Pines Nursing And Rehab
Inspection history, citations, penalties and survey trends for this long-term care facility in Easton, Maryland.
- Location
- 610 Dutchman's Lane, Easton, Maryland 21601
- CMS Provider Number
- 215010
- Inspections on file
- 19
- Latest survey
- March 12, 2026
- Citations (last 12 mo.)
- 90
Citation history
Health deficiencies cited at Pines Nursing And Rehab during CMS and state inspections, most recent first.
Staff failed to maintain resident dignity by not ensuring appropriate clothing and linens, not covering Foley catheter drainage bags with required dignity bags, and restricting resident access to the dining room for dinner and weekend meals. One resident was found unclothed in bed with stained bedding and later complained of being cold and improperly dressed, while laundry backlogs and broken equipment delayed personal clothing availability. Two residents with Foley catheters had visible drainage bags that were not placed in privacy bags, contrary to facility policy acknowledged by the DON. Multiple residents and the resident council president reported that they were not allowed to eat dinner or weekend meals in the dining room and wished to socialize there, and the Administrator and department managers stated that the dining room was closed for those meals due to insufficient staff.
Surveyors found that staff failed to keep call lights within reach for multiple residents on one unit, despite care plans directing that call lights be accessible and used to request assistance for residents with decreased mobility, dementia, encephalopathy, schizophrenia, and poor safety awareness. During observations, several residents in bed or sitting on the bed had call bells on the floor, behind or under the bed, or wrapped around the bed frame; one resident reported staff took the call bell away, and another reported staff turned off the call bell and did not return. A staff member acknowledged the issue with call bells and indicated it was an ongoing problem, and leadership was later informed.
Staff failed to maintain a sanitary, safe, and comfortable environment, particularly on one unit, where a resident was found in bed without clothes, lying on stained linens with a soiled sheet covered in gnats placed on a trashcan, and in a room cluttered with discarded incontinence products and clothing on the floor. Multiple rooms and common areas had stained and cracked ceiling tiles, missing or damaged flooring and laminate surfaces, non-functioning or uncovered lights, rusted exhaust fans, peeling drywall, and dirty, sticky, or discolored floors. One room’s wall A/C unit had visible gaps to the outside, with cold air entering, accumulated dust, cobwebs, and a loose electrical box, while several beds on the unit had no linen. A staff member reported there was no linen available overnight or in the morning, and the maintenance director acknowledged ongoing linen shortages and inoperable laundry equipment, as well as unaddressed structural and cleanliness issues inside and outside the building.
The facility failed to maintain complete and accurate medical records when podiatry visit notes for multiple residents were not uploaded into the EMR, despite staff reporting that podiatry care had been provided. Additionally, care plan meeting documentation for several residents was kept only on paper in a file cabinet by a social worker and was not entered into the medical record, leaving gaps between the dates of documented care plan meetings and the actual meetings held.
Facility staff did not maintain all laundry equipment in working order, contributing to delays in personal laundry and insufficient linen supply for residents. Surveyors observed that only 2 of 3 washers and 2 of 4 dryers were operational, with one of the working dryers being much smaller than the commercial unit. A laundry staff member reported that the broken washer and two dryers had been out of service for some time and that the smaller dryer could not handle the same volume as the larger dryer. The Maintenance and Housekeeping Director confirmed that staff were unable to keep up with residents’ personal laundry needs due to the limited functional equipment.
Facility staff failed to notify a resident’s representative of a scheduled orthopedic appointment, even though the representative typically accompanies the resident to all medical visits. On the day of the appointment, the resident reported being told that morning that there was a doctor’s visit but did not know its purpose, and the representative, present during interview, stated they had not been informed and therefore could not attend. Record review showed the resident went to an orthopedic appointment and received a left shoulder injection, and the DON confirmed that staff did not notify the representative of this appointment.
Staff failed to accurately code MDS assessments for two residents, leading to incorrect documentation of fall history and urinary continence. One resident was admitted after a documented fall that caused a left intertrochanteric femur fracture, yet the admission MDS coded fall history as "unable to determine" despite clear hospital and NP documentation of the fall. Another resident had a physician’s order for a Foley catheter for urinary retention and was observed with a Foley drainage bag at the bedside, but the quarterly MDS coded urinary continence as "always incontinent" instead of reflecting the presence of an indwelling catheter. The MDS Coordinator acknowledged both coding errors during interview.
Facility staff failed to develop and implement a care plan for a resident with an indwelling Foley catheter ordered for urinary retention. The resident’s MDS and Treatment Administration Records documented ongoing catheter use, and the catheter drainage bag with urine was observed hanging at the bedside and visible from the hallway. Despite this, review of the medical record showed no care plan addressing the catheter, even though the MDS Coordinator indicated that the nursing team was responsible for creating and implementing care plans.
Facility staff failed to hold a required quarterly care plan meeting for a resident after completion of a quarterly MDS assessment. The facility’s process requires the IDT to meet after each MDS to review and revise the care plan, which guides individualized care and is reviewed at least quarterly. Record review showed the last care plan meeting occurred months before the most recent quarterly MDS, with no subsequent meeting documented. Social Services, who keeps care plan documentation, reported that a meeting had been scheduled but then postponed and not rescheduled, resulting in the missed quarterly care plan review.
Surveyors found that a resident with a physician’s order for continuous oxygen at 2 L for comfort was not receiving oxygen despite the presence of an oxygen concentrator at the bedside. Across multiple observations, the concentrator remained off and the nasal cannula was coiled on top of the machine rather than in the resident’s nostrils. Review of the MAR showed that six licensed nurses, including RNs and/or LPNs, had documented each shift that the resident was receiving oxygen as ordered, despite the lack of actual oxygen administration. The DON and administrator were informed that the medical record had been falsified, and the DON confirmed the findings.
Staff failed to maintain appropriate shower water temperatures on the Wye Oak Unit, where one of two showers was found to have water at 87°F and a faucet that could not be turned toward the hot setting, while the other shower measured 110°F. The Director of Maintenance and Housekeeping confirmed the low temperature, acknowledged that shower temperatures should be between 100°F and 120°F, and reported being unaware of the problem. No signage was posted to prevent staff from using the malfunctioning shower, and this issue was identified during a complaint survey of one of four nursing units.
The facility failed to maintain an effective pest control program on one nursing unit, where numerous gnats were observed in resident rooms and hallways. In one room, a soiled sheet left on top of a trashcan was covered with multiple gnats, and in another room gnats were seen around the toilet area. A resident was observed in bed with empty plastic juice containers left on the tray table, and gnats were flying around the resident’s chin; a staff member acknowledged that gnats were sometimes present because containers were not removed. Pest management records showed the unit had been treated several weeks earlier, with no documentation of a gnat problem despite staff confirming its presence, and leadership was later informed of these concerns.
A resident's representative was not informed when the resident's Foley catheter was discontinued and a voiding trial was initiated. Although the provider was notified and the change was documented, there was no evidence that the representative was contacted, despite facility policy requiring such notification and documentation. Both an LPN and the DON confirmed the expectation for timely communication with representatives regarding changes in resident status.
A cognitively impaired resident with a history of falls and recent agitation was left unsupervised in a memory care unit, attempting to get out of a Geri-chair without nursing staff present. The resident's care plan lacked specific interventions for monitoring, and staff were not available in the common area, resulting in a deficiency related to inadequate supervision and accident prevention.
Multiple residents experienced both verbal abuse from an LPN and repeated physical abuse from another resident with dementia and behavioral issues. Despite staff and medical director awareness of these incidents, including injuries and emotional distress, effective interventions were not implemented, resulting in continued harm to vulnerable residents.
Facility staff did not ensure the availability of necessary linens for resident care, with ongoing shortages of washcloths, towels, and fitted sheets, and delays in returning personal clothing due to malfunctioning laundry equipment and budget constraints. Staff interviews and resident council minutes confirmed persistent linen issues, leading to improvised solutions such as cutting up towels or bed sheets. Additionally, multiple maintenance problems were observed in resident rooms and common areas, including damaged fixtures, exposed pipes, and non-working call bell systems, resulting in an environment that was not safe, clean, or comfortable.
The facility did not provide enough nursing staff to meet resident needs, resulting in high resident-to-staff ratios, delayed care, missed showers, unanswered call bells, and cold food. Staff and resident interviews, council meeting minutes, and staffing records confirmed frequent short staffing, with some shifts having a single GNA for up to 30 residents. Observations included an unattended medication cart and a resident with a history of falls left unsupervised, requiring surveyor intervention. The facility failed to consistently meet the required minimum hours of bedside care per resident per day.
Surveyors found that annual performance reviews were not conducted for several GNAs, as required. Personnel files lacked documentation of yearly evaluations, and the NHA confirmed that the facility was behind on these reviews and related staff education.
The facility did not have a qualified social worker employed full-time, as required for its size. Residents reported being unable to see social workers to address their concerns, and the Social Work Assistant, who worked part-time and lacked the required qualifications, was unable to hold care plan meetings for part of the review period. The Administrator confirmed the absence of a full-time qualified social worker.
The facility failed to keep essential equipment, including the hot water system, laundry machines, and kitchen dishwasher, in safe working order. A resident reported ongoing hot water issues, and staff confirmed that both hot water and laundry equipment problems persisted for months, leading to cold showers and linen shortages. The kitchen dishwasher was also found to be operating below required sanitization temperatures, with staff continuing to use it despite the deficiency.
The facility did not maintain proper documentation to verify that a geriatric nursing assistant received the required annual competency training hours. Although in-service attendance was recorded, the duration of each session was not tracked, and there was no formal system to ensure compliance with training requirements.
A resident dependent on staff for bathing due to spinal cord disease was left naked and uncovered in a shower chair facing the door after two nursing assistants left to assist with a new admission. Another staff member later discovered the resident in this state, provided care, and reported the incident to a nurse.
The facility did not consistently report suspected abuse, neglect, or theft to the Office of Health Care Quality (OHCQ) within required timeframes, and failed to maintain documentation of final report submissions. In several cases, residents' allegations of abuse were not reported promptly by staff, and internal communication breakdowns led to delays in notifying both administration and regulatory agencies.
The facility did not thoroughly investigate or document multiple incidents involving alleged abuse, injuries, and a gas leak. In several cases, residents reported injuries or altercations, but the facility lacked complete investigation files, incident reports, or interviews. Some investigations were incomplete, missing interviews with key staff or residents, and in one case, there was no documentation of a reported gas leak or related staff education.
Multiple residents dependent on staff for activities of daily living did not consistently receive showers, bed baths, toileting, or repositioning as required. Documentation showed missed care on numerous occasions, and interviews with residents and staff confirmed lapses in providing and recording necessary assistance. Staff and management were often unaware of these deficiencies, and required documentation of care or refusals was incomplete.
Facility staff failed to follow up on a prescribed medication for a resident with Ankylosing spondylitis, resulting in missed doses due to insurance and pharmacy issues. Staff also did not perform or document required neuro checks and change of condition assessments after unwitnessed falls for a resident admitted for rehabilitation. Additionally, the facility did not obtain an ongoing or PRN order for oxygen for a resident with complex medical needs, leading to an episode of hypoxia during transport to dialysis and subsequent hospitalization.
A facility failed to ensure a registered dietician conducted and documented regular nutritional assessments for a resident, resulting in no documented assessments for over a year and only a remote dietician available. The resident's diet was limited to fish and peanut butter crackers, with no ongoing evaluation of nutritional needs.
