Northampton Manor Nursing And Rehabilitation Cente
Inspection history, citations, penalties and survey trends for this long-term care facility in Frederick, Maryland.
- Location
- 200 East 16th Street, Frederick, Maryland 21701
- CMS Provider Number
- 215217
- Inspections on file
- 14
- Latest survey
- January 30, 2026
- Citations (last 12 mo.)
- 1
Citation history
Health deficiencies cited at Northampton Manor Nursing And Rehabilitation Cente during CMS and state inspections, most recent first.
A resident with noted behavioral concerns was seen by social services after staff expressed worry about the resident’s welfare, and the resident was documented as calm, pleasant, and redirectable. However, no suicide ideation assessment was completed, despite a nursing assistant having reported to a nurse that the resident said they wanted to die, a report that was only documented later as a late-entry note and was not available to the social worker at the time of the visit. The resident was later found on the floor with a plastic bag over their head and was transported to the hospital for a behavioral emergency, while facility policy required a brief suicide ideation assessment whenever a resident voiced or indicated suicidal ideation.
A resident with moderate cognitive impairment and a history of erratic behavior was identified as an elopement risk, but the facility failed to implement a wander guard device or initiate a care plan. Despite a physician's note indicating the resident's desire to leave, staff did not take appropriate action, leading to the resident's elopement. The root cause was identified as an LPN's failure to follow through with interventions and communicate the risk to the oncoming nurse.
The facility failed to report and investigate abuse allegations as required by its policies. A resident reported verbal abuse by a GNA, but the DON did not report it due to conflicting staff accounts. Another resident's abuse allegation against a GNA was dismissed by the DON due to the resident's history of complaints. Additionally, a resident's complaint about nurses refusing medication was not initially reported or investigated. The NHA was unaware of these incidents and confirmed the failure to report and investigate.
The facility failed to report and investigate abuse allegations within the mandated timeframe for several residents. Incidents included a GNA making threatening gestures, staff yelling and hitting a resident, and verbal abuse. The DON often did not report or investigate these allegations, citing reasons such as resident denial or lack of corroborating reports. The facility's policies required immediate reporting, which was not adhered to, resulting in deficiencies.
The facility failed to conduct thorough investigations of abuse allegations involving multiple residents and staff. Essential components such as witness statements, physical assessments, and evidence of staff education were missing from investigation files. The DON and Nursing Home Administrator acknowledged the deficiencies, and the original investigation files could not be located.
The facility failed to provide adequate administrative oversight, resulting in non-compliance with state staffing regulations, improper reporting of abuse allegations, and insufficient staff training. The Nursing Home Administrator was unaware of these issues, and the Director of Nursing was inexperienced. Several incidents of resident abuse and harm were identified, indicating significant deficiencies in the facility's operations.
The facility failed to ensure that several GNAs and LPNs completed mandatory abuse and neglect training, with missing records spanning multiple years. Despite requests, the facility could not provide documentation confirming training completion. Additionally, an agency GNA's abuse training was undocumented, with the facility unable to provide further evidence.
The facility failed to conduct annual performance evaluations for all GNAs, as required. During a survey, it was found that three GNAs did not have documented evaluations for 2022, and one GNA also lacked evaluations for 2020, 2021, and 2023. This was confirmed by the DON and HR Director, indicating a deficiency in maintaining sufficient and competent staffing.
The facility did not post actual nursing staffing hours for 31 days in July and 21 days in August during a staffing investigation. A review of documents revealed blank spaces where hours should have been recorded. The DON confirmed the absence of recorded hours, acknowledging the deficiency.
Nursing staff failed to follow infection control procedures during medication administration. An LPN used a BP monitor on multiple residents without sanitizing it, and staff used a glucometer on different residents without cleaning it between uses. The DON was informed of these issues.
The facility failed to offer COVID-19 vaccinations and education to six staff members, including GNAs and LPNs, as identified during an infection control investigation. Interviews with the DON and HR confirmed the absence of documentation proving that these staff members were educated or offered the vaccine, despite educational materials being posted at the staff entrance.
The facility failed to provide federally required communication training to its staff, as evidenced by a review of training records for three GNAs and three LPNs. This deficiency was identified during a recertification survey, leading to an extended survey task due to substandard quality of care. Despite requests for evidence from the HR Director and further inquiries with the DON, no additional evidence was provided.
The facility failed to provide evidence of resident rights training for two GNAs and three LPNs, as revealed during an extended survey. Training records requested showed no documentation of such training for the years 2022, 2023, or 2024. Interviews with the HR Director and nursing leadership confirmed the absence of required training documentation, with no additional evidence provided by the survey's conclusion.
The facility failed to provide federally required QAPI training to its staff, including three GNAs and three LPNs. Training records reviewed during an extended survey investigation showed no evidence of such training. Despite requests for additional documentation from the HR Director and nursing leadership, no further evidence was provided, potentially affecting all residents.
The facility failed to provide behavioral health training to its staff, as evidenced by the absence of training records for three GNAs and three LPNs. This deficiency was confirmed during interviews with the HR Director and nursing leadership, who acknowledged the lack of a behavioral health training program. The deficiency had the potential to affect all residents, leading to a determination of substandard quality of care.
A resident with hypothyroidism repeatedly refused levothyroxine, a thyroid medication, over a period of time. Despite the refusals and an elevated thyroid level indicated by routine blood work, the primary care provider was not notified. The DON confirmed that the facility's protocol requires notifying the provider when medication is frequently refused.
The facility failed to accurately code MDS assessments for several residents, leading to deficiencies in care planning. A resident's MDS did not reflect oxygen therapy, hospice care, and pressure ulcers accurately. Other residents' MDS assessments inaccurately documented anticoagulant administration, and a resident's fall with injury was not coded. These inaccuracies were confirmed by the MDS coordinator and reported to the DON.
