Northwest Healthcare Center
Inspection history, citations, penalties and survey trends for this long-term care facility in Baltimore, Maryland.
- Location
- 4601 Pall Mall Road, Baltimore, Maryland 21215
- CMS Provider Number
- 215346
- Inspections on file
- 17
- Latest survey
- January 23, 2026
- Citations (last 12 mo.)
- 16
Citation history
Health deficiencies cited at Northwest Healthcare Center during CMS and state inspections, most recent first.
The facility failed to adhere to professional standards for food safety and storage, affecting 83 residents. Observations revealed staff not wearing hair or beard nets, undated and improperly stored food items, and cleanliness issues in the kitchen, including mildew and dirt buildup. The Healthcare Services Group District Manager confirmed the need for cleaning and adherence to food safety policies.
A resident and an Activities Director were attacked by another resident, but the facility failed to notify the resident's representative. The AD intervened during the assault and informed the former Administrator, who did not consider the incident serious. There was no documentation in the resident's medical record, and it is unclear if the responsible party was informed.
The facility failed to provide written discharge notices to two residents and their representatives. One resident was sent to the hospital after an assault, and another was transferred to a dementia unit without a 30-day notice. Staff confirmed that notifications were typically given verbally.
A facility failed to develop a comprehensive care plan for a resident with a history of substance use disorder. The care plan lacked necessary interventions for over two weeks after the resident's admission, despite documented history. The Executive Director admitted the oversight during an interview.
The facility failed to update care plans for three residents after significant events or assessments. A resident received Narcan for an opioid overdose, but no substance use prevention interventions were added to the care plan. Another resident's care plan was not reviewed within the required timeframe after an MDS assessment. Additionally, a resident's behavior care plan was not revised following an assault on another resident.
A facility failed to implement an effective discharge planning process for a resident, lacking documentation of ongoing planning, resident goals, and intervention evaluations. The Social Services Director initiated contact with a Medicaid waiver program, but follow-up documentation was missing, and no formal discharge care plan was developed.
The facility failed to document provider discharge summaries for two residents after their discharge. Both residents were transferred to a local hospital for psychiatric evaluation and did not return to the facility. The Executive Director admitted that the discharge summaries were not entered into the residents' medical records.
The facility failed to maintain complete medical records by not filing X-Ray reports in a resident's record and not documenting an assault incident involving a resident and the Activity Director. Additionally, the facility lacked a system to secure investigative records, as evidenced by the inability to locate an investigation report for a reported incident.
The facility failed to ensure that two residents had advance directives or were provided with written information about their rights to accept or refuse medical treatment and to formulate an advance directive. The Social Services Director confirmed the absence of documentation and information provision, violating the facility's policy.
The facility failed to protect residents from abuse, involving incidents where a resident was punched during an argument, two residents engaged in a physical altercation, and an employee verbally and physically abused a resident by positioning their wheelchair to face a wall. The residents involved had varying degrees of cognitive impairment and psychiatric diagnoses.
The facility failed to report incidents of injury of unknown origin and resident-to-resident abuse to the state agency in a timely manner. One resident with severe cognitive impairment had rib fractures, and another resident required Naloxone for suspected opioid overdose, but reports were delayed. Additionally, a resident-to-resident abuse incident was not documented or reported, and another resident's injury was reported four days late.
The facility failed to thoroughly investigate multiple allegations of abuse involving residents. Incidents included unexplained injuries, resident altercations, and staff abuse allegations, with insufficient documentation and lack of interviews with involved parties. The facility did not adhere to its policy requiring immediate reporting and investigation of such incidents.
A resident was transferred to the hospital after an assault without documented preparation and orientation for the transfer. The absence of documentation was confirmed by an LPN during an interview.
Food Safety and Storage Deficiencies
Penalty
Summary
The facility failed to ensure proper food storage, preparation, distribution, and service in accordance with professional standards, potentially leading to food-borne illness among 83 residents. During observations, the Infection Preventionist was seen in the kitchen without a hair net, and a staff member with a beard was not wearing a beard net. Several food items, including applesauce, thickened apple juice, cream of wheat, and strawberry shakes, were found opened and undated, contrary to the facility's policy requiring dates for opened items. Additionally, the kitchen had cleanliness issues, such as black mildew behind the dishwasher, expired chlorine test strips, dirt buildup on the ice machine, and debris on the kitchen floor. Further observations revealed an opened and undated bag of cereal on the food preparation table and a dirty air conditioning unit blowing air onto kitchen utensils. The Healthcare Services Group District Manager confirmed the need for cleaning and acknowledged the responsibility of dietary staff for maintaining cleanliness. The facility's policy emphasized the importance of discarding unsafe foods and maintaining proper storage conditions, which were not adhered to, as evidenced by the observations of undated and improperly stored food items.