Multiple residents did not receive prescribed medications, including treatments for depression, pain, and multiple sclerosis, due to delays in ordering, pharmacy delivery, and untimely submission of prior authorization forms. Staff reported inconsistent medication reordering practices and ongoing pharmacy issues, resulting in extended periods where medications were unavailable.
Multiple residents reported not receiving menu items as ordered, with meals often missing components or substituted without explanation. Residents also described food as cold and unappetizing, and temperature checks confirmed hot foods were served below required standards. Ongoing concerns about meal quality and accuracy were documented in resident council meetings and acknowledged by facility leadership.
Surveyors found that food items were improperly stored, with unsealed and undated containers on the floor, a cracked walnut container, and undated sherbet in the freezer. The sink near the food prep area lacked soap, and required daily temperature logs for refrigeration units were not maintained, as confirmed by the Dietary Manager.
Several residents' medical records were found to be incomplete or inaccurate, including missing documentation of bathing care, lack of discharge notes for two residents, and a physician's erroneous entry regarding a resident who never returned from the hospital. Staff interviews confirmed that required documentation was not completed as per facility policy.
A survey revealed that the call bell system was not functioning in numerous occupied rooms on one nursing unit. Many rooms lacked manual call bells at the bedside, and in one case, a manual bell was out of reach. The Administrator confirmed the system was not operational and no contractor was on-site to repair it.
Surveyors found that the facility did not have an effective pest control program, as flies, gnats, and ants were observed in the kitchen, laundry, and other areas over two days. Staff acknowledged the persistent pest problem, and documentation showed that pest control visits were not frequent enough to address the issue, with treatments not targeting the specific pests present.
Facility staff failed to inform two residents and/or their representatives about changes in treatment plans involving psychotropic medications and did not obtain consent prior to administration. In one case, a terminally ill resident received Ativan and Morphine for end-of-life care without notification or consent, and in another, a resident was started on Duloxetine for neuropathic pain without proper communication or consent documentation. The medical records lacked evidence of informed consent or notification regarding the risks and benefits of these medications.
Facility staff failed to notify physicians when two residents experienced significant changes: one resident had a change in condition after a staff member stepped on their foot, and another resident did not receive a prescribed medication for hepatic encephalopathy due to unavailability. In both cases, there was no documentation that the physician was informed, as confirmed by the DON and the attending physician.
A resident with significant medical needs and cognitive impairment had multiple personal items, including a purse with cash and important cards, go missing after being admitted to a dementia unit. Despite efforts to secure the belongings due to concerns about another resident, the facility failed to maintain inventory records or ensure the safety of the resident's property, resulting in the loss of several items.
A resident with multiple neuropsychiatric diagnoses and recent behavioral disturbances did not receive a complete quarterly MDS assessment, as required sections on cognition, mood, and behavior were left unassessed. The MDS Coordinator confirmed the omission occurred because the social worker responsible for these sections was absent and no other staff completed the assessment.
Staff failed to accurately code MDS assessments for two residents, omitting documented aggressive behaviors for one and incorrectly recording the severity of a hip fracture for another. These errors were confirmed by the MDS coordinator following review of medical records and staff interviews.
The facility did not consistently develop or update comprehensive care plans after required assessments, nor did it hold regular IDT care plan meetings with resident representatives. One resident's care plan lacked specific interventions for fall risk, and another resident with a history of aggressive behavior had no documented interventions or care plan for several months despite multiple incidents. These deficiencies were confirmed by staff interviews and record review.
A practitioner prescribed end-of-life medications to a full code resident without informing or obtaining consent from the resident or their representative, and nursing staff failed to document the administration of psychotropic medications in the MAR. The resident, who had advanced liver cancer and encephalopathy, received Ativan and Morphine without proper documentation or consent, and doses were removed from controlled substance counts without corresponding entries in the MAR.
A resident with a deep tissue injury to the left heel did not receive required weekly skin assessments or prescribed treatments on multiple occasions. The DON confirmed that staff failed to assess the wound and missed several treatment dates, resulting in a deficiency in pressure ulcer care.
A resident with multiple chronic conditions experienced a significant delay in receiving a motorized wheelchair after their previous one stopped working. Although Medicaid approved the replacement and the facility ordered it, miscommunication and technical issues led to emails and invoices being sent to a former business office manager, resulting in the order not being processed in a timely manner. Key staff were unaware of the order's status, and the resident waited at least four months without the necessary equipment to support mobility.
Staff did not assess a resident with neuromuscular bladder dysfunction for removal of an indwelling urinary catheter. The resident reported increased sensation and was told a voiding trial would be performed, but this was not done. The Medical Director confirmed that a voiding trial had not been conducted despite the resident's reported changes.
A resident with complex medical conditions was given antihypertensive and hypotensive medications without adherence to physician-ordered blood pressure parameters. Medications were administered when blood pressure readings were outside of prescribed limits, and in several instances, there was no documentation that blood pressure was checked prior to administration, resulting in a deficiency related to unnecessary drug use.
A resident with terminal illness, not on hospice or palliative care and with full code status, was prescribed and administered Ativan and Morphine for end-of-life symptoms without documented consent or discussion with the resident's representative. The medications were ordered and given while the resident remained a full code, and staff interviews confirmed that appropriate communication and documentation were lacking.
A resident with hepatic encephalopathy and other serious conditions did not receive prescribed Rifaximin on multiple occasions due to the medication not being available in the facility. Staff inaccurately documented that the medication was administered even when it was not present, and failed to provide complete documentation when doses were missed. The attending physician was not informed of the missed doses, and the DON acknowledged awareness of false documentation by staff.
A medication cart containing various resident medications, including anti-hypertensives, anti-psychotics, and anti-depressants, was found unlocked and unattended on a memory care unit. The cart was accessible to residents while no nursing staff were present, as the assigned nurse had left early and the unit manager was attending to another unit. The issue was identified by a surveyor and later reported to facility leadership.
Two residents were not consistently provided with required meals and snacks according to their needs and preferences. One resident did not always receive prescribed snacks, with staff confirming that snacks were often not delivered. Another resident, admitted for rehab with multiple medical conditions, had no documentation of receiving meals on two days, and staff could not provide evidence that meals were served.
A resident did not have a physician-ordered sleep study scheduled to rule out sleep apnea, which was necessary for obtaining a CPAP device. The order was acknowledged by the former DON, but the appointment was never made before the resident was discharged. The deficiency was identified during a complaint survey through record review and staff interviews.
Staff failed to maintain and post current daily nursing staffing information, with the posted schedule displaying outdated data from several days prior. The Administrator confirmed that daily staffing sheets with assignments, census, and actual hours worked were not kept until recently, resulting in a deficiency identified during a complaint survey.
Failure to Maintain Resident Dignity in Clothing, Catheter Privacy, and Dining Access
Penalty
Summary
Facility staff failed to maintain resident dignity in multiple ways, beginning with inadequate clothing and linen management for one resident. On one observation, this resident was found lying in bed with no clothes on, covered only by a blanket that had a dried yellow stain, with a fitted sheet stained with dried food and yellow discoloration, and half of a diaper on the fall mat next to the bed. A hospital gown was observed on the floor near the bathroom alcove. Later, the same resident was observed in the dining/activity room crying, stating that they were cold and that women were supposed to wear long pants, while wearing only a short-sleeved shirt, khaki shorts, and slipper socks. A GNA reported that the resident had no other clothes in the room. In the laundry room, a large backlog of personal laundry was observed, and laundry staff reported that personal laundry had not been done over the weekend, that only one of three commercial dryers and a small non-commercial dryer were functioning, and that it was taking 4–5 days to complete laundry. The Director of Maintenance and Housekeeping confirmed that two dryers and one washer were not working and that staff were unable to keep up with personal laundry. Additional dignity concerns were identified for residents with Foley catheters. One resident was observed lying in bed wearing a hospital gown with a Foley catheter drainage bag hanging on the side of the bed, visible and not placed in a privacy/dignity bag. Another resident was observed lying in bed with a Foley catheter drainage bag visible from the hallway, also not covered by a dignity bag. The DON confirmed that residents with Foley catheters should have dignity bags and provided the facility’s Catheter Care Policy, which states that privacy bags will be available and catheter drainage bags will be covered at all times while in use. These observations showed that the facility did not follow its own policy regarding the use of privacy/dignity bags for catheter drainage bags. Residents also reported restrictions on their ability to dine in the dining room for dinner and on weekends, affecting their right to dignity, self-determination, and socialization. Multiple residents stated that they would like to use the dining room for dinner and to socialize with other residents, but that staff would not allow it, reportedly due to insufficient staffing. Observation of dinner service showed that residents on two units received dinner trays in their rooms, and the dining room was dark and empty during the dinner hour. Resident council notes documented prior concerns from residents about not being able to eat dinner and weekend meals in the dining room, and a council concern form showed that the Administrator had responded that the dining room was only open for breakfast and lunch on weekdays because there was not enough staff to support dinner or weekend meals. The Dietary Manager and Activities Director both stated they understood that dinner and weekend dining room service were not provided due to staffing limitations, and the Administrator confirmed that residents could not use the dining room for dinner and weekends because of lack of staff.
Failure to Keep Call Lights Within Reach as Care Planned
Penalty
Summary
Surveyors identified a deficiency in the facility’s failure to ensure residents’ call lights were kept within reach as required by individualized care plans, thereby limiting residents’ ability to summon assistance. During a tour of the Homestead unit, multiple residents were observed in bed or sitting on the edge of the bed with their call bells on the floor, behind the bed, or wrapped around or under the bed frame. One resident’s call bell was found on the floor behind the bed on two separate observations, and the resident stated that staff had taken the call bell away. Another resident’s call bell was repeatedly observed hanging under the bed frame and dragging on the floor. A third resident, who reported using the call button to call the nurse, had the call bell lying on the floor behind the bed. A fourth resident, sitting on the edge of the bed, had the call bell on the floor behind the bed and reported that when the call bell was used, staff came in, turned it off, and did not return. Review of the residents’ care plans showed that several had documented ADL self-care performance deficits related to conditions such as decreased mobility, dementia, encephalopathy, schizophrenia, and poor safety awareness, with specific interventions directing staff to encourage use of the call bell and to ensure the call light was within reach, with prompt response to all requests for assistance. These care plans, initiated on various dates, consistently required that call lights be accessible to residents at risk for falls and with mobility or cognitive impairments. Despite these documented interventions, staff did not maintain the call bells within reach for at least seven residents on the Homestead unit. When a staff member was shown a call bell on the floor, the staff member acknowledged the need for a clip to secure the cord to the sheet and stated that the situation with call bells was a known problem. The DON and Nursing Home Administrator were later informed of these concerns.
