Potomac Valley Rehabilitation And Healthcare
Inspection history, citations, penalties and survey trends for this long-term care facility in Rockville, Maryland.
- Location
- 1235 Potomac Valley Road, Rockville, Maryland 20850
- CMS Provider Number
- 215026
- Inspections on file
- 17
- Latest survey
- October 10, 2025
- Citations (last 12 mo.)
- 3
Citation history
Health deficiencies cited at Potomac Valley Rehabilitation And Healthcare during CMS and state inspections, most recent first.
Staff failed to report allegations of abuse involving two residents within the required two-hour timeframe, resulting in delayed notification to facility administration and the state survey agency. In both cases, staff either did not recognize the need to report or assumed others would handle it, despite clear documentation of the allegations and facility policy requiring immediate action.
A resident with cognitive impairment alleged that a GNA hit them with a metal rod, prompting a 911 call and police response. Despite facility policy requiring immediate suspension of staff accused of abuse, the GNA was allowed to complete their shift before being suspended. The DON and Administrator acknowledged this was an oversight and not in line with policy.
A resident with a history of adrenal suppression and Addison's disease did not receive a prescribed steroid medication as ordered due to a flagged allergy in the pharmacy system and delayed communication between facility staff and the pharmacy. The medication was not delivered or administered for several days after admission, despite repeated follow-up attempts by nursing staff.
The facility failed to conduct interdisciplinary team care plan meetings and update care plans after changes in residents' status. Several residents did not have documented care plan meetings as required, with some missing updates after comprehensive assessments. The Director of Nursing and other staff confirmed these deficiencies, acknowledging the lack of quarterly meetings.
Multiple residents did not receive meals as specified on their meal tickets, with missing items such as milk, juice, jelly, margarine, and other components, and in some cases, incorrect substitutions were made. Staff confirmed that meal tickets and resident preferences were not consistently followed, resulting in residents not receiving their prescribed nutrition.
Surveyors found that food items, including opened salad dressing, leftover sausage links, pancakes, and salads, were not properly labeled or stored according to facility policy. Staff confirmed that these items should have been labeled and dated, but several were found without required information, leading to a deficiency in food storage practices.
Surveyors identified that the facility failed to maintain complete and accurate medical records for three residents, including delays in updating MOLST forms, failure to void outdated MOLSTs, and inconsistent documentation regarding a resident's decision-making capacity and use of a wander guard.
The facility failed to accurately code MDS assessments for several residents, leading to deficiencies in care planning. One resident's vision impairment was not documented, another's range of motion limitations were overlooked, and a third resident's mental illness was inaccurately recorded. These errors were confirmed by the MDS nurse, highlighting issues in the facility's assessment processes.
A facility failed to accurately assess a resident's nutritional status due to an incorrect height measurement. The resident was initially documented as 68 inches tall, but upon re-measurement, was found to be 74.5 inches tall. The dietitian relied on nursing staff for height documentation, and the DON admitted there was no process to ensure accurate measurements, resulting in the oversight.
A resident was observed being dragged backwards in a Geri chair by a Physical Therapy Aide in the hallway outside the rehabilitation department. The aide confirmed the action and did not express concern about it. Facility leadership was aware of the incident, which was determined to be a failure to treat the resident with dignity.
A resident with a personal funds account managed by the facility reported not receiving quarterly statements and was unaware of their account balance. The Business Office Manager confirmed that no residents or their representatives received personal fund statements for the last quarter, due to a lapse in staff responsibility.
The facility did not provide required information and education about advance directives to two residents who did not have them, as shown by repeated documentation in social worker assessments and confirmed by the DON and Director of Social Services. The process for offering and documenting advance directive information was not followed for these residents.
A resident who required supervision or touching assistance with eating was not consistently provided the necessary support, as evidenced by staff documentation and meal intake records. On days when less assistance was given, the resident consumed less than half of their meals and subsequently experienced a significant weight loss of over 10% within a month, as confirmed by the dietician and acknowledged by the DON.
A resident with an indwelling urinary catheter was found with their urine collection bag lying directly on the floor and not properly secured, contrary to the care plan interventions that required regular checking and proper placement of the bag. The issue was confirmed by a GNA and acknowledged by the DON.
Two residents did not receive pain management in accordance with professional standards: one received opioid medication without documented attempts at non-pharmacological interventions, and another, admitted after a recent amputation, did not receive prescribed pain medication or alternative interventions until the day after reporting severe pain, despite facility procedures allowing for immediate access to pain relief.
A resident with a history of PTSD did not have a care plan that identified specific trauma triggers or interventions to prevent retraumatization. Although trauma screenings and a care plan were completed and updated, the plan lacked necessary details on triggers and staff actions, as confirmed by the DON.
Nursing staff failed to accurately reconcile and document controlled medications, with narcotic counts being prematurely recorded and conducted by only one licensed staff member instead of two. Inaccurate documentation of medication administration times was also observed, and staff interviews confirmed these discrepancies, which did not align with facility policy requiring dual verification at each shift change.
A resident receiving multiple high-risk medications had irregularities identified during a pharmacist's monthly drug regimen review. The provider responded to the review with brief notes but did not document the rationale for continuing these medications in the medical record, as required. This deficiency was confirmed through record review and staff interviews.
A controlled medication, Lorazepam, was found stored in an unlocked compartment inside a medication refrigerator. A nurse was unable to locate the key to secure the compartment, and the facility's policy requiring double-locked storage for controlled substances was not followed. The DON confirmed the failure to maintain proper security for these medications.
A resident with ongoing dental issues did not receive timely follow-up on a dentist's recommendation for tooth extractions, as required documentation and medical clearance were not completed. Dental notes were not consistently uploaded to the medical record, and the process for ensuring follow-up on dental care recommendations was not effectively implemented by staff, resulting in a lapse in care.
