Shady Grove Nursing And Rehabilitation Center
Inspection history, citations, penalties and survey trends for this long-term care facility in Rockville, Maryland.
- Location
- 9701 Medical Center Drive, Rockville, Maryland 20850
- CMS Provider Number
- 215164
- Inspections on file
- 21
- Latest survey
- December 19, 2025
- Citations (last 12 mo.)
- 3
Citation history
Health deficiencies cited at Shady Grove Nursing And Rehabilitation Center during CMS and state inspections, most recent first.
A resident with a suprapubic catheter was observed on multiple occasions without the catheter tubing secured to the leg, leading to frequent disconnection and urine leakage that saturated bed linens. Despite available supplies, staff did not provide a securement device, and the resident reported ongoing discomfort and inconvenience.
Staff did not adhere to infection prevention protocols during perineal care for two residents with complex medical needs, including improper hand hygiene, failure to change gloves between tasks, use of double gloves, and inappropriate handling of catheter equipment and soiled materials. These actions were inconsistent with facility policy and were confirmed by both observation and staff interviews.
A resident with severe cognitive and physical impairments, fully dependent on staff, sustained a comminuted femur fracture after being transferred by a CNA using a mechanical lift without a second staff member, contrary to facility policy and manufacturer guidelines. The CNA acted alone due to a busy shift and space constraints, and there was confusion among staff regarding sling selection and compatibility. The injury was discovered after the resident showed signs of pain and swelling, highlighting failures in staff training, supervision, and adherence to transfer protocols.
A resident was found with multiple medications at bedside, including prescription and over-the-counter drugs, without documented assessment or authorization for self-administration as required by facility policy. The resident, who was cognitively intact and independent, expressed a desire to self-administer but had not been evaluated for this ability. Staff were unaware of the medications at bedside, and the care plan and physician orders did not address self-administration or bedside storage.
The facility did not assess nonverbal or cognitively impaired residents during an abuse investigation, despite policy requiring a thorough investigation of all potential victims. The DON confirmed that these residents were not evaluated, resulting in an incomplete investigation.
The facility exceeded the acceptable medication error rate when two LPNs administered insulin to a resident with diabetes without priming the Tresiba FlexTouch pen, as required by manufacturer instructions and facility policy. Staff interviews revealed a misunderstanding of proper insulin administration procedures, contributing to a 6.66% medication error rate.
Facility staff did not consistently review or update residents' care plans to reflect current interventions, particularly for those with respiratory needs, and failed to hold required annual and quarterly care plan meetings. Several residents were not given the opportunity to participate in care planning, and some were unaware of their care plans or discharge status. Staff confirmed that care plan meetings had not been completed as required, and documentation to support timely meetings was lacking.
Facility staff did not consistently report allegations of abuse, neglect, or theft to the state agency within the required two-hour timeframe. In several cases, reports were delayed or documentation of timely reporting was missing, and some final investigation results were not submitted within five working days. Interviews revealed confusion among staff regarding reporting requirements.
A resident who returned from the hospital with a leg fracture did not have a care plan developed to address the new diagnosis until several weeks after the injury. Although the physician assessed the fracture and discussed the plan with staff, the comprehensive care plan was not updated in a timely manner, as confirmed by the DON and Social Worker.
The facility did not provide required supervision or maintain accurate assessments for residents who smoke, resulting in residents using the smoking area unsupervised and without necessary safety equipment, despite documentation indicating some required supervision and/or a smoking apron. Staff interviews revealed a lack of awareness and inaccurate recordkeeping regarding residents' supervision needs.
Kitchen staff did not consistently label or date opened food items, left some foods uncovered in storage, and failed to ensure all staff wore proper hair coverings. Additionally, food was not thawed properly in the refrigerator, and exposed food items were observed during a survey.
Staff failed to follow professional standards by not completing or documenting required weights for a resident on GLP-1 medication, administering medications late to another resident, and not documenting PICC line dressing changes or correctly entering wound vac orders. Additionally, a resident with cognitive decline was not reevaluated for decision-making ability, and another was prescribed risperidone for an incorrect diagnosis, with the order later updated by a provider.
Staff failed to accurately document and update residents' personal belongings, with inventory forms not reflecting actual items present and missing grievance documentation. Medical records for several residents were incomplete or inaccurate, including missing or outdated smoking assessments, improper documentation of narcotic administration, and incorrect medication administration codes. Staff also signed off on care tasks before completion and maintained outdated orders, resulting in records that did not accurately reflect residents' current care or status.
A facility failed to establish and implement adequate written policies and procedures for investigating and reporting abuse allegations. The existing policy lacked guidance on identifying unobserved abuse, interviewing all involved parties, and specifying reporting timeframes. In one case, a resident who reported being assaulted and later diagnosed with a leg fracture was not interviewed as part of the facility's investigation, and the allegation could not be verified.
Facility staff did not complete thorough investigations into multiple alleged abuse incidents and an injury of unknown origin. In several cases, investigations lacked proper documentation, including missing or incorrect staffing sheets, absence of staff discipline identification, and failure to interview alleged victims or notify authorities. The DON was unable to provide required investigation files for some incidents, resulting in incomplete records.
Surveyors observed that several residents did not have their call bells within reach, with call bells found on the floor, hanging from the wall, or draped over the side of the bed. Staff interviews confirmed that GNAs are supposed to check call bell accessibility during rounds, but this was not consistently done, resulting in multiple residents being unable to easily request assistance.
A resident with multiple medical conditions and a need for assistance with dressing was repeatedly observed wearing a hospital gown instead of personal clothing, despite expressing a preference to wear their own clothes and having them available. Staff interviews confirmed the resident's need for help and preference, but the resident continued to be seen in a hospital gown during daily activities. The resident's foley bag was also observed on the floor without a privacy cover.
Staff did not consistently obtain or maintain copies of Advance Directives in resident medical records, nor did they always provide or document discussions and information about Advance Directives with residents or their representatives. In several cases, documentation was missing or incomplete, and staff confirmed that required records were not available.
A resident was discharged without receiving the required SNF Beneficiary Notice, which informs individuals of their Medicare/Medicaid coverage and potential financial liability for services not covered. Documentation review confirmed that the necessary notice was not provided prior to discharge, and staff acknowledged the oversight during the survey.
Staff did not ensure a homelike environment by failing to address multiple maintenance issues in resident rooms, including damaged drywall, rust, a leaking faucet, and broken furniture. These deficiencies were observed in several rooms across two units, despite the facility's system for reporting and scheduling repairs.
A resident who experienced an acute leg fracture and required pain management, orthopedic follow-up, and a knee immobilizer did not have this significant medical event accurately reflected in their quarterly MDS assessment. The MDS Coordinator did not update the assessment despite physician documentation, citing internal criteria for capturing new diagnoses. This resulted in an inaccurate assessment record.
Staff failed to complete required PASARR documentation for three residents, including missing Level II screenings when indicated and incomplete Level I forms, as confirmed by record review and staff interviews.
Two residents reported not receiving regular showers as scheduled, with one indicating they had not been offered a shower since admission. Review of electronic medical records showed no documentation of showers being provided, despite facility policy requiring showers to be offered twice weekly and refusals to be documented.
A resident with a history of recurrent UTIs did not receive a timely repeat urine culture after an initial sample was found to be contaminated and the lab recommended a repeat. The delay in obtaining a new sample led to a delay in diagnosis and treatment, as the repeat culture was not ordered until the resident's symptoms worsened.
Two residents did not receive nutrition in accordance with physician orders: one was not given double portions as prescribed, and another received regular texture fruit instead of the required mechanically altered consistency for dysphagia. Staff interviews and meal ticket reviews confirmed that dietary and kitchen staff did not ensure the correct diet orders were followed.
Facility staff failed to provide timely and appropriate pain management for two residents. One resident did not receive prescribed Oxycodone due to delayed medication reordering, resulting in unmanaged pain. Another resident with severe foot pain did not have their pain addressed because the care team was not informed and no pain management plan was documented.
A resident was observed using bilateral enabler bed rails without proper documentation of informed consent. Although the DON stated that consent is obtained before bed rails are used, the consent form did not specify from whom consent was obtained, and the DON could not identify the resident representative who provided consent. Staff are expected to document the name of the individual providing consent, but this was not done.
A resident with a reinserted Foley catheter did not have physician orders in place for catheter size, care, or maintenance, nor a Urology consult, following the procedure. This deficiency was identified through record review and interviews, which confirmed the absence of required orders to address the resident's immediate care needs.
Surveyors identified that the facility did not maintain accurate records for controlled drugs and failed to promptly remove a discontinued narcotic from storage. During a shift change, a nurse did not document the administration of a controlled medication as required. In a separate incident, an LPN administered a discontinued dose of Oxycodone to a resident and recorded it only on the narcotic sheet, not in the electronic medical record, due to the order being discontinued. The DON was unaware of this medication error until informed by surveyors.
Licensed staff failed to ensure a medication error rate below 5 percent, as two residents experienced errors: one did not receive a prescribed topical medication that was documented as given, and another received an incorrect cranberry supplement and did not receive a prescribed topical pain medication, which was also falsely documented as administered. These actions resulted in an error rate of 11.54 percent.
Surveyors found that medications and treatment supplies were not properly stored or labeled, including medicated creams left at a resident's bedside and a jar of zinc oxide cream without a label. Additionally, a resident was administered a discontinued controlled substance (Oxycodone IR 15mg) because it was not promptly removed from the narcotic medication cart, resulting in a medication administration error. Staff confirmed these practices did not meet facility expectations.