The facility failed to conduct and revise care plans for residents after assessments. A resident with COPD and obstructive uropathy had care plans that were not evaluated after assessments. Another resident with hearing difficulties had inconsistent documentation regarding hearing aid use, and their care plan was not revised to address this. A third resident reported not participating in care plan meetings, with only one documented meeting despite multiple assessments.
A facility failed to maintain a medication error rate below 5%, with errors involving incorrect dosages and improper documentation by LPNs. One resident received the wrong dose of Acetaminophen, and another had medication left at the bedside without a physician's order. The errors were acknowledged by the facility's nursing leadership.
The facility failed to protect residents from abuse and neglect, with incidents involving staff pushing a resident, inappropriate touching by another resident, and refusal to administer medications. Investigations were incomplete, lacking interviews with affected individuals and proper documentation.
The facility failed to implement care plans for two residents. A resident with hearing loss did not consistently receive hearing aids as required, and another resident identified as a fall risk did not have a fall mat in place as per the care plan. The DON acknowledged these deficiencies.
A facility failed to adjust air mattress settings for a resident who lost significant weight, leading to a fall and fractures. Additionally, another resident's change in condition was not promptly reported to a primary care provider, delaying treatment for a groin abscess. These deficiencies highlight a lack of monitoring processes and communication failures within the facility.
The facility failed to maintain a safe and clean environment on the [NAME] Creek 2 unit, with issues such as torn wallpaper, crumbled drywall, and a persistent stain on the floor. The maintenance director was unaware of these issues until pointed out by the surveyor. Additionally, a bathroom had unaddressed smudges on the railing, which housekeeping staff were unaware of until shown by the surveyor.
The facility failed to provide activities based on residents' preferences and care plans. One resident's care plan included music and animal interactions, but no activities were documented. Another resident's preferences for Spanish music, magazines, and religious services were not consistently met. The Activities Director acknowledged the oversight, and the DON was informed of the issue.
A resident in an LTC facility was not provided with proper treatment and assistive devices to maintain hearing abilities. Despite a physician's order for daily use of hearing aids, the aids were not consistently placed in the resident's ears, and the right hearing aid was reported missing without a documented search. Staff interviews revealed a lack of awareness and documentation regarding the missing hearing aid, and the DON acknowledged the oversight.
The facility failed to ensure therapy recommendations were communicated and implemented by nursing staff for two residents. One resident with a history of stroke did not have a care plan for splint use, and the splint was not used as recommended. Another resident with dementia was discharged with a Home Exercise Program (HEP), but there was no documentation or communication of the HEP to nursing staff. This led to deficiencies in maintaining or improving the residents' range of motion and mobility.
A resident experienced a significant weight loss of 50 pounds in one month, which was not promptly verified or communicated to the physician. Despite requests for a reweight, it was not conducted due to the resident's transfer to the Covid Unit. The facility's delay in addressing the weight loss was acknowledged by the DON, and the issue was under review by the Quality Assurance program.
The facility failed to ensure timely physician visits for two residents, with one resident only seen twice by a physician over a year and another not seen by a physician for over a year, contrary to the facility's policy of visits every 120 days.
A facility failed to limit a PRN psychotropic medication order to 14 days for a resident on hospice care with COPD and heart failure. The resident's MAR showed a PRN order for Lorazepam without a 14-day limit, and no rationale for extending the order was documented. The DON confirmed the issue, noting previous problems with hospice orders.
The facility failed to manage medications properly, with expired medications found in carts, improper labeling, and a resident's inhaler left at bedside. Observations revealed expired Lantaprost and Bevespi inhalers, unlabeled lancets, and an expired Clobetasol cream. A resident reported an inhaler left overnight, confirmed by the DON, leading to an agency nurse's Do Not Return status.
The facility failed to ensure proper cool down procedures for potentially hazardous food items during two kitchen inspections. Cooked food items were found without labels or documentation of the cool down process. The dietary manager acknowledged the absence of records and identified the responsible cooks. The items were discarded to prevent use, and the issue was discussed with nursing leadership.
A facility failed to maintain accurate medical records for a resident, with incorrect medication indications for conditions such as extrapyramidal symptoms and urinary retention. Additionally, another resident's dialysis care was inaccurately documented, noting a fistula assessment despite the resident having a permacath. The DON and unit manager confirmed these errors during a survey.
The facility failed to maintain the kitchen's walk-in freezer in a safe operating condition, as observed during a tour with the dietary manager. Icicles extended 3 feet from overhead fans, and ice accumulated on the floor below. The dietary manager confirmed the issue and planned to notify maintenance. The Director of Nursing and other staff acknowledged the ice buildup was not a recent occurrence, indicating a lack of proper maintenance.
The facility failed to assess staff training needs for residents receiving dialysis care. A resident was observed heading to a dialysis center, yet the Facility Assessment inaccurately stated that the facility does not care for such residents. The staff education needs section omitted dialysis care, and interviews confirmed the absence of a training plan. No evidence of staff training on dialysis care was provided by the survey's end.
The facility failed to provide mandatory infection control training to its staff, specifically for an LPN. During a survey, it was found that the LPN did not have any evidence of infection control training. Training records were reviewed, and interviews with HR and nursing leadership confirmed the absence of such training records.
