Orchard Hill Rehabilitation And Healthcare Center
Inspection history, citations, penalties and survey trends for this long-term care facility in Towson, Maryland.
- Location
- 111 West Road, Towson, Maryland 21204
- CMS Provider Number
- 215069
- Inspections on file
- 20
- Latest survey
- January 21, 2026
- Citations (last 12 mo.)
- 16
Citation history
Health deficiencies cited at Orchard Hill Rehabilitation And Healthcare Center during CMS and state inspections, most recent first.
The facility failed to thoroughly investigate an allegation of neglect involving a resident who was transferred to the hospital. Although the DON reported interviewing nursing staff who had cared for the resident in the 72 hours before the transfer, the only documented interview and written statement was from the GNA who provided care on the morning of the transfer. No additional interview notes or statements from other staff who had cared for the resident during the prior shifts were found. The NHA confirmed that interviews from those previous shifts were missing and acknowledged that those staff should have been interviewed.
A resident who was unable to manage toileting independently repeatedly called out for help to be changed while two nurses, including the assigned nurse, were present outside the room. The assigned nurse told the resident they had just used the call bell and to wait, but the resident continued to call out, and a strong urine odor was noted from the room. The resident reported they had last been changed during the night and had not been changed by late morning, later stating they were finally changed about an hour after the initial observation. The DON was notified of these observations.
A resident on oxygen via nasal cannula was observed receiving 4 L/min despite a physician order for 2 L/min, and the humidification bottle and oxygen tubing lacked dates indicating when they were opened or applied. The prior day, the resident experienced respiratory distress and was found on a non-rebreather mask, diaphoretic and tachypneic, but the only record was a brief RT note with no further documentation of the event. An NP reported being called for low O2 saturation, placing the resident on a non-rebreather, and administering an Ipratropium breathing treatment for abnormal lung sounds, then admitted she had not documented this assessment, the respiratory episode, or the treatment in the medical record.
A resident did not receive a needed gynecology appointment after the attending MD requested an evaluation for symptoms and possible infection. The request was routed to a staff member responsible for arranging outside appointments and transportation, who was unable to schedule with the usual gynecologists because they would not accept the resident due to the large stretcher required. The staff member stated the resident’s daughter makes all appointments, but the daughter reported she was unaware of the need for a gynecology visit and said she could have obtained an appointment. The DON acknowledged she would look into the situation, but the MD was never informed that the appointment had not been made, and no alternative outside professional resource was secured.
The facility did not maintain adequate nursing staff, resulting in delayed or missed essential care such as cleaning, turning, showers, and therapy for multiple residents. Staff interviews described high resident-to-staff ratios, inability to complete required care tasks, and lack of management support. Documentation confirmed missed showers, delayed therapy, and medication errors due to staffing shortages.
Facility staff did not inform a resident's physician when BiPap therapy, ordered for a resident with a history of respiratory failure and hypercapnia, was not administered on multiple occasions. Despite the critical need for BiPap as noted in the hospital discharge summary and physician orders, there was no documentation or notification to the physician regarding the missed treatments, as confirmed by both the physician and the DON.
A resident with dementia and multiple contractures, fully dependent on staff for mobility, was found to have a displaced right hip fracture after complaining of foot pain and swelling. Although the injury was confirmed by x-ray, the facility did not report the incident to OHCQ within the required two-hour window, instead submitting the report two days later. The DON confirmed the delay in notification.
A resident who sustained a displaced right hip fracture and received opioid pain management was not accurately represented in the MDS assessment, as the fracture and opioid use were omitted from the relevant sections. This deficiency was confirmed through medical record review and staff interview during a complaint survey.
A resident admitted for rehabilitation did not have a baseline care plan reviewed or provided to their representative within 48 hours of admission. The required care plan, which should include initial goals, physician orders, therapy, dietary, and social services, as well as admission medications, was not documented as given or discussed with the representative. Both the DON and the resident confirmed the representative was not included in the care planning process as required.
A nurse failed to administer and accurately document multiple prescribed medications for a resident with end stage renal disease and intact cognition. The nurse, untrained on the medication cart and covering a shift alone, signed off on medications that were not given, which was later confirmed by another staff member and the resident.
Facility staff did not provide scheduled bathing assistance to two residents who were dependent or required partial help with ADLs. One resident did not receive any showers for over a month despite care plans and physician orders, while another missed multiple scheduled showers, with staff citing short staffing and questioning the need for assistance. The DON confirmed these deficiencies through documentation review.
Two residents did not receive care in accordance with physician orders and professional standards. One resident with end stage renal disease did not receive Midodrine at the prescribed time before dialysis, and another resident with dementia and multiple contractures had inadequate documentation and assessment following complaints of pain and swelling, despite physician orders for intervention. The DON confirmed these deficiencies.
A resident with multiple chronic conditions and pressure ulcers did not receive consistent wound care and monitoring, as evidenced by missing documentation of wound assessments and gaps in the Treatment Administration Record. The DON confirmed ongoing issues with documentation and continuity of care due to frequent turnover among wound care staff.
A medication cart was left unlocked and unattended by a nurse, allowing a surveyor to access medications including an opened sterile water vial without a date and multiple insulin pens that were either undated, had broken seals, or lacked resident identification. These actions failed to meet professional standards for medication labeling and storage.
The facility did not ensure complete and accurate medical records for two residents with complex wound care needs. For one resident, wound treatments were not signed off in the TAR on multiple occasions, despite being performed. For another, wound assessments and treatment documentation were missing or incomplete over several weeks, leaving gaps in the medical record.
Facility staff did not maintain accurate nurse staffing records, as schedules provided by the DON did not match actual staff attendance and assignments. Time punch reviews revealed daily discrepancies, with some staff incorrectly listed as working and others omitted. The HR Director confirmed the schedules were outdated and not properly updated due to changes in schedulers, resulting in inaccurate documentation of daily nurse staffing.
The facility was found to have several deficiencies in food storage, labeling, and dishwashing practices. Food items were not properly labeled or discarded, with some found expired and crusty. A juice line was on the floor, and the walk-in freezer had excessive ice accumulation. Cleaning chemicals were improperly stored near food items. The dishwashing machine failed to maintain required temperatures for sanitization, leading to the use of chemical sanitization as a backup. These issues were acknowledged by the Certified Dietary Manager.
The facility failed to maintain accurate records for the administration of Oxycodone for four residents, with discrepancies found between the controlled medication utilization records and the MAR. Staff interviews confirmed the requirement for documentation in both records, which was not adhered to.
The facility's kitchen steam table was found to be in disrepair, with two indicator lights inoperable and four knobs missing, compromising its safe operation. This issue was acknowledged by staff and discussed during the exit conference with the DON and Administrator.
A facility failed to provide a resident with information to formulate an advance directive and ensure its documentation in the medical record. Despite the resident having the capacity to make decisions, there was no record of an advance directive or any discussion about it. The facility's policy requires inquiry and documentation of advance directives, but the Social Services Director confirmed the absence of such documentation, leading to the deficiency.
A resident experienced a significant weight loss over 30 days, dropping from 164.0 lbs to 134.4 lbs, as flagged in the electronic medical record. However, the facility staff failed to notify the physician or resident representative of this change. Interviews with the ADON and Regional Dietician confirmed the lack of documentation and notification, despite acknowledging the necessity of informing the physician and resident representative.
A resident reported that the shower room in one unit lacked hot water, leading to infrequent showers. The Maintenance Director confirmed the water temperature was only 88.8°F, despite other units having adequate hot water. Previous maintenance logs showed similar issues, and although a vendor had repaired the water tank, the problem persisted. The Maintenance Director acknowledged the issue and contacted a plumber, but the deficiency remained unresolved.
A resident's funds were misappropriated by a GNA, who used the resident's bank account for personal transactions. The facility confirmed the misappropriation and terminated the GNA. However, the facility failed to report the incident to the Maryland Board of Nursing, as confirmed by the DON and other staff. This deficiency was noted during the facility's recertification and complaint survey.
