Oak Crest Village
Inspection history, citations, penalties and survey trends for this long-term care facility in Parkville, Maryland.
- Location
- 8800 Walther Boulevard, Parkville, Maryland 21234
- CMS Provider Number
- 215308
- Inspections on file
- 22
- Latest survey
- October 10, 2025
- Citations (last 12 mo.)
- 7
Citation history
Health deficiencies cited at Oak Crest Village during CMS and state inspections, most recent first.
Facility staff did not fully inform the POA of a resident receiving hospice care before performing an X-ray, despite a prior refusal of the procedure. Documentation was inconsistent regarding the POA's wishes, and staff confirmed there was no evidence of consultation with the POA before the X-ray was conducted.
Staff failed to maintain the confidentiality of resident medical records when a cart with an open laptop displaying patient information and a paper listing details for 11 residents, including MOLST status and medications, was left unattended and visible in a hallway. An LPN left the cart to attend to a resident, and both the ADON and LPN later acknowledged that the information should have been covered.
Facility staff did not update the care plan for a resident who developed arm bruises from contact with wheelchair brake extenders while self-propelling. Although the incident and related interventions were documented in progress notes, the care plan was not revised to reflect the resident's risk and necessary interventions.
A resident with Parkinson's disease and other conditions requiring adaptive eating equipment was not provided with built-up utensils or a plate guard during a meal, despite these being specified in the care plan and facility documentation. The necessary devices were found stored in the resident's room and not in use, and staff were unaware of the oversight until it was pointed out by a surveyor.
A resident with complex medical needs did not receive prescribed nutritional supplements, including ice cream and mashed potatoes with gravy, as outlined in their care plan and Dining Detail. Direct observation and staff interviews confirmed these items were missing from the resident's meal, despite clear documentation of the requirement.
A resident receiving hospice care experienced worsening symptoms of a swollen and painful knee. While a hospice nurse suspected a possible disarticulation and discussed care decisions with the resident's power of attorney, this information was not communicated to facility nursing staff. Facility staff primarily relied on verbal updates and did not formally document or review hospice notes, resulting in a lack of coordinated care and documentation.
A Care Associate returned to work after suspension for an abuse allegation involving a resident with dementia, but there was no documentation that required abuse training was completed prior to their return. The Nursing Home Administrator confirmed that such training is required but was not done in this case.
The facility failed to protect residents from abuse and neglect, resulting in multiple incidents. One resident with severe dementia and aggressive behavior was not consistently supervised, leading to a physical altercation with another resident. Another incident involved a resident being left on a bedpan for an extended period, resulting in discomfort. Additional incidents included a staff member refusing to care for a COVID-positive resident and another providing rough incontinence care. These incidents highlight inadequate care and supervision.
A resident with severe cognitive impairment and a history of aggression was inadequately supervised, leading to an altercation with another resident. Despite a care plan requiring supervision, the facility failed to ensure the consistent presence of a Private Duty Aide, contributing to the incident. The lack of documentation and communication regarding the resident's care and supervision further exacerbated the deficiency.
The facility failed to monitor and address significant weight loss in multiple residents, including one who lost over 50 pounds. Despite being aware of the weight loss, staff did not implement timely dietary interventions or conduct consistent weight checks. Observations showed residents not consuming meals, and there were delays in updating care plans and notifying medical staff.
The facility failed to report allegations of abuse, neglect, and injuries of unknown origin to the state agency within the required timeframes for 16 residents. Incidents were reported late, with initial reports submitted hours after the required timeframe and final reports delayed beyond the five-day limit. Interviews with staff confirmed lapses in timely reporting, despite the facility's policy mandating immediate reporting.
During a kitchen tour, several deficiencies were noted, including unlabeled cooking oil, a cook not wearing gloves or practicing hand hygiene, and expired food items in the freezer. Additionally, sanitizer test strips were improperly stored, and logs for the sanitizer and dish machine temperatures were incomplete. Ice buildup was also observed in a walk-in freezer. These issues were communicated to the Certified Dietary Manager.
A resident experienced a lack of dignity when a GNA improperly turned them using their arms instead of a draw sheet, resulting in bruising. The resident was on Aspirin as a blood thinner at the time.
A resident's dietary needs were not accommodated as required. The resident needed assistance with opening containers and cutting food, as well as specific dietary supplements. Observations showed the resident's meal tray had an uncut sandwich, unopened ice cream, and untouched fruit cup, indicating a lack of provided assistance.