Staff failed to follow droplet precaution protocols for two residents with pneumonia, including not wearing required gowns and improperly storing PPE inside a resident's room. Staff interviews revealed confusion about PPE access and use, and leadership confirmed these practices did not meet infection control standards.
A resident who alleged abuse by an LPN was not offered a psychiatric evaluation or consultation, as confirmed by the DON. This deficiency was identified during a complaint survey, highlighting a failure in providing necessary behavioral health care and services.
A facility failed to retain a complete medical record for a resident for the required five years post-discharge. The resident's records, including TARs, MARs, and CNA task records, were missing due to a change in ownership and issues with the electronic medical record system. The DON noted that not all information migrated over during the ownership change, and the Executive Director confirmed the facility's responsibility to maintain records as per federal requirements.
Failure to Timely Report Allegations of Abuse
Penalty
Summary
The facility failed to ensure that staff reported allegations of abuse within the required two-hour timeframe, as mandated by both facility policy and regulatory requirements. In the case of one resident with a history of Parkinson's disease, bipolar disorder, and dementia, the resident alleged that a staff member hit them with a metal rod. The incident occurred in the early morning hours, and although emergency services and police responded promptly, the Director of Nursing (DON) did not notify the Administrator until several hours later, and the initial report to the state survey agency was not submitted until the afternoon. Multiple staff members who were present or aware of the allegation did not report it immediately, with some assuming that the presence of a supervisor or the lack of observed abuse negated the need for reporting. Another resident, with diagnoses including a displaced fracture, schizophrenia, and psychosis, made several statements to staff and a physician about being abused. These statements were documented in progress notes but were not reported to the appropriate authorities or the facility's abuse coordinator in a timely manner. The Assistant Director of Nursing (ADON) only became aware of a new allegation after being notified by a hospital liaison, and subsequently reported it to the Administrator and state survey agency, but this report was also submitted late. Interviews with staff revealed a lack of awareness or recall regarding the need to report such allegations, and the DON and Administrator acknowledged that the reports were not made within the required timeframe. The deficiency affected two residents who were reviewed for abuse or neglect. Both cases demonstrated failures in communication and adherence to policy regarding the timely reporting of abuse allegations. Documentation in the residents' records indicated that staff either did not recognize the need to report or assumed others would handle the reporting, resulting in significant delays in notifying both facility administration and the state survey agency as required.
Failure to Immediately Remove Staff Following Abuse Allegation
Penalty
Summary
The facility failed to immediately implement protective interventions following an allegation of abuse made by a resident against a Geriatric Nursing Assistant (GNA). According to the report, a resident with a history of Parkinson's disease, bipolar disorder, and dementia, who had moderate cognitive impairment, alleged that a GNA hit them with a metal rod. The resident called 911, prompting police and EMS to respond to the facility. The facility's policy requires immediate suspension or corrective action for any employee accused of abuse, but the GNA in question was allowed to complete their scheduled shift after the allegation was made. Interviews and documentation confirmed that the GNA worked from late evening until the following morning, despite the abuse allegation being reported during the shift. The Director of Nursing and the Administrator both acknowledged that the GNA should have been sent home immediately after the allegation was made, but this did not occur due to an oversight. The failure to remove the accused staff member from duty immediately after the allegation was reported resulted in non-compliance with the facility's abuse prevention policy.
Delayed Administration of Prescribed Steroid Due to Allergy Flag and Communication Lapses
Penalty
Summary
The facility failed to provide a prescribed medication, methylprednisolone, to a resident in a timely manner following admission. The resident, who had a history of rheumatoid arthritis, Addison's disease, and adrenal suppression, was discharged from the hospital with a tapering dose of methylprednisolone. The medication was ordered on the day of admission, but was not delivered to the facility until four days later, and the resident did not receive the first dose until five days after the order was placed. Documentation in the Medication Administration Record and progress notes confirmed that the medication was not available and not administered as ordered during this period. The delay in medication administration was due to a flagged allergy to prednisone in the resident's record, which caused the pharmacy to place the order on hold pending clarification. The pharmacy did not make an outbound call for clarification after the initial order, and subsequent attempts by the facility to reorder the medication were also delayed due to the allergy flag. Communication between the facility and the pharmacy was inconsistent, with the pharmacy waiting for clarification and the facility staff following up multiple times before the medication was finally delivered and administered. Interviews with facility staff, including nursing management and the DON, revealed that the process for ensuring medication availability involved checking the emergency medication cabinet, contacting the pharmacy, and notifying the provider. However, in this case, the follow-up was not sufficiently aggressive to resolve the issue promptly. The resident reported not receiving the medication, and staff documented ongoing efforts to obtain it, but the medication was not provided as ordered until several days after admission.
Failure to Conduct and Update Care Plan Meetings
Penalty
Summary
The facility staff failed to ensure that interdisciplinary team (IDT) care plan meetings were conducted and care plans were updated after changes in residents' status. This deficiency was identified for several residents, including one who had been in the facility for three weeks without attending any care plan meetings, despite being alert and oriented. Another resident, who had eloped from the facility, had a care plan that was not updated to reflect their current risk status, even after being assessed as competent by attending providers. The report highlights multiple instances where care plan meetings were not held as required. For example, one resident had comprehensive assessments completed on several occasions, but there was no documentation of care plan meetings between certain periods. Another resident's care plan meeting was missed after a comprehensive assessment, and the Director of Social Services confirmed the lack of documentation for the meeting. Additionally, some residents had no care plan meetings documented after specific assessments, with explanations such as family unavailability being provided, but without evidence of attempts to contact them. The Director of Nursing and other staff members confirmed the deficiencies, acknowledging that care plan meetings were not held quarterly as required. The report includes several cases where care plan meetings were not documented for extended periods, and the facility's process for scheduling these meetings was questioned. The Nursing Home Administrator also confirmed the deficiency, acknowledging that care plan meetings should occur upon admission and at least quarterly.