A facility failed to implement its policies on abuse and misappropriation, as a GNA misappropriated funds from a resident's bank account. The facility verified the allegations and terminated the GNA, but did not investigate or report additional allegations from other residents. The facility also failed to report the incident to the Maryland Board of Nursing, leading to a deficiency.
A facility failed to complete a Significant Change in Status Assessment (SCSA) for a resident who enrolled and discontinued hospice care. Despite having two physician orders for hospice, no SCSAs were completed. The MDS Coordinator and DON confirmed the oversight, acknowledging an error in the resident's MDS documentation.
The facility failed to conduct timely care plan meetings for residents, resulting in care plans being based on outdated MDS assessments. This deficiency was identified for three residents, with care plan meetings either delayed or held before the MDS assessments. Facility staff acknowledged the discrepancies but did not provide evidence to dispute the findings.
A resident with a medical order for nectar thick liquids due to aspiration precautions was found with thin water in their room on multiple occasions. Despite clear directives in the resident's care plan and speech therapy recommendations, the facility failed to adhere to the prescribed diet, as confirmed by an LPN and acknowledged by the facility's nursing leadership.
The facility failed to monitor residents' smoking activities, leading to unsupervised smoking incidents. Residents accessed smoking materials outside scheduled times, and one resident handed a lit cigarette to another, violating the facility's smoking policy. The facility did not conduct immediate follow-up evaluations or update care plans after these incidents.
A resident experienced an 18% weight loss over a month, dropping from 164.0 lbs to 134.4 lbs, without adequate monitoring or intervention by the facility. Despite orders for weekly weight checks, weights were not obtained on two occasions, and the dietician was not notified of the significant weight change. The Regional Dietician confirmed no interventions were in place prior to surveyor intervention, and neither the physician nor the responsible party were informed.
A facility failed to monitor and document pre- and post-dialysis body weights for a resident with end-stage kidney disease, leading to discrepancies between facility and dialysis center records. The resident was hospitalized for respiratory failure due to volume overload, highlighting the importance of accurate weight monitoring. Staff interviews confirmed reliance on a communication record, but inconsistencies were found, which were acknowledged by the ADON.
The facility staff did not post nurse staffing information in an easily accessible location for most of the survey period. The survey team observed that the information was not displayed as required, and later found it placed on a table in the reception area next to holiday decorations. This issue was noted during the exit conference.
During a survey, an unlocked medication cart was observed on a nursing unit, with staff members passing by without securing it. The DON later locked the cart after being informed by the surveyor that it had been unsecured for nearly 15 minutes.
A resident with broken teeth requiring surgical extraction did not receive timely dental care due to insurance issues and scheduling delays. Despite recommendations for surgery, the procedure was not arranged, and the resident continued to experience discomfort. The DON acknowledged the delay and lack of documentation in securing a dentist.
A facility failed to ensure timely documentation of wound care services and did not restrict access to medical records for providers no longer involved in resident care. A CRNP documented wound care visits months after the service date, including for a resident who had passed away. The facility lacked a formal policy for terminating access to medical records, leading to unauthorized access by the CRNP.
A facility failed to monitor antibiotic use, resulting in a delayed start of Augmentin and an extra dose of Fluconazole for a resident. The Infection Control Preventionist confirmed the errors, highlighting issues in antibiotic stewardship and medication administration.
Two residents in a long-term care facility suffered falls during ADL care due to inadequate supervision and failure to follow care plans. One resident, with multiple medical conditions, fell from the bed while being repositioned, resulting in a pelvic fracture and hematoma. Another resident, requiring total dependence, fell during care when a GNA attempted to assist alone, leading to bilateral femur fractures. The facility's care plans lacked specific instructions, contributing to these incidents.
The facility staff failed to administer medications and treatments as ordered for several residents, including delayed pain medication for a resident with endometrial cancer, untimely treatment updates for a resident with arterial wounds, missed doses of Tacrolimus for a post-lung transplant resident, and inaccurate skin assessments for a resident with dementia. These deficiencies were confirmed by the facility's nursing leadership.
The facility failed to notify a resident's physician when BiPAP therapy was not administered, and did not inform another resident's family about an antibiotic-resistant organism diagnosis. The DON confirmed these communication lapses.
A facility failed to protect a resident from inappropriate sexual contact by a GNA from a staffing agency. The incident involved a GNA found engaged in a sexual act with a resident who required full care and had a history of mental health disorders. The resident claimed the act was consensual, but the GNA was reported to be under the influence. The facility reported the GNA to the agency and the Board of Nursing.
The facility failed to report allegations of abuse to the OHCQ within the required 2-hour timeframe for three incidents. In one case, a resident alleged being hit by a GNA, but the report was delayed. Another resident alleged inappropriate touching, but documentation was missing. A third resident alleged wrist twisting during repositioning, but the facility lacked intake information. The NHA and DON confirmed these findings.
The facility failed to investigate allegations of abuse, neglect, and mistreatment for four residents. For one resident, the facility could not locate the investigation related to an allegation of neglect. Another resident's allegation of inappropriate touching by a GNA was not thoroughly investigated. A third resident's mistreatment allegation during repositioning lacked documentation. Lastly, a resident's report of rough treatment by a GNA was incomplete as it did not include a direct statement from the resident.
The facility failed to accurately code MDS assessments for two residents. One resident's fracture was not documented in the MDS, and another resident's MDS inaccurately recorded the receipt of antipsychotic medications. These errors were confirmed by staff interviews, and the DON and Nursing Home Administrator were informed.
Facility staff failed to update care plans for two residents when their needs changed and lacked evidence of care plan meetings. One resident, known to resist care, had an incident involving staff, but the care plan lacked strategies like redirection. Another resident, with a history of COPD, was found without oxygen, and the care plan did not include oxygen usage details. The DON confirmed these deficiencies.
A resident with pressure ulcers did not receive timely and appropriate treatment as recommended by hospital discharge and a Wound Nurse Practitioner. The facility delayed ordering a Bunny air boot and an air mattress, and did not update the treatment plan for the resident's right heel wound in a timely manner, as confirmed by the DON.
The facility failed to provide necessary respiratory care for two residents. One resident did not receive timely BiPAP therapy, and another lacked proper documentation and orders for continuous oxygen therapy. The DON confirmed these deficiencies.
A resident's drug regimen was not free from unnecessary drugs as the facility administered Metoprolol on dialysis days, contrary to the physician's orders. The resident was supposed to skip the medication on the mornings of dialysis days, but records showed administration on those days. The DON confirmed the error during an interview.
A resident with muscle wasting and a tibia fracture did not receive foot drop splints as recommended by a specialist, despite a physician's order. The DON was unaware of the need, and the DOR confirmed efforts to obtain the splints were ongoing, indicating a delay in providing necessary medical equipment.
The facility failed to maintain accurate medical records and ensure proper communication during care plan meetings. One resident's medical record lacked crucial wound evaluation reports, while another resident's care plan meeting was attended by a nursing manager unfamiliar with the resident's care. The responsible party attended the meeting via phone, but the appropriate nursing manager was absent due to other commitments.
A call bell system failure affected two residents in a room on Unit 3, with the system being non-functional for over a week. A resident reported that maintenance was waiting for a part, and a surveyor confirmed a delayed response time of 18 minutes due to noise in the hallway. The issue was identified as a motherboard problem, and the part was ordered and replaced after the surveyor's observation.
