Patapsco Healthcare
Inspection history, citations, penalties and survey trends for this long-term care facility in Randallstown, Maryland.
- Location
- 9109 Liberty Road, Randallstown, Maryland 21133
- CMS Provider Number
- 215084
- Inspections on file
- 20
- Latest survey
- February 9, 2026
- Citations (last 12 mo.)
- 6
Citation history
Health deficiencies cited at Patapsco Healthcare during CMS and state inspections, most recent first.
Surveyors found that the facility failed to maintain complete and accurate medical records in several areas. Multiple residents identified as independent smokers lacked required admission and quarterly Safe Smoker Assessments, and a resident with a fall history had repeated Fall Risk Evaluations that were missing medication and gait documentation. One resident’s MOLST and code status were inconsistently documented across paper and electronic records and dialysis communication forms, while capacity certifications for two residents were completed with only one physician signature instead of two. A resident who reported missing clothing had no personal belongings inventory in the record. For residents with urinary catheters and other complex needs, urology consult notes and other outside provider documentation were not present in the charts until after surveyor intervention. Additionally, a hospital transfer form for a resident contained conflicting dates and times for the transfer and clinical information, and the DON could not explain the discrepancies, confirming that the form should have been reviewed for accuracy.
Facility staff did not notify a resident's representative about significant changes in the treatment plan, including the scheduling and completion of a vascular intervention for a resident with severe cognitive impairment and peripheral artery disease. The representative only became aware of the procedure after receiving an insurance statement, as there was no documentation of notification by staff.
A resident sustained facial bruising, and the facility failed to conduct a thorough investigation into the cause of the injury. Initial reports conflicted, with one GNA stating the resident poked themselves in the eye and later accounts suggesting a fall during a transfer. The facility did not complete comprehensive assessments, failed to interview all relevant staff or residents, and did not update the care plan to reflect the resident's changing needs.
A resident with complex medical needs was transferred to the hospital for a worsening pressure wound, but the facility failed to document a comprehensive assessment, notify the physician, or provide necessary written notifications and summaries to the resident, their representative, or the receiving hospital.
The facility did not have a qualified activities director on staff for an extended period, as confirmed by staff interviews and review of the staff roster. The position was vacant for over a month, with the previous director leaving and a new one not hired until later.
A facility with 160 beds did not employ a qualified full-time social worker during two separate periods, relying instead on the Activities Director and a Regional Social Worker to handle social services tasks. The absence of a full-time qualified social worker was confirmed by staff interviews and review of the staff roster.
The facility failed to secure narcotic medications, leading to missing medications and discrepancies in inventory sheets. An LPN left a medication cart unlocked, allowing a resident to take medications. Another nurse was unable to account for missing medications, and discrepancies were found in narcotic counts. A blister pack was tampered with, and narcotics for a discharged resident were not removed as per policy.
The facility failed to maintain a dignified environment for residents, with multiple instances of residents being left in undignified and unsanitary conditions. A resident was repeatedly observed in a hospital gown despite wanting to get dressed, and another had to provide their own linens due to the facility's failure. Unsanitary conditions were prevalent, with soiled items left unattended and clogged toilets not addressed, reflecting systemic neglect in care.
The facility failed to maintain a safe and homelike environment due to insufficient linens and a water leakage incident. Observations revealed a shortage of necessary linens, confirmed by staff and a resident, impacting care delivery. Additionally, a water leak on the Promenade unit was not promptly addressed by staff, leaving a resident in a potentially unsafe situation without available towels or blankets to manage the water.
The facility failed to develop and implement baseline care plans within 48 hours of admission for several residents, as required. This deficiency was identified during an annual survey, where it was found that 7 out of 12 residents reviewed did not have timely baseline care plans. Additionally, there was no documentation to confirm that baseline care plans were provided to some residents or their representatives, and one resident with an indwelling catheter lacked a care plan for its management.
The facility failed to report and investigate incidents involving residents within the required timeframes. Incidents included injuries of unknown origin, elopement, misappropriation of property, and potential abuse. Reports were often submitted late, and follow-up investigations were delayed or incomplete, highlighting deficiencies in compliance with regulatory requirements.
A nurse practitioner failed to ensure proper documentation and management of resident care, leading to several deficiencies. Pharmacy recommendations for a resident were not properly signed or addressed, and oxygen therapy orders for another resident were incomplete. Additionally, a resident with heart failure was not properly monitored, and a critical incident involving a change in mental status and hypoxia was not documented, despite the nurse practitioner's assessment.
A facility failed to provide appropriate care and documentation for three residents. One resident with severe cognitive impairment refused a swallow evaluation, but the refusal was not documented, nor was the POA notified. Another resident lacked dentures and hearing aids for extended periods despite grievances filed by their representative. A third resident with respiratory issues did not receive supplemental oxygen as needed, leading to hospitalization. These deficiencies highlight lapses in care and communication within the facility.
The facility failed to prevent resident-to-resident altercations and ensure a safe environment. Two residents with a history of wandering were involved in altercations, resulting in injuries. Additionally, a resident was found with a microwave in their room, posing a safety hazard. These incidents highlight inadequate supervision and monitoring of residents.
Two residents experienced deficiencies in care: one due to the misappropriation of oxycodone by an agency nurse, and another due to prolonged mismanagement of dentures and hearing aids. The facility failed to maintain accurate medication records and safeguard resident property, resulting in unresolved issues despite multiple communications with staff.
A resident was discharged from a facility without an adequate discharge process, leading to a deficiency in ensuring continuity of care at the receiving facility. The resident, who was cognitively intact and required assistance with certain ADLs, was discharged due to a violation of a smoking and behavioral contract. However, the facility failed to document a discharge plan or confirm that the receiving facility was informed of the resident's care needs.
A facility failed to transmit an MDS assessment within the required 14 days for a resident. The MDS, a crucial tool for care planning, was transmitted 37 days after completion. This deficiency was confirmed by the MDS Coordinator during an interview.
A resident complained of heartburn and abdominal pain, and despite being assessed and medicated by a nurse, the physician was not notified until hours later. The delay in contacting the physician led to a late hospital transfer order, violating facility protocols.
The facility failed to complete care plans for two residents, one receiving hospice care and another prescribed oxygen therapy. A resident's care plan did not reflect their hospice status, conflicting with their MOLST form, while another resident lacked a care plan for oxygen therapy. These issues were acknowledged by the DON.
A facility failed to conduct quarterly care plan meetings for a resident, as required. The absence of these meetings was confirmed through a review of the resident's electronic medical record and interviews with facility staff. The Social Work Assistant responsible for scheduling the meetings had not been working at the facility for the past three quarters, leading to the oversight. The Social Work Director acknowledged the issue, confirming that the meetings were not held as required.
The facility failed to adhere to professional standards in oxygen administration and narcotic handling. A resident received oxygen without a specified order, and multiple issues were found with narcotic counts, including missing signatures and unreported discrepancies. An investigation into missing narcotics was ongoing.
Facility staff failed to arrange medical transportation for a resident's follow-up appointment, leading to a missed appointment for urinary catheter removal. The resident's treatment records lacked documentation of catheter care, and the DON admitted no baseline care plan was created due to the absence of a qualifying urinary diagnosis. The appointment was noted in the resident's chart, but the unit manager did not arrange transportation.
A facility failed to maintain an accurate staffing schedule and ensure agency staff wore name badges. During a survey, the assignment board was outdated, and the staff present did not match the listed assignments. Agency staff were also not wearing name badges, as required. Interviews revealed that the nurse on duty was unaware of the responsibility to update the board, and the GNAs confirmed they were not provided with badges.