Failure to Complete Suicide Ideation Assessment After Behavioral Change
Penalty
Summary
The deficiency involves the facility’s failure to assess a resident for behavioral health needs, specifically suicidal ideation, following a change in behavior. Intake documentation showed that the resident was transported to the hospital for a behavioral emergency. A social services progress note, entered late and dated two days before the hospital transfer, documented that social services visited the resident due to staff concerns about the resident’s welfare and behavior. During that visit, the resident was described as calm, pleasant, and redirectable, and there was no documentation that a suicide ideation assessment interview was completed. Subsequent review of clinical documentation revealed that a late-entry nursing note, written several days after the events, indicated that a nursing assistant had reported the resident stated they wanted to die. This late-entry note, referring to an earlier date, was not available in the record at the time the social worker evaluated the resident, and the social worker reported being unaware that the resident had voiced a desire to die. Later documentation showed that the resident was found lying on the floor with a plastic bag over their head and was assessed and transported to the hospital, with police, physician, and family notified. Review of the facility’s suicide precaution management policy showed that a brief suicide ideation assessment was required for any current resident who voiced or indicated suicidal ideation in any manner, but such an assessment was not completed for this resident.
Failure to Implement Elopement Interventions for Resident
Penalty
Summary
The facility failed to ensure that a resident with an elopement risk had the appropriate interventions in place to prevent an elopement. This was evident for Resident #109, who was admitted to the facility with a history of lewd and erratic behavior, a UTI, and worsening dementia. The resident's admission MDS documented a BIMS score of 11/15, indicating moderate cognitive impairment, and the resident was independent for indoor ambulation with a walker. An elopement assessment conducted on 2/29/24 by an LPN identified the resident as an elopement risk and recommended a wander guard device. However, the assessment was not closed until 4/24/24, and the wander guard was not ordered until 5/1/24. Additionally, no care plan was initiated for the elopement risk, and there was no evidence that the wander guard device was placed on the resident at the time of the assessment. Further review of the medical record revealed that during a physician's visit on 3/6/24, the resident was noted to be alert and oriented only to themselves and expressed a desire to be discharged, indicating an elopement risk. Despite this, facility staff failed to implement the wander guard device following the physician's visit. On 4/24/24, Resident #109 eloped from the facility. The receptionist noted that the resident mentioned going to meet their daughter and advised them to wait inside due to windy conditions. However, the resident was not seen after the receptionist turned around to check in another resident. A code for elopement was called, and the resident was found walking towards a nearby housing development and was brought back to the facility. The facility's investigation revealed that the root cause of the elopement was the LPN's failure to follow through with the implementation of interventions following the elopement assessment. The LPN reported being unable to find a wander guard and forgot to pass the information to the oncoming nurse. The facility's corrective actions included reassessing the resident for elopement, developing a care plan, and placing a wander guard on the resident. The facility also reviewed current residents' elopement assessments for accuracy and updated the wander guard list and elopement notebook.
Failure to Report and Investigate Abuse Allegations
Penalty
Summary
The facility failed to implement its abuse policies and procedures by not reporting all allegations of abuse to the state agency and the facility's abuse coordinator, and by not conducting thorough investigations of all allegations. This deficiency was identified during a review of the facility's policies and procedures, which were last revised in 2017. The policies required immediate reporting of abuse allegations and a prompt investigation by the facility's leadership. However, the surveyor found three instances where these procedures were not followed. In the first instance, a resident reported verbal abuse by a Geriatric Nursing Assistant (GNA) to the Director of Nursing (DON), who did not report the incident to the state agency because two staff members claimed the allegation was untrue. In the second instance, another resident reported an abuse allegation against a male GNA, which was not reported or investigated by the DON, who dismissed the claim due to the resident's history of making complaints. The third instance involved a resident's complaint about nurses refusing to administer medications, which was not initially reported or investigated thoroughly by the DON and Assistant DON. Interviews with the Nursing Home Administrator (NHA) revealed that he was unaware of these incidents and confirmed that the refusal to administer medications was a reportable offense. The NHA acknowledged the concern that the DON had not reported and thoroughly investigated all allegations. The failure to report and investigate these allegations was discussed with the DON, ADON, and Corporate Clinical Nurse, who all acknowledged the concern.
Failure to Timely Report and Investigate Abuse Allegations
Penalty
Summary
The facility failed to have an effective system in place to ensure that all allegations of abuse were reported to the state agency within the mandated timeframe and to report the results of investigations no later than five working days after the incident. This deficiency was evident in six residents reviewed for abuse. For instance, Resident #25 reported an incident involving a GNA, but the facility reported the allegation to the state agency past the required two-hour timeframe and failed to report the investigation results within five working days. In another case, Resident #67 was involved in an allegation of abuse where staff reportedly yelled at and hit the resident. The DON did not conduct an investigation or report the incident because the resident denied the occurrence. Similarly, Resident #92 was involved in an incident of abuse by another resident, but the facility delayed reporting the incident to the Office of Health Care Quality by several days, which was non-compliant with reporting regulations. Additional incidents involved Resident #19, who reported verbal abuse by a GNA, and Resident #9, who reported abuse and deprivation of services by staff. In both cases, the DON did not report or investigate the allegations as required. Resident #6's allegation of abuse was also reported late, approximately 34 hours after the facility was made aware. The facility's policies and procedures required immediate reporting of alleged violations, but these were not followed, leading to the deficiencies noted.
Incomplete Investigations of Abuse Allegations
Penalty
Summary
The facility staff failed to conduct thorough investigations of abuse allegations for several residents and facility-reported incidents (FRIs). In one case, an allegation was made that staff mistreated a resident by ripping a remote control from their hand. The investigation file lacked essential components such as staff witness statements, a physical assessment of the resident, and evidence of staff education following the incident. The Director of Nursing (DON) confirmed the investigation was incomplete, and the Nursing Home Administrator acknowledged the deficiency. Another incident involved a male Geriatric Nursing Assistant allegedly grabbing a resident's leg, leaving a mark. The investigation file was missing staff statements, a list of staff on duty, and a statement from the resident about the incident. Additionally, there was no evidence of a 5-day final report to the Office of Health Care Quality (OHCQ) or staff education on abuse prevention. The DON admitted the investigation was incomplete, and the Nursing Home Administrator validated the deficiency. Further deficiencies were noted in the investigation of an allegation of abuse between two residents, where the investigation file lacked clinical information, witness statements, and evidence of a police report. Another resident reported verbal abuse by a GNA, but the allegation was not thoroughly investigated, and no facility report was made. Additionally, a resident's allegations of abuse and medication refusal were not properly investigated, with no evidence of investigation found. The facility also failed to maintain evidence of a completed investigation for an incident involving a staff member witnessing abuse. The DON and Assistant DON acknowledged the concerns, but the original investigation file could not be located.
