Regency Care Of Silver Spring, Llc
Inspection history, citations, penalties and survey trends for this long-term care facility in Silver Spring, Maryland.
- Location
- 9101 Second Avenue, Silver Spring, Maryland 20910
- CMS Provider Number
- 215060
- Inspections on file
- 13
- Latest survey
- March 11, 2026
- Citations (last 12 mo.)
- 7
Citation history
Health deficiencies cited at Regency Care Of Silver Spring, Llc during CMS and state inspections, most recent first.
A resident with multiple serious conditions had an updated MOLST indicating DNR/DNI status after discussion with the attending physician and power of attorney, but staff did not void the prior full-code MOLST and failed to ensure the updated form was sent and clearly communicated to EMS during a change in condition, resulting in CPR and intubation contrary to the resident’s documented wishes. In a separate case, another resident had an order for Lisinopril with instructions to hold the dose only if systolic BP was below 100 mm Hg, yet an LPN withheld several doses when systolic readings were between 106 and 109 mm Hg, contrary to the physician’s specific parameters.
A resident with severe cognitive impairment, dysphagia, severe calorie malnutrition, dementia, and prostate cancer underwent a FEES swallowing evaluation after the SLP, following discussion with the responsible party, obtained physician orders for repeat testing to consider a diet upgrade. The FEES results, available the same day, recommended a soft and bite-sized/mechanical soft chopped diet with thin liquids and specific compensatory strategies, including upright positioning, no straws, single sips, small bites, and slow intake, with possible use of a PROVALE cup. Review of the clinical record and an interview with the DON showed there was no nursing documentation that the physician had been notified of these FEES results, constituting a failure to immediately inform the physician of a significant change in swallowing assessment findings.
Facility staff failed to immediately report a suspected abuse incident to local law enforcement after a resident was found to have a fractured left humerus of unknown origin. The injury was reported to the State agency as an injury of unknown source, and a 5-day follow-up investigation documented that an x-ray confirmed the fracture, there were no witnesses, and the resident could not explain how the injury occurred. The resident’s BIMS score was recorded as 13/15, with noted fluctuation. Although facility policy assigns an Abuse Prevention Coordinator to report allegations or suspected abuse to the State Survey Agency and other officials per State law, the allegation was not reported to police, a fact later confirmed by the administrator and DON.
A resident with severe malnutrition, pharyngeal dysphagia, dementia, and other comorbidities had an existing nutritional risk care plan with goals and interventions related to diet tolerance and monitoring for dysphagia. After an SLP evaluation and a FEES exam, new recommendations were made for a soft and bite-sized/mechanical soft chopped diet with thin liquids and specific compensatory swallowing strategies, including upright positioning, no straws, single sips, small bites, and slow intake, with possible use of a Provale cup. Although these results were available to staff, the RN confirmed that the resident’s nutritional care plan was not updated with any new nursing interventions based on the FEES findings, resulting in a failure to revise the care plan to meet the resident’s needs.
Surveyors observed a medication cart on one nursing unit that was left unlocked and unattended in a hallway outside a room, with no staff present nearby. This situation was identified and reported to an LPN and later to the DON, demonstrating that medications were not consistently maintained in locked compartments as required.
A resident with a PRN order for Oxycodone 5 mg for left arm pain received multiple doses of this schedule II medication that were recorded on the controlled medication utilization record but not consistently documented on the MAR, and pain assessments were not completed or recorded for several administrations. The facility’s Medication Administration policy required staff to sign the MAR after giving medications and to sign the narcotic book for controlled substances, but the policy lacked implementation and revision dates, and the DON acknowledged that none of the facility’s policies had such dates. Review of the resident’s records showed a discrepancy between the 18 Oxycodone doses signed out on the controlled medication record and only 6 doses documented on the MAR, with several dates where Oxycodone was signed out but no corresponding MAR initials or pain assessments were recorded.
A resident did not receive an important piece of mail when staff failed to deliver an unopened letter from the local county DHS program that was later found in the facility activity area months after it was postmarked. During a complaint survey, the letter, still unopened and addressed to the discharged resident, was observed in the activity area, and the DON, when interviewed, was unable to explain why the resident had not received it.
Surveyors found that outdated food items, including mustard and bread, were not removed from storage as required, and a frozen meat item was left unlabeled and undated after being removed from its original packaging. Additionally, vegetables were rinsed in a non-designated sink, contrary to sanitary procedures. Dietary staff and the DoD confirmed these lapses in food storage, labeling, and preparation practices.
Surveyors found that two residents, both capable of making their own decisions, did not have documented evidence that advance directives were discussed or that information was provided. The Director of Social Services confirmed the absence of required documentation in both cases, despite facility procedures stating such discussions should occur on admission.
The facility did not promptly notify the physician or responsible party in two cases: one involving a resident who did not receive prescribed medication due to pharmacy unavailability, and another where a resident's ordered urine test was not completed and the lack of sample collection was not communicated. In both instances, documentation and staff interviews confirmed that required notifications were not made in a timely manner.
