Mountain City Rehab Center
Inspection history, citations, penalties and survey trends for this long-term care facility in Frostburg, Maryland.
- Location
- 48 Tarn Terrace, Frostburg, Maryland 21532
- CMS Provider Number
- 215277
- Inspections on file
- 16
- Latest survey
- March 6, 2026
- Citations (last 12 mo.)
- 10
Citation history
Health deficiencies cited at Mountain City Rehab Center during CMS and state inspections, most recent first.
A resident with chronic back pain had an active order for oxycodone 5 mg four times daily. An LPN signed for receipt of 30 oxycodone tablets from the pharmacy, but days later an RN discovered that all 30 tablets and the related administration record were missing. Review of the MAR and progress notes showed the resident did not receive several scheduled oxycodone doses because the medication was unavailable, and the facility could not account for the missing controlled drugs.
Multiple residents with cognitive and physical impairments experienced repeated falls and injuries due to inadequate supervision, incomplete adherence to care plans, and insufficient investigation of incidents. One resident suffered a severe leg laceration during an improper transfer by a single staff member, while another resident with a history of falls was left unsupervised multiple times, resulting in several injuries. Staff interviews revealed gaps in supervision, documentation, and the effectiveness of interventions for high-risk residents.
The facility did not consistently report allegations of abuse, neglect, or injuries of unknown origin to the state survey agency within the required timeframe. Multiple incidents involving residents with cognitive and physical impairments, including altercations and unexplained injuries, were either reported late or not reported at all. Staff confusion about what constituted a reportable event and delays caused by waiting for corporate guidance contributed to these failures, impacting resident safety and regulatory compliance.
Multiple deficiencies occurred when the facility did not thoroughly investigate alleged abuse, neglect, or injuries of unknown origin, failed to document staff and resident interviews, and did not immediately remove an LPN accused of abuse from the premises. In several cases, incidents were not reported to the state agency or the Administrator, and required investigative steps were not followed, affecting several residents with cognitive impairment and complex medical needs.
The facility did not develop or document a written action plan to address repeated falls, despite reviewing fall incidents in QAPI meetings and recording a high number of falls among residents. Nursing staff were not involved in QAPI activities or performance improvement projects, and interventions were communicated verbally without systematic tracking or evaluation of their effectiveness.
A resident with multiple comorbidities, including cardiovascular disease and on anticoagulant therapy, experienced a fall and vomiting episodes. Nursing staff failed to communicate the fall and vomiting to the provider, only reporting elevated pulse and low oxygen saturation. This incomplete communication led to the provider making care decisions without all relevant information, as confirmed by staff and provider interviews. The resident was later found unresponsive and expired, with documentation showing that critical details were not relayed as required by policy.
A resident with significant medical and cognitive impairments was subjected to rough and verbally abusive treatment by an LPN during post-fall care, as witnessed and reported by multiple GNAs. The LPN was observed pulling and jerking the resident's arms, yelling, and forcefully removing a blood pressure cuff, actions that were corroborated by staff statements and confirmed by the facility's investigation as abuse.
A facility failed to follow its own policies for investigating, documenting, and reporting a resident-to-resident abuse incident involving two residents with severe cognitive impairment. Staff separated the residents and obtained witness statements after one resident grabbed and pushed another, but no incident report or risk management form was completed, and the event was not reported to authorities as required. Interviews revealed that staff believed the incident should have been reported, but leadership instructed otherwise, and no assessment was done to determine if the residents could remain roommates.
A resident admitted with multiple medical conditions, including a pressure ulcer and who sustained a fall with a skin tear, was inaccurately coded on the 5-day MDS assessment as having no falls and no pressure ulcers. Despite documentation and care planning addressing these issues, the MDS Coordinator did not clarify or accurately code the events, resulting in an assessment that did not reflect the resident's true condition.
A resident with multiple comorbidities and on anticoagulant therapy experienced a fall, after which staff failed to perform a thorough assessment or communicate critical information, such as the fall and vomiting, to the provider. The resident continued to receive anticoagulant medication, and changes in vital signs were not fully recognized or reported. Incomplete documentation and communication led to a lack of appropriate response to the resident's deteriorating condition, resulting in the resident being found unresponsive and expiring.
A resident with psychiatric diagnoses and a history of wandering behavior attempted to elope from the facility. Despite being deemed unable to make healthcare decisions, the resident was found in the parking garage attempting to access a vehicle. The facility failed to conduct an elopement assessment or include interventions in the care plan, contributing to the incident.
A resident with dementia and limited mobility developed four pressure ulcers due to the facility's failure to consistently implement preventative measures, such as using a pressure-reducing mattress and regular turning. The facility's documentation lacked evidence of adherence to the care plan, leading to actual harm.
The facility did not submit their Payroll Based Journal (PBJ) information to Medicare for the 3rd quarter ending June 30, 2024. This deficiency was identified during the recertification survey and confirmed by the DON and NHA, who noted that the previous owner submitted the report one day late. The issue was acknowledged by the Corporate Clinical Services President.
The facility failed to inform residents of their right to formulate an advance directive, as evidenced by the lack of documentation and follow-up for several residents. A resident had no advance directive on file, and there was no documentation indicating they were informed of their right. The social services director admitted to not discussing this right with current residents, despite facility policy. Additionally, other residents' records lacked advance directives and documentation of discussions about them, confirmed by the DON and social services director.
A facility failed to notify a primary care provider of a resident's abnormal TSH lab result, despite the resident being on Synthroid for hypothyroidism. The high TSH level was not documented or communicated to the provider until a surveyor's inquiry prompted staff to address the oversight.
The facility failed to accurately document MDS assessments for two residents, one with hearing difficulties and another in the dementia care unit. The first resident's hearing was inaccurately marked as adequate despite evidence of impairment, while the second resident's behavioral symptoms were not correctly recorded, leading to discrepancies in their care plans.
The facility failed to properly store and manage medications, including not discarding expired medications, improperly storing medicated creams, and administering discontinued Ativan to a resident. Additionally, a nurse pre-signed a narcotic count sheet, violating inventory reconciliation policies.
The facility failed to report abuse allegations and incidents in a timely manner, involving multiple residents and staff. In one case, a GNA was terminated for verbal abuse, but the incident was not reported to OHCQ. Another incident of inappropriate behavior between two residents was not initially reported. Additionally, a resident's injury and another abuse allegation were reported late. Staff confirmed these deficiencies during interviews.
The facility did not provide a summary of the baseline care plan to three residents or their representatives within 48 hours of admission, as required. The baseline care plan should include initial goals and a list of current medications. The DON stated that care plans were developed upon admission and provided during care plan meetings, but there was no documentation confirming that the residents or their representatives received copies. The Director of Clinical Operations acknowledged these findings.
The facility failed to invite two alert and oriented residents to their care plan meetings. One resident was not informed of their meeting, which included staff and a representative, while another was not invited, despite being cognitively intact. The social worker admitted to not notifying the second resident, and the Director of Nursing was made aware of these deficiencies.
The facility failed to follow physician orders and accurately assess residents, leading to deficiencies in care. A resident did not have their care plan updated to reflect a change from a cast to a brace, another resident's elopement risk was not properly assessed, and compression stockings were not applied as ordered. Additionally, bowel protocol medications were not administered, and a hospice consultation was not conducted as ordered.
The facility failed to respond promptly to resident call lights, with reports of delays up to 60 minutes. Observations showed that staff did not address call lights in a timely manner, despite being nearby. Residents expressed concerns about the call light system's functionality and response times.
A facility failed to provide a resident with advance notice of the termination of Medicare Part A coverage for skilled services. The resident received the Notice of Medicare Provider Non-Coverage (NOMNC) and Skilled Nursing Facility Advance Beneficiary Notice of Non-Coverage (SNFABN) on the same day services ended, not allowing time for an appeal. The social worker admitted to not realizing the discharge date, resulting in the notification being given on the day of discharge instead of three days prior.
A resident was transferred to the hospital without receiving the required written notification. The facility's policy mandates written notice for transfers, but staff confirmed that notifications were done verbally. The DON acknowledged the absence of a written notification process.
