Restore Health Rehabilitation Center
Inspection history, citations, penalties and survey trends for this long-term care facility in White Plains, Maryland.
- Location
- 4615 Einstein Place, White Plains, Maryland 20695
- CMS Provider Number
- 215362
- Inspections on file
- 16
- Latest survey
- July 22, 2025
- Citations (last 12 mo.)
- 34
Citation history
Health deficiencies cited at Restore Health Rehabilitation Center during CMS and state inspections, most recent first.
Surveyors found that the facility did not develop or implement complete care plans for multiple residents, including those with recent falls, those receiving new or ongoing medications such as diuretics, antipsychotics, insulin, and anticoagulants, and those requiring oxygen therapy. These omissions were confirmed through staff interviews and record reviews, showing that residents' current medical needs were not reflected in their care plans.
A resident alleged rough treatment by staff during ADL care, which was documented in nursing notes and reported internally. However, the facility could not provide evidence that this abuse allegation was reported to the Office of Health Care Quality as required, and no investigative record was available when requested by surveyors.
A facility did not conduct or retain an investigation file for an alleged abuse incident involving a resident and a family member, despite self-reporting the incident and having documentation in the medical record. Only the initial and final self-reports were found, with no investigation file available for surveyor review.
The facility failed to provide written notice to the State LTC Ombudsman for a resident's discharge to home and did not ensure a physician completed a discharge summary for another resident who died in the facility. Staff interviews and record reviews confirmed the absence of required notifications and documentation.
A resident with a known history of pressure ulcers was admitted with instructions to continue wound care, but initial nursing assessments failed to identify or document existing wounds, and no wound care was initiated until several days later when physician orders were obtained. Multiple pressure ulcers and DTIs were subsequently identified, indicating a delay in assessment and treatment.
A registered nurse administered a subcutaneous Heparin injection to a resident with Dementia and Diabetes Mellitus without closing the door or pulling the privacy curtain, resulting in a lack of privacy during the procedure. The nurse acknowledged the omission, and the DON confirmed that staff are required to provide privacy during such care.
Surveyors identified that two residents did not have timely updates to their care plans following significant changes in condition, including a fall and the initiation of a Foley catheter. The care plans were not revised to reflect these events or to add appropriate interventions, and updates were only made after surveyor involvement.
The facility did not ensure that nurse staffing information was posted with the correct and current date, as required. The posted information was observed to be outdated, and staff confirmed that the daily update process had not been followed correctly until the issue was identified and brought to their attention.
Surveyors found that food items stored in a dining area refrigerator were not consistently labeled with resident names or dates, and some items were expired. The Director of Dining Services confirmed that all food should be labeled and discarded after three days, in line with facility policy.
Surveyors identified that two residents had incomplete and inaccurate medical records, including conflicting mattress orders documented as completed despite only one being in use, and a physician order that did not appear on the TAR. Additionally, a nursing note indicated pain medication was given to another resident, but there was no documentation in the MAR or controlled drug records to confirm administration. Staff interviews confirmed these documentation lapses.
A registered nurse failed to perform hand hygiene before dispensing medications and after shaking hands with a visitor while administering medications to a resident with hypertension and myocardial infarction. The nurse only sanitized her hands after being prompted by a surveyor, despite facility policy requiring hand hygiene at these times.
Surveyors observed that a dining area cabinet beneath a non-operating ice and water dispenser was missing a handle, had a broken and crumbled pressed wood floor, brownish stains on the interior, and a broken pipe. The Director of Maintenance was unaware of the damage, and the Administrator confirmed the cabinet had been in this state for an extended period, with repairs pending due to cost.
Failure to Develop and Implement Comprehensive Care Plans
Penalty
Summary
Surveyors identified that the facility failed to develop and implement comprehensive care plans for several residents, as required. In one instance, a resident who experienced a fall in the bathroom did not have a care plan addressing the actual fall event, despite documentation of the incident and the resident's ongoing knee pain. The care plan only addressed the risk for falls, not the specific event or its aftermath, until after surveyor intervention. Another resident admitted for short-term rehabilitation was receiving both a diuretic (Lasix) and an antipsychotic (Seroquel), but the care plan did not reflect the administration or monitoring of these medications. The resident had been receiving Seroquel at home and Lasix was newly ordered at the facility, yet no care plan was developed or implemented to address the use of these medications or their potential effects. Additional deficiencies were found for residents requiring oxygen therapy and anticoagulant medications, as well as for a resident with insulin-dependent diabetes and anticoagulant use. In both cases, the care plans did not include these significant medical needs, despite clear documentation in the medical records and medication administration records. Staff interviews confirmed that these omissions were not in line with facility policy and that the care plans were not updated to reflect the residents' current conditions and treatments.