A pharmacist failed to timely communicate the need to discontinue duplicate Flonase orders for a resident, resulting in both orders being signed off as administered. Despite pharmacy reviews in August and September, no recommendations were made, and the pharmacist admitted to delays in updating records.
A resident with cracked teeth and tooth pain did not receive necessary dental care due to the facility's failure to follow physician orders and schedule appointments. The in-house dental provider did not accept the resident's insurance, and no alternative provider was sought.
The facility failed to properly store and label food items, with expired and undated products found in the kitchen and freezer. Additionally, the Dietary Manager inaccurately maintained dishwasher temperature logs, recording specific temperatures on a day she was not present.
The facility's assessment was not updated to reflect the current needs and conditions of residents, including those requiring wound care and with compromised musculoskeletal systems. It lacked details on addressing residents' ethnic, cultural, or religious factors, and the staffing plan was incomplete. Staff training and competencies did not align with provided forms, and there were no policies for care provision or plans for recruiting trained NPs.
The facility failed to document medication administration for a resident experiencing heartburn and abdominal pain, leading to a hospital transfer. Additionally, discrepancies were found in the inventory records of residents' belongings, with one resident lacking an Inventory of Personal Effects form and another having an outdated form. The LPN Unit Manager explained the process, but documentation was not accurately maintained.
The facility failed to follow infection control practices, with issues including stained cover pads on the floor, improper linen handling, and inadequate waste disposal. A resident's room had flies landing on them, and staff were observed mishandling waste and standing on a bedside commode.
During a survey, deficiencies in facility maintenance were observed, including a clogged commode, a fallen window trim, and a non-functional privacy curtain, leaving a resident exposed. Interviews revealed unclear responsibilities and inadequate maintenance procedures, with staff acknowledging ongoing issues and the development of a preventative maintenance schedule.
A resident was involved in an abuse incident with a GNA who pushed the resident after the resident put food down the GNA's shirt. The incident was reported to the DON, Administrator, and relevant authorities. The GNA was suspended and terminated after admitting to the action, and the facility completed an investigation.
The facility failed to investigate and document several incidents involving residents, including alleged abuse and injuries of unknown origin. In one case, documentation for a resident-to-resident abuse incident was missing, and in another, a delayed report of a hematoma was not submitted to OHCQ within the required timeframe. Additionally, a grievance involving potential property damage was not investigated, and necessary documentation was incomplete.
Incomplete and Inaccurate Medical Records, Missing Assessments, and Absent Consult Documentation
Penalty
Summary
The deficiency involves the facility’s failure to maintain complete, accurate, and readily available medical records in accordance with accepted professional standards. Surveyors found that multiple residents who were identified as independent smokers did not have required Safe Smoker Assessments completed at admission or at required quarterly intervals, despite being listed on the facility’s smoker list. For one resident with a history of falls, several Fall Risk Evaluations were incomplete, lacking required documentation of medications used and gait analysis, even though the resident had a known fall history. Another resident’s personal belongings were not documented anywhere in the medical record or paper chart, despite the resident reporting missing clothing and the facility’s expectation that belongings be recorded on a personal belongings form at admission and updated as needed. The surveyors also identified serious inconsistencies and omissions in documentation related to advance directives, capacity determinations, and hospital transfers. One resident had two conflicting Maryland MOLST forms in the paper chart—one indicating Do Not Resuscitate/Do Not Intubate and another indicating attempt CPR—while the electronic medical record contained an active physician order and uploaded MOLST reflecting full code. This conflicting documentation extended into other records, including a care conference note and dialysis communication forms, where the resident’s code status was alternately documented as full code and DNI. For two other residents, Physician Certifications of incapacity were completed with only one physician signature, despite the requirement for two qualified professionals to certify lack of decision-making capacity. Surveyors further found that the facility failed to maintain and retain outside consult documentation from urology and other providers in residents’ medical records. For one resident with a urinary catheter, no urology specialist documentation could be found in either the electronic or hard-copy chart, even though facility documentation referenced urology visits and refusals. For another resident reviewed in connection with a neglect complaint, the DON initially could not provide nurse practitioner notes or urology consult records and could not confirm whether urology records were present in the chart; subsequent review confirmed that urology consults were not in the resident’s medical record until they were later obtained from the outside provider. In addition, for a resident who had two separate hospital transfers, the hospital transfer form contained inconsistent dates, with the transfer date and hospital notification date not matching the dates of the clinical information and vital signs documented on the same form, and the DON was unable to explain these discrepancies. Collectively, these findings show that the facility did not ensure that medical records, including assessments, code status documentation, capacity certifications, personal property records, outside consult notes, and transfer forms, were complete, accurate, and maintained in accordance with professional standards. Finally, the surveyors noted that for one resident who called 911 and was transported to the hospital, the DON initially stated there was no transfer form because the resident dialed 911, but then produced a transfer form that contained conflicting dates and times for the transfer and clinical data. The DON acknowledged that the information on the transfer form should have been reviewed to ensure accuracy and that it should reflect the resident’s status at the time of transfer. Across these various findings, the surveyors determined that the facility failed to maintain medical records that accurately and completely reflected residents’ conditions, services provided, and external consultations, as required by accepted professional standards and practices.
Failure to Notify Resident Representative of Significant Change in Treatment Plan
Penalty
Summary
Facility staff failed to notify a resident's representative of significant changes in the resident's treatment plan, specifically regarding a scheduled and completed vascular intervention. The resident, who had severe cognitive impairment and multiple wounds related to peripheral artery disease, was evaluated by a physician and determined to require a right lower extremity angiogram with intervention. Documentation showed that the need for the procedure, its scheduling, and its completion were recorded in the medical record, but there was no evidence that the resident's representative was informed at any of these stages. The medical record indicated that the representative was notified when a new wound was first identified, but subsequent significant developments—including the scheduling of a vascular specialist appointment, the recommendation and scheduling of the angiogram with intervention, and the outcome of the procedure—were not communicated to the representative. The deficiency was identified during a complaint survey after the representative learned of the procedure through an insurance statement, rather than from facility staff.
Failure to Conduct Thorough Investigation of Resident Injury
Penalty
Summary
The facility failed to thoroughly investigate an injury sustained by a resident, as evidenced by incomplete documentation and inconsistent accounts regarding the cause of the injury. The initial self-report indicated that a resident was found with bruising to the left eye, and the GNA who provided care stated the resident had poked themselves in the eye. However, subsequent investigation reports referenced a fall during a transfer as the cause of injury, with two GNAs reportedly corroborating this account, but without clear identification or statements from these staff members. There was also a lack of documentation explaining the discrepancy between the initial and final accounts of the incident. Further review revealed that the facility did not complete a comprehensive assessment of the resident when the injury was first identified, nor was there evidence of an assessment of other residents on the same assignment. The investigation documentation lacked interviews with other staff or residents who may have witnessed or been aware of the incident. Additionally, there was no documentation in the medical record to confirm that a fall had occurred prior to the resident's transfer to the hospital, nor was there evidence that a comprehensive assessment was completed after the facility became aware of the fall. The resident's care plan and medical record showed inconsistencies regarding the level of assistance required for transfers and ambulation, with some documentation indicating a need for two-person assist and others indicating hand-held assistance. The facility also failed to update the care plan to reflect changes in the resident's status or with each MDS assessment. There was no evidence of staff abuse training or education related to RAI documentation in the investigation materials. These deficiencies were acknowledged by the Nursing Home Administrator during the surveyor's review.