A facility failed to complete a Significant Change in Status MDS assessment within 14 days after a resident with Parkinson's disease experienced a significant decline in functional abilities. The resident's condition changed from requiring minimal assistance to total dependence on staff for ADLs. Despite these changes, the necessary MDS assessment was not completed, as confirmed by the MDS coordinator.
A facility failed to ensure staff assisted a resident with wearing eyeglasses, as observed on multiple occasions. The resident had an order for eyeglasses to be collected at bedtime and stored in the medication cart, but there was no documentation of assistance during the day. A GNA was unaware of the eyeglasses, and a nurse confirmed they were kept in the cart. After inquiry, the nurse placed the glasses on the resident, who expressed gratitude. The DON confirmed the GNA should have been aware of the glasses.
The facility failed to provide necessary devices for two residents with limited range of motion. One resident with a left foot drop was not wearing the prescribed brace due to a documentation error, while another resident with right-sided paralysis was without a splint because the order was not placed. Both cases highlight lapses in communication and documentation.
A facility failed to document reasons for administering PRN pain medication and did not adequately assess a resident's pain, including location and type, before and after medication. Despite having a care plan for pain management, the facility did not record non-pharmacological interventions or specific indications for medication use. The DON confirmed these documentation lapses.
A resident with end-stage renal disease did not have pre-dialysis vitals documented consistently, as required by the facility's procedures. Despite having a system for recording vital signs before dialysis, the facility failed to complete the necessary forms on several occasions, leading to incomplete communication with the dialysis center. Interviews confirmed that nurses were expected to document these vitals, but this was not consistently done.
The facility failed to document and carry out ordered 15-minute checks for a resident with suicidal ideation and administered Ativan without a current order to another resident with Alzheimer's and depression. The first resident's checks were not consistently documented, and the second resident was given Ativan despite the order being discontinued, leading to a fall without proper physician notification.
A facility failed to provide a resident with dementia care based on their preferences. The resident was observed without meaningful activities, and preference evaluations were marked as non-responsive. An Activities Assistant admitted to not following proper procedures for conducting interviews with cognitively impaired residents, leading to a lack of personalized care.
The facility failed to manage a resident's drug regimen by not specifying a removal time for a lidocaine patch, leading to inadequate documentation. Additionally, a resident with dementia and incontinence was improperly treated with antifungal cream instead of a barrier cream, as staff were not trained on proper cream application. These deficiencies highlight issues in medication management and staff training.
A facility failed to document specific reasons for administering a psychotropic medication and did not implement non-pharmacological interventions (NPI) before administering the medication as needed (PRN) for a resident. The medication was administered without documenting specific behaviors or attempting NPI, and there was no evidence of ongoing monitoring of behaviors or side effects. The DON confirmed these concerns.
A facility failed to keep medication error rates below 5%, with two errors observed out of 36 opportunities. An RN administered incorrect doses of Calcium with Vitamin D and Acetaminophen to two residents, differing from the prescribed orders. The RN acknowledged the discrepancies, and the DON was aware of the issue, with the error rate calculated at 5.56%.
The facility failed to meet the required staffing levels as per The Code of Maryland Regulations for Nursing Services, with deficiencies noted in April, May, October, and from September to November. Interviews with staff confirmed the non-compliance, and no additional evidence was provided to demonstrate compliance.
The facility's assessment was found to be inaccurate, as it incorrectly reported the number of beds in the Dementia unit. The assessment marked 'not applicable' for the number of beds, while indicating an average daily census of 30 beds. The DON confirmed the unit had only 22 beds, acknowledging the discrepancy but providing no further information by the survey exit.
A facility failed to maintain proper infection control during dressing changes for a resident with pressure ulcers, as a nurse did not change gloves or sanitize hands between wounds. Additionally, the laundry room lacked a physical barrier between clean and soiled areas, risking cross-contamination.
A facility failed to protect residents from verbal abuse and narcotic misappropriation. A GNA verbally abused a resident in the dementia unit, witnessed by staff and a family member, leading to the GNA's termination. In another case, discrepancies in narcotic administration records revealed misappropriation by a nurse, who was also terminated. The incidents were reported to authorities, but no documentation of staff education was found.
The facility failed to thoroughly investigate two abuse allegations. In one case, an LPN was accused of abusing a resident, but the investigation lacked a statement from the alleged perpetrator. In another case, a GNA observed two residents engaged in sexual relations, but witness interviews were delayed by several days. The DON confirmed the investigations were incomplete.
A facility failed to provide adequate denture care for a resident, as identified during a recertification survey. The resident had mouth sores and there was no documentation of denture care, despite having dentures listed in their personal belongings inventory. The DON confirmed that the necessary care was not documented or provided, highlighting a deficiency in the care for activities of daily living.
The facility failed to provide an activities program that met the needs and preferences of two residents. One resident, with a preference for music and outdoor activities, was observed without engagement, and their care plan was not updated. Another resident with dementia was not documented as participating in activities for extended periods. Staff confirmed the lack of documentation and activity engagement.
The facility failed to conduct a competency evaluation for an RN involved in a resident's care, as revealed during a staffing investigation and complaint review. Despite requests for evidence, the DON and HR confirmed no evaluations existed, acknowledging the deficiency in the facility's hiring and evaluation processes.
A resident with Alzheimer's and depression was given lorazepam without an active order, leading to a significant medication error. The facility's policy for controlled substances was not followed, as discontinued medications were not properly secured or documented. The nursing staff failed to document the administration of the medication and did not notify the physician of the resident's behaviors or the medication error.
A resident experienced a delay in receiving necessary radiological services after an oncologist recommended an MRI for hip pain. The facility did not order the MRI or an alternative diagnostic test in a timely manner, and the oncologist's consult note was not received until weeks later. The DON confirmed the delay in providing radiology services.
The facility failed to accurately document records for two residents. One resident's eyeglasses were not in the facility as required by orders, yet staff inaccurately documented compliance. Another resident's medication side effects were improperly recorded with check marks instead of using the specified legend, due to an order setup error.
The facility failed to maintain an AED in working order, as it emitted a low battery warning and had a red light indicating it required attention. The nurse was unaware of the procedure for a low battery, and the ADON confirmed the AED needed service. Documentation did not support regular checks, and a new checklist was introduced without prior records.
The facility's resident call system was not functioning properly, leading to significant delays in response times. Complaints were received about response times of 45-60 minutes, and residents reported waiting 30-40 minutes for assistance. The call system had been malfunctioning since May 2024, with issues such as non-visible call lights and lack of a computer alert system at the Haven unit. Staff had to rely on visual cues that were obstructed, impacting their ability to respond promptly.
Failure to Safeguard and Account for Controlled Pain Medication
Penalty
Summary
Surveyors identified a deficiency related to the facility’s failure to monitor and prevent misappropriation of a resident’s property, specifically controlled pain medication. Record review showed that a resident, in the facility since 2023, had an order dated 2/3/25 for oxycodone 5 mg four times daily for chronic back pain. On 10/27/25, an LPN (staff #24) signed a pharmacy packing slip at 9:16 PM confirming receipt of 30 tablets of oxycodone 5 mg for this resident. However, on 10/31/25, an RN (staff #25) discovered that all 30 oxycodone tablets and the administration record sheet for the resident were missing, and the facility was unable to locate the medications. Further review of the resident’s medication administration record and progress notes for November 2025 showed that the resident did not receive scheduled oxycodone doses on multiple occasions due to medication unavailability. Specifically, the resident did not receive the ordered 5 mg oxycodone doses on 11/1/25 at 12:00 AM and 6:00 AM, and on 11/2/25 at 12:00 AM and 6:00 AM, with progress notes documenting missed doses on 11/1/25 at 12:00 AM and 6:00 AM, and 11/2/25 at 12:00 AM because the medication was not available. During an interview, the acting DON reported that staff #24 continued to deny opening the plastic bag containing the drugs, but the missing controlled medications and associated documentation could not be accounted for, resulting in the resident not receiving ordered pain medication for chronic back pain during the documented times.
