Oakwood Snf Llc
Inspection history, citations, penalties and survey trends for this long-term care facility in Middle River, Maryland.
- Location
- 1300 Windlass Drive, Middle River, Maryland 21220
- CMS Provider Number
- 215181
- Inspections on file
- 17
- Latest survey
- February 4, 2026
- Citations (last 12 mo.)
- 18
Citation history
Health deficiencies cited at Oakwood Snf Llc during CMS and state inspections, most recent first.
Facility staff failed to accurately code falls on the MDS for several residents. One resident had two falls during the look-back period, including one with a scalp laceration requiring staples, but only a single fall without injury was coded. Another resident had two documented unwitnessed falls to the floor near the bed with no injuries, yet only one fall without injury was recorded on the MDS. Additional residents had documented falls, including one during a transfer attempt and another reported by a housekeeper after the resident coughed and sat on the floor, but their MDS assessments indicated no falls. The MDS Coordinator acknowledged these omissions during interviews, and the concern was reported to the Nursing Home Administrator.
Surveyors observed that a resident room was not maintained in a safe, clean, and comfortable condition. Trash, including wrappers, tissues, a hair brush, and food, was scattered on the floor, with leftover food and crumbs on both residents’ bedside tables and stuck-on food on a wheelchair cushion. The floor mat and room corners were dirty and dusty. When shown these conditions, the charge nurse noted that the resident is a messy eater, but the roommate’s side of the room was also unclean, demonstrating a failure to adequately clean and maintain the shared room environment.
A resident with adult FTT developed a new skin condition on the buttock that was later assessed by a wound physician as a Stage III pressure ulcer, with an order for daily Calcium Alginate dressing. Review of documentation showed staff continued using wound cleanser and did not implement the ordered Calcium Alginate treatment for several days until the order was changed to zinc ointment every shift. The Regional Director of Clinical Operations confirmed that the ordered pressure ulcer treatment was not provided as directed.
Facility staff failed to follow dietitian recommendations and physician follow-up for two residents with weight loss and malnutrition. For one resident with dementia, FTT, and mild protein-calorie malnutrition, staff did not obtain or file results of an ordered GI telehealth consult and missed one of the weekly weights ordered by the dietitian. For another resident with malnutrition, staff obtained only two of four recommended weekly weights, and the dietitian did not reassess the resident after the initial evaluation. These inactions resulted in incomplete monitoring and follow-up for residents identified as experiencing weight loss.
A resident with a history of goiter had a chest X-ray that showed worsening mediastinal findings and specifically recommended a CT scan, but staff did not obtain a CT in a timely manner. The CT was ordered weeks after the initial recommendation, then the scheduled test was discontinued when the imaging provider would not accept the resident on a stretcher, and no alternative arrangements were documented. Subsequent hospital imaging again recommended outpatient chest CT correlation, yet the CT was not ordered or completed until the resident was later sent back to the hospital. The Regional Director of Clinical Operations confirmed staff failed to follow up and obtain the CT over this extended period.
The facility failed to clearly post the location of its survey results book, preventing residents and visitors from easily identifying where to access survey, certification, and complaint investigation results. A surveyor found no signage in the lobby and had to ask the receptionist, who indicated the book was stored in a drawer of a black table near the NHA’s office, with no sign on or near the table. A sign found on a nursing unit wall only stated that the survey book was in the front lobby and did not mention it was kept in a drawer. The NHA reported the book was kept in the drawer because a resident had previously torn it apart, and the Regional Director of Clinical Operations and receptionist were unable to locate the usual sign.
A review of grievance records revealed that the facility failed to maintain an effective grievance system, with missing forms for several months and incomplete documentation on available forms. Two residents' complaints, including missing personal items and unreturned calls, were not properly documented or resolved according to facility policy, as confirmed by interviews with the DON and Administrator.
Multiple residents were left without proper hygiene care due to ongoing shortages of clean towels, washcloths, and other hygiene materials. Staff and family members reported that residents were left in soiled briefs and unable to be bathed, with staff sometimes resorting to using bed sheets or pillowcases as substitutes. Facility staff confirmed that linen shortages were frequent and that the process for distributing and recycling linens was disorganized, resulting in inadequate care for residents.
A resident was observed walking in a hallway wearing only a hospital gown that exposed their back and shoulder, due to a lack of available clothing. Staff interviews confirmed that multiple residents lacked proper clothes and that this situation was recognized as a dignity issue by nursing leadership.
A resident dependent on staff for ADLs and diagnosed with Parkinson's Disease did not receive showers as preferred, despite a physician's order and clear documentation of this preference. The care plan failed to reflect the resident's wish for showers, and records showed only bed/towel baths were provided. Facility leadership acknowledged that resident preferences should be honored and documented.
Staff did not maintain a clean and homelike environment, as strong odors of urine and possible body odor were repeatedly observed in two nursing units. These issues were confirmed through both complaints and direct surveyor observation.