Failure to Serve Meals According to Prescribed Menus and Resident Preferences
Penalty
Summary
The facility failed to serve meals to residents according to predetermined menus that incorporated residents' preferences and dietary requirements. During a lunch tray line observation, a resident's tray was missing both the specified amount of coleslaw and milk as listed on the meal ticket, and it was confirmed that the incorrect serving utensil was used. Additional breakfast observations revealed that multiple residents did not receive all items listed on their meal tickets, such as milk, juice, jelly, margarine, sausage patty, pancake, and fruit cup. In one case, a resident received cranberry juice instead of the apple juice specified in their preferences and did not receive the requested jellies. Staff interviews confirmed that the missing items were not served as required, and that staff were not consistently following the meal tickets or residents' stated preferences. These failures resulted in residents not receiving meals that met their documented nutritional needs and preferences, as required by facility policy and regulatory standards.
Improper Food Storage and Labeling Practices Identified
Penalty
Summary
Surveyors observed multiple instances of improper food storage in the facility's kitchen, including an opened container of French salad dressing kept beyond the one-month limit after opening, leftover ground sausage links stored past the allowable one-day period, and a bag of pancakes left open without a label indicating the date it was opened. Additionally, plates of leftover cold salad and chef salad were found without labels indicating their preparation dates. Staff interviews confirmed that all opened and leftover food items should be labeled and dated according to facility policy, which requires leftovers to be covered, labeled, dated, and used within seven days. Despite this policy, several food items in the walk-in and reach-in refrigerators were not properly labeled or dated, as confirmed by both staff and the regional director of food services.
Incomplete and Inaccurate Medical Record Documentation
Penalty
Summary
The facility failed to ensure that residents' medical records were complete and accurately documented, as evidenced by issues with Medical Orders for Life-Sustaining Treatment (MOLST) forms and documentation of decision-making capacity. For one resident, a MOLST form was not updated in the medical record after the family requested changes to include hospital transfer orders. Although the physician completed a new MOLST, it was left in an inbox and not uploaded to the resident's record, resulting in a delay in updating the resident's chart with the most current orders. In another case, a resident's medical record contained two MOLST forms with different dates, and the older form was not voided, leaving two active MOLSTs in the system. Additionally, for a third resident, there were inconsistencies in documentation regarding the use of a wander guard and the resident's decision-making capacity. The medical record included certifications from two providers stating the resident could make their own decisions, but several notes from another provider indicated the resident lacked capacity and continued to use a wander guard, even after it had been discontinued. These discrepancies in documentation and failure to maintain accurate and up-to-date records contributed to the deficiency.
Inaccurate MDS Assessments Lead to Deficiencies
Penalty
Summary
The facility failed to ensure accurate coding of Minimum Data Set (MDS) assessments for several residents, leading to deficiencies in care planning and service provision. For one resident, the MDS inaccurately documented adequate vision despite the nursing admission assessment and trauma-informed screen indicating poor vision and blindness in one eye. This discrepancy was confirmed by the MDS nurse, who admitted to relying on the nursing admission assessment for documentation, yet failed to capture the resident's impaired visual status. Another resident's MDS assessments inaccurately recorded no functional limitations in range of motion, despite an occupational therapy evaluation noting a left-hand contracture due to a history of stroke. The MDS nurse confirmed these errors across multiple assessments. Additionally, a third resident with a positive Level 2 PASRR evaluation for mental illness was inaccurately documented in the MDS as not having serious mental illness or intellectual disability. These inaccuracies were acknowledged by the MDS nurse, indicating a failure in the facility's assessment and documentation processes.
Inaccurate Height Measurement Leads to Nutritional Assessment Failure
Penalty
Summary
The facility failed to ensure that a resident's nutritional status was accurately assessed due to an incorrect height measurement. Resident #128 was observed walking in the hallway, appearing much taller than the Geriatric Nursing Assistant accompanying them. A review of the resident's records showed a height of 68 inches documented in August 2023. However, upon re-measurement on March 20, 2025, the resident's height was found to be 74.5 inches. The facility dietitian confirmed that she had assessed the resident in person but relied on the nursing staff's documentation for height and weight. The Director of Nursing admitted that there was no process in place to ensure accurate height measurements, leading to the oversight of the discrepancy in the resident's height documentation.
Resident Dragged Backwards in Geri Chair by Staff
Penalty
Summary
A resident was observed seated in a Geri chair in the hallway outside the rehabilitation department. A Physical Therapy Aide was seen dragging the resident backwards in the Geri chair down the hall to the resident's room. When interviewed, the aide confirmed pulling the resident backwards and did not acknowledge any concern with this action. The incident was reviewed with both the Nursing Home Administrator and the Director of Nursing, who confirmed awareness of the event. The report documents that the facility failed to treat the resident with dignity during this incident.
Failure to Provide Quarterly Personal Fund Statements
Penalty
Summary
The facility failed to provide quarterly statements of personal funds to residents or their representatives, as required. One resident, who had been residing in the facility since 2023 and had a personal funds account managed by the facility, reported not knowing the balance of their account and confirmed that they had not received quarterly statements. Review of the resident's records indicated that the resident's funds were discussed with a social worker, but there was no documentation that statements had been provided. The Business Office Manager confirmed during interviews that for the last quarter ending on 12/31/24, no residents or their representatives received personal fund statements. The manager explained that the responsibility had previously belonged to an assistant who had since left the facility, and acknowledged that the statements were missed for that quarter. The Nursing Home Administrator was made aware of the issue and acknowledged the concern.