Failure to Prevent Accidents and Provide Adequate Supervision
Penalty
Summary
The facility failed to ensure that the environment was free from accident hazards and did not provide adequate supervision to prevent accidents, as evidenced by multiple incidents involving several residents. One resident, who had a history of muscle weakness, difficulty walking, and moderate cognitive impairment, required two staff for safe transfers according to their care plan and Kardex. Despite this, the resident was transferred by a single staff member, resulting in a severe laceration to the leg that required 15 sutures. The injury was caused by the resident's leg hitting an uncapped edge of the bed frame during the improper transfer. The staff member involved did not follow the care plan, and the incident was reported as an injury of unknown source before the cause was determined. Another resident with severe cognitive impairment, a history of falls, and dependence on staff for mobility experienced multiple unwitnessed falls over several months. The care plan included interventions such as keeping the call light within reach, frequent checks, and supervision at the nurses' station. However, the resident was repeatedly found alone in their room or in other areas without adequate supervision, leading to several falls, some resulting in injuries such as skin tears and a possible clavicle fracture. Staff interviews revealed that the resident was unable to use the call light effectively and could not remember instructions, yet was left unsupervised on multiple occasions. Staff also acknowledged that interventions like visual cues and education were ineffective due to the resident's cognitive status. Incident reports and post-fall investigations were often incomplete, lacking details about the circumstances leading to the falls, when the resident was last seen, and what interventions were in place at the time. Staff interviews confirmed that required documentation and witness statements were not consistently obtained, and that there was no clear assignment of responsibility for supervising high-risk residents at the nurses' station. These failures in supervision, adherence to care plans, and thorough investigation contributed to an environment where accident hazards were not minimized, directly resulting in harm and repeated incidents for multiple residents.
Failure to Timely Report Abuse, Neglect, and Injuries of Unknown Origin
Penalty
Summary
The facility failed to report multiple allegations of abuse, neglect, and injuries of unknown origin to the state survey agency within the required timeframe, as outlined in their own policy and federal regulations. Several incidents involving resident-to-resident altercations, injuries of unknown origin, and alleged staff abuse were either not reported at all or were reported late. In some cases, staff and leadership were unclear about what constituted a reportable event, leading to delays or omissions in reporting. For example, altercations between residents, such as one resident attempting to dump another from a wheelchair or a resident grabbing another by the shirt collar, were not reported to the state agency as required. In other cases, injuries of unknown origin, such as a resident's acute wrist fracture, were reported more than two hours after discovery, contrary to policy requirements. The report details that staff, including LPNs, RNs, and DONs, sometimes failed to recognize or escalate incidents as reportable abuse or altercations. In several instances, staff deferred to corporate guidance before submitting reports, which contributed to delays. There were also communication breakdowns, with some administrators and regional staff not being informed of incidents in a timely manner. For example, after a resident was found with a new fracture, the DON waited for corporate input before reporting, resulting in a late submission. In another case, a DON instructed staff not to report a resident-to-resident altercation, classifying it as a behavioral issue instead, despite staff concerns that it met the criteria for abuse. Residents involved in these incidents often had significant cognitive impairments, dementia, or physical limitations, making them particularly vulnerable. The lack of timely reporting prevented prompt investigation and intervention, as required by both facility policy and regulatory standards. The facility's failure to consistently recognize, document, and report these events as abuse, neglect, or injuries of unknown origin led to noncompliance with reporting requirements and affected the safety and well-being of multiple residents.
Failure to Investigate and Protect Residents Following Alleged Abuse and Injuries
Penalty
Summary
The facility failed to conduct thorough investigations and maintain evidence of investigations into multiple alleged incidents of abuse, neglect, and injuries of unknown origin. In several cases, the facility did not obtain or document staff and resident interviews, body audits, or other investigative steps as required by policy. For example, after an alleged altercation between two residents, there was no evidence of an investigation or documentation, and the incident was not reported to the state agency. In another case, a resident sustained rib fractures, but the facility's investigation lacked interviews with staff or residents and did not include body audits to rule out abuse or other causes. The facility also failed to protect residents from potential further abuse by not immediately removing alleged abusers from the premises. In one incident, an LPN accused of being rough and verbally abusive to a resident was allowed to continue working and interacting with the resident for several hours after the allegation was reported. Documentation showed the LPN continued to perform neurological checks on the resident and remained in the building until the end of the shift, contrary to facility policy requiring immediate suspension and removal of the accused staff member. Additionally, the facility did not consistently report alleged violations to the state survey agency or notify the Administrator as required. In several incidents involving resident-to-resident altercations or injuries of unknown origin, there was no evidence of timely reporting, comprehensive documentation, or assessment of all involved parties. The lack of thorough investigations and failure to follow established protocols affected multiple residents with varying degrees of cognitive impairment and complex medical histories.
Failure to Implement Effective QAPI Plan for Falls
Penalty
Summary
The facility failed to ensure that its Quality Assurance Performance Improvement (QAPI) program effectively implemented a plan to address quality deficiencies related to falls. Documentation from QAPI meetings over several months showed that falls were reviewed, and in one month, 25 falls involving 22 residents were recorded, with two residents accounting for five of those falls. However, there was no evidence in the facility's records of corrective actions being developed or implemented to address the high number of falls, nor was there documentation of a good faith effort to resolve the issue. Interviews with nursing staff revealed that they had not been involved in QAPI meetings or performance improvement projects, and their input on fall prevention was not solicited in a structured manner. Further interviews with the Director of Nursing (DON) and the Administrator indicated that while falls were discussed in meetings and some interventions, such as increased rounds, were verbally communicated, there was no written action plan or systematic tracking of interventions and their effectiveness. The DON expected a written plan with measurable goals and tools to assess outcomes, but was not involved in follow-up or action items. The Administrator acknowledged that interventions were discussed verbally and corrections were made on an individual basis, but there was no formal, documented plan to address the ongoing issue of falls.
Failure to Communicate Change in Condition and Pertinent Information to Physician
Penalty
Summary
The facility failed to ensure that staff communicated all pertinent information to a physician regarding a resident who experienced a fall and subsequent change in condition. According to facility policy, staff are required to promptly notify the resident, their attending physician, and the resident representative of any significant changes in the resident's condition, including accidents, incidents, or changes in physical or mental status. In this case, a resident with a history of dysphagia, aphasia, COPD, atrial fibrillation, cardiovascular disease, and congestive heart failure, who was also on anticoagulant medication, experienced a fall from bed and vomited twice around the time of the fall. Documentation and interviews revealed that after the fall, the nurse completed a change in condition assessment and notified a nurse practitioner (NP) about the resident's elevated pulse and low oxygen saturation, but did not communicate the occurrence of the fall or the vomiting episodes. The NP ordered laboratory tests and medication administration based on the information provided, but was not made aware of the fall or the resident's anticoagulant use at that time. Multiple staff interviews confirmed that there was an assumption among nurses that the fall had already been reported to the provider, leading to incomplete communication. The DON and other staff acknowledged that vomiting after a fall and the use of anticoagulants were significant details that should have been reported to the provider. Further interviews with the NP and the medical director confirmed that if they had been notified of the fall and vomiting, they would have considered holding the anticoagulant medication and would have asked additional questions. The lack of complete and accurate communication prevented the provider from making a fully informed decision regarding the resident's care. The resident was later found unresponsive and expired, with documentation and staff interviews indicating that critical information was not relayed to the provider as required by facility policy.