A facility failed to report suspected abuse in a timely manner, allowing the alleged perpetrator, a CA, to continue working with the resident before the investigation began. The incident was reported by an LPN to an RN, but the state agency was not notified until the next day. Despite facility policy, the CA was not immediately suspended and continued to work a double shift with the resident.
Facility staff did not follow professional nursing standards by failing to sign the medication record after administering an antibiotic to a resident. An alternative antibiotic was ordered and given by a nurse, but the administration was not documented in the medication record. Interviews with the Assistant Director of Nursing and a registered nurse confirmed that nurses are expected to sign the medication record after administering medications.
A resident with a prosthetic hip infection was prescribed Cefazolin IV every 8 hours, but the facility failed to administer the first dose and another subsequent dose. An alternative antibiotic was given without proper documentation. The ADON stated that medication administration is monitored weekly through exception reports.
Facility staff failed to document a resident's shower during admission. The DON explained that a shower/skin sheet is usually completed by GNAs and the assigned nurse, but the Administrator confirmed that these sheets are not part of the medical record, leaving no verification that the resident received a shower.
Failure to Inform POA Prior to Diagnostic Procedure
Penalty
Summary
Facility staff failed to fully inform the Power of Attorney (POA) of a resident prior to conducting a diagnostic procedure. The resident, who was under hospice care and had a history of a possible left knee disarticulation, was noted by a nurse to have significant changes and visible pain in the affected leg. Although the hospice nurse had previously discussed the situation with the POA, who declined an X-ray and opted for comfort care, facility staff later ordered and performed an X-ray without documented evidence of further discussion with the POA regarding this change in care. Documentation reviewed by the surveyor showed conflicting notes regarding the POA's wishes, with one entry stating the POA declined the X-ray and another indicating the POA was not opposed to X-rays but only to surgical intervention. Interviews with facility staff confirmed that there was no documentation supporting that the POA was consulted before the X-ray was performed, despite the prior refusal. The Assistant Director of Nursing acknowledged that staff were expected to inform providers of the resident's hospice status and the POA's prior decisions, but this was not documented as having occurred.
Resident Medical Information Left Unprotected in Hallway
Penalty
Summary
Facility staff failed to protect the privacy of residents' medical information on one of three nursing units observed during a complaint survey. A cart was left unattended in the hallway with a laptop displaying patient information and a paper listing medical details for 11 residents, including their MOLST status, diet, and medications. The information was visible to anyone passing by. The surveyor observed the cart for seven minutes while the nurse was inside a resident's room, during which time someone walked by and could have seen the exposed information. When questioned, both the Assistant Director of Nursing and the LPN responsible for the cart acknowledged that resident information should not be left visible and uncovered. The LPN explained that she left the cart to attend to a resident who was leaning in a way she did not like, but during this time, the surveyor noted that the nurse and resident were calmly conversing about daily tasks. The Nursing Home Administrator was informed of the situation and acknowledged understanding of the concern.
Failure to Update Care Plan After Resident Injury
Penalty
Summary
Facility staff failed to revise the interdisciplinary care plan to accurately reflect interventions for a resident who sustained bruises of unknown origin. The resident was found to have bruises on both arms, which, after investigation, were determined to be caused by the resident's arms coming into contact with wheelchair brake extenders while self-propelling. The initial evaluation indicated the resident required assistance but was able to self-propel the wheelchair, and a subsequent therapist assessment confirmed that self-propelling with an extended brake was beneficial for the resident. Despite documenting the incident and the therapist's findings in progress notes, the facility did not update the resident's care plan to address the risk of bruising from the wheelchair brake extenders. During interviews, facility leadership confirmed that while interventions were documented in progress notes, they were not incorporated into the care plan. This omission resulted in the care plan not reflecting the resident's current risk factors and necessary interventions following the incident.
Failure to Provide Required Assistive Devices for ADL Independence
Penalty
Summary
The facility failed to provide necessary assistive devices to a resident with Parkinson's disease and other significant medical conditions, resulting in the resident not having access to built-up utensils and a plate guard during meals. The resident's care plan and the facility's Dining Details Report both specified the need for built-up utensils and a plate guard to maximize independence with eating. However, during observation, the resident was found eating lunch in bed with standard utensils and without a plate guard, despite having sliced peaches that required a fork. The required adaptive equipment was found stored in the resident's dresser drawer, not in use at the time of the meal. Interviews with staff revealed a lack of awareness and follow-through regarding the resident's assistive device needs. The Geriatric Nursing Assistant was unsure of the current requirements, and the Assistant Director of Nursing confirmed that the necessary devices were not in use during the meal observation. The absence of these devices was only addressed after surveyor intervention, indicating a lapse in ensuring that assistive devices were consistently provided as outlined in the resident's care plan and documented needs.