Failure to Offer Advance Directive Information and Education
Penalty
Summary
The facility failed to provide information and education regarding advance directives to residents who did not have them, as evidenced by record reviews and staff interviews. For one resident, multiple social worker assessments over several months documented that the resident did not have an advance directive and that no information was offered. The facility's process, as described by a social worker, requires that residents be asked about advance directives at admission and be provided with information and forms if they do not have one, with documentation of these actions in the medical record. However, there was no evidence in the records or from staff interviews that this process was followed for the resident in question. Similarly, another resident's records showed no advance directive document and repeated documentation by the social worker that the resident did not have an advance directive and was not offered information. The DON confirmed that there was no evidence that advance directive information or education had been provided to this resident. These findings were acknowledged by the Director of Social Services and the Nursing Home Administrator.
Failure to Provide Required Assistance with Eating Resulting in Significant Weight Loss
Penalty
Summary
A deficiency was identified when a resident who required supervision or touching assistance with eating was not consistently provided the necessary support by staff. Documentation showed that on multiple days, the resident received less assistance than indicated in their comprehensive assessment, specifically receiving only setup help or no physical help at all. This lack of appropriate assistance corresponded with days when the resident consumed less than 50% of their meals. Over the course of approximately one month, the resident experienced a significant weight loss of 10.04%. The dietician confirmed the weight loss and noted that it occurred in less than a month, with meal intake records supporting the finding that inadequate assistance was provided during meals. The DON reviewed the documentation and acknowledged the concern that the resident was not given the required help to maintain their weight.
Failure to Secure Urine Collection Bag for Catheterized Resident
Penalty
Summary
A deficiency was identified when a resident with an indwelling urinary catheter was observed with their urine collection bag lying directly on the floor, under the bed, while the resident was sleeping. There was no slack in the tubing connecting the collection bag to the resident, and the bag was not secured as required. The observation was confirmed by the assigned Geriatric Nursing Assistant, who acknowledged the finding and indicated the intention to empty the bag. A review of the resident's care plan revealed that the resident required the use of a urinary catheter, with specific interventions in place for catheter care, including checking the placement and emptying the urine collection bag as needed throughout each shift. The Director of Nursing acknowledged that the urine collection bag should have been secured under the bed and off the floor, in accordance with the care plan interventions.
Failure to Provide Safe and Appropriate Pain Management
Penalty
Summary
The facility failed to provide pain management services according to professional standards of practice for two residents. One resident, who had an order for Oxycodone every four hours as needed for severe pain, received the medication frequently over two months. However, there was no documentation indicating that non-pharmacological interventions were attempted or provided prior to administering the pain medication, as required. The Director of Nursing confirmed that such interventions should be offered first and acknowledged the lack of documentation in the resident's medical record. Another resident, recently admitted after a below-the-knee amputation and with a history of diabetic neuropathy, reported experiencing pain upon admission but did not receive prescribed pain medication or any non-pharmacological interventions until the following day. The resident's pain level was not documented, and staff interviews revealed that facility procedures allowed for the use of stock medications or contacting the pharmacy, but these steps were not taken. The failure to address the resident's pain on the day of admission was confirmed by both nursing staff and the Director of Nursing.
Failure to Provide Trauma-Informed Care for Resident with PTSD
Penalty
Summary
The facility failed to provide appropriate trauma-informed care for a resident with a documented history of post-traumatic stress disorder (PTSD). Record review showed that trauma-informed screenings were completed and a care plan was in place and revised, but the care plan did not identify the specific triggers related to the resident's trauma or outline interventions to mitigate or eliminate those triggers. This omission was confirmed by the director of nursing, who acknowledged that the care plan lacked details on triggers and staff actions to reduce the risk of retraumatization.
Inaccurate Narcotic Reconciliation and Documentation by Nursing Staff
Penalty
Summary
Facility staff failed to accurately reconcile and document controlled medications on two out of four nursing units. Observations and record reviews revealed that three licensed personnel on three different care units inaccurately documented narcotic reconciliation, and one licensed personnel inaccurately documented the administration of a narcotic. Specifically, narcotic counts were documented prematurely, with only one licensed staff member conducting the count instead of the required two. In several instances, narcotic counts for later shifts were recorded as completed during the morning hours, and medication administration was documented for times that had not yet occurred. Interviews with nursing staff and unit managers confirmed the inaccuracies in narcotic documentation and reconciliation practices. The facility's policy requires that at each shift change, two licensed personnel—one from the outgoing and one from the incoming shift—physically count and verify all controlled substances, documenting their initials. However, this procedure was not followed, as evidenced by the premature and inaccurate documentation in the narcotic books and medication administration records.
Failure to Document Rationale for Continued Use of High-Risk Medications After Drug Regimen Review
Penalty
Summary
The facility failed to ensure that the attending physician documented the rationale for not changing medications after irregularities were identified during the monthly drug regimen review for one resident. The resident, who had been in the facility since 2020 and was recently readmitted after hospitalization, had several high-risk medications flagged by the pharmacist during the review. These included Duloxetine HCL, Lacosamide, Phenobarbital, Risperidone, Oxycodone HCL, Diphenhydramine HCL, and Diphenoxylate with Atropine. The pharmacist recommended that the provider evaluate the continued use of these medications, consider safer alternatives, or document a risk/benefit analysis in the medical record. The nurse practitioner acknowledged the report and wrote brief responses such as "psych consult" or "continue" for the identified irregularities but did not provide any documented rationale in the resident's medical record for continuing the medications. Interviews with the nurse practitioner confirmed that no further documentation was made beyond the written responses on the report, and the rationale for continuing the high-risk medications was not recorded. This lack of documentation was also confirmed by a review of the resident's medical record and by the Director of Nursing.