The facility did not ensure timely reporting of two separate abuse allegations. In one case, a resident's report of rough handling by a GNA was not communicated to the DON or reported to OHCQ within the required two-hour window. In another case, an incident involving a resident exposing themselves to another was reported to OHCQ more than two hours after the administrator was notified. The DON confirmed both incidents were not reported within the mandated timeframe.
Facility staff failed to accurately code the MDS assessment for a resident, marking antibiotic use for a UTI when there was no evidence in the medical or pharmacy records that antibiotics had been ordered or administered. The error was confirmed by the MDS coordinator and DON after review.
Facility staff did not complete required PASARR re-evaluations or Level II referrals for three residents whose initial screenings indicated the need for further assessment of mental disorder or intellectual disability. Medical record reviews and staff interviews confirmed that necessary follow-up screenings and documentation were not performed within the mandated timeframe.
Surveyors found that the facility did not develop or implement care plans for three residents: one with wounds, one receiving hospice care, and one taking antipsychotic and antidepressant medications. The absence of these care plans was confirmed by interviews with the DON and Unit Manager, and the residents' records lacked necessary interventions and approaches for their specific needs.
The facility did not conduct or document required interdisciplinary care plan meetings, failed to update care plans after changes in residents' cognitive status and therapy services, and continued to document therapy services after they were discontinued for two residents. Staff interviews confirmed lapses in documentation and communication regarding care plan updates and therapy discontinuation.
A resident who was fully dependent on staff for ADLs and had multiple co-morbidities did not receive scheduled showers as required, receiving only two bed baths without documentation of preference or refusal. This deficiency was identified after a complaint was made regarding the resident's hygiene upon transfer to a hospital, and the DON was unable to explain the lack of scheduled showers.
A resident receiving oxygen therapy did not have their oxygen tubing properly labeled with the date of change, was administered oxygen at a higher flow rate than ordered, and was given humidification without a physician's order. The LPN was unaware of the correct flow rate or last tubing change, and the care plan lacked specific goals and interventions for oxygen therapy. The DON confirmed these deficiencies.
Two residents receiving pain medications did not have documentation showing that nonpharmacological pain management interventions, as outlined in their care plans, were attempted prior to medication administration. The Treatment Administration Record lacked evidence that measures such as turning, music, or hot/cold applications were used before giving prescribed pain medications, and this was confirmed by the DON.
A resident with multiple cardiac conditions, including a left ventricular thrombus and low ejection fraction, did not receive timely follow-up with a cardiologist as recommended upon hospital discharge, and experienced an interruption in prescribed anticoagulation therapy. The attending physician was aware of these needs but did not ensure that a cardiology consult was ordered or documented, and responsibility for arranging the consult was deferred to facility staff.
The facility did not provide documentation that physicians reviewed or addressed irregularities identified by the pharmacist during monthly drug regimen reviews for two residents. Required reports were missing from the medical records, and the DON could not confirm whether the irregularities were communicated to or addressed by the physicians, as required by facility policy.
A resident with bipolar disorder was prescribed risperidone, and although psychiatric notes indicated stable mood and no behavioral concerns, required behavior monitoring associated with antipsychotic use was not documented in the Treatment Administration Record. The DON confirmed that the behavior monitoring tool, needed for psychiatric review and medication management, was not utilized.
A review of employee files revealed that an LPN was working with a non-renewed license, as confirmed through the Maryland Board of Nursing's verification system. The HR/Staff Scheduler tracked licenses using a spreadsheet and sent reminders, but this did not prevent the lapse. The DON and HR/Staff Scheduler were notified of the deficiency.
A resident admitted after a CVA due to a left ventricular thrombus was not provided with a timely cardiology consult as recommended upon hospital discharge. Despite documentation of the need for outpatient cardiology follow-up, no orders were placed and the consult was not arranged, with both the attending physician and DON acknowledging the lapse in coordination and follow-up.
A resident's hygiene care was not accurately documented, with inconsistencies between paper and electronic records regarding who performed and recorded bed baths. The staff member who provided care did not document in the EHR, and another staff member entered information without confirming the resident's preferences or refusals. The DON acknowledged discrepancies and could not verify if care was based on the resident's wishes.
A resident receiving hospice care did not have a hospice plan of care available in either paper or electronic records. Both the LTC Unit Manager and the DON confirmed the absence of this essential documentation, which is necessary to ensure the resident's needs are addressed and met during hospice services.
The facility did not provide evidence that its QAPI committee met at least quarterly as required, with missing documentation for certain periods and no paper records available. The DON reported that a computer system hack prevented access to electronic records.
A resident was transferred to the hospital following a fall, but the facility did not provide the required bed hold policy notification to the responsible representative. Staff interviews revealed confusion about the process, with some staff unaware of the policy and others unsure if it was sent to the responsible party. Only an admission acknowledgment was on file, and the DON was not aware of the mailing requirement.