A resident with poor dentition was not provided with dental services. Staff interviews confirmed that although dental care is available upon request, the resident had not been seen by a dentist.
Staff did not ensure gloves were available on PPE carts for multiple EBP-designated rooms, and an LPN entered an EBP resident's room without performing hand hygiene as required, only sanitizing hands upon exit. These lapses in infection control practices were observed during survey rounds.
Surveyors observed missing insulation and metal on the refrigerator entry and missing wall tiles in four areas of the kitchen. These maintenance issues were confirmed by the administrator during the survey.
A resident was observed using bilateral enabler bed rails, but the facility did not provide documentation showing that an entrapment risk assessment had been completed. Although the DON and maintenance staff indicated that assessments were performed, there was no record of these evaluations, resulting in a failure to ensure regular and documented inspection of bed frames, mattresses, and bed rails for safety.
Staff did not complete a recommended diagnostic imaging order for a resident with a new wound, failed to obtain a required monthly weight for another resident without documenting refusal, and did not notify a resident's representative after a fall in the shower, as required. These deficiencies were identified through record review, staff and resident interviews.
A resident with concerns about dietary needs and medication management related to IBS did not have a documented diagnosis in their record. After a gastroenterologist recommended medication changes and a dairy-free diet, the facility physician confirmed the new orders but failed to document the diagnosis or dietary needs in progress notes, and did not record his clinical judgment or an alternative plan. This lack of documentation led to a failure to implement recommended dietary changes and update the care plan.
A facility was found to lack a system for after-hours visitor access, as highlighted by a complaint involving a spouse unable to admit a resident from the hospital. Despite knocking and calling, the family had to involve the police to gain entry. Surveyors observed the front door locked before business hours and multiple unanswered phone calls. Staff eventually directed the surveyor to an alternative entrance, indicating unclear after-hours access procedures. The DON acknowledged ongoing issues with phone responsiveness and access, despite specific directions for ambulances. Instances of patients arriving with discharge paperwork suggested inconsistencies in access protocols.
The facility failed to notify a resident's representative of a significant change in the resident's condition, specifically the reopening and worsening of a sacral wound. Despite the wound's deterioration, there was no documentation of notification to the family.
Facility staff failed to report an injury of unknown origin to OHCQ as required. A resident with vascular dementia was found with a swollen left eye, and the injury was documented by a nurse and in a hospital record. The Director of Nursing confirmed the injury was not reported to OHCQ.
Facility staff failed to complete and accurately update the PASRR for a resident who remained in the facility past the original 30 days and on readmission. The resident, with a history of schizophrenia and multiple inpatient psychiatric admissions, was not referred for a PASRR level II screening as required.
The facility did not update the care plan for a resident when their pressure ulcer status changed from unstageable to Stage 3, and additional skin concerns developed. The care plan remained outdated despite these changes. Additionally, the facility failed to conduct the required quarterly care plan meetings for another resident, missing all scheduled meetings in 2023 and 2024. This lack of updates and meetings was confirmed during an interview with the DON, indicating a gap in the care planning process.
Preventative measures for a resident with an unstageable pressure ulcer on the sacrum were not clearly communicated to all staff responsible for implementation. Physician orders for interventions such as floating bilateral heels, pressure relieving cushion, preventative mattress, and turning/repositioning every 2-3 hours were inconsistently documented. The Wound Nurse Practitioner's treatment recommendations were not effectively communicated to GNAs. Interviews with an LPN and the DON revealed that GNAs relied on the Kardex, which did not consistently include all prescribed interventions, and limitations in the electronic medical record system hindered proper documentation of GNA tasks.
Facility staff failed to administer Depo-Provera 150 mg every 3 months as ordered by the physician for a resident. This was confirmed through a review of Medication Administration Records and an interview with the DON.
The facility failed to ensure a resident's pain medication was available as ordered and did not conduct proper pain assessments or offer non-pharmacological pain management interventions. Another resident's care plan was not followed, and pain assessments were not documented consistently.
A facility did not maintain complete and accurate medical records for a resident who was readmitted and required daily wound care management with a wound vac. The EMR and TAR did not reflect the physician's orders. The DON acknowledged that the nurse should have corrected the orders during routine chart checks.
The facility failed to ensure adequate ventilation, resulting in a lingering smell of urine in four nursing units. The issue was confirmed by the Maintenance Director, who identified problems with the exhaust fans.
Failure to Secure Suprapubic Catheter Resulting in Dislodgement and Urine Leakage
Penalty
Summary
The facility failed to ensure proper securement of a suprapubic catheter for one resident with paraplegia and multiple urinary and renal diagnoses. Observations on two consecutive days revealed that the resident's suprapubic catheter tubing was not secured to the leg with an anchor or stabilization device, as required. The resident reported discomfort and frequent disconnection of the tubing, which led to urine leakage and saturation of bed linens. The care plan for the resident included interventions related to catheter care but did not address the need to assess securement of the tubing. Interviews with staff indicated a lack of communication and follow-through regarding the provision of securement devices. Central Supply confirmed that securement devices were available and had not been requested, while the Unit Manager stated that devices were kept in a locked office and could not explain why one had not been provided to the resident. The resident continued to experience issues with catheter dislodgement and urine leakage due to the absence of a securement device.
Failure to Follow Infection Control Protocols During Perineal Care
Penalty
Summary
Staff failed to follow the facility's infection prevention and control program during perineal care for two residents with complex medical needs, including suprapubic catheters and pressure ulcers. Observations revealed that staff did not perform proper hand hygiene between glove changes, used double gloving instead of single gloves, and did not change gloves when moving between contaminated and clean body sites. In one instance, staff wiped the resident's genitals and buttocks without changing gloves or performing hand hygiene, and failed to apply a moisture barrier after care. Additionally, soiled incontinence pads were handled in a manner that could spread contamination, and catheter care was performed without appropriate handwashing or glove changes. For another resident, staff did not perform hand hygiene before donning gloves and handled catheter collection bags inappropriately by placing them in a trash can and then reusing them. Wash cloths for perineal care were placed on an unprotected chair, and staff touched soiled briefs and then their own hands without changing gloves. During perineal care, staff wiped fecal matter and then the resident's back with the same gloves, further violating infection control protocols. These actions were inconsistent with the facility's policies, which require handwashing at appropriate times, glove changes between contaminated and clean sites, and the use of protective barriers during care. Interviews with staff and management confirmed a lack of adherence to established infection control procedures. Staff admitted to not using basins with soap and water for catheter care, double gloving due to misunderstanding, and not following proper glove and hand hygiene protocols. Management acknowledged the deficiencies and described the correct procedures, indicating that staff actions during the observed care did not meet facility expectations or policy requirements.
Failure to Follow Mechanical Lift Policy Results in Resident Fracture
Penalty
Summary
A deficiency occurred when staff failed to follow both facility policy and manufacturer guidelines for the use of a mechanical lift during the transfer of a resident who was completely dependent on staff for all activities of daily living and mobility. The facility's policy required two trained staff to assist with mechanical lift transfers and to follow the manufacturer's guidelines. However, a certified nursing assistant (CNA) transferred the resident alone, despite knowing the policy, due to a hectic workday and the perception that other staff were unavailable. The CNA also reported that the resident's room was small and not suitable for transferring with both the mechanical lift and the chair present, leading her to move the chair into the hallway and maneuver the resident out of the room by herself. The resident involved had severe cognitive and physical impairments, including anoxic brain damage, hemiplegia, contractures, and was bedbound. The resident was unable to communicate pain verbally and was highly dependent on staff for care. During the transfer, the CNA reported that the resident exhibited jerking movements, but she believed she had prevented the resident from coming into contact with any objects. The CNA also selected a sling for the lift based on her own judgment, without clear guidance or oversight, and there was confusion among staff regarding the compatibility and sizing of slings and lifts. Interviews revealed that staff were not consistently trained or observed in the use of mechanical lifts, and there was a lack of clarity about which slings should be used with which lifts, as well as how to select the appropriate sling size. Following the transfer, the resident was found to have a severely comminuted and displaced fracture of the right femur, which required hospital transfer and treatment. Documentation and interviews indicated that the injury was discovered after staff noticed swelling, warmth, and discoloration of the resident's leg, and the resident exhibited facial expressions of pain. The incident was further complicated by inconsistent training, lack of oversight, and confusion regarding equipment use, as well as the failure to adhere to the facility's own policy requiring two staff for mechanical lift transfers.
Failure to Assess and Authorize Self-Administration of Medication
Penalty
Summary
The facility failed to assess and properly authorize a resident for self-administration of medication, despite the presence of multiple medications at the resident's bedside. Facility policy required that residents requesting to self-administer medication undergo a safety assessment and interdisciplinary team review before being permitted to keep medications at bedside. However, the resident in question had medications including trazadone, Tylenol ES, Imodium, saline nasal spray, and Aspercreme at their bedside without any documented assessment, care plan intervention, or physician order allowing self-administration or bedside storage of these medications. The resident, who had a history of depression, GERD, and facial fractures, was cognitively intact and functionally independent according to the most recent MDS. The resident reported using trazadone at bedtime and Tylenol for pain, and expressed a desire to self-administer medication, but stated they had not been assessed for this ability by nursing staff. The care plan only directed staff to administer medications as ordered and did not address self-administration. Medication orders did not include permission for bedside storage or self-administration, and some medications present at the bedside were not listed in the active orders. Multiple staff members, including RNs and CNAs, reported being unaware of any medications at the resident's bedside and had not observed or reported them during their assigned shifts. When the medications were eventually discovered, staff acknowledged that medications should not have been present at the bedside without proper assessment and authorization. The DON confirmed that only one resident in the facility had been assessed and approved for self-administration, and it was not this resident.