Failure to Notify Resident Representative of Assault
Penalty
Summary
The facility staff failed to notify a resident representative of a resident-to-resident assault involving Resident #20. The incident occurred on 11/3/21 when Resident #20 and a staff member, identified as the Activities Director (AD), were attacked by another resident. The AD recalled the incident, stating that the aggressor was hitting and kicking Resident #20, and when the AD intervened, they were also kicked. Despite informing the former Administrator, the incident was not deemed serious, and there was no documentation in Resident #20's medical record regarding the incident. The AD was unsure if the facility staff followed up with Resident #20's responsible party. This issue was later discussed with the Administrator and Mobile Director of Nursing (MDON).
Failure to Provide Written Discharge Notices
Penalty
Summary
The facility staff failed to provide written discharge or transfer notices to residents and their representatives, as required. In the case of one resident, after being assaulted by another resident, the individual was sent to the hospital for evaluation. Although the resident's guardian was notified of the incident by the Unit Manager, there was no evidence that a written discharge notice was provided to either the resident or their representative. Interviews with the Unit Manager and the Social Services Director confirmed that the facility typically notifies residents and their representatives verbally rather than in writing. In another instance, a resident was transferred to another facility with a dementia unit. The Social Work Director informed the resident's responsible party about the planned transfer, but there was no documentation of a 30-day involuntary notice of transfer being issued to the resident or their representative. The Social Work Director confirmed in an interview that neither the resident nor their responsible party received the required 30-day notice. These deficiencies were discussed with the facility's Administrator and Mobile Director of Nursing.
Failure to Develop Comprehensive Care Plan for Resident with Substance Use Disorder
Penalty
Summary
The facility failed to provide a comprehensive care plan for a resident with a history of substance use disorder. During an annual survey, it was found that the care plan for this resident did not include necessary interventions to prevent or assist with difficulties related to their substance use disorder. This deficiency was identified through a review of records, which showed that the resident had been admitted with a documented history of substance use disorder, yet the care plan lacked appropriate interventions for over two weeks after admission. The Executive Director of the facility acknowledged during an interview that the care plan was not fully developed to include interventions for the resident's substance use disorder. This oversight was noted for one of the fifty residents reviewed during the survey.
Failure to Update Resident Care Plans
Penalty
Summary
The facility failed to review and revise resident care plans after each assessment or as resident care needs changed over time, affecting three residents. For Resident #911, the facility administered Narcan to reverse an opioid overdose on 5/2/23, but did not update the care plan to include interventions for substance use prevention. The Executive Director acknowledged this oversight during an interview. Resident #51's care plan was not reviewed and revised within 7 days after the Quarterly MDS assessment on 3/8/24, as required. The next care plan meeting was delayed until 6/4/24, just before the subsequent Quarterly MDS assessment. Additionally, Resident #14's care plan, which addressed behavioral issues, was not updated following a resident-to-resident assault on 6/15/23. The Administrator confirmed that the care plan was not evaluated or revised to address the aggressive behavior.
Deficiency in Discharge Planning Process
Penalty
Summary
The facility failed to develop and implement an effective discharge planning process for a resident, which was evident during a survey. The resident was admitted in September 2022, and the Social Services Director (SSD) initiated contact with the Medicaid waiver program in January 2023 to enroll the resident. However, there was no follow-up documentation regarding the callback from the waiver program. In March 2023, a waiver interview was conducted, and the application was sent to the waiver coordinator. By November 2023, the resident was on the waiver program waitlist, but there was no documentation of the updated status in the resident's record. The comprehensive care plan for the resident lacked a discharge planning component, and there was no documentation of an ongoing discharge planning process. This included the absence of the resident's goals, actions taken by staff to facilitate goal achievement, evaluation of intervention effectiveness, and updates on progress. During an interview, the SSD acknowledged that discharge planning was discussed at admission and quarterly care plan meetings but confirmed that a formal discharge care plan was not developed. Instead, progress notes were used to document ongoing discharge care planning needs.