Failure to Provide Prescribed Nutritional Supplements per Care Plan
Penalty
Summary
The facility failed to provide nutritional supplements as documented in a resident's care plan and Dining Detail. Specifically, a resident with diagnoses including Parkinson's with dyskinesia, dementia, dysphagia, and chronic pain was not given prescribed supplements such as vanilla ice cream and mashed potatoes with gravy (super spuds) with lunch and dinner, as well as in-house shakes at 2 p.m., despite these being clearly outlined in both the care plan and the Dining Details Report. The care plan had been updated multiple times to reflect the resident's preferences and nutritional needs, including the removal of ice cream at breakfast per the resident's wishes, and the continuation of ice cream and super spuds with lunch and dinner, along with a daily shake. During the survey, direct observation of the resident's lunch revealed the absence of both super spuds with gravy and vanilla ice cream, with only a sandwich, a drink, and sliced peaches present. Interviews with staff confirmed that these supplements were not provided at the observed meal. The Assistant Director of Nursing also verified that the required items were missing from the resident's meal tray, acknowledging the concern. The deficiency was identified through review of the complaint, medical record, care plan, and direct observation.
Failure to Coordinate and Document Hospice Care Communication
Penalty
Summary
The facility failed to coordinate care for a resident who was receiving hospice services, resulting in a lack of communication and documentation between facility nursing staff and the hospice team. The resident developed swelling, redness, and pain in the left knee, which was initially diagnosed as cellulitis and treated with antibiotics and ibuprofen. Over time, the resident's condition worsened, with further swelling and pain noted. A hospice nurse assessed the resident and suspected a possible disarticulation (fracture vs. dislocation), discussed the situation with the resident's spouse, and decided not to send the resident to the hospital. However, this assessment and decision were not communicated to the facility nursing staff, who later noted a possible dislocation without knowledge of the hospice nurse's previous findings. Interviews with facility staff revealed that communication with hospice staff was primarily verbal and not formally documented. Hospice staff maintained their own paper documentation, which was not routinely shared or reviewed by facility staff. The facility's leadership confirmed that there was no documentation to show that the facility nursing staff acknowledged or discussed the hospice nurse's assessment and the decision made with the resident's power of attorney. This lack of coordinated communication and documentation led to a deficiency in the provision and coordination of hospice care for the resident.
Failure to Document Abuse Training for Care Associate After Suspension
Penalty
Summary
The facility failed to document that a Care Associate (CA) received abuse training after returning from suspension related to an allegation of abuse. The incident involved a resident with dementia and a history of confusion, who alleged that the CA pushed and pulled him and unplugged his television. The CA denied the allegations, and interviews with other staff and residents did not corroborate the claim. The resident was assessed and found to have no pain, and an X-ray showed no acute injury. The investigation concluded that the allegation of abuse was not verified. Despite the outcome of the investigation, a review of the CA's personnel record revealed that there was no documentation of abuse training being completed after the suspension and prior to the CA returning to work. The Nursing Home Administrator confirmed that abuse training is required before returning to work following an abuse allegation, but acknowledged that the required training had not been completed or documented for this CA.
Failure to Protect Residents from Abuse and Neglect
Penalty
Summary
The facility failed to protect residents from abuse and neglect, resulting in multiple incidents involving several residents. One significant incident involved an altercation between two residents, where one resident with a history of severe dementia and aggressive behavior entered another resident's room, leading to a physical confrontation. The aggressive resident, who had been readmitted to the facility with a private duty aide, was not consistently supervised, and the facility lacked proper documentation of the aide's presence. This lack of supervision and documentation contributed to the incident where the aggressive resident pushed another resident, causing injuries. Another incident involved a resident being left on a bedpan for an extended period without follow-up assistance, leading to discomfort and neglect. The care associate responsible for this neglect was identified and subsequently terminated. The facility's investigation revealed that the care associate had placed the resident on the bedpan and then attended to other duties, neglecting to check back on the resident in a timely manner. Additional incidents of abuse were reported, including a staff member refusing to care for a COVID-positive resident, resulting in the resident missing a meal, and another staff member providing rough incontinence care despite the resident's complaints of pain. These incidents highlight a pattern of inadequate care and supervision, as well as a failure to ensure residents' safety and well-being, leading to substantiated allegations of abuse and neglect.