Failure to Document and Communicate Required Discharge and Transfer Information
Penalty
Summary
The facility failed to ensure that discharge information was sufficiently documented in the medical record for a resident who was transferred to the hospital. The medical record review revealed that the resident, who had complex medical conditions including pressure wounds, was admitted in February and transferred to the hospital in October after a request for hospital evaluation due to a worsening sacral wound. Documentation in the electronic medical record only noted the resident's request to go to the hospital and that the outgoing nurse sent the resident for wound evaluation, but did not include a comprehensive assessment prior to transfer, the reason for the transfer, or evidence that the physician was notified of the resident's request and status. Further review showed there was no documentation that appropriate and necessary information, such as a summary of the resident's status and the reason for transfer, was communicated to the receiving hospital. Additionally, there was no evidence that the resident or their representative was notified in writing of the transfer and the reasons for the move, nor was a written bed-hold notice specifying the duration of the bed-hold policy provided. The medical record also lacked a discharge summary completed by the resident's physician following the transfer and discharge from the facility.
Failure to Employ Qualified Activities Director
Penalty
Summary
The facility failed to employ a qualified activities director for the period from October 2024 to December 2024. This deficiency was identified during a complaint survey, which included a review of staff rosters and staff interviews. The last activities director left in October 2024, and a new activities director was not hired until December 2024, leaving the position vacant for the entire month of November 2024. Interviews with facility staff, including the current activities director and a unit manager, confirmed the absence of a qualified activities director during this time frame. The administrator, who began employment in May 2025, was not aware of the deficiency until informed by the surveyor.
Failure to Employ Full-Time Qualified Social Worker in Facility Over 120 Beds
Penalty
Summary
The facility, with a capacity of 160 beds, failed to employ a qualified full-time social worker during two separate periods: from April 2025 to May 2025, and again from July 2025 to the present. This deficiency was identified during a complaint survey, where it was confirmed through staff interviews and review of the staff roster that the last full-time qualified social worker left in June 2025. During the periods without a full-time social worker, the Activities Director assisted with social services tasks, and a Regional Social Worker provided supervision and support as needed. The Administrator confirmed the absence of a full-time qualified social worker during the specified periods and acknowledged that the facility relied on other staff to fulfill social services responsibilities.
Narcotic Medication Security Breach
Penalty
Summary
The facility failed to maintain a secure system for storing and counting narcotic medications, as evidenced by incidents involving two medication carts. On one occasion, an agency LPN left a medication cart and narcotics box unlocked, resulting in the disappearance of four narcotic pain medication blister packs belonging to three residents. The incident was reported to the Unit Manager and the Director of Nursing (DON), who initiated an investigation. An Environmental Service (EVS) employee observed a resident taking medication from the open cart and failed to report the incident immediately. In another instance, during a narcotic observation, an agency nurse was unable to account for missing medications and noted discrepancies in the controlled substance shift inventory sheets. The outgoing nurse had not signed the inventory sheet, and the incoming nurse was unaware of the missing medications. The DON confirmed that the missing narcotics were related to the previous incident involving the resident taking medications from the cart. Additionally, a surveyor and an agency nurse discovered discrepancies in the narcotic count on another unit. A blister pack had been tampered with, and a pill was replaced and taped shut. The outgoing nurse claimed the narcotic count was accurate, but the incoming nurse had not signed the inventory form. The surveyor also noted that narcotics for a discharged resident were still being counted, contrary to the facility's policy of removing such medications weekly.
Deficiencies in Resident Dignity and Care
Penalty
Summary
The facility failed to provide a dignified environment for residents, as evidenced by multiple observations and interviews. Resident #42 was repeatedly observed in bed wearing a hospital gown despite expressing a desire to get dressed and out of bed. The staff's protocol for getting residents up was inconsistent, and the resident's request to have the television turned on was not initially honored. Additionally, Resident #2 was found to have urine and stool in a plastic bag inside the bedside commode, a practice not aligned with facility protocol, indicating a lack of proper care and respect for the resident's dignity. Several residents were found in unsanitary and undignified conditions. Resident #48 was observed wearing only an incontinence brief without proper covering, and the room was in disarray with soiled items. Resident #71 reported having to urinate on the floor due to the unavailability of a urinal, and was found in a soiled incontinence brief. Resident #76's room had a strong odor due to residents urinating inappropriately, and Resident #281's family had to provide clean linens due to the facility's failure to supply them. These conditions reflect a broader issue of neglect and inadequate care. The facility also demonstrated a lack of cleanliness and maintenance, as seen with the clogged toilets in shared bathrooms and the insufficient supply of linens on the units. Resident #34's room had soiled pads left unattended, and Resident #15 was found uncovered with a saturated pad on the floor. These observations highlight systemic issues in maintaining a clean and dignified environment for residents, contributing to the overall deficiency in care and respect for residents' rights.
Deficiency in Providing a Safe and Homelike Environment
Penalty
Summary
The facility failed to provide a safe, clean, and homelike environment as evidenced by the lack of sufficient linens and a water leakage incident. During a facility tour, it was observed that the laundry room had insufficient linens to meet the required PAR level, resulting in a shortage of towels, washcloths, gowns, and pillowcases in the second-floor linen closet. Interviews with staff and a resident confirmed the shortage, with staff indicating they often had to wait for laundry to be completed to provide care. The administrator acknowledged the issue, stating that extra linens had been ordered, but they continued to disappear. Additionally, a water leakage incident was observed on the Promenade unit, where water was coming through a sprinkler above a light fixture and trickling down the bathroom wall, creating a puddle on the floor. Staff at the nurse's station were aware of the alarm but did not immediately address the situation. A GNA on the Liberty unit was observed standing by as a resident tried to understand the situation, and there were no towels or blankets available to absorb the water. The administrator later assisted the resident and confirmed that maintenance had been notified to address the issue.
Failure to Develop Timely Baseline Care Plans
Penalty
Summary
The facility failed to develop and implement baseline care plans within 48 hours of admission for several residents, as required. This deficiency was identified during an annual survey, where it was found that 7 out of 12 residents reviewed did not have timely baseline care plans. For instance, Resident #27's baseline care plan was completed 15 days after admission, and Resident #104's was completed 16 days post-admission. Additionally, there was no documentation to confirm that baseline care plans were provided to Residents #12 and #48 or their representatives. Furthermore, Residents #49 and #54 had baseline care plans completed, but there were no signatures from the residents or their representatives to confirm receipt and understanding of the care plans. Resident #281's case highlighted a specific issue where the resident was admitted with an indwelling catheter but lacked a care plan for its management. The DON admitted that a baseline care plan was not created due to the absence of a qualifying urinary diagnosis, despite the resident's need for catheter care. This oversight in creating and communicating baseline care plans compromises the continuity of care and safety of the residents, as these plans are crucial for addressing immediate healthcare needs upon admission.
Failure to Timely Report and Investigate Incidents
Penalty
Summary
The facility failed to report and submit facility-related incident reports (FRI) to the Office of Health Care Quality (OHCQ) within the required two-hour timeframe for initial reports and five days for follow-up reports. This deficiency was evident in nine out of 38 facility-reported incidents reviewed during the survey. The incidents involved various issues, including injury of unknown origin, serious bodily injury, elopement, misappropriation of resident property, and potential employee-related abuse towards residents. One significant incident involved a resident who was found with a left breast hematoma of unknown origin. The initial facility incident report was submitted almost a month after the condition was first documented, and the final report was submitted even later. Another case involved a resident who eloped from the facility, and the initial report was submitted beyond the required timeframe. Additionally, there were instances of alleged staff abuse where the facility failed to submit timely reports to the state agency, and in some cases, follow-up investigation reports were either delayed or not completed at all. The facility also failed to report incidents of misappropriation of resident property, such as missing dentures, and did not conduct timely investigations into allegations of abuse. In one case, a resident's daughter reported a fractured rib, but the facility had not documented or reported the incident until after the daughter's notification. These failures to report and investigate incidents in a timely manner highlight significant deficiencies in the facility's compliance with regulatory requirements for reporting and investigating incidents involving residents.
