Resorts At Chester River Manor Corp
Inspection history, citations, penalties and survey trends for this long-term care facility in Chestertown, Maryland.
- Location
- 200 Morgnec Road, Chestertown, Maryland 21620
- CMS Provider Number
- 215262
- Inspections on file
- 19
- Latest survey
- December 16, 2025
- Citations (last 12 mo.)
- 17
Citation history
Health deficiencies cited at Resorts At Chester River Manor Corp during CMS and state inspections, most recent first.
A resident who was dependent on staff for bathing received only one documented shower during their stay, despite requiring substantial assistance with ADLs. Documentation and interviews confirmed that showers were not consistently provided or recorded according to scheduled shower days, resulting in inadequate personal hygiene care.
A resident experienced five days without a documented bowel movement following changes to their bowel regimen and administration of an antidiarrheal. Despite facility policy requiring intervention after 72 hours without a bowel movement, there was no evidence that the bowel protocol was initiated or that the provider was notified, and no as-needed suppository was administered during this period.
A resident with pressure ulcers did not receive prescribed Tramadol doses as ordered, with records showing discrepancies between the MAR and the Narcotics Record. Staff signed off on medication administration in error and failed to document any resident refusal in the progress notes, contrary to facility expectations.
Surveyors identified multiple failures in maintaining accurate and complete medical records, including inaccurate assessments of a resident's dental status, missing and untimely provider notes for a resident's care, incomplete documentation of therapy sessions, and an active monitoring order for anticoagulant medication without a corresponding medication order or documentation. These deficiencies were found through record reviews and staff interviews.
The facility failed to maintain accurate medical records for several residents, including improper documentation of wheelchair assessments, incomplete PASSAR assessments, unsigned transportation request forms, discrepancies in controlled drug receipt records, incorrect electronic SOAP notes, and incorrect diagnoses for medication administration.
The facility failed to maintain the dignity and privacy of a resident by leaving their nephrostomy bags uncovered during a social coffee time, making the resident's urine visible. An LPN and the Administrator confirmed that the bags should have been covered.
The facility staff failed to ensure that residents' call bells were within reach to request assistance. During observation rounds, one resident's call bell was found draped over the bedside table, and another's was on the floor. These findings were confirmed by a social worker and acknowledged by the DON, who stated that managers and GNAs are expected to ensure call bells are accessible.
A facility failed to ensure scheduled pain medications were not misappropriated, as evidenced by a discrepancy in the narcotic drawer for a resident's Tramadol 50 mg tablets. The controlled drug receipt record and medication administration audit report did not match, and the nurse involved admitted to failing to sign the controlled drug receipt record for another resident's medication.
The facility staff failed to include necessary dental care assistance in a resident's ADL care plan, despite recommendations and the resident's expressed need. The resident had not seen a dentist in almost a year and experienced pain while brushing, which was known to the nursing staff but not reflected in the care plan.
The facility staff failed to conduct quarterly care plan meetings for a resident, as evidenced by a review of the resident's EMR, which revealed that the last care plan meeting was held several months ago. The social worker indicated that care plan meetings are supposed to be held quarterly and as needed, but the required meeting was not conducted within the expected timeframe.
The facility staff failed to document medication administration in a timely manner for a resident. An LPN admitted to documenting the medication late, although it was given on time. The facility's policy requires immediate documentation after administering medication, which was not followed. The DON confirmed the standard practice, and the deficiency was identified during a survey.
The facility failed to ensure proper medication administration and documentation, including discrepancies in controlled drug counts and late administration of scheduled medications. These issues were identified during a survey and confirmed through interviews and medical record reviews.
A physician failed to timely evaluate a resident's sore throat despite the resident's repeated complaints and a Nurse Practitioner being informed. The NP intended to see the resident but became busy and did not follow through until the next day, when medication orders were finally written.
The facility staff failed to maintain a medication error rate below 5%, with errors including late administration, failure to instruct a resident to rinse their mouth after inhaler use, and improper handling of medications. The DON acknowledged the issues, indicating previous training had been conducted.
Facility staff failed to adhere to infection control practices during medication administration. An LPN did not clean a tablet crusher after use, and another LPN picked up a dropped tablet with an ungloved hand, both actions violating facility policies.
The facility staff failed to offer and administer the pneumococcal vaccine to a resident with a history of Diabetes Mellitus, alcohol abuse, and Viral Chronic Hepatitis C. Despite the facility's policy and CDC guidelines, the resident was not offered the vaccine, and no consent or declination form was completed.