Failure to Assess Nonverbal and Cognitively Impaired Residents During Abuse Investigation
Penalty
Summary
The facility failed to ensure that nonverbal and/or cognitively impaired residents were assessed during an abuse investigation. According to facility policy, the Administrator and/or Director of Nursing (DON) are required to immediately initiate a thorough internal investigation of any alleged abuse, which includes collecting evidence and interviewing alleged victims and witnesses. In this case, a resident reported physical abuse, prompting the suspension of a male staff member and interviews with staff and other residents on the same hallway. However, the investigation documentation revealed that two residents were unable to speak and one was unable to answer, and there was no evidence that these nonverbal or cognitively impaired residents were assessed as part of the investigation. During an interview, the DON confirmed that she could not verify whether nonverbal or cognitively impaired residents were assessed during the investigation. She acknowledged that she should have assessed these residents and admitted that a thorough investigation was not completed. The facility's failure to include assessments of nonverbal and cognitively impaired residents during the abuse investigation constituted a deficiency in following their own investigative protocols.
Failure to Prime Insulin Pen Results in Medication Errors Above 5% Threshold
Penalty
Summary
The facility failed to maintain a medication error rate below 5%, as required, with 2 errors identified out of 30 observed opportunities, resulting in a 6.66% error rate. Both errors involved the administration of insulin using a Tresiba FlexTouch pen to a resident with type 2 diabetes mellitus and a history of daily insulin use. During two separate medication passes, LPNs prepared and administered the insulin without priming the needle, contrary to the manufacturer's instructions and facility policy, which require priming to ensure accurate dosing. Interviews with staff revealed a lack of understanding regarding the necessity of priming the insulin pen, with one LPN stating it was unnecessary and the ADON initially supporting this view to avoid wasting insulin. However, upon reviewing the manufacturer's instructions, the ADON acknowledged that priming should occur before administration. The DON also confirmed the expectation that air should be removed from the needle prior to insulin administration. These actions and inactions led to the identified medication errors affecting a resident with moderate cognitive impairment and a diagnosis of diabetes mellitus.
Failure to Review, Revise, and Conduct Timely Care Plan Meetings
Penalty
Summary
Facility staff failed to ensure that residents' person-centered care plans were reviewed and revised in response to current interventions, particularly for those with complex respiratory needs. For example, one resident with chronic respiratory failure and a tracheostomy did not have their care plan updated to reflect current respiratory therapy recommendations, such as specific trach care procedures, oxygen requirements, and emergency protocols. Additionally, physician orders for certain respiratory interventions were missing from the care plan, and the care plan did not include all necessary details to address the resident's current condition. The facility also failed to consistently offer residents the opportunity to participate in the care planning process by not holding required annual and quarterly care plan meetings. Multiple residents' records showed significant gaps between care plan meetings, with some not having a meeting for nearly a year despite quarterly MDS assessments being completed. Documentation to support that care plan meetings were held in a timely manner was not provided when requested, and interviews with staff confirmed that care plan meetings had not been consistently conducted as required. Further, some residents were unaware of their plan of care or had not been involved in discharge planning discussions. In one case, a resident reported not being informed about their care plan or discharge status, and another resident's complaint about missing property and lack of discharge planning assistance was not substantiated with documentation. Staff interviews revealed that the facility had only recently identified these deficiencies and acknowledged that care plan meetings were not being completed as required.
Failure to Timely Report Allegations of Abuse to State Agency
Penalty
Summary
Facility staff failed to notify the state agency of allegations of abuse, neglect, or theft within the required two-hour timeframe in multiple cases. In six out of twelve facility-reported incidents reviewed, staff either delayed reporting or did not provide documentation showing timely notification. Specific incidents included allegations of sexual abuse, physical abuse, and injury of unknown origin. In several cases, the initial reports to the state agency were submitted several hours after staff became aware of the allegations, exceeding the mandated two-hour window. Additionally, some final investigation reports were not submitted within the required five working days. Interviews with facility leadership, including the Administrator and Director of Nursing (DON), revealed a lack of understanding or inconsistent application of the reporting requirements. Some staff believed only confirmed injuries or certain categories of incidents required immediate reporting, while others reported all incidents by the end of the day. Documentation reviews confirmed that in several cases, the facility either failed to report within the required timeframe or could not provide evidence of timely reporting, as required by regulations.
Failure to Timely Develop Care Plan for New Diagnosis
Penalty
Summary
The facility failed to develop a care plan to address a resident's new medical diagnosis following a leg fracture. After the resident sustained a leg fracture and was transported to the emergency department, they returned to the facility, where the physician assessed the injury and discussed the assessment and plan with staff. However, a review of the resident's medical records revealed that the comprehensive care plan did not address the leg fracture until several weeks after the incident. Interviews with the DON and Social Worker confirmed that care plans were not being completed during this period, and no care plan was developed for the resident's fracture in a timely manner.
Failure to Provide Supervision and Accurate Assessments for Smoking Residents
Penalty
Summary
The facility failed to ensure appropriate precautions and supervision for residents who smoke, as well as to maintain accurate and updated smoking assessments and care plans. Observations revealed that residents were smoking outside without staff supervision during times not designated for supervised smoking, despite posted schedules indicating when supervision should occur. Multiple residents were seen possessing their own smoking materials and using the smoking area without staff present. The facility's smoker list, as of 2/26/2025, indicated that all residents identified as smokers did not require supervision or special equipment, but further review of medical records showed discrepancies. Specifically, some residents required supervision and/or a smoking apron, and one resident had no smoking assessment at all. Interviews with recreation staff and the DON revealed a lack of awareness regarding which residents required supervision or equipment while smoking. Staff stated that no residents needed supervision or aprons, contradicting documentation and medical records. The DON confirmed that nursing staff were not completing smoking assessments accurately or updating them to reflect residents' current needs. The facility's process for updating the smoker list during morning meetings was not effective in ensuring accurate and current assessments, leading to residents being unsupervised while smoking despite documented needs for supervision and safety equipment.
Improper Food Storage, Labeling, and Staff Hygiene in Kitchen
Penalty
Summary
Kitchen staff failed to properly store and label food items, did not ensure all staff wore appropriate hair coverings, and did not thaw food correctly in the refrigerator. During a kitchen tour, a dietary aide was observed with exposed hair while wearing a knitted hat. The freezer contained multiple opened, unlabeled, and undated food items, including pepperoni, veggie patties, hot dogs, breaded oysters, tilapia, and shrimp, with some items left uncovered. In the refrigerator, there was undated and exposed American cheese and a box of un-thawed chicken on a sheet pan with a red substance. These issues were observed and brought to the attention of dietary staff and the kitchen manager during the survey.
Failure to Adhere to Professional Standards in Physician Orders, Medication Administration, and Documentation
Penalty
Summary
Facility staff failed to adhere to professional nursing standards in several key areas, including the implementation of physician orders, medication administration, and documentation. For one resident, weekly weights ordered for monitoring GLP-1 medications were not documented on multiple occasions, and there were no nursing notes explaining the missed weights. Another resident experienced repeated late administration of scheduled medications, with documentation showing significant delays beyond the expected administration window. The DON confirmed that nurses are expected to follow physician orders and administer medications within a specific timeframe, but could not provide explanations for the lapses. Additional deficiencies were identified in wound care management and documentation. One resident with a PICC line had no documented dressing changes from the time of insertion until discontinuation, despite standard practice requiring weekly and as-needed changes. The same resident also had a wound vac order that was incorrectly entered, resulting in a missed dressing change at the start of the order period. The DON acknowledged these errors and confirmed that the orders should have been implemented as written. Further review revealed failures in the assessment and documentation of residents' decision-making abilities and medication indications. A resident with significant cognitive decline, as indicated by a low BIMS score on the MDS assessment, was not reevaluated for decision-making capacity as required. Another resident was prescribed risperidone with an indication of schizophrenia, but the medical record only supported a diagnosis of schizoaffective disorder. The psychiatric provider noted the discrepancy and later updated the medication order to reflect the correct diagnosis.
Deficient Documentation and Inaccurate Medical Records
Penalty
Summary
Facility staff failed to accurately document and maintain records of residents' personal belongings, as evidenced by the case of a resident whose inventory forms indicated no belongings, despite the presence of clothing in their room. Additionally, there was no grievance form on file regarding the resident's missing shoes, and inventory sheets were not updated when new items were brought in. This demonstrates a lack of adherence to procedures for tracking and safeguarding resident property. The facility also did not maintain accurate and up-to-date medical records for several residents. Discrepancies were found in the documentation of smoking assessments and equipment needs, with some residents requiring supervision or special equipment for smoking not properly documented in their records. Furthermore, a resident's narcotic medication was administered after the order had been discontinued, and the administration was not recorded in the electronic medical record due to the discontinued status. In another instance, an LPN inaccurately documented medication administration codes, marking residents as sleeping instead of indicating that medications were given. Additional deficiencies included staff signing off on care tasks, such as showers, before they were completed, and maintaining outdated or inaccurate orders in residents' records, such as orders for oxygen or tube feeding that were no longer applicable. These actions and omissions resulted in medical records that did not accurately reflect residents' current status or care provided, failing to meet accepted professional standards for recordkeeping.