Deficiencies in Documentation and Resident Care Management
Penalty
Summary
The nurse practitioner at the facility failed to ensure proper documentation and management of resident care, leading to several deficiencies. For Resident #56, pharmacy recommendations from May to July 2024 were not properly signed, dated, or addressed, resulting in a lack of changes to the medication administration record. The Director of Nursing acknowledged that the process for handling pharmacy recommendations was not followed before their tenure. Additionally, for Resident #67, an order for oxygen therapy was incomplete, lacking specific details on the amount of oxygen required. Resident #129's records showed incomplete documentation and monitoring of treatment effectiveness for heart failure and pleural effusions. The nurse practitioner did not document the effectiveness of a diuretic treatment or monitor the resident's weight. Furthermore, for Resident #139, there was a failure to document the nurse practitioner's assessment during a critical incident involving a change in mental status and hypoxia, which led to a hospital transfer. The nurse practitioner admitted to not documenting the resident's condition, including observed bruises and swelling, during the assessment.
Deficiencies in Resident Care and Documentation
Penalty
Summary
The facility failed to ensure that Resident #27 received appropriate treatment and care according to professional standards. The resident, who had severe cognitive impairment and dementia, was referred for a swallow evaluation to potentially change their diet from pureed to mechanical soft. However, the resident refused the evaluation, and there was no documentation of this refusal in the medical record. Additionally, the resident's Power of Attorney (POA) was not notified of the refusal, which was a necessary step given the resident's cognitive impairment. The Director of Rehabilitation confirmed that the proper parties should have been contacted to ensure the resident received appropriate care. Resident #104 experienced a deficiency in care related to missing dentures and hearing aids. The resident, also diagnosed with severe cognitive impairment and dementia, had been without dentures for about a year and hearing aids for approximately eight months. Despite multiple reports and grievances filed by the resident's representative, the facility failed to resolve the issue. The facility's administration had not followed up adequately on the resident's dental insurance status or the missing hearing aids, leaving the resident without essential aids for an extended period. Resident #61's care was compromised due to a failure to administer supplemental oxygen as needed. The resident, with a history of chronic obstructive pulmonary disease and other respiratory issues, experienced a significant drop in oxygen saturation levels, leading to hospitalization. The medical records did not document the administration of oxygen as ordered, nor did they include the resident's oxygen levels on the day of the incident. The Director of Nursing acknowledged that no interventions were implemented during the time the resident's oxygen levels were critically low, indicating a lapse in the standard of care provided.
Inadequate Supervision and Safety Hazards in LTC Facility
Penalty
Summary
The facility failed to provide adequate supervision to prevent resident-to-resident altercations, as evidenced by incidents involving three residents. In the first incident, a resident with a history of wandering entered another resident's room and was struck, resulting in a skin tear. The facility did not have a record of an investigation into this incident. In the second incident, another resident wandered into a room and was hit on the head, causing a laceration. Both incidents highlight a lack of effective monitoring and intervention for residents known to wander. Additionally, the facility failed to ensure that residents were free from accident hazards. During observation rounds, a resident was found with a microwave plugged in and resting on the bed, which posed a potential safety risk. The resident stated that the microwave was used to heat food because staff did not assist with this task. The microwave was subsequently removed by the Maintenance Director, indicating a lapse in ensuring a safe environment for residents.
Misappropriation of Medication and Mismanagement of Resident Property
Penalty
Summary
The facility failed to maintain accurate records and safeguard controlled medications, leading to the misappropriation of oxycodone for Resident #101. On 4/1/24, it was discovered that the medication and its count log were missing from the medication cart. An investigation revealed discrepancies in the narcotic count process, with conflicting reports from staff about who completed the count. Camera footage confirmed that an agency nurse removed the medication and count sheet, leading to the termination of involved staff and a report to the board of nursing. Resident #104 experienced a prolonged period without dentures and hearing aids due to mismanagement and miscommunication regarding insurance and replacement processes. The resident's representative reported the missing dentures and hearing aids, which had been absent for about a year and eight months, respectively. Despite multiple communications with facility staff, including the Unit Manager and Nursing Home Administrator, the issues remained unresolved, and the resident continued to lack these essential items. The medical record for Resident #104 indicated severe cognitive impairment and a care plan addressing potential oral health problems. Despite documented interventions, the facility failed to ensure the resident received necessary dental and hearing aid replacements. Interviews with staff confirmed the resident's previous possession of these items and highlighted the lack of follow-up on insurance and replacement arrangements, leaving the resident without essential aids for an extended period.
Inadequate Discharge Process for Resident
Penalty
Summary
The facility failed to implement a proper discharge process for a resident, leading to a deficiency in ensuring continuity of care at the proposed post-discharge facility. The resident, who was cognitively intact and their own representative, was discharged without adequate planning. The resident was wheelchair-bound, a complete paraplegic, and required assistance with showering. They had diagnoses including depression, neurogenic bladder requiring urinary catheterizations, and schizophrenia, and were on medications such as antipsychotics, antidepressants, opioids, and anticonvulsants. The deficiency was identified during a revisit survey following a complaint. The complaint alleged that the resident was discharged without an adequate process in place. The facility's Nursing Home Administrator and Director of Nursing were unable to provide evidence of a documented discharge plan or confirmation that the receiving facility was aware of the resident's transfer and care needs. The discharge was reportedly due to the resident violating a smoking and behavioral contract, which was grounds for involuntary discharge according to a settlement agreement. However, there was no documentation to support that the resident's care needs were communicated to the receiving facility.
Delayed Transmission of MDS Assessment
Penalty
Summary
The facility failed to transmit the Minimum Data Set (MDS) assessments within the required 14 days of completion for a resident. The MDS is a federally mandated assessment tool used to gather information on each resident's strengths and needs, which is crucial for care planning decisions. The assessment for a resident was completed, but the transmission of this data to the State was delayed, occurring 37 days after the assessment was completed. This deficiency was confirmed during an interview with the MDS Coordinator, who acknowledged the failure to meet the 14-day transmission requirement.
Failure to Timely Notify Physician of Resident's Condition Change
Penalty
Summary
The facility staff failed to notify the physician in a timely manner regarding a significant change in condition for a resident receiving MD or ID services. On 10/7/23, at approximately 3 AM, the resident complained of heartburn and was assessed by Nurse #59 during the night shift. The nurse administered antacid and pain medication. However, at 5:30 AM, the resident's daughter called, reporting the resident's abdominal pain and suggesting hospital transfer if the facility's intervention was ineffective. Despite this, the physician was not contacted until 7 AM, at which point an order was given to transfer the resident to the hospital via 911. The delay in contacting the physician constituted a failure to follow facility protocols, as verified by the Administrator.
Failure to Complete Care Plans for Hospice and Oxygen Therapy
Penalty
Summary
The facility failed to complete care plans for two residents, leading to deficiencies in their care management. Resident #67, who was receiving hospice care, did not have a care plan reflecting this status. Instead, the care plan indicated the resident was a Full Code, which conflicted with the resident's MOLST form that specified No CPR Option B Palliative & Supportive Care. This discrepancy was acknowledged by the Director of Nursing during an interview. Additionally, Resident #126, who was prescribed oxygen therapy, did not have a care plan for the administration of oxygen, which was also brought to the attention of the Director of Nursing.