Failure to Provide Adequate Bathing Assistance for Dependent Resident
Penalty
Summary
The facility failed to provide necessary services to maintain good personal hygiene for a dependent resident who required assistance with activities of daily living (ADLs), specifically bathing. Documentation review revealed that during the resident's stay from mid-March to mid-April, there was only one recorded instance of the resident being assisted with a shower. Intake records and Point of Care (POC) documentation indicated that the resident was dependent or needed substantial to maximal assistance with showering and bathing, but only one date was documented for a shower transfer. Interviews with the unit manager confirmed that there was limited documentation to support that multiple showers were provided, and skin check sheets did not indicate that showers were given on the assigned days. The unit manager acknowledged that, at the time, showers and transfers were prompted on an as-needed basis rather than on scheduled shower days, and there was no additional documentation to demonstrate that the resident received more than one shower during the reviewed period.
Failure to Provide Timely Bowel Management Interventions
Penalty
Summary
The facility failed to identify and provide appropriate interventions for a resident experiencing constipation and diarrhea. Record review showed that the resident had orders for Miralax and Senna for constipation, which were both reduced or discontinued on 3/19/25, and Imodium was started for diarrhea. Despite these medication changes, the resident had no documented bowel movement for five days (3/25/25-3/29/25). During this period, the bowel regimen had been decreased and an antidiarrheal was administered. The Bisacodyl suppository, ordered as needed, was not documented as given during March 2025. Nursing notes during this time indicated active bowel sounds and noted constipation, but no further interventions were documented. Facility policy required daily monitoring of bowel movements and initiation of a bowel protocol if no bowel activity was noted in 72 hours, with results to be documented in the electronic health record. The surveyor's review found that the resident's lack of bowel movement was not addressed according to protocol, and there was no evidence that the provider was notified or that the bowel protocol was initiated after five days without a bowel movement. The deficiency was confirmed through record review, interviews, and policy review, with no additional information provided by the facility at the time of exit.
Failure to Administer Prescribed Pain Medication and Document Refusals
Penalty
Summary
The facility failed to provide pain management as prescribed for a resident with large pressure ulcers who required pain medication during wound treatment. Medical record review and staff interviews revealed that the resident was not administered Tramadol every 8 hours as ordered, specifically missing the 2 pm dose on several consecutive days. The Medication Administration Record (MAR) indicated that the medication had been given, but a comparison with the Narcotics Record showed it had not actually been administered. Staff involved reported signing the MAR in error and believed the resident had refused the medication, but there was no documentation in the progress notes to support a refusal. The facility's expectation was that any refusal should be documented in the progress notes, which was not done in this case.
Failure to Maintain Accurate and Complete Medical Records
Penalty
Summary
The facility failed to maintain complete and accurate medical records in accordance with accepted professional standards, as evidenced by multiple deficiencies identified during a recertification and complaint survey. In one instance, a resident who reported having no teeth for years was inaccurately assessed in both the nursing admission assessment and the Minimum Data Set (MDS) assessment, with documentation failing to indicate the resident was edentulous. The MDS coordinator relied on documentation from other disciplines rather than direct assessment, resulting in incorrect coding of the resident's oral status. Another deficiency involved a resident whose medical record lacked timely and complete provider notes. Progress notes indicated that a nurse practitioner had seen the resident and ordered medication, but the corresponding provider notes were missing from the electronic medical record. When the surveyor requested these notes, they were subsequently uploaded with creation dates much later than the effective dates, confirming that the documentation was not completed in a timely manner and was not part of the resident's record at the time of care. Additional findings included incomplete documentation of therapy services and inaccurate physician orders. One resident had a physician order for physical therapy 3-5 times per week, but therapy was only provided twice in one week without documentation explaining the missed sessions, despite the resident being available for other therapies. Another resident had an active physician order for monitoring anticoagulant medication, but there was no corresponding order for the medication itself, and the medication was not listed on the MAR, care plan, or MDS assessments. These deficiencies demonstrate failures in maintaining accurate, complete, and timely medical records for residents.
Deficiencies in Medical Record-Keeping and Documentation
Penalty
Summary
The facility failed to maintain complete and accurate medical records for several residents. For Resident #37, the wheelchair and cushion were reported to be inappropriate, and the facility could not provide documentation that the wheelchair was assessed for proper fit. Resident #42's PASSAR assessment was incomplete as it lacked a signature, and Resident #58's transportation request form was not signed or dated by the staff. Additionally, discrepancies were found in the controlled drug receipt records for Resident #5 and Resident #10, where medications were either not administered as recorded or not signed off correctly by the nurse responsible. During a review of Resident #77's medical record, it was found that the electronic SOAP note incorrectly stated that the resident was on no known medications, despite the resident being on medications at the time of the visit. The nurse practitioner acknowledged the error and indicated that the electronic system needs correction. Furthermore, Resident #24's MAR indicated an incorrect diagnosis for the administration of Seroquel, which was being given for psychosis with behavioral disturbances but was recorded as being for depression. These deficiencies highlight significant lapses in documentation and record-keeping practices within the facility, affecting the accuracy and reliability of resident medical records. The issues were identified through medical record reviews, staff interviews, and observations during the survey, and were discussed with the administration team at the time of exit.