Failure to Protect Resident from Physical and Verbal Abuse by Staff
Penalty
Summary
The facility failed to protect a resident's right to be free from physical and verbal abuse by a staff member. According to facility policy, all staff are prohibited from physically, mentally, or emotionally abusing, mistreating, or neglecting residents, and are required to immediately report any such incidents. In this case, a resident with a history of cerebral infarction, dysphagia, aphasia, and other significant medical conditions, who required maximal assistance for activities of daily living, was subjected to rough and rude treatment by an LPN during an assessment following a fall. Multiple staff members, including several GNAs, witnessed the LPN being physically rough with the resident, including pulling and jerking the resident's arms, yelling at the resident to stop moving, and removing a blood pressure cuff in a forceful manner that caused it to break. Written statements and interviews from the GNAs consistently described the LPN's actions as rough, rude, and mean, with the LPN yelling at the resident and handling the resident in a way that was considered abusive by the witnesses. The resident, who had moderate cognitive impairment and was unable to move independently, was unable to verbally respond due to aphasia. The incident was promptly reported by the GNAs to another nurse, who escalated the report to the DON. The facility's internal investigation, as documented in the follow-up report, verified the allegations of abuse, with multiple staff corroborating the account of rough and verbally abusive behavior by the LPN toward the resident. The resident did not sustain serious bodily harm or injuries as a result of the incident, but the actions of the LPN constituted a failure to protect the resident from abuse as required by facility policy.
Failure to Investigate and Report Resident-to-Resident Abuse Incident
Penalty
Summary
The facility failed to implement its policies and procedures regarding the investigation, documentation, and reporting of a resident-to-resident abuse incident. According to facility policy, all altercations, including those that may represent abuse, are to be investigated, documented, and reported to the nursing supervisor, director of nursing, administrator, and appropriate agencies. However, when an incident occurred in which one resident with severe cognitive impairment and a history of behavioral issues grabbed another resident, also with severe cognitive impairment, by the shirt collar and pushed them in a wheelchair, the required steps were not followed. Staff separated the residents and obtained witness statements, but no incident report or risk management form was completed, and the event was not reported to the state or police as required by policy. The residents involved both had significant cognitive impairments and behavioral histories. One resident had a diagnosis of cerebral infarction and exhibited physical and verbal behaviors toward others, while the other had dementia and was noted for inappropriate behaviors. During the incident, staff observed one resident holding and pulling on the other's shirt collar, with the affected resident becoming upset and crying. Staff intervened to separate the residents, but the incident was not properly documented or reported according to facility policy. Interviews with staff and administration revealed a breakdown in communication and adherence to policy. The DON and RN involved believed the incident constituted resident-to-resident abuse and should have been reported and investigated, but the former DON and regional director determined it was not an altercation and instructed staff not to report it. The administrator was not fully informed of the details and agreed that the facility did not follow its own policy regarding investigation, documentation, and reporting. Additionally, there was no assessment to determine if the residents could safely remain roommates after the incident.
Inaccurate MDS Assessment Coding for Fall and Pressure Ulcer
Penalty
Summary
The facility failed to ensure the accuracy of a Minimum Data Set (MDS) assessment for one resident. The resident, who was admitted with a history of dysphagia, aphasia following a stroke, chronic obstructive pulmonary disease, and congestive heart failure, had a documented pressure ulcer on the coccyx and sustained a fall resulting in a skin tear to the right hand shortly after admission. Despite these documented conditions, the 5-day MDS assessment indicated that the resident had no falls since admission and no pressure ulcers. The MDS Coordinator, who completed and signed the assessment, did not accurately code these events, as confirmed by interviews and record reviews. The facility's policy required staff to certify the accuracy of each portion of the MDS, and the CMS RAI Manual provided clear coding instructions for falls and pressure ulcers, which were not followed in this case. Further review of the resident's care plan and progress notes confirmed the presence of a pressure ulcer and a fall, both of which were addressed in care planning and interventions. Interviews with the DON, MDS Coordinator, and Administrator revealed that the MDS Coordinator did not clarify the pressure ulcer information with nursing staff and failed to code the fall, despite being aware of both incidents. The inaccuracy of the MDS assessment had the potential to affect the resident's care and care planning, as the assessment did not reflect the resident's actual status.
Failure to Assess and Respond to Change in Condition After Fall
Penalty
Summary
Staff failed to accurately assess and respond to a resident's change in condition following a fall. The resident, who had a history of dysphagia, aphasia, stroke, gastrostomy tube, COPD, atrial fibrillation, atherosclerotic heart disease, and congestive heart failure, was found on the floor after a fall, had vomited twice, and was on anticoagulant therapy. Despite these risk factors, there was no evidence that nursing staff performed a thorough assessment, such as auscultating the lungs or assessing the abdomen, and critical information about the fall and vomiting was not communicated to the provider. Documentation and communication lapses were evident throughout the incident. The nurse practitioner was contacted but was not informed of the resident's fall, and the SBAR form was incomplete, omitting key details such as the fall and the resident's anticoagulant use. The resident continued to receive anticoagulant medication after the fall, and neurological checks were performed, but changes in vital signs and the significance of vomiting were not fully recognized or reported. Multiple staff interviews revealed assumptions that the provider was already aware of the fall, and there was a lack of clarity regarding who was responsible for communicating critical changes. The facility's policies required detailed assessment and prompt, complete communication with providers in the event of an acute change in condition, especially for residents on anticoagulants who experience a fall. However, these protocols were not followed. The resident's deteriorating condition, including elevated pulse, low oxygen saturation, and repeated vomiting, was not adequately addressed, and the provider was not given the necessary information to make informed decisions. Ultimately, the resident was found unresponsive and expired, with staff and providers acknowledging in hindsight that the resident should have been sent to the hospital and that the anticoagulant should have been held.
Failure to Prevent Resident Elopement
Penalty
Summary
The facility failed to provide adequate supervision to prevent a vulnerable resident from exiting the facility unattended. The resident, who had multiple psychiatric diagnoses including paranoid schizophrenia, was admitted to the facility in December 2021 and was receiving multiple psychoactive medications. Despite having a court-ordered guardian and being deemed unable to make healthcare decisions, the resident exhibited wandering behavior and had packed belongings on several occasions, indicating a desire to leave the facility. On November 30, 2022, the resident attempted to elope and was found in the parking garage by two GNAs. The resident was attempting to gain access to a vehicle and was dressed in a hospital gown, pants, shoes, and a jacket, carrying a bag with clothing. The resident was returned to the facility without incident by staff. Prior to this incident, there was no documentation of an elopement assessment, and the care plans did not include interventions to address the potential for elopement. Interviews with staff revealed that the resident's behavior of packing belongings was known, but the resident was not considered an elopement risk. The facility's layout included a main entrance leading to a lobby and a parking garage, with access to the second floor where resident rooms were located. The doors to the parking garage were unlocked, allowing the resident to exit the building. The facility's failure to assess and address the resident's risk of elopement contributed to the incident.
Failure to Prevent Pressure Ulcers in Resident
Penalty
Summary
The facility failed to provide adequate care to prevent the development of pressure ulcers for a resident with multiple health conditions, including dementia and limited mobility. The resident had a history of being at risk for pressure ulcers, and there were orders in place for preventative measures, such as the use of a Medline mattress with a pump and regular turning and repositioning. However, the facility did not ensure these measures were consistently implemented. The resident's medical record lacked documentation of the use of the pressure-reducing mattress and the regular turning and repositioning as outlined in the care plan. The resident developed four pressure ulcers, which were identified during a new consult by a wound nurse practitioner. The ulcers included an unstageable ulcer and deep tissue injuries with significant slough and eschar. The facility's documentation failed to indicate the presence of these ulcers in the weeks leading up to their identification, and there was no evidence that the staff had been monitoring the functionality of the pressure-reducing mattress or adhering to the turning and repositioning schedule. Interviews with facility staff revealed inconsistencies in the use of pressure-reducing mattresses and a lack of clarity regarding the resident's care. The Director of Nursing was unable to confirm the type of mattress used prior to the identification of the pressure ulcers, and the wound nurse practitioner indicated that the wounds could not have developed in a single day, suggesting a lapse in preventative care. The facility's failure to adhere to the care plan and monitor the resident's condition resulted in actual harm to the resident.
Failure to Submit PBJ Information to Medicare
Penalty
Summary
The facility failed to submit their Payroll Based Journal (PBJ) information to Medicare, as required. During the off-site preparation for the recertification survey, the survey team discovered that no data was submitted for the 3rd quarter ending June 30, 2024. This was confirmed during an entrance conference with the Director of Nursing (DON) and the Nursing Home Administrator (NHA), who were made aware of the issue. The DON later confirmed that the previous owner submitted the report one day late, and both the DON and NHA acknowledged the deficiency. The issue was further discussed with the Corporate Clinical Services President, who also confirmed the deficiency.