Failure to Thoroughly Investigate Allegation of Neglect
Penalty
Summary
The facility failed to provide documentation that an allegation of neglect was thoroughly investigated for one resident involved in a facility-reported incident. On 1/20/26, the Regional Director received a call regarding potential neglect of Resident #3 after the resident had been transferred to the hospital. Review of the facility’s investigation showed a summary indicating that the DON had interviewed nursing staff who provided care to the resident during the 72 hours prior to the hospital transfer. However, the only documented interview and written statement in the investigation packet was from the GNA who cared for the resident on the morning of the transfer. There were no additional written statements or interview documentation from other staff who had provided care to the resident during the preceding 72 hours. During an interview on 1/21/26 at 1:30 PM, the NHA reviewed the investigation and confirmed the absence of interviews with other staff who had cared for the resident leading up to the hospital transfer. The NHA also stated that she had searched the previous DON’s files and was unable to locate any such interviews, and confirmed that staff from previous shifts should have been interviewed.
Failure to Provide Timely Incontinence Care and Toileting Assistance
Penalty
Summary
The deficiency involves the facility’s failure to provide timely assistance with activities of daily living, specifically toileting and incontinence care, for a resident who was unable to perform these tasks independently. On 1/20/26 at 11:00 a.m., Resident #6 was heard calling out from outside their room, requesting to be changed, while two nurses, including the resident’s assigned nurse (Staff #4), were observed standing outside the room. Staff #4 responded to the resident by stating that the resident had just put on the call bell and to give staff a chance to get there, but the resident continued to call out for help. A strong odor of urine was noted coming from the resident’s room at that time. During an interview conducted at the time of the observation, Resident #6 reported not being changed in a timely manner and stated that the last time they had been changed was in the middle of the night, and that as of 11:00 a.m. they had not yet been changed. In a follow-up interview at 1:00 p.m., the resident reported that they were changed about one hour after the initial observation, around 12:00 noon. The Director of Nursing was informed of the observation and responded, “ok.” This deficiency was identified for 1 of 1 residents reviewed for assistance with activities of daily living and toileting/incontinence care.
Failure to Follow Oxygen Orders and Document Respiratory Distress and Treatment
Penalty
Summary
The facility failed to provide respiratory services in accordance with professional standards of practice for one resident receiving oxygen therapy. During observation, the resident was found in bed on oxygen via nasal cannula with the concentrator set at 4 L/min, while the physician’s order in the medical record specified oxygen at 2 L/min. The humidification water bottle and oxygen tubing in use had no dates indicating when the bottle was opened or when the tubing was applied. The DON confirmed at the bedside that the oxygen was set at 4 L/min and stated she would review the nurse’s actions and the physician’s orders. Further record review showed a respiratory therapy note from the previous day documenting that the resident had been found on a non-rebreather mask, diaphoretic, and breathing fast, but there was no additional documentation in the medical record regarding this episode of respiratory distress or the use of the non-rebreather mask. In interviews, the RT reported being called by an NP to assist with the resident, who was on a non-rebreather, and described using breathing techniques and touch therapy with the NP and ADON to help calm the resident and reduce the respiratory rate. The NP stated she had been called because the resident was having trouble breathing with low oxygen saturation, placed the resident on a non-rebreather mask, and administered an Ipratropium breathing treatment due to “junky” lung sounds. When asked, the NP acknowledged she had not documented this assessment, the respiratory distress event, or the treatment in the medical record and stated she would document it after the interview.
Failure to Arrange Required Gynecology Appointment for Dependent Resident
Penalty
Summary
The facility failed to obtain an outside professional gynecological service for Resident #6 after the attending physician requested a gynecology appointment on 11/23/25 for symptoms and possible infection. The physician’s request was sent to Staff #5, who is responsible for arranging outside appointments and transportation. Staff #5 was unable to schedule the appointment because the gynecologists typically used by the facility would not accept the resident due to the large stretcher required, which they stated would not fit through their office doors. Staff #5 reported that the resident’s daughter makes all appointments, but the daughter stated she was unaware that an appointment with a gynecologist was needed and indicated she would have been able to obtain one. The DON stated she would look into the matter, but the physician was never notified that the resident had not yet received the gynecology appointment. This resulted in Resident #6 not receiving the requested evaluation by a gynecologist, and the facility did not employ or obtain an outside qualified professional resource to provide the required service when its usual providers could not accommodate the resident’s needs.
Failure to Provide Sufficient Nursing Staff for Resident Care
Penalty
Summary
The facility failed to provide sufficient nursing staff to meet the needs of its residents, as evidenced by multiple complaints, staff and resident interviews, and review of staffing documentation. Six out of nine complaints submitted to the Office of Health Care Quality alleged inadequate staffing, resulting in delayed or missed essential care such as timely cleaning after bowel movements, turning and repositioning, showers, and basic hygiene. Residents and their representatives reported waiting hours to be changed, being left soiled or wet, missing scheduled showers, and experiencing delays in being assisted after dialysis or for therapy appointments. Documentation confirmed that some residents did not receive scheduled showers, and one resident's physical therapy was delayed due to lack of available therapists. Front-line staff interviews consistently described high resident-to-staff ratios, with some staff responsible for 15 to 20 residents per shift. Staff reported being unable to complete all required care tasks, such as turning and repositioning every two hours, providing showers, and performing nail care. Staff also noted that management did not assist during short staffing, and that excessive charting requirements further limited the time available for direct resident care. Some staff described situations where only one aide was present for an entire unit, and new staff left after orientation due to overwhelming workloads. Review of staffing sheets from multiple days confirmed that units often operated with only two GNAs for 27 to 37 residents, resulting in ratios as high as 1:18 or 1:19. Additional documentation revealed medication administration issues when a nurse was required to cover a cart without proper training, leading to missed medication passes. Observations of staffing boards and further interviews with the DON confirmed ongoing concerns about inadequate staffing levels throughout the facility.
Failure to Notify Physician of Missed BiPap Administration
Penalty
Summary
Facility staff failed to notify a resident's physician when the resident's BiPap therapy was not administered on three separate occasions, as documented in the October 2025 Treatment Administration Record. The resident, who had a history of acute and chronic respiratory failure with hypercapnia, was admitted with physician orders for BiPap use at bedtime and as needed for naps. The hospital discharge summary emphasized the critical importance of BiPap use for this resident due to their history of respiratory failure and CO2 retention. Despite missed BiPap administrations on 10/3, 10/11, and 10/12/25, there was no documentation in the nursing notes indicating that the physician was notified of these omissions. Interviews with the resident's physician and the Director of Nursing confirmed that the expected notification did not occur.
Failure to Timely Report Injury of Unknown Origin
Penalty
Summary
The facility failed to report an injury of unknown origin within the required two-hour timeframe to the regulatory agency, the Office of Health Care Quality (OHCQ). Specifically, a resident with a history of dementia, failure to thrive, and multiple contractures was found to have a displaced fracture of the right hip. The resident, who was dependent on staff for all mobility, complained of right foot pain and was observed with swelling. The physician was notified, and orders were given for leg elevation, followed by an x-ray and doppler study. The x-ray, performed the following day, revealed a displaced fracture. Despite the discovery of the injury, the facility did not submit the initial report to OHCQ until two days after the x-ray confirmed the fracture. Review of the facility's investigation confirmed the delay in reporting, and the Director of Nursing acknowledged that staff failed to notify administration in a timely manner. This deficiency was identified during a complaint survey and was evident for one of four residents reviewed for facility-reported incidents.
Inaccurate MDS Assessment Coding for Resident with Hip Fracture
Penalty
Summary
Facility staff failed to ensure that Minimum Data Set (MDS) assessments were accurately coded for a resident who experienced a displaced fracture of the right hip. Medical record review showed that the resident had a physician's order for an x-ray and doppler study, and the x-ray confirmed a displaced fracture. The resident was subsequently sent to the emergency room for further evaluation. Additionally, the resident's Medication Administration Record (MAR) documented administration of Tramadol, an opioid medication, for pain management on two occasions prior to the assessment reference date. Despite these documented events, the MDS assessment with a reference date corresponding to the incident did not capture the fracture in Section I (diagnoses) or the use of Tramadol in Section N (medications). During staff interviews, it was confirmed that these omissions occurred, and it was noted that the facility was without an MDS coordinator at the time, though new staff had recently been hired. The deficiency was identified during a complaint survey and confirmed through both record review and staff interview.