Failure to Maintain Resident Dignity and Privacy
Penalty
Summary
The facility failed to maintain the dignity and privacy of a resident as evidenced by the resident's nephrostomy bags being left uncovered while outside of their room. This was observed during a social coffee time in the Terrace Lounge, where the resident's urine was visible through the clear bags. An LPN confirmed that the nephrostomy bags should have been covered when the resident was outside their room and took the resident back to their room to cover the bags. The Administrator was also made aware of the situation and confirmed that the bags should have been covered.
Call Bell Accessibility Deficiency
Penalty
Summary
The facility staff failed to ensure that residents' call bells were within reach to request assistance. This deficiency was observed in two residents. During observation rounds, one resident was found sitting on the side of the bed with the call bell draped over the bedside table, out of reach. Another resident's call bell was found on the floor near the left side of the bed. These findings were confirmed by a social worker. The Director of Nursing stated that managers are expected to make rounds twice in the morning and twice in the evening, and Geriatric Nursing Assistants are expected to check on residents periodically throughout the day to ensure call bells are accessible.
Medication Misappropriation and Documentation Discrepancy
Penalty
Summary
The facility failed to ensure that scheduled pain medications for a resident were not misappropriated. During a review of a medication cart on the Osprey Unit, a discrepancy was found in the narcotic drawer for a resident's Tramadol 50 mg tablets. The controlled drug receipt record indicated that one tablet was given at 0900 with six tablets remaining, but the blister pack contained seven pills. The medication administration audit report showed the medication was documented as administered at 08:39 AM. The nurse involved could not explain the discrepancy and admitted to failing to sign the controlled drug receipt record for another resident's medication. An interview with the resident revealed no complaints of pain, and the Director of Nursing confirmed that a medication error form was completed for the omission of the scheduled dose. The facility provided documentation of staff education on the issue. The deficiency was discussed with the Director of Nursing during the exit meeting with the survey team.
Failure to Include Dental Care in Resident's ADL Care Plan
Penalty
Summary
The facility staff failed to generate a person-centered care plan for a resident who required assistance with dental care. During an interview, the resident expressed the need to see a dentist. The last dental visit was recorded almost a year prior, and a dental summary from several months earlier recommended assistance with teeth brushing. However, this assistance was not included in the resident's Activities of Daily Living (ADL) care plan. The Director of Nursing confirmed that the care plan did not include teeth brushing, despite the resident sometimes experiencing pain while brushing and requiring assistance. The Geriatric Nursing Assistant also noted that the resident had been struggling with this issue for about a year, and the nursing staff was aware of it but had not updated the care plan accordingly.
Failure to Conduct Quarterly Care Plan Meetings
Penalty
Summary
The facility staff failed to conduct quarterly care plan meetings for Resident #73, as evidenced by a review of the resident's electronic medical record (EMR) on 03/05/24, which revealed that the last care plan meeting was held on 09/02/23. During an interview with Social Worker #7, it was revealed that care plan meetings are supposed to be held quarterly and as needed. The social worker receives a monthly list of residents whose care plan meetings are due and usually schedules these meetings on Tuesdays. Invitations are sent a week beforehand to the responsible party (RP) and the resident, and the meetings typically include Therapy, Activities, Social Services, and the resident's RP, with Nursing attending if available. Despite this process, the required quarterly care plan meeting for Resident #73 was not conducted within the expected timeframe.
Failure to Document Medication Administration Timely
Penalty
Summary
The facility staff failed to document medication administration in a timely manner for Resident #32. Upon review of the medication administration audit record (MAAR) for the period of 3/1/24 to 3/6/24, it was found that medications were documented as administered late. Specifically, on 3/4/24, the medication omeprazole, scheduled for 8:00 AM, was documented as administered at 11:44 AM. Licensed Practical Nurse (LPN #23) admitted to documenting the medication administration late, although she claimed the medication was given on time. The facility's policy requires that medication administration be documented immediately after administering the medication to each resident, which was not followed in this instance. The Director of Nursing (DON) confirmed that the standard practice is to document medication administration immediately after it is given. This deficiency was identified during a survey, and the DON, Regional DON, and Administrator were made aware of the concerns at the time of the survey exit. The failure to document medication administration promptly is a violation of the facility's policy and professional standards of quality care.