Failure to Inform Residents of Advance Directive Rights
Penalty
Summary
The facility failed to ensure that residents were informed of their right to formulate an advance directive, as evidenced by the lack of documentation and follow-up for seven out of nine residents reviewed. Resident #1, who had been living in the facility since August 2022, had no advance directive on file, and there was no documentation indicating that the resident or their representative had been informed of their right to formulate one. Interviews with the social services director revealed that she only assessed if newly admitted residents had advance directives and did not discuss this right with current residents, despite the facility's policy requiring her to do so. Similarly, Resident #31's medical record indicated the resident was capable of making healthcare decisions, yet there was no follow-up documentation regarding the initiation of an advance directive. The social worker admitted to not following up if the initial response was negative. Additionally, the medical records of Residents #82, #83, #236, #241, and #250 lacked advance directives and any documentation of discussions about them. The Director of Nursing and the social services director confirmed these findings during interviews.
Failure to Notify Provider of Abnormal Lab Result
Penalty
Summary
The facility failed to notify a primary care provider of an abnormal lab result for a resident diagnosed with hypothyroidism. The resident, who was admitted in 2022, was receiving Synthroid for the condition. A lab test for thyroid-stimulating hormone (TSH) was conducted, and the results, which were reported on 11/14/24, indicated a high TSH level of 17.98, significantly above the reference range of 0.45 - 4.50. However, there was no documentation in the medical record to show that the primary care provider was informed of this abnormal result. The resident was seen by a nurse practitioner on 11/19/24 for a follow-up after laboratory testing, but the progress note did not mention the high TSH level. It was only after the surveyor's inquiry on 11/21/24 that the facility staff took steps to address the oversight. The Assistant Director of Nursing and other staff members were unaware of the issue until it was brought to their attention by the surveyor, indicating a lapse in communication and documentation regarding the resident's lab results.
Inaccurate MDS Documentation for Residents
Penalty
Summary
The facility failed to ensure accurate documentation of Minimum Data Set (MDS) assessments for two residents, leading to deficiencies in their care plans. For one resident, who had been experiencing hearing difficulties, the MDS assessment inaccurately documented their hearing as adequate, despite observations and staff reports indicating significant hearing impairment. The resident had been noted to have difficulty hearing during an observation, and their care plan had been revised to address this issue. However, the MDS assessment did not reflect the resident's actual hearing condition, as confirmed by the Director of Nursing. Another resident, residing in the dementia care unit, was inaccurately coded in their MDS assessment regarding behavioral symptoms. The MDS coordinator documented that the resident did not exhibit physical aggression, despite the electronic Treatment Administration Record (eTAR) showing an episode of physical aggression. The Director of Nursing acknowledged the discrepancy between the eTAR and the MDS assessment, indicating that the resident's behavior should have been accurately marked in the assessment. These inaccuracies in MDS documentation highlight the facility's failure to provide accurate assessments necessary for developing appropriate care plans.
Medication Storage and Controlled Substance Management Deficiencies
Penalty
Summary
The facility failed to adhere to professional standards for medication storage and labeling, as evidenced by several deficiencies observed during a survey. One incident involved an opened Fluticasone Propionate and Salmetrol inhalation powder labeled for a resident, which was not discarded after the recommended one-month period post-opening. This oversight was confirmed by a registered nurse during the inspection, and the Director of Nursing acknowledged the medication should have been discarded earlier. Another deficiency was noted when a Geriatric Nurse Assistant was observed retrieving antifungal creams from an unlocked dresser drawer in a resident's room, contrary to the facility's policy that such medications should be stored in a locked medication room. The Assistant Director of Nursing confirmed the improper storage and acknowledged the potential confusion due to the proximity of storage bins for different creams. Further inspection revealed expired and improperly stored medications in residents' rooms, which was against the facility's policy requiring medications to be locked and accessed only by nurses. Additionally, the facility failed to properly manage controlled substances, as evidenced by the administration of discontinued Ativan to a resident. The Controlled Drug Administration Record showed doses were removed without an active order, and the error was only identified after the medication was administered. The facility's policy requires discontinued controlled substances to be securely locked until destroyed, but this was not followed. Furthermore, a discrepancy was noted in the controlled substance inventory process, where a nurse pre-signed the narcotic count sheet, which was against the facility's policy for reconciling controlled medication inventory at shift changes.
Failure to Timely Report Abuse and Incidents
Penalty
Summary
The facility failed to report allegations of abuse and did not report them in a timely manner, as evidenced by several incidents involving multiple residents. In one case, a Geriatric Nursing Assistant was terminated for verbal abuse of two residents, but the facility did not report this incident to the Office of Health Care Quality (OHCQ). Additionally, the facility was aware of an inappropriate sexual behavior incident between two residents but failed to submit the initial report to OHCQ within the required timeframe. The Nursing Home Administrator and staff confirmed these deficiencies during interviews. Further deficiencies were noted in the reporting of a resident's injury and another abuse allegation. A resident's fractured pelvis was reported to the facility on a specific date, but the injury was not reported to OHCQ until several days later. Another incident involved an abuse allegation that was reported to the regional vice president and the Nursing Home Administrator but was not forwarded to the state agency within the required two-hour window. Interviews with the Director of Nursing and other staff confirmed these reporting delays and deficiencies.
Failure to Provide Baseline Care Plan Summary to Residents
Penalty
Summary
The facility failed to provide a summary of the baseline care plan to three residents or their representatives within 48 hours of admission, as required. The baseline care plan should include initial goals based on admission orders, physician orders, dietary orders, therapy services, and social services, along with a list of the resident's current medications. During a record review, it was found that the baseline care plans were not discussed with the residents or their representatives. The Director of Nurses stated that the care plans were developed upon admission and provided during care plan meetings, but there was no documentation to confirm that the residents or their representatives received copies of the baseline care plans. The Director of Clinical Operations acknowledged these findings.
Failure to Invite Residents to Care Plan Meetings
Penalty
Summary
The facility failed to invite alert and oriented residents to their care plan meetings, as evidenced by the cases of two residents. Resident #52, who was admitted in October 2024 and was determined to be alert and oriented, was not aware of or invited to their care plan meeting held on October 29, 2024. The interdisciplinary care conference included staff from various departments and the resident's representative, but the resident themselves was not informed or present. This oversight was confirmed during an interview with the social services director, who did not indicate that the resident was notified or invited. Similarly, Resident #136, who was also admitted in October 2024 and had a BIMS score indicating cognitive intactness, was not aware of their care plan meeting. The social worker admitted to not inviting the resident to the meeting, which was attended by an activities aide, the social worker, and a family member. The medical record review showed a late entry note for the care plan conference, but it did not explain why the resident was not present. The Director of Nursing was informed of this issue, highlighting the facility's failure to ensure resident participation in care planning.
Deficiencies in Following Physician Orders and Assessments
Penalty
Summary
The facility failed to ensure that staff reviewed and acknowledged specialist recommendations, completed assessments accurately, and followed physician orders for several residents. For Resident #31, the facility did not update the care plan to reflect the change from a cast to a hand brace after an orthopedic consultation. The resident was observed without the brace, and staff were unaware of its location or the need for its use, indicating a lack of communication and documentation regarding the specialist's recommendations. Resident #256's elopement risk was not accurately assessed despite documentation of previous wandering behavior and a history of elopement. The resident had been admitted with altered mental status and a recent stroke, yet the elopement risk assessment did not reflect these factors. The Director of Nursing acknowledged that the assessment was not completed accurately, which contributed to the resident's elopement from the facility. For Resident #16, the facility failed to apply compression stockings as ordered by the attending provider, and incorrect documentation was made by the nursing staff. Resident #11 did not receive bowel protocol medications as ordered, despite documentation indicating the need for intervention. Additionally, Resident #83 did not receive a hospice consultation as ordered before passing away, highlighting a failure to follow through with physician orders in a timely manner.