Inadequate Administrative Oversight Leads to Multiple Deficiencies
Penalty
Summary
The facility failed to ensure adequate administrative oversight in several critical areas, including nursing staffing, reporting of abuse allegations, staff training, and clinical services. The survey identified non-compliance with state staffing regulations, affecting all residents. Six residents who alleged abuse were not properly reported, and six staff members lacked required in-service training. Additionally, the facility failed to address two complaints and five facility-reported incidents, which included cases of resident abuse, neglect, immediate jeopardy, and actual harm. During an interview, the Nursing Home Administrator (NHA), who had been in his position for 10 months, admitted to being unaware of the non-compliance issues. He mentioned that the Director of Nursing (DON) was inexperienced and that he had requested competitive wages and referral bonuses to address staffing issues. The NHA also stated that he was unaware of the facility's failure to comply with abuse reporting regulations and staff training requirements. The lack of clinical services oversight was evident in several incidents of resident abuse and harm, highlighting significant deficiencies in the facility's operations.
Failure to Ensure Staff Completion of Abuse and Neglect Training
Penalty
Summary
The facility failed to ensure that staff members completed mandatory abuse and neglect training, as evidenced by the lack of training records for several Geriatric Nursing Assistants (GNAs) and Licensed Practical Nurses (LPNs). Specifically, GNA #11, GNA #13, GNA #14, LPN #9, LPN #10, and LPN #12 were found to have missing records of annual abuse and neglect training for various years, ranging from 2020 to 2024. Despite requests for additional evidence, the facility's Human Resources Director and nursing leadership were unable to provide documentation confirming that these staff members had completed the required training. Additionally, the facility failed to document abuse training for GNA #34, an agency staff member. The Human Resources department indicated that no paper records were available, and the online records provided were incomplete. The Director of Nursing confirmed that the facility had no further documentation to support the completion of abuse training for this staff member. This lack of documentation highlights a systemic issue in ensuring that all staff, including agency personnel, receive and complete necessary training to prevent abuse and neglect.
Failure to Conduct Annual Performance Evaluations for GNAs
Penalty
Summary
The facility failed to ensure that all Geriatric Nursing Assistants (GNAs) received annual performance evaluations, as required. This deficiency was identified during the recertification survey's Sufficient and Competent staffing task portion. Specifically, the files for three GNAs, identified as GNA #11, GNA #13, and GNA #14, were reviewed, and it was found that none of them had documented performance evaluations for the year 2022. Additionally, GNA #13's file lacked performance evaluations for the years 2020, 2021, and 2023. This oversight was confirmed during an interview with the Director of Nursing (DON) and the Director of Human Resources, who acknowledged the absence of these evaluations, thus confirming the deficiency.
Failure to Post Actual Nursing Staffing Hours
Penalty
Summary
The facility failed to post the actual hours of nursing staffing for 31 days in July 2024 and 21 days in August 2024 during a Sufficient Staffing task investigation conducted as part of the recertification survey. On August 22, 2024, at 3:54 PM, staff posting documents for July and August 2024 were requested. A record review conducted on August 23, 2024, at 8:33 AM revealed that the staff posting documents for July 1-31, 2024, and August 1-22, 2024, contained blank spaces where the actual hours for each nursing discipline should have been recorded. During an interview on August 23, 2024, at 11:55 AM, the Director of Nursing (DON) confirmed that none of the staff posting documents listed the actual hours worked, acknowledging this as a deficiency.
Infection Control Lapses During Medication Administration
Penalty
Summary
The facility's nursing staff failed to adhere to basic infection control procedures and standard precautions during medication administration. Specifically, a Licensed Practical Nurse (LPN) was observed using a blood pressure (BP) monitor and cuff on multiple residents without sanitizing the equipment before or after use. The LPN used the BP monitor on Resident #92 and then on Resident #41 without cleaning the cuff, potentially exposing residents to cross-contamination. Additionally, the facility's staff did not follow standard precautions during blood glucose testing. Staff members were observed using a glucometer on multiple residents without cleaning it before or after each use. This was evident when Staff #19 and Staff #23 tested the blood glucose levels of different residents using the same glucometer without sanitizing it between uses. The reuse of fingerstick devices without proper cleaning could potentially expose residents to bloodborne infections. The Director of Nursing (DON) was informed of these concerns but did not provide further comments.
Failure to Offer COVID-19 Vaccination and Education to Staff
Penalty
Summary
The facility failed to ensure that Geriatric Nursing Assistants (GNAs) and Licensed Practical Nurses (LPNs) were offered COVID-19 vaccinations and educated about them. This deficiency was identified during a recertification survey's infection control investigation. Specifically, six staff members, including three GNAs and three LPNs, were reviewed for immunizations, and none had evidence of receiving a COVID-19 vaccine or education regarding it. Interviews with the Director of Human Resources, the Director of Nursing (DON), and the Assistant Director of Nursing (ADON) confirmed the lack of evidence for offering vaccines or providing education to the staff in question. Although the DON mentioned that educational materials were posted at the staff entrance, no documentation was available to prove that the specific staff members had been educated or offered the vaccine. The deficiency was further confirmed in a follow-up interview with the DON, ADON, and the Corporate Nurse, where no additional evidence was provided.