Failure to Provide Baseline Care Plan to Resident's Representative Within 48 Hours of Admission
Penalty
Summary
The facility failed to provide a baseline care plan to a resident's representative within 48 hours of admission, as required. Upon review of the medical record and interviews, it was found that the resident was admitted from the hospital for rehabilitation services, but there was no documentation that a baseline care plan was reviewed or given to the resident's representative. The baseline care plan should have included initial goals, physician orders, therapy services, dietary services, and social services, as well as a list of admission medications. Interviews with the resident's representative confirmed that they were not given a baseline care plan or included in a meeting to discuss the resident's admission within the first 48 hours. The DON stated that the process is to assess the resident and generate a baseline care plan, which is then reviewed with the resident or their representative, but confirmed that this did not occur for this admission. The resident also expressed a desire for their representative to have been involved in the care planning meeting.
Failure to Administer and Document Medications per Professional Standards
Penalty
Summary
Facility staff failed to follow professional standards of practice in medication administration for one resident. The resident, who was admitted with end stage renal disease and was dependent on renal dialysis, had an intact cognitive status as assessed by a BIMS score of 15 out of 15. On the date in question, a nurse (Staff #22) was working their first shift as night supervisor without a preceptor and had to cover a medication cart due to another nurse calling out. Staff #22 reported not being trained on the cart and did not consider passing medications until it was too late, as the next doses were soon due. Documentation review revealed that Staff #22 signed off on the administration of multiple medications for the resident, including Dasatinib, Duloxetine, Fenofibrate, Ferrous Sulfate, Folic Acid, Pantoprazole, a multivitamin, Apixaban, and Midodrine, despite not actually administering them. This was confirmed by another staff member who observed the discrepancy and by the resident, who stated they had not received their medications during the overnight shift. The Director of Nursing confirmed that Staff #22 had documented the administration of medications that were not given.
Failure to Provide Required Bathing Assistance to Dependent Residents
Penalty
Summary
Facility staff failed to provide necessary assistance with activities of daily living (ADLs), specifically bathing, to residents who were dependent or required partial assistance. One resident was admitted for rehabilitation and assessed as dependent for bathing, with a care plan and physician orders specifying scheduled showers twice weekly. Despite these orders and the resident's representative requesting showers, documentation and staff interviews confirmed that the resident did not receive any showers from admission until discharge, a period of approximately one and a half months. Another resident, who required partial to moderate assistance with bathing, reported missing multiple scheduled showers. The resident stated that GNAs told them it was unnecessary for staff to remain in the shower room and cited short staffing as a reason for not providing assistance. Review of shower logs and GNA documentation confirmed that several scheduled showers were not provided, with entries marked as not applicable. The DON reviewed and confirmed these findings during the survey.
Failure to Provide Care and Documentation per Physician Orders and Standards
Penalty
Summary
Facility staff failed to provide treatment and care in accordance with professional standards of practice for two residents. For one resident with end stage renal disease and dependent on renal dialysis, the hospital discharge summary and physician notes specified that Midodrine should be administered one hour prior to hemodialysis, typically at 5:00 AM. However, review of the Medication Administration Record showed that the medication was given at 5:30 AM and 5:25 AM on two occasions, rather than at the prescribed time. The DON confirmed that the medication was not administered at the correct time as ordered. For another resident with a history of dementia, failure to thrive, and multiple contractures, there was a lack of documentation and assessment following a complaint of right foot pain and observed swelling. Although the physician was notified and ordered the leg to be elevated, and later ordered an x-ray and doppler study, the medical record did not contain documentation of an assessment of the swelling, a specific pain assessment of the leg/ankle, or details of the conversation with the physician when the x-ray was ordered. The DON confirmed the absence of this documentation.
Failure to Provide Consistent Pressure Ulcer Care and Documentation
Penalty
Summary
The facility failed to provide adequate treatment and services to prevent and heal pressure ulcers for a resident with multiple complex medical conditions, including lymphedema, chronic kidney disease, and a history of infected wounds. Upon admission, the resident was noted to be bed bound with chronic wounds and pressure ulcers at the sacrum and right thigh. Medical documentation indicated the presence of a stage 3 pressure ulcer on the right thigh and a stage 2 ulcer on the sacrum, with wound therapy assessments and specific wound care orders in place. However, there were significant gaps in the documentation of wound assessments, including missing weekly skin assessments with measurements and wound characteristics, making it unclear whether the prescribed treatments were consistently performed or effective. Further review of the Treatment Administration Record (TAR) revealed blank entries on several dates, indicating that wound care may not have been administered as ordered. The Director of Nursing confirmed challenges with documentation and continuity of care due to turnover among wound care nurses and the use of multiple outside wound care teams. No wound assessments or measurements were found for an entire month, and the facility was unable to provide documentation to demonstrate ongoing evaluation or progress of the resident's wounds during that period.
Unsecured Medication Cart and Improper Medication Labeling
Penalty
Summary
Facility staff failed to keep a medication cart locked when it was left unattended outside a resident's room. The nurse responsible for the cart was inside the room and not visible from the hallway, leaving the cart accessible. During this time, a surveyor was able to open the top drawer of the cart and found an opened 20 ml vial of sterile water without a date indicating when it was opened. Additionally, several insulin pens were found in the cart, some of which were opened without being dated, and one insulin pen had a broken seal and no resident name. Another insulin pen was opened and dated, but still present beyond the recommended usage period. According to the National Institute of Health, sterile water vials should be discarded no later than 4 hours after being punctured, and insulin pens should be dated when opened and discarded 28 days after opening, per manufacturer instructions. The observed failure to properly label and store medications and biologicals, as well as to secure the medication cart, constituted a deficiency in compliance with accepted professional principles for medication management.
Failure to Maintain Complete and Accurate Medical Records
Penalty
Summary
The facility failed to maintain complete and accurate medical records for two residents, as required by professional standards. For one resident with multiple sclerosis and a stage IV sacral pressure ulcer receiving hospice care, review of the Treatment Administration Records (TARs) for August, September, and October revealed that staff did not sign off on wound treatments on several specific dates. The wound nurse confirmed in an interview that the dressings were completed on those days but she forgot to document them in the TARs. The Director of Nursing also confirmed the lack of accurate documentation for the wound treatments on the identified dates. For another resident admitted with multiple chronic conditions, including bilateral lower extremity wounds, lymphedema, and severe chronic kidney disease, the medical record review showed incomplete wound documentation. There were missing wound assessment notes for over a month, and the TAR for wound care was left blank on several days, making it unclear if treatments were performed. Additionally, weekly skin sheets lacked measurements for multiple weeks, resulting in an incomplete medical record related to the resident's wounds.
Failure to Maintain Accurate Nurse Staffing Data
Penalty
Summary
Facility staff failed to maintain accurate nursing staffing data over an 18-day period, as evidenced by discrepancies between the actual worked nursing schedules and staff statements during a complaint survey. The surveyor found that the schedules provided by the DON did not match the investigation findings regarding which staff worked on specific days. Upon further review, time punches were requested to verify the accuracy of the schedules, revealing inconsistencies such as staff being listed as worked when they had not, and others who had worked not being included on the schedule. The Human Resources Director confirmed that the schedules given to the surveyor were not correct, attributing the issue to a lack of updates in the On-Shift scheduling system due to changes in schedulers. The schedules provided were outdated and did not reflect the actual staff assignments, and even the posted schedules were inaccurate. This failure to accurately document and post daily nurse staffing information was communicated to the DON, highlighting the facility's inability to keep an accurate account of staff presence and assignments for each day and shift during the reviewed period.