Failure to Conduct Quarterly Care Plan Meetings
Penalty
Summary
The facility staff failed to conduct quarterly care plan meetings for a resident, as required. During a review of the electronic medical record for a resident, it was found that there were no notes indicating that care plan meetings had been held. Interviews with facility staff revealed that the Social Work Assistant, responsible for scheduling these meetings, had not been working at the facility for the past three quarters, which contributed to the oversight. The Social Work Director confirmed that the meetings were not held quarterly as required and acknowledged the issue was identified in August 2024. The deficiency was evident in the lack of documentation and the absence of quarterly care plan meetings for the resident. The Social Work Director explained that all department heads, along with the resident and family, are supposed to attend these meetings, and if the family cannot attend in person, they are invited to participate via phone. However, the process was not followed, and the resident did not receive the necessary quarterly care plan meetings, as confirmed by the review of care plan notes and sign-in sheets.
Deficiencies in Oxygen Administration and Narcotic Handling
Penalty
Summary
The facility staff failed to adhere to professional nursing standards in several instances. For Resident #67, a Nurse Practitioner ordered oxygen therapy as needed for shortness of breath, but the order did not specify the number of liters to be administered. Despite this, the resident was observed receiving 2 liters of oxygen via nasal cannula. When questioned, LPN #26 indicated that residents are generally started on 2 liters, but the order lacked specific instructions. This oversight in following proper protocol for oxygen administration was noted during the survey. Additionally, there were multiple deficiencies related to the handling of narcotics. Agency RN #63 did not complete the narcotic count at the beginning of their shift, and LPN #26 failed to provide a report or verify the narcotic count. The Controlled Substance Shift Inventory Form was incomplete, lacking the signature of the incoming nurse. Furthermore, there were incidents of narcotics being taped in blister packs without proper reporting or wasting procedures. An investigation into a separate incident revealed that narcotic blister packs were missing, and the narcotic count sheets were not properly signed. The Director of Nursing confirmed these discrepancies and acknowledged that the investigation was ongoing.
Failure to Arrange Medical Transportation for Resident's Follow-Up Appointment
Penalty
Summary
Facility staff failed to arrange medical transportation for a resident's follow-up appointment, resulting in the resident missing a scheduled appointment to have their urinary catheter removed. During the survey, it was discovered that the resident and a family member reported the missed appointment, which was scheduled for 8:30 AM. The review of the resident's treatment administration records did not reveal any urinary catheter treatments or a care plan. The Director of Nursing (DON) admitted that a baseline care plan was not created because the resident was admitted without a qualifying urinary diagnosis. Additionally, the DON explained that the follow-up appointment was noted in the resident's paper chart, but the unit manager failed to arrange the necessary medical transportation.
Inaccurate Staffing Schedule and Lack of Name Badges
Penalty
Summary
The facility failed to ensure that the posted staffing schedule was updated and accurate, as observed during a survey conducted on the Memory Unit. During a tour at 2:15 AM, the assignment board was found to be outdated, displaying staff assignments from the previous day. The nurse on duty was not the one listed on the board, and one of the GNAs present was not listed, while another listed GNA was absent. Additionally, the agency staff present were not wearing name badges, which is a requirement. Interviews with the staff revealed that the nurse on duty was an agency nurse who did not usually work at the facility and was unaware of the responsibility to update the assignment board. The GNAs, also from an agency, confirmed they were not provided with name badges. The Nursing Home Administrator acknowledged the issues when informed and stated that the nurse was responsible for updating the board and that agency staff should have badges or temporary ones from the front desk.
Pharmacist's Delay in Addressing Duplicate Medication Orders
Penalty
Summary
The deficiency involved a failure by the pharmacist to communicate the need to discontinue two unnecessary intranasal medications for a resident. The issue was identified during a review of the resident's medication administration record, which revealed duplicate orders for Flonase, both of which were being signed off as administered by the nursing staff. The initial order for Flonase was made in June, followed by a duplicate order in August. Despite the pharmacy review conducted in August and September, no recommendations were made to address the duplicate medication orders. The surveyor's investigation included interviews with the pharmacist and nursing staff. The pharmacist acknowledged the duplicate orders and indicated that a recommendation to address the issue was pending communication to the physician. However, the pharmacist admitted that recommendations are sometimes staggered and aimed to be updated by the end of the month. The review of the resident's monthly medication reviews for August and September showed no pharmacy recommendations, indicating a lapse in timely communication and action to rectify the unnecessary medication orders.
Failure to Schedule Dental Appointments for Resident
Penalty
Summary
Facility staff failed to follow physician orders and schedule necessary dental appointments for a resident experiencing tooth pain. The resident reported pain in their left upper and lower molars due to cracked teeth, but had not been taken to a dentist. Despite having physician orders for dental consults on two separate occasions, the facility did not ensure these appointments were scheduled or attended. The Director of Nursing was unaware of the resident's dental issues until prompted by the surveyor, and a new dental appointment order was only placed after the surveyor's inquiry. The facility's in-house dental provider did not accept the resident's insurance, and there was no documentation of attempts to find an alternative provider. This lack of action resulted in the resident's dental needs being unmet.
Deficiencies in Food Storage and Record-Keeping
Penalty
Summary
The facility failed to properly store and label food items in accordance with professional standards, as observed during an initial tour of the kitchen. The walk-in refrigerator contained ham loosely covered with saran wrap and undated, and ground beef logs without expiration dates. The dietary staff in charge was unable to confirm the safety of these items for consumption. Additionally, several food products were mislabeled with incorrect expiration dates, and some items, such as pickles and celery, were confirmed to be expired. The walk-in freezer contained undated hamburger and hotdog buns, and an open jar of jelly was improperly stored with spices instead of being refrigerated. Mold was also found on a loaf of bread with an expired date. The facility also failed to accurately maintain dishwasher temperature logs. The Dietary Manager admitted to signing the logs for specific temperatures on a day she was not present, relying instead on verbal confirmation from another staff member that the dishwasher was functioning properly. This discrepancy in record-keeping raises concerns about the accuracy and reliability of the facility's documentation practices.
Incomplete Facility Assessment and Resource Planning
Penalty
Summary
The facility failed to update its facility-wide assessment to accurately reflect the current needs and conditions of its residents, as well as the resources required to care for them. During the survey, it was discovered that the facility assessment did not include the current facility manager's information, nor did it accurately reflect the diagnoses and acuity levels of the residents, such as those requiring wound care and with compromised musculoskeletal systems. Additionally, the assessment lacked details on how the facility addresses the ethnic, cultural, or religious factors of the residents. The staffing plan was incomplete, failing to specify the number of nurses and geriatric nursing assistants needed. Furthermore, the staff training, education, and competencies were not fully aligned with the competency form provided by the Director of Nursing. The assessment also omitted policies and procedures for care provision and did not outline strategies for recruiting and retaining adequately trained nurse practitioners, despite having an NP currently working in the facility. An updated assessment was provided by the administrator, but it still contained missing information.
Deficiencies in Medication Documentation and Inventory Records
Penalty
Summary
The facility nursing staff failed to document the administration of medication for a resident who complained of heartburn and abdominal pain. The resident was assessed by a nurse during the night shift and was given antacid and pain medication. However, the medical record, Medication Administration Record, and progress notes did not contain an order for these medications, and they were not signed off as administered. The resident's daughter called the facility expressing concern about the resident's abdominal pain, leading to the resident being transferred to the hospital. An Employee Counseling Form for the nurse involved was provided, but it contained a date error. Additionally, the facility failed to maintain accurate records of residents' belongings. During a survey, it was found that one resident's paper chart did not contain an Inventory of Personal Effects form, while another resident's form did not match the actual belongings observed. The LPN Unit Manager explained the process for managing residents' personal items, but discrepancies were noted in the documentation, indicating a failure to update and maintain accurate records of residents' belongings.