Widespread Environmental and Linen Failures Leading to Unsanitary Resident Conditions
Penalty
Summary
Facility staff failed to maintain a safe, clean, sanitary, and comfortable environment in common areas and on one nursing unit, as evidenced by multiple observations during a complaint survey. A complaint alleged that a resident room on the Homestead unit was in deplorable condition, with feces on walls and floors and cold air entering through an air conditioning unit, creating unsanitary conditions. During the tour, surveyors observed multiple stained and cracked ceiling tiles in the conference room, entrance hallway, and Homestead unit hallway, as well as dirty, sticky, and discolored hallway flooring. In the Homestead dining room, drywall was peeling, a section of wall was caved in, several ceiling exhaust fans were rusted, and a piece of ceiling molding was hanging down. In one resident room on the Homestead unit, a resident was in bed without clothes but covered with a blanket, yelling and asking why they had no clothes and where their clothes were. The blanket had a dried yellow stain, and the fitted sheet was yellow and stained with dried food. Half of a diaper was on the fall mat next to the bed, a hospital gown was on the floor near the bathroom alcove, and a soiled sheet covered with gnats was sitting on top of the trashcan by the sink. The laminate on the headboard was missing in a section. In another room, a soiled sheet with a pink stain was on the bed, the overhead light in the toilet area was not working, and the ceiling tile in that toilet area was cracked. In additional rooms, there were missing floor tiles, gnats by the toilet, cracked and stained ceiling tiles, missing light covers, and missing laminate on a closet door. In a room with a wall air conditioner above the radiator, cold air was coming through visible gaps and holes around the unit, with the outside visible through these openings. The bracket around the air conditioner had a black substance, dirt, dust, and cobwebs, and the top of the radiator was full of dust; the electrical box was hanging away from the wall by about an inch, and the bed footboard had peeling laminate and was loose, with a split in the covering of a positioning wedge. Several beds on the unit had no linen, and a staff member reported there had been no linen during the night and that they did not have morning linen to start. The Director of Maintenance and Housekeeping later confirmed that two dryers and a washing machine were down, that they were not able to keep up with laundry, and that there was not enough linen to support the residents. Additional exterior observations included hardy board under the front porch hanging down and a hole in the hardy board, and the Director of Maintenance and Housekeeping stated he had not been aware of the porch ceiling condition until it was pointed out and acknowledged that the air conditioner area had not been cleaned.
Failure to Maintain Complete and Accurate Medical Records and Care Plan Documentation
Penalty
Summary
The deficiency involves the facility’s failure to maintain complete and accurate medical records in accordance with accepted professional standards for multiple residents. For one resident, a complaint alleged that toenails were so long they were growing into the skin. Review of the paper and electronic medical records did not show any podiatry documentation, despite staff stating the resident had been seen by a podiatrist due to thick toenails. The DON was initially unable to locate podiatry notes in the EMR and later produced podiatry visit notes for this resident and 27 other residents, confirming that these office visit records had never been uploaded into the residents’ medical records. The deficiency also includes missing documentation of care plan meetings for three other residents. One resident’s record showed the last documented care plan meeting several months earlier, with only an invitation for a more recent meeting and no record that the meeting occurred until the social worker later produced a paper care plan summary that had not been uploaded. Another resident had a scheduled care plan meeting with no evidence of the meeting in the medical record until the social worker provided paper notes kept in an office file. A third resident’s record showed the last care plan meeting many months prior, and the resident was unsure of the last meeting date; the social worker then produced paper notes of a more recent care plan meeting that were also not in the medical record. The social worker reported keeping care plan documentation on paper in a file cabinet and stated that due to workload, these notes were not consistently uploaded into the EMR and expressed uncertainty about the requirement for them to be in the medical record.
Nonfunctional Laundry Equipment Leading to Inadequate Laundry Capacity
Penalty
Summary
Facility staff failed to maintain essential laundry equipment in working order, resulting in insufficient capacity to meet residents’ laundry and linen needs. During a complaint survey focused on reports of delayed personal laundry and inadequate linen supply, observation of the laundry room showed that 1 of 3 washers and 2 of 4 dryers were not functioning, and one of the two operational dryers was significantly smaller than the other commercial dryer. A laundry staff member reported that the nonfunctioning washer and two dryers had been out of service for an extended period and confirmed that the smaller dryer could not handle the same volume as the larger unit. The Maintenance and Housekeeping Director acknowledged that staff had been unable to keep up with residents’ personal laundry due to this equipment situation, confirming that the facility did not have all washers and dryers in working order to meet residents’ needs. No specific resident medical histories or clinical conditions were described in relation to this deficiency.
Failure to Notify Resident Representative of Physician Appointment
Penalty
Summary
Facility staff failed to notify a resident’s representative of a scheduled physician appointment, resulting in the resident attending the appointment without the representative’s knowledge or presence. During an interview, the resident stated that he/she had a doctor’s appointment that day and indicated that someone had informed him/her of the appointment that morning, but the resident did not know the purpose of the visit. The resident’s representative, who was present during the interview, stated that he/she was unaware of the appointment, typically takes the resident to all medical appointments, and was unable to do so that day due to the lack of prior notice. Medical record review later confirmed that the resident attended an orthopedic appointment and received a left shoulder injection. The DON confirmed that the resident’s representative customarily accompanies the resident to all doctor appointments and that staff failed to notify the representative of this orthopedic appointment.
Inaccurate MDS Coding for Fall History and Urinary Catheter Use
Penalty
Summary
Facility staff failed to ensure accurate completion of MDS assessments for two residents, resulting in incorrect coding of key clinical information. For one resident admitted after a fall that caused a left intertrochanteric femur fracture, hospital records and a nurse practitioner’s initial note documented that the resident had fallen, resulting in hip pain, inability to ambulate, and the fracture. Despite this clear history, the admission MDS with an assessment reference date of 1/20/26 coded Section J1700A (fall history in the last month prior to admission/entry or reentry) as “9 – unable to determine,” rather than capturing the documented fall. For another resident with a physician’s order for a Foley catheter for urinary retention, surveyor observation from the hallway showed a Foley drainage bag with urine hanging at the bedside. The resident’s quarterly MDS with an assessment reference date of 1/6/26 coded Section H0300 (urinary continence) as “always incontinent.” Because the resident had an indwelling urinary catheter in place, urinary continence should have been coded based on catheter use rather than rated as incontinence. In both cases, the MDS Coordinator confirmed the coding errors during interview.
Failure to Develop Care Plan for Resident With Indwelling Foley Catheter
Penalty
Summary
Facility staff failed to develop and implement a care plan addressing a resident’s specific needs related to an indwelling Foley catheter. The resident had a physician’s order for a Foley catheter for urinary retention dated 1/3/26, and the quarterly MDS with an assessment reference date of 1/6/26 documented indwelling catheter use in Section H0100A. The Treatment Administration Records for January, February, and March 2026 also documented ongoing use of an indwelling Foley catheter. Despite these documented orders and assessments, review of the care plan section of the resident’s medical record did not reveal any care plan related to the Foley catheter. On 3/11/26 at 12:55 PM, surveyors observed the resident lying in bed with a Foley catheter drainage bag containing urine hanging on the left side of the bed and visible from the hallway. During an interview at 1:37 PM, the MDS Coordinator stated that the nursing team was responsible for creating and implementing care plans. Later that afternoon, the DON and the Nursing Home Administrator were informed of the finding that no care plan had been developed for the resident’s indwelling Foley catheter, despite its documented use and the facility’s responsibility to ensure care is planned based on identified needs.
Missed Quarterly Care Plan Meeting Following MDS Assessment
Penalty
Summary
Facility staff failed to conduct a required quarterly care plan meeting for Resident #13 following completion of a quarterly MDS assessment. The facility’s process is that once an in-depth assessment (MDS) is completed, the interdisciplinary team meets to develop and review care plans, which are to be reviewed and revised at each assessment time and at least quarterly. Care plans are intended to provide direction for individualized care, organized by the resident’s specific needs, and to communicate and organize actions to ensure needs are attended to. For Resident #13, who was admitted in 2022, the medical record review on 3/9/26 showed the last quarterly care plan meeting occurred on 10/29/25. Further review revealed that a quarterly MDS assessment for Resident #13 was completed on 12/21/25, but there was no documentation of a subsequent quarterly care plan meeting after the 10/29/25 meeting and the 12/21/25 MDS assessment. Social Services, who maintains care plan meeting documentation in her office, was unable to provide any record of a care plan meeting during that period. In interview, Social Services stated that a care plan meeting for Resident #13 had been scheduled for 12/23/25 but had to be rescheduled, and she did not realize it had not been rescheduled. On 3/10/26, the Surveyor informed the DON that Resident #13 did not have a quarterly care plan meeting following the 12/21/25 MDS assessment.
Failure to Provide Ordered Continuous Oxygen and Falsification of MAR Documentation
Penalty
Summary
Surveyors determined that the facility failed to provide respiratory services in accordance with professional standards of practice for one resident who had a physician’s order for continuous oxygen. The resident had an order written on 2/24/26 for oxygen at 2 liters continuous for comfort every shift. During multiple observations over three consecutive days, surveyors repeatedly observed the resident lying in bed with an oxygen concentrator present in the room but turned off, and the nasal cannula coiled and resting on top of the concentrator under the handle, not in use. At no time during these observations was the resident seen receiving oxygen. Review of the resident’s March 2026 MAR showed that nurses had initialed each shift on the dates in question, documenting that the resident was receiving oxygen around the clock as ordered. The initials belonged to six different licensed nurses, indicating that each had recorded that oxygen was being administered when, based on surveyor observations, it was not. On 3/11/26, the DON and Nursing Home Administrator were informed that these six licensed nurses had falsified the medical record by documenting that the resident was receiving oxygen each shift when the oxygen concentrator was off and the nasal cannula was not applied. The DON later confirmed these findings.
Failure to Maintain Safe and Adequate Shower Water Temperature
Penalty
Summary
Facility staff failed to maintain safe and appropriate shower water temperatures on the Wye Oak Unit, resulting in one of two showers in that unit not providing hot water. During a complaint survey regarding lack of hot showers, a Surveyor measured the water temperature in the Wye Oak shower room and found the left shower at 87°F and the right shower at 110°F. The left shower faucet could not be turned toward the "H" (hot) setting, preventing adjustment to the appropriate temperature range. When the Surveyor returned with the Director of Maintenance and Housekeeping (Staff #11), Staff #11 confirmed the left shower temperature was 87°F, acknowledged that shower water temperatures should be between 100°F and 120°F, and stated he was unaware of any issue with the left shower faucet. Observation also showed there were no signs posted to direct staff not to use the malfunctioning left shower. This deficiency was identified on one of two showers in the Wye Oak Unit and one of four nursing units observed during the complaint survey, and the findings were shared with the Administrator the same day.
Failure to Maintain Effective Pest Control Resulting in Gnat Infestation
Penalty
Summary
The facility failed to maintain an effective pest control program on one nursing unit, as evidenced by numerous gnats observed in resident rooms and common areas. On 3/9/26 at 9:06 AM, a gnat was seen flying in a resident room, and a soiled sheet sitting on top of the trashcan by the sink was covered with at least nine gnats. In another room, gnats were observed flying around the toilet area. Frequent gnats were also seen flying in the hallway on the Homestead unit. On 3/10/26 at 8:35 AM, a resident was observed lying in bed with empty plastic juice containers on the bed tray table, and gnats were flying around the resident’s chin; a staff member confirmed that gnats were sometimes present because staff did not remove the juice containers. Review of the pest management documentation on 3/10/26 at 10:11 AM showed the pest control company last treated the Homestead unit on 2/17/26, with no documentation of a gnat problem on the unit despite staff acknowledgment of the issue. On 3/11/26 at 2:50 PM, the Nursing Home Administrator and Director of Nursing were informed of the concerns regarding the presence of gnats and the lack of effective pest control measures and documentation on the affected unit.
Failure to Notify Resident Representative of Change in Condition
Penalty
Summary
The facility failed to notify a resident's representative of a significant change in condition, specifically the discontinuation of a Foley catheter and initiation of a voiding trial. During a telephone interview, the resident's representative expressed surprise and concern about not being informed of the catheter removal, stating that notification had not occurred. Review of the resident's progress notes confirmed that while the provider was notified and a voiding trial was ordered, there was no documentation indicating that the resident's representative had been informed. Interviews with an LPN and the DON confirmed that facility policy requires notification of both the physician and the resident's representative for any change in condition or order, and that such notifications should be documented in the medical record.