Deficiencies in Food Storage and Dishwashing Practices
Penalty
Summary
The facility was found to have several deficiencies related to food storage, labeling, and sanitation practices. During an inspection, it was observed that food items in the kitchen were not properly labeled or discarded according to their use-by dates. Specifically, a metal container of gravy and several side item containers were found with expired labels and crusty appearances, indicating they were not discarded in a timely manner. Additionally, a juice line was found lying on the kitchen floor, which was stained and had debris, posing a contamination risk. Further observations revealed issues with the facility's walk-in freezer, which had extensive ice accumulation covering a significant portion of the ceiling. This could potentially affect the storage conditions of food items. In the kitchen's storage room, cleaning chemicals were improperly stored near disposable food pans and utensils, increasing the risk of contamination. The storage practices were not in line with professional standards, as chemicals were placed next to food-related items, and cleaning tools were resting on food storage racks. The facility's dishwashing machine was also found to be deficient, as it was unable to maintain the required temperatures for hot water sanitization. The temperature gauges on the machine were not functioning properly, and the machine was observed to be using chemical sanitization as a backup method. The facility was awaiting the installation of a larger booster to address the temperature issues, as the current setup was inadequate to meet the necessary sanitization standards. These deficiencies were acknowledged by the Certified Dietary Manager and discussed during the facility's exit conference with the Director of Nursing and Administrator.
Discrepancies in Narcotic Medication Documentation
Penalty
Summary
The facility failed to maintain accurate drug records for the administration of narcotic medications, specifically Oxycodone, for four residents. The surveyor found discrepancies between the controlled medication utilization records (count sheets) and the Medication Administration Records (MAR) for these residents. For Resident #100, the count sheet showed three administrations of Oxycodone that were not recorded in the MAR. Resident #31's MAR indicated an administration of Oxycodone that was not documented on the count sheet. Resident #52's MAR showed multiple administrations of Oxycodone that were missing from the count sheet, and the count sheet also recorded administrations not found in the MAR. Similarly, Resident #14 had several administrations documented on the count sheet that were absent from the MAR. Interviews with facility staff, including a Registered Nurse and the Director of Nursing, confirmed that the facility's protocol required documentation of controlled medications in both the MAR and the count sheet. The staff acknowledged the discrepancies and verified that the nurses were expected to document the date, time, quantity used, remaining, and signature for each administration. The Director of Nursing confirmed the requirement for accurate documentation and validated the surveyor's findings.
Deficiency in Kitchen Steam Table Maintenance
Penalty
Summary
The facility failed to maintain the kitchen steam table in safe operating condition, as observed during the surveyor's initial tour. The steam table, which was used to hold food, had two out of six indicator lights inoperable and four out of six knobs missing, which are essential for controlling the temperature levels of the steam wells. This deficiency was confirmed through interviews with a staff member and the Certified Dietary Manager, who acknowledged the longstanding issue with the steam table. The concern was also discussed during the facility's exit conference with the Director of Nursing and Administrator present.
Failure to Document and Provide Information on Advance Directives
Penalty
Summary
The facility failed to provide a resident with information to formulate an advance directive and ensure that a current copy of the resident's advance directive was in the medical record. This deficiency was identified during a recertification/complaint survey for one resident. The review of the resident's medical record revealed that there was no documentation of an advance directive or any discussion about it, despite the resident having the capacity to make such decisions as noted in a hospital discharge summary. The facility's policy requires that the social services director or designee inquire about the existence of any written advance directives and provide information on the right to refuse or accept medical treatment and to formulate an advance directive. However, the Social Services Director confirmed that there was no documentation in the medical record indicating that the resident was offered assistance in establishing an advance directive. The lack of documentation and adherence to the facility's policy led to the deficiency.
Failure to Notify of Significant Weight Loss
Penalty
Summary
The facility staff failed to notify a provider and/or resident representative of a significant weight loss for a resident. This deficiency was identified during a review of the medical records for a resident who experienced a significant weight loss over a 30-day period, as documented in the electronic medical record. The resident's weight decreased from 164.0 pounds to 134.4 pounds, which was flagged in the medical record. However, there was no documentation indicating that the physician or resident representative was informed of this significant change. Interviews with the Assistant Director of Nursing (ADON) and the Regional Dietician confirmed the absence of notification to the physician and resident representative regarding the weight loss, despite acknowledging that such notification is necessary.
Failure to Maintain Proper Shower Water Temperature
Penalty
Summary
The facility staff failed to ensure that the showers in one of the nursing units maintained proper temperatures, as observed during a recertification/complaint survey. A resident from Unit 2 reported that the shower room did not have hot water, resulting in fewer showers being taken. During a facility tour, the Maintenance Director confirmed that the water temperature in the Unit 2 shower room was only 88.8 degrees Fahrenheit, which is below the acceptable range for hot water. Despite checking other units and finding adequate hot water, the issue persisted in Unit 2. The maintenance logs revealed that the water temperature in the Unit 2 shower room had previously dropped to 55 degrees Fahrenheit on two occasions, prompting a vendor to repair the water tank. Although the vendor confirmed that hot water had returned, the problem reoccurred, with the water temperature remaining below 100 degrees Fahrenheit. The Maintenance Director acknowledged the ongoing issue and indicated that a plumber had been contacted to address the problem. However, the deficiency remained unresolved at the time of the survey.
Misappropriation of Resident Funds by GNA
Penalty
Summary
The facility failed to protect a resident from the misappropriation of personal funds, as evidenced by a verified incident involving a Geriatric Nursing Assistant (GNA) who misused the resident's bank account. The incident was reported by the resident's family, who noticed unusual financial transactions on the resident's account. The facility's investigation confirmed that the GNA used the resident's bank account to pay a water bill and received a personal payment into the resident's account. This misappropriation was substantiated by the facility, leading to the termination of the GNA involved. Further investigation revealed that the same GNA was implicated in another incident involving a different resident, where they were observed accessing the resident's purse. Despite these findings, the facility did not report the misappropriation incidents to the Maryland Board of Nursing, as confirmed by interviews with the Director of Nursing (DON) and other staff members. The lack of reporting was acknowledged by the facility's administration during the survey process. The surveyor's review of the facility's documentation and interviews with staff highlighted the failure to report the GNA's actions to the appropriate regulatory body. This oversight was discussed with the facility's leadership, who confirmed their understanding of the surveyor's concerns. The deficiency was noted during the facility's recertification and complaint survey, with no documentation provided to indicate that the misappropriation had been reported to the Maryland Board of Nursing.
Failure to Implement Policies on Misappropriation of Resident Funds
Penalty
Summary
The facility failed to implement its policies and procedures regarding abuse, neglect, exploitation, and misappropriation, as evidenced by the misappropriation of funds from a resident's personal bank account. The incident involved a Geriatric Nursing Assistant (GNA) who was found to have used the resident's bank account information to pay a personal water bill and received a payment intended for another employee into the resident's account. The facility verified these allegations and terminated the GNA's employment. During the investigation, it was revealed that there were additional allegations of misappropriation involving other residents, which were not adequately addressed by the facility. Two residents reported missing personal belongings and credit cards, but the facility did not conduct investigations or report these incidents to the appropriate authorities. The Business Office Director and the Administrator were unaware of any actions taken in response to these additional allegations. Furthermore, the facility did not report the misappropriation by the GNA to the Maryland Board of Nursing, as required by their policies. Despite the facility's policies mandating thorough investigations and reporting of such incidents, the facility failed to comply with these requirements, leading to a deficiency in their handling of the situation.