Lack of Communication Training for Staff
Penalty
Summary
The facility failed to provide federally required communication training to its staff, as evidenced during an extended survey investigation. Training records for three Geriatric Nursing Assistants (GNAs) and three Licensed Practical Nurses (LPNs) were reviewed, revealing a lack of documentation for communication training. This deficiency was identified during a recertification survey, which led to an extended survey task due to substandard quality of care. Despite requests for evidence of training from the Human Resources Director and further inquiries with the Director of Nursing, Assistant Director of Nursing, and Corporate Nurse, no additional evidence was provided by the end of the survey.
Lack of Resident Rights Training for Staff
Penalty
Summary
The facility failed to ensure that staff were trained about resident rights, as evidenced by the lack of training records for two Geriatric Nursing Assistants (GNAs) and three Licensed Practical Nurses (LPNs) reviewed during an extended survey investigation. On August 20, 2024, training records were requested for specific GNAs and LPNs as part of the Sufficient and Competent Staffing portion of the standard survey. By August 27, 2024, it was determined that substandard quality of care existed, triggering an extended survey task. A review of employee training records revealed no evidence of resident rights training for the specified GNAs and LPNs in 2022, 2023, or 2024. Interviews with the Human Resources Director and nursing leadership confirmed the absence of required training documentation, and no additional evidence was provided by the end of the survey.
Lack of QAPI Training for Staff
Penalty
Summary
The facility failed to provide Quality Assurance Performance Improvement (QAPI) training to its staff, as evidenced during an extended survey investigation. Training records were requested and reviewed for three Geriatric Nursing Assistants (GNAs) and three Licensed Practical Nurses (LPNs), revealing a lack of evidence for the federally required QAPI training. Despite multiple requests for additional evidence from the Human Resources Director and the nursing leadership team, no further documentation was provided by the end of the survey. This deficiency had the potential to affect all residents in the facility.
Lack of Behavioral Health Training for Staff
Penalty
Summary
The facility failed to provide behavioral health training to its staff, as evidenced by the lack of training records for three Geriatric Nursing Assistants (GNAs) and three Licensed Practical Nurses (LPNs) reviewed during an extended survey investigation. On August 20, 2024, training records for the specified GNAs and LPNs were requested and reviewed, revealing no evidence of behavioral health training. This deficiency was confirmed during interviews with the Human Resources Director and the Director of Nursing, Assistant Director of Nursing, and Corporate Nurse, who acknowledged the absence of a behavioral health training program at the facility. The lack of training had the potential to affect all residents, leading to a determination of substandard quality of care and triggering an extended survey task.
Failure to Notify Provider of Medication Refusal
Penalty
Summary
The facility failed to notify the primary care provider of a change in condition for a resident who was refusing medication. Resident #28, diagnosed with hypothyroidism, had an order for levothyroxine since July 10, 2024. Between July 12 and August 3, 2024, the resident refused the medication on 15 occasions. Despite this, the primary care provider was not informed of the repeated refusals. Additionally, routine blood work on August 6, 2024, indicated an elevated thyroid level, yet there was no documentation of provider notification. The Director of Nursing confirmed that the expectation is to contact the primary care provider when a resident frequently refuses medication.
Inaccurate MDS Coding Leads to Deficiencies in Resident Care
Penalty
Summary
The facility staff failed to ensure that Minimum Data Set (MDS) assessments were accurately coded for several residents, leading to deficiencies in resident care planning. For Resident #95, the MDS assessment did not accurately reflect the resident's receipt of oxygen therapy, hospice care, and the presence of pressure ulcers. Despite documentation in the electronic medical record (EMR) indicating the resident was receiving oxygen therapy and hospice care, these were not coded in the MDS. Additionally, the MDS inaccurately documented the resident's pressure ulcers, failing to note a Stage 4 pressure ulcer and incorrectly indicating an unstageable pressure ulcer. For Resident #1, #33, and #6, the MDS assessments inaccurately documented the administration of anticoagulants during the look-back period, despite the medication administration records (MAR) showing no evidence of such prescriptions or administration. This discrepancy highlights a failure in accurately capturing the residents' medication regimens, which is crucial for ensuring appropriate care and treatment. Resident #112 experienced a fall resulting in a fracture and subsequent hospitalization, yet the MDS assessments with Assessment Reference Dates (ARD) of 6/5/24 and 6/20/24 failed to code the fall and the associated major injury. The MDS coordinator acknowledged the inaccuracies in coding, which were not reflective of the resident's status. These deficiencies in MDS coding were confirmed by the MDS coordinator and brought to the attention of the Director of Nursing (DON), who did not provide further comments at the time.
Failure to Conduct and Revise Care Plans
Penalty
Summary
The facility failed to conduct care plan meetings and review and revise resident care plans after each assessment, as required. This deficiency was observed in the cases of three residents. Resident #95, who was readmitted to the facility with multiple diagnoses including COPD and obstructive uropathy, had care plans that were not evaluated for effectiveness and revised following quarterly assessments. Despite having orders for oxygen therapy and a Foley catheter, the care plans for these treatments were last evaluated on 6/29/24, with no further documentation indicating evaluation or revision after subsequent assessments on 7/7/24 and 8/12/24. Resident #25, who had hearing difficulties and a physician order for the use of hearing aids, was found to have inconsistent documentation regarding the placement of hearing aids. The resident's care plan, which included approaches for hearing aid use, was not evaluated or revised to address the resident's lack of hearing aid use in the right ear. The care plan evaluation on 8/28/24 did not reflect any changes or interventions based on the resident's needs, indicating a failure to assess and adjust the care plan appropriately. Resident #6, admitted in late 2023, reported not participating in care plan meetings, nor did the resident believe their family was invited. The only documented care conference note was from 1/31/24, with no evidence of subsequent care plan meetings despite completed quarterly MDS assessments. Staff #28, responsible for documenting care conferences, confirmed the absence of additional care plan meetings, acknowledging a lapse in documentation and adherence to mandated timeframes for care plan meetings.