Failure to Provide Supervision for Cognitively Impaired Resident with Fall History
Penalty
Summary
A deficiency occurred when a cognitively impaired resident with a history of falls and a recent fracture was left unsupervised in a secured memory care unit. The resident, who had diagnoses including ataxia, bipolar disorder, unspecified dementia with agitation, and Wernicke's encephalopathy, was observed attempting to get out of a Geri-chair in the common area without any nursing staff present. The only staff member in the area was a housekeeper, who intervened but was unable to locate nursing staff, leaving the resident at risk. During this time, the surveyor also noted an unlocked and unattended medication cart in the same area. The resident's medical record documented ongoing behaviors such as attempting to get out of chairs, sitting or scooting on the floor, and recent episodes of agitation, restlessness, and psychosis. Previous incidents included a fall resulting in a nasal bone fracture and another episode where the resident pulled down a dresser and sustained a minor injury. Despite these documented risks and behaviors, there was no increase in staff supervision or specific interventions implemented to monitor the resident while in the Geri-chair. Additionally, the resident's care plan identified risks related to falls, gait and balance problems, psychoactive drug use, and impulsiveness, but failed to include resident-centered interventions for monitoring while in the Geri-chair. The lack of staff presence in the common area and the absence of appropriate supervision for a high-risk resident directly led to the deficiency, as observed by the surveyor during the complaint survey.
Failure to Protect Residents from Abuse and Neglect
Penalty
Summary
The facility failed to protect residents from abuse and neglect, as evidenced by multiple incidents involving both staff-to-resident and resident-to-resident abuse. One incident involved a Licensed Practical Nurse (LPN) who was verbally aggressive toward a resident, telling the resident to get out of bed and not to dismiss her. The LPN's comments were witnessed by other staff, and the resident reported feeling upset and sad as a result of the interaction. The resident had a history of insomnia, depression, and anxiety, and the psychiatric evaluation documented that the nurse's words negatively affected the resident's mood that day. In addition to staff-to-resident abuse, the facility failed to prevent repeated resident-to-resident physical abuse on the dementia unit. One resident with a history of refusing medications and some memory loss was involved in multiple altercations, including physically assaulting other residents who entered his room. These incidents resulted in injuries such as a red mark, scratch, and bleeding from the mouth, and in one case, a resident required hospital evaluation and stitches. Despite these repeated incidents, the resident remained in the facility, and there was a lack of timely and effective interventions to address the ongoing risk. Interviews with staff and the medical director confirmed awareness of the repeated incidents and the need for interventions, such as psychiatric evaluation, behavior medication, and consideration of alternative placement. However, the facility did not implement sufficient measures to prevent further harm, and the resident continued to pose a danger to others. The failure to protect vulnerable residents from both staff and peer abuse resulted in emotional and physical harm to multiple residents.
Failure to Provide Adequate Linen and Maintain Safe, Homelike Environment
Penalty
Summary
Facility staff failed to provide residents with a safe, clean, comfortable, and homelike environment by not ensuring the availability of necessary linens and by not maintaining the physical environment. Multiple complaints and resident council meeting minutes documented ongoing issues with linen shortages, including the lack of washcloths, towels, and fitted sheets, as well as delays in returning residents' personal clothing from laundry. Staff interviews consistently confirmed that linen shortages were a persistent problem, with some staff reporting the need to cut up towels or bed sheets to use as washcloths and that linen was often unavailable, especially during certain shifts. The shortage was attributed to both budget constraints and malfunctioning laundry equipment, with only one washer and one dryer operational for an extended period, further exacerbating the issue. Observations and interviews revealed that the laundry department was operating with only one working washer and dryer out of four, and repairs had been delayed for at least two months. Staff reported that linen supplies were insufficient to meet residents' needs, and the turnover time for laundering residents' personal clothing often exceeded the expected 72 hours. The lack of adequate linen and laundry services led to staff having to retrieve linen from other units or make do with what was available, impacting the ability to provide proper bathing and incontinence care. Additionally, a tour of the facility revealed multiple maintenance issues in resident rooms and common areas, including ripped fall mats, cracked ceiling tiles, loose heater vents, exposed pipes and insulation, missing mirrors, holes in drywall, rusted vents, and non-working call bell systems. These deficiencies were confirmed by staff and observed by the surveyor, indicating a failure to maintain a sanitary, orderly, and comfortable interior environment for residents.
Failure to Provide Sufficient Nursing Staff and Supervision
Penalty
Summary
The facility failed to provide sufficient nursing staff to meet the needs of its residents, as evidenced by multiple sources including complaints, staff and resident interviews, resident council meeting minutes, and review of staffing schedules and time punches. Ten out of forty-two complaints submitted to the Office of Health Care Quality alleged inadequate staffing, with geriatric nursing assistants (GNAs) responsible for 15 to 30 residents per shift. This resulted in delays in care, missed showers and bed baths, untimely response to call bells, and cold food being served to residents. Resident council meeting minutes repeatedly documented ongoing concerns about unanswered call bells, insufficient staff, and lack of proper care, with both old and new business items highlighting persistent staffing shortages and their impact on resident care. A review of the CMS 672 form indicated that the majority of residents were dependent on staff for essential activities of daily living, including toileting, bathing, dressing, transferring, and eating. Despite this high level of need, staffing schedules revealed that the facility did not consistently meet the required minimum of 3 hours of bedside care per resident per day, as mandated by state regulations. Staff interviews corroborated these findings, with multiple staff members reporting frequent short staffing, high resident-to-staff ratios, inability to provide full baths, missed documentation, and challenges in managing residents with behavioral health needs. Staff also reported that on certain shifts, a single GNA was responsible for up to 30 residents, and that department heads occasionally assisted with direct care due to staffing shortages. Observations during the survey further confirmed the impact of inadequate staffing. On one occasion, a medication cart was left unlocked and unattended on the dementia unit, with no nursing staff present and only a housekeeper visible. During this time, a resident with a history of falls attempted to get out of a Geri-chair without assistance, and surveyor intervention was required to prevent harm. Additionally, a resident reported waiting 20 to 25 minutes for call lights to be answered, infrequent bed changes, and missed showers, all attributed to insufficient staffing. The facility's own assessment and scheduler interviews acknowledged the staffing challenges, with actual worked hours frequently falling below the required threshold.
Failure to Complete Annual Performance Reviews for GNAs
Penalty
Summary
The facility failed to conduct yearly performance reviews for all five Geriatric Nursing Assistants (GNAs) whose personnel files were reviewed during a complaint survey. Each GNA had been employed for over a year, yet their files did not contain documentation of annual performance evaluations as required. This deficiency was confirmed during an interview with the Nursing Home Administrator, who acknowledged that the facility was behind on completing yearly reviews and education for staff. The absence of these reviews was directly observed in the personnel files examined by surveyors.
Failure to Employ Qualified Full-Time Social Worker
Penalty
Summary
The facility failed to employ a qualified social worker on a full-time basis, as required for facilities with more than 120 beds. Review of resident council meeting minutes from January and February 2025 showed that residents discussed not being able to see social workers to address their concerns. An interview with the Social Work Assistant (SWA) revealed she worked part-time, three days a week, and did not possess a Bachelor's degree in social work or a human services field, but was instead pursuing an Associate's degree in nursing. The SWA also stated she was unable to hold any care plan meetings in January because she was the only social work staff present until the third week of January, when the Regional Social Worker began coming to the facility two days per week. The Administrator confirmed that the facility did not have a qualified social worker on a full-time basis.
Failure to Maintain Essential Equipment in Safe Working Order
Penalty
Summary
The facility failed to maintain essential equipment in safe working order, resulting in multiple deficiencies affecting resident care and daily operations. There were ongoing issues with the hot water supply, particularly during the night and in specific units, which persisted for several months. Residents reported having to bathe with cold water, and staff interviews confirmed that the hot water problem began in mid-January and recurred intermittently. Maintenance staff admitted to resetting the boiler as a temporary fix without promptly notifying higher management or arranging for timely repairs. Work order records indicated similar hot water issues as far back as August, with delays in obtaining necessary parts and resolving the problem. Additionally, the facility experienced significant shortages of clean linen due to malfunctioning laundry equipment. Staff and residents reported a lack of washcloths, towels, and fitted sheets, with some staff resorting to tearing up bed sheets for use as washcloths. Only one washer and one dryer were operational for an extended period, despite the facility having four of each. This situation led to frequent linen shortages, delayed return of residents' personal clothing, and insufficient linen availability for certain shifts. Staff interviews and direct observation confirmed that the laundry equipment issues had persisted for several months, with repairs only being addressed when surveyors were present. The kitchen's dishwasher was also found to be operating below the required temperature for chemical sanitization, with both the wash and rinse cycles consistently registering at 110 degrees instead of the minimum 120 degrees specified by the manufacturer. Staff continued to use the dishwasher despite the inadequate temperature, and the issue was only escalated to maintenance and corporate staff after surveyor intervention. These equipment failures collectively had the potential to affect all residents in the facility.
Failure to Document and Track Required Yearly GNA Training Hours
Penalty
Summary
The facility failed to ensure that geriatric nursing assistants (GNAs) received the required minimum of 12 hours of competency training per year. During a review of personnel files, it was found that one GNA's file did not contain documentation to validate the yearly training hours received. Although there were in-service signature sheets for various topics, the amount of time credited for each in-service was not documented, making it impossible to confirm compliance with training requirements. Interviews with the staff educator and the Nursing Home Administrator confirmed that there was no formal system in place to track the number of hours of education completed by GNAs, and that the facility was behind in maintaining education records.
Resident Left Uncovered and Exposed During Shower
Penalty
Summary
Facility staff failed to treat a resident with dignity during a showering incident. The resident, who was dependent on staff for bathing due to a spinal cord disease, reported being left naked and uncovered in a shower chair facing the door. This occurred after two nursing assistants placed the resident in the shower chair, turned on the water, and then left to assist with a new admission at the request of a nurse. The resident was unable to recall the names of the nursing assistants but remembered that another staff member later discovered them in this state. Upon entering the shower room, the staff member found the resident still naked and uncovered, facing the door. The staff member then provided the resident with a shower and later informed the nurse that the resident had been left exposed. The nurse confirmed that he had asked for assistance with a new admission and was told afterward that the resident had been left uncovered. The incident was reviewed with the facility administrator.
Failure to Timely Report and Document Abuse Allegations to Regulatory Authorities
Penalty
Summary
The facility failed to ensure timely and proper reporting of suspected abuse, neglect, or theft, as well as the results of investigations, to the appropriate regulatory agency, the Office of Health Care Quality (OHCQ). In several instances, documentation was missing regarding when final reports were submitted, and initial reports of abuse were not made within the required two-hour timeframe. For example, in the case of a resident with a right hip fracture, the facility could only provide documentation of the initial report and not the final submission. In another case, a resident reported abuse to a police officer, but the incident was not reported to OHCQ because the RN did not notify the Nursing Home Administrator (NHA). Additionally, there was a delay in reporting an alleged assault by a GNA, as the NHA and former DON became aware of the incident days later and the report to OHCQ was not made within two hours of awareness. Further deficiencies were identified when a resident alleged assault while at the hospital, but the facility could not locate the investigation file or confirm timely reporting to OHCQ, as the current NHA was not employed at the time. In another incident, a GNA observed two residents tied to chairs but did not report the allegation for several days, and the LPN who was informed also delayed reporting to administration. These failures demonstrate lapses in both the timely internal reporting of abuse allegations and the required external notifications to regulatory authorities.