Surveyors found that the facility did not display required daily nurse staffing information in a prominent and accessible location for residents and visitors. Both the DON and staffing coordinator were unaware of the posting requirement.
Failure to Honor MOLST DNR/DNI Orders and Misapplication of BP Parameters for Cardiac Medication
Penalty
Summary
The deficiency involves the facility’s failure to honor a resident’s updated end-of-life wishes as documented on a revised Maryland Medical Orders for Life-Sustaining Treatment (MOLST) form. One resident was initially admitted with a MOLST indicating full code status and all life-sustaining treatments. After a subsequent hospitalization and readmission, the attending physician documented an extensive discussion with the resident’s power of attorney and determined that the resident, who lacked capacity to make medical decisions and had multiple serious diagnoses including cerebrovascular accident with residual weakness, atrial fibrillation, diabetes, chronic anemia, gastrostomy tube, and metastatic prostate cancer to bone, was to be DNR/DNI with other measures permitted. A new MOLST form was completed indicating No CPR and Do Not Intubate, but the prior full-code MOLST was not voided by facility staff. When the resident later experienced a change in condition characterized by vomiting coffee-ground-like material, an LPN notified the on-call physician, obtained an order to transfer the resident to the hospital via 911, and prepared copies of the medical record, including medication orders and the MOLST form, for EMS. The LPN could not recall the specific contents of the MOLST form sent and only identified the resident as a hospital transfer. The attending physician stated they were unaware which MOLST form was sent with the resident. Review of the hospital record showed that the MOLST accompanying the resident was the earlier full-code form, labeled with the resident’s hospital information, and that the updated DNR/DNI MOLST had not been clearly communicated to EMS. As a result, the resident, who had documented DNR/DNI status on the newer MOLST, received CPR and intubation during EMS transport and was subsequently treated in the hospital ICU for 20 days. A second deficiency concerns the facility’s failure to follow specific physician-ordered blood pressure parameters for administering a cardiac medication to another resident. The physician ordered Lisinopril 10 mg by mouth once daily for hypertension, with instructions to hold the dose if the systolic blood pressure was less than 100 mm Hg. Review of the medication administration records for two months showed that nursing staff withheld multiple doses of Lisinopril on days when the resident’s systolic blood pressure readings were between 106 and 109 mm Hg, all above the ordered hold parameter. In an interview, the LPN who withheld these doses confirmed they were responsible for the omissions and acknowledged that, upon re-reading the physician’s prescribed parameters, the doses should have been administered as ordered.
Failure to Notify Physician of Swallow Evaluation Results
Penalty
Summary
The deficiency involves the facility’s failure to immediately notify a resident’s physician of the results of a swallowing evaluation. A complaint was received by the Office of Health Care Quality alleging that staff did not notify the physician regarding the results of a swallowing test. Review of the closed clinical record for Resident #1 showed the resident was admitted with severe calorie malnutrition, pharyngeal dysphagia, dementia, and malignant neoplasm of the prostate, and had significant cognitive impairment with a BIMS score of 3/15. During admission, the facility SLP spoke with the resident’s responsible party, who reported that the resident had failed a swallowing test in the hospital but wanted another swallowing test to attempt a diet upgrade. The SLP obtained physician orders and scheduled a FEES exam to be completed at the facility. On the scheduled date, the FEES procedure was performed and the results were available to staff the same day. The FEES report recommended a soft and bite-sized/mechanical soft chopped diet with thin liquids, along with compensatory strategies such as sitting upright, no straws, single sips, small bites, and a slow rate of intake, and suggested consideration of a PROVALE cup if single sips could not be completed independently. Despite the availability of these results and recommendations, there were no nursing progress notes in the resident’s chart indicating that the physician had been informed of the FEES results. In an interview, the DON confirmed that the record lacked documentation that the resident’s physician was made aware of the swallowing evaluation findings.
Failure to Report Suspected Abuse to Law Enforcement
Penalty
Summary
Facility staff failed to immediately report an allegation of suspected resident abuse to local law enforcement after a resident was found to have a fractured left humerus. On 02/03/26, the Office of Health Care Quality (OHCQ) received a facility-reported incident concerning this resident’s injury, which was reported by the facility as an injury of unknown source. A subsequent 5-day follow-up investigation by the facility, reviewed on 03/03/26, documented that an x-ray confirmed the left humerus fracture, that there were no witnesses to the incident, and that the resident was unable to tell staff how the injury occurred. The facility’s investigation concluded that the cause of the injury was inconclusive and that abuse had been ruled out. During the investigation, the facility measured the resident’s Brief Interview for Mental Status (BIMS) and recorded a score of 13/15, while noting that the resident’s BIMS score fluctuates. A review of the facility’s abuse policy on 03/05/26 showed that the facility designates an Abuse Prevention Coordinator responsible for reporting allegations or suspected abuse, neglect, or exploitation to the State Survey Agency and other officials in accordance with State law. Despite this policy and the requirement that allegations of abuse be reported to both OHCQ and local police in a timely manner, the 5-day follow-up investigation indicated that the allegation was not reported to law enforcement. In an interview on 03/11/26 during the exit conference, the administrator and DON confirmed that law enforcement had not been notified of the allegation related to the resident’s fractured humerus.