Medication Administration and Documentation Deficiencies
Penalty
Summary
The facility failed to ensure that a resident received a scheduled dose of medication as ordered by the physician. During a review of a medication cart, it was found that a resident's Tramadol 50 mg blister pack had a discrepancy in the count, with 7 pills observed instead of the expected 6. The controlled drug receipt record indicated that 1 tablet was given at 0900, but the medication administration audit report showed the medication was documented as administered at 08:39 AM. The nurse admitted to thinking she had given the medication but failed to sign the controlled drug receipt record properly. Another resident's Pregabalin 100 mg capsule was also found to have a discrepancy, with the controlled drug receipt record indicating 1 tablet was given, but the blister pack still contained 29 pills instead of 30. The nurse acknowledged the error and stated that she failed to sign the controlled drug receipt record after administering the medication. The Director of Nursing confirmed that a medication error form was completed for the omission of the scheduled dose and that staff would be re-educated on the proper procedures for medication administration and documentation. The facility also failed to administer scheduled medications to residents at the physician-ordered times. During a medication administration observation, it was noted that a resident's Omeprazole 20 mg capsule, scheduled for 8:00 AM, was administered at 10:38 AM. Another resident's Seroquel 50 mg tablet, also scheduled for 8:00 AM, was administered at 10:43 AM. Additionally, a third resident's Seroquel 50 mg and Celexa 10 mg tablets, scheduled for 8:00 AM, were administered at 10:48 AM. The nurse was observed crushing the medications together and mixing them with pudding to ensure the resident would not spit them out. These discrepancies in medication administration times were confirmed through a review of the residents' medical records. The Director of Nursing, Regional Director of Nursing, and Administrator were made aware of these concerns during the survey exit. The facility's failure to administer medications as ordered and to properly document controlled drug administration led to these deficiencies being identified during the survey.
Physician's Delay in Evaluating Resident's Change in Condition
Penalty
Summary
The physician failed to evaluate a resident with a change in condition in a timely manner. During observation rounds, a resident complained of a sore throat and stated they had informed the nurse. The following day, the resident reiterated the complaint and requested to see the doctor. The Nurse Practitioner (NP) was informed of the complaint but did not see the resident until the next day. The Unit Manager claimed the resident did not inform the nurse of the sore throat initially. The NP admitted she intended to see the resident but became busy and did not follow through. The medical record confirmed the resident was seen by the NP the day after the initial complaint, and medication orders were written at that time.
Medication Administration Errors
Penalty
Summary
The facility staff failed to ensure a medication error rate of less than 5% during a medication administration observation, resulting in an error rate of 18.52%. This was evident in several instances, including an LPN administering Omeprazole and Fluticasone-Salmeterol to a resident without instructing them to rinse their mouth afterward, and administering the medications late. Another resident received Seroquel late, and a third resident was given Seroquel and Celexa crushed together, despite Seroquel being on the Do Not Crush List. Additionally, an LPN was observed picking up a dropped Potassium Chloride tablet with an ungloved hand and placing it into a medication cup, contrary to facility policy. The medical records reviewed confirmed that the medications were administered at incorrect times and inappropriately crushed. The facility's policy on medication administration was not followed, as evidenced by the actions of the LPNs. The Director of Nursing acknowledged the issues and indicated that previous in-service training had been conducted to address timely medication administration. However, the observed practices during the survey indicated non-compliance with the established guidelines.
Infection Control Lapses During Medication Administration
Penalty
Summary
The facility staff failed to adhere to infection control practices during medication administration, as observed by surveyors. In the first instance, an LPN was observed dispensing medications for a resident by crushing two tablets together and mixing them with pudding without cleaning the tablet crusher after use. This action was contrary to the facility's policy, which requires the tablet crusher to be cleaned after each use. The LPN stated that the medications were mixed with pudding to prevent the resident from spitting them out, but the failure to clean the tablet crusher posed a risk of cross-contamination and infection transmission. In a second instance, another LPN was observed preparing medications for a different resident and dropped a Potassium Chloride tablet onto the top of the medication cart. The LPN then picked up the tablet with an ungloved hand and placed it into the medication cup, which violated the facility's policy that prohibits touching medications with fingers. The Director of Nursing (DON) confirmed that touching medications with fingers or hands, even if sanitized, is not allowed. These observations indicate a lack of adherence to infection control practices as outlined in the facility's medication administration guidelines.
Failure to Administer Pneumococcal Vaccine
Penalty
Summary
The facility staff failed to offer and administer the pneumococcal vaccine to a resident, as evidenced by the review of Resident #40's medical records. The resident, who had a history of Diabetes Mellitus, alcohol abuse, and Viral Chronic Hepatitis C, did not receive another pneumococcal vaccine after receiving the Pneumococcal Conjugate 13 vaccine in 2012. The facility's policy indicated that the pneumonia vaccine should be offered to all residents, with a consent or declination form completed and maintained in the medical record. However, Resident #40 did not have a consent or declination form in either the paper medical record or the electronic medical record (EMR). The Assistant Director of Nursing/Infection Preventionist confirmed that the resident was not offered the vaccine because they were not 65 or older, despite CDC guidelines indicating that the resident's medical history made them a candidate for the vaccine. During the survey, it was revealed that the facility's immunization report and the resident's EMR did not align with the facility's policy for resident immunizations. The Assistant Director of Nursing/Infection Preventionist stated that immunizations are reviewed upon admission and that a report is kept to track who needs a vaccine. However, the resident was not offered the vaccine, and no declination form was completed. This discrepancy highlights a failure in the facility's adherence to its own immunization policy and CDC guidelines, resulting in the resident not receiving the necessary pneumococcal vaccine.