Failure to Document Provider Discharge Summaries
Penalty
Summary
The facility failed to place a provider discharge summary on the medical records of two residents after their discharge. For one resident, the medical record review revealed no evidence of a provider discharge summary following their discharge from the facility after being transferred to a local hospital for psychiatric evaluation. The Executive Director confirmed that the resident did not return to the facility after receiving psychiatric treatment at the hospital and admitted that the facility failed to enter the discharge summary on the resident's medical record. Similarly, for another resident, the medical record review showed no evidence of a provider discharge summary after their discharge from the facility. This resident was also transferred to a local hospital for psychiatric evaluation and did not return to the facility after treatment. The Executive Director acknowledged the omission of the discharge summary in the resident's medical record.
Deficiencies in Medical Record Maintenance and Incident Documentation
Penalty
Summary
The facility staff failed to maintain complete and accurate medical records for a resident by not ensuring that X-Ray reports were filed in the medical record. Physician orders for repeat lumbar X-Rays were dated, but the reports were not found in the resident's record until the surveyor intervened. The Unit Manager LPN later provided copies of the reports, indicating that they should have been uploaded into the Electronic Medical Record (EMR) but were not. This oversight was only corrected after the surveyor requested the reports, highlighting a lapse in the facility's record-keeping procedures. Additionally, the facility failed to document an assault incident involving a resident and the Activity Director, who were both assaulted by another resident. There was no documentation in the assaulted resident's medical record regarding the event, including any assessment or interventions implemented by the facility staff. Furthermore, the facility lacked a system to ensure investigative records were secured, as evidenced by the inability to locate an investigation report for a facility-reported incident. The Administrator admitted that the investigation could not be found, which was a concern during the survey.
Failure to Provide Advance Directive Information
Penalty
Summary
The facility failed to ensure that residents had an advance directive in place or were provided with written information about their rights to accept or refuse medical or surgical treatment and to formulate an advance directive. This deficiency was identified for two residents during a review of their electronic medical records (EMR). The facility's policy on advance directives, dated 03/27/24, mandates that upon admission, the facility should determine if a resident has an advance directive and provide information on how to formulate one if not. However, for Resident 61 and Resident 55, there was no documentation in their EMRs indicating that they had an advance directive or that they were given the necessary information to formulate one. During an interview, the Social Services Director confirmed that the residents did not have advance directives and that there was no documentation available to show that they were provided with written information regarding their rights. Additionally, there was no evidence of a signed Admission Package, which would have included information about advance directives. This lack of documentation and failure to provide necessary information to the residents or their representatives constitutes a violation of the facility's policy and the residents' rights.
Failure to Protect Residents from Abuse
Penalty
Summary
The facility failed to protect residents from verbal, mental, and physical abuse, affecting four of the 61 residents reviewed. In one incident, a resident with severe cognitive impairment attempted to intervene in an argument between two other residents and was punched in the nose by one of them. This resident was visibly upset and required hospital evaluation for a nosebleed. The resident who committed the act had a moderate cognitive impairment and a history of paranoid schizophrenia. In another incident, two residents with psychiatric diagnoses, including schizophrenia and PTSD, were involved in a physical altercation in the hallway. One resident, displaying agitation, shoved the other, who retaliated by shoving back. Both residents were separated, and no injuries were noted. The resident who initiated the altercation was severely impaired and had a history of generalized anxiety. Additionally, an employee was reported for verbally and physically abusing a resident by positioning the resident's wheelchair to face a wall as a form of punishment. This incident was witnessed by two LPNs, who reported that the GNA involved yelled at the resident and refused to explain their actions. The resident involved had a history of altered mental status and a very low cognitive score, indicating severe impairment.