Failure to Revise Nutritional Care Plan After Swallowing Assessment
Penalty
Summary
The deficiency involves the facility’s failure to revise a resident’s care plan to reflect updated swallowing assessment results and related nursing interventions. A resident was admitted with diagnoses including severe calorie malnutrition, pharyngeal dysphagia, dementia, and malignant neoplasm of the prostate, and had a BIMS score of 3/15, indicating severe cognitive impairment. The dietician developed a nutritional risk care plan dated 12/29/25, with goals for the resident to tolerate a modified diet texture/consistency and maintain adequate nutritional status, and interventions such as administering medications as ordered, monitoring and reporting signs and symptoms of dysphagia, providing 1:1 assistance with meals as needed, providing supplements, serving the ordered diet and monitoring intake, and having the dietician evaluate and recommend diet changes as needed. During the admission process, the facility SLP evaluated the resident on 12/30/25 and, after discussion with the responsible party, obtained physician orders and scheduled a FEES exam, which was completed on 01/09/26. The FEES results recommended a soft and bite-sized/mechanical soft chopped diet with thin liquids and compensatory strategies including sitting upright, no straws, single sips, small bites, and a slow rate of intake, with consideration of a Provale cup if single sips were not completed independently. These FEES results were available to staff the same day. However, interview with an RN on 03/05/26 confirmed that the resident’s Nutritional Risk care plan was not updated with any new nursing interventions following the 01/09/26 FEES procedure, leading to the determination that the facility failed to revise the care plan to meet the resident’s needs.
Unlocked and Unattended Medication Cart in Hallway
Penalty
Summary
The deficiency involves the facility’s failure to ensure medications were kept in locked compartments as required. During observation of one of four nursing units (the 100 hall), a surveyor observed a medication cart unlocked and unattended in the hallway outside a resident room. At the time of this observation, no staff members were present around the medication cart. The unlocked and unattended cart was identified by the surveyor and then brought to the attention of a licensed practical nurse, and the observation was later reported to the director of nurses. No additional information about specific residents, their medical histories, or conditions at the time of the deficiency is provided in the report.
Incomplete Documentation of Controlled Pain Medication Administration
Penalty
Summary
The deficiency involves the facility’s failure to maintain complete and accurate clinical records, specifically related to medication administration documentation for one resident. The facility’s Medication Administration policy instructs nursing staff to sign the Medication Administration Record (MAR) after administering medications and to sign the narcotic book for controlled substances; however, the policy itself lacked implementation and revision dates and did not identify who reviewed or revised it. During an interview, the DON stated that none of the facility’s policies and procedures had dates indicating when they were implemented. A physician’s order dated 02/04/26 directed staff to administer Oxycodone 5 mg orally every 6 hours as needed for left arm pain greater than 5/10 for 30 days. Review of the resident’s controlled medication utilization record showed that nursing staff administered 18 doses of Oxycodone 5 mg between 02/05/26 and 03/09/26, while the February and March MARs reflected documentation of only 6 administered doses during that same period. For three of the documented doses, the MAR entries recorded pain scores of 3/10 and 0/10 at the time of administration. Further review revealed that on multiple specific dates and times, staff signed out Oxycodone on the controlled medication utilization record but failed to perform and document pain assessments and failed to initial the MAR to show administration of the 5 mg Oxycodone doses. This discrepancy between the controlled substance record and the MAR, along with missing pain assessments, demonstrated that the facility did not have an effective system to ensure complete and accurate clinical documentation for this resident’s medication administration.
Failure to Deliver Resident Mail from County DHS Program
Penalty
Summary
Facility staff failed to ensure a resident received mail, resulting in an unopened letter addressed to Resident #5 being found in the facility activity area. During an observation of the first-floor activity area at 2:00 p.m. on 03/04/26, surveyors observed an unopened letter addressed to Resident #5 from the local county DHS program, postmarked 10/24/25. A review of Resident #5’s closed record showed that the resident had been admitted and later discharged home, though the specific dates were not detailed in the report. When the DON was interviewed at 3:32 p.m. the same day and handed the letter, the DON stated that Resident #5 had recently been discharged and could not provide any explanation for why the resident had not received the letter when it arrived in October 2025. This deficiency was identified for 1 of 8 residents reviewed during a complaint survey and demonstrates that the facility did not ensure reasonable access to and privacy in the use of communication methods, specifically mail delivery, for Resident #5.