Latest citations in Maryland
The facility did not ensure that its Infection Preventionist (IP) met required qualifications for managing the Infection Prevention and Control Program. The DON reported serving as the IP but acknowledged lacking the specialized infection control training required for the role, and confirmed that no other staff member was currently qualified. Records showed that the previously qualified IP left several months earlier, and the Administrator and DON confirmed they were still seeking a replacement, leaving the infection control program without a properly trained leader.
Staff failed to consistently secure medications and medical supplies across three units, including an oxygen tank left on the floor behind a resident’s bed without a supporting device, a treatment cart with Collagenase Santyl cream left on top while two residents in power wheelchairs passed by, an unattended and unlocked treatment cart at a nursing station, and another treatment cart with Diclofenac gel and dressings left on top, indicating repeated lapses in maintaining locked and secure storage for drugs, biologicals, and related supplies.
The facility failed to provide sufficient dietitian coverage and timely nutritional assessments for several residents with significant dietary needs. A resident admitted for diabetic management with a high A1C was placed on a regular diet instead of the recommended carb-controlled diet and had only one weight taken in the first two weeks, with no dietitian review of the record. Another resident with prior significant weight loss had no documented dietitian follow-up despite continued weight loss, and a resident admitted with severe protein-calorie malnutrition experienced further significant weight loss without any dietitian assessment. The dietitian reported working limited hours and prioritizing certain high-risk cases, resulting in delayed or missed evaluations for new admissions and residents with ongoing nutritional concerns.
The facility failed to maintain adequate linen and incontinence supplies and did not keep resident care areas in good repair, resulting in delays and alterations in incontinence care and substandard environmental conditions. Staff reported that towels and washcloths were used instead of wipes and then discarded due to heavy soiling, and that linen deliveries to units were late, leaving residents waiting for care. Observations showed very limited numbers of clean washcloths and other linens on units and in the laundry, with no stock of disposable wipes or backup washcloth supply despite repeated reports to housekeeping. Additional observations revealed recliner chairs blocking a dining-area handwashing sink and kitchenette, multiple resident and shared bathrooms with unfinished spackle, chipped paint, musty odors, black substances near showers, missing threshold molding, exposed cracks and nails, and eroded, rusted baseboard heaters. Hallway handrails on both units were worn, chipped, and splintered, and a shower room contained fecal odors, dried brown stains on the toilet, and deteriorated fixtures, all contributing to a failure to provide a safe, clean, and homelike environment.
Facility staff did not thoroughly investigate two separate abuse allegations involving a resident and an injury of unknown origin involving another resident. In both cases, investigations focused on the directly affected resident and included staff interviews, but there were no interviews of other residents on the unit or documented assessments of those residents for signs of abuse or injuries of unknown origin, including residents unable to communicate due to cognitive status.
Two residents who were dependent on staff for oral care, including one with a tracheostomy, were observed with thick, white or milky substances coating their mouths and teeth, indicating inadequate oral hygiene. One resident communicated that staff did not brush their teeth and that staff "need to." In another case, despite oral care supplies being present in the room, the resident’s mouth and teeth remained unclean on multiple observations, with a thick milky substance caking the teeth and stringing between them when the resident tried to open their mouth. These findings showed that staff did not consistently provide oral care to residents who relied on them for this ADL.
Staff failed to maintain complete and accurate medical records for multiple residents, including missing and inconsistent documentation of wound care, delayed pain assessment after discovery of an injury of unknown origin in a cognitively impaired resident, and inaccurate recording of a PPD test result that was documented as negative despite no evidence the injection was administered and no supporting nurse’s note. Residents reported not receiving certain treatments, while MAR entries either lacked signatures for completion or contained conflicting information about whether care was provided.
Surveyors found that the facility failed to consistently implement and communicate correct transmission-based precautions and PPE use. One resident with a Foley catheter related to wounds had no precaution signage posted, while another resident in a double room had a contact precautions sign at the door, yet the NP entered without PPE and the GNA provided high-contact care wearing only gloves. Staff in that room stated the resident was not on contact precautions and later reversed the sign to show no PPE requirement. Therapy staff reported they rely solely on posted signs to determine PPE, and surveyors identified broader issues with inaccurate signage and staff awareness of which residents required contact precautions.
Surveyors found that MDS assessments were inaccurately coded for two residents. In one case, a resident sustained a femoral neck fracture after a fall, but the subsequent significant change MDS did not code the fall as a major injury and failed to capture prn Tylenol use documented on the MAR within the look-back period. In the other case, a quarterly MDS indicated opioid use for a resident, but the MAR for the same period showed no prescribed opioid, indicating incorrect coding of high-risk drug classes.