Failure to Develop and Implement Comprehensive Abuse Investigation and Reporting Policies
Penalty
Summary
The facility failed to develop and implement comprehensive written policies and procedures for investigating and reporting allegations of abuse. The existing abuse policy did not provide guidance on how staff should identify abuse that was not directly observed, nor did it outline procedures for interviewing all relevant parties, including the alleged victim, alleged perpetrator, witnesses, and others with knowledge of the incident. Additionally, the policy lacked specific timeframes for reporting alleged abuse. Interviews with the DON and Administrator revealed inconsistent understanding of reporting requirements, with the DON stating that only confirmed injuries were reported within 2 hours and other allegations by the end of the day, while the Administrator indicated all incidents were reported within 24 hours and those with bodily injuries within 2 hours. A review of an incident involving a resident who was hospitalized for a scheduled leg fracture repair surgery revealed further deficiencies. The resident had reported to a hospital nurse liaison that they were assaulted by a staff member, resulting in a leg fracture. The facility's incident report showed that the alleged victim was not interviewed, and the allegation of abuse could not be verified. The resident stated that they had informed the Unit Manager about the incident and requested hospital transport due to ongoing leg pain, but initial x-rays at the facility did not show a fracture. The lack of a thorough investigation and failure to interview the alleged victim contributed to the deficiency.
Failure to Conduct and Document Thorough Abuse Investigations
Penalty
Summary
Facility staff failed to conduct thorough investigations into alleged incidents of abuse and an injury of unknown origin, as evidenced in four out of twelve facility-reported investigations reviewed during the recertification survey. In one case, a resident reported an alleged incident of sexual abuse, but the investigation lacked clear identification of staff interviewed, and the staffing sheet provided did not correspond to the date of the alleged incident, making it impossible to confirm a comprehensive investigation. The Director of Nursing (DON) acknowledged completing the investigation but could not provide adequate documentation to verify the process. The facility's standard for a thorough investigation, as described by the Administrator, includes interviewing all present staff and witnesses, but this was not demonstrated in the documentation provided. In another case, an alleged assault resulting in a fracture was reported, but the facility failed to interview the alleged victim and did not notify law enforcement or required agencies. Additionally, for two other incidents involving allegations of abuse, the facility was unable to provide any investigation documentation or related records when requested by the surveyor. The DON confirmed the inability to locate these files and acknowledged the facility's responsibility to maintain thorough and accurate records for all reported incidents.
Failure to Ensure Resident Access to Call Bells
Penalty
Summary
Facility staff failed to ensure that residents had access to their call bells to notify staff for assistance when needed. During initial observation rounds, multiple residents were found without their call bells within reach. Specific instances included call bells found on the floor near beds, hanging from the call bell system on the wall, or draped over the side of the bed. These observations were confirmed by Geriatric Nursing Assistants (GNAs) present at the time. The issue was observed with seven residents during the survey period. Interviews with staff revealed that GNAs are expected to check on residents and ensure call bells are close to them during their rounds. However, despite these procedures, several residents were still found without accessible call bells. The Director of Nursing was made aware of the situation after the surveyor's findings. The deficiency was identified based on direct observations and staff interviews, indicating a lapse in ensuring residents' ability to request assistance when needed.
Resident Preference for Personal Clothing Not Honored
Penalty
Summary
Facility staff failed to ensure that a resident was dressed in their personal clothing as preferred, despite the resident having personal clothing available in their closet. Multiple observations over several days showed the resident awake in bed, eating lunch, and waiting for breakfast while wearing a hospital gown. The resident was admitted with multiple medical conditions, including generalized weakness, and required assistance with personal care and dressing. Interviews confirmed that the resident preferred to be out of bed and dressed in their own clothing, and staff acknowledged the resident's need for assistance. Despite these preferences and needs, the resident continued to be observed in a hospital gown during various times of the day, both in bed and in common areas. Additionally, during one observation, the resident's foley bag was noted to be on the floor without a privacy cover. These findings indicate that staff did not honor the resident's right to self-determination and choice regarding personal attire, as required.
Failure to Obtain, Maintain, and Document Advance Directives
Penalty
Summary
Facility staff failed to ensure that copies of residents' Advance Directives were obtained and maintained in the medical records, and did not consistently provide or document discussions and information about Advance Directives with residents or their representatives. For one resident, the Discharge Planning Psychosocial Assessment indicated the presence of an Advance Directive, but no written document was found in the electronic medical record, and staff confirmed that a copy was not available. For another resident, there was no documentation of an Advance Directive or any indication that the topic had been discussed. In a third case, the assessment noted the absence of an Advance Directive, but there was no evidence that the facility provided information to the resident or representative about initiating one. Interviews with the social worker revealed that the facility's process is to ask about Advance Directives at admission and to provide information if one is not in place, but documentation supporting these actions was missing for the residents reviewed. The Director of Nursing confirmed the absence of required documentation for at least one resident. These findings were based on record reviews and staff interviews, and were evident in three out of ten residents reviewed for Advance Directives.
Failure to Provide SNF Beneficiary Notice Prior to Discharge
Penalty
Summary
Facility staff failed to provide a required Skilled Nursing Facility (SNF) Beneficiary Notice to a resident prior to discharge. During a recertification survey, it was found that out of three resident records reviewed for proper discharge documentation, one resident did not receive the SNF Beneficiary Notice, which is necessary to inform residents of their Medicare/Medicaid coverage and potential liability for non-covered services. Documentation provided by the Medical Social Worker (MSW) confirmed that while one resident was discharged voluntarily, two others, including the resident in question, were not given the required notice before discharge. The MSW acknowledged the omission when questioned by the surveyor.
Failure to Maintain Homelike Environment Due to Unaddressed Room Repairs
Penalty
Summary
Facility staff failed to maintain a homelike environment for residents by not making timely repairs in resident rooms, as evidenced by multiple observations during survey rounds. Specific deficiencies included rust on bathroom tiles, damaged and missing drywall behind beds and below windows, a bathroom faucet that could not be turned off and had a steady flow of water, an armoire that was hanging by its hinge and could not be closed, and exposed corner bead near a privacy curtain. These issues were observed in several rooms across two of three facility units. During an interview, the Director of Maintenance stated that staff report maintenance concerns through a records system accessible to all staff and that a preventative maintenance schedule is in place, with routine room checks for concerns.
Failure to Accurately Document Significant Change on MDS Assessment
Penalty
Summary
The facility failed to ensure that a resident's quarterly assessment was accurately documented on the Minimum Data Set (MDS). Specifically, a resident who had sustained an acute comminuted fracture of the left leg, as documented in physician progress notes, did not have this significant medical event reflected in their quarterly MDS assessment. The resident's medical records included physician notes detailing the fracture, pain management, orthopedic follow-up, and a recommendation for surgery, as well as the use of a knee immobilizer. During an interview, the MDS Coordinator explained that updates to the Resident Assessment Instrument (RAI) are made based on physician notes within a 60-day look-back period, and that new diagnoses are only captured if there are two documented changes in the resident's condition. Despite the presence of clear documentation regarding the fracture and subsequent care, the coordinator did not update the resident's quarterly assessment to reflect this significant change. The deficiency was identified when the surveyor noted the omission and questioned the staff about the lack of documentation on the MDS.
Incomplete PASARR Documentation for Residents with Mental Disorders or Intellectual Disabilities
Penalty
Summary
Facility staff failed to ensure that Preadmission Screening and Resident Review (PASARR) forms were completed correctly for three out of four residents reviewed. Specifically, two residents had Level I PASARR screenings indicating the need for a Level II screening, but there was no documentation of a completed Level II PASARR in their medical records. For another resident, only section A of the Level I PASARR was completed, with the remainder of the screening left incomplete as prompted by the form. Interviews with the facility's social worker confirmed the absence of required documentation and an inability to explain the incomplete PASARR form. The social worker acknowledged that certain diagnoses should have triggered further screening and was unable to provide the necessary documentation for the identified residents. The deficiency was identified through record review and staff interviews, with the lack of proper PASARR documentation directly observed in the residents' medical records.
Failure to Provide Regular Showers to Residents
Penalty
Summary
Facility staff failed to ensure that residents received regular showers, as evidenced by two residents who reported not receiving showers as scheduled. One resident stated they had not received a shower since admission and had never been asked if they wanted one, despite being scheduled for showers on specific days and having intact cognition as indicated by a BIMS score of 14/15. Review of the electronic medical records for both residents showed no documentation verifying that showers had been provided as scheduled. The Director of Nursing confirmed that residents were supposed to be offered showers twice a week, and that refusals should be documented, but there was no evidence this process was followed for the affected residents.
Failure to Timely Repeat Urine Culture Following Contaminated Sample
Penalty
Summary
A deficiency occurred when the facility failed to reorder a urine culture for a resident with a history of recurrent urinary tract infections (UTIs) after an initial urine sample was found to be contaminated. The resident had previously complained of pain while voiding, prompting a physician order for a urinalysis and culture. The urinalysis showed abnormal results, and the laboratory specifically recommended a repeat culture due to contamination. However, there was no documentation of a repeat urine culture being ordered or collected at that time. The delay in obtaining a repeat urine culture resulted in a lack of timely diagnosis and treatment for the resident, who continued to experience symptoms. It was not until the resident's condition changed and symptoms increased that a new order for urinalysis and culture was placed, leading to the eventual diagnosis and treatment of a UTI. Interviews with staff confirmed that abnormal results are typically communicated to physicians, but in this case, the recommended follow-up was not completed until a significant delay had occurred.