The facility did not conduct comprehensive investigations into two incidents: one involving a resident who sustained a rib fracture and pneumothorax after reporting being pushed, and another where a resident suffered a femur fracture during transport. In both cases, required documentation such as witness statements, staff interviews, and communication records were missing, and the facility was unable to provide evidence of a thorough investigation.
A resident with left-sided paralysis and weakness, who was dependent on staff for ADLs including mobility, did not have a care plan that addressed their specific mobility needs or interventions. Review of records and staff interviews confirmed the absence of a comprehensive, individualized mobility care plan.
Surveyors found that staff failed to provide timely incontinence care and regular showers for several dependent residents, with one resident waiting nearly an hour for care after a bowel movement and another left in a hallway for hours after an incontinence episode. Documentation showed that some residents did not receive scheduled showers, and staff confirmed that only a limited number of showers were available due to maintenance issues.
A resident with severe intellectual disabilities was found on the floor with a head injury and bleeding after attempting to walk to the bathroom unassisted. Staff provided immediate care and sent the resident to the hospital, but the facility's investigation did not include interviews with staff or the roommate, limiting the ability to determine the root cause of the fall.
Staff did not ensure that cold food items on a test tray, including cream cheese, milk, and apple juice, were served at or below the required 41°F, with all items found above this limit during a survey. The issue was identified for one of two test trays sampled.
A resident was served a meal tray without a meal ticket, which is necessary to confirm dietary requirements, allergies, and other pertinent information. A GNA admitted to serving the tray without proper verification, and staff interviews confirmed that trays without tickets should be returned to the kitchen for verification.
Facility staff did not maintain complete medical records for a resident with advanced osteoporosis who sustained a leg injury during transport to dialysis. The communication flow sheet from the dialysis center, which included the nurse's notes and signature about the incident, was missing from the resident's file. Staff interviews revealed gaps and inconsistencies in documentation, and the original notes from the dialysis nurse were not found in the facility's records.
A resident was subjected to abuse by a GNA, resulting in a facial injury. The incident occurred when the resident resisted care, leading to a physical altercation where the GNA punched the resident multiple times. The event was witnessed by the resident's roommate and confirmed through interviews, highlighting a failure in the facility's duty to protect residents from harm.
The facility failed to notify the Ombudsman of resident transfers to the hospital and discharges, affecting multiple residents. Despite recent efforts to send notifications via email, the facility did not provide documentation of notifications for several hospitalizations and discharges, as confirmed by the NHA and staff interviews.
The facility failed to maintain a safe, clean, and homelike environment, with surveyors observing multiple repair needs in resident rooms, including missing faucet handles, unsecured cove basing, and sticky floors. The NHA and Maintenance Director were unaware of some issues, and the facility's documentation system, TELS, did not reflect these repair needs.
The facility failed to accurately code MDS assessments for multiple residents, leading to discrepancies in medical records. A resident's catheter use was not reflected in the MDS, another's pressure ulcer was not coded, and discharge statuses were inaccurately recorded. The DON acknowledged these inaccuracies during interviews.
A facility failed to respect a resident's medical power of attorney by continuing to contact the resident's son instead of the appointed Health Care Agent, the granddaughter. Despite the resident's clear preference and the signed documentation, the facility did not adhere to the resident's wishes, as confirmed by a late note from social services.
A resident filed a complaint about staff behavior, including delayed smoking sessions and argumentative interactions. Despite meeting with the Administrator, no grievance was initiated or corrective action taken, contrary to the facility's policy. The Regional Director of Clinical Operations highlighted the need for staff to follow the grievance process promptly.
The facility failed to update care plans for two residents, leading to inappropriate interventions. One resident, a bilateral amputee, had a care plan requiring footwear, which was not applicable. Another resident continued to have anticoagulant-related interventions active after the medication was discontinued. The DON confirmed these oversights.
The facility failed to provide appropriate respiratory care for two residents. One resident was found with undated oxygen tubing and an empty humidifier bottle, contrary to physician orders and facility policy. Another resident's oxygen tubing was also undated while using an emergency oxygen tank. These observations were communicated to the Regional Nurse Consultant.
A surveyor observed a resident with medications improperly stored at their bedside, including inhalers and tablets, without proper orders or supervision. The CMA admitted to leaving medications at the bedside due to time constraints, contrary to expected procedures.
The facility staff failed to properly label and dispose of expired food products in the kitchen. During a tour, items such as mustard, ricotta cheese, coleslaw dressing, and teriyaki sauce were found with incomplete labeling or past expiration dates. Some containers also showed mold-like growth. The Dietary Manager was informed of these issues.
The facility failed to ensure proper infection control practices, as staff did not perform hand hygiene before entering rooms with Enhanced Barrier Precautions, and contaminated pillows were stored with clean ones in the laundry room. Signage for EBP was not placed on doors, and PPE carts were not visible, contributing to non-compliance.
The facility's laundry room was found to be unsanitary, with dirty and sticky floor tiles, rusty drain pit covers surrounded by dirt, and chemicals stored on a platform covered with a thick white substance. The condition was observed twice by a surveyor, and staff acknowledged the need for cleaning. The Administrator suggested a power wash due to the building's age.