Failure to Report Alleged Abuse to State Authorities
Penalty
Summary
The facility failed to report an allegation of suspected resident abuse to the Office of Health Care Quality (OHCQ) as required. On 11/10/2022, a resident alleged that staff members washed them in a rough manner while providing assistance with activities of daily living. Nursing progress notes documented the resident's refusal to be changed by two aides, stating they did not want to be abused, and that the incident was reported to the writer and the Assistant Director of Nursing (ADON). Further documentation described the resident as combative during care, with staff intervention including a shower, transfer with a Hoyer lift, and subsequent aggressive behavior by the resident. The police were called, and the resident refused to speak with the officer. The responsible party was notified, and a psychiatric consult was requested. Upon surveyor request, the facility was unable to provide an investigative record related to the incident, and the Administrator could not confirm that the allegation of abuse was reported to OHCQ. The Administrator acknowledged the expectation to report all abuse allegations in a timely manner but was unable to provide evidence that the required notification occurred. No additional documentation was provided to show that the OHCQ was notified of the resident's allegation.
Failure to Investigate Alleged Abuse by Family Member
Penalty
Summary
The facility failed to investigate an alleged violation of abuse involving a resident and the resident's family member. The Office of Healthcare Quality received a self-reported incident from the facility's Assistant Director of Nursing regarding an allegation that a resident's son yelled at the resident and possibly grabbed the resident's face during a visit. Progress notes in the resident's medical record documented the incident and the resident's responses to questions about feeling safe and whether the son had grabbed their face. Despite the self-report and documentation in the medical record, the facility was unable to produce an investigation file related to the alleged abuse when requested by the surveyor. The facility's policy requires the collection, retention, and safeguarding of all information and evidentiary material pertinent to investigations of alleged abuse or neglect. However, only the initial and final self-reports were located in the administrator's email, and no investigation file was provided to the surveyor.
Failure to Notify Ombudsman and Complete Physician Discharge Summary
Penalty
Summary
Facility staff failed to provide written notice to the Office of the State Long Term Care Ombudsman regarding the discharge of a resident who was admitted and later discharged home. Review of the clinical record and facility documentation revealed no evidence that the ombudsman was notified of this discharge, and staff interviews confirmed that while notifications were sent for hospital transfers, there was no confirmation or documentation for discharges to home. The facility was unable to provide any evidence of notification to the ombudsman for this resident's discharge at the time of the survey. Additionally, the facility did not ensure that a discharge summary was completed by a physician for another resident who was found unresponsive and later pronounced deceased. The medical record contained a nursing progress note and documentation of the release of remains, but lacked a physician's progress note or discharge summary. Interviews with the DON and Medical Records Coordinator confirmed that a physician note was expected but not present, and the responsible physician was no longer employed at the time of the survey.
Failure to Initiate Timely Wound Care for Pressure Ulcers Upon Admission
Penalty
Summary
The facility failed to initiate wound care upon admission for a resident with multiple pressure ulcers. Upon admission, the resident had a documented history of a right thigh decubitus ulcer, with hospital discharge instructions to continue wound care. Initial assessments by nursing staff noted bruises and dry skin, but did not identify or document any open wounds or pressure ulcers. No wound care orders or treatments were initiated at this time, and there was no documentation of wound care being provided prior to new physician orders being placed several days after admission. Subsequent assessments revealed multiple pressure ulcers and deep tissue injuries (DTIs) on the resident, including wounds on the right and left feet, right upper thigh, sacrum, and ischium. Wound care orders were eventually obtained and documented, but not until several days after admission, resulting in a delay in treatment. Interviews with facility leadership confirmed that wound care should have been started earlier and that any wounds identified upon admission should have been documented, assessed, and treated promptly.
Failure to Provide Privacy During Injection Administration
Penalty
Summary
Facility staff failed to provide privacy to a resident during the administration of a subcutaneous injection. A review of the clinical record showed the resident had diagnoses of Dementia and Diabetes Mellitus. During a medication pass, a registered nurse entered the resident's room to administer a Heparin injection but did not close the door or pull the privacy curtain. The nurse informed the resident about the injection, lifted the resident's gown, and administered the medication without ensuring privacy. The nurse later acknowledged not providing privacy during the procedure. The Director of Nursing confirmed that facility policy requires staff to provide privacy during injection administration, either by closing the door in a private room or drawing the curtain in a semi-private room. These actions resulted in a failure to honor the resident's right to privacy and dignity during a medical procedure, as observed and confirmed by both staff and facility leadership.