Infection Control and Linen Management Deficiencies
Penalty
Summary
The facility failed to adhere to infection control practices and guidelines, as evidenced by several observations during the survey. In one instance, a room was found with two cover pads on the floor, stained with a dark brown substance, and flies were observed landing on a resident. This was reported to the nursing staff and the Nursing Home Administrator. Additionally, two employees were seen transporting uncovered linen in an elevator and leaving it on the floor in the laundry room, which was not properly managed or stored. The Employee Success Manager was unable to explain why the linen was on the floor. Another deficiency was observed in a resident's room where urine and stool were left in a plastic bag inside a bedside commode. A Geriatric Nursing Assistant was present but discarded the waste improperly in a trash can. Furthermore, the Environmental Services Director was seen standing on the resident's bedside commode, an action they later claimed was out of character. These incidents highlight lapses in infection control and proper waste management within the facility.
Facility Maintenance Deficiencies Observed
Penalty
Summary
The facility staff failed to maintain essential equipment and the environment in good operating condition, as observed during a survey on the [NAME] Cove unit. On 09/16/24, a surveyor found a shared bathroom commode in room [ROOM NUMBER] filled with urine and excrement, which nearly overflowed when flushed. Additionally, the trim below a window in the Dayroom was found on the floor, and a privacy curtain in a resident's room could not be fully extended, leaving the resident exposed. The surveyor informed an agency LPN about the clogged commode, but no immediate action was taken. Interviews with facility staff revealed a lack of clear responsibility and effective maintenance procedures. The Maintenance Director mentioned that floor techs were responsible for curtain maintenance and that a preventative maintenance schedule was being developed. The Director of Nursing stated that Maintenance and Environmental Services should ensure proper curtain installation, with nursing staff as a secondary check. Furthermore, a call bell outside another room was found to be hypersensitive and had been removed by an LPN, indicating further issues with equipment maintenance and responsiveness.
Resident Abuse Incident Involving GNA
Penalty
Summary
The facility failed to ensure that residents remained free of abuse, as evidenced by an incident involving a resident and a Geriatric Nursing Assistant (GNA). The incident occurred when the GNA was collecting trays in the hallway, and a resident with a plate full of food was approached by the GNA, who asked for the plate. The resident ignored the request, and when the GNA repeated herself and attempted to take the plate, the resident put a handful of food down the GNA's shirt. In response, the GNA pushed the resident, causing the resident to fall. The incident was reported to the Director of Nursing and the Administrator, and the facility notified the state agency, law enforcement, ombudsman, and physician on the same day. The GNA was suspended immediately and later terminated after admitting to pushing the resident. The facility's investigation was completed quickly, and the final report was sent to the state agency. The Human Resource Manager confirmed the termination was due to a substantiated allegation of abuse, and the GNA was reported to the board of nursing.
Failure to Investigate and Document Resident Incidents
Penalty
Summary
The facility staff failed to conduct thorough investigations into several incidents involving residents, leading to deficiencies in handling alleged abuse and injuries of unknown origin. In one case, the facility was unable to provide documentation for an alleged resident-to-resident abuse incident involving a skin tear, as the investigation records were not maintained. Another incident involved a resident with a hematoma of unknown origin, where the facility delayed initiating an incident report and failed to report the injury to the Office of Health Care Quality (OHCQ) within the required two-hour timeframe. Additionally, the facility did not provide the surveyor with the necessary documentation before the surveyor's exit. In another incident, a resident expressed concerns about potential damage to personal property following a false allegation made by another resident. The facility did not conduct an investigation into the incident, and the grievance documents lacked statements from the affected resident or nearby witnesses. The facility's failure to maintain and provide investigation documentation for these incidents highlights a lack of adherence to proper procedures for handling and documenting resident grievances and incidents.
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The facility did not ensure that its Infection Preventionist (IP) met required qualifications for managing the Infection Prevention and Control Program. The DON reported serving as the IP but acknowledged lacking the specialized infection control training required for the role, and confirmed that no other staff member was currently qualified. Records showed that the previously qualified IP left several months earlier, and the Administrator and DON confirmed they were still seeking a replacement, leaving the infection control program without a properly trained leader.
Staff failed to consistently secure medications and medical supplies across three units, including an oxygen tank left on the floor behind a resident’s bed without a supporting device, a treatment cart with Collagenase Santyl cream left on top while two residents in power wheelchairs passed by, an unattended and unlocked treatment cart at a nursing station, and another treatment cart with Diclofenac gel and dressings left on top, indicating repeated lapses in maintaining locked and secure storage for drugs, biologicals, and related supplies.
The facility failed to provide sufficient dietitian coverage and timely nutritional assessments for several residents with significant dietary needs. A resident admitted for diabetic management with a high A1C was placed on a regular diet instead of the recommended carb-controlled diet and had only one weight taken in the first two weeks, with no dietitian review of the record. Another resident with prior significant weight loss had no documented dietitian follow-up despite continued weight loss, and a resident admitted with severe protein-calorie malnutrition experienced further significant weight loss without any dietitian assessment. The dietitian reported working limited hours and prioritizing certain high-risk cases, resulting in delayed or missed evaluations for new admissions and residents with ongoing nutritional concerns.
The facility failed to maintain adequate linen and incontinence supplies and did not keep resident care areas in good repair, resulting in delays and alterations in incontinence care and substandard environmental conditions. Staff reported that towels and washcloths were used instead of wipes and then discarded due to heavy soiling, and that linen deliveries to units were late, leaving residents waiting for care. Observations showed very limited numbers of clean washcloths and other linens on units and in the laundry, with no stock of disposable wipes or backup washcloth supply despite repeated reports to housekeeping. Additional observations revealed recliner chairs blocking a dining-area handwashing sink and kitchenette, multiple resident and shared bathrooms with unfinished spackle, chipped paint, musty odors, black substances near showers, missing threshold molding, exposed cracks and nails, and eroded, rusted baseboard heaters. Hallway handrails on both units were worn, chipped, and splintered, and a shower room contained fecal odors, dried brown stains on the toilet, and deteriorated fixtures, all contributing to a failure to provide a safe, clean, and homelike environment.
Facility staff did not thoroughly investigate two separate abuse allegations involving a resident and an injury of unknown origin involving another resident. In both cases, investigations focused on the directly affected resident and included staff interviews, but there were no interviews of other residents on the unit or documented assessments of those residents for signs of abuse or injuries of unknown origin, including residents unable to communicate due to cognitive status.
Two residents who were dependent on staff for oral care, including one with a tracheostomy, were observed with thick, white or milky substances coating their mouths and teeth, indicating inadequate oral hygiene. One resident communicated that staff did not brush their teeth and that staff "need to." In another case, despite oral care supplies being present in the room, the resident’s mouth and teeth remained unclean on multiple observations, with a thick milky substance caking the teeth and stringing between them when the resident tried to open their mouth. These findings showed that staff did not consistently provide oral care to residents who relied on them for this ADL.
Staff failed to maintain complete and accurate medical records for multiple residents, including missing and inconsistent documentation of wound care, delayed pain assessment after discovery of an injury of unknown origin in a cognitively impaired resident, and inaccurate recording of a PPD test result that was documented as negative despite no evidence the injection was administered and no supporting nurse’s note. Residents reported not receiving certain treatments, while MAR entries either lacked signatures for completion or contained conflicting information about whether care was provided.