Delayed Response to Resident Call Lights
Penalty
Summary
The facility failed to respond in a timely manner to resident requests for assistance, as evidenced by observations and interviews. On multiple occasions, residents reported extended wait times for staff to respond to call lights, with some instances taking 45-60 minutes. During a resident council meeting, concerns were raised about the call light system not functioning properly, leading to delays in response times. Specific incidents were observed where residents activated their call lights, but staff did not respond promptly, despite being in proximity to the alerts. In one instance, a resident's call light was activated for over an hour before a nurse addressed the issue, even though the nurse was seated near the call system. Another resident's call light remained on for 17 minutes without staff response, despite staff presence in the hallway. Interviews with staff revealed a lack of immediate response due to assignment issues, and the Director of Nursing acknowledged the expectation for staff to respond within five minutes, which was not met in these cases.
Failure to Provide Timely Medicare Coverage Termination Notice
Penalty
Summary
The facility failed to provide advance notification to a resident regarding the termination of Medicare Part A coverage for skilled services. Specifically, the deficiency was identified for one resident who was discharged from Medicare-covered Part A services while still residing at the facility. The review of documentation revealed that the resident was given both a Notice of Medicare Provider Non-Coverage (NOMNC) and a Skilled Nursing Facility Advance Beneficiary Notice of Non-Coverage (SNFABN) on the same day that services ended, which was 8/7/24. This did not allow the resident adequate time to appeal the decision to end services, as the notification was not provided in advance. During an interview, the social worker (SW) responsible for the resident's case indicated that the usual practice is to provide notification forms three days prior to the end of services. However, in this instance, the SW admitted to not realizing the resident was discharging and consequently provided the notification on the day of discharge. This oversight resulted in the resident not being informed in a timely manner, thus failing to ensure the resident's right to appeal the decision to terminate Medicare coverage.
Failure to Provide Written Notification of Transfer
Penalty
Summary
The facility failed to provide written notification of transfer to a resident and their representative, as required by policy. This deficiency was identified during a review of the medical records of a resident who had been residing in the facility since late 2022 and was sent to the hospital in July 2024. The review revealed no evidence of a written notification of transfer being provided to the resident or their representative. Interviews with facility staff, including the Social Services Director and an LPN, confirmed that the facility's practice was to notify residents and their representatives verbally, either face-to-face or over the phone, rather than in writing. The Director of Nursing acknowledged that there was no written notification process in place, contrary to the facility's policy, which requires written notice for transfers and discharges. This lack of written notification was discussed with the Director of Nursing, who acknowledged the concern.
Failure to Complete Significant Change in Status MDS Assessment
Penalty
Summary
The facility failed to complete a Significant Change in Status Minimum Data Set (MDS) assessment within 14 days following a significant decline in a resident's condition. This deficiency was identified for one resident who had been living in the facility since December 2022 and was diagnosed with Parkinson's disease. A review of the resident's medical records revealed a significant decline in their functional abilities, including a transition from requiring minimal assistance to total dependence on staff for various activities of daily living (ADLs). Despite these changes, the facility did not complete the required MDS assessment to document and address the resident's significant change in status. Interviews with facility staff further highlighted the oversight. The therapy manager noted that therapy interventions for the resident's contractures began in March 2023, and the resident's ambulation became limited by November 2023. The MDS coordinator acknowledged that the resident's decline was gradual and admitted to missing the completion of a Significant Change in Status MDS assessment. This oversight resulted in a failure to accurately assess and plan for the resident's care needs following their significant decline.
Failure to Assist Resident with Eyeglasses
Penalty
Summary
The facility failed to ensure that staff assisted a resident with wearing eyeglasses, which was evident for two out of three residents reviewed for vision and hearing. Specifically, Resident #31 had an order in place since October 15, 2024, for the nurse to collect the glasses at bedtime and place them in a black case in the medication cart every night shift. However, observations on November 12 and November 19, 2024, revealed that the resident was not wearing eyeglasses during the day. The resident's Minimum Data Set assessment indicated the use of corrective lenses, and the care plan addressed impaired visual function but did not include the use of eyeglasses. Further investigation showed that the November Treatment Administration Record documented compliance with the order to place the glasses in the med cart at night, but there was no documentation of assistance with wearing the glasses during the day. On November 19, 2024, a Geriatric Nursing Assistant (GNA) assigned to the resident was unaware of the eyeglasses, and a nurse confirmed that the glasses were kept in the medication cart. After the surveyor's inquiry, the nurse retrieved the glasses and placed them on the resident, who expressed gratitude. The Director of Nursing confirmed that the GNA should have been aware of the glasses.
Failure to Provide Prescribed ROM Devices for Residents
Penalty
Summary
The facility failed to provide appropriate care for residents with limited range of motion, as evidenced by the cases of two residents. Resident #16, who had a left foot drop, was observed without the prescribed brace on multiple occasions. Despite an order from the attending provider for the resident to wear a brace every shift, the resident reported not having worn the device for weeks. Interviews with staff revealed a breakdown in communication and documentation, as the order was not visible in the electronic health record, preventing nurses from applying the brace as required. Similarly, Resident #40, who had right-sided paralysis due to a stroke, was observed without a splint or palm protector to prevent contractures. Although a specialized hand splint was discussed and an order was placed, the Director of Rehabilitation admitted to not having ordered it, leaving the resident without necessary intervention. The Treatment Administration Record and care plan for this resident also lacked documentation for the use of a splint or other preventive measures, further indicating a lapse in care.
Inadequate Documentation of Pain Management
Penalty
Summary
The facility failed to consistently document the reasons for administering as-needed (PRN) pain medication and did not adequately document pain assessments for a resident with chronic back pain. The resident had been residing in the facility since December 2022 and had a care plan for pain management that included both pharmacological and non-pharmacological interventions. Despite this, the medical record review revealed that the facility did not document the location and type of pain, nor did it record the non-pharmacological interventions attempted before administering PRN pain medication. Additionally, the specific indications for administering the medication were not documented. The medication administration records showed that the resident received Hydrocodone-Acetaminophen for various pain levels, but there was a lack of documentation regarding pain assessments before and after medication administration. The records also failed to show continued pain management efforts after administering the medication. The Director of Nursing confirmed these concerns, stating that nurses were expected to attempt non-pharmacological interventions before administering PRN medications and should have recorded the reasons for administering the medication along with pre and post-pain assessments.
Failure to Document Pre-Dialysis Vitals
Penalty
Summary
The facility staff failed to obtain and document pre-dialysis treatment records for a resident with end-stage renal disease who required hemodialysis. The resident had a hospital discharge summary indicating the need for dialysis three times a week. Despite having a system in place for documenting pre-dialysis vitals and conditions, the facility did not record these vitals on several occasions, including specific dates in October and November. The dialysis communication forms, which were supposed to be filled out entirely and sent with the resident, were incomplete, lacking vital signs and other necessary information. Interviews with facility staff revealed that nurses were expected to record the resident's temperature, pulse, respiration, and blood pressure before dialysis and complete the communication form. However, this was not consistently done, as evidenced by feedback from the dialysis center noting the absence of pre-dialysis information. The Director of Nursing confirmed the expectation for nurses to assess and document the resident's vitals before each dialysis session, highlighting a lapse in following established procedures for ensuring safe and appropriate dialysis care.
Failure to Document and Administer Behavioral Health Orders
Penalty
Summary
The facility failed to ensure that ordered 15-minute checks for suicidal ideation were consistently documented and carried out for a resident with multiple psychiatric diagnoses, including paranoid schizophrenia. Despite an order for 15-minute checks being placed on 11/10/22, the electronic health record did not reflect this order, and there was insufficient documentation to confirm that these checks were consistently performed. The Director of Nursing confirmed that such orders should be documented in the electronic health record and appear on the Treatment Administration Record. Additionally, there was no documentation indicating that the resident was seen by psychiatric services in November 2022. Another resident with Alzheimer's disease and depression was administered Ativan without a current order due to increased agitation. The Ativan order had been discontinued on 10/18/24, yet it was administered on 11/15/24, 11/16/24, and 11/17/24 without a valid order. The resident experienced a fall on 11/16/24, but the physician was not informed of the behaviors that led to the administration of Ativan. The corporate nurse was informed of the concern that the Ativan was administered without an order, and the physician was not notified of the resident's behaviors.