Failure to Complete Significant Change Assessment for Hospice Enrollment
Penalty
Summary
The facility failed to complete a Significant Change in Status Assessment (SCSA) within 14 days for a resident who was enrolled and then discontinued from hospice care. This deficiency was identified during a recertification/complaint survey. The Minimum Data Set (MDS) is a federally mandated assessment tool used to gather information on each resident's strengths and needs, which drives care planning decisions. A SCSA is required when a resident enrolls in or discontinues hospice services to ensure a comprehensive review of the resident's condition and care planning. However, for one resident, there were no SCSAs completed for the periods when hospice services were initiated and discontinued. The resident in question was admitted to the facility and had two separate physician orders for hospice care. The first order was from September 23, 2022, to October 3, 2022, and the second order was from April 22, 2023, to the present. Despite these orders, the facility did not complete the required SCSAs. Interviews with the MDS Coordinator and the Director of Nursing confirmed the absence of these assessments. The MDS Coordinator acknowledged an error in not marking the resident's annual MDS as a significant change MDS, and the Director of Nursing verified the lack of SCSAs for the hospice orders.
Failure to Conduct Timely Care Plan Meetings
Penalty
Summary
The facility failed to conduct care plan meetings of the interdisciplinary team for residents at the time of the quarterly revision of the Minimum Data Set (MDS). This deficiency was identified for three residents during a recertification/complaint survey. The MDS is a core set of data elements that form the foundation of a comprehensive assessment for all residents of nursing homes certified to participate in Medicare or Medicaid. Care plans are required to be developed within seven days of the completion of a resident's admission comprehensive MDS assessment and revised at least every quarter. However, the facility did not adhere to this timeline, resulting in care plans being developed based on outdated assessments. For Resident #55, care plan meetings were held significantly after the MDS assessments, with delays ranging from one to two months. Resident #104 had care plans developed before the completion of the MDS, leading to potential inaccuracies. Resident #37's care plan meetings were either held before the MDS assessment or not held at all after certain assessments. Interviews with facility staff, including the Director of Nursing and social workers, confirmed the discrepancies between the MDS assessments and care plan meetings. The staff acknowledged the issue but did not provide evidence to dispute the findings.
Failure to Follow Medical Orders for Thickened Liquids
Penalty
Summary
The facility failed to ensure that medical orders for thickened liquids were followed for a resident. During the survey, it was observed that the resident, who was supposed to receive nectar thick liquids due to aspiration precautions, had thin water available in their room on multiple occasions. The resident's medical record indicated a diet order for pureed texture and nectar thick liquids, which was not adhered to as evidenced by the presence of thin water. The surveyor noted that the resident's care plan, initiated months prior, specified the need for nectar thick liquids, and this was confirmed by a speech therapy discharge summary. Despite these clear directives, the resident was found with thin water in their room, which was acknowledged by an LPN who removed the inappropriate liquids. The facility's Assistant Director of Nursing and Director of Nursing were informed of the issue, and they acknowledged the deficiency.
Failure to Monitor Resident Smoking Leads to Potential Hazards
Penalty
Summary
The facility failed to adequately monitor and assess residents in relation to smoking, leading to potential smoking accidents. This deficiency was identified during a recertification/complaint survey involving five residents. On one occasion, four residents were found smoking in the courtyard outside of scheduled smoking times. The facility's policy required cigarettes to be kept in a lockbox and residents to smoke only at designated times under supervision. However, these residents managed to access smoking materials and smoke unsupervised, possibly by following a family member of another resident. The facility did not conduct immediate follow-up evaluations or update smoking assessments after this incident. Additionally, another incident involved a resident handing a lit cigarette to another resident during a scheduled smoking time, which was against the facility's smoking policy. Despite the facility's policy prohibiting the sharing of smoking materials, this behavior was observed on video footage. The facility's response included discussions with the involved residents and their family members, but there was no updated care plan or smoking evaluation for the residents involved in this incident.
Failure to Monitor and Address Significant Weight Loss
Penalty
Summary
The facility failed to adequately monitor and address a significant weight loss in a resident, identified as Resident #113, during a recertification/complaint survey. The resident experienced an 18% weight loss over a one-month period, dropping from 164.0 lbs to 134.4 lbs. Despite having an order for weekly weight checks, the facility did not obtain weights on two occasions, specifically on 1/29/25 and 3/12/25. This lack of monitoring was confirmed by the Assistant Director of Nursing. Furthermore, the facility's policy required that any weight change of 5% or more be retaken the next day for confirmation and that the dietician be notified immediately in writing, which did not occur in this case. The Regional Dietician confirmed that prior to surveyor intervention, no interventions were put in place to address the resident's significant weight loss, and neither the physician nor the responsible party were notified. The dietician could not explain why no further action was taken. The resident's medical record did not show any evidence of the dietician being notified or addressing the weight loss, highlighting a failure in communication and intervention regarding the resident's nutritional needs.
Failure to Monitor Dialysis Weights
Penalty
Summary
The facility staff failed to properly monitor and document pre- and post-dialysis body weights for a resident requiring hemodialysis, leading to discrepancies in records. The resident, who has end-stage kidney disease, was admitted to the hospital due to respiratory failure with hypoxia secondary to volume overload, and was recommended for follow-up with outpatient paracentesis. Despite the use of a 'Hemodialysis Communication Record' form to communicate with the dialysis center, the facility's records showed inconsistencies with the dialysis center's treatment reports, indicating a lack of accurate monitoring. Interviews with staff revealed that the facility relied on the communication record to monitor residents' conditions, including vital signs and body weights. However, the surveyor identified discrepancies in the recorded weights, which were crucial for monitoring the resident's condition, especially given the recommendation for repeat paracentesis. The Assistant Director of Nursing acknowledged the importance of monitoring body weight for dialysis residents and validated the concerns raised by the surveyor.
Failure to Post Nurse Staffing Information
Penalty
Summary
The facility staff failed to post nurse staffing information in an easily accessible location for 4 out of the 7 days during the recertification/complaint survey. Upon entrance and during subsequent tours, the survey team observed that the staffing information was not displayed as required. On March 14, 2025, the survey team noted that the staffing information was placed on a table in the reception area, adjacent to St Patrick's Day decorations. This deficiency was communicated to the facility during the exit conference.
Medication Cart Security Lapse
Penalty
Summary
The facility staff failed to ensure medications were kept in a secure location, as observed during a recertification/complaint survey. On Unit Two, an unlocked medication cart was found between rooms, with no residents present in the hallway at the time. Three facility staff members passed by the cart without locking it. At 8:22 AM, the Director of Nursing (DON) approached the cart, opened the controlled substance logbook, and then pushed in the lock. The surveyor informed the DON that the cart had been unlocked for almost 15 minutes, which the DON confirmed.
Failure to Provide Timely Dental Care
Penalty
Summary
The facility failed to ensure timely dental care for Resident #61, who had broken teeth with retained roots requiring surgical extraction. Despite a dental consultation being placed in April 2024 and a recommendation for surgical extraction made in June 2024, the necessary procedure was not arranged. The resident continued to experience discomfort from the sharp, broken teeth, and no follow-up consultation for the extraction was scheduled, even though the resident was seen for routine dental cleanings and fluoride varnish applications. The Director of Nursing (DON) acknowledged the delay in arranging the oral surgery, citing issues with the resident's insurance not covering the procedure and the time taken to find a suitable dentist. The DON confirmed that the facility had not documented efforts to secure a dentist for the resident. The contracted dental group had recommended an outside facility for the extraction, but the procedure was not completed, and subsequent appointments were not scheduled until much later, leading to a significant delay in addressing the resident's dental needs.
Deficiency in Timely Documentation and Access Control for Wound Care Services
Penalty
Summary
The facility failed to ensure timely documentation of wound care services provided by an outside contractor, as evidenced by the delayed entry of notes into the medical records of three residents. For Resident #121, a note was written by a Certified Registered Nurse Practitioner (CRNP #34) for a wound care visit that occurred almost four months prior. The Director of Nursing (DON) was unaware of who CRNP #34 was and acknowledged the delay in documentation. Similarly, for Resident #119, a wound note was entered into the medical record more than two months after the resident's death, despite the CRNP and their group being terminated from the facility prior to the note's entry. Additionally, the facility failed to restrict access to medical records for providers who were no longer involved in resident care. Resident #270's medical record contained a wound note entered by CRNP #34, despite the resident having been discharged and the CRNP's contract terminated months earlier. The facility's Administrator and DON were unaware that CRNP #34 still had access to the medical records and confirmed that the facility was not uploading notes on behalf of the CRNP. The facility lacked a formal policy for terminating access to medical records for outside providers once their contract ended. The DON admitted that there was no written policy or procedure in place, and access termination was handled by the facility's IT department. The surveyor's review of the wound care provider contracts confirmed that the agreement with the provider group, including CRNP #34, was terminated, yet access to medical records was not appropriately revoked.