Failure to Timely Report Incidents and Injuries
Penalty
Summary
The facility failed to report incidents of injury of unknown origin and resident-to-resident abuse to the state agency in a timely manner. For one resident, an injury of unknown origin was identified, but the initial incident report was not submitted to the state survey agency within the required two-hour timeframe. Additionally, the five-day report following the investigation was not submitted. This resident had severe cognitive impairment and was found to have rib fractures, which were identified through an x-ray after complaints of pain. Another resident, who was cognitively intact, experienced an altered mental status and required Naloxone for suspected opioid overdose. The initial investigation report was submitted late, and the facility could not provide documentation of the completed investigation being submitted to the state. Furthermore, a complaint involving a resident-to-resident abuse incident was not documented or reported to the state agency as required. The incident involved a resident and a staff member being attacked by another resident, but no documentation was found in the medical records. The facility also failed to report an injury of unknown origin for another resident within the required timeframe. The resident had discoloration to the left lower eye, but the report was submitted four days after the injury was identified. These deficiencies indicate a failure in the facility's reporting processes, as outlined in their policy, which requires timely reporting of incidents to federal, state, and local authorities.
Failure to Investigate Abuse Allegations
Penalty
Summary
The facility staff failed to thoroughly investigate allegations of abuse for several residents. In one instance, a resident was found with a large cut above the right eye, but the investigation did not attempt to rule out abuse or determine how the injury occurred. Another complaint involved a resident and a staff member being attacked by another resident, but there was no documentation of an investigation into the incident. Additionally, a resident was found with a black eye, but the investigation did not include interviews with staff or other residents to determine the cause of the injury. In another case, a resident reported being hit by another resident with a walking cane, but the investigation lacked interviews with the involved residents or witnesses. The final report stated the incident was substantiated, but there was no evidence of a thorough investigation. Furthermore, a staff member was alleged to have been verbally and physically abusive to a resident, but the facility could not provide documentation of an investigation into the allegation. The facility also failed to properly investigate an altercation between two residents, where one resident was shoved by another. The investigation did not include interviews with other residents or documentation of a PTSD evaluation for the resident displaying agitation. The facility's policy on abuse, neglect, and misappropriation requires immediate reporting and investigation of such incidents, but the facility did not adhere to these guidelines.
Failure to Prepare Resident for Safe Transfer
Penalty
Summary
The facility staff failed to ensure that a resident was adequately prepared and oriented for a safe and orderly transfer from the facility. This deficiency was identified during a survey review of 50 residents, specifically concerning one resident who was sent to the hospital for evaluation after being assaulted by another resident. The medical record review revealed a Social Services note indicating the transfer, but there was no documentation showing that the resident was prepared and oriented for the transfer. An interview with the Unit Manager, an LPN, confirmed the absence of such documentation, as she was unable to explain or find any record of preparation and orientation for the resident prior to the hospital transfer.
Latest citations in Maryland
The facility did not ensure that its Infection Preventionist (IP) met required qualifications for managing the Infection Prevention and Control Program. The DON reported serving as the IP but acknowledged lacking the specialized infection control training required for the role, and confirmed that no other staff member was currently qualified. Records showed that the previously qualified IP left several months earlier, and the Administrator and DON confirmed they were still seeking a replacement, leaving the infection control program without a properly trained leader.
Staff failed to consistently secure medications and medical supplies across three units, including an oxygen tank left on the floor behind a resident’s bed without a supporting device, a treatment cart with Collagenase Santyl cream left on top while two residents in power wheelchairs passed by, an unattended and unlocked treatment cart at a nursing station, and another treatment cart with Diclofenac gel and dressings left on top, indicating repeated lapses in maintaining locked and secure storage for drugs, biologicals, and related supplies.
The facility failed to provide sufficient dietitian coverage and timely nutritional assessments for several residents with significant dietary needs. A resident admitted for diabetic management with a high A1C was placed on a regular diet instead of the recommended carb-controlled diet and had only one weight taken in the first two weeks, with no dietitian review of the record. Another resident with prior significant weight loss had no documented dietitian follow-up despite continued weight loss, and a resident admitted with severe protein-calorie malnutrition experienced further significant weight loss without any dietitian assessment. The dietitian reported working limited hours and prioritizing certain high-risk cases, resulting in delayed or missed evaluations for new admissions and residents with ongoing nutritional concerns.