Failure to Provide Dementia Care Based on Resident Preferences
Penalty
Summary
The facility failed to ensure that services provided to a resident with dementia were based on their choices and preferences. This deficiency was identified during a survey where Resident #57, who was admitted in early 2023, was observed in the dementia unit on multiple occasions without any meaningful activities being provided. The resident was seen watching TV during these observations, indicating a lack of engagement in activities that align with their preferences. A review of the resident's preference evaluations revealed that the most recent evaluation, conducted by an Activities Assistant (Staff #13) on 11/6/24, showed all questions marked as 'No response' or 'non-responsive.' A similar evaluation conducted on 8/6/24 also showed the same results. Staff #13 admitted during an interview that she did not conduct the interviews correctly, as she was not informed of the proper procedure, which includes contacting family members for input when residents are cognitively impaired. This oversight led to the resident not receiving activities tailored to their preferences, impacting their well-being.
Deficiencies in Medication Management and Monitoring
Penalty
Summary
The facility failed to ensure that a resident's drug regimen was free from unnecessary drugs by not specifying a time for the removal of a topical anesthetic patch. Resident #10 had an order for Aspercreme Lidocaine External Patch 4% to be applied twice daily for pain management. However, the order did not include a specific time for the patch's removal, leading to a lack of documentation on when the patch was removed. This oversight was confirmed through interviews with staff, including a registered nurse and the director of nursing, who acknowledged that the order was entered into the electronic record without a removal time. Additionally, the facility did not provide adequate monitoring and indications for the use of biological creams for Resident #30, who was admitted with unspecified dementia and other behavioral disturbances. The resident was frequently incontinent and required treatment for Moisture Associated Skin Damage (MASD). However, a Geriatric Nurse Assistant (GNA) was observed applying antifungal cream as a barrier cream, which was not ordered for the resident. Interviews with staff, including a Nurse Practitioner and the Assistant Director of Nursing, revealed that antifungal cream was not considered a barrier cream and that GNAs were not supposed to apply medicated creams. The Medication Administration Record (MAR) showed an order for Zinc Oxide but not for antifungal cream, indicating a lack of proper medication management and training for staff.
Failure to Document and Implement Non-Pharmacological Interventions Before PRN Medication
Penalty
Summary
The facility failed to document the specific reasons for administering a psychotropic medication and did not implement non-pharmacological interventions (NPI) before administering the medication as needed (PRN) for a resident. The medical record review for the resident showed orders for antianxiety medication to be administered every 8 hours PRN for anxiety, and later, twice daily for anxiety/agitation. The medication administration record (MAR) indicated that the PRN antianxiety medication was administered on specific dates, but the post-medication assessments stated the medication was ineffective. The review did not show documentation of the specific behaviors for which the medication was administered, nor any NPI attempted before administering the medication. Additionally, there was no evidence of interventions implemented when the medication was deemed ineffective, nor ongoing monitoring of changes in behaviors or side effects related to the medication use. The director of nursing confirmed these concerns and stated that the expectation was for nurses to attempt NPI before administering the medication as needed.
Medication Error Rate Exceeds 5% During Administration
Penalty
Summary
The facility failed to maintain medication error rates below 5% during a medication administration task, as observed by a surveyor. Specifically, two errors were identified out of 36 medication administration opportunities. The first error involved a registered nurse (RN) administering a tablet of Calcium 600 mg with 10 mcg of Vitamin D to a resident, whereas the medical record indicated the order was for a tablet of Calcium 600 mg with 200 mg of Vitamin D. The second error occurred when the same RN administered two tablets of Acetaminophen 500 mg to another resident, despite the medical record showing an order for only one tablet of 500 mg. The RN acknowledged the discrepancies upon review and confirmed that the administered doses did not match the prescribed orders. The RN mentioned that the Calcium with 10 mcg of Vitamin D was what the facility had in stock, and she believed the second resident was supposed to receive two tablets of Acetaminophen due to severe back pain, although the order was for one tablet. The Director of Nursing was aware of the medication errors and acknowledged the concern, with the facility's medication error rate calculated at 5.56%.
Facility Fails to Meet Staffing Requirements
Penalty
Summary
The facility failed to comply with The Code of Maryland Regulations for Nursing Services - Staffing, which mandates a minimum of 3 hours of bedside care per occupied bed per day. This deficiency was evident in the facility's staffing data for several months. Specifically, during April and May 2023, the facility did not meet the required staffing levels on 16 out of 61 days. Similarly, in October 2023, the facility's PPD was below the required 3.0 for 9 out of 31 days. Furthermore, from September 1, 2024, to November 14, 2024, the facility only met the required staffing levels on three days, with the PPD falling below 3.0 on 38 out of 75 days. Interviews with facility staff, including the Staffing Coordinator, Director of Nursing, Assistant Director of Nursing, and Corporate Nurse, confirmed the deficiency in staffing levels. The facility's staff acknowledged the non-compliance with state regulations and indicated awareness of the issue. Despite being aware of the deficiency, no additional evidence or information was provided to demonstrate compliance with the required staffing levels. The facility's failure to maintain adequate staffing levels as per state regulations was a consistent issue over the reviewed periods.
Inaccurate Facility Assessment in Specialty Unit
Penalty
Summary
The facility failed to maintain an accurate and complete facility-wide assessment, which is crucial for determining the necessary resources to care for residents competently. During a review conducted by a surveyor, it was found that the facility marked 'not applicable' in the section regarding the number of beds in the specialty unit, despite indicating an average daily census of 30 beds in the same unit. Upon further investigation, the Director of Nursing (DON) confirmed that the facility was licensed for a specialty unit, specifically a Dementia unit, which actually had only 22 beds. This discrepancy was acknowledged by the DON, who stated she would investigate further, but no additional information was provided by the time of the survey exit.
Infection Control Deficiencies in Dressing Changes and Laundry Room
Penalty
Summary
The facility failed to ensure proper infection control practices during dressing changes for a resident with pressure ulcers. The resident, who has been residing at the facility for several years and has a diagnosis including dementia, had two unhealed pressure ulcers on both feet. On a specific date, a nurse was observed performing dressing changes on the resident's wounds. The nurse sanitized hands and donned gloves before starting the procedure but did not change gloves or perform hand sanitation between changing the dressings on the right and left foot. This lapse in protocol was confirmed by the nurse during an interview. Additionally, the facility's laundry room was found to lack a physical barrier between the clean and soiled areas, which is necessary to prevent cross-contamination. During a tour of the laundry room, an opening was observed between these areas without any door or barrier. The director of environmental services acknowledged the issue, and the assistant director of nursing and infection prevention nurse confirmed that the facility's newer ownership was aware of the concern.
Verbal Abuse and Narcotic Misappropriation in LTC Facility
Penalty
Summary
The facility failed to protect residents from verbal abuse and misappropriation of narcotics, as evidenced by incidents involving two residents. In the first case, a Geriatric Nursing Assistant (GNA) verbally abused a resident in the dementia unit by calling them derogatory names. This incident was witnessed by other staff members and a family member of another resident. The GNA admitted to the verbal abuse during an interview with the former Nursing Home Administrator, Director of Nursing, and Human Resources Director, leading to their suspension and termination. In the second case, discrepancies were found in the administration of narcotic medication to a resident. The facility's records showed inconsistencies between the electronic Medication Administration Record (eMAR) and the written sign-out sheet for Oxycodone/APAP, a controlled substance prescribed for the resident's knee pain. The resident reported not receiving the medication as documented, and a review revealed that Nurse #50 had removed more doses than were recorded as administered. This discrepancy suggested misappropriation of narcotics by the nurse, who was later terminated. The facility's investigation into the narcotic misappropriation included witness statements from nursing staff and the resident, confirming the discrepancies in medication administration. The incident was reported to local authorities and the Drug Enforcement Agency (DEA). Despite the Assistant Director of Nursing's claim of conducting staff education following the incident, no documentation was found to support this claim.