A resident who had recently been admitted and experienced a fall received multiple doses of the narcotic analgesic Tramadol, but the facility failed to accurately document all administered doses on the Medication Administration Record (MAR). Review showed only one Tramadol dose recorded on the MAR, while the Controlled Drug Receipt/Record/Disposition Form on the med cart reflected three doses given over two days. In interview, the DON stated staff are expected to document narcotic administration on the MAR and confirmed that two administered doses were not recorded there, resulting in an incomplete and inaccurate medical record.
Unqualified Infection Preventionist Overseeing Infection Control Program
Penalty
Summary
The facility failed to ensure that its designated Infection Preventionist (IP) met the mandatory qualifications for overseeing the Infection Prevention and Control Program. During an interview on 3/24/26 at 10:00 AM, the DON confirmed that she/he was serving as the facility’s IP but had not completed the specialized training in infection control required for the position. The DON further stated that no other staff member currently met the qualifications to serve as IP. Record review showed that the previously qualified IP left the facility in October 2025, and as of the survey date, the position remained unfilled by a qualified individual. At 1:30 PM on the same day, the Administrator and DON confirmed they were still in the process of finding a qualified IP for the facility, leaving the Infection Prevention and Control Program without a properly trained and qualified leader. No specific residents, medical histories, or clinical conditions were described in relation to this deficiency.
Unsecured Medications, Treatment Carts, and Oxygen Equipment
Penalty
Summary
Facility staff failed to ensure that drugs, biologicals, and related medical supplies were securely stored and properly maintained on multiple units. On one unit, an oxygen tank assigned to a resident was observed sitting on the floor behind the resident’s bed without any supporting device. On another unit, a treatment cart was observed with a tube of Collagenase Santyl cream labeled for a specific resident left on top of the cart, while residents in power wheelchairs passed by and staff were present at the nursing station. These observations showed that medications and oxygen equipment were not consistently secured as required. Further observations on additional units revealed an unattended and unlocked treatment cart at a nursing station, and on a separate occasion, a treatment cart with Diclofenac gel labeled for a resident left on top along with multiple packs of dressings. These incidents occurred across three units and on more than one date, demonstrating repeated failures to keep medications and treatment supplies in locked compartments or otherwise secured from unauthorized access.
Insufficient Dietitian Coverage and Delayed Nutritional Assessments
Penalty
Summary
The deficiency involves the facility’s failure to employ sufficient food and nutrition staff, including adequate dietitian coverage, to ensure timely assessment and appropriate diets for residents with significant nutritional and diabetic needs. A resident admitted over two weeks earlier with multiple comorbidities and an A1C of 11.5% had a hospital discharge recommendation for a carbohydrate-controlled diet, but was placed on a regular diet at admission with no acknowledgment of the recommended diet until one week later, when the resident requested larger portions. As of the survey date, the dietitian had not yet seen or reviewed this resident’s medical record, and the resident reported not having seen a dietitian and being very frustrated with the meals. During the first two weeks after admission, only one weight was obtained for this resident, despite physician notes stating the resident’s weight was “stable.” Further review of other residents showed additional failures in timely dietitian assessment and follow-up. One resident, readmitted in January and previously seen by the dietitian in September for a 6.4 lb weight loss over 30 days, had no documented follow-up despite continued weight loss totaling 22 lbs since the last dietitian review. Another resident admitted at the end of February with severe protein-calorie malnutrition had not been seen by the dietitian after about a month in the facility, despite a documented 14 lb (7%) weight loss over two weeks. The dietitian reported working only 12 hours per week at the facility and stated that she must prioritize which residents to see, focusing first on residents with tube feedings and those identified in risk meetings, resulting in delayed or absent assessments for new admissions and residents with ongoing weight loss and malnutrition diagnoses.