The facility failed to maintain adequate linen and incontinence supplies and did not keep resident care areas in good repair, resulting in delays and alterations in incontinence care and substandard environmental conditions. Staff reported that towels and washcloths were used instead of wipes and then discarded due to heavy soiling, and that linen deliveries to units were late, leaving residents waiting for care. Observations showed very limited numbers of clean washcloths and other linens on units and in the laundry, with no stock of disposable wipes or backup washcloth supply despite repeated reports to housekeeping. Additional observations revealed recliner chairs blocking a dining-area handwashing sink and kitchenette, multiple resident and shared bathrooms with unfinished spackle, chipped paint, musty odors, black substances near showers, missing threshold molding, exposed cracks and nails, and eroded, rusted baseboard heaters. Hallway handrails on both units were worn, chipped, and splintered, and a shower room contained fecal odors, dried brown stains on the toilet, and deteriorated fixtures, all contributing to a failure to provide a safe, clean, and homelike environment.
Facility staff did not thoroughly investigate two separate abuse allegations involving a resident and an injury of unknown origin involving another resident. In both cases, investigations focused on the directly affected resident and included staff interviews, but there were no interviews of other residents on the unit or documented assessments of those residents for signs of abuse or injuries of unknown origin, including residents unable to communicate due to cognitive status.
Two residents who were dependent on staff for oral care, including one with a tracheostomy, were observed with thick, white or milky substances coating their mouths and teeth, indicating inadequate oral hygiene. One resident communicated that staff did not brush their teeth and that staff "need to." In another case, despite oral care supplies being present in the room, the resident’s mouth and teeth remained unclean on multiple observations, with a thick milky substance caking the teeth and stringing between them when the resident tried to open their mouth. These findings showed that staff did not consistently provide oral care to residents who relied on them for this ADL.
Staff failed to maintain complete and accurate medical records for multiple residents, including missing and inconsistent documentation of wound care, delayed pain assessment after discovery of an injury of unknown origin in a cognitively impaired resident, and inaccurate recording of a PPD test result that was documented as negative despite no evidence the injection was administered and no supporting nurse’s note. Residents reported not receiving certain treatments, while MAR entries either lacked signatures for completion or contained conflicting information about whether care was provided.
Surveyors found that the facility failed to consistently implement and communicate correct transmission-based precautions and PPE use. One resident with a Foley catheter related to wounds had no precaution signage posted, while another resident in a double room had a contact precautions sign at the door, yet the NP entered without PPE and the GNA provided high-contact care wearing only gloves. Staff in that room stated the resident was not on contact precautions and later reversed the sign to show no PPE requirement. Therapy staff reported they rely solely on posted signs to determine PPE, and surveyors identified broader issues with inaccurate signage and staff awareness of which residents required contact precautions.
Surveyors found that MDS assessments were inaccurately coded for two residents. In one case, a resident sustained a femoral neck fracture after a fall, but the subsequent significant change MDS did not code the fall as a major injury and failed to capture prn Tylenol use documented on the MAR within the look-back period. In the other case, a quarterly MDS indicated opioid use for a resident, but the MAR for the same period showed no prescribed opioid, indicating incorrect coding of high-risk drug classes.
A resident who had recently been admitted and experienced a fall received multiple doses of the narcotic analgesic Tramadol, but the facility failed to accurately document all administered doses on the Medication Administration Record (MAR). Review showed only one Tramadol dose recorded on the MAR, while the Controlled Drug Receipt/Record/Disposition Form on the med cart reflected three doses given over two days. In interview, the DON stated staff are expected to document narcotic administration on the MAR and confirmed that two administered doses were not recorded there, resulting in an incomplete and inaccurate medical record.
Unqualified Infection Preventionist Overseeing Infection Control Program
Penalty
Summary
The facility failed to ensure that its designated Infection Preventionist (IP) met the mandatory qualifications for overseeing the Infection Prevention and Control Program. During an interview on 3/24/26 at 10:00 AM, the DON confirmed that she/he was serving as the facility’s IP but had not completed the specialized training in infection control required for the position. The DON further stated that no other staff member currently met the qualifications to serve as IP. Record review showed that the previously qualified IP left the facility in October 2025, and as of the survey date, the position remained unfilled by a qualified individual. At 1:30 PM on the same day, the Administrator and DON confirmed they were still in the process of finding a qualified IP for the facility, leaving the Infection Prevention and Control Program without a properly trained and qualified leader. No specific residents, medical histories, or clinical conditions were described in relation to this deficiency.