Surveyors found that the facility failed to consistently implement and communicate correct transmission-based precautions and PPE use. One resident with a Foley catheter related to wounds had no precaution signage posted, while another resident in a double room had a contact precautions sign at the door, yet the NP entered without PPE and the GNA provided high-contact care wearing only gloves. Staff in that room stated the resident was not on contact precautions and later reversed the sign to show no PPE requirement. Therapy staff reported they rely solely on posted signs to determine PPE, and surveyors identified broader issues with inaccurate signage and staff awareness of which residents required contact precautions.
Surveyors found that MDS assessments were inaccurately coded for two residents. In one case, a resident sustained a femoral neck fracture after a fall, but the subsequent significant change MDS did not code the fall as a major injury and failed to capture prn Tylenol use documented on the MAR within the look-back period. In the other case, a quarterly MDS indicated opioid use for a resident, but the MAR for the same period showed no prescribed opioid, indicating incorrect coding of high-risk drug classes.
A resident who had recently been admitted and experienced a fall received multiple doses of the narcotic analgesic Tramadol, but the facility failed to accurately document all administered doses on the Medication Administration Record (MAR). Review showed only one Tramadol dose recorded on the MAR, while the Controlled Drug Receipt/Record/Disposition Form on the med cart reflected three doses given over two days. In interview, the DON stated staff are expected to document narcotic administration on the MAR and confirmed that two administered doses were not recorded there, resulting in an incomplete and inaccurate medical record.
Unqualified Infection Preventionist Overseeing Infection Control Program
Penalty
Summary
The facility failed to ensure that its designated Infection Preventionist (IP) met the mandatory qualifications for overseeing the Infection Prevention and Control Program. During an interview on 3/24/26 at 10:00 AM, the DON confirmed that she/he was serving as the facility’s IP but had not completed the specialized training in infection control required for the position. The DON further stated that no other staff member currently met the qualifications to serve as IP. Record review showed that the previously qualified IP left the facility in October 2025, and as of the survey date, the position remained unfilled by a qualified individual. At 1:30 PM on the same day, the Administrator and DON confirmed they were still in the process of finding a qualified IP for the facility, leaving the Infection Prevention and Control Program without a properly trained and qualified leader. No specific residents, medical histories, or clinical conditions were described in relation to this deficiency.
Unsecured Medications, Treatment Carts, and Oxygen Equipment
Penalty
Summary
Facility staff failed to ensure that drugs, biologicals, and related medical supplies were securely stored and properly maintained on multiple units. On one unit, an oxygen tank assigned to a resident was observed sitting on the floor behind the resident’s bed without any supporting device. On another unit, a treatment cart was observed with a tube of Collagenase Santyl cream labeled for a specific resident left on top of the cart, while residents in power wheelchairs passed by and staff were present at the nursing station. These observations showed that medications and oxygen equipment were not consistently secured as required. Further observations on additional units revealed an unattended and unlocked treatment cart at a nursing station, and on a separate occasion, a treatment cart with Diclofenac gel labeled for a resident left on top along with multiple packs of dressings. These incidents occurred across three units and on more than one date, demonstrating repeated failures to keep medications and treatment supplies in locked compartments or otherwise secured from unauthorized access.
Insufficient Dietitian Coverage and Delayed Nutritional Assessments
Penalty
Summary
The deficiency involves the facility’s failure to employ sufficient food and nutrition staff, including adequate dietitian coverage, to ensure timely assessment and appropriate diets for residents with significant nutritional and diabetic needs. A resident admitted over two weeks earlier with multiple comorbidities and an A1C of 11.5% had a hospital discharge recommendation for a carbohydrate-controlled diet, but was placed on a regular diet at admission with no acknowledgment of the recommended diet until one week later, when the resident requested larger portions. As of the survey date, the dietitian had not yet seen or reviewed this resident’s medical record, and the resident reported not having seen a dietitian and being very frustrated with the meals. During the first two weeks after admission, only one weight was obtained for this resident, despite physician notes stating the resident’s weight was “stable.” Further review of other residents showed additional failures in timely dietitian assessment and follow-up. One resident, readmitted in January and previously seen by the dietitian in September for a 6.4 lb weight loss over 30 days, had no documented follow-up despite continued weight loss totaling 22 lbs since the last dietitian review. Another resident admitted at the end of February with severe protein-calorie malnutrition had not been seen by the dietitian after about a month in the facility, despite a documented 14 lb (7%) weight loss over two weeks. The dietitian reported working only 12 hours per week at the facility and stated that she must prioritize which residents to see, focusing first on residents with tube feedings and those identified in risk meetings, resulting in delayed or absent assessments for new admissions and residents with ongoing weight loss and malnutrition diagnoses.
Linen Shortages and Poor Environmental Maintenance Compromise Resident Care and Comfort
Penalty
Summary
The deficiency involves the facility’s failure to maintain an adequate supply of clean linens and appropriate incontinence wipes, resulting in delays and alterations in residents’ incontinence care, as well as the use of towels and washcloths in place of disposable wipes. During the initial tour, the surveyor observed that the linen supply on one nursing unit hallway was low. Complaint reviews included concerns about delays in incontinence care and bed linens not being changed regularly, with residents left without clean bedding. A complainant reported that there was not enough clean linen available for residents. Staff interviews confirmed that towels, sheets, and washcloths were being used to wipe residents for incontinence care due to the absence of wipes, and that many of these linens were being thrown away when soiled. Staff also reported a shortage of linen, that linen deliveries to the units were late, and that residents who preferred to get up before breakfast had to wait for care when linen was delayed. Further observations showed that the clean supply room contained no disposable wipes or cloths for incontinence care, and a resident reported that staff did not use wipes, that the resident had to purchase their own, and that heavily soiled towels or washcloths were discarded. A tour of all nursing unit linen carts and closets revealed only six clean washcloths and limited supplies of towels, gowns, and bed linens. In the laundry room, only three washcloths were present, and the laundry assistant stated that there were only three washcloths available for each nursing unit that morning, that the facility was short on linen supply, and that these concerns had been repeatedly reported to the Director of Housekeeping over the preceding month and again that morning. The laundry assistant confirmed there was no additional laundry in process. The DON stated that wipe squares should be used for incontinence care, but no such wipes were found in the clean medical supply room, and no backup supply of washcloths was present in the emergency linen supply. The Director of Housekeeping confirmed there was no backup supply of washcloths. The deficiency also includes environmental and maintenance issues affecting resident bathrooms, handrails, and common areas. In the main dining area, a recliner chair was observed positioned directly in front of the handwashing sink, and two recliner chairs were stored in front of the nutrition area kitchenette. Multiple resident bathrooms and shared bathrooms were repeatedly observed over several days with unfinished spackle on walls that needed resurfacing and painting, chipped paint around sinks, uneven boards nailed to walls under sinks that appeared to partially cover holes, musty odors, black substances between shower bases and walls, missing threshold transition molding exposing cracks, missing tiles, and a nail, as well as eroded and chipped paint on baseboard heaters with exposed dark brown metal and rust-like material. Hallway handrails on both nursing units were observed to be worn, with chips, splintering, holes, and areas where the wood finish had worn off. A shower room was observed with a foul fecal odor, dried brown stains on the back of the toilet seat and in the toilet bowl, and a baseboard heater with eroded, chipped paint and rust-like material, along with chipped paint on the handrail. These conditions were acknowledged by the Director of Maintenance and other leadership, and some areas were noted to be in the process of renovation, but the observed deficiencies remained present during the survey period. Overall, the facility did not maintain a safe, clean, comfortable, and homelike environment in good repair across both nursing units and the dining area. The lack of adequate linen and incontinence supplies, combined with the poor condition of resident bathrooms, handrails, and certain common areas, constituted the basis for the cited deficiency. The observations and staff and resident reports consistently described shortages of essential hygiene supplies, delayed care related to linen availability, and multiple unresolved environmental and maintenance issues in resident care areas and shared spaces.