Failure to Investigate and Document Abuse, Injuries, and Environmental Hazards
Penalty
Summary
The facility failed to provide documentation that allegations of abuse, injuries of unknown origin, and a gas leak were thoroughly investigated for multiple residents and one facility incident. In several cases, residents reported or were observed to have suffered injuries, alleged abuse, or were involved in altercations, but the facility either did not complete or could not locate investigation files, incident reports, or interview documentation. For example, a resident was found with a hip fracture, another alleged abuse to a police officer, and another suffered a nasal bone fracture from a fall, yet the facility was unable to produce investigative paperwork or complete records for these incidents. In other instances, the facility's investigations were incomplete, lacking interviews with all relevant staff or residents, or missing skin assessments for non-interviewable residents. There were also cases where altercations between residents resulted in visible injuries, but no incident reports or interviews were conducted, and the administrator was unaware of the events. Additionally, a reported gas leak in the kitchen was not supported by any investigation documentation, interviews, or evidence of staff education, and the current administrator had no information or records regarding the incident. The deficiencies were identified through review of facility-reported incidents, medical records, and staff interviews, revealing a pattern of missing or incomplete investigations for allegations of abuse, injuries, and environmental hazards. The lack of thorough documentation and investigation was evident for nine residents and one facility incident, as confirmed by the administrator and review of available records.
Failure to Provide Required ADL Care for Dependent Residents
Penalty
Summary
The facility failed to provide necessary activities of daily living (ADL) care for multiple residents who were dependent on staff for assistance. Medical record reviews and interviews revealed that several residents did not consistently receive showers, bed baths, or assistance with toileting and repositioning as required by their care plans and documented needs. For example, one resident with neurocognitive impairment and extensive ADL needs did not receive regular bathing, turning, or toileting on multiple documented dates, and both the administrator and unit manager were unaware of these lapses. Another resident, who required staff assistance to shower, reported not receiving showers on scheduled days and experienced a fall in the shower when left unattended by staff. Additional findings included a resident with a spinal cord disease who was dependent on staff for bathing and reported not receiving showers for extended periods, with no documentation to support that showers were provided as scheduled. Another bedbound resident with ankylosing spondylitis was found to have received bed baths on less than half of the days in several months, despite being fully dependent on staff for all ADLs. Staff interviews confirmed that refusals of care were to be documented, but there were gaps in documentation, and the DON acknowledged that bed baths should be offered daily and refusals documented, with no blank spaces in records. The deficiencies were identified through complaint investigations, medical record reviews, and resident and staff interviews, which consistently showed that dependent residents were not receiving the level of care required for their conditions. The lack of consistent documentation and staff awareness contributed to the failure to provide adequate ADL care, as evidenced by missed showers, bed baths, toileting, and repositioning for residents with significant physical and cognitive impairments.
Failure to Follow Up on Medication, Neuro Checks, and Oxygen Orders
Penalty
Summary
Facility staff failed to follow up on a prescribed medication for a resident with Ankylosing spondylitis. The resident was ordered to receive Enbrel injections weekly, but there were multiple documented instances where the medication was not available due to insurance denial and pharmacy issues. Although the facility agreed to cover the cost of one injection and the nurse practitioner offered alternative treatments, there was no further documentation of efforts to resolve the insurance issue or obtain the medication after a certain point. The medical director acknowledged the lack of follow-up and was unable to explain why the resident had been without the medication for an extended period. Another deficiency involved the failure to perform and document neurological checks and change of condition assessments after unwitnessed falls for a resident admitted for rehabilitation. The resident experienced several unwitnessed falls, but after the initial assessment, there were no documented neuro checks or change of condition assessments for multiple incidents. The Director of Nursing confirmed that these assessments were not completed as required. Additionally, the facility failed to obtain an ongoing or as-needed order for oxygen for a resident with multiple complex medical conditions, including end-stage renal disease and COPD. The resident, who was dependent for all activities of daily living, was transported to dialysis without oxygen, resulting in an episode of hypoxia and subsequent hospitalization. There was no documented order for oxygen, and the resident later passed away at the facility. The administrator was made aware of these deficiencies.
Failure to Provide and Document On-Site Dietician Assessments
Penalty
Summary
The facility failed to ensure that a registered dietician conducted and documented nutritional assessments for residents, as required. Specifically, for one resident, there were no nutritional notes or assessments documented in the medical record from the time of admission through a period of over one year. The only weight recorded for the resident was at admission, and the resident had refused subsequent weights. The resident's diet consisted solely of fish for all meals and peanut butter crackers with medication, as per their request. There was no evidence of ongoing evaluation or adjustment of the resident's nutritional needs during this time. Interviews revealed that the facility had not had an on-site registered dietician since the previous dietician resigned several months prior, and the current arrangement only provided for a remote dietician. The previous dietician reported being unable to consistently see residents every three months or keep up with documentation due to workload and being pulled into kitchen duties. The lack of regular assessments and documentation was confirmed by both the nursing home administrator and the previous dietician.
Failure to Provide Timely Medication Administration Due to Ordering and Authorization Delays
Penalty
Summary
The facility failed to provide timely pharmaceutical services to meet the needs of multiple residents, as evidenced by repeated instances where prescribed medications were not available or administered as ordered. For one resident, Escitalopram for depression and a nicotine transdermal patch for smoking cessation were not given on several occasions because the medications were still on order. Staff interviews revealed inconsistent practices regarding medication reordering and follow-up, with some staff reordering medications at varying intervals and reporting ongoing issues with pharmacy delivery. Another resident did not receive Naproxen for pain management and several supplements, including Zinc, Garlic, and Vitamin D3, over multiple days due to the medications being on order or awaiting delivery from the pharmacy. A third resident experienced delays in receiving Gilenya for multiple sclerosis and Oxycontin for pain, with documentation showing that the required prior authorization forms were not submitted in a timely manner, resulting in extended periods without the prescribed medications. These findings indicate a lack of effective processes to ensure medication availability and timely follow-up on prior authorization requirements.
Failure to Provide Palatable, Correct, and Safe-Temperature Meals
Penalty
Summary
Facility staff failed to prepare and serve food that was palatable, attractive, and at a safe and appetizing temperature, as evidenced by multiple resident complaints, direct observations, and review of resident council meeting minutes. Several residents reported not receiving the food items listed on the menu or what they had ordered, with trays missing key components such as vegetables or dinner rolls. Observations confirmed that food was sometimes ground instead of bite-sized, and substitutions were made without apparent reason. Residents consistently reported dissatisfaction with the taste and temperature of the food, noting that meals were often cold and not as requested. Test tray temperature checks revealed that hot foods were served well below the required 135 degrees, with readings as low as 104 degrees for vegetables and 119 degrees for noodles with gravy. Resident council meeting minutes over several months documented ongoing concerns about late, cold, and incorrect food being served, including reports of frozen food on weekends. These findings were confirmed through interviews with residents, direct observation of meal service, and review of facility documentation, with both the Dietary Manager and DON acknowledging the issues when presented by surveyors.
Deficient Food Storage and Temperature Monitoring in Kitchen
Penalty
Summary
Surveyors identified multiple deficiencies in the facility's food storage and temperature monitoring practices during a kitchen tour with the Dietary Manager. In the dry storage area, a large bag of cornmeal was found on the bottom shelf with a ripped, unsealed area, and four large containers of dry goods labeled thick it, flour, panko, and sugar were stored on the floor without any dates to indicate how long the contents had been in the bins. A plastic container of walnuts was observed to have a crack, preventing it from being sealed. In the freezer, a tray of 16 individual plastic containers of sherbet was found without any dates. Additionally, the sink next to the food prep area did not contain soap. Review of temperature logs revealed that daily temperatures for the reach-in refrigerator, walk-in refrigerator, and freezer were not recorded from 3/1 through 3/17/25. The Dietary Manager confirmed these findings and stated that staff had been instructed to record temperatures daily, but the cook had recorded them in a notebook that was accidentally taken home.
Failure to Maintain Complete and Accurate Medical Records
Penalty
Summary
The facility failed to maintain complete and accurate medical records in accordance with accepted professional standards for several residents. For one resident, review of bathing records over multiple months revealed numerous blank spaces in the documentation of bed baths and refusals by geriatric nursing assistants (GNAs) across all shifts. Interviews with staff, including an LPN and the Director of Nursing (DON), confirmed that GNAs are required to document all care provided or refused, and that blank spaces should not be present in the records. Despite this, the records showed incomplete documentation, with many days lacking any entry regarding whether care was provided or refused. Additionally, the facility did not properly document the discharge of two residents. Their medical records lacked any note or assessment at discharge, including information about their status or where they were discharged to. The DON confirmed that staff failed to document these discharges as required. There was also an incident involving a resident who was sent to the hospital with a hip fracture and never returned to the facility. However, a physician entered progress notes in the facility's electronic medical record system as if the resident had returned, including a discharge note stating the resident had expired. Upon review, it was determined that the physician had documented in the wrong chart, possibly due to confusion with similar names or selecting the wrong facility in the electronic system. This resulted in inaccurate and misleading entries in the resident's official medical record.
Failure to Maintain Resident Call Bell System in Working Order
Penalty
Summary
Surveyors found that the facility failed to maintain a functioning resident call bell system on one of its nursing units, specifically the Homestead Unit. During a tour with a staff member, multiple occupied rooms were observed to lack a working call bell, with some rooms having no manual bells at the bedside and one room having a manual bell placed out of the resident's reach. The issue was confirmed in an interview with the Administrator, who acknowledged that the call bell system was not operational and that no contractor was present to address the problem at the time of the survey. These findings were based on direct observation and staff interview during a complaint investigation, and the deficiency was evident in a significant number of occupied rooms on the unit.
Failure to Maintain Effective Pest Control Program
Penalty
Summary
Surveyors observed that the facility failed to maintain an effective pest control program, as evidenced by the presence of flies, gnats, and ants in multiple areas over two consecutive days. On several occasions, flies and gnats were seen in the conference room, laundry room, and kitchen, including over food preparation and serving areas. Standing water was noted in the laundry room, and an open trash can with a used yogurt container was found to be attracting numerous gnats and flies. Staff confirmed the ongoing pest issue, with one staff member stating that the flies had been a persistent problem in the kitchen. Documentation review revealed that the pest control company visited the facility every two weeks, with the most recent treatment occurring six days prior to the observations. However, pest control logs indicated that no specific pest issues were reported during the last visit, and only baseboards were treated. Staff interviews further confirmed awareness of the pest problem and suggested that the frequency of pest control visits was insufficient to address the ongoing infestation.
Failure to Inform Residents/Representatives and Obtain Consent for Psychotropic Medications
Penalty
Summary
Facility staff failed to inform residents and/or their representatives of changes in treatment plans related to medication, specifically regarding the initiation of psychotropic medications, and did not obtain consent prior to administration. In one case, a terminally ill resident who was not on hospice or palliative care was prescribed and administered Ativan (anxiolytic) and Morphine (opioid) for end-of-life care without notifying the resident's representative or obtaining consent. The medical record did not contain documentation that the representative was informed of the risks and benefits of these medications or that consent was obtained before administration. The attending physician later stated that he was unaware the medications were for end-of-life care and believed that the family did not want such treatment, emphasizing that providers are responsible for discussing these matters with families. In another instance, a resident with multiple diagnoses, including hypertension, cirrhosis, hepatic encephalopathy, and kidney failure, was prescribed Duloxetine (Cymbalta) for neuropathic pain. The medication was administered for several days before being placed on hold and then discontinued. The medical record lacked documentation that the resident or their representative was informed of the new medication or that consent was obtained prior to its initiation. The attending physician reported that the medication was ordered by another practitioner and that, had he ordered it, he would have notified the representative immediately. In both cases, the facility's documentation did not show that residents or their representatives were fully informed about changes in treatment plans, the risks and benefits of psychotropic medications, or that consent was obtained prior to administration. These deficiencies were acknowledged by the Director of Nursing and Nursing Home Administrator when presented with the findings.