Inadequate Supervision Leads to Resident Altercation
Penalty
Summary
The facility failed to provide adequate supervision to a resident with a documented history of wandering, agitation, and physically aggressive behaviors, resulting in an altercation with another resident. The resident, who had severe cognitive impairment and a history of aggression, was readmitted to the facility after a hospital stay. Despite the known risks, the facility did not consistently ensure the presence of a Private Duty Aide (PDA) to supervise the resident, particularly during critical times when the resident's agitation was known to increase. The resident's medical records indicated a pattern of aggressive behavior, including wandering into other residents' rooms and physical altercations. The facility's care plan included supervision and redirection strategies, but these were not effectively implemented. Staff interviews revealed that the PDA was not consistently present, and there was a lack of documentation regarding the PDA's schedule and presence. This inconsistency in supervision contributed to the incident where the resident entered another resident's room, leading to a physical altercation and injury. The facility's investigation acknowledged the lack of consistent supervision and the failure to document interventions adequately. Staff were aware of the resident's aggressive tendencies, yet the necessary precautions were not consistently in place. The incident occurred during a shift change, highlighting the need for continuous supervision, which was not provided. The facility's documentation and communication regarding the resident's care and supervision were insufficient, contributing to the deficiency.
Failure to Address Significant Weight Loss in Residents
Penalty
Summary
The facility staff failed to monitor and implement interventions to address the nutritional needs of residents experiencing significant weight loss. This deficiency was evident in five residents, with Resident #127 experiencing harm due to the lack of timely dietary interventions and consistent weight checks. Despite being aware of Resident #127's significant weight loss through emails and documentation, the facility staff did not take corrective actions promptly. The resident lost over 50 pounds between November 2023 and January 2024, and the facility failed to implement dietary interventions or conduct consistent weight checks. Resident #22 experienced a significant weight loss of 8.17% over three months, yet there were no provider notes addressing this change in condition until much later. The resident's meal ticket indicated the need for assistance with eating and specific dietary supplements, but observations showed that the resident did not consume much of the provided meals. Despite notifications to medical staff and the resident's representative, there was a delay in addressing the weight loss and implementing additional interventions. Resident #17, who had a history of significant weight loss, was not reweighed promptly after being readmitted to the facility. The facility failed to follow through with monitoring and assessing the resident's weight loss, despite the dietician's practice of sending updates to the medical and administrative teams. Similarly, Resident #40 experienced a 10% weight loss in a short period, but the facility delayed implementing interventions and updating the care plan. Resident #33 also experienced significant weight loss, with delays in notifying the physician and implementing measures to address the issue.
Failure to Timely Report Abuse and Neglect Incidents
Penalty
Summary
The facility failed to report allegations of abuse, neglect, and injuries of unknown origin to the state agency, OHCQ, within the required timeframes. This deficiency was identified for all 16 residents selected for abuse investigation. The facility's policy mandates that such incidents be reported within two hours for the initial report and within five working days for the final report. However, multiple incidents were reported late, with some initial reports being submitted several hours after the required timeframe and final reports being delayed beyond the five-day limit. Specific cases highlight the facility's non-compliance. For instance, Resident #120 was found with a fracture of unknown origin, and the incident was reported to the state agency several hours after the discovery. Similarly, Resident #92's injuries were reported late, and the Director of Nursing mistakenly believed there was a 24-hour window for reporting. Other residents, such as Resident #119 and Resident #66, also experienced delays in reporting their respective incidents to the state agency. Interviews with facility staff, including the Administrator and Director of Nursing, confirmed the lapses in timely reporting. The facility's abuse policy clearly states the requirement for immediate reporting, yet there was a history of non-compliance. Staff members were reportedly educated on the importance of timely reporting, but the facility continued to struggle with adhering to the mandated timeframes, as evidenced by the numerous incidents of late reporting documented in the surveyor's findings.
Deficiencies in Kitchen Food Storage and Preparation Practices
Penalty
Summary
During an initial tour of the kitchen, several deficiencies were identified concerning food storage and preparation practices. An unlabeled opened cooking oil container was found on the shelf in the dry kitchen, and a cook was observed handling and preparing food without wearing gloves and without practicing hand hygiene before putting on gloves. A full container of prepared soup was covered with plastic but lacked a date label. Expired food items, including cooked stuffed cabbage, ground beef, cheese, and burgers, were found in the freezer, and the Certified Dietary Manager was seen discarding these items upon being informed. Additionally, the sanitizer test strips for the three-compartment sink were wrapped in aluminum foil, obscuring the expiration date, and the sanitizer log was incomplete for several days. The dish machine temperature log was also incomplete, with missing documentation for several days, yet dishes were being processed through the machine. Lastly, there was ice buildup observed in the walk-in freezer located in the hallway outside the kitchen. These concerns were communicated to the Certified Dietary Manager during the tour.