Deficiencies in Food Storage, Labeling, and Sanitary Practices
Penalty
Summary
Surveyors identified several deficiencies related to food storage, preparation, and labeling during a kitchen tour. Outdated nourishment, specifically a quarter jar of yellow mustard with an open date several months prior, was found in the refrigerator and had not been removed as required. Additionally, two and a half loaves of sliced bread with an expiration date that had already passed were also found in the refrigerator. An unlabeled and undated frozen meat item was discovered in the freezer, and staff confirmed that it should have been labeled and dated immediately after being removed from its original packaging. Further observations revealed that a tray containing celery, onions, and green peppers was placed in the manual rinse compartment of the three-compartment dishwasher sink, rather than the designated food preparation sink. Staff admitted to sometimes rinsing vegetables in the incorrect area, acknowledging that this was not in accordance with proper sanitary procedures. These findings were confirmed through interviews with dietary staff and the Director of Dietary, who acknowledged that the observed practices did not meet required standards.
Failure to Document Advance Directive Discussions and Provision of Information
Penalty
Summary
The facility failed to ensure that advance directives were discussed with, and information regarding advance directives was provided to, residents and/or their responsible representatives. For one resident who had the capacity to make their own decisions, there was no documented evidence that the facility provided education about or obtained an advance directive. The Director of Social Services confirmed that no advance directive documentation was found for this resident, despite the facility's stated process of evaluating residents on admission and offering the opportunity to formulate advance directives if none were present. For another resident, the medical record included a Maryland Order for Life Sustaining Treatment (MOLST) and a certificate of capacity indicating the resident was cognitively intact and capable of making decisions. However, there was no advance directive document found in either the paper chart or electronic medical record, and no documentation that a discussion about advance directives had occurred with the resident or their responsible party. The Director of Social Services confirmed that the admission assessment and social services progress notes did not document any discussion or provision of information regarding advance directives for this resident.
Failure to Timely Notify Physician and Responsible Party of Medication and Diagnostic Test Issues
Penalty
Summary
The facility failed to notify the physician, Medical Director, or responsible party in a timely manner regarding two separate incidents involving two residents. In the first case, a resident was prescribed Benadryl anti-itch cream, but the medication was not available from the pharmacy for three days. Documentation showed that staff were aware of the unavailability and that the medication was not administered as ordered, but there was no timely notification to the physician or a change in medication until three days after the initial order. The resident's family only became aware of the issue through the resident, not from facility staff. In the second case, a resident experienced a change in condition, prompting new orders for diagnostic urine testing via in-and-out catheterization every shift for two days. The health record did not show that attempts were made to obtain the urine sample on one of the days, nor was there documentation that the physician or responsible party was notified of the missed collection and incomplete test. The lack of notification persisted until the resident was transferred to the hospital, at which point the physician and family were informed. The DON confirmed that both the physician and responsible party should have been notified of the inability to obtain the urine specimen.
Failure to Timely Report Alleged Abuse Incidents
Penalty
Summary
The facility failed to ensure timely reporting of abuse allegations for two residents. In the first instance, a resident reported to a unit manager that a Geriatric Nursing Assistant was rough during care, describing the staff as a white woman with yellow hair who did not allow enough time for the resident to turn and handled the resident roughly. Despite this report, there was no evidence that the incident was communicated to the Director of Nursing (DON), the Administrator, or the Office of Healthcare Quality (OHCQ) within the required timeframe. The DON confirmed she had not been informed of the incident, and no documentation was provided to show that the allegation was reported to OHCQ within two hours as required. In the second instance, an ancillary staff member observed a resident exposing their private area to another resident. The facility administrator was notified of this allegation, but the report to OHCQ was made more than two hours after the administrator was informed. The DON acknowledged the late reporting after reviewing the documentation and confirmed that the report was not made within the mandated timeframe. These failures demonstrate that the facility did not adhere to timely reporting requirements for abuse allegations.
Inaccurate MDS Coding for Antibiotic Use
Penalty
Summary
Facility staff failed to ensure that Minimum Data Set (MDS) assessments were accurately coded for a resident reviewed for antibiotic use. During an interview, the resident denied having a urinary tract infection (UTI) and was unsure about taking antibiotics. However, the facility's 30-day admissions matrix indicated that the resident was taking antibiotics for a UTI. Upon further review of the resident's medical records, including pharmacy orders and medication administration records, there was no evidence that antibiotics had been ordered or administered to the resident. The MDS assessment for the resident, dated March 23, 2025, was coded to indicate antibiotic use in Section N0415. The MDS coordinator confirmed that there were no antibiotics found in the resident's current or discontinued medication records. The coordinator explained that the assessment was completed by a weekend MDS coordinator and acknowledged that the coding for antibiotic use was incorrect. The Director of Nursing also agreed that the MDS assessment was inaccurately coded.