Failure to Provide Physician-Ordered Diets and Appropriate Food Consistency
Penalty
Summary
Facility staff failed to provide adequate nutrition and follow physician diet orders for two residents. One resident with an active order for a regular diet with double portions consistently did not receive double portions at meals, as confirmed by both the resident and review of meal tickets, which did not indicate the double portion requirement. Despite the resident's repeated reports to dietary staff and management, the issue persisted, and meal tickets continued to reflect only regular portions, contrary to the physician's order and dietary notes. Another resident, who had a diet order for dysphagia with mechanically altered texture and thin liquids, was observed receiving a lunch tray with regular texture sliced peaches, which were not appropriate for their ordered diet. The resident was also missing several teeth, further necessitating the need for mechanically altered food. Staff interviews confirmed that the meal ticket listed sliced canned peaches instead of the required diced or mechanical soft peaches, and responsibility for ensuring correct food consistency was acknowledged to be shared among dietary aides, kitchen staff, and nursing staff.
Failure to Ensure Timely and Appropriate Pain Management
Penalty
Summary
Facility staff failed to ensure that residents had a sufficient supply of prescribed pain medication and that their pain was appropriately addressed. One resident, who was prescribed Oxycodone HCl 20mg every six hours as needed, reported that the facility frequently ran out of this medication, resulting in unmanaged pain. Documentation confirmed that the resident did not receive the medication as ordered over a weekend due to delayed reordering by nursing staff, who often waited until the last dose before initiating a refill. Narcotic count sheets and interviews with staff confirmed a lapse in medication availability and administration during this period. Another resident was observed crying in pain, and a wound consult documented severe bilateral foot pain rated 10 out of 10. The nurse practitioner assessed the pain but did not document a plan to address it and stated she was waiting for diagnostic imaging results before addressing the pain. The nurse responsible for the resident's care was not informed of the pain concern, as there was no documented recommendation for pain medication. This resulted in the resident's pain not being managed in a timely manner.
Failure to Obtain Proper Informed Consent for Bed Rail Use
Penalty
Summary
The facility failed to obtain proper informed consent prior to the use of bed rails for a resident. Observation showed the resident in bed with bilateral enabler bed rails. During an interview, the DON stated that consent is obtained before bed rails are initiated, but when documentation was reviewed, the consent form only indicated that consent was obtained without specifying from whom (the resident or their representative). Further, the DON was unable to identify which resident representative had provided consent, and acknowledged that staff are expected to document the name of the individual from whom consent was obtained for it to be considered valid.
Lack of Physician Orders for Foley Catheter Care After Reinsertion
Penalty
Summary
A deficiency occurred when a resident with an indwelling Foley catheter did not have physician orders in place for the catheter's size, care, and maintenance after the device was reinserted. The resident's Foley catheter was initially removed, and the resident was placed on a voiding trial. The following day, the resident experienced abdominal pain and decreased urinary output, leading to the reinsertion of the Foley catheter. Despite this, a review of the electronic medical record revealed that there were no active physician orders for the Foley catheter or related care, nor was there an order for a Urology consult at that time. Interviews with the resident and the DON confirmed that orders for Foley catheter size and care should have been in place following reinsertion. The lack of these orders was observed during the survey, and the deficiency was identified based on the absence of required documentation and physician directives to address the resident's immediate care needs related to the indwelling catheter.
Deficiencies in Controlled Drug Accountability and Timely Removal of Discontinued Medications
Penalty
Summary
The facility failed to ensure that an accurate and complete account of all controlled drugs was maintained, as well as to promptly identify and remove discontinued controlled drugs from the narcotic lock box. During a narcotic count observation, a registered nurse admitted to not signing off on the administration of Vimpat 100mg for a resident at the time of administration, contrary to facility procedures that require immediate documentation on the narcotic report sheet. The nurse acknowledged the error when questioned and explained the correct process, which was not followed in this instance. Additionally, a review of narcotic count sheets and electronic medical records revealed that a resident's Oxycodone IR 15mg, which had been discontinued, was still present in the narcotic lock box and was administered after discontinuation. The medication was signed out on the narcotic record sheet, but not documented in the electronic medical record due to the discontinued order. The LPN involved completed a Medication Error Report after the fact, but the DON was unaware of the incident until it was brought to her attention by the surveyor.
Medication Administration Errors Exceed Acceptable Rate
Penalty
Summary
Licensed nursing staff failed to maintain a medication error rate below 5 percent during observed medication administration. Specifically, one resident was due to receive Voltaren External gel to the right shoulder, but the LPN did not administer the medication as the resident preferred to use it at night. Despite this, the LPN documented in the electronic medical record that the medication had been administered. The surveyor confirmed through record review and audit that the medication was not given at the observed time, yet was marked as completed. In another instance, a different resident was administered Cranberry Juice 425mg tablets, although the active order was for Cranberry Oral capsule 450mg, and there was no order for the juice tablets. Additionally, the LPN documented that Lidocaine External aerosol was administered, but the surveyor did not observe this, and the resident later confirmed that the medication had not been given. These actions resulted in an overall medication error rate of 11.54 percent, exceeding the acceptable threshold.
Improper Storage and Labeling of Medications; Administration of Discontinued Controlled Substance
Penalty
Summary
Surveyors identified that medications and medical treatment supplies were not stored and labeled according to professional standards in the facility. Specifically, two small plastic jars of medicated cream labeled for a resident and marked 'refrigerate,' along with a small plastic jar of zinc oxide cream with no label, were found on a resident's nightstand on two consecutive days. The creams were not properly stored, as the refrigerated cream was left at room temperature and the zinc oxide cream lacked appropriate labeling, including the resident's name and date opened. Staff confirmed that these items should not have been left at the bedside and that proper storage and labeling procedures were not followed. Additionally, a review of the controlled substance records revealed that a resident received a dose of Oxycodone IR 15mg after the medication had been discontinued. The medication remained in the narcotic medication cart after discontinuation, which led to its administration in error. The Director of Nursing confirmed that the discontinued medication was still accessible in the cart and that the facility's policy requires immediate removal and destruction of discontinued medications to prevent such errors.
Failure to Provide Dental Services to Resident with Poor Dentition
Penalty
Summary
Facility staff failed to ensure that a resident with poor dentition received necessary dental services. During the recertification survey, a resident was observed to have poor dentition, and subsequent interviews with the administrator and the director of nursing revealed that the resident had not been seen by a dentist. The administrator stated that dental care is offered to residents upon request, and residents are added to the caseload if they or their family request services. However, it was confirmed by the director of nursing that this particular resident had not received dental care.
Failure to Maintain PPE Availability and Hand Hygiene for EBP Residents
Penalty
Summary
Facility staff failed to ensure the availability of personal protective equipment (PPE), specifically gloves, for residents on enhanced barrier precautions (EBP). During surveyor observations, gloves were missing from PPE carts outside six out of eighteen rooms designated for EBP. The central supply staff member responsible for restocking PPE stated that he replenishes supplies daily on weekdays, and that supervisors are responsible for restocking when he is off on weekends. The deficiency was observed before the central supply staff restocked the carts, indicating a lapse in maintaining continuous PPE availability. Additionally, an LPN was observed entering a resident's room, which was under EBP, without performing hand hygiene as required. The LPN adjusted equipment above the resident's bed and only used hand sanitizer upon exiting the room, despite signage indicating the need for EBP and the LPN's own acknowledgment that hand hygiene is expected both upon entering and exiting resident rooms. These actions demonstrate a failure to adhere to proper infection control practices for residents requiring enhanced precautions.
Failure to Maintain Kitchen Equipment and Surfaces
Penalty
Summary
Facility staff failed to make necessary repairs in the kitchen, as observed during a recertification survey. On the morning of 03/12/25, a surveyor, accompanied by the kitchen manager, identified missing insulation and metal on both the inside and outside of the distal portion of the refrigerator's entry. Additionally, four separate areas in the kitchen were noted to have missing wall tiles. These maintenance issues were reviewed with the facility administrator, who acknowledged the concerns during the survey.
Failure to Document Bed Rail Entrapment Risk Assessments
Penalty
Summary
The facility failed to conduct and document regular inspections of bed frames, mattresses, and bed rails to identify potential areas of entrapment. During an observation, a resident was found in bed with bilateral enabler bed rails. Although the DON stated that residents are assessed quarterly for the need and entrapment risk of enabler rails, documentation provided did not indicate that an entrapment risk assessment had been completed for the resident. Additionally, the Director of Maintenance reported that while enabler bed rails were often assessed for entrapment, these assessments were not documented.
Failure to Complete Diagnostic Orders, Monthly Weights, and Family Notification After Fall
Penalty
Summary
Facility staff failed to ensure that a recommendation for diagnostic imaging for a resident with a new left heel wound was completed as ordered by a nurse practitioner. The nurse practitioner assessed the resident and recommended diagnostic imaging, but a review of the medical record several days later showed that the imaging had not been ordered. The nurse practitioner did not follow up on the recommendation during a subsequent visit, and the unit manager, who received the recommendation via email, could not explain why it was not completed. Additionally, staff did not weigh a resident in accordance with an active monthly weight order, and there was no documentation of a refusal for the missed month. In a separate incident, a resident who experienced a fall in the shower did not have documentation indicating that their representative was notified of the fall, contrary to facility expectations. These deficiencies were identified through record reviews, staff interviews, and resident interviews during the recertification survey.