Medication Administration Errors Exceeding 5% in LTC Facility
Penalty
Summary
The facility failed to maintain a medication error rate of less than 5%, as evidenced by 4 errors identified out of 25 opportunities, resulting in a 16% medication administration error rate. One incident involved a Licensed Practical Nurse (LPN) who dispensed 9 medications into a cup for a resident, including Acetaminophen 500 mg, instead of the prescribed 650 mg. Additionally, the LPN documented that a multi-vitamin and folic acid were administered, although they were not observed being given during the medication administration. The Corporate Clinical Director of Nursing and the Corporate Regulatory Nurse were informed of these errors and acknowledged the concerns. Another incident involved an LPN who dispensed Sevelamer (Renvela) tablets for a resident and left them at the resident's bedside without a physician's order, instructing the resident to take them with lunch. The resident's medication administration record indicated that the medication should be administered at 11:30 AM, and there was no order allowing the medication to be left at the bedside. The Director of Nurses was informed of this observation and acknowledged the concern, noting that there was a specific physician order allowing medication to be left at the bedside only on certain days and times for dialysis preparation.
Failure to Protect Residents from Abuse and Neglect
Penalty
Summary
The facility failed to protect residents from abuse, as evidenced by multiple incidents involving different residents. In one case, a staff member witnessed another staff member, GNA #53, pushing Resident #424 during a transfer, causing the resident to fall partially onto the bed. The resident reported that GNA #53 had hurt their right arm and mocked them. The facility's investigation was incomplete, lacking interviews with other residents or staff who might have been affected or had knowledge of the incident. In another incident, Resident #170 was reported to have inappropriately touched Resident #104. The facility's investigation did not include interviews with other residents who might have been abused by Resident #170. Law enforcement was involved, and Resident #170 was removed from the facility and charged with assault and a sex offense. The facility monitored Resident #104 for any ill effects from the abuse and offered victim support, which was declined. Additionally, Resident #9 reported that two nurses refused to administer their medications on separate occasions. The facility's documentation was incomplete, with missing records of medication administration and refusal of care. The Director of Nursing and Assistant Director of Nursing confirmed the resident's complaint but failed to provide evidence of a thorough investigation. The facility later initiated a report regarding the deprivation of services to Resident #9.
Failure to Implement Care Plans for Hearing Aids and Fall Prevention
Penalty
Summary
The facility failed to implement interventions based on the comprehensive care plan for two residents. Resident #25, who has hearing loss, was not provided with hearing aids consistently as per the care plan. The care plan required that hearing aids be placed in the resident's ears during morning care and removed at bedtime. However, the Medication Administration Record (MAR) for July and August 2024 showed multiple instances where the hearing aids were not placed in the resident's ears or were only placed in one ear. This failure to follow the care plan was acknowledged by the Director of Nursing (DON) during discussions with the surveyor. Resident #108, identified as a fall risk, had a care plan that included the use of a fall mat on the right side of the bed to prevent falls. Despite this, observations on multiple occasions revealed that the fall mat was not in place. Additionally, there was no evidence of a physician's order for the fall mat, which the DON confirmed was never ordered. The DON acknowledged that the fall mat was not implemented as per the care plan, despite having documented that all interventions were evaluated to be appropriate.
Failure to Monitor Air Mattress Settings and Timely Evaluate Change in Condition
Penalty
Summary
The facility failed to monitor and adjust the air pressure settings on a low air loss mattress for a resident who experienced significant weight loss. The resident, initially weighing 214.8 lbs, had lost 35.7 lbs over an 11-month period, reducing their weight to 178.8 lbs. Despite the weight loss, the air mattress settings were not adjusted accordingly, leading to over-inflation. This over-inflation caused the resident to slide out of bed, resulting in a hip fracture and fractures of the proximal tibia and fibula. The facility's investigation revealed that the air mattress was set incorrectly at a level 5 when it should have been at a level 3 for the resident's current weight. Additionally, the facility failed to ensure timely evaluation of a resident's change in condition by a primary care provider. A resident developed swelling in the groin area, which was noted by nursing staff, but the primary care provider was not notified until several days later. Although the Nurse Practitioner was present in the facility, there was no documentation of the swelling being reported or evaluated until a SOAP note was completed by the DON six days after the initial observation. This delay in communication and evaluation resulted in a delay in treatment for the resident's condition. The deficiencies highlight a lack of processes in place to monitor and adjust medical equipment settings based on residents' changing conditions and a failure to ensure timely communication with primary care providers regarding significant changes in residents' health status. These oversights led to harm and delayed treatment for the residents involved.
Facility Fails to Maintain Safe and Clean Environment
Penalty
Summary
The facility failed to maintain a safe, clean, and homelike environment on the [NAME] Creek 2 unit, as observed during a survey. Multiple observations revealed issues such as torn wallpaper, crumbled drywall, and a persistent tea-like stain on the floor. Additionally, the nurses' station had a damaged section, and a rolling chair was stripped of its material. Despite these conditions being noted over several days, the maintenance director was unaware of these issues and no active maintenance work orders were in place. The maintenance director acknowledged the concerns only after they were pointed out by the surveyor. Further observations in a specific room's bathroom revealed a brown smudge and a pink dried substance on the bathroom railing, which remained unaddressed over multiple days. Housekeeping staff were unaware of these issues until they were shown by the surveyor. The housekeeping manager and district manager later claimed to have addressed the concern, but the deficiency persisted during the survey period. The Director of Nursing was also informed about the failure to maintain the facility's conditions.