Failure to Complete Required PASARR Re-Evaluations and Referrals
Penalty
Summary
Facility staff failed to ensure that required PASARR (Preadmission Screening and Resident Review) screenings were re-evaluated and completed as mandated for residents with indications of mental disorder or intellectual disability. For three residents reviewed, the initial Level I PASARR screens indicated the need for further evaluation (Level II PASARR) or re-screening if the stay extended beyond 30 days. However, there was no evidence in the clinical records that these follow-up screenings or referrals to the appropriate agencies were completed within the required 40-day timeframe. The deficiency was identified through medical record reviews and staff interviews, which confirmed the absence of updated PASARR documentation and necessary Level II evaluations. Specifically, one resident had a Level I PASARR screen indicating the need for a Level II evaluation, but no such evaluation was found in the records. Another resident's PASARR form also indicated the need for re-evaluation and referral, but again, no evidence of a Level II screen was present. For a third resident, the PASARR Level I form responses required a Level II evaluation, but staff acknowledged that this was not completed. These findings were corroborated by interviews with the Director of Social Services and the DON, who confirmed the lack of required follow-up PASARR documentation and evaluations.
Failure to Develop and Implement Comprehensive Care Plans
Penalty
Summary
The facility failed to develop and implement complete care plans for three residents, as identified during a Medicare/Medicaid recertification and complaint survey. One resident was admitted with a history of epilepsy, hemiplegia, and hemiparesis, and had both a stage 2 pressure wound and a venous wound documented by the wound team. Despite these findings, there was no care plan in place addressing the management of the resident's wounds. Interviews with the Unit Manager and DON confirmed that a wound care plan should have been created but was not present in the resident's record. Another resident with a terminal prognosis was admitted to hospice care, but the facility did not initiate a hospice care plan. The Unit Manager and DON both acknowledged the absence of a hospice care plan for this resident. Additionally, a third resident was receiving antipsychotic and antidepressant medications for depression and bipolar disorder, but the care plan did not include any focus, goals, or interventions related to these medications. The DON confirmed that a comprehensive care plan addressing the use of these medications was not developed or implemented.
Failure to Conduct and Update Interdisciplinary Care Plans and Therapy Documentation
Penalty
Summary
The facility failed to conduct required interdisciplinary care plan meetings, update care plans to reflect residents' current needs, and revise care plans following changes in therapy services. For one resident, there was no documentation that care plan meetings were held after each Minimum Data Set (MDS) assessment, nor evidence that the resident or their family representative was included or notified of these meetings. Staff interviews confirmed that attempts to contact family representatives were not documented, and there was a lack of evidence supporting that care plan meetings occurred as required. Additionally, the care plan for this resident was not updated to reflect changes in cognitive status or interventions following an incident involving wandering and inappropriate behavior. Although interventions for elopement and impaired safety awareness were in place, there was no recent review or revision of these interventions, and the last elopement assessment was outdated. The Director of Nursing acknowledged that the care plan interventions were not current and that the resident was no longer at risk for elopement. For another resident, the care plan was not updated after the discontinuation of Physical Therapy (PT) and Occupational Therapy (OT). Despite therapy services being discontinued, nursing staff continued to document that the resident was receiving PT and OT, and the care plan still reflected ongoing therapy. The Director of Nursing confirmed that care plans should have been updated to reflect the discontinuation of services and that staff should not have documented services that were not provided.
Failure to Provide Scheduled Showers for Dependent Resident
Penalty
Summary
A resident with multiple co-morbidities who was dependent on staff for all activities of daily living (ADL) was admitted to the facility and was scheduled to receive showers twice per week on Mondays and Thursdays during the 3 pm to 11 pm shift. During a complaint investigation, it was found that the resident did not receive any showers during their stay at the facility, as documented in the shower log. Instead, the resident received only two bed baths, with no documentation indicating that this was based on the resident's preference or that showers were offered and refused. The deficiency was identified after a complaint was made regarding the resident's hygiene when transferred to a hospital, where a hospital nurse observed the resident to be dirty. The Director of Nursing (DON) confirmed that the resident was supposed to receive scheduled showers and was unaware of why this did not occur. The lack of proper documentation and failure to provide the scheduled showers led to the deficiency cited during the Medicare/Medicaid recertification and complaint survey.
Failure to Provide Safe and Appropriate Respiratory Care
Penalty
Summary
The facility failed to provide safe and appropriate respiratory care for a resident by not properly labeling oxygen tubing with the date it was changed, not following the physician's order for the prescribed oxygen flow rate, and not developing or implementing a comprehensive, person-centered care plan for oxygen therapy. During observation, a resident was found using a nasal cannula connected to a humidifier bottle and oxygen concentrator set at 4 liters per minute (LPM), while the physician's order specified 2 LPM via nasal cannula. The oxygen tubing was not labeled with the date or time of the last change, and the nurse on duty was unable to confirm when the tubing was last changed or the correct flow rate for the resident's oxygen therapy. Review of the resident's medical record revealed orders for weekly oxygen tubing changes and continuous oxygen at 2 LPM, but there was no order for the use of a humidifier bottle. Documentation in the Medication Administration Record (MAR) and Treatment Administration Record (TAR) did not indicate the use of humidification, and the care plan lacked a focus on oxygen therapy with specific goals and interventions. The Director of Nursing confirmed these deficiencies, noting that the oxygen tubing should be labeled and that oxygen therapy should be addressed in the care plan.
