Pickersgill Retirement Community
Inspection history, citations, penalties and survey trends for this long-term care facility in Towson, Maryland.
- Location
- 615 Chestnut Avenue, Towson, Maryland 21204
- CMS Provider Number
- 215259
- Inspections on file
- 15
- Latest survey
- February 11, 2025
- Citations (last 12 mo.)
- 0
Citation history
Health deficiencies cited at Pickersgill Retirement Community during CMS and state inspections, most recent first.
The facility staff failed to label canned goods and opened food items with expiration and used by dates. During a kitchen observation, a surveyor found canned goods without expiration dates and an open box of crackers without a known expiration date. Additionally, an open carton of heavy whipping cream lacked a label for the open and discard dates, which the Dietary Chef acknowledged should have been done.
The facility failed to maintain resident dignity and respect by placing over-the-door organizers containing personal care items, including briefs, on the outside of resident room doors. A resident expressed privacy concerns and dissatisfaction with this arrangement, indicating a lack of understanding of its purpose.
A facility failed to protect a resident's medical record confidentiality when a medication cart was left unlocked with a computer screen displaying sensitive information. An RN later secured the cart and closed the screen, admitting she was distracted by a resident need and did not follow protocol.
Facility staff failed to accurately update the MDS assessments for three residents, leading to deficiencies in reflecting their medical conditions. A resident's stage 3 pressure ulcer was not documented as unhealed, another resident's pressure ulcer injury was omitted, and a third resident's multiple wounds were not recorded. The inaccuracies were due to reliance on incorrect staff documentation and progress notes.
A facility failed to provide care based on professional standards for a resident with a skin condition. A bruise-like area on the resident's clavicle was not documented, and the Quality Assurance Nurse was unaware of it until informed by a surveyor. The facility had transitioned to online documentation for weekly skin checks, during which the resident's checks were missed, leaving no records available.
The facility failed to follow oxygen therapy orders and post cautionary signs for residents receiving oxygen. A resident was observed receiving oxygen at a higher rate than prescribed, and the nasal cannula was not changed as required. Additionally, two residents receiving oxygen therapy did not have cautionary signs on their doors, as confirmed by the DON.
The facility failed to obtain informed consent and document alternatives before using bed rails for two residents. Observations revealed that both residents had bed rails installed without proper documentation. The Director of Rehabilitation and the DON were unable to provide reasons or documentation for the use of bed rails, indicating a lapse in the facility's compliance with required procedures.
The facility did not conduct annual performance reviews for four GNAs, as revealed during an annual survey. The surveyor requested documentation for the years 2023 and 2024, but the DON admitted the facility was non-compliant in providing these reviews.
A facility was found to have a medication error rate of 11.54%, exceeding the acceptable threshold of less than 5%. Errors included a missed dose of Bicalutamide for a resident, incorrect administration of Ophthalmic solution to another resident, and improper application of OcuSoft Lid Scrub to a third resident. These discrepancies were confirmed through observation, record review, and interviews with the DON.
A significant medication error occurred when a nurse documented administering five medications to a resident, including Bicalutamide 50MG, which was not observed to be given. A pill count revealed inconsistencies with the administration records, confirming the error.
The facility did not perform regular inspections of bed frames, mattresses, and bed rails to identify potential entrapment risks. Two residents were observed with raised 1/4 bed rails, and the Director of Maintenance could not provide documentation of routine entrapment assessments. Maintenance checks did not include these assessments for residents with transfer bars or bed rails.
The facility did not ensure GNAs completed the required 12 hours of in-service training annually. During a survey, it was found that one GNA received 3 hours, another 5 hours, and a third received no training in 2024. The DON confirmed the facility's non-compliance.
Deficiency in Food Labeling and Storage Practices
Penalty
Summary
The facility staff failed to ensure that canned goods and dry food were labeled with expiration dates, and opened food items were not labeled with a used by date. During a kitchen observation, a surveyor noted a rack of canned goods without expiration dates. When questioned, the Director of Dietary Services (DDS) and the Dietary Chef were unable to explain the process for discarding outdated canned goods, revealing that there was no system in place to track expiration or best by dates for these items. Additionally, an open box of Kellogg's Club Crackers was found without an expiration date, and neither the DDS nor the Dietary Chef could determine when it was opened or expired. In the dairy refrigerator, an open carton of heavy whipping cream was observed without a label indicating the date it was opened or its discard date. The Dietary Chef acknowledged that labeling dairy products with these dates was expected but had not been done in this instance.