Failure to Provide Resident-Specific Activities
Penalty
Summary
The facility failed to provide activities to residents based on their preferences and care plans, as evidenced by the cases of two residents. Resident #113's care plan included preferences for listening to music and being around animals, but there was no documentation of activities being provided in June, July, or August. The Activity Director was unable to provide any records of activities conducted for this resident, indicating a lack of adherence to the care plan. Similarly, Resident #28's care plan highlighted the importance of Spanish music, magazines, religious services, and outdoor activities. However, the activity logs for June, July, and August did not reflect these preferences, and the Activities Director admitted that these activities had not been consistently provided. The Director of Nursing was informed of the failure to ensure activities aligned with the residents' comprehensive assessments and care plans.
Failure to Ensure Proper Use and Maintenance of Hearing Aids
Penalty
Summary
The facility failed to ensure that a resident received proper treatment and assistive devices to maintain hearing abilities. The resident, who was hard of hearing, reported not attending activity programs due to hearing difficulties and mentioned not wearing hearing aids for a long time. A review of the resident's medical records revealed a physician's order for the resident to wear hearing aids daily, but the hearing aids were not placed in the resident's ears on multiple occasions in July and August 2024. Additionally, the resident's right hearing aid was reported missing, and there was no documentation indicating a thorough search was conducted to locate it. Staff interviews revealed inconsistencies in the handling of the resident's hearing aids. A registered nurse acknowledged the resident's hearing difficulties and noted the absence of a right hearing aid. A licensed practical nurse was unaware of the missing hearing aid and the lack of documentation regarding the search for it. The Director of Nursing was informed of these issues and acknowledged the concerns, indicating that a process should have been in place to search for the missing hearing aid and notify the resident's family.
Failure to Implement Therapy Recommendations for Residents
Penalty
Summary
The facility failed to ensure that therapy recommendations were communicated and implemented by nursing staff for Resident #37, who had a history of stroke and right-sided weakness. Occupational Therapy (OT) recommended the use of a hand roll and finger separators to improve Passive Range of Motion (PROM) and reduce pain. However, observations revealed that the splint was not being used as recommended, and interviews with staff indicated a lack of documentation and communication regarding the use of the splint. The nursing staff did not have an order for the splint, and there was no care plan for contracture prevention or splinting. For Resident #28, who was dependent on staff for Activities of Daily Living (ADLs) and had a diagnosis of dementia, the facility failed to document and implement a Home Exercise Program (HEP) recommended upon discharge from therapy. The Director of Rehabilitation indicated that HEPs are provided to maintain residents' optimal level of ability, but there was no documentation of the specific exercises or communication to the nursing staff. Interviews revealed that the nursing staff was responsible for implementing these recommendations, but there was no evidence of communication or documentation regarding the HEP for Resident #28. The lack of communication and documentation regarding therapy recommendations for both residents led to deficiencies in their care. The facility did not have a process in place to ensure that therapy recommendations were effectively communicated to and implemented by nursing staff, resulting in a failure to provide appropriate care to maintain or improve the residents' range of motion and mobility.
Failure to Address Significant Weight Loss in Resident
Penalty
Summary
The facility failed to adequately address a resident's significant weight loss, which was documented as a 50-pound loss over one month. The resident's weight was recorded on two occasions, showing a substantial decrease, but there was no evidence that the weight was verified or that the physician was notified in a timely manner. The dietician noted the weight loss and requested a reweight, but it was not obtained due to the resident's transfer to the facility's Covid Unit. Despite multiple requests for a reweight, it was not conducted, and the physician was not informed until much later. The resident's weight continued to decrease, with a further loss recorded, yet the facility did not take immediate action to verify the weight or address the issue with the physician. The Director of Nurses acknowledged the delay in addressing the weight loss and indicated that the issue was being reviewed through the facility's Quality Assurance program. The Corporate Registered Nurse later confirmed that the physician was eventually made aware of the weight loss and the resident's use of diuretics.
Failure to Provide Timely Physician Visits
Penalty
Summary
The facility failed to provide timely physician services to residents, as evidenced by the lack of physician visits for two residents. Resident #37, a long-term resident, was only seen by a physician twice between August 2023 and August 2024, which did not meet the facility's expectation of a physician visit at least every 120 days. The Assistant Director of Nursing confirmed that the resident was seen on two occasions, specifically on September 3, 2023, and June 12, 2024, failing to adhere to the required frequency of visits. Similarly, Resident #92 did not receive timely physician visits, with documentation showing only monthly visits by a Nurse Practitioner and no recent physician visits in the past year. The Director of Nursing and Assistant Director of Nursing confirmed the absence of physician notes for the past year, and the Medical Director acknowledged not having seen the resident in that time frame. The Nursing Home Administrator was unaware of this deficiency until informed during the survey.
Failure to Limit PRN Psychotropic Medication Duration
Penalty
Summary
The facility staff failed to ensure that a psychotropic medication prescribed as needed (PRN) for a resident had an end date limited to 14 days. This deficiency was identified during a review of a resident's medical record, who was readmitted to the facility following an acute hospitalization and later admitted to hospice with a terminal diagnosis of Chronic Obstructive Pulmonary Disease (COPD) and heart failure. The resident's Medication Administration Record (MAR) for August 2024 showed a PRN order for Lorazepam (Ativan) concentrate, prescribed for generalized anxiety disorder, which was not limited to a 14-day duration. There was no documented rationale for continuing the order beyond 14 days in the resident's medical record. The Director of Nurses (DON) confirmed the findings and acknowledged previous issues with hospice orders, which were typically identified by the pharmacist.