Linen Shortages and Poor Environmental Maintenance Compromise Resident Care and Comfort
Penalty
Summary
The deficiency involves the facility’s failure to maintain an adequate supply of clean linens and appropriate incontinence wipes, resulting in delays and alterations in residents’ incontinence care, as well as the use of towels and washcloths in place of disposable wipes. During the initial tour, the surveyor observed that the linen supply on one nursing unit hallway was low. Complaint reviews included concerns about delays in incontinence care and bed linens not being changed regularly, with residents left without clean bedding. A complainant reported that there was not enough clean linen available for residents. Staff interviews confirmed that towels, sheets, and washcloths were being used to wipe residents for incontinence care due to the absence of wipes, and that many of these linens were being thrown away when soiled. Staff also reported a shortage of linen, that linen deliveries to the units were late, and that residents who preferred to get up before breakfast had to wait for care when linen was delayed. Further observations showed that the clean supply room contained no disposable wipes or cloths for incontinence care, and a resident reported that staff did not use wipes, that the resident had to purchase their own, and that heavily soiled towels or washcloths were discarded. A tour of all nursing unit linen carts and closets revealed only six clean washcloths and limited supplies of towels, gowns, and bed linens. In the laundry room, only three washcloths were present, and the laundry assistant stated that there were only three washcloths available for each nursing unit that morning, that the facility was short on linen supply, and that these concerns had been repeatedly reported to the Director of Housekeeping over the preceding month and again that morning. The laundry assistant confirmed there was no additional laundry in process. The DON stated that wipe squares should be used for incontinence care, but no such wipes were found in the clean medical supply room, and no backup supply of washcloths was present in the emergency linen supply. The Director of Housekeeping confirmed there was no backup supply of washcloths. The deficiency also includes environmental and maintenance issues affecting resident bathrooms, handrails, and common areas. In the main dining area, a recliner chair was observed positioned directly in front of the handwashing sink, and two recliner chairs were stored in front of the nutrition area kitchenette. Multiple resident bathrooms and shared bathrooms were repeatedly observed over several days with unfinished spackle on walls that needed resurfacing and painting, chipped paint around sinks, uneven boards nailed to walls under sinks that appeared to partially cover holes, musty odors, black substances between shower bases and walls, missing threshold transition molding exposing cracks, missing tiles, and a nail, as well as eroded and chipped paint on baseboard heaters with exposed dark brown metal and rust-like material. Hallway handrails on both nursing units were observed to be worn, with chips, splintering, holes, and areas where the wood finish had worn off. A shower room was observed with a foul fecal odor, dried brown stains on the back of the toilet seat and in the toilet bowl, and a baseboard heater with eroded, chipped paint and rust-like material, along with chipped paint on the handrail. These conditions were acknowledged by the Director of Maintenance and other leadership, and some areas were noted to be in the process of renovation, but the observed deficiencies remained present during the survey period. Overall, the facility did not maintain a safe, clean, comfortable, and homelike environment in good repair across both nursing units and the dining area. The lack of adequate linen and incontinence supplies, combined with the poor condition of resident bathrooms, handrails, and certain common areas, constituted the basis for the cited deficiency. The observations and staff and resident reports consistently described shortages of essential hygiene supplies, delayed care related to linen availability, and multiple unresolved environmental and maintenance issues in resident care areas and shared spaces.
Failure to Thoroughly Investigate Abuse Allegations and Injuries of Unknown Origin
Penalty
Summary
Facility staff failed to thoroughly investigate allegations of potential abuse involving one resident and an injury of unknown origin involving another resident. For one resident, there were two separate allegations of abuse occurring on different days in early February. The facility’s investigation packets included interviews with staff who cared for or were scheduled to work with this resident on the days of the alleged incidents, and the investigations focused solely on this resident. However, there were no interviews conducted with other residents on the unit to inquire about abusive or neglectful treatment by the staff who were working during the times of the allegations. The surveyors noted that, although the allegations were not validated, there was no documentation that other residents were interviewed, if able, or assessed for signs or symptoms of injury. In a separate incident, another resident was identified on March 4 with a new bruise on the right eye, documented as a change in condition at 4:09 AM. This resident had a BIMS score of 99, indicating the resident was unable to complete an interview and therefore could not report how the injury occurred. The facility’s investigation identified a potential cause of the injury but did not reach a definitive resolution. Additionally, there were no interviews of other residents on the unit regarding possible abuse, nor were there documented assessments of other residents for injuries of unknown origin, particularly for those unable to speak for themselves, as in this resident’s case.
Failure to Provide Oral Care to Dependent Residents
Penalty
Summary
The deficiency involves the facility’s failure to provide oral care to residents who were dependent on staff for activities of daily living, specifically oral hygiene. One resident with a tracheostomy was observed with a thick, sticky white substance in the mouth and was noted to intermittently chew on nearby bedding. This resident made good eye contact and, when asked if staff brushed their teeth, shook their head no and mouthed that staff “need to.” According to the resident’s Minimum Data Set (MDS) dated 2/11/26, the resident was dependent on staff for oral care. Another resident, also dependent on staff for oral care per the 3/11/26 MDS, was observed sitting propped up in bed and able to respond with smiles. During the initial observation, the inside of this resident’s lips and upper and lower teeth had a thick, clear, white milky substance visible when the resident tried to open their mouth to smile. Oral care supplies were present in the nightstand, but the resident’s mouth and teeth were not clean. On a subsequent observation with the DON, NHA, and Corporate VP of clinical services, the same resident again had a thick, clear, milky substance between the lips and caking the teeth, which would string between the teeth when the resident attempted to open their mouth, demonstrating a lack of consistent oral care for residents dependent on staff for this ADL.