Incomplete Investigations of Abuse Allegations
Penalty
Summary
The facility failed to thoroughly investigate allegations of abuse in two reported incidents during the recertification survey. In the first incident, an LPN was accused of physically and verbally abusing a resident. The facility's investigation was incomplete as it lacked a statement from the alleged perpetrator, despite having other staff and resident witness statements. The Director of Nursing confirmed the absence of this crucial statement, acknowledging the investigation's incompleteness. In the second incident, potential resident-to-resident abuse was reported when a GNA observed two residents engaged in sexual relations. The investigation was delayed, with staff and resident witness interviews conducted three to four days after the incident. The Assistant Director of Nursing was unable to explain the delay, indicating a lack of immediate action following the report. The Director of Nursing, Nursing Home Administrator, and Corporate Nurse confirmed that an immediate investigation was not conducted, and no further information was provided by the end of the survey.
Deficiency in Denture Care for a Resident
Penalty
Summary
The facility failed to provide adequate care for activities of daily living, specifically in the case of a resident who had dentures. The deficiency was identified during a recertification survey following a complaint investigation. The complaint alleged neglectful care, including the presence of mouth sores and lack of denture care for the resident. Upon reviewing the resident's clinical records, it was found that there was no documentation of denture care being provided, despite the resident having dentures as indicated in their personal belongings inventory. Interviews with the Director of Nursing (DON) revealed that the Geriatric Nursing Assistant (GNA) care documentation did not include denture care for the resident. The DON confirmed that the Kardex Report, which should have listed the resident's dentures to inform the GNA of the necessary care, did not include this information. The DON was unable to provide any evidence that denture care was administered, confirming the deficiency in care for the resident's dentures.
Failure to Provide Resident-Centered Activities
Penalty
Summary
The facility failed to provide an activities program that met the needs and preferences of two residents, as observed and documented by surveyors. Resident #10 was repeatedly observed lying in bed without any activities, music, or fresh air, despite their MDS assessment indicating a strong preference for music, pet interaction, and outdoor activities. The care plan for Resident #10 was not updated to reflect these preferences, and activity logs showed minimal engagement, with no activities documented for the first half of November 2024. Staff interviews revealed that activities were provided based on assumptions rather than documented preferences. Similarly, Resident #34, who has dementia, was observed in bed without participating in activities or receiving visits from activity staff. The care plan included interventions such as spiritual activities, one-on-one visits, and sensory stimulation, but documentation was lacking for significant periods in September, October, and November 2024. Staff confirmed the absence of documentation for one-on-one visits since late October. The Director of Nursing acknowledged the lack of activity documentation for both residents, indicating a systemic issue in meeting residents' activity needs.
Deficiency in Nursing Staff Competency Evaluation
Penalty
Summary
The facility was found to have a deficiency in employing competent nursing staff, as evidenced during a staffing task investigation and a specific complaint review. The investigation revealed that the facility failed to conduct a competency or skills evaluation for a registered nurse (RN #25) who was involved in the care of a resident associated with complaint #MD00205800. Despite requests for evidence of such evaluations, the Director of Nursing (DON) and the Director of Human Resources (Staff #28) confirmed that no competency evaluations existed for RN #25. This lack of competency assessment was acknowledged by the DON, the Nursing Home Administrator, and the Corporate Clinical President during a review meeting, confirming the deficiency in the facility's hiring and evaluation processes.
Failure to Prevent Significant Medication Error with Lorazepam
Penalty
Summary
The facility failed to ensure that a resident was free from significant medication errors, specifically involving the administration of lorazepam. A resident with a history of Alzheimer's disease and depression, who also had a history of falls related to lorazepam, was administered doses of lorazepam without an active order. The medication was removed from the supply on three separate occasions, despite the order being discontinued. The Medication Administration Record (MAR) did not document the administration of these doses, and there was a lack of documentation explaining the need for the medication on two of the three occasions. The facility's policy for controlled substances requires that discontinued medications be securely locked and accounted for until destroyed, but this was not adhered to. The nursing staff failed to document the administration of the medication and did not notify the physician of the resident's behaviors or the administration of the medication. The Assistant Director of Nursing later noted that the medication was given in error, as the nurse on duty did not realize the order had been discontinued. Despite the error, the resident did not exhibit any adverse effects from the medication.
Delay in Radiological Services for Resident
Penalty
Summary
The facility failed to provide timely radiological services to its residents, as evidenced by a specific incident involving a resident who was found to have a fractured pelvis. The deficiency was identified during a recertification survey, where it was noted that the resident had been recommended for an MRI by an oncologist due to complaints of left hip pain. However, the clinical record did not contain any order for the MRI, and the facility did not provide an alternative diagnostic test in a timely manner. The Director of Nursing (DON) explained that the oncologist's consult note was sent to a different facility and was not received until several weeks later. The expectation was that if a report from an outside provider was not received, the facility staff should contact the provider within a week. The DON confirmed that there was a delay in obtaining the necessary radiology services for the resident, which contributed to the deficiency.
Inaccurate Documentation of Resident Records
Penalty
Summary
The facility failed to accurately document resident records for two residents. For one resident in the dementia unit, there was a discrepancy between the documented orders and the actual practice regarding the use of eyeglasses. The orders required the resident to wear eyeglasses during the day and have them stored in the treatment room at night. However, observations showed the resident awake without eyeglasses on multiple occasions, and interviews revealed that the eyeglasses were not in the facility but were kept by the resident's spouse. Despite this, the electronic Treatment Administration Record (eTAR) was inaccurately signed off by staff as if the orders were followed. For another resident, the facility failed to properly document the monitoring of medication side effects. The Medication Administration Record (MAR) indicated an order for anti-anxiety and antidepressant medications, with a requirement to document any observed side effects using a specific legend. However, the documentation from a specified period only contained check marks, which were not part of the legend, indicating a failure to accurately record the resident's condition. The Director of Nursing confirmed the documentation was incorrect due to an error in the order setup, which did not allow for proper documentation of side effects.
Failure to Maintain AED in Working Order
Penalty
Summary
The facility failed to maintain an automated external defibrillator (AED) in working order, as evidenced by the lack of a process to ensure regular checks and maintenance. During an observation, a nurse demonstrated the use of an AED located in the 200 hallway, which emitted an audible low battery warning. The nurse was unaware of the procedure to follow in response to the low battery warning and indicated she would inform the assistant director of nursing (ADON). Further inspection revealed a red light on the AED, indicating it required attention, and only one AED pad set was available instead of the required two. The ADON confirmed the observations and acknowledged the need for service from the AED company. Although the ADON claimed to check the emergency carts daily and the AEDs weekly, there was no documentation to support that the AED had been routinely checked. The provided Daily CPR Cart Checklist did not include a section for the AED, and no records were available to confirm regular maintenance checks. A new AED Maintenance Checklist was introduced, but no documentation was provided for the period in question prior to the survey's conclusion.
Deficient Call System Functionality
Penalty
Summary
The facility failed to ensure that the resident call system was functioning properly, which was evident during random observations and had the potential to affect all resident rooms. Numerous complaints were received by the facility ombudsman regarding delayed response times to residents' calls for assistance, with alleged response times ranging from 45 to 60 minutes. During a resident council meeting, residents expressed concerns about the call light system not functioning properly, leading to wait times of 30 to 40 minutes for assistance. The Director of Maintenance confirmed that the call system had not been fully functioning since May 2024, and the system was currently under repair. Observations revealed that the call light system at the Unit One nurse's station was not displaying the location of activated call buttons, and the audible alert was continuously going off without indicating the room. Staff reported that they relied on visual cues from lights above the rooms, which were not visible from the nurse's station due to obstructions. Additionally, the Haven unit, which covers the facility's dementia unit, lacked a computer call light system, and the call lights were not visible from the nurses' station. The DON was aware of the system's malfunction but was unaware of the visibility issues in certain rooms.
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.