Medication Management Deficiencies in LTC Facility
Penalty
Summary
The facility failed to properly store and manage medications, as evidenced by several observations during the survey. On one occasion, a medication cart was found to contain expired medications, including an opened bottle of Lantaprost Ophthalmic Solution and a Bevespi inhaler, both of which were not discarded after their expiration dates. Additionally, blue lancets for blood glucose testing were not stored in their original packaging, making it impossible to determine their expiration date. Another observation revealed a wound treatment cart containing a tube of Clobetasol propionate topical cream that was not labeled with a resident's name and was expired. Furthermore, a medication cart on Unit 2B contained an Advair Diskus inhaler that was not labeled with the date it was opened, and another inhaler that was not discarded after its expiration date. The report also highlights a complaint from a resident who reported that an inhaler was left at their bedside overnight. This incident was confirmed by the DON, who provided incident reports indicating that an agency nurse left an inhaler at the resident's bedside on a separate occasion. The nurse was subsequently placed on Do Not Return status with the facility. These findings indicate a pattern of deficiencies in medication management, including failure to discard expired medications, improper labeling, and failure to return medications to their proper location after administration.
Failure to Document Cool Down Procedures for Hazardous Foods
Penalty
Summary
The facility failed to ensure that potentially hazardous food items were cooled according to acceptable standards, as observed during two separate kitchen inspections. During the first inspection, two cooked food items in the walk-in refrigerator were found without labels. The dietary manager, identified as Staff #3, acknowledged that these items were chicken fried steak and sausage patties from previous meals. Upon inquiry, Staff #3 admitted that the cool down process documentation was missing and could not be found in the designated binder or in her office. She indicated that it was the responsibility of the cook, identified as Staff #4, to perform and document the cool down procedures. In a subsequent kitchen observation, the cool down log was reviewed, revealing that the latest entries were for pork items dated the previous day. However, two other cooked food items labeled as sausage and mechanical sausage were found without documentation of the cool down process. Staff #3 confirmed the absence of documentation and identified Staff #55 as the responsible cook. The items were subsequently discarded to prevent their use. The issue was later discussed with the Director of Nursing, Assistant Director of Nursing, and the Corporate Clinical Nurse, who acknowledged the failure to ensure proper cool down procedures for potentially hazardous food items.
Inaccurate Medical Records and Documentation in LTC Facility
Penalty
Summary
The facility failed to maintain complete and accurate medical records for Resident #15, as evidenced by incorrect indications for medication use. Resident #15, who was admitted for long-term care and had multiple diagnoses including extrapyramidal and movement disorders, was prescribed Benztropine for a psychotic disorder, which was inaccurate as the medication is used to treat extrapyramidal symptoms. Similarly, Bethanechol was prescribed for extrapyramidal and movement disorders instead of urinary retention, and Bumetanide was prescribed for hypotension instead of edema. Additionally, Trazodone was inaccurately documented for insomnia, despite being prescribed for depression. The facility also failed to accurately document dialysis care for Resident #51. The resident, who had a permacath for dialysis due to end-stage renal disease, was incorrectly documented by LPN #9 as having a good thrill and bruit, which are assessments for a fistula that the resident no longer had. The Potomac 2 Unit Manager and the DON confirmed the documentation error, acknowledging that the resident's dialysis access was a permacath, not a fistula. These deficiencies were identified during a review of medical records and staff interviews. The Director of Nursing and the Assistant Director of Nursing acknowledged the concerns regarding the inaccurate medication indications for Resident #15, while the Potomac 2 Unit Manager and the DON confirmed the incorrect documentation related to Resident #51's dialysis care. No further comments or explanations were provided by the facility staff at the time of the survey.
Failure to Maintain Safe Operating Condition of Kitchen Equipment
Penalty
Summary
The facility failed to maintain essential equipment in a safe operating condition, specifically in the kitchen's walk-in freezer. During a tour conducted with the dietary manager, icicle formation was observed from the overhead fans, extending about 3 feet long. Additionally, ice had accumulated on the floor below the icicle, measuring approximately 6 inches high and 5 inches in diameter. The dietary manager confirmed these observations and noted the need to inform maintenance for resolution. The issue was later discussed with the Director of Nursing, Assistant Director of Nursing, and the Corporate Clinical Nurse, who acknowledged that the ice buildup did not occur overnight, indicating a failure to maintain the freezer properly.
Failure to Assess Staff Training Needs for Dialysis Care
Penalty
Summary
The facility failed to accurately assess staff training needs in relation to the resident population, specifically for those receiving dialysis care. During the recertification survey, it was found that the Facility Assessment did not include a plan for staff education regarding the care of residents who receive dialysis, despite the facility caring for residents who undergo hemodialysis at an off-site center. This deficiency was highlighted when a resident was observed on their way to a dialysis center, and the Facility Assessment review showed no mention of dialysis care in the staff education needs section. Interviews with the Nursing Home Administrator, Director of Nursing, and Corporate Regulatory Nurse confirmed the absence of a training plan for dialysis care, and no evidence of such training was provided by the end of the survey. The deficiency was evident when a resident, who was on their way to a dialysis center, was observed and interviewed. The Facility Assessment inaccurately stated that the facility does not care for residents receiving dialysis, and the staff education needs section did not list dialysis. The Corporate Regulatory Nurse confirmed the lack of a plan for staff education on dialysis care, and the Director of Nursing failed to provide evidence of any staff training related to dialysis care by the survey's conclusion.
Infection Control Training Deficiency
Penalty
Summary
The facility failed to provide mandatory infection control training to its staff, specifically for one Licensed Practical Nurse (LPN). During an extended survey investigation of the recertification survey, it was found that LPN #9 did not have any evidence of infection control training. Training records for several staff members, including LPN #9, were requested and reviewed. Upon review, it was determined that there was no documentation of infection control training for LPN #9. Interviews with the Human Resources Director and nursing leadership confirmed the absence of such training records for LPN #9.
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.