Failure to Document Nonpharmacological Pain Management Interventions
Penalty
Summary
The facility failed to document the use of nonpharmacological interventions for pain management for two residents who were prescribed pain medications. For one resident, a physician order was in place for Roxicodone to be administered as needed for pain or prior to physical therapy. The resident's care plan specified that nonpharmacological interventions such as turning and repositioning, music, television, low light, hot or cold applications, and noise reduction should be used for pain management. However, a review of the Treatment Administration Record (TAR) revealed no documentation that these interventions were attempted or implemented prior to administering pain medication. Similarly, another resident had a physician order for tramadol for pain, and their care plan also directed nursing staff to use nonpharmacological pain management strategies. Upon review, there was no evidence in the TAR that these interventions were documented as being used before administering the medication. An interview with the Director of Nursing confirmed that the care plan interventions should have been added to the TAR and acknowledged the lack of documentation to validate the use of nonpharmacological measures.
Failure to Ensure Timely Cardiology Consult and Continuity of Anticoagulation Therapy
Penalty
Summary
A deficiency occurred when the attending physician failed to follow up on hospital discharge recommendations and her own notes regarding a necessary cardiology consult for a resident with significant cardiac conditions, including a left ventricular thrombus, low ejection fraction, prior stroke, ischemic cardiomyopathy, and coronary artery disease. The resident was discharged from the hospital with instructions to follow up with a cardiologist within three months and to continue anticoagulation therapy for at least three months. However, the medical record review revealed that the resident's anticoagulant was discontinued for approximately one month within two months of admission, and there was no documented evidence of a cardiology consult being ordered or completed during this period. During interviews, the attending physician acknowledged awareness of the need for a cardiology consult and the importance of continued anticoagulation but deferred responsibility to the facility for arranging the consult. She also could not confirm whether the resident had seen a cardiologist and admitted that any order for a consult may have been given verbally, with no documentation found in the chart. The Director of Nursing was also made aware of the attending physician's lack of follow-through on the resident's care plan, specifically regarding the cardiology consult and monitoring of the resident's cardiac condition.
Failure to Document Physician Review of Pharmacy-Identified Drug Regimen Irregularities
Penalty
Summary
The facility failed to provide documentation that the attending physician reviewed irregularities identified by the pharmacist during monthly drug regimen reviews for two residents. For one resident, there were four dates on which the pharmacist identified irregularities, but the facility was only able to locate documentation for one of those dates. The remaining records could not be found, and there was no proof that the reviews were completed or seen by the appropriate discipline. The facility's own policy requires that the pharmacist communicate irregularities in writing to the attending physician, medical director, and DON, and that these communications become a permanent part of the resident's medical record. For another resident, two dates were identified where the pharmacist noted irregularities and made recommendations, but the facility could not provide the corresponding reports in the resident's chart. The DON stated that the pharmacist sends consultation reports via email, which are then printed and given to unit managers to follow up with physicians. However, the DON was unable to find the reports or confirm whether the physician had reviewed or addressed the irregularities. No additional documentation was provided to show that the irregularities were addressed by the physician.
Failure to Implement Behavior Monitoring for Antipsychotic Use
Penalty
Summary
The facility failed to implement behavior monitoring for a resident who was prescribed antipsychotic medication. Medical record review showed that the resident was admitted with a diagnosis of bipolar disorder and had a physician's order for risperidone. Psychiatry consult notes indicated the resident was stable, with no reports of sleep disturbances, appetite changes, suicidal or homicidal ideation, hallucinations, or delusions, and no observed agitation or aggression. The psychiatrist's plan included considering a gradual dose reduction or discontinuation of risperidone if stability continued. However, review of the Treatment Administration Record revealed that behavior monitoring, which is required for residents receiving antipsychotic medications, was not documented. The Director of Nursing confirmed that the behavior monitoring tool was not used, which was necessary for the psychiatrist to make informed decisions regarding medication management.
LPN Worked Without Active License
Penalty
Summary
The facility failed to ensure that all nursing staff maintained an active license as required by state law. During a review of five employee files, it was discovered that one LPN was working with a license status of NON-RENEWED, with the expiration date having already passed. The Maryland Board of Nursing's online verification system was used to confirm the license status. The Human Resource/Staff Scheduler reported using a spreadsheet to track license expirations and sending reminders to employees, but this process did not prevent the lapse in licensure for the LPN. Both the Human Resource/Staff Scheduler and the Director of Nursing were made aware of the issue during the survey.