Failure to Secure Controlled Medications in Locked Refrigerator Compartment
Penalty
Summary
The facility failed to maintain and secure controlled medications in accordance with regulatory requirements. During an observation of medication storage, it was found that one of two medication refrigerators had an unlocked compartment containing controlled medications, specifically Lorazepam, a Schedule IV drug. A nurse accessed the refrigerator and acknowledged that the controlled compartment was unlocked and open, and did not have or know the location of the key needed to secure it. The key was eventually retrieved from another nurse. The facility's policy requires that Schedule II through V medications be stored in a permanently affixed, double-locked compartment, and that controlled substances requiring refrigeration be kept within a locked box inside the refrigerator. The Director of Nursing confirmed that the facility did not maintain and secure the controlled medications in a separately locked, permanently affixed compartment as required.
Failure to Follow Through on Dental Care Recommendations
Penalty
Summary
The facility failed to ensure that dental recommendations for a resident were properly followed through. A resident reported having two problematic teeth that were identified before Christmas, for which a dentist had recommended extraction after an x-ray and had prescribed antibiotics for an abscess. Despite these findings and recommendations, the necessary dental procedures were not completed, and the required medical clearance for the extractions remained pending. Review of the resident's medical record revealed incomplete documentation of dental visits and recommendations. Dental notes were not consistently uploaded to the resident's medical record, and there was a lack of follow-up on the dentist's recommendations. The process for handling dental notes involved multiple staff receiving emails, but it was the unit manager's responsibility to review and act on these recommendations, which did not occur in this case. The deficiency was identified through interviews and record reviews, confirming that the facility did not have an effective system to ensure dental care recommendations were implemented.
Failure to Adhere to Droplet Precaution Protocols and Proper PPE Storage
Penalty
Summary
The facility failed to follow accepted infection control procedures for two residents who were placed on droplet precautions due to a pneumonia outbreak. In the first instance, a geriatric nurse assistant was observed providing morning care to a resident on droplet precautions while wearing gloves and a mask, but not a gown as required. The staff member acknowledged forgetting to wear the gown, and both the attending nurse and infection preventionist confirmed that the resident was on droplet precautions and that staff were expected to wear gloves, gowns, and masks upon entry to the room. Medical records supported the need for these precautions. In the second instance, another resident on droplet precautions had no personal protective equipment (PPE) available outside the room, and the PPE supply was instead kept inside the resident's room. Staff interviews revealed confusion about where to obtain PPE, with one staff member stating she was told not to use the PPE inside the room and to get supplies from the nursing station. The Director of Nursing confirmed that PPE stored inside the room of an infected or potentially infected resident was inappropriate, and the Nursing Home Administrator acknowledged the deficiency.
Failure to Provide Psychiatric Evaluation After Alleged Abuse
Penalty
Summary
The facility failed to provide necessary behavioral health care and services to a resident who alleged abuse. Specifically, the medical records of a resident revealed that after alleging abuse by an LPN, the resident was not offered a psychiatric evaluation or consultation. This deficiency was identified during a complaint survey, where it was confirmed by the Director of Nursing that there was no evidence of a psychiatric evaluation being offered following the alleged abuse event.
Incomplete Medical Record Retention
Penalty
Summary
The facility failed to retain a complete medical record for a resident for five years from the discharge date, as required by federal regulations. The facility's policy on Medical Record Management, dated January 9, 2020, stated that closed patient medical records should be kept for ten years from discharge. However, the medical record for Resident #16, who was admitted on September 14, 2020, and discharged on February 16, 2021, lacked treatment administration records (TARs), medication administration records (MARs), and certified nursing assistant (CNA) task records for the period the resident was in the facility. During interviews, the Director of Nursing (DON) explained that a change in ownership in 2020 resulted in not all information migrating over in the electronic medical record system, which prevented access to records from 2020. The Executive Director acknowledged the facility's responsibility to maintain residents' medical records for a minimum of five years, as per federal requirements.
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The facility did not ensure that its Infection Preventionist (IP) met required qualifications for managing the Infection Prevention and Control Program. The DON reported serving as the IP but acknowledged lacking the specialized infection control training required for the role, and confirmed that no other staff member was currently qualified. Records showed that the previously qualified IP left several months earlier, and the Administrator and DON confirmed they were still seeking a replacement, leaving the infection control program without a properly trained leader.
Staff failed to consistently secure medications and medical supplies across three units, including an oxygen tank left on the floor behind a resident’s bed without a supporting device, a treatment cart with Collagenase Santyl cream left on top while two residents in power wheelchairs passed by, an unattended and unlocked treatment cart at a nursing station, and another treatment cart with Diclofenac gel and dressings left on top, indicating repeated lapses in maintaining locked and secure storage for drugs, biologicals, and related supplies.
The facility failed to provide sufficient dietitian coverage and timely nutritional assessments for several residents with significant dietary needs. A resident admitted for diabetic management with a high A1C was placed on a regular diet instead of the recommended carb-controlled diet and had only one weight taken in the first two weeks, with no dietitian review of the record. Another resident with prior significant weight loss had no documented dietitian follow-up despite continued weight loss, and a resident admitted with severe protein-calorie malnutrition experienced further significant weight loss without any dietitian assessment. The dietitian reported working limited hours and prioritizing certain high-risk cases, resulting in delayed or missed evaluations for new admissions and residents with ongoing nutritional concerns.
The facility failed to maintain adequate linen and incontinence supplies and did not keep resident care areas in good repair, resulting in delays and alterations in incontinence care and substandard environmental conditions. Staff reported that towels and washcloths were used instead of wipes and then discarded due to heavy soiling, and that linen deliveries to units were late, leaving residents waiting for care. Observations showed very limited numbers of clean washcloths and other linens on units and in the laundry, with no stock of disposable wipes or backup washcloth supply despite repeated reports to housekeeping. Additional observations revealed recliner chairs blocking a dining-area handwashing sink and kitchenette, multiple resident and shared bathrooms with unfinished spackle, chipped paint, musty odors, black substances near showers, missing threshold molding, exposed cracks and nails, and eroded, rusted baseboard heaters. Hallway handrails on both units were worn, chipped, and splintered, and a shower room contained fecal odors, dried brown stains on the toilet, and deteriorated fixtures, all contributing to a failure to provide a safe, clean, and homelike environment.