Failure to Notify Physician of Change in Condition and Medication Unavailability
Penalty
Summary
Facility staff failed to notify a resident's physician of a change in status and did not inform the physician when a prescribed medication was unavailable. For one resident admitted for rehabilitation, a nurse's note documented that a staff member accidentally stepped on the resident's foot during a transfer, but the resident denied pain. Despite this incident, there was no documentation that the physician was notified to determine if further treatment was needed for the affected foot. The Director of Nursing confirmed that the physician was not notified of this change in condition. For another resident with multiple diagnoses, including hypertension, cirrhosis, hepatic encephalopathy, and kidney failure requiring hemodialysis, the medical record showed that a prescribed medication, Rifaximin, was not administered as ordered on numerous occasions due to unavailability. Documentation indicated that the medication was not available, but there was no evidence that the physician was notified about the missed doses or the medication's unavailability. The attending physician later confirmed not being informed and stated that the physician should be notified whenever a resident is out of medication.
Failure to Safeguard Resident's Personal Belongings
Penalty
Summary
A resident with multiple medical conditions, including severe sepsis, pneumonia, autoimmune hepatitis, and cognitive impairment, was admitted to the dementia unit. The resident was alert and oriented, as indicated by a BIMS score of 14/15. Upon admission, the resident's belongings, including a purse containing $63, insurance cards, credit cards, and a debit card, were supposed to be secured due to concerns about another resident taking items. Despite being locked up at the nurse's station, the purse and several other personal items, such as blankets, chargers, a pillow, clothing, and a partial dental plate, went missing. The resident reported that the partial dental plate was lost after a fall, during which a male nurse allegedly tossed the resident back into bed, but the nurse could not be identified. Facility staff failed to maintain accurate inventory records of the resident's belongings upon admission, and there was a lack of communication with the resident's family regarding the missing items. The administrator later found a wallet with cash but no identification and attempted to verify its ownership. The absence of proper inventory documentation and secure handling of the resident's property contributed to the misappropriation and loss of personal items.
Incomplete Quarterly MDS Assessment Due to Missed Cognition, Mood, and Behavior Evaluation
Penalty
Summary
Facility staff failed to conduct a complete and accurate quarterly assessment for a resident with diagnoses including bipolar disorder, dementia, and Wernicke's encephalopathy. Medical record review showed that the resident exhibited behavioral disturbances and had a recent increase in Seroquel dosage. However, the quarterly Minimum Data Set (MDS) assessment with a reference date of 1/15/25 did not include evaluations of cognition, mood, or behavior, rendering the assessment incomplete. During an interview, the MDS Coordinator confirmed the omission, explaining that the social worker, who typically completes these sections, was absent and no alternative staff member performed the required assessments.
Inaccurate MDS Coding for Behaviors and Injury Severity
Penalty
Summary
Facility staff failed to ensure that Minimum Data Set (MDS) assessments were accurately coded for two residents during a complaint survey. For one resident, a quarterly MDS assessment did not reflect documented behavioral symptoms, including physical and verbal aggression such as hitting, throwing objects, and cursing at staff, as well as aggressive use of a wheelchair. These behaviors were recorded in the medical record but were not coded in Section E0200 of the MDS, which is designated for such behaviors. The MDS coordinator confirmed this coding error during an interview. For another resident, the discharge return anticipated MDS assessment inaccurately coded the number and severity of falls. The resident had sustained a right hip fracture and was sent to the emergency room, but the MDS was coded as an injury (except major) rather than a major injury, which should include bone fractures. This error was also confirmed by the MDS coordinator. Both deficiencies were identified through medical record review and staff interviews.
Failure to Develop and Update Comprehensive Care Plans and Hold Regular IDT Meetings
Penalty
Summary
The facility failed to develop and update comprehensive care plans within the required timeframe following comprehensive assessments, as well as to hold regular care plan meetings involving the interdisciplinary team (IDT) and resident representatives. For one resident, quarterly MDS assessments were completed, but there was no documentation of care plan meetings following these assessments. Staff confirmed that a care plan meeting was not held due to staffing limitations and unsuccessful attempts to contact the resident's representative. Additionally, the IDT did not meet to review or revise the care plan after the assessments. Another resident experienced a fall resulting in a nasal fracture, and was later observed attempting to get out of a geri-chair without appropriate supervision. The care plan for this resident, who was at risk for falls due to cognitive impairment and other factors, did not include specific, resident-centered interventions for monitoring while in the geri-chair. This lack of individualized interventions was confirmed by facility leadership during interviews. A third resident, with a history of substance abuse and aggressive behavior, repeatedly struck other residents over several months. Despite multiple incidents, there was no care plan or interventions documented until several months after the initial events, at which point only minimal interventions were added. Interviews with staff and the medical director confirmed that behavioral interventions and care planning were not implemented in a timely manner. These deficiencies were identified for three residents during a complaint survey.
Failure to Obtain Consent and Document Administration of End-of-Life Medications
Penalty
Summary
A practitioner failed to follow professional standards of clinical practice by prescribing end-of-life medications, specifically Ativan (anxiolytic) and Morphine (opioid), to a resident who was a full code without ensuring that the resident or the resident's representative was fully informed about the use of these medications or obtaining consent. The resident had a MOLST form indicating a full code status and was not on hospice or receiving palliative care. The nurse practitioner entered active orders for these medications in the electronic medical record and left physical prescriptions with the Director of Nursing, with the stipulation that they be used if the code status changed, but did not have the required conversation with the family or obtain consent prior to initiating the medications. There was no documentation in the medical record that the resident or representative was informed or that consent was obtained before the medications were administered. Nursing staff also failed to follow professional standards of nursing practice when administering psychotropic medications by not documenting in the medication administration record (MAR) when the medications were given. The controlled substance count sheets indicated that doses of Lorazepam and Morphine were removed and presumably administered, but these administrations were not consistently documented in the MAR. Specifically, doses removed at certain times were not recorded as given in the MAR, indicating a lapse in required medication administration documentation. The resident involved had multiple significant diagnoses, including hepatocellular carcinoma and hepatic encephalopathy, and was transferred from another facility. The resident was admitted, received the medications in question, and was later transferred to the hospital after becoming unresponsive. The lack of documentation regarding consent for end-of-life medications and the failure to accurately document medication administration were both identified as deficiencies during the complaint survey.
Failure to Assess and Treat Pressure Ulcer
Penalty
Summary
Facility staff failed to provide appropriate assessment and treatment for a resident with a deep tissue injury (DTI) to the left heel. The resident, who was admitted in May 2023, was assessed by the Wound Nurse Practitioner in June 2023 and identified as having a DTI. However, during the week of July 3rd, 2023, staff did not perform the required weekly skin assessment, which should have included measurements and documentation of the pressure ulcer's status. Additionally, the facility's July 2023 Treatment Administration Records showed that staff did not provide the prescribed treatment for the resident's left heel DTI on four separate dates: July 7th, 10th, 16th, and 18th. The Director of Nursing confirmed these lapses in both assessment and treatment during an interview. These failures represent a lack of adherence to protocols for pressure ulcer care and prevention.
Delay in Obtaining Motorized Wheelchair Due to Communication Failures
Penalty
Summary
Facility staff failed to ensure timely follow-up and acquisition of a motorized wheelchair for a resident with multiple complex medical conditions, including multiple sclerosis, diabetes, arthritis, and peripheral vascular disease. The resident's previous power wheelchair had stopped working, and although Medicaid had approved a replacement and the facility had ordered it, the resident had been waiting for at least four months without receiving the new wheelchair. Interviews revealed that the process was delayed due to miscommunication and technical issues, including emails regarding the wheelchair order and invoice being sent to a former business office manager who no longer worked at the facility, resulting in critical information not being received or acted upon by current staff. Further investigation showed that the medical supply company had reached out to the facility about the expiring prior authorization and the need for payment before delivery, but this information was not relayed to the appropriate personnel. The Director of Physical Therapy was unaware of the status of the wheelchair order, and the Regional Business Office Manager only became aware of the issue after the surveyor's inquiry. As a result, the resident experienced a significant delay in receiving necessary equipment to maintain or improve mobility, with no documented medical reason for the delay.
Failure to Assess Catheter Removal and Perform Voiding Trial
Penalty
Summary
Facility staff failed to assess a resident with neuromuscular dysfunction of the bladder for the removal of an indwelling urinary catheter. The resident was admitted with a catheter and reported increased sensation and awareness of urination, and stated that a voiding trial had been discussed but not performed. Medical record review confirmed the absence of a voiding trial, and during interview, the Medical Director acknowledged that a voiding trial had not been conducted, despite the resident's reported changes in condition and the potential for regaining some bladder function.
Failure to Follow Physician-Ordered Blood Pressure Parameters for Medication Administration
Penalty
Summary
The facility failed to ensure a resident’s drug regimen was free from unnecessary drugs by not following physician-ordered blood pressure (BP) parameters for administering antihypertensive and hypotensive medications. Specifically, a resident with multiple diagnoses including hypertension, cirrhosis, hepatic encephalopathy, kidney failure, and who was receiving hemodialysis, was administered Amlodipine on two occasions when the resident’s systolic BP was below the ordered threshold, contrary to the physician’s order to hold the medication for systolic BP less than 110. Additionally, the medication administration record (MAR) showed that Midodrine was given on eleven occasions without documentation that BP was monitored prior to administration, despite orders to hold for systolic BP greater than 140. Further, Propranolol was administered multiple times in February without documentation that the resident’s BP was checked prior to administration, as required by the physician’s order to hold for systolic BP less than 110. These failures were confirmed through medical record review and staff interview, with the Director of Nursing acknowledging the concerns. The lack of adherence to medication administration parameters and absence of required BP monitoring led to the deficiency.
Failure to Obtain Consent and Properly Manage Psychotropic Medication for End-of-Life Care
Penalty
Summary
Facility staff failed to ensure that a resident's medication regimen was free from unnecessary psychotropic medication. A terminally ill resident, who was not on hospice or receiving palliative care and had a full code status per a signed MOLST form, was prescribed and administered Ativan (anxiolytic) and Morphine (opioid) for end-of-life symptoms. The orders for these medications were entered into the electronic medical record by a nurse practitioner (NP) with the intention that they would be used if the resident's code status changed to palliative care, but the medications were made active and administered while the resident remained a full code. Medical record review revealed that there was no documentation indicating that the resident or the resident's representative was informed of the risks and benefits of the psychotropic medications, nor was consent obtained prior to their initiation. There was also no evidence that end-of-life care or a change in code status was discussed with the resident's representative before the medications were started. The NP stated that the prescriptions were left with the DON with the stipulation that they would only be used if the code status changed, but the orders were entered as active and administered regardless. Interviews with facility staff, including the NP, medical director, and attending physician, confirmed that the medications were given for end-of-life care while the resident was still a full code, and that appropriate communication with the resident's representative did not occur. The attending physician stated that it was the provider's responsibility to speak with the family before initiating such medications and would not have left prescriptions for end-of-life care without this discussion. The DON acknowledged the concerns when they were presented.