Antibiotic Monitoring Deficiency
Penalty
Summary
The facility failed to adequately monitor and track antibiotic usage, as evidenced by two incidents involving a resident. In the first incident, a resident with a urinary tract infection was prescribed Augmentin, but there was a delay in starting the medication. The initial order was discontinued, and a new order with the same details was placed to start the following day, resulting in the resident receiving a total of 11 doses instead of the intended 10. The facility's Infection Control Preventionist confirmed that the medication was not given as initially documented and that the delay was due to the reordering process. In the second incident, the same resident was prescribed Fluconazole for a yeast infection in the urine. The resident received an extra dose due to a change in the order's indication from infection to yeast in urine. The Medication Administration Record showed that the resident received six doses instead of the prescribed five. The Infection Control Preventionist acknowledged the error and confirmed that the resident should have received only five doses. Both incidents highlight deficiencies in the facility's antibiotic stewardship and medication administration processes.
Failure to Prevent Falls During ADL Care
Penalty
Summary
The facility failed to prevent falls for residents requiring extensive assistance or total dependence during activities of daily living (ADL) care, resulting in harm to two residents. Resident #33, who had multiple medical conditions including end-stage renal disease and hemiplegia, fell from the bed while being repositioned by a Geriatric Nursing Assistant (GNA). The GNA did not realize the resident was close to the edge of the bed and inadvertently caused the resident to fall, resulting in a pelvic fracture and a hematoma. The GNA was unaware of the resident's mobility status and did not know where to find this information. Resident #17, who also had end-stage renal disease and hemiplegia, fell from the bed during ADL care. The resident required total dependence with two or more persons for assistance, but the GNA attempted to provide care alone after initially receiving help to transfer the resident to bed. The resident fell onto a Geri-chair and tote, resulting in bilateral femur fractures. The GNA involved in this incident had previously received training on bed mobility and turning and repositioning but chose to perform the task alone despite the resident's known need for two-person assistance. The facility's investigation revealed that the care plans and Kardex were not patient-centered, lacking specific instructions on the number of staff required for assistance. The GNA involved in the second incident was terminated following the investigation. Despite previous training sessions, the facility's staff failed to adhere to the documented care requirements, leading to these incidents.
Medication and Treatment Administration Deficiencies
Penalty
Summary
The facility staff failed to administer medications and treatments as ordered by the physician for several residents. Resident #5, who was admitted with a diagnosis of malignant neoplasm of the endometrium, did not receive timely administration of pain medications, including Morphine Sulfate and Gabapentin, as per the physician's orders. The Medication Administration Audit Report revealed multiple instances where these medications were either delayed or not given at all, which was confirmed by the Director of Nursing. Resident #22, admitted with multiple wounds including an unstageable right heel and sacral pressure ulcer, did not have their treatment plan updated in a timely manner. The Wound Nurse Practitioner recommended a change in treatment for the resident's right leg and foot arterial wounds on January 11, 2023, but the facility staff did not implement these changes until January 26, 2023. This delay in updating the treatment plan was acknowledged by the Director of Nursing. Resident #47, who was admitted with chronic respiratory failure and status post lung transplant, did not receive Tacrolimus as ordered on several occasions. The medication, crucial for preventing organ transplant rejection, was not administered on specific dates in September and October 2023. Additionally, Resident #56, who had a history of anemia, congestive heart failure, and dementia, had inaccurate skin assessments documented by LPN #13. Despite the presence of skin issues identified by the Assistant Director of Nursing, these were not recorded in the resident's medical record, leading to a lack of accurate documentation and assessment.
Failure to Notify Physician and Family of Changes in Resident Condition
Penalty
Summary
The facility staff failed to notify the physician of a resident when there was a change in the resident's condition. Resident #47, who was admitted with chronic respiratory failure and was on BiPAP therapy, did not receive the BiPAP treatment on two occasions. The facility staff did not document the administration of BiPAP on 10/4 and 10/6/23, and there was no notification to the resident's physician to potentially adjust the oxygen treatment orders. The Director of Nursing confirmed the failure to notify the physician when the BiPAP was unavailable. Additionally, the facility staff did not communicate with the family of Resident #9 regarding the resident's plan of care and identification with an antibiotic-resistant organism. Although the resident was informed of the condition by the Assistant Director of Nursing, there was no documentation indicating that the responsible party was notified. The Director of Nursing acknowledged that the family was not informed when the resident was first identified with the antibiotic-resistant organism.
Failure to Protect Resident from Inappropriate Sexual Contact
Penalty
Summary
The facility failed to protect a resident from inappropriate sexual contact by a geriatric nursing assistant (GNA) during a complaint survey. The incident involved a GNA from a staffing agency who was found by staff engaged in a sexual act with a resident who was alert and oriented. The resident, who required full care and used a power wheelchair, stated that the act was consensual and was not upset by the incident. However, the resident had a history of major depressive disorder, generalized anxiety disorder, and other persistent mood disorders, which made them vulnerable. The facility's investigation revealed that the GNA initiated the sexual advances while providing care. The incident was discovered by a unit nurse who noticed the GNA with their scrubs down and on top of the resident. The supervising LPN assessed that the GNA appeared to be under the influence of substances, as they were acting erratically and refused to leave the room. The police were notified, and the GNA was sent home. The facility reported the GNA to the staffing agency as a 'do not return' and submitted a write-up to the Board of Nursing. Despite the resident's claim of consent, the facility acknowledged the concern due to the GNA's professional capacity and the resident's vulnerable condition.
Failure to Timely Report Allegations of Abuse
Penalty
Summary
The facility failed to report allegations of abuse within the required 2-hour timeframe to the Office of Health Care Quality (OHCQ) for three incidents. In the first incident, a resident alleged being hit by a GNA while preparing for dialysis. The MDS nurse reported the incident to the Nursing Home Administrator (NHA), and the initial report was sent to OHCQ after the 2-hour window. The facility's investigation included an email from the GNA involved, who described the resident's distress and accusations. An LPN present during the incident did not report the allegation immediately to administration, which was acknowledged by the Assistant Director of Nursing (ADON) during an interview. In the second incident, a resident alleged inappropriate touching by a GNA during a specific week, but the facility could not locate any documentation or files related to the incident, leaving the timing of the report to OHCQ unknown. The third incident involved a resident alleging wrist twisting by staff during repositioning, but the resident could not identify the staff involved. The facility was unable to find any intake information or investigation details, making it unclear if the report was sent timely. The NHA and DON confirmed these findings during the survey.
Failure to Investigate Allegations of Abuse and Neglect
Penalty
Summary
The facility failed to thoroughly investigate allegations of abuse, neglect, exploitation, or mistreatment for four residents during an annual survey. For Resident #6, the facility could not locate the investigation related to an allegation of neglect reported by the resident's emergency contact. The Director of Nursing (DON) confirmed that the facility did not complete a thorough investigation, as they could not find the email with grievances or any interviews conducted with the resident, emergency contact, or staff. Similarly, for Resident #3, the facility failed to provide a copy of the investigation regarding an allegation of inappropriate touching by a geriatric nursing assistant (GNA). Despite efforts to locate the files, the investigation was not provided to the surveyor. Resident #10 alleged mistreatment by staff during repositioning, but the facility could not find any files related to the incident. The Nursing Home Administrator (NHA) and DON confirmed that the investigations could not be found. For Resident #43, who had intact cognition, the facility's investigation into an allegation of rough treatment by GNA #51 was incomplete as it did not include a direct statement from the resident. The Social Services Director (SSD) emphasized the importance of obtaining a direct statement from the resident to complete a thorough investigation. The NHA, who was not employed at the time of the incident, acknowledged that a direct statement should always be obtained from residents alleging abuse or mistreatment.