Physician Documentation Lacking for Resident's Care Review
Penalty
Summary
Facility staff failed to ensure that the physician's documentation reflected a comprehensive review of a resident's total care. Specifically, a resident with reported concerns regarding dietary needs and medication management related to irritable bowel syndrome (IBS) did not have a documented medical diagnosis of IBS in their medical record. The resident was evaluated by a gastroenterologist, who recommended discontinuing two medications, starting two new ones, and implementing a dairy-free diet based on IBS symptoms. These recommendations were communicated to the facility and confirmed by the facility's physician. However, the physician's subsequent progress note only mentioned that the resident had seen a gastroenterologist and started new medication, with a recommendation for follow-up, but did not document the IBS diagnosis or address the resident's dietary needs. During an interview, the physician stated disagreement with the IBS diagnosis but acknowledged failing to document his clinical judgment or an alternative treatment plan. This lack of documentation contributed to the facility's failure to implement the recommended dietary orders and update the resident's plan of care.
After-Hours Visitor Access Deficiency
Penalty
Summary
The facility in question failed to have a system in place to allow for visitor access after hours, as highlighted in a specific complaint (#MD00180288) reviewed by surveyors. The complaint detailed an incident where a spouse attempted to admit Resident #59 directly from the hospital but was unable to gain access to the facility. Despite knocking on the door and calling the facility with no response, the family had to involve the police to enter the premises. During a subsequent surveyor visit, it was observed that the front door was locked before business hours, and multiple attempts to contact the facility via phone went unanswered for an extended period. Staff eventually directed the surveyor to an alternative entrance, indicating a lack of clarity in after-hours access procedures. Interviews with the Director of Nursing (DON) revealed that while there had been previous concerns with the phone system, interventions had been attempted without complete resolution. The DON acknowledged ongoing issues with phone responsiveness and access, despite ambulances being directed to a specific entrance for after-hours admissions. The report also noted instances where patients arrived with discharge paperwork from the hospital, suggesting a potential inconsistency in the application of access protocols. The deficiency in visitor access procedures, as evidenced by the complaint and surveyor observations, highlighted gaps in the facility's ability to facilitate after-hours entry for visitors and potential new residents.
Failure to Notify Resident's Representative of Change in Condition
Penalty
Summary
The facility failed to notify the resident's representative of a change in condition for Resident #51, who had a history of hemiplegia after a stroke, chronic pain syndrome, presence of a gastrostomy tube, and dementia. Upon initial admission, multiple pressure ulcers were identified and treated, but the sacral wound reopened and worsened over time. Despite the significant change in the wound's condition, there was no documentation indicating that the resident's representative was informed of this change. During an interview, RN Staff #3, who was responsible for wound care and infection control, stated that the admitting nurse is responsible for initial skin assessments and notifications, while the assigned unit-nurse handles day-to-day changes. The Director of Nursing was made aware of the concern regarding the lack of notification to the family about the reopening of the wounds, but no documentation of notification was found in the medical record.
Failure to Report Injury of Unknown Origin
Penalty
Summary
The facility staff failed to report an injury of unknown origin to the Office of Health Care Quality (OHCQ) as required. Resident #19, who was admitted with a diagnosis of vascular dementia, was found with a swollen left eye on 10/9/22. A nurse's note documented the injury at 10:15 AM, and a subsequent hospital record noted the injury at 6:51 PM, with no awareness of how the injury occurred. An interview with the Director of Nursing confirmed that the injury was not reported to OHCQ as required.
Failure to Complete and Accurately Update PASRR for Resident
Penalty
Summary
Facility staff failed to ensure the Preadmission Screening and Resident Review (PASRR) was completed after a resident remained in the facility past the original 30 days and to accurately complete the PASRR on readmission. Initially, a PASRR level 1 was completed indicating the resident would stay for 30 days or less, which did not require further evaluation for mental disorder (MD) or intellectual disability (ID). However, the resident was not discharged within 30 days, and a second PASRR was not completed. The resident had a history of schizophrenia and multiple admissions for inpatient psychiatric care, which was documented by a psychiatrist and the attending physician. Despite this, the PASRR on readmission was inaccurately completed, failing to indicate the resident's serious functional limitations and multiple episodes of treatment, which should have qualified the resident for a PASRR level II screening. The staff member who completed the form no longer works at the facility. The current Social Services Director confirmed that the questions in section C of the PASRR should have been answered affirmatively, and the resident should have been referred for a PASRR level II screening. This referral would have involved the local health department's Adult Evaluation and Review Services (AERS) program to ensure the resident received the necessary specialized services. The deficiency was discussed with the Nursing Home Administrator.
Care Plan Updates and Quarterly Meetings Deficiency
Penalty
Summary
The facility failed to update the care plan for Resident #8 when there was a change in the resident's pressure ulcer status from unstageable to a Stage 3 pressure ulcer on multiple occasions. Despite the development of additional areas of concern on Resident #8's skin, including suspected deep tissue injuries on different body parts, the care plan remained outdated. This deficiency in updating the care plan to reflect the resident's evolving condition was identified during the survey. Additionally, the facility did not conduct the required quarterly care plan meetings for Resident #15 in 2023 and none in 2024 as mandated by regulations. The lack of these meetings indicates a failure to involve the interdisciplinary team, resident, and resident's representative in reviewing and revising the care plan to ensure it aligns with the resident's specific needs and current condition. This deficiency in holding care plan meetings as scheduled was confirmed during an interview with the Director of Nursing, highlighting a gap in the facility's care planning process.
Communication Gaps in Pressure Ulcer Preventative Measures
Penalty
Summary
During a complaint survey, it was found that preventative measures prescribed by the physician for Resident #8, who had an unstageable pressure ulcer on the sacrum, were not clearly communicated to all staff responsible for implementation. The medical record review revealed that despite physician orders for interventions such as floating bilateral heels, pressure relieving cushion, preventative mattress, and turning/repositioning every 2-3 hours, these measures were not consistently documented as being implemented. The Wound Nurse Practitioner provided treatment recommendations, but there was a lack of communication to the Geriatric Nursing Assistants (GNAs) responsible for carrying out these interventions. Staff interviews with a Licensed Practical Nurse (LPN) and the Director of Nursing (DON) revealed gaps in communication and documentation processes within the facility. The LPN indicated that GNAs did not have access to residents' Care Plans and were expected to rely on the Kardex for task information, which did not consistently include all prescribed interventions. The DON acknowledged limitations in the electronic medical record system that hindered proper documentation of GNA tasks related to pressure ulcer prevention and treatment.
Failure to Administer Medication as Ordered
Penalty
Summary
The facility staff failed to administer medication as ordered by the physician for Resident #35. The resident was admitted to the facility and had a physician order for Depo-Provera 150 mg every 3 months. However, a review of the Medication Administration Records for October 2022 and January 2023 revealed that the facility staff did not administer the medication as ordered. This deficiency was confirmed during an interview with the Director of Nursing on 3/22/24.
Failure to Provide Adequate Pain Management
Penalty
Summary
The facility failed to ensure a resident's pain medication was available as ordered by the physician and did not conduct a proper pain assessment or offer non-pharmacological pain management interventions. Resident #41, who had multiple back and colon surgeries, reported severe pain due to the unavailability of their prescribed 30mg Oxycodone. The resident's medication was not available at the scheduled times of 2:00 AM and 6:00 AM, and the facility did not notify the physician or attempt alternative pain treatments promptly. The DON acknowledged the issue but cited difficulties with the pharmacy and insurance coverage as contributing factors. Despite the resident's high pain score, the facility failed to provide timely and effective pain management interventions, leading to repeated instances of the resident's medication not being available. Additionally, the facility did not document any pain assessments or offer other PRN medications until after the second missed dose. The facility's interim box contained 5mg Oxycodone, but the resident's physician did not approve its use, further complicating the situation. The facility's failure to manage the resident's pain effectively was evident in the medical records and interviews with the DON and the resident. The facility also failed to ensure clear indications for use and proper pain assessments for another resident, Resident #17. The resident's care plan included administering pain medication as ordered and encouraging non-pharmacological pain interventions. However, the facility did not document pain assessments or offer non-pharmacological interventions consistently. The resident's pain levels ranged from 4 to 8 out of 10, but the facility did not provide adequate documentation or follow the care plan's interventions. Interviews with staff and the DON revealed a lack of protocol for determining which pain medication to administer based on pain scores. The attending physician expected staff to administer acetaminophen for moderate pain and oxycodone for severe pain, but the facility had no clear guidelines for staff to follow. The facility's pain management policy required documenting pain assessments, including the location, duration, and type of pain, but this was not consistently done. The facility's failure to follow its pain management policy and provide appropriate pain management interventions for Resident #17 was evident in the medical records and staff interviews.
Incomplete Medical Records for Wound Care Management
Penalty
Summary
The facility failed to maintain complete and accurate medical records for Resident #20, who was readmitted on [DATE]. Despite physician's orders for daily wound care management with a wound vac, the Electronic Medical Record and Treatment Administration Record did not reflect this care. The Director of Nursing acknowledged the oversight, noting that the Nurse should have corrected the orders during routine chart checks.