Failure to Maintain Resident Dignity and Privacy
Penalty
Summary
The facility failed to ensure residents were treated with dignity and respect, as observed during a survey of 19 rooms on the Decker Unit. Over-the-door organizers were placed on the outside of resident room doors, containing various resident care items, including briefs. This arrangement was noted in rooms 406, 413, 416, 418, 419, 420, 421, 422, 424, 425, 426, 427, 428, 429, 430, 431, 432, 434, and 435. An interview with a resident revealed dissatisfaction and privacy concerns regarding the placement of these organizers. The resident expressed a lack of understanding as to why the organizers were positioned outside the room, indicating a failure to maintain the residents' dignity and respect.
Failure to Protect Resident's Medical Record Confidentiality
Penalty
Summary
The facility failed to ensure the confidentiality of a resident's medical record, as observed during a survey. On January 30, 2025, at 7:57 AM, a medication cart on the 400 hallway of the Decker Unit was found with a computer screen displaying a resident's name, date of birth, and Medication Administration Record (MAR). The medication cart was also unlocked, allowing access to several resident medications. At 8:00 AM, a Registered Nurse Supervisor (RN) approached the cart, closed the screen displaying the resident's information, and locked the cart. During an interview, the RN confirmed that the expectation was to close out of computer screens showing resident information and to lock the medication cart when unattended. She admitted that she was distracted by a resident need and failed to secure the cart and the computer screen.
Inaccurate MDS Assessments for Residents
Penalty
Summary
Facility staff failed to update the Minimum Data Set (MDS) assessments accurately for three residents, leading to deficiencies in reflecting their medical conditions. For Resident #8, the MDS did not indicate an unhealed stage 3 pressure ulcer by the Assessment Reference Date (ARD) of 01/15/25, despite documentation showing the wound was not fully healed. The MDS coordinator relied on staff documentation that inaccurately recorded the ulcer as healed, which was later corrected after the surveyor's inquiry. Resident #16's MDS with an ARD of 12/6/24 failed to reflect a pressure ulcer injury on the left first toe, despite medical records indicating the presence of such a wound. Similarly, Resident #31's MDS with an ARD of 1/13/25 did not document any wounds or skin conditions, even though medical records and observations showed multiple wounds on the resident's body. The MDS coordinator admitted that the assessments were based on progress notes and wound evaluations, which were not accurately reflected in the MDS.
Failure to Document and Monitor Resident's Skin Condition
Penalty
Summary
The facility failed to ensure that a resident received care based on professional standards, specifically in the area of skin condition monitoring. Resident #16 was observed to have a small bruise-like area on the left clavicle, which was not documented in the medical record. The Quality Assurance Nurse, who was assigned to the resident, was unaware of the skin condition until it was pointed out by the surveyor. Further investigation revealed that the facility had transitioned from paper to online documentation for weekly skin checks between November and December 2024, during which time Resident #16's weekly skin checks were missed, and no documentation was available to provide to the surveyor.
Oxygen Therapy Deficiency and Lack of Signage
Penalty
Summary
The facility failed to ensure that a resident receiving oxygen therapy had orders that were being followed and failed to post cautionary signs indicating the use of oxygen. Specifically, Resident #31 was observed receiving oxygen at a rate of 3.5 to 4 liters per minute, despite having an active order for continuous oxygen at 3 liters per minute. Additionally, the nasal cannula used by Resident #31 was not changed as per the order, which required it to be replaced every Thursday night shift and labeled with the date. The nasal cannula was dated 1/17/25, indicating it had not been changed as required. Furthermore, the facility did not post cautionary signs indicating the use of oxygen for residents receiving oxygen therapy. During observations, it was noted that Resident #31's room did not have a red oxygen sign on the door, as expected by the Director of Nursing (DON). Similarly, Resident #9, who was also receiving oxygen by nasal cannula, did not have a sign on the door indicating the use of oxygen. These deficiencies were confirmed through interviews with the DON and observations made by the surveyor.