Facility staff did not thoroughly investigate two separate abuse allegations involving a resident and an injury of unknown origin involving another resident. In both cases, investigations focused on the directly affected resident and included staff interviews, but there were no interviews of other residents on the unit or documented assessments of those residents for signs of abuse or injuries of unknown origin, including residents unable to communicate due to cognitive status.
Two residents who were dependent on staff for oral care, including one with a tracheostomy, were observed with thick, white or milky substances coating their mouths and teeth, indicating inadequate oral hygiene. One resident communicated that staff did not brush their teeth and that staff "need to." In another case, despite oral care supplies being present in the room, the resident’s mouth and teeth remained unclean on multiple observations, with a thick milky substance caking the teeth and stringing between them when the resident tried to open their mouth. These findings showed that staff did not consistently provide oral care to residents who relied on them for this ADL.
Staff failed to maintain complete and accurate medical records for multiple residents, including missing and inconsistent documentation of wound care, delayed pain assessment after discovery of an injury of unknown origin in a cognitively impaired resident, and inaccurate recording of a PPD test result that was documented as negative despite no evidence the injection was administered and no supporting nurse’s note. Residents reported not receiving certain treatments, while MAR entries either lacked signatures for completion or contained conflicting information about whether care was provided.
Surveyors found that the facility failed to consistently implement and communicate correct transmission-based precautions and PPE use. One resident with a Foley catheter related to wounds had no precaution signage posted, while another resident in a double room had a contact precautions sign at the door, yet the NP entered without PPE and the GNA provided high-contact care wearing only gloves. Staff in that room stated the resident was not on contact precautions and later reversed the sign to show no PPE requirement. Therapy staff reported they rely solely on posted signs to determine PPE, and surveyors identified broader issues with inaccurate signage and staff awareness of which residents required contact precautions.
Surveyors found that MDS assessments were inaccurately coded for two residents. In one case, a resident sustained a femoral neck fracture after a fall, but the subsequent significant change MDS did not code the fall as a major injury and failed to capture prn Tylenol use documented on the MAR within the look-back period. In the other case, a quarterly MDS indicated opioid use for a resident, but the MAR for the same period showed no prescribed opioid, indicating incorrect coding of high-risk drug classes.
A resident who had recently been admitted and experienced a fall received multiple doses of the narcotic analgesic Tramadol, but the facility failed to accurately document all administered doses on the Medication Administration Record (MAR). Review showed only one Tramadol dose recorded on the MAR, while the Controlled Drug Receipt/Record/Disposition Form on the med cart reflected three doses given over two days. In interview, the DON stated staff are expected to document narcotic administration on the MAR and confirmed that two administered doses were not recorded there, resulting in an incomplete and inaccurate medical record.
Unqualified Infection Preventionist Overseeing Infection Control Program
Penalty
Summary
The facility failed to ensure that its designated Infection Preventionist (IP) met the mandatory qualifications for overseeing the Infection Prevention and Control Program. During an interview on 3/24/26 at 10:00 AM, the DON confirmed that she/he was serving as the facility’s IP but had not completed the specialized training in infection control required for the position. The DON further stated that no other staff member currently met the qualifications to serve as IP. Record review showed that the previously qualified IP left the facility in October 2025, and as of the survey date, the position remained unfilled by a qualified individual. At 1:30 PM on the same day, the Administrator and DON confirmed they were still in the process of finding a qualified IP for the facility, leaving the Infection Prevention and Control Program without a properly trained and qualified leader. No specific residents, medical histories, or clinical conditions were described in relation to this deficiency.
Unsecured Medications, Treatment Carts, and Oxygen Equipment
Penalty
Summary
Facility staff failed to ensure that drugs, biologicals, and related medical supplies were securely stored and properly maintained on multiple units. On one unit, an oxygen tank assigned to a resident was observed sitting on the floor behind the resident’s bed without any supporting device. On another unit, a treatment cart was observed with a tube of Collagenase Santyl cream labeled for a specific resident left on top of the cart, while residents in power wheelchairs passed by and staff were present at the nursing station. These observations showed that medications and oxygen equipment were not consistently secured as required. Further observations on additional units revealed an unattended and unlocked treatment cart at a nursing station, and on a separate occasion, a treatment cart with Diclofenac gel labeled for a resident left on top along with multiple packs of dressings. These incidents occurred across three units and on more than one date, demonstrating repeated failures to keep medications and treatment supplies in locked compartments or otherwise secured from unauthorized access.
Insufficient Dietitian Coverage and Delayed Nutritional Assessments
Penalty
Summary
The deficiency involves the facility’s failure to employ sufficient food and nutrition staff, including adequate dietitian coverage, to ensure timely assessment and appropriate diets for residents with significant nutritional and diabetic needs. A resident admitted over two weeks earlier with multiple comorbidities and an A1C of 11.5% had a hospital discharge recommendation for a carbohydrate-controlled diet, but was placed on a regular diet at admission with no acknowledgment of the recommended diet until one week later, when the resident requested larger portions. As of the survey date, the dietitian had not yet seen or reviewed this resident’s medical record, and the resident reported not having seen a dietitian and being very frustrated with the meals. During the first two weeks after admission, only one weight was obtained for this resident, despite physician notes stating the resident’s weight was “stable.” Further review of other residents showed additional failures in timely dietitian assessment and follow-up. One resident, readmitted in January and previously seen by the dietitian in September for a 6.4 lb weight loss over 30 days, had no documented follow-up despite continued weight loss totaling 22 lbs since the last dietitian review. Another resident admitted at the end of February with severe protein-calorie malnutrition had not been seen by the dietitian after about a month in the facility, despite a documented 14 lb (7%) weight loss over two weeks. The dietitian reported working only 12 hours per week at the facility and stated that she must prioritize which residents to see, focusing first on residents with tube feedings and those identified in risk meetings, resulting in delayed or absent assessments for new admissions and residents with ongoing weight loss and malnutrition diagnoses.