Failure to Provide and Accurately Document Prescribed Medication Administration
Penalty
Summary
The facility failed to ensure that a resident was free from significant medication errors by not providing a prescribed medication, Rifaximin, in a timely manner and by inaccurately documenting medication administration. The resident, who had multiple complex medical conditions including hepatic encephalopathy, hypertension, cirrhosis, and kidney failure requiring hemodialysis, was admitted following an acute hospitalization. The medication Rifaximin was ordered to be administered twice daily for hepatic encephalopathy, but review of the electronic Medication Administration Record (eMAR) and pharmacy dispensing records revealed that the medication was not available for administration on numerous scheduled occasions. Despite the medication not being available, staff frequently documented in the eMAR that the medication had been administered, or used a code indicating the medication was not given but failed to provide accurate and complete documentation in the administration notes. Pharmacy records showed that the number of doses dispensed did not match the number of administrations recorded as given, and staff sometimes falsely documented administration when the medication was not present in the facility. Notes in the EMR and from the nurse practitioner indicated ongoing issues with medication availability, delays due to payment authorization, and lack of communication with the attending physician regarding the missed doses. Interviews with facility staff, including the attending physician and DON, confirmed that the physician was unaware of the missed doses and that staff had documented administration when the medication was not available. The DON acknowledged awareness of staff who may have falsely documented medication administration. The failure to ensure medication availability and accurate documentation resulted in the resident not receiving Rifaximin as prescribed for an extended period.
Unattended and Unlocked Medication Cart on Memory Care Unit
Penalty
Summary
Facility staff failed to keep a medication cart locked when it was left unattended on the Homestead Unit, a locked memory care unit. On the date of observation, a surveyor found the medication cart next to the nurse's station, adjacent to the dining/activity room, with no nursing staff present. The surveyor was able to open the top drawer and observed resident medications and a pair of scissors, as well as additional drawers containing anti-hypertensive, anti-psychotic, anti-depressant, and other medications. Residents were observed ambulating in the hallways and dining/activity area during this time. The medication cart remained unattended and unlocked for at least seven minutes until the Administrator in Training (AIT) returned and attempted to lock it. Upon inquiry, it was revealed that the nurse assigned to the unit had left early, and the unit manager was responsible for two units and was providing patient care elsewhere at the time. The unit manager subsequently locked the cart after being informed by the surveyor of the situation. The Nursing Home Administrator and Director of Nursing were notified of the incident later that day.
Failure to Provide Required Meals and Snacks to Residents
Penalty
Summary
Facility staff failed to consistently provide meals and snacks in accordance with residents' needs and preferences, as evidenced by two residents' experiences. One resident reported not always receiving an evening snack, despite a physician's order for peanut butter crackers three times daily and as needed. The Dietary Director confirmed that there were frequent instances where snacks were not delivered to the resident, with snacks remaining in the pantry or refrigerator instead of being passed to the resident. The Dietary Director also noted that concerns about this issue had been raised with the administrator, and that the problem had persisted over several months. Another resident, admitted for rehabilitation following a knee injury and with multiple diagnoses including hypertension, diabetes, and COPD, was not provided with meals on two days following admission. Documentation for one of those days showed no record of the resident receiving breakfast or lunch, and the Dietary Manager was unable to provide meal tickets or evidence that meals had been served. The lack of documentation and inability to confirm meal provision indicated that the resident may not have received required meals during their stay.
Failure to Schedule Physician-Ordered Sleep Study
Penalty
Summary
The facility failed to schedule a sleep study for a resident as ordered by a physician to rule out sleep apnea, which was necessary for obtaining a CPAP device. The order for the sleep study was documented on 1/20/24 and was acknowledged by the former Director of Nursing, but the appointment was never made. The resident was later discharged to another facility on 2/23/24. The current administrator was not present during the time of the incident and had no information regarding the resident, and the former DON was no longer available to provide an explanation for the missed appointment. This deficiency was identified during a complaint survey through medical record review and staff interviews.
Failure to Maintain and Post Current Nursing Staffing Data
Penalty
Summary
Facility staff failed to maintain and post up-to-date daily nursing staffing information as required. On observation, the posted nursing schedule in the lobby was found to display staffing data from four days prior, rather than the current day's information. The posted form included the census and projected hours per patient day (HPPD) for a previous date, and had not been updated for several days. During the survey, the Administrator confirmed that daily nursing staffing sheets, including staff assignments, census, and actual hours worked, were not maintained until a recent date, indicating a gap in required documentation and posting practices. This deficiency was identified during a complaint survey and was based on review of facility documentation, interviews, and direct observation.
Latest citations in Maryland
The facility did not ensure that its Infection Preventionist (IP) met required qualifications for managing the Infection Prevention and Control Program. The DON reported serving as the IP but acknowledged lacking the specialized infection control training required for the role, and confirmed that no other staff member was currently qualified. Records showed that the previously qualified IP left several months earlier, and the Administrator and DON confirmed they were still seeking a replacement, leaving the infection control program without a properly trained leader.
Staff failed to consistently secure medications and medical supplies across three units, including an oxygen tank left on the floor behind a resident’s bed without a supporting device, a treatment cart with Collagenase Santyl cream left on top while two residents in power wheelchairs passed by, an unattended and unlocked treatment cart at a nursing station, and another treatment cart with Diclofenac gel and dressings left on top, indicating repeated lapses in maintaining locked and secure storage for drugs, biologicals, and related supplies.
The facility failed to provide sufficient dietitian coverage and timely nutritional assessments for several residents with significant dietary needs. A resident admitted for diabetic management with a high A1C was placed on a regular diet instead of the recommended carb-controlled diet and had only one weight taken in the first two weeks, with no dietitian review of the record. Another resident with prior significant weight loss had no documented dietitian follow-up despite continued weight loss, and a resident admitted with severe protein-calorie malnutrition experienced further significant weight loss without any dietitian assessment. The dietitian reported working limited hours and prioritizing certain high-risk cases, resulting in delayed or missed evaluations for new admissions and residents with ongoing nutritional concerns.
The facility failed to maintain adequate linen and incontinence supplies and did not keep resident care areas in good repair, resulting in delays and alterations in incontinence care and substandard environmental conditions. Staff reported that towels and washcloths were used instead of wipes and then discarded due to heavy soiling, and that linen deliveries to units were late, leaving residents waiting for care. Observations showed very limited numbers of clean washcloths and other linens on units and in the laundry, with no stock of disposable wipes or backup washcloth supply despite repeated reports to housekeeping. Additional observations revealed recliner chairs blocking a dining-area handwashing sink and kitchenette, multiple resident and shared bathrooms with unfinished spackle, chipped paint, musty odors, black substances near showers, missing threshold molding, exposed cracks and nails, and eroded, rusted baseboard heaters. Hallway handrails on both units were worn, chipped, and splintered, and a shower room contained fecal odors, dried brown stains on the toilet, and deteriorated fixtures, all contributing to a failure to provide a safe, clean, and homelike environment.
Facility staff did not thoroughly investigate two separate abuse allegations involving a resident and an injury of unknown origin involving another resident. In both cases, investigations focused on the directly affected resident and included staff interviews, but there were no interviews of other residents on the unit or documented assessments of those residents for signs of abuse or injuries of unknown origin, including residents unable to communicate due to cognitive status.
Two residents who were dependent on staff for oral care, including one with a tracheostomy, were observed with thick, white or milky substances coating their mouths and teeth, indicating inadequate oral hygiene. One resident communicated that staff did not brush their teeth and that staff "need to." In another case, despite oral care supplies being present in the room, the resident’s mouth and teeth remained unclean on multiple observations, with a thick milky substance caking the teeth and stringing between them when the resident tried to open their mouth. These findings showed that staff did not consistently provide oral care to residents who relied on them for this ADL.
Staff failed to maintain complete and accurate medical records for multiple residents, including missing and inconsistent documentation of wound care, delayed pain assessment after discovery of an injury of unknown origin in a cognitively impaired resident, and inaccurate recording of a PPD test result that was documented as negative despite no evidence the injection was administered and no supporting nurse’s note. Residents reported not receiving certain treatments, while MAR entries either lacked signatures for completion or contained conflicting information about whether care was provided.
Surveyors found that the facility failed to consistently implement and communicate correct transmission-based precautions and PPE use. One resident with a Foley catheter related to wounds had no precaution signage posted, while another resident in a double room had a contact precautions sign at the door, yet the NP entered without PPE and the GNA provided high-contact care wearing only gloves. Staff in that room stated the resident was not on contact precautions and later reversed the sign to show no PPE requirement. Therapy staff reported they rely solely on posted signs to determine PPE, and surveyors identified broader issues with inaccurate signage and staff awareness of which residents required contact precautions.
Surveyors found that MDS assessments were inaccurately coded for two residents. In one case, a resident sustained a femoral neck fracture after a fall, but the subsequent significant change MDS did not code the fall as a major injury and failed to capture prn Tylenol use documented on the MAR within the look-back period. In the other case, a quarterly MDS indicated opioid use for a resident, but the MAR for the same period showed no prescribed opioid, indicating incorrect coding of high-risk drug classes.
A resident who had recently been admitted and experienced a fall received multiple doses of the narcotic analgesic Tramadol, but the facility failed to accurately document all administered doses on the Medication Administration Record (MAR). Review showed only one Tramadol dose recorded on the MAR, while the Controlled Drug Receipt/Record/Disposition Form on the med cart reflected three doses given over two days. In interview, the DON stated staff are expected to document narcotic administration on the MAR and confirmed that two administered doses were not recorded there, resulting in an incomplete and inaccurate medical record.
Unqualified Infection Preventionist Overseeing Infection Control Program
Penalty
Summary
The facility failed to ensure that its designated Infection Preventionist (IP) met the mandatory qualifications for overseeing the Infection Prevention and Control Program. During an interview on 3/24/26 at 10:00 AM, the DON confirmed that she/he was serving as the facility’s IP but had not completed the specialized training in infection control required for the position. The DON further stated that no other staff member currently met the qualifications to serve as IP. Record review showed that the previously qualified IP left the facility in October 2025, and as of the survey date, the position remained unfilled by a qualified individual. At 1:30 PM on the same day, the Administrator and DON confirmed they were still in the process of finding a qualified IP for the facility, leaving the Infection Prevention and Control Program without a properly trained and qualified leader. No specific residents, medical histories, or clinical conditions were described in relation to this deficiency.
Unsecured Medications, Treatment Carts, and Oxygen Equipment
Penalty
Summary
Facility staff failed to ensure that drugs, biologicals, and related medical supplies were securely stored and properly maintained on multiple units. On one unit, an oxygen tank assigned to a resident was observed sitting on the floor behind the resident’s bed without any supporting device. On another unit, a treatment cart was observed with a tube of Collagenase Santyl cream labeled for a specific resident left on top of the cart, while residents in power wheelchairs passed by and staff were present at the nursing station. These observations showed that medications and oxygen equipment were not consistently secured as required. Further observations on additional units revealed an unattended and unlocked treatment cart at a nursing station, and on a separate occasion, a treatment cart with Diclofenac gel labeled for a resident left on top along with multiple packs of dressings. These incidents occurred across three units and on more than one date, demonstrating repeated failures to keep medications and treatment supplies in locked compartments or otherwise secured from unauthorized access.