Inadequate Ventilation Leading to Odor Issues
Penalty
Summary
The facility failed to have adequate ventilation to ensure good air quality circulation, resulting in a lingering smell of urine in Nursing Units 200, 300, 400, and 500. This deficiency was observed on 3/19/24 at 11:15 AM. The lack of airflow was confirmed during a tour with the Maintenance Director, who identified that one exhaust fan motor needed replacement and the other three exhaust fans required fixing. The Director of Nursing was made aware of the concern on 3/21/24 at 9:00 AM.
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The facility did not ensure that its Infection Preventionist (IP) met required qualifications for managing the Infection Prevention and Control Program. The DON reported serving as the IP but acknowledged lacking the specialized infection control training required for the role, and confirmed that no other staff member was currently qualified. Records showed that the previously qualified IP left several months earlier, and the Administrator and DON confirmed they were still seeking a replacement, leaving the infection control program without a properly trained leader.
Staff failed to consistently secure medications and medical supplies across three units, including an oxygen tank left on the floor behind a resident’s bed without a supporting device, a treatment cart with Collagenase Santyl cream left on top while two residents in power wheelchairs passed by, an unattended and unlocked treatment cart at a nursing station, and another treatment cart with Diclofenac gel and dressings left on top, indicating repeated lapses in maintaining locked and secure storage for drugs, biologicals, and related supplies.
The facility failed to provide sufficient dietitian coverage and timely nutritional assessments for several residents with significant dietary needs. A resident admitted for diabetic management with a high A1C was placed on a regular diet instead of the recommended carb-controlled diet and had only one weight taken in the first two weeks, with no dietitian review of the record. Another resident with prior significant weight loss had no documented dietitian follow-up despite continued weight loss, and a resident admitted with severe protein-calorie malnutrition experienced further significant weight loss without any dietitian assessment. The dietitian reported working limited hours and prioritizing certain high-risk cases, resulting in delayed or missed evaluations for new admissions and residents with ongoing nutritional concerns.
The facility failed to maintain adequate linen and incontinence supplies and did not keep resident care areas in good repair, resulting in delays and alterations in incontinence care and substandard environmental conditions. Staff reported that towels and washcloths were used instead of wipes and then discarded due to heavy soiling, and that linen deliveries to units were late, leaving residents waiting for care. Observations showed very limited numbers of clean washcloths and other linens on units and in the laundry, with no stock of disposable wipes or backup washcloth supply despite repeated reports to housekeeping. Additional observations revealed recliner chairs blocking a dining-area handwashing sink and kitchenette, multiple resident and shared bathrooms with unfinished spackle, chipped paint, musty odors, black substances near showers, missing threshold molding, exposed cracks and nails, and eroded, rusted baseboard heaters. Hallway handrails on both units were worn, chipped, and splintered, and a shower room contained fecal odors, dried brown stains on the toilet, and deteriorated fixtures, all contributing to a failure to provide a safe, clean, and homelike environment.
Facility staff did not thoroughly investigate two separate abuse allegations involving a resident and an injury of unknown origin involving another resident. In both cases, investigations focused on the directly affected resident and included staff interviews, but there were no interviews of other residents on the unit or documented assessments of those residents for signs of abuse or injuries of unknown origin, including residents unable to communicate due to cognitive status.
Two residents who were dependent on staff for oral care, including one with a tracheostomy, were observed with thick, white or milky substances coating their mouths and teeth, indicating inadequate oral hygiene. One resident communicated that staff did not brush their teeth and that staff "need to." In another case, despite oral care supplies being present in the room, the resident’s mouth and teeth remained unclean on multiple observations, with a thick milky substance caking the teeth and stringing between them when the resident tried to open their mouth. These findings showed that staff did not consistently provide oral care to residents who relied on them for this ADL.
Staff failed to maintain complete and accurate medical records for multiple residents, including missing and inconsistent documentation of wound care, delayed pain assessment after discovery of an injury of unknown origin in a cognitively impaired resident, and inaccurate recording of a PPD test result that was documented as negative despite no evidence the injection was administered and no supporting nurse’s note. Residents reported not receiving certain treatments, while MAR entries either lacked signatures for completion or contained conflicting information about whether care was provided.
Surveyors found that the facility failed to consistently implement and communicate correct transmission-based precautions and PPE use. One resident with a Foley catheter related to wounds had no precaution signage posted, while another resident in a double room had a contact precautions sign at the door, yet the NP entered without PPE and the GNA provided high-contact care wearing only gloves. Staff in that room stated the resident was not on contact precautions and later reversed the sign to show no PPE requirement. Therapy staff reported they rely solely on posted signs to determine PPE, and surveyors identified broader issues with inaccurate signage and staff awareness of which residents required contact precautions.
Surveyors found that MDS assessments were inaccurately coded for two residents. In one case, a resident sustained a femoral neck fracture after a fall, but the subsequent significant change MDS did not code the fall as a major injury and failed to capture prn Tylenol use documented on the MAR within the look-back period. In the other case, a quarterly MDS indicated opioid use for a resident, but the MAR for the same period showed no prescribed opioid, indicating incorrect coding of high-risk drug classes.
A resident who had recently been admitted and experienced a fall received multiple doses of the narcotic analgesic Tramadol, but the facility failed to accurately document all administered doses on the Medication Administration Record (MAR). Review showed only one Tramadol dose recorded on the MAR, while the Controlled Drug Receipt/Record/Disposition Form on the med cart reflected three doses given over two days. In interview, the DON stated staff are expected to document narcotic administration on the MAR and confirmed that two administered doses were not recorded there, resulting in an incomplete and inaccurate medical record.
Unqualified Infection Preventionist Overseeing Infection Control Program
Penalty
Summary
The facility failed to ensure that its designated Infection Preventionist (IP) met the mandatory qualifications for overseeing the Infection Prevention and Control Program. During an interview on 3/24/26 at 10:00 AM, the DON confirmed that she/he was serving as the facility’s IP but had not completed the specialized training in infection control required for the position. The DON further stated that no other staff member currently met the qualifications to serve as IP. Record review showed that the previously qualified IP left the facility in October 2025, and as of the survey date, the position remained unfilled by a qualified individual. At 1:30 PM on the same day, the Administrator and DON confirmed they were still in the process of finding a qualified IP for the facility, leaving the Infection Prevention and Control Program without a properly trained and qualified leader. No specific residents, medical histories, or clinical conditions were described in relation to this deficiency.
Unsecured Medications, Treatment Carts, and Oxygen Equipment
Penalty
Summary
Facility staff failed to ensure that drugs, biologicals, and related medical supplies were securely stored and properly maintained on multiple units. On one unit, an oxygen tank assigned to a resident was observed sitting on the floor behind the resident’s bed without any supporting device. On another unit, a treatment cart was observed with a tube of Collagenase Santyl cream labeled for a specific resident left on top of the cart, while residents in power wheelchairs passed by and staff were present at the nursing station. These observations showed that medications and oxygen equipment were not consistently secured as required. Further observations on additional units revealed an unattended and unlocked treatment cart at a nursing station, and on a separate occasion, a treatment cart with Diclofenac gel labeled for a resident left on top along with multiple packs of dressings. These incidents occurred across three units and on more than one date, demonstrating repeated failures to keep medications and treatment supplies in locked compartments or otherwise secured from unauthorized access.
Insufficient Dietitian Coverage and Delayed Nutritional Assessments
Penalty
Summary
The deficiency involves the facility’s failure to employ sufficient food and nutrition staff, including adequate dietitian coverage, to ensure timely assessment and appropriate diets for residents with significant nutritional and diabetic needs. A resident admitted over two weeks earlier with multiple comorbidities and an A1C of 11.5% had a hospital discharge recommendation for a carbohydrate-controlled diet, but was placed on a regular diet at admission with no acknowledgment of the recommended diet until one week later, when the resident requested larger portions. As of the survey date, the dietitian had not yet seen or reviewed this resident’s medical record, and the resident reported not having seen a dietitian and being very frustrated with the meals. During the first two weeks after admission, only one weight was obtained for this resident, despite physician notes stating the resident’s weight was “stable.” Further review of other residents showed additional failures in timely dietitian assessment and follow-up. One resident, readmitted in January and previously seen by the dietitian in September for a 6.4 lb weight loss over 30 days, had no documented follow-up despite continued weight loss totaling 22 lbs since the last dietitian review. Another resident admitted at the end of February with severe protein-calorie malnutrition had not been seen by the dietitian after about a month in the facility, despite a documented 14 lb (7%) weight loss over two weeks. The dietitian reported working only 12 hours per week at the facility and stated that she must prioritize which residents to see, focusing first on residents with tube feedings and those identified in risk meetings, resulting in delayed or absent assessments for new admissions and residents with ongoing weight loss and malnutrition diagnoses.