Linen Shortages and Poor Environmental Maintenance Compromise Resident Care and Comfort
Penalty
Summary
The deficiency involves the facility’s failure to maintain an adequate supply of clean linens and appropriate incontinence wipes, resulting in delays and alterations in residents’ incontinence care, as well as the use of towels and washcloths in place of disposable wipes. During the initial tour, the surveyor observed that the linen supply on one nursing unit hallway was low. Complaint reviews included concerns about delays in incontinence care and bed linens not being changed regularly, with residents left without clean bedding. A complainant reported that there was not enough clean linen available for residents. Staff interviews confirmed that towels, sheets, and washcloths were being used to wipe residents for incontinence care due to the absence of wipes, and that many of these linens were being thrown away when soiled. Staff also reported a shortage of linen, that linen deliveries to the units were late, and that residents who preferred to get up before breakfast had to wait for care when linen was delayed. Further observations showed that the clean supply room contained no disposable wipes or cloths for incontinence care, and a resident reported that staff did not use wipes, that the resident had to purchase their own, and that heavily soiled towels or washcloths were discarded. A tour of all nursing unit linen carts and closets revealed only six clean washcloths and limited supplies of towels, gowns, and bed linens. In the laundry room, only three washcloths were present, and the laundry assistant stated that there were only three washcloths available for each nursing unit that morning, that the facility was short on linen supply, and that these concerns had been repeatedly reported to the Director of Housekeeping over the preceding month and again that morning. The laundry assistant confirmed there was no additional laundry in process. The DON stated that wipe squares should be used for incontinence care, but no such wipes were found in the clean medical supply room, and no backup supply of washcloths was present in the emergency linen supply. The Director of Housekeeping confirmed there was no backup supply of washcloths. The deficiency also includes environmental and maintenance issues affecting resident bathrooms, handrails, and common areas. In the main dining area, a recliner chair was observed positioned directly in front of the handwashing sink, and two recliner chairs were stored in front of the nutrition area kitchenette. Multiple resident bathrooms and shared bathrooms were repeatedly observed over several days with unfinished spackle on walls that needed resurfacing and painting, chipped paint around sinks, uneven boards nailed to walls under sinks that appeared to partially cover holes, musty odors, black substances between shower bases and walls, missing threshold transition molding exposing cracks, missing tiles, and a nail, as well as eroded and chipped paint on baseboard heaters with exposed dark brown metal and rust-like material. Hallway handrails on both nursing units were observed to be worn, with chips, splintering, holes, and areas where the wood finish had worn off. A shower room was observed with a foul fecal odor, dried brown stains on the back of the toilet seat and in the toilet bowl, and a baseboard heater with eroded, chipped paint and rust-like material, along with chipped paint on the handrail. These conditions were acknowledged by the Director of Maintenance and other leadership, and some areas were noted to be in the process of renovation, but the observed deficiencies remained present during the survey period. Overall, the facility did not maintain a safe, clean, comfortable, and homelike environment in good repair across both nursing units and the dining area. The lack of adequate linen and incontinence supplies, combined with the poor condition of resident bathrooms, handrails, and certain common areas, constituted the basis for the cited deficiency. The observations and staff and resident reports consistently described shortages of essential hygiene supplies, delayed care related to linen availability, and multiple unresolved environmental and maintenance issues in resident care areas and shared spaces.
Failure to Thoroughly Investigate Abuse Allegations and Injuries of Unknown Origin
Penalty
Summary
Facility staff failed to thoroughly investigate allegations of potential abuse involving one resident and an injury of unknown origin involving another resident. For one resident, there were two separate allegations of abuse occurring on different days in early February. The facility’s investigation packets included interviews with staff who cared for or were scheduled to work with this resident on the days of the alleged incidents, and the investigations focused solely on this resident. However, there were no interviews conducted with other residents on the unit to inquire about abusive or neglectful treatment by the staff who were working during the times of the allegations. The surveyors noted that, although the allegations were not validated, there was no documentation that other residents were interviewed, if able, or assessed for signs or symptoms of injury. In a separate incident, another resident was identified on March 4 with a new bruise on the right eye, documented as a change in condition at 4:09 AM. This resident had a BIMS score of 99, indicating the resident was unable to complete an interview and therefore could not report how the injury occurred. The facility’s investigation identified a potential cause of the injury but did not reach a definitive resolution. Additionally, there were no interviews of other residents on the unit regarding possible abuse, nor were there documented assessments of other residents for injuries of unknown origin, particularly for those unable to speak for themselves, as in this resident’s case.
Failure to Provide Oral Care to Dependent Residents
Penalty
Summary
The deficiency involves the facility’s failure to provide oral care to residents who were dependent on staff for activities of daily living, specifically oral hygiene. One resident with a tracheostomy was observed with a thick, sticky white substance in the mouth and was noted to intermittently chew on nearby bedding. This resident made good eye contact and, when asked if staff brushed their teeth, shook their head no and mouthed that staff “need to.” According to the resident’s Minimum Data Set (MDS) dated 2/11/26, the resident was dependent on staff for oral care. Another resident, also dependent on staff for oral care per the 3/11/26 MDS, was observed sitting propped up in bed and able to respond with smiles. During the initial observation, the inside of this resident’s lips and upper and lower teeth had a thick, clear, white milky substance visible when the resident tried to open their mouth to smile. Oral care supplies were present in the nightstand, but the resident’s mouth and teeth were not clean. On a subsequent observation with the DON, NHA, and Corporate VP of clinical services, the same resident again had a thick, clear, milky substance between the lips and caking the teeth, which would string between the teeth when the resident attempted to open their mouth, demonstrating a lack of consistent oral care for residents dependent on staff for this ADL.