Facility staff failed to maintain accurate clinical records, as activity logs showed a resident participating in activities while hospitalized. The Activity Director noted a switch to computer-based records, but discrepancies were found, confirmed by the Administrator and Regional Director of Clinical Services.
Inaccurate MDS Coding of Resident Falls
Penalty
Summary
Facility staff failed to ensure that Minimum Data Set (MDS) assessments were accurately coded for multiple residents with documented falls. For one resident, medical record review showed two falls within the assessment look-back period: one fall without injury and a subsequent fall resulting in a scalp laceration requiring emergency room evaluation and placement of two staples. However, the annual MDS with an assessment reference date of 11/20/25 captured only one fall without injury and did not include the fall with injury. For another resident, records documented two separate falls, both described in change in condition notes as the resident being found on the floor near the bed with no injuries noted, but the MDS with an assessment reference date of 11/21/25 captured only one fall without injury. Additional record reviews identified further inaccuracies in MDS fall coding. One resident had a documented fall where the resident was found kneeling on the floor after attempting to transfer from bed to wheelchair, with no injury noted, yet the MDS with an assessment reference date of 11/18/25 documented no falls. Another resident experienced a fall reported by a housekeeper, where the resident was standing at the end of the bed, began coughing, and then sat on the floor, with no injuries noted; the MDS with an assessment reference date of 1/6/26 also documented no falls for this resident. In each of these cases, the MDS Coordinator confirmed during interview that the falls had not been accurately captured on the MDS assessments, and the Nursing Home Administrator was informed of the concern.
Failure to Maintain Clean and Homelike Resident Room Environment
Penalty
Summary
Surveyor observation identified a failure to maintain a safe, clean, comfortable, and homelike environment in one resident room. On 2/3/26 at approximately 10:15 AM, the surveyor entered room [ROOM NUMBER] B, where Resident #1 resides, and observed trash scattered on the floor, including wrappers, Kleenex, a hair brush, and food. Leftover food and crumbs were present on the bedside tables for both Resident #1 and the roommate, and there was stuck-on food on the cushion of the wheelchair. The floor mat was dirty, and the corners of the room were dusty and dirty. These conditions were shown to the Charge Nurse (staff #7) and the DON (staff #2); staff #7 stated that Resident #1 is a messy eater and gets food everywhere, but the roommate’s side of the room was also observed to be just as dirty. The Administrator was made aware of these findings. This deficiency reflects the facility’s failure to adequately clean the resident room, including sweeping and mopping the floor and maintaining clean surfaces and equipment, for 1 of 1 residents and rooms reviewed in this context.
Failure to Implement Ordered Pressure Ulcer Treatment
Penalty
Summary
Facility staff failed to provide ordered treatment and services to prevent and heal a pressure ulcer for one resident. The resident was admitted in 2024 with diagnoses including adult failure to thrive, characterized by unintentional weight loss, decreased appetite, poor nutrition, and physical inactivity. On 3/18/25, a weekly skin observation note documented a new skin condition measuring 4 cm by 1 cm on the resident, described as pink in color with no drainage, which was cleansed with wound cleanser and dressed. On 3/20/25, a Wound Doctor assessed this area as a Stage III pressure ulcer on the left buttock and ordered a daily Calcium Alginate dressing. On 3/27/25, the Wound Doctor discontinued the Calcium Alginate dressing and ordered zinc ointment to be applied every shift. Review of the March 2025 Treatment Administration Record showed that facility staff did not implement the Wound Doctor’s 3/20/25 order and continued using wound cleanser instead of changing to the ordered Calcium Alginate dressing from 3/20/25 through 3/27/25. In an interview on 2/4/26, the Regional Director of Clinical Operations confirmed these findings, verifying that the ordered pressure ulcer treatment was not provided during that period.
Failure to Implement Dietitian Recommendations and Follow Up on Weight Loss Evaluation
Penalty
Summary
Facility staff failed to implement the dietitian’s recommendations and to follow up on a physician-ordered GI consult for residents experiencing weight loss. One resident with dementia, adult failure to thrive, mild protein-calorie malnutrition, and other comorbidities continued to lose weight despite supplementation and meal assistance. The dietitian assessed this resident and documented that a GI telehealth consult had been ordered due to ongoing weight loss and a history of being underweight. However, there were no GI consult notes in the electronic or paper medical record, and the Acting DON confirmed that staff did not have the results of the consult, leaving the facility unable to determine if there were any recommendations related to the resident’s weight loss. The dietitian also ordered weekly weights times four for this same resident, but the weight for one of the scheduled weeks was not obtained, as confirmed by the Regional Director of Clinical Operations. A second resident, admitted with a diagnosis including malnutrition, was assessed by the dietitian for weight loss, and the dietitian again recommended weekly weights times four. Staff obtained only two weights and then stopped, and the dietitian did not see this resident again after the initial assessment. These missed weights and lack of follow-up on the GI consult occurred for two of three residents reviewed for weight loss during a complaint survey.