Insufficient Dietitian Coverage and Delayed Nutritional Assessments
Penalty
Summary
The deficiency involves the facility’s failure to employ sufficient food and nutrition staff, including adequate dietitian coverage, to ensure timely assessment and appropriate diets for residents with significant nutritional and diabetic needs. A resident admitted over two weeks earlier with multiple comorbidities and an A1C of 11.5% had a hospital discharge recommendation for a carbohydrate-controlled diet, but was placed on a regular diet at admission with no acknowledgment of the recommended diet until one week later, when the resident requested larger portions. As of the survey date, the dietitian had not yet seen or reviewed this resident’s medical record, and the resident reported not having seen a dietitian and being very frustrated with the meals. During the first two weeks after admission, only one weight was obtained for this resident, despite physician notes stating the resident’s weight was “stable.” Further review of other residents showed additional failures in timely dietitian assessment and follow-up. One resident, readmitted in January and previously seen by the dietitian in September for a 6.4 lb weight loss over 30 days, had no documented follow-up despite continued weight loss totaling 22 lbs since the last dietitian review. Another resident admitted at the end of February with severe protein-calorie malnutrition had not been seen by the dietitian after about a month in the facility, despite a documented 14 lb (7%) weight loss over two weeks. The dietitian reported working only 12 hours per week at the facility and stated that she must prioritize which residents to see, focusing first on residents with tube feedings and those identified in risk meetings, resulting in delayed or absent assessments for new admissions and residents with ongoing weight loss and malnutrition diagnoses.
Linen Shortages and Poor Environmental Maintenance Compromise Resident Care and Comfort
Penalty
Summary
The deficiency involves the facility’s failure to maintain an adequate supply of clean linens and appropriate incontinence wipes, resulting in delays and alterations in residents’ incontinence care, as well as the use of towels and washcloths in place of disposable wipes. During the initial tour, the surveyor observed that the linen supply on one nursing unit hallway was low. Complaint reviews included concerns about delays in incontinence care and bed linens not being changed regularly, with residents left without clean bedding. A complainant reported that there was not enough clean linen available for residents. Staff interviews confirmed that towels, sheets, and washcloths were being used to wipe residents for incontinence care due to the absence of wipes, and that many of these linens were being thrown away when soiled. Staff also reported a shortage of linen, that linen deliveries to the units were late, and that residents who preferred to get up before breakfast had to wait for care when linen was delayed. Further observations showed that the clean supply room contained no disposable wipes or cloths for incontinence care, and a resident reported that staff did not use wipes, that the resident had to purchase their own, and that heavily soiled towels or washcloths were discarded. A tour of all nursing unit linen carts and closets revealed only six clean washcloths and limited supplies of towels, gowns, and bed linens. In the laundry room, only three washcloths were present, and the laundry assistant stated that there were only three washcloths available for each nursing unit that morning, that the facility was short on linen supply, and that these concerns had been repeatedly reported to the Director of Housekeeping over the preceding month and again that morning. The laundry assistant confirmed there was no additional laundry in process. The DON stated that wipe squares should be used for incontinence care, but no such wipes were found in the clean medical supply room, and no backup supply of washcloths was present in the emergency linen supply. The Director of Housekeeping confirmed there was no backup supply of washcloths. The deficiency also includes environmental and maintenance issues affecting resident bathrooms, handrails, and common areas. In the main dining area, a recliner chair was observed positioned directly in front of the handwashing sink, and two recliner chairs were stored in front of the nutrition area kitchenette. Multiple resident bathrooms and shared bathrooms were repeatedly observed over several days with unfinished spackle on walls that needed resurfacing and painting, chipped paint around sinks, uneven boards nailed to walls under sinks that appeared to partially cover holes, musty odors, black substances between shower bases and walls, missing threshold transition molding exposing cracks, missing tiles, and a nail, as well as eroded and chipped paint on baseboard heaters with exposed dark brown metal and rust-like material. Hallway handrails on both nursing units were observed to be worn, with chips, splintering, holes, and areas where the wood finish had worn off. A shower room was observed with a foul fecal odor, dried brown stains on the back of the toilet seat and in the toilet bowl, and a baseboard heater with eroded, chipped paint and rust-like material, along with chipped paint on the handrail. These conditions were acknowledged by the Director of Maintenance and other leadership, and some areas were noted to be in the process of renovation, but the observed deficiencies remained present during the survey period. Overall, the facility did not maintain a safe, clean, comfortable, and homelike environment in good repair across both nursing units and the dining area. The lack of adequate linen and incontinence supplies, combined with the poor condition of resident bathrooms, handrails, and certain common areas, constituted the basis for the cited deficiency. The observations and staff and resident reports consistently described shortages of essential hygiene supplies, delayed care related to linen availability, and multiple unresolved environmental and maintenance issues in resident care areas and shared spaces.
Failure to Thoroughly Investigate Abuse Allegations and Injuries of Unknown Origin
Penalty
Summary
Facility staff failed to thoroughly investigate allegations of potential abuse involving one resident and an injury of unknown origin involving another resident. For one resident, there were two separate allegations of abuse occurring on different days in early February. The facility’s investigation packets included interviews with staff who cared for or were scheduled to work with this resident on the days of the alleged incidents, and the investigations focused solely on this resident. However, there were no interviews conducted with other residents on the unit to inquire about abusive or neglectful treatment by the staff who were working during the times of the allegations. The surveyors noted that, although the allegations were not validated, there was no documentation that other residents were interviewed, if able, or assessed for signs or symptoms of injury. In a separate incident, another resident was identified on March 4 with a new bruise on the right eye, documented as a change in condition at 4:09 AM. This resident had a BIMS score of 99, indicating the resident was unable to complete an interview and therefore could not report how the injury occurred. The facility’s investigation identified a potential cause of the injury but did not reach a definitive resolution. Additionally, there were no interviews of other residents on the unit regarding possible abuse, nor were there documented assessments of other residents for injuries of unknown origin, particularly for those unable to speak for themselves, as in this resident’s case.
Failure to Provide Oral Care to Dependent Residents
Penalty
Summary
The deficiency involves the facility’s failure to provide oral care to residents who were dependent on staff for activities of daily living, specifically oral hygiene. One resident with a tracheostomy was observed with a thick, sticky white substance in the mouth and was noted to intermittently chew on nearby bedding. This resident made good eye contact and, when asked if staff brushed their teeth, shook their head no and mouthed that staff “need to.” According to the resident’s Minimum Data Set (MDS) dated 2/11/26, the resident was dependent on staff for oral care. Another resident, also dependent on staff for oral care per the 3/11/26 MDS, was observed sitting propped up in bed and able to respond with smiles. During the initial observation, the inside of this resident’s lips and upper and lower teeth had a thick, clear, white milky substance visible when the resident tried to open their mouth to smile. Oral care supplies were present in the nightstand, but the resident’s mouth and teeth were not clean. On a subsequent observation with the DON, NHA, and Corporate VP of clinical services, the same resident again had a thick, clear, milky substance between the lips and caking the teeth, which would string between the teeth when the resident attempted to open their mouth, demonstrating a lack of consistent oral care for residents dependent on staff for this ADL.
Incomplete and Inaccurate Medical Record Documentation for Treatments and Assessments
Penalty
Summary
Facility staff failed to maintain complete and accurate medical records and documentation for multiple residents. For one resident with wound care needs, review of the MAR showed that wound care and related treatments were signed as completed on the dates initially reported, despite the resident’s ongoing complaints that wound dressings were not being changed. When additional dates were reviewed, there were missing staff signatures for wound care on two specific dates, as well as three instances where application of A&D ointment to the resident’s feet was not signed off out of 24 days reviewed. Another resident with severe cognitive impairment, as evidenced by a BIMS score of 00, was found to have an injury of unknown origin (a bruise on the left hand). Documentation showed that a change in condition was initiated late in the morning, but a formal pain evaluation was not initiated and completed until that night, and the resident was unable to explain how the injury occurred or verbalize pain using a standard pain scale. For a third resident, documentation related to the admission PPD test was inconsistent and incomplete. The MAR contained an entry indicating “9” for the administration date, meaning “see nurse’s note,” but there was no corresponding nurse’s note. Despite the absence of a signed administration of the PPD injection, staff documented the PPD result as “negative” on the scheduled read date. The resident reported never receiving the PPD injection, and the DON confirmed that the facility had been out of PPD solution at the time, so the test would not have been administered. These findings demonstrate failures in accurate documentation of treatments and assessments, including wound care, pain assessment, and TB screening, as well as missing or incomplete supporting notes in the medical record.
Failure to Implement and Communicate Correct Transmission-Based Precautions
Penalty
Summary
Surveyors identified a deficiency in the facility’s infection prevention and control program related to inconsistent and incorrect implementation of transmission-based precautions and PPE use. During a complaint investigation focused on residents on transmission-based precautions, one resident with a visible Foley catheter was observed in the room with physical therapy, but there were no signs posted indicating any need for PPE, despite the resident being a new admission with a Foley catheter placed related to wounds. In another double-occupancy room, a contact precautions sign was posted at the doorway, but the nurse practitioner was in the room on a personal phone with no PPE, and the assigned GNA was repositioning the resident in bed while wearing only gloves. When questioned, the NP, RN, and GNA all stated that the resident in the room was not on contact precautions, and the GNA reported that signs were hanging at all doors and that this particular resident’s sign was “just wrong.” The surveyor observed the GNA later return to the room and turn the sign around to indicate no PPE requirement. Subsequent interviews revealed that therapy staff relied on posted signage to determine PPE use and that if the sign was wrong, the PPE used would be wrong. Overall, surveyors found problems with signage accuracy and staff awareness of which residents required contact precautions, as well as observed failures to follow appropriate PPE use for residents who should have been on contact precautions.
Inaccurate MDS Coding for Falls, Pain Management, and High-Risk Medications
Penalty
Summary
Facility staff failed to ensure Minimum Data Set (MDS) assessments were accurately coded for two residents reviewed during a complaint survey. For one resident, a facility-reported incident showed that the resident was found seated on the floor beside the bed and was diagnosed with a non-displaced femoral neck impaction fracture of the left hip following an x-ray. Despite this fall with a major injury, the subsequent significant change MDS dated 11/4/25 did not code the fall with major injury in Section J1900C. Review of the resident’s Medication Administration Records for October and November 2025 showed administration of Tylenol on 10/31/25 at 9:30 PM, which fell within the 5-day look-back period for the MDS, but Section J0100 (prn pain) of the same significant change MDS did not capture the use of Tylenol. For another resident, review of a quarterly MDS with an assessment reference date of 10/15/25 showed that Section N0415 (High-Risk Drug Classes) documented the use of an opioid medication. However, review of the resident’s October 2025 Medication Administration Record did not show that the resident had been prescribed an opioid during that period. In both cases, MDS staff later confirmed that these were errors in MDS coding, demonstrating that the assessments did not accurately reflect the residents’ clinical status and medication use as documented in their medical records.
Incomplete Documentation of Narcotic Administration on MAR
Penalty
Summary
The facility failed to maintain complete and accurate medical records in accordance with accepted professional standards for one resident receiving narcotic medication. The resident, admitted in March 2026, had a fall on 3/6/26 and was sent to the hospital on 3/9/26. Review of the March 2026 Medication Administration Record (MAR) showed documentation of a single 25 mg dose of Tramadol administered on 3/8/26 at 9:23 AM. However, review of the resident’s Controlled Drug Receipt/Record/Disposition Form, kept on the nurse’s medication cart and not in the medical record, showed that Tramadol 25 mg was administered three times between 3/8/26 and 3/9/26: at 11:00 AM and 9:00 PM on 3/8/26, and at 9:00 AM on 3/9/26. In interview, the DON stated that staff are expected to document narcotic administration on the MAR and confirmed that only one of the three Tramadol doses reflected on the controlled drug record was documented on the resident’s MAR. This discrepancy between the controlled substance record and the MAR, with missing documentation of two administered doses of Tramadol on the official medical record, constituted the failure to maintain a complete and accurate medical record for the resident.
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