Incomplete and Inaccurate Medical Record Documentation for Treatments and Assessments
Penalty
Summary
Facility staff failed to maintain complete and accurate medical records and documentation for multiple residents. For one resident with wound care needs, review of the MAR showed that wound care and related treatments were signed as completed on the dates initially reported, despite the resident’s ongoing complaints that wound dressings were not being changed. When additional dates were reviewed, there were missing staff signatures for wound care on two specific dates, as well as three instances where application of A&D ointment to the resident’s feet was not signed off out of 24 days reviewed. Another resident with severe cognitive impairment, as evidenced by a BIMS score of 00, was found to have an injury of unknown origin (a bruise on the left hand). Documentation showed that a change in condition was initiated late in the morning, but a formal pain evaluation was not initiated and completed until that night, and the resident was unable to explain how the injury occurred or verbalize pain using a standard pain scale. For a third resident, documentation related to the admission PPD test was inconsistent and incomplete. The MAR contained an entry indicating “9” for the administration date, meaning “see nurse’s note,” but there was no corresponding nurse’s note. Despite the absence of a signed administration of the PPD injection, staff documented the PPD result as “negative” on the scheduled read date. The resident reported never receiving the PPD injection, and the DON confirmed that the facility had been out of PPD solution at the time, so the test would not have been administered. These findings demonstrate failures in accurate documentation of treatments and assessments, including wound care, pain assessment, and TB screening, as well as missing or incomplete supporting notes in the medical record.
Failure to Implement and Communicate Correct Transmission-Based Precautions
Penalty
Summary
Surveyors identified a deficiency in the facility’s infection prevention and control program related to inconsistent and incorrect implementation of transmission-based precautions and PPE use. During a complaint investigation focused on residents on transmission-based precautions, one resident with a visible Foley catheter was observed in the room with physical therapy, but there were no signs posted indicating any need for PPE, despite the resident being a new admission with a Foley catheter placed related to wounds. In another double-occupancy room, a contact precautions sign was posted at the doorway, but the nurse practitioner was in the room on a personal phone with no PPE, and the assigned GNA was repositioning the resident in bed while wearing only gloves. When questioned, the NP, RN, and GNA all stated that the resident in the room was not on contact precautions, and the GNA reported that signs were hanging at all doors and that this particular resident’s sign was “just wrong.” The surveyor observed the GNA later return to the room and turn the sign around to indicate no PPE requirement. Subsequent interviews revealed that therapy staff relied on posted signage to determine PPE use and that if the sign was wrong, the PPE used would be wrong. Overall, surveyors found problems with signage accuracy and staff awareness of which residents required contact precautions, as well as observed failures to follow appropriate PPE use for residents who should have been on contact precautions.
Inaccurate MDS Coding for Falls, Pain Management, and High-Risk Medications
Penalty
Summary
Facility staff failed to ensure Minimum Data Set (MDS) assessments were accurately coded for two residents reviewed during a complaint survey. For one resident, a facility-reported incident showed that the resident was found seated on the floor beside the bed and was diagnosed with a non-displaced femoral neck impaction fracture of the left hip following an x-ray. Despite this fall with a major injury, the subsequent significant change MDS dated 11/4/25 did not code the fall with major injury in Section J1900C. Review of the resident’s Medication Administration Records for October and November 2025 showed administration of Tylenol on 10/31/25 at 9:30 PM, which fell within the 5-day look-back period for the MDS, but Section J0100 (prn pain) of the same significant change MDS did not capture the use of Tylenol. For another resident, review of a quarterly MDS with an assessment reference date of 10/15/25 showed that Section N0415 (High-Risk Drug Classes) documented the use of an opioid medication. However, review of the resident’s October 2025 Medication Administration Record did not show that the resident had been prescribed an opioid during that period. In both cases, MDS staff later confirmed that these were errors in MDS coding, demonstrating that the assessments did not accurately reflect the residents’ clinical status and medication use as documented in their medical records.
Incomplete Documentation of Narcotic Administration on MAR
Penalty
Summary
The facility failed to maintain complete and accurate medical records in accordance with accepted professional standards for one resident receiving narcotic medication. The resident, admitted in March 2026, had a fall on 3/6/26 and was sent to the hospital on 3/9/26. Review of the March 2026 Medication Administration Record (MAR) showed documentation of a single 25 mg dose of Tramadol administered on 3/8/26 at 9:23 AM. However, review of the resident’s Controlled Drug Receipt/Record/Disposition Form, kept on the nurse’s medication cart and not in the medical record, showed that Tramadol 25 mg was administered three times between 3/8/26 and 3/9/26: at 11:00 AM and 9:00 PM on 3/8/26, and at 9:00 AM on 3/9/26. In interview, the DON stated that staff are expected to document narcotic administration on the MAR and confirmed that only one of the three Tramadol doses reflected on the controlled drug record was documented on the resident’s MAR. This discrepancy between the controlled substance record and the MAR, with missing documentation of two administered doses of Tramadol on the official medical record, constituted the failure to maintain a complete and accurate medical record for the resident.
Trusted data from CMS and state health departments
Every citation, penalty and Plan of Correction is sourced from public CMS records (latest release May 27, 2026) and official state health department websites — never guesswork.
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