Incomplete and Inaccurate Medical Record Documentation for Treatments and Assessments
Penalty
Summary
Facility staff failed to maintain complete and accurate medical records and documentation for multiple residents. For one resident with wound care needs, review of the MAR showed that wound care and related treatments were signed as completed on the dates initially reported, despite the resident’s ongoing complaints that wound dressings were not being changed. When additional dates were reviewed, there were missing staff signatures for wound care on two specific dates, as well as three instances where application of A&D ointment to the resident’s feet was not signed off out of 24 days reviewed. Another resident with severe cognitive impairment, as evidenced by a BIMS score of 00, was found to have an injury of unknown origin (a bruise on the left hand). Documentation showed that a change in condition was initiated late in the morning, but a formal pain evaluation was not initiated and completed until that night, and the resident was unable to explain how the injury occurred or verbalize pain using a standard pain scale. For a third resident, documentation related to the admission PPD test was inconsistent and incomplete. The MAR contained an entry indicating “9” for the administration date, meaning “see nurse’s note,” but there was no corresponding nurse’s note. Despite the absence of a signed administration of the PPD injection, staff documented the PPD result as “negative” on the scheduled read date. The resident reported never receiving the PPD injection, and the DON confirmed that the facility had been out of PPD solution at the time, so the test would not have been administered. These findings demonstrate failures in accurate documentation of treatments and assessments, including wound care, pain assessment, and TB screening, as well as missing or incomplete supporting notes in the medical record.
Failure to Implement and Communicate Correct Transmission-Based Precautions
Penalty
Summary
Surveyors identified a deficiency in the facility’s infection prevention and control program related to inconsistent and incorrect implementation of transmission-based precautions and PPE use. During a complaint investigation focused on residents on transmission-based precautions, one resident with a visible Foley catheter was observed in the room with physical therapy, but there were no signs posted indicating any need for PPE, despite the resident being a new admission with a Foley catheter placed related to wounds. In another double-occupancy room, a contact precautions sign was posted at the doorway, but the nurse practitioner was in the room on a personal phone with no PPE, and the assigned GNA was repositioning the resident in bed while wearing only gloves. When questioned, the NP, RN, and GNA all stated that the resident in the room was not on contact precautions, and the GNA reported that signs were hanging at all doors and that this particular resident’s sign was “just wrong.” The surveyor observed the GNA later return to the room and turn the sign around to indicate no PPE requirement. Subsequent interviews revealed that therapy staff relied on posted signage to determine PPE use and that if the sign was wrong, the PPE used would be wrong. Overall, surveyors found problems with signage accuracy and staff awareness of which residents required contact precautions, as well as observed failures to follow appropriate PPE use for residents who should have been on contact precautions.
Inaccurate MDS Coding for Falls, Pain Management, and High-Risk Medications
Penalty
Summary
Facility staff failed to ensure Minimum Data Set (MDS) assessments were accurately coded for two residents reviewed during a complaint survey. For one resident, a facility-reported incident showed that the resident was found seated on the floor beside the bed and was diagnosed with a non-displaced femoral neck impaction fracture of the left hip following an x-ray. Despite this fall with a major injury, the subsequent significant change MDS dated 11/4/25 did not code the fall with major injury in Section J1900C. Review of the resident’s Medication Administration Records for October and November 2025 showed administration of Tylenol on 10/31/25 at 9:30 PM, which fell within the 5-day look-back period for the MDS, but Section J0100 (prn pain) of the same significant change MDS did not capture the use of Tylenol. For another resident, review of a quarterly MDS with an assessment reference date of 10/15/25 showed that Section N0415 (High-Risk Drug Classes) documented the use of an opioid medication. However, review of the resident’s October 2025 Medication Administration Record did not show that the resident had been prescribed an opioid during that period. In both cases, MDS staff later confirmed that these were errors in MDS coding, demonstrating that the assessments did not accurately reflect the residents’ clinical status and medication use as documented in their medical records.
Incomplete Documentation of Narcotic Administration on MAR
Penalty
Summary
The facility failed to maintain complete and accurate medical records in accordance with accepted professional standards for one resident receiving narcotic medication. The resident, admitted in March 2026, had a fall on 3/6/26 and was sent to the hospital on 3/9/26. Review of the March 2026 Medication Administration Record (MAR) showed documentation of a single 25 mg dose of Tramadol administered on 3/8/26 at 9:23 AM. However, review of the resident’s Controlled Drug Receipt/Record/Disposition Form, kept on the nurse’s medication cart and not in the medical record, showed that Tramadol 25 mg was administered three times between 3/8/26 and 3/9/26: at 11:00 AM and 9:00 PM on 3/8/26, and at 9:00 AM on 3/9/26. In interview, the DON stated that staff are expected to document narcotic administration on the MAR and confirmed that only one of the three Tramadol doses reflected on the controlled drug record was documented on the resident’s MAR. This discrepancy between the controlled substance record and the MAR, with missing documentation of two administered doses of Tramadol on the official medical record, constituted the failure to maintain a complete and accurate medical record for the resident.
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