Unsecured Medications, Treatment Carts, and Oxygen Equipment
Penalty
Summary
Facility staff failed to ensure that drugs, biologicals, and related medical supplies were securely stored and properly maintained on multiple units. On one unit, an oxygen tank assigned to a resident was observed sitting on the floor behind the resident’s bed without any supporting device. On another unit, a treatment cart was observed with a tube of Collagenase Santyl cream labeled for a specific resident left on top of the cart, while residents in power wheelchairs passed by and staff were present at the nursing station. These observations showed that medications and oxygen equipment were not consistently secured as required. Further observations on additional units revealed an unattended and unlocked treatment cart at a nursing station, and on a separate occasion, a treatment cart with Diclofenac gel labeled for a resident left on top along with multiple packs of dressings. These incidents occurred across three units and on more than one date, demonstrating repeated failures to keep medications and treatment supplies in locked compartments or otherwise secured from unauthorized access.
Insufficient Dietitian Coverage and Delayed Nutritional Assessments
Penalty
Summary
The deficiency involves the facility’s failure to employ sufficient food and nutrition staff, including adequate dietitian coverage, to ensure timely assessment and appropriate diets for residents with significant nutritional and diabetic needs. A resident admitted over two weeks earlier with multiple comorbidities and an A1C of 11.5% had a hospital discharge recommendation for a carbohydrate-controlled diet, but was placed on a regular diet at admission with no acknowledgment of the recommended diet until one week later, when the resident requested larger portions. As of the survey date, the dietitian had not yet seen or reviewed this resident’s medical record, and the resident reported not having seen a dietitian and being very frustrated with the meals. During the first two weeks after admission, only one weight was obtained for this resident, despite physician notes stating the resident’s weight was “stable.” Further review of other residents showed additional failures in timely dietitian assessment and follow-up. One resident, readmitted in January and previously seen by the dietitian in September for a 6.4 lb weight loss over 30 days, had no documented follow-up despite continued weight loss totaling 22 lbs since the last dietitian review. Another resident admitted at the end of February with severe protein-calorie malnutrition had not been seen by the dietitian after about a month in the facility, despite a documented 14 lb (7%) weight loss over two weeks. The dietitian reported working only 12 hours per week at the facility and stated that she must prioritize which residents to see, focusing first on residents with tube feedings and those identified in risk meetings, resulting in delayed or absent assessments for new admissions and residents with ongoing weight loss and malnutrition diagnoses.
Linen Shortages and Poor Environmental Maintenance Compromise Resident Care and Comfort
Penalty
Summary
The deficiency involves the facility’s failure to maintain an adequate supply of clean linens and appropriate incontinence wipes, resulting in delays and alterations in residents’ incontinence care, as well as the use of towels and washcloths in place of disposable wipes. During the initial tour, the surveyor observed that the linen supply on one nursing unit hallway was low. Complaint reviews included concerns about delays in incontinence care and bed linens not being changed regularly, with residents left without clean bedding. A complainant reported that there was not enough clean linen available for residents. Staff interviews confirmed that towels, sheets, and washcloths were being used to wipe residents for incontinence care due to the absence of wipes, and that many of these linens were being thrown away when soiled. Staff also reported a shortage of linen, that linen deliveries to the units were late, and that residents who preferred to get up before breakfast had to wait for care when linen was delayed. Further observations showed that the clean supply room contained no disposable wipes or cloths for incontinence care, and a resident reported that staff did not use wipes, that the resident had to purchase their own, and that heavily soiled towels or washcloths were discarded. A tour of all nursing unit linen carts and closets revealed only six clean washcloths and limited supplies of towels, gowns, and bed linens. In the laundry room, only three washcloths were present, and the laundry assistant stated that there were only three washcloths available for each nursing unit that morning, that the facility was short on linen supply, and that these concerns had been repeatedly reported to the Director of Housekeeping over the preceding month and again that morning. The laundry assistant confirmed there was no additional laundry in process. The DON stated that wipe squares should be used for incontinence care, but no such wipes were found in the clean medical supply room, and no backup supply of washcloths was present in the emergency linen supply. The Director of Housekeeping confirmed there was no backup supply of washcloths. The deficiency also includes environmental and maintenance issues affecting resident bathrooms, handrails, and common areas. In the main dining area, a recliner chair was observed positioned directly in front of the handwashing sink, and two recliner chairs were stored in front of the nutrition area kitchenette. Multiple resident bathrooms and shared bathrooms were repeatedly observed over several days with unfinished spackle on walls that needed resurfacing and painting, chipped paint around sinks, uneven boards nailed to walls under sinks that appeared to partially cover holes, musty odors, black substances between shower bases and walls, missing threshold transition molding exposing cracks, missing tiles, and a nail, as well as eroded and chipped paint on baseboard heaters with exposed dark brown metal and rust-like material. Hallway handrails on both nursing units were observed to be worn, with chips, splintering, holes, and areas where the wood finish had worn off. A shower room was observed with a foul fecal odor, dried brown stains on the back of the toilet seat and in the toilet bowl, and a baseboard heater with eroded, chipped paint and rust-like material, along with chipped paint on the handrail. These conditions were acknowledged by the Director of Maintenance and other leadership, and some areas were noted to be in the process of renovation, but the observed deficiencies remained present during the survey period. Overall, the facility did not maintain a safe, clean, comfortable, and homelike environment in good repair across both nursing units and the dining area. The lack of adequate linen and incontinence supplies, combined with the poor condition of resident bathrooms, handrails, and certain common areas, constituted the basis for the cited deficiency. The observations and staff and resident reports consistently described shortages of essential hygiene supplies, delayed care related to linen availability, and multiple unresolved environmental and maintenance issues in resident care areas and shared spaces.