Failure to Timely Update and Revise Resident Care Plans
Penalty
Summary
The facility failed to ensure that residents' care plans were revised and updated in a timely manner, as required. For one resident who experienced a fall while attempting to transfer from the toilet to a wheelchair, the care plan did not reflect the actual fall or include any new interventions following the incident. Although the resident had a care plan indicating risk for falls, no updates or additional interventions were added after the fall occurred, and the care plan was only updated after surveyor intervention. Another resident had a physician order for an indwelling Foley catheter due to urinary retention, but there was no corresponding care plan addressing the catheter. The lack of a care plan for the Foley catheter was confirmed during record review and acknowledged by the RN MDS Coordinator. Both deficiencies were substantiated through observation, interviews, and record review, and were acknowledged by facility leadership.
Failure to Post Accurate and Current Nurse Staffing Information
Penalty
Summary
The facility failed to ensure that the posted nurse staffing information was accurate and current, as required. During an observation in the facility lobby, the surveyor noted that the nurse staffing information displayed at the receptionist desk was dated for the previous day, rather than the current date. This information is required to be posted daily at the beginning of each shift in a prominent and accessible location, and must be up-to-date and accurate. Interviews with staff revealed that the Administrator-In-Training was responsible for posting the daily nurse staffing information. When the surveyor pointed out the incorrect date to a staff member, the staff member obtained an updated form and replaced the outdated posting. The Director of Nursing was also informed of the issue and acknowledged that the incorrect date had been posted before it was corrected.
Failure to Properly Label and Store Resident Food Items
Penalty
Summary
Surveyors observed that the facility failed to store food in accordance with professional standards and its own policies. During an inspection of a refrigerator in one of the dining areas, multiple food containers were found that were either expired or lacked required labeling, such as the resident's name and the date the item was placed in the refrigerator. Specific items included a container for a resident dated five days prior, a plate of salad with no date, several containers and bags with missing names or dates, and some with only a room number. The Director of Dining Services confirmed that all items should be labeled with the resident's name and the date, and that items should be discarded after three days, as per facility policy. Review of the facility's nutrition policy also confirmed these requirements.
Incomplete and Inaccurate Medical Record Documentation
Penalty
Summary
The facility failed to ensure that medical records for two residents were complete and accurate, as evidenced by discrepancies in physician orders and medication documentation. For one resident, there were conflicting orders for a pressure-relieving mattress and an air mattress, with both orders documented as completed on the Treatment Administration Record (TAR) despite only one type of mattress being present. Staff interviews revealed uncertainty about which order should be followed, and it was later clarified that the air mattress order should have been discontinued after a decision by the family and physician. Additionally, a physician order for the resident to be out of bed on specific days did not transfer to the TAR, resulting in the order not being visible or actionable for nursing staff. For another resident, a nursing progress note indicated that pain medication was administered at a specific time, but there was no corresponding documentation in the Medication Administration Record (MAR) or controlled drug records to confirm that any medication was given at that time. Staff interviews confirmed that medications should be documented in the MAR immediately after administration, and there was no evidence to support that the medication was provided as noted in the progress note. These findings demonstrate lapses in maintaining accurate and complete medical records in accordance with professional standards.
Failure to Perform Hand Hygiene During Medication Administration
Penalty
Summary
Facility staff failed to perform appropriate hand hygiene during medication administration for a resident admitted with diagnoses including hypertension and myocardial infarction. During a medication pass, a registered nurse took the resident's blood pressure, recorded it, and proceeded to dispense medication without performing hand hygiene. The nurse only sanitized her hands after the surveyor intervened and pointed out the omission. Later in the same medication pass, the nurse shook hands with a visitor and then continued to dispense medications without performing hand hygiene until prompted by the surveyor. In interviews, the nurse acknowledged the failure to perform hand hygiene at the required times, and the Director of Nursing confirmed that facility policy requires hand hygiene before and after resident care, after leaving a resident's room, before handling the medication cart, and after contact with visitors.
Failure to Maintain Sanitary and Functional Dining Area Environment
Penalty
Summary
The facility failed to maintain a functional and sanitary environment in one of its dining areas, specifically the Sycamore Café. During observations, a non-operating ice and water dispenser was found on the counter, and the cabinet below it was missing a handle on the right door. The floor inside the cabinet was broken and crumbled in the center, with brownish stains running down the interior walls and broken flooring. A broken pipe was also present inside the cabinet. The Director of Maintenance, who had been employed for about four and a half months, was unaware of the damaged cabinet and identified the crumbled flooring as pressed wood. The Administrator acknowledged that the cabinet had been in this condition for some time and stated that repairs were planned but described them as a significant expenditure.
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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