Failure to Obtain Informed Consent and Document Alternatives for Bed Rails
Penalty
Summary
The facility failed to obtain informed consent and document alternatives attempted prior to the initiation of bed rails for two residents. During the survey, it was observed that both residents had bed rails installed without proper documentation of informed consent or assessment of alternatives. Resident #31 was observed with two 1/4 bed rails on either side of the bed, and the Director of Rehabilitation was unable to provide a reason for their use, as the resident was not on the case load. Similarly, Resident #13's bed was observed with two 1/4 bed rails, and the Director of Nursing mentioned that verbal consent was obtained but could not provide documentation. The surveyor requested documentation for both residents regarding the assessment of alternatives and informed consent, but the Director of Nursing was unable to provide this information. The lack of documentation and informed consent indicates a failure in the facility's process for ensuring the safe and appropriate use of bed rails, which are associated with potential risks. This deficiency was identified during the survey, highlighting the facility's non-compliance with the required procedures for bed rail use.
Failure to Conduct Annual Performance Reviews for GNAs
Penalty
Summary
The facility failed to ensure that staff received annual performance reviews, as evidenced by the lack of documentation for four GNAs during the annual survey. On January 30, 2024, the surveyor requested documentation of annual performance reviews for the years 2023 and 2024 for GNA #7, GNA #19, GNA #21, and GNA #26. However, during an interview on January 31, 2025, the Director of Nursing revealed that the facility was unable to provide the requested documentation, indicating non-compliance with the requirement for annual performance reviews for these GNAs.
Medication Administration Errors Exceed Acceptable Rate
Penalty
Summary
The facility was found to have a medication error rate of 11.54%, exceeding the acceptable threshold of less than 5%. This was identified during a surveyor's observation of medication administration for three residents. For Resident #236, a discrepancy was noted when the RN Supervisor documented the administration of five medications, including Bicalutamide 50MG, which was not observed to be prepared or administered. A subsequent audit and pill count confirmed that the medication had not been given as documented, as there were 26 pills remaining in the bottle, indicating a missed dose since the bottle was opened. Additionally, errors were observed in the administration of medications to Resident #9 and Resident #16. Resident #9 received two drops of Ophthalmic solution 0.5% carboxymethylcellulose in each eye, contrary to the order for one drop per eye. Similarly, Resident #16 was administered OcuSoft Lid Scrub to both eyes, while the order specified application only to the left eye. These observations were reviewed with the Director of Nursing, who acknowledged the discrepancies in medication administration.
Significant Medication Error in Resident's Treatment
Penalty
Summary
The facility failed to ensure that a resident was free from significant medication errors, as observed during a survey. On the morning of January 30, 2025, a surveyor observed a Registered Nurse Supervisor administer four medications to a resident. However, the documentation later showed that five medications were signed off as administered, including Bicalutamide 50MG, which was not observed to be prepared or given to the resident. This discrepancy was confirmed through a review of the Medication Administration Record (MAR) and an audit conducted by the surveyor. Further investigation revealed that the Bicalutamide medication bottle, which initially contained 30 pills, had a date of January 27, 2025, indicating when it was first opened. A pill count conducted on January 31, 2025, showed 26 pills remaining, suggesting that only four pills had been administered since the bottle was opened. This count was inconsistent with the expected number of pills if the medication had been administered daily as prescribed. The Director of Nursing (DON) confirmed the significant medication error, acknowledging that the number of pills remaining did not align with the administration records.
Failure to Conduct Regular Bedrail Entrapment Assessments
Penalty
Summary
The facility failed to conduct regular inspections of bed frames, mattresses, and bed rails to identify potential areas of entrapment, as evidenced by observations and staff interviews. During the survey, it was observed that two residents had 1/4 bed rails raised on either side of the top end of their beds. The Director of Maintenance admitted that there was no documentation available for routine bedrail entrapment assessments for these residents. Although maintenance staff conducted routine checks of resident rooms, these checks did not include assessments for the risk of entrapment for residents with transfer bars or bed rails.
Non-Compliance with GNA In-Service Training Requirements
Penalty
Summary
The facility failed to ensure that Geriatric Nursing Assistants (GNAs) completed the required 12 hours of in-service training annually. This deficiency was identified during a survey where the records of five GNAs were reviewed. Specifically, GNA #7 received only 3 hours, GNA #19 received 5 hours, and GNA #21 received no in-service training in 2024. An interview with the Director of Nursing confirmed the facility's non-compliance with the annual training requirement for these staff members.
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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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