Failure to Obtain Timely CT Imaging After Abnormal Chest X-Ray
Penalty
Summary
Facility staff failed to obtain a timely diagnostic CT scan as recommended and ordered for a resident with a history of goiter. The resident was admitted in 2024 with diagnoses including goiter and later had a chest X-ray on 3/3/25 to rule out pneumonia. The X-ray report noted nonspecific superior mediastinal widening with overall findings worse compared to a prior study from 4/22/2024 and specifically recommended a CT scan. Despite this recommendation, a physician order for the CT scan was not placed until 3/28/25. That order was updated on 4/3/25 to include a scheduled CT date of 4/8/25. On 4/7/25, the CT scan order was discontinued because the imaging provider would not take the resident on a stretcher, and no alternative arrangements were documented in the record at that time. The resident was hospitalized from 4/15 to 4/18/25, and the hospital discharge summary again referenced imaging that showed moderate left paratracheal soft tissue density deviating the trachea to the right, compatible with probable substernal thyroid, and recommended correlation with a chest CT as an outpatient. The chest CT was not ordered or obtained until the resident was sent to the hospital on 6/9/25. The Regional Director of Clinical Operations confirmed that facility staff failed to follow up and obtain the CT scan from 3/3/25 until 6/9/25.
Failure to Clearly Post Location of Survey Results Book
Penalty
Summary
The facility failed to post a notice indicating where the results of the most recent surveys, certifications, and complaint investigations were located, limiting residents’ and visitors’ ability to easily view the survey book. During a complaint survey, a surveyor observed that there were no signs in the lobby identifying the location of the survey book and had to ask the receptionist, who stated the book was kept in a drawer of a black table across the lobby from the Nursing Home Administrator’s (NHA) office. The table had plants on top and two drawers, and there was no signage on or near the table, on the wall, or elsewhere in the lobby to direct individuals to the survey book. Later, a survey sign was found on a wall in a nursing unit stating that the state survey book was located in the front lobby, but it did not specify that the book was kept in a drawer. In an interview, the NHA explained that she kept the survey binder in the drawer because a resident had previously torn the book apart. The Regional Director of Clinical Operations reported that they usually had a sign posted but could not locate it, and the receptionist did not know where the sign was, confirming that no clear notice of the survey book’s location was available at the time of the survey.
Failure to Maintain Effective Grievance System and Documentation
Penalty
Summary
The facility failed to maintain an effective grievance system as required, as evidenced by missing and incomplete grievance documentation over a six-month period. Specifically, grievance forms were unavailable for four out of six months reviewed, and the forms that were available for one month lacked essential information such as actions taken to investigate grievances, summaries of conclusions, dates of resolution, corrective actions implemented, and documentation of how the disposition was communicated to the complainant. This deficiency was identified during a complaint survey following allegations from two residents, one regarding missing personal belongings and another concerning unreturned calls after voicing concerns. Interviews with the DON and Administrator confirmed that the facility's process involves documenting concerns on forms and distributing them to the appropriate departments, with an expectation that grievances are resolved within seven days and all details are documented. However, both the DON and Administrator acknowledged that the grievance forms for the reviewed period were either missing or not fully documented, and the facility was unable to provide forms for four of the six months requested. This lack of documentation and incomplete records demonstrated the facility's failure to establish and maintain an effective grievance policy and process.
Failure to Provide Adequate Linen and Hygiene Supplies for Resident Care
Penalty
Summary
The facility failed to provide adequate quality of care services by not ensuring the availability of clean towels, washcloths, and other hygiene materials for residents. Multiple complaint intakes revealed that residents were left in soiled adult briefs for extended periods and were not bathed during their initial days at the facility due to a lack of clean linens. Family members had to purchase towels and washcloths themselves to provide basic care. Staff interviews confirmed that linen shortages were a frequent issue, with aides often unable to find necessary supplies and sometimes being instructed to use bed sheets or pillowcases as substitutes. Observations of linen carts on multiple units showed a lack of washcloths and only a few towels available. Further interviews with staff, including a Geriatric Nursing Assistant and a laundry aide, indicated that the facility did not have enough linen to meet residents' needs, and the process for recycling and distributing linens was disorganized. Staff reported that linens were sometimes hidden in residents' closets or discarded when heavily soiled, exacerbating the shortage. The Environmental Services Director and the Administrator acknowledged ongoing complaints from residents, staff, and families regarding linen shortages, and confirmed that the issue persisted, directly impacting the ability to provide timely and appropriate care.
Resident Dignity Compromised Due to Inadequate Clothing
Penalty
Summary
The facility failed to provide an environment that promotes resident respect and dignity, as evidenced by a resident ambulating down a hallway wearing only a hospital gown that was hanging off one shoulder and exposing the resident's back. During interviews, a Geriatric Nursing Assistant stated that many residents were seen in hospital gowns because they did not have clothes. Observation of the resident's closet revealed only one sweatshirt available. The Registered Nurse confirmed the resident had been exposed while walking in the hallway, and the Assistant Director of Nursing acknowledged that such exposure would be considered a dignity issue.