Linen Shortages and Poor Environmental Maintenance Compromise Resident Care and Comfort
Penalty
Summary
The deficiency involves the facility’s failure to maintain an adequate supply of clean linens and appropriate incontinence wipes, resulting in delays and alterations in residents’ incontinence care, as well as the use of towels and washcloths in place of disposable wipes. During the initial tour, the surveyor observed that the linen supply on one nursing unit hallway was low. Complaint reviews included concerns about delays in incontinence care and bed linens not being changed regularly, with residents left without clean bedding. A complainant reported that there was not enough clean linen available for residents. Staff interviews confirmed that towels, sheets, and washcloths were being used to wipe residents for incontinence care due to the absence of wipes, and that many of these linens were being thrown away when soiled. Staff also reported a shortage of linen, that linen deliveries to the units were late, and that residents who preferred to get up before breakfast had to wait for care when linen was delayed. Further observations showed that the clean supply room contained no disposable wipes or cloths for incontinence care, and a resident reported that staff did not use wipes, that the resident had to purchase their own, and that heavily soiled towels or washcloths were discarded. A tour of all nursing unit linen carts and closets revealed only six clean washcloths and limited supplies of towels, gowns, and bed linens. In the laundry room, only three washcloths were present, and the laundry assistant stated that there were only three washcloths available for each nursing unit that morning, that the facility was short on linen supply, and that these concerns had been repeatedly reported to the Director of Housekeeping over the preceding month and again that morning. The laundry assistant confirmed there was no additional laundry in process. The DON stated that wipe squares should be used for incontinence care, but no such wipes were found in the clean medical supply room, and no backup supply of washcloths was present in the emergency linen supply. The Director of Housekeeping confirmed there was no backup supply of washcloths. The deficiency also includes environmental and maintenance issues affecting resident bathrooms, handrails, and common areas. In the main dining area, a recliner chair was observed positioned directly in front of the handwashing sink, and two recliner chairs were stored in front of the nutrition area kitchenette. Multiple resident bathrooms and shared bathrooms were repeatedly observed over several days with unfinished spackle on walls that needed resurfacing and painting, chipped paint around sinks, uneven boards nailed to walls under sinks that appeared to partially cover holes, musty odors, black substances between shower bases and walls, missing threshold transition molding exposing cracks, missing tiles, and a nail, as well as eroded and chipped paint on baseboard heaters with exposed dark brown metal and rust-like material. Hallway handrails on both nursing units were observed to be worn, with chips, splintering, holes, and areas where the wood finish had worn off. A shower room was observed with a foul fecal odor, dried brown stains on the back of the toilet seat and in the toilet bowl, and a baseboard heater with eroded, chipped paint and rust-like material, along with chipped paint on the handrail. These conditions were acknowledged by the Director of Maintenance and other leadership, and some areas were noted to be in the process of renovation, but the observed deficiencies remained present during the survey period. Overall, the facility did not maintain a safe, clean, comfortable, and homelike environment in good repair across both nursing units and the dining area. The lack of adequate linen and incontinence supplies, combined with the poor condition of resident bathrooms, handrails, and certain common areas, constituted the basis for the cited deficiency. The observations and staff and resident reports consistently described shortages of essential hygiene supplies, delayed care related to linen availability, and multiple unresolved environmental and maintenance issues in resident care areas and shared spaces.
Failure to Thoroughly Investigate Abuse Allegations and Injuries of Unknown Origin
Penalty
Summary
Facility staff failed to thoroughly investigate allegations of potential abuse involving one resident and an injury of unknown origin involving another resident. For one resident, there were two separate allegations of abuse occurring on different days in early February. The facility’s investigation packets included interviews with staff who cared for or were scheduled to work with this resident on the days of the alleged incidents, and the investigations focused solely on this resident. However, there were no interviews conducted with other residents on the unit to inquire about abusive or neglectful treatment by the staff who were working during the times of the allegations. The surveyors noted that, although the allegations were not validated, there was no documentation that other residents were interviewed, if able, or assessed for signs or symptoms of injury. In a separate incident, another resident was identified on March 4 with a new bruise on the right eye, documented as a change in condition at 4:09 AM. This resident had a BIMS score of 99, indicating the resident was unable to complete an interview and therefore could not report how the injury occurred. The facility’s investigation identified a potential cause of the injury but did not reach a definitive resolution. Additionally, there were no interviews of other residents on the unit regarding possible abuse, nor were there documented assessments of other residents for injuries of unknown origin, particularly for those unable to speak for themselves, as in this resident’s case.
Failure to Provide Oral Care to Dependent Residents
Penalty
Summary
The deficiency involves the facility’s failure to provide oral care to residents who were dependent on staff for activities of daily living, specifically oral hygiene. One resident with a tracheostomy was observed with a thick, sticky white substance in the mouth and was noted to intermittently chew on nearby bedding. This resident made good eye contact and, when asked if staff brushed their teeth, shook their head no and mouthed that staff “need to.” According to the resident’s Minimum Data Set (MDS) dated 2/11/26, the resident was dependent on staff for oral care. Another resident, also dependent on staff for oral care per the 3/11/26 MDS, was observed sitting propped up in bed and able to respond with smiles. During the initial observation, the inside of this resident’s lips and upper and lower teeth had a thick, clear, white milky substance visible when the resident tried to open their mouth to smile. Oral care supplies were present in the nightstand, but the resident’s mouth and teeth were not clean. On a subsequent observation with the DON, NHA, and Corporate VP of clinical services, the same resident again had a thick, clear, milky substance between the lips and caking the teeth, which would string between the teeth when the resident attempted to open their mouth, demonstrating a lack of consistent oral care for residents dependent on staff for this ADL.
Incomplete and Inaccurate Medical Record Documentation for Treatments and Assessments
Penalty
Summary
Facility staff failed to maintain complete and accurate medical records and documentation for multiple residents. For one resident with wound care needs, review of the MAR showed that wound care and related treatments were signed as completed on the dates initially reported, despite the resident’s ongoing complaints that wound dressings were not being changed. When additional dates were reviewed, there were missing staff signatures for wound care on two specific dates, as well as three instances where application of A&D ointment to the resident’s feet was not signed off out of 24 days reviewed. Another resident with severe cognitive impairment, as evidenced by a BIMS score of 00, was found to have an injury of unknown origin (a bruise on the left hand). Documentation showed that a change in condition was initiated late in the morning, but a formal pain evaluation was not initiated and completed until that night, and the resident was unable to explain how the injury occurred or verbalize pain using a standard pain scale. For a third resident, documentation related to the admission PPD test was inconsistent and incomplete. The MAR contained an entry indicating “9” for the administration date, meaning “see nurse’s note,” but there was no corresponding nurse’s note. Despite the absence of a signed administration of the PPD injection, staff documented the PPD result as “negative” on the scheduled read date. The resident reported never receiving the PPD injection, and the DON confirmed that the facility had been out of PPD solution at the time, so the test would not have been administered. These findings demonstrate failures in accurate documentation of treatments and assessments, including wound care, pain assessment, and TB screening, as well as missing or incomplete supporting notes in the medical record.
Failure to Implement and Communicate Correct Transmission-Based Precautions
Penalty
Summary
Surveyors identified a deficiency in the facility’s infection prevention and control program related to inconsistent and incorrect implementation of transmission-based precautions and PPE use. During a complaint investigation focused on residents on transmission-based precautions, one resident with a visible Foley catheter was observed in the room with physical therapy, but there were no signs posted indicating any need for PPE, despite the resident being a new admission with a Foley catheter placed related to wounds. In another double-occupancy room, a contact precautions sign was posted at the doorway, but the nurse practitioner was in the room on a personal phone with no PPE, and the assigned GNA was repositioning the resident in bed while wearing only gloves. When questioned, the NP, RN, and GNA all stated that the resident in the room was not on contact precautions, and the GNA reported that signs were hanging at all doors and that this particular resident’s sign was “just wrong.” The surveyor observed the GNA later return to the room and turn the sign around to indicate no PPE requirement. Subsequent interviews revealed that therapy staff relied on posted signage to determine PPE use and that if the sign was wrong, the PPE used would be wrong. Overall, surveyors found problems with signage accuracy and staff awareness of which residents required contact precautions, as well as observed failures to follow appropriate PPE use for residents who should have been on contact precautions.
Inaccurate MDS Coding for Falls, Pain Management, and High-Risk Medications
Penalty
Summary
Facility staff failed to ensure Minimum Data Set (MDS) assessments were accurately coded for two residents reviewed during a complaint survey. For one resident, a facility-reported incident showed that the resident was found seated on the floor beside the bed and was diagnosed with a non-displaced femoral neck impaction fracture of the left hip following an x-ray. Despite this fall with a major injury, the subsequent significant change MDS dated 11/4/25 did not code the fall with major injury in Section J1900C. Review of the resident’s Medication Administration Records for October and November 2025 showed administration of Tylenol on 10/31/25 at 9:30 PM, which fell within the 5-day look-back period for the MDS, but Section J0100 (prn pain) of the same significant change MDS did not capture the use of Tylenol. For another resident, review of a quarterly MDS with an assessment reference date of 10/15/25 showed that Section N0415 (High-Risk Drug Classes) documented the use of an opioid medication. However, review of the resident’s October 2025 Medication Administration Record did not show that the resident had been prescribed an opioid during that period. In both cases, MDS staff later confirmed that these were errors in MDS coding, demonstrating that the assessments did not accurately reflect the residents’ clinical status and medication use as documented in their medical records.
Incomplete Documentation of Narcotic Administration on MAR
Penalty
Summary
The facility failed to maintain complete and accurate medical records in accordance with accepted professional standards for one resident receiving narcotic medication. The resident, admitted in March 2026, had a fall on 3/6/26 and was sent to the hospital on 3/9/26. Review of the March 2026 Medication Administration Record (MAR) showed documentation of a single 25 mg dose of Tramadol administered on 3/8/26 at 9:23 AM. However, review of the resident’s Controlled Drug Receipt/Record/