Failure to Thoroughly Investigate Abuse Allegations and Injuries of Unknown Origin
Penalty
Summary
Facility staff failed to thoroughly investigate allegations of potential abuse involving one resident and an injury of unknown origin involving another resident. For one resident, there were two separate allegations of abuse occurring on different days in early February. The facility’s investigation packets included interviews with staff who cared for or were scheduled to work with this resident on the days of the alleged incidents, and the investigations focused solely on this resident. However, there were no interviews conducted with other residents on the unit to inquire about abusive or neglectful treatment by the staff who were working during the times of the allegations. The surveyors noted that, although the allegations were not validated, there was no documentation that other residents were interviewed, if able, or assessed for signs or symptoms of injury. In a separate incident, another resident was identified on March 4 with a new bruise on the right eye, documented as a change in condition at 4:09 AM. This resident had a BIMS score of 99, indicating the resident was unable to complete an interview and therefore could not report how the injury occurred. The facility’s investigation identified a potential cause of the injury but did not reach a definitive resolution. Additionally, there were no interviews of other residents on the unit regarding possible abuse, nor were there documented assessments of other residents for injuries of unknown origin, particularly for those unable to speak for themselves, as in this resident’s case.
Failure to Provide Oral Care to Dependent Residents
Penalty
Summary
The deficiency involves the facility’s failure to provide oral care to residents who were dependent on staff for activities of daily living, specifically oral hygiene. One resident with a tracheostomy was observed with a thick, sticky white substance in the mouth and was noted to intermittently chew on nearby bedding. This resident made good eye contact and, when asked if staff brushed their teeth, shook their head no and mouthed that staff “need to.” According to the resident’s Minimum Data Set (MDS) dated 2/11/26, the resident was dependent on staff for oral care. Another resident, also dependent on staff for oral care per the 3/11/26 MDS, was observed sitting propped up in bed and able to respond with smiles. During the initial observation, the inside of this resident’s lips and upper and lower teeth had a thick, clear, white milky substance visible when the resident tried to open their mouth to smile. Oral care supplies were present in the nightstand, but the resident’s mouth and teeth were not clean. On a subsequent observation with the DON, NHA, and Corporate VP of clinical services, the same resident again had a thick, clear, milky substance between the lips and caking the teeth, which would string between the teeth when the resident attempted to open their mouth, demonstrating a lack of consistent oral care for residents dependent on staff for this ADL.
Incomplete and Inaccurate Medical Record Documentation for Treatments and Assessments
Penalty
Summary
Facility staff failed to maintain complete and accurate medical records and documentation for multiple residents. For one resident with wound care needs, review of the MAR showed that wound care and related treatments were signed as completed on the dates initially reported, despite the resident’s ongoing complaints that wound dressings were not being changed. When additional dates were reviewed, there were missing staff signatures for wound care on two specific dates, as well as three instances where application of A&D ointment to the resident’s feet was not signed off out of 24 days reviewed. Another resident with severe cognitive impairment, as evidenced by a BIMS score of 00, was found to have an injury of unknown origin (a bruise on the left hand). Documentation showed that a change in condition was initiated late in the morning, but a formal pain evaluation was not initiated and completed until that night, and the resident was unable to explain how the injury occurred or verbalize pain using a standard pain scale. For a third resident, documentation related to the admission PPD test was inconsistent and incomplete. The MAR contained an entry indicating “9” for the administration date, meaning “see nurse’s note,” but there was no corresponding nurse’s note. Despite the absence of a signed administration of the PPD injection, staff documented the PPD result as “negative” on the scheduled read date. The resident reported never receiving the PPD injection, and the DON confirmed that the facility had been out of PPD solution at the time, so the test would not have been administered. These findings demonstrate failures in accurate documentation of treatments and assessments, including wound care, pain assessment, and TB screening, as well as missing or incomplete supporting notes in the medical record.