Inaccurate MDS Coding for Two Residents
Penalty
Summary
The facility staff failed to ensure that Minimum Data Set (MDS) assessments were accurately coded for two residents during a complaint survey. For one resident, the medical record review revealed a fracture of the proximal phalanx of the fifth toe, as indicated by an x-ray report. However, the Discharge Return Anticipated MDS with an assessment reference date failed to capture this fracture in the diagnosis section. This error was confirmed by the Regional Director of Clinical Case Management and the MDS coordinator, who noted that a significant change in condition was planned but not executed as the resident did not return to the facility. For another resident, the MDS documented the receipt of antipsychotic medications during a specified 7-day lookback period. However, a review of the Medication Administration Record for the same period did not provide evidence that the resident received such medication. This discrepancy was confirmed by the MDS coordinator, who stated that she was not responsible for completing the MDS. The Director of Nursing and the Nursing Home Administrator were informed of these findings during the exit conference.
Failure to Update Care Plans and Document Meetings
Penalty
Summary
The facility staff failed to update care plans when there were changes in resident needs and did not have evidence of care plan meetings. For one resident, an incident was reported where the resident was allegedly slapped by staff during ADL care. The resident was known to be periodically resistant to care, and the care plan included interventions such as allowing decision-making and providing clear explanations. However, the care plan was not updated to include strategies like redirection, speaking softly, or returning later when the resident was calm. The Director of Nursing acknowledged that additional interventions should have been included in the care plan. Another resident's guardian reported finding the resident in a poor state without oxygen, which was later addressed by a visiting nurse. The resident had a history of myasthenia gravis and COPD, requiring oxygen. Despite documentation of the resident's condition and oxygen use, the care plan did not include details about oxygen usage, such as the amount, equipment care, or target oxygen saturation levels. Additionally, there was no documentation of care plan meetings with the guardian. The Director of Nursing confirmed these findings.
Failure to Provide Timely Pressure Ulcer Treatment
Penalty
Summary
The facility staff failed to provide timely and appropriate treatment for a resident with pressure ulcers, as identified during a complaint survey. The resident was admitted with an unstageable right heel and sacral pressure ulcer, a left below the knee amputation surgical wound, and right leg and foot arterial wounds. The hospital discharge summary recommended the use of a Bunny air boot while the resident was in bed, but this was not ordered and documented until over a month later. Additionally, the resident's right heel pressure ulcer was assessed by the Wound Nurse Practitioner, who ordered daily skin prep and a specialty bed, but these orders were not implemented in a timely manner. The Treatment Administration Record showed that the treatment for the right heel wound was not updated from the hospital's discharge orders to the Wound Nurse Practitioner's recommendations until 15 days after the assessment. Furthermore, the air mattress, which was part of the recommended treatment, was not ordered until over a month after the initial assessment. The Director of Nursing confirmed these delays in ordering the necessary equipment and changing the treatment plan, which contributed to the deficiency in care for the resident's pressure ulcers.
Failure to Provide Respiratory Care for Residents
Penalty
Summary
The facility staff failed to provide necessary respiratory care treatment for two residents, leading to deficiencies in their care. Resident #47, who was admitted with chronic respiratory failure and a history of lung transplant, did not have their BiPAP therapy ordered or documented for the first four days after admission. Additionally, there were lapses in the administration of the BiPAP on specific dates in October 2023. A nurse's note indicated that the BiPAP mask was missing, which was to be followed up with the respiratory therapist. The Director of Nursing confirmed these failures in ordering and administering the BiPAP therapy. For Resident #4, who had a history of myasthenia gravis, COPD, and chronic respiratory failure, there was a failure to document and order oxygen therapy. Despite the resident's need for continuous oxygen, as noted in various nursing notes, there were no physician orders or documentation in the Medication Administration Record (MAR) or Treatment Administration Record (TAR) for the oxygen therapy. Complaints were made regarding the resident's condition without oxygen, and a visiting nurse had to intervene. The Director of Nursing confirmed the absence of necessary orders and documentation for the resident's oxygen therapy.
Failure to Adhere to Prescribed Drug Regimen for a Resident
Penalty
Summary
The facility failed to ensure that a resident's drug regimen was free from unnecessary drugs. This deficiency was identified during a complaint survey for one resident. The resident was admitted to the facility from the hospital with a discharge summary indicating that Metoprolol 25 mg should be administered twice daily, except on the mornings of dialysis days. The resident attended dialysis on Tuesdays, Thursdays, and Saturdays. However, the medical record review revealed that the resident received Metoprolol on dialysis days, specifically on 9/28, 9/30, 10/3, and 10/5/23, contrary to the physician's orders. An interview with the Director of Nursing confirmed that the facility staff administered Metoprolol on dialysis days, not adhering to the prescribed regimen.
Failure to Provide Timely Medical Equipment for Resident
Penalty
Summary
The facility staff failed to obtain necessary outside services for a resident in a timely manner, as evidenced by the case of a resident who did not receive foot drop splints as recommended by a vascular specialist. The resident, who was readmitted to the facility with muscle wasting, atrophy of the right lower leg, and a tibia fracture of the left leg, was advised by a specialist on two separate occasions to use foot drop splints. Despite a physician's order for the splints dated 6/18/24, the resident reported not having received them during an interview on 10/17/24. The Director of Nursing was unaware of the resident's need for the splints until the surveyor's inquiry, and the Director of Rehabilitation confirmed that the therapist was working with a vendor to obtain the splints. The lack of timely action in acquiring the necessary equipment for the resident's condition was confirmed by the Director of Nursing, highlighting a deficiency in the facility's process for obtaining required medical equipment for residents.
Deficiencies in Medical Record Maintenance and Care Plan Communication
Penalty
Summary
The facility failed to maintain complete and accurate medical records for two residents, which is a violation of accepted professional standards. For one resident, the medical record did not include wound evaluation reports from visits by the Wound Nurse Practitioner on two specific dates. These reports are crucial as they contain wound measurements, observations, and dressing instructions. The absence of these reports was confirmed by the Director of Nursing during an interview. For another resident, there was a failure in communication regarding the resident's plan of care. Although a quarterly care plan meeting was held, the nursing unit manager who attended was not familiar with the resident's care plan, as the resident resided on a different unit. The responsible party attended the meeting via phone, but the nursing manager from the resident's unit did not attend due to other commitments. This lack of appropriate staff attendance and communication was acknowledged by the facility's Director of Nurses.
Call Bell System Failure in Resident Room
Penalty
Summary
The facility staff failed to maintain the resident call bell system in working order, affecting two residents in one of the rooms on Unit 3. During an observation, it was noted that small handheld bells were placed on the over-the-bed tray tables of the affected residents. One of the residents reported that the call bell had not been functioning for over a week, and maintenance was waiting for a part to fix the issue. The surveyor tested the handheld bell, and it took 18 minutes for a staff member to respond, who only heard the bell because she had just exited the bathroom. The room was located at the end of the hallway, and the noise from a dehumidifier and a loud television in the hallway contributed to the delay in response. The Maintenance Director explained that repairs were reported through a system called TELS, and issues could also be communicated directly in the hallway. The problem with the call bell system was identified as an issue with the motherboard, not the plug-in part of the cord. The part needed for the repair was ordered on 10/14/24 and arrived on 10/16/24, at which point it was replaced in the resident's room. The Nursing Home Administrator and the Director of Nursing were informed of the issue several days later.
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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