Improper Turning Technique Leads to Resident Bruising
Penalty
Summary
The facility failed to treat a resident with dignity by improperly turning them, which was evident in one of the nine residents reviewed for dignity. During an interview, the resident recalled an incident involving a staff member but could not remember the name. The facility reported an allegation of physical abuse after a Geriatric Nursing Assistant (GNA) noticed multiple bruises on the resident's arms. Upon investigation, GNA #66 admitted to using the resident's arms to turn them in bed instead of using a draw sheet. At the time of the incident, the resident was on Aspirin as a blood thinner to prevent blood clots.
Failure to Accommodate Dietary Needs
Penalty
Summary
The facility failed to accommodate the dietary needs of a resident, as observed during a survey. The resident's meal ticket indicated that they required assistance with opening containers and cutting food, as well as specific dietary supplements including a milkshake and ice cream. During an observation, the resident was seen eating lunch in bed with a meal tray that included an uncut sandwich, a drink, a mixed fruit bowl, and a closed container of ice cream. The resident was later observed sleeping with the meal tray still in front of them, with the sandwich only partially cut, the ice cream container unopened, and the fruit cup untouched. The resident's care plan confirmed the need for assistance with opening containers and cutting food, which was not provided, leading to the deficiency.
Failure to Timely Report and Suspend Alleged Abuser
Penalty
Summary
The facility failed to ensure timely reporting of suspected abuse, resulting in the alleged perpetrator continuing to provide care to the victim before the investigation began. This deficiency was identified during a recertification survey for one resident out of eight reviewed for abuse. On June 8, 2024, a resident informed an LPN that they were mishandled by a Care Associate (CA) during care. The LPN conducted a physical assessment and reported the incident to a supervising RN. However, the report to the state agency was not submitted until the following day, June 9, 2024. Despite the facility's policy requiring immediate suspension of the alleged perpetrator, the CA continued to work with the resident throughout the morning shift on the day of the incident. The administrator confirmed that the CA worked a double shift and was only reassigned during the evening shift. This failure to suspend or reassign the CA immediately after the allegation was reported allowed the alleged perpetrator to remain in contact with the resident, contrary to the facility's stated procedures.
Failure to Sign Medication Record After Antibiotic Administration
Penalty
Summary
The facility staff failed to adhere to professional nursing standards by not signing the medication record after administering an antibiotic to a resident. This deficiency was identified during a survey when a review of the electronic medical record (EMR) showed that a resident was prescribed antibiotic therapy, but the medication was initially unavailable. An alternative antibiotic was ordered and administered by a nurse, as noted in the nursing documentation. However, the nurse did not sign off on the medication record to confirm the administration of the antibiotic. Interviews with the Assistant Director of Nursing and another registered nurse confirmed that the expectation is for nurses to sign the medication record after giving medications to residents.
Failure to Administer Antibiotic Therapy as Ordered
Penalty
Summary
The facility staff failed to administer antibiotic therapy as ordered for a resident who was admitted with a known infection of the right prosthetic hip. The resident was prescribed Cefazolin 2 grams intravenously every 8 hours for 6 weeks. However, the medication administration record revealed that the first dose of the antibiotic therapy was not given as scheduled. A note by Nurse #78 indicated that the prescribed IV antibiotic was not available, but an alternative antibiotic was ordered and available in the Omnicell medication dispensing machine. Further review showed that the resident received Ceftriaxone 1 gram IV at 2 am, but this was not signed off on the medication administration record. Additionally, the resident missed another dose of the antibiotic therapy later that day. The surveyor and the Assistant Director of Nursing verified that the resident missed two doses of the prescribed antibiotic therapy. During an interview, the ADON explained that the nursing management team monitors the medication exception report weekly and reviews notes in the system to verify medication administration.
Lack of Documentation for Resident Shower
Penalty
Summary
The facility staff failed to provide documentation verifying that a resident received a shower during their admission. This deficiency was identified during a survey when reviewing the records of one resident. During an interview, the Director of Nursing explained that a shower/skin sheet is typically completed by the Geriatric Nursing Assistants, who give the resident a shower, and the assigned nurse, who assesses the resident's skin and documents the shower on the form. However, the Administrator confirmed that the resident's skin sheets are not part of the medical record, and there was no documentation available to verify that the resident received a shower.
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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