Failure to Implement and Communicate Correct Transmission-Based Precautions
Penalty
Summary
Surveyors identified a deficiency in the facility’s infection prevention and control program related to inconsistent and incorrect implementation of transmission-based precautions and PPE use. During a complaint investigation focused on residents on transmission-based precautions, one resident with a visible Foley catheter was observed in the room with physical therapy, but there were no signs posted indicating any need for PPE, despite the resident being a new admission with a Foley catheter placed related to wounds. In another double-occupancy room, a contact precautions sign was posted at the doorway, but the nurse practitioner was in the room on a personal phone with no PPE, and the assigned GNA was repositioning the resident in bed while wearing only gloves. When questioned, the NP, RN, and GNA all stated that the resident in the room was not on contact precautions, and the GNA reported that signs were hanging at all doors and that this particular resident’s sign was “just wrong.” The surveyor observed the GNA later return to the room and turn the sign around to indicate no PPE requirement. Subsequent interviews revealed that therapy staff relied on posted signage to determine PPE use and that if the sign was wrong, the PPE used would be wrong. Overall, surveyors found problems with signage accuracy and staff awareness of which residents required contact precautions, as well as observed failures to follow appropriate PPE use for residents who should have been on contact precautions.
Inaccurate MDS Coding for Falls, Pain Management, and High-Risk Medications
Penalty
Summary
Facility staff failed to ensure Minimum Data Set (MDS) assessments were accurately coded for two residents reviewed during a complaint survey. For one resident, a facility-reported incident showed that the resident was found seated on the floor beside the bed and was diagnosed with a non-displaced femoral neck impaction fracture of the left hip following an x-ray. Despite this fall with a major injury, the subsequent significant change MDS dated 11/4/25 did not code the fall with major injury in Section J1900C. Review of the resident’s Medication Administration Records for October and November 2025 showed administration of Tylenol on 10/31/25 at 9:30 PM, which fell within the 5-day look-back period for the MDS, but Section J0100 (prn pain) of the same significant change MDS did not capture the use of Tylenol. For another resident, review of a quarterly MDS with an assessment reference date of 10/15/25 showed that Section N0415 (High-Risk Drug Classes) documented the use of an opioid medication. However, review of the resident’s October 2025 Medication Administration Record did not show that the resident had been prescribed an opioid during that period. In both cases, MDS staff later confirmed that these were errors in MDS coding, demonstrating that the assessments did not accurately reflect the residents’ clinical status and medication use as documented in their medical records.
Incomplete Documentation of Narcotic Administration on MAR
Penalty
Summary
The facility failed to maintain complete and accurate medical records in accordance with accepted professional standards for one resident receiving narcotic medication. The resident, admitted in March 2026, had a fall on 3/6/26 and was sent to the hospital on 3/9/26. Review of the March 2026 Medication Administration Record (MAR) showed documentation of a single 25 mg dose of Tramadol administered on 3/8/26 at 9:23 AM. However, review of the resident’s Controlled Drug Receipt/Record/Disposition Form, kept on the nurse’s medication cart and not in the medical record, showed that Tramadol 25 mg was administered three times between 3/8/26 and 3/9/26: at 11:00 AM and 9:00 PM on 3/8/26, and at 9:00 AM on 3/9/26. In interview, the DON stated that staff are expected to document narcotic administration on the MAR and confirmed that only one of the three Tramadol doses reflected on the controlled drug record was documented on the resident’s MAR. This discrepancy between the controlled substance record and the MAR, with missing documentation of two administered doses of Tramadol on the official medical record, constituted the failure to maintain a complete and accurate medical record for the resident.
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