Failure to Honor Resident's Shower Preference
Penalty
Summary
A resident with Parkinson's Disease, who is dependent on staff for activities of daily living (ADLs), expressed a clear preference for receiving showers rather than bed baths. Despite a physician's order specifying a weekly shower schedule and the resident's stated preference, the resident reported not having received a shower in over two years. The resident also noted that the shower room on the unit was not in use and was being used to store wheelchairs. Medical record review confirmed that the resident's care plan did not include the preference for showers and that documentation for the month showed only bed/towel baths were provided, with no record of showers. Interviews with facility leadership, including the DON, confirmed that resident preferences should be honored and reflected in the care plan, but this was not done in this case.
Failure to Maintain Odor-Free and Homelike Environment
Penalty
Summary
Facility staff failed to ensure a safe, clean, and homelike environment by not maintaining the facility free from odors. During tours conducted on multiple days, a surveyor observed persistent smells of urine and foul odors, possibly body odor, in specific areas of two out of four nursing units. These odors were noted at the far end of the 300 unit on several occasions and halfway down the hall farthest from the nurses station in the 500 unit. The findings were based on both anonymous and family complaints, as well as direct observations by the surveyor during the complaint survey. No specific information about the medical history or condition of individual residents was provided in the report. The deficiency was discussed with facility administration during the exit conference.
Failure to Conduct Thorough Investigations of Abuse Allegation and Serious Injury
Penalty
Summary
The facility failed to conduct thorough investigations into two separate incidents involving residents. In the first case, a resident was hospitalized with a rib fracture and pneumothorax after a fall, and reported to hospital staff that they had been pushed by an unknown person, constituting an abuse allegation. Although the facility initiated an abuse investigation upon the resident's return, there was no documentation of witness statements or interviews with staff and other residents. The DON was unable to provide these documents, stating that the investigation had been handled by former staff and that the necessary records could not be located. In the second incident, another resident complained of leg pain and swelling upon arrival at a dialysis center, stating they had been dropped at the facility. The dialysis nurse communicated this to the facility and documented the conversation, but the corresponding communication flow sheet later returned to the facility was missing the nurse's written notes and signature. The facility's incident report indicated the resident was injured during transport due to not being strapped in, resulting in a femur fracture. Despite this, there were no statements from the van driver, escort, resident, facility nurse, or geriatric nursing assistants involved in the incident, and the facility could not produce documentation of a thorough investigation. Both incidents demonstrate a lack of comprehensive documentation and investigative follow-through, as required when responding to allegations of abuse or serious injury. The absence of witness statements, staff interviews, and relevant communication records contributed to the facility's failure to appropriately respond to and investigate these significant events.
Failure to Develop Individualized Mobility Care Plan
Penalty
Summary
The facility failed to develop a care plan addressing impaired mobility for a resident with a history of left-sided paralysis and weakness. During a complaint survey, it was found that the resident was dependent on staff for activities of daily living, including mobility and transfers. Despite this, there was no documented evidence that a resident-specific care plan was created to address the resident's mobility needs or to outline the interventions implemented to assist with mobility. The deficiency was identified through a review of medical records and care plans, as well as interviews with facility staff. The Assistant Director of Nursing confirmed that the care plan did not adequately address the resident's mobility needs after reviewing the documentation. The lack of a comprehensive, individualized care plan for mobility was observed in one of four residents reviewed for mobility needs during the survey.
Failure to Provide Timely Incontinence Care and Adequate Bathing for Dependent Residents
Penalty
Summary
The facility failed to provide timely and professional incontinence care, as well as adequate bathing for dependent residents. In one instance, a resident who returned from therapy after a bowel movement waited 57 minutes before receiving incontinence care, despite multiple staff being informed of the need. Staff interviews revealed that coverage during breaks was inconsistent, leading to extended wait times for residents requiring assistance. Additionally, documentation showed that another resident was not bathed according to their scheduled shower days during their short stay, and a review of another dependent resident's records indicated they received only one shower in a month without any documentation of refusal. Staff confirmed that only one of two shower rooms in a unit was functional, with the other out of order for several months, resulting in only four working showers for 130 residents. Furthermore, a resident was left in a hallway from 4 AM to 12 Noon after being moved out of bed for linen changes following an incontinence episode. Interviews with family and anonymous sources confirmed that the resident called out for help throughout the night and was left unattended in the hallway for several hours. These findings were based on observations, record reviews, and staff and family interviews, demonstrating a pattern of delayed and inadequate care for residents dependent on staff for activities of daily living.