Failure to Arrange Timely Cardiology Consult for Resident with LV Thrombus
Penalty
Summary
A deficiency was identified when the facility failed to provide timely access to outside professional services for a resident who required specialized care. The resident was admitted following a cerebral vascular accident (CVA) caused by a left ventricular (LV) thrombus and was discharged from the hospital with instructions to continue anticoagulation therapy for at least three months, with a follow-up cardiology assessment and repeat imaging recommended. Review of the resident's medical records showed that, over the course of a year, there was only one physician note referencing the need for an outpatient cardiology consult, and no orders were placed to arrange this consult. Interviews with the attending physician and the Director of Nursing (DON) revealed a lack of follow-through on the recommendation for a cardiology appointment. The attending physician stated that while recommendations could be made verbally or in writing, it was the facility's responsibility to ensure the appointment was scheduled. The DON was made aware of the concern regarding the absence of a cardiology consult for the resident, highlighting a breakdown in coordination and follow-up for required outside professional services.
Failure to Accurately Document Resident Hygiene Preferences and ADL Care
Penalty
Summary
The facility failed to ensure accurate and consistent documentation of a resident's personal hygiene preferences and the completion of activities of daily living (ADL) care. Specifically, for one resident, there were discrepancies between the paper shower log and the electronic health record (EHR) regarding who performed and documented bed baths on two separate dates. The paper shower log indicated that a Geriatric Nursing Assistant (GNA) provided the care, while the EHR showed that an LPN and a different GNA documented the same tasks. The staff member who performed the care did not document in the EHR, and another staff member documented on their behalf without confirming the resident's preferences or whether a shower was offered and refused. Interviews with staff revealed that the GNA responsible for providing the bed baths only documented in the paper shower log and did not use the EHR for any residents. The LPN confirmed that she documented in the EHR when the person who completed the task had not done so, rather than ensuring the actual caregiver completed the documentation. The Director of Nursing acknowledged the mismatch in documentation and was unable to confirm if the resident's hygiene care was based on their preferences or if refusals were properly recorded.
Failure to Maintain Hospice Plan of Care Documentation
Penalty
Summary
A deficiency was identified when a resident with a terminal prognosis, who was receiving hospice services, did not have a hospice plan of care available in either the paper or electronic medical records. During a review of the resident's records, surveyors were unable to locate the required hospice plan of care or documentation of the communication process related to hospice services. The absence of this documentation was confirmed by the Long-Term Care Unit Manager, who acknowledged that the plan of care should have been present in the resident's health records. Further inquiry revealed that the Director of Nursing was also unable to provide the hospice plan of care at the time of the initial request and was waiting for the necessary documents to be sent from the hospice provider. The lack of a hospice plan of care meant that there was no documented guidance to ensure the resident's needs were being addressed and met as part of their hospice care.
Failure to Hold and Document Required QAPI Committee Meetings
Penalty
Summary
The facility failed to ensure that its Quality Assurance and Performance Improvement (QAPI) committee met at least quarterly as required. Review of the Quality Assurance Committee sign-in sheets for the period from January 2024 to March 2025 showed that meetings were held on several dates, but there was no documented evidence of a meeting in June 2024 or for certain other periods. During an interview, the DON stated that the facility's computer system had been hacked and that no paper documentation was available to verify the missing meetings. This lack of documentation and failure to meet the required frequency of QAPI meetings was identified during the recertification/complaint survey.
Failure to Provide Bed Hold Policy Notification on Resident Transfer
Penalty
Summary
The facility failed to provide the required bed hold policy notification to the responsible representative when a resident was transferred out to the hospital. Medical record review showed that the resident had multiple hospital transfers, with the most recent involving a fall and subsequent transfer via 911. While the resident had acknowledged receipt of the bed hold policy upon admission, there was no evidence that a copy was provided or mailed to the responsible representative at the time of the most recent transfer. Staff interviews revealed inconsistencies and lack of awareness regarding the process for distributing the bed hold policy during transfers. One nurse was unfamiliar with the bed hold policy, while another stated the policy was given to the resident but was unsure if it was sent to the responsible representative. The Admissions Director indicated that nursing was responsible for this task, but also confirmed that only the admission acknowledgment was on file. The DON was not aware of the requirement to mail the policy to the responsible representative upon transfer.
Failure to Post Daily Nurse Staffing Information
Penalty
Summary
The facility failed to post the required daily nurse staffing information in a prominent and accessible location for residents and visitors. During the recertification and complaint survey, surveyors observed that no nurse staffing information was displayed at the main entrance or in common areas from 4/9/25 through 4/17/25. Interviews with the DON and the staffing coordinator revealed that both were unaware of the requirement to post this information in a location easily accessible to visitors and staff. No information about specific residents, their medical history, or their condition at the time of the deficiency was provided in the report.
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.
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.
Trusted by long-term care providers and associations.
