chest tube management, as evidenced by the lack of adherence to physician orders and absence of a comprehensive policy for chest tube care. Specifically, the facility did not document the drainage of the resident's chest tube on two occasions, despite having physician orders to do so every other day and as needed. Additionally, there was no documentation of care provided to the chest tube insertion site, and the facility lacked specific orders or a policy to guide such care. Interviews with the Director of Nursing and the Regional Nurse revealed that the facility relied on a nursing manual for procedures, but there was no specific guidance or physician order for the care of the chest tube site. The Regional Nurse acknowledged that the facility nurse should have contacted the physician for specific site care orders. The Nursing Home Administrator and the DON confirmed the deficiency, acknowledging the absence of documentation and specific policies for chest tube site care.
Failure to Maintain Clean and Sanitary Shower/Bathroom Environment
Penalty
Summary
A deficiency was identified when surveyors observed that a ceiling tile in stall #1 of the 3rd floor shower/bathroom was discolored and covered with a black and fuzzy white substance, indicating a lack of cleanliness and sanitation. The observation was made in the presence of a nurse, the NHA, and the DON, all of whom confirmed the condition of the tile. The NHA stated that there had been recent repairs for a leaking pipe in the same stall and suggested the tile may not have been replaced after the repair. However, the Maintenance Director later reported that the tile had been replaced following the repair and that the current issue with the black and fuzzy white substance had not been reported to him by staff. No additional information was provided by the facility prior to the end of the survey. The deficiency was limited to one of two combination shower/bathrooms observed during the survey, and no specific residents or their medical conditions were mentioned in relation to the incident.
Failure to Maintain Walk-In Refrigerator Door in Kitchen
Penalty
Summary
The facility failed to maintain essential kitchen equipment by not ensuring that the walk-in refrigerator door would routinely close. During a kitchen tour, the surveyor observed that the refrigerator door was not fully closed and noted a sign reminding staff to ensure the door closed completely. The Certified Dietary Manager (CDM) confirmed that the door had ongoing issues with closing, despite previous attempts to fix it. Staff were required to monitor the door closely and check refrigerator temperatures more frequently due to this problem. The surveyor, accompanied by the CDM, observed the door failing to close on its own in multiple attempts. Further observations showed that the door did not close behind staff members entering or exiting the refrigerator. The CDM acknowledged the persistent issue and stated that staff needed to push the door forcefully to ensure it closed. The problem had been ongoing for some time, and the CDM confirmed the deficiency during interviews and direct observation with the surveyor. The issue was also discussed with the Nursing Home Administrator and the Director of Nursing.
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.
Trusted data from CMS and state health departments
Every citation, penalty and Plan of Correction is sourced from public CMS records (latest release May 27, 2026) and official state health department websites — never guesswork.
Trusted by long-term care providers and associations.