Failure to Conduct Thorough Accident Investigation
Penalty
Summary
Facility staff failed to conduct a thorough investigation following an accident involving a resident with severe intellectual disabilities who was found on the floor of their room with a hematoma and a laceration over the left eyebrow, accompanied by significant bleeding. The resident reported getting up to walk to the bathroom and falling, resulting in head trauma. Staff provided immediate care, including applying ice and a pressure dressing, and the resident was sent to the hospital. Upon review, it was found that the facility's assessment of the incident did not include interviews with staff or the resident's roommate, which limited the ability to determine the root cause of the fall. The assessment only noted the resident's alertness, periods of forgetfulness, impaired memory, and gait imbalance, and concluded that ambulating without assistance was a predisposing factor. The lack of comprehensive investigation denied staff the opportunity to fully evaluate the causes of this and potential future accidents.
Failure to Serve Cold Foods at Safe Temperatures
Penalty
Summary
Facility staff failed to ensure that food was served in a palatable manner, as observed during a test tray evaluation. On 10/9/25 at 8:30 AM, a test tray was provided to the survey team, and while the scrambled eggs and bacon were at a palatable temperature, the cream cheese, milk, and apple juice were all served above the 41-degree Fahrenheit limit for cold foods, with temperatures recorded at 53.9 F, 52.8 F, and 49.6 F respectively. This deficiency was identified for one out of two test trays sampled and was communicated to the facility administrative team during the exit conference.
Failure to Verify Meal Information Before Service
Penalty
Summary
The facility failed to properly verify essential meal information prior to serving food to a resident. During a meal service observation, a Geriatric Nursing Assistant served a meal tray to a resident without a meal ticket, which is required to confirm the resident's name, room number, diet type, food texture, liquid consistency, and allergies. The GNA acknowledged that the tray should not have been served without this verification. Interviews with staff confirmed that the standard procedure is to return any meal tray lacking a meal ticket to the kitchen, and the Director of Nursing stated that staff are expected to verify all meal tickets before serving trays to residents.
Incomplete Medical Records and Missing Dialysis Communication Documentation
Penalty
Summary
Facility staff failed to maintain complete and accurate medical records for a resident who experienced a leg injury during transport to a dialysis center. The incident began when the resident, who had a history of advanced osteoporosis and a prior fracture in the same leg, complained of leg pain and swelling upon arrival at the dialysis center. The dialysis nurse documented the resident's complaints, vital signs, and communication with the facility nurse on a flow sheet, which was sent back to the facility. However, upon review, the communication flow sheet for the relevant date was missing the dialysis nurse's written notes and signature. The facility's records included an incident report and subsequent medical interventions, such as Tylenol administration, notification of the CRNP, diagnostic imaging, and pain management, but lacked the original documentation from the dialysis center. Interviews with facility staff, the dialysis nurse, and the Director of Nursing revealed inconsistencies and gaps in the documentation process. The Director of Nursing stated that the previous Administrator may have taken investigation records with them, and the dialysis communication flow sheet for the incident date was found to be incomplete. Staff interviewed were unaware of the missing documentation, and the communication logs provided did not contain the dialysis nurse's original notes. This failure to safeguard and maintain complete resident medical records, specifically the communication flow sheets with the dialysis center, constituted the identified deficiency.
Resident Abuse by GNA Results in Injury
Penalty
Summary
The facility staff failed to protect a resident from abuse, as evidenced by an incident involving two Geriatric Nursing Assistants (GNAs) and a resident. On the morning of the incident, GNA #8 was providing care to Resident #97, who was resisting. GNA #8 requested assistance from GNA #9, who then entered the room and held the resident's arms while GNA #8 attempted to change the resident. During the process, the resident managed to free an arm and hit GNA #9, who retaliated by punching the resident in the face multiple times. This resulted in a facial injury just below the resident's left eye. The incident was witnessed by the resident's roommate, who confirmed the sequence of events. The resident was evaluated for physical and psychosocial harm following the incident. The facility's investigation included interviews with the involved staff and the resident's roommate, all of whom corroborated the occurrence of abuse. The Maryland Office of Health Care Quality (OHCQ) determined that the incident met the Federal definition of Actual Harm Past Non-compliance (PNC). The facility's failure to prevent this abuse and ensure the resident's safety constitutes a significant deficiency in care.
Failure to Notify Ombudsman of Resident Transfers and Discharges
Penalty
Summary
The facility failed to provide timely notification to the Ombudsman regarding residents who were transferred to the hospital or discharged from the facility. This deficiency was identified through staff interviews and medical record reviews, which revealed that the facility did not notify the Ombudsman for nine residents who were hospitalized or discharged. The Nursing Home Administrator (NHA) confirmed that the facility had not been completing these notifications until a few months prior to the survey. Specific instances included Resident #8, who was hospitalized at Greater Baltimore Medical Center, and Resident #33, who had multiple hospitalizations due to falls. In both cases, there was no documentation of Ombudsman notification. Similarly, Resident #41 was hospitalized on several occasions, yet the facility failed to notify the Ombudsman. The surveyor reviewed documentation provided by the NHA, which included emails and reports from August to October 2024, but found no evidence of notifications for these residents. Additional cases involved Resident #4, who was hospitalized in July 2024, and Resident #24, who was hospitalized from late July to early August 2024, with no Ombudsman notification. Resident #105 had two hospitalizations in August and September 2024 without notification. Resident #60 had multiple hospital transfers from December 2023 to March 2024, and Resident #118 was discharged in July 2024, both without Ombudsman notification. Resident #32 was transferred to the hospital in November 2023, and again, no notification was provided. The facility's failure to notify the Ombudsman was confirmed through interviews with the NHA and other staff members.