Failure to Thoroughly Investigate Abuse Allegations and Injuries of Unknown Origin
Penalty
Summary
Facility staff failed to thoroughly investigate allegations of potential abuse involving one resident and an injury of unknown origin involving another resident. For one resident, there were two separate allegations of abuse occurring on different days in early February. The facility’s investigation packets included interviews with staff who cared for or were scheduled to work with this resident on the days of the alleged incidents, and the investigations focused solely on this resident. However, there were no interviews conducted with other residents on the unit to inquire about abusive or neglectful treatment by the staff who were working during the times of the allegations. The surveyors noted that, although the allegations were not validated, there was no documentation that other residents were interviewed, if able, or assessed for signs or symptoms of injury. In a separate incident, another resident was identified on March 4 with a new bruise on the right eye, documented as a change in condition at 4:09 AM. This resident had a BIMS score of 99, indicating the resident was unable to complete an interview and therefore could not report how the injury occurred. The facility’s investigation identified a potential cause of the injury but did not reach a definitive resolution. Additionally, there were no interviews of other residents on the unit regarding possible abuse, nor were there documented assessments of other residents for injuries of unknown origin, particularly for those unable to speak for themselves, as in this resident’s case.
Failure to Provide Oral Care to Dependent Residents
Penalty
Summary
The deficiency involves the facility’s failure to provide oral care to residents who were dependent on staff for activities of daily living, specifically oral hygiene. One resident with a tracheostomy was observed with a thick, sticky white substance in the mouth and was noted to intermittently chew on nearby bedding. This resident made good eye contact and, when asked if staff brushed their teeth, shook their head no and mouthed that staff “need to.” According to the resident’s Minimum Data Set (MDS) dated 2/11/26, the resident was dependent on staff for oral care. Another resident, also dependent on staff for oral care per the 3/11/26 MDS, was observed sitting propped up in bed and able to respond with smiles. During the initial observation, the inside of this resident’s lips and upper and lower teeth had a thick, clear, white milky substance visible when the resident tried to open their mouth to smile. Oral care supplies were present in the nightstand, but the resident’s mouth and teeth were not clean. On a subsequent observation with the DON, NHA, and Corporate VP of clinical services, the same resident again had a thick, clear, milky substance between the lips and caking the teeth, which would string between the teeth when the resident attempted to open their mouth, demonstrating a lack of consistent oral care for residents dependent on staff for this ADL.
Incomplete and Inaccurate Medical Record Documentation for Treatments and Assessments
Penalty
Summary
Facility staff failed to maintain complete and accurate medical records and documentation for multiple residents. For one resident with wound care needs, review of the MAR showed that wound care and related treatments were signed as completed on the dates initially reported, despite the resident’s ongoing complaints that wound dressings were not being changed. When additional dates were reviewed, there were missing staff signatures for wound care on two specific dates, as well as three instances where application of A&D ointment to the resident’s feet was not signed off out of 24 days reviewed. Another resident with severe cognitive impairment, as evidenced by a BIMS score of 00, was found to have an injury of unknown origin (a bruise on the left hand). Documentation showed that a change in condition was initiated late in the morning, but a formal pain evaluation was not initiated and completed until that night, and the resident was unable to explain how the injury occurred or verbalize pain using a standard pain scale. For a third resident, documentation related to the admission PPD test was inconsistent and incomplete. The MAR contained an entry indicating “9” for the administration date, meaning “see nurse’s note,” but there was no corresponding nurse’s note. Despite the absence of a signed administration of the PPD injection, staff documented the PPD result as “negative” on the scheduled read date. The resident reported never receiving the PPD injection, and the DON confirmed that the facility had been out of PPD solution at the time, so the test would not have been administered. These findings demonstrate failures in accurate documentation of treatments and assessments, including wound care, pain assessment, and TB screening, as well as missing or incomplete supporting notes in the medical record.
Failure to Implement and Communicate Correct Transmission-Based Precautions
Penalty
Summary
Surveyors identified a deficiency in the facility’s infection prevention and control program related to inconsistent and incorrect implementation of transmission-based precautions and PPE use. During a complaint investigation focused on residents on transmission-based precautions, one resident with a visible Foley catheter was observed in the room with physical therapy, but there were no signs posted indicating any need for PPE, despite the resident being a new admission with a Foley catheter placed related to wounds. In another double-occupancy room, a contact precautions sign was posted at the doorway, but the nurse practitioner was in the room on a personal phone with no PPE, and the assigned GNA was repositioning the resident in bed while wearing only gloves. When questioned, the NP, RN, and GNA all stated that the resident in the room was not on contact precautions, and the GNA reported that signs were hanging at all doors and that this particular resident’s sign was “just wrong.” The surveyor observed the GNA later return to the room and turn the sign around to indicate no PPE requirement. Subsequent interviews revealed that therapy staff relied on posted signage to determine PPE use and that if the sign was wrong, the PPE used would be wrong. Overall, surveyors found problems with signage accuracy and staff awareness of which residents required contact precautions, as well as observed failures to follow appropriate PPE use for residents who should have been on contact precautions.
Inaccurate MDS Coding for Falls, Pain Management, and High-Risk Medications
Penalty
Summary
Facility staff failed to ensure Minimum Data Set (MDS) assessments were accurately coded for two residents reviewed during a complaint survey. For one resident, a facility-reported incident showed that the resident was found seated on the floor beside the bed and was diagnosed with a non-displaced femoral neck impaction fracture of the left hip following an x-ray. Despite this fall with a major injury, the subsequent significant change MDS dated 11/4/25 did not code the fall with major injury in Section J1900C. Review of the resident’s Medication Administration Records for October and November 2025 showed administration of Tylenol on 10/31/25 at 9:30 PM, which fell within the 5-day look-back period for the MDS, but Section J0100 (prn pain) of the same significant change MDS did not capture the use of Tylenol. For another resident, review of a quarterly MDS with an assessment reference date of 10/15/25 showed that Section N0415 (High-Risk Drug Classes) documented the use of an opioid medication. However, review of the resident’s October 2025 Medication Administration Record did not show that the resident had been prescribed an opioid during that period. In both cases, MDS staff later confirmed that these were errors in MDS coding, demonstrating that the assessments did not accurately reflect the residents’ clinical status and medication use as documented in their medical records.
Incomplete Documentation of Narcotic Administration on MAR
Penalty
Summary
The facility failed to maintain complete and accurate medical records in accordance with accepted professional standards for one resident receiving narcotic medication. The resident, admitted in March 2026, had a fall on 3/6/26 and was sent to the hospital on 3/9/26. Review of the March 2026 Medication Administration Record (MAR) showed documentation of a single 25 mg dose of Tramadol administered on 3/8/26 at 9:23 AM. However, review of the resident’s Controlled Drug Receipt/Record/Disposition Form, kept on the nurse’s medication cart and not in the medical record, showed that Tramadol 25 mg was administered three times between 3/8/26 and 3/9/26: at 11:00 AM and 9:00 PM on 3/8/26, and at 9:00 AM on 3/9/26. In interview, the DON stated that staff are expected to document narcotic administration on the MAR and confirmed that only one of the three Tramadol doses reflected on the controlled drug record was documented on the resident’s MAR. This discrepancy between the controlled substance record and the MAR, with missing documentation of two administered doses of Tramadol on the official medical record, constituted the failure to maintain a complete and accurate medical record for the resident.
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