Deficiencies in Facility Environment and Maintenance
Penalty
Summary
The facility was found to have deficiencies in maintaining a safe, clean, comfortable, and homelike environment for its residents. During a tour, surveyors observed several items in need of repair in six out of eight resident rooms. These included a missing handle for the warm water faucet, unsecured cove basing, a missing drawer in a closet, and marred walls in multiple rooms. The Nursing Home Administrator (NHA) and the Maintenance Director were unaware of some of these issues until they were pointed out by the surveyor. The facility uses the TELS platform for documenting repair needs, but these issues had not been recorded. Additional environmental issues were noted during the surveyor's tours, including baseboard molding coming off the wall and a sticky floor around a resident's bed. These observations were made over several days, indicating that the issues were not promptly addressed. The Maintenance Director acknowledged awareness of the marred walls and had a plan for their repair, but other issues such as the sticky floor persisted over multiple observations.
Inaccurate MDS Coding for Multiple Residents
Penalty
Summary
The facility staff failed to ensure accurate coding of Minimum Data Set (MDS) assessments for several residents, leading to discrepancies in their medical records. For Resident #41, the MDS assessments did not accurately reflect the use of a Foley catheter, despite the resident's care plan and physician orders indicating its use for urinary retention. Similarly, Resident #77's MDS did not accurately code the presence of a pressure ulcer/injury, even though the resident had redness to the sacrum and a care plan for skin integrity issues. Resident #119's discharge status was inaccurately coded in the MDS as 'Home/Community' instead of 'Not listed,' despite being discharged to the custody of the County Police Department. Additionally, Resident #133's MDS inaccurately indicated no falls, even though the resident had a documented fall prior to discharge. The Director of Nursing acknowledged these inaccuracies during interviews with the surveyor. Resident #118's discharge MDS was initially coded as discharged to a short-term general hospital, but progress notes indicated the resident was discharged to a shelter. This discrepancy was later modified in the MDS record. The surveyor discussed these coding inaccuracies with the facility's VP of Clinical Services, Director of Nursing, and Regional Risk Nurse, highlighting the need for accurate MDS coding to ensure proper resident care and documentation.
Failure to Respect Resident's Medical Power of Attorney
Penalty
Summary
The facility staff failed to respect a resident's right to determine who speaks for them, as evidenced by the handling of a resident's medical power of attorney. The resident was admitted with the assistance of their granddaughter, who was appointed as the Health Care Agent through a Medical Power of Attorney form signed on March 15, 2024, and a second signature obtained on March 18, 2024. Despite this, the facility continued to contact the resident's son instead of the granddaughter. A late note by social services on March 21, 2024, confirmed the resident's preference for support from the granddaughter, not the son. This issue was discussed with the Regional Director of Clinical Services before the survey team's exit.
Failure to Implement Grievance Process
Penalty
Summary
The facility failed to implement its grievance process, as evidenced by the case of a resident who filed a complaint regarding staff behavior. The resident reported concerns about staff delaying a smoking session and being argumentative. Despite meeting with the Administrator to discuss these grievances, no action was taken to address the issues, and the resident was subsequently discharged. The Administrator acknowledged receiving the complaint but did not initiate a grievance or develop a corrective plan. The facility's policy mandates that all grievances and complaints be investigated and resolved, with the Administrator serving as the Grievance Officer. However, the Administrator did not adhere to this policy, as confirmed by the Regional Director of Clinical Operations. The RDCO expressed concern over the failure to implement the grievance process and emphasized the expectation for staff to promptly address grievances according to the facility's policy.
Failure to Update Care Plans for Two Residents
Penalty
Summary
The facility staff failed to review and revise the interdisciplinary care plans to accurately reflect the needs of two residents, leading to deficiencies in their care. Resident #32, who was a bilateral amputee, had a care plan intervention that required the resident to wear appropriate footwear, which was not applicable given the resident's condition. This intervention remained active until it was discontinued after the surveyor's review. The Director of Nursing confirmed that the intervention was inappropriate for the resident's condition. Resident #91, who had diagnoses including Congestive Heart Failure and Atrial Fibrillation, was receiving an anticoagulant medication as per the physician's order. However, after the medication was discontinued, the care plan interventions related to the anticoagulant continued to remain active until the resident's expiration. The Director of Nursing acknowledged that the care plan should have been revised following the discontinuation of the medication.
Failure to Provide Appropriate Respiratory Care
Penalty
Summary
The facility failed to provide appropriate respiratory care and services for two residents, as observed by the surveyor. Resident #8 was found with oxygen in use, but the oxygen tubing was not dated or labeled, and the oxygen humidifier bottle attached to the delivery system was empty and dated 9/20/2024, indicating it had not been replaced in a timely manner. The Registered Nurse (RN) #11 acknowledged the empty humidifier bottle and stated it would be replaced. A follow-up observation on 10/4/2024 showed that the oxygen tubing and humidifier bottle were dated 10/03/2024, suggesting a delay in compliance with the physician's orders and facility policy, which required oxygen tubing to be changed every 7 days and dated/labeled. Similarly, Resident #57 was observed using oxygen in the hallway with an emergency oxygen tank attached to the wheelchair, but the oxygen tubing was not dated. A chart review confirmed that Resident #57 had physician orders for oxygen usage, with the requirement for the oxygen tubing to be dated and changed every 7 days, consistent with the facility's oxygen administration policy. The surveyor communicated these concerns to the Regional Nurse Consultant, highlighting the facility's failure to adhere to its own policies and physician orders regarding respiratory care.
Medication Storage and Administration Deficiency
Penalty
Summary
The facility failed to store medications appropriately, as observed during a survey on Nursing Unit 100. A surveyor found two respiratory medication inhalers at a resident's bedside without an order for medications to be kept there. The resident had a locked drawer available, but the inhalers were not stored in it. Additionally, a self-administration medication assessment was completed for the resident after the initial observation. Further observations revealed that the same resident had five tablets in a medication cup on their meal tray, which were identified as Metoprolol, Mucinex, Zoloft, Aspirin, and Hydroxyzine. The Certified Medication Aide (CMA) responsible for administering these medications admitted to leaving them at the bedside due to time constraints in passing medications to all residents. The CMA acknowledged that the expectation was to stay with the resident while they took their medications, but this was not done.
Improper Food Labeling and Expired Products in Kitchen
Penalty
Summary
The facility staff failed to ensure that food products were properly labeled and disposed of when past their expiration dates. During a kitchen tour, several items were found with either incomplete labeling or past expiration dates. Specifically, a container of mustard was labeled with an open date of 7/4 and a use-by date of 8/4, but the year was missing, suggesting it was past the use-by date. Two containers of ricotta cheese had expiration dates of 9/27/24, and a 1-gallon container of coleslaw dressing had both a use-by and expiration date of 8/12. Another container of coleslaw dressing was not labeled at all. A container of teriyaki sauce had a use-by date of 7/30, and four boxes of sun cups had a warning to serve within 10 days, but no label indicated when they were thawed. Additionally, several containers of dressing in the cooler exhibited black mold-like growth. The Dietary Manager was shown these items and acknowledged the issues.
Infection Control Deficiencies in Hand Hygiene and Laundry Practices
Penalty
Summary
The facility failed to maintain a safe and sanitary environment to prevent the transmission of infections, as evidenced by two main deficiencies. Firstly, staff did not perform hand hygiene before entering rooms of residents under Enhanced Barrier Precautions (EBP), which are measures to prevent the spread of multidrug-resistant organisms. Observations revealed that staff entered rooms without using hand sanitizer, despite the presence of dispensers in the hallway. Additionally, there were no Personal Protective Equipment (PPE) storage carts visible on the unit, which are necessary for implementing EBP effectively. Staff interviews indicated that while signage was used to indicate EBP, it was not placed on doors to maintain a homelike environment, potentially leading to non-compliance with hand hygiene protocols. Secondly, the facility's laundry room practices were found to be inadequate in preventing cross-contamination. Clean pillows were stored in plastic bags on a rack, but contaminated pillows were also placed uncovered on the same rack. This practice was confirmed by the Director of Housekeeping, who did not provide a clear infection control process for pillow cleaning. Upon a follow-up visit, all pillows were observed to be covered, indicating a previous lapse in maintaining separation between clean and contaminated items.
Unsanitary Conditions in Laundry Room
Penalty
Summary
The facility failed to maintain a sanitary environment in the laundry room, as observed by a surveyor on two separate occasions. On the first observation, the surveyor noted that the floor tiles in the room with the washing machines were visibly dirty and sticky with a brown-colored substance. Additionally, there were two large, rusty drain pit covers surrounded by an accumulation of dirt. Chemicals for the washing machines were stored in buckets attached to hoses on a platform covered with a thick, powder-like white substance, which was also scattered on the floor next to the platform. Staff present during the observation acknowledged the need for cleaning. During a second observation, the room remained in the same unsanitary condition, and the Administrator suggested the possibility of using a power wash for cleaning, citing the age of the building.
Inaccurate Documentation of Resident Activities
Penalty
Summary
The facility staff failed to maintain accurate clinical records for a resident, as evidenced by discrepancies in the activity logs. The Activity Director indicated that activities information was now recorded in the computer system. However, upon review, the activity logs showed that a resident was documented as participating in activities on specific dates, despite being hospitalized during that period. This inconsistency was confirmed by the Administrator and Regional Director of Clinical Services, who acknowledged that activities were incorrectly documented while the resident was in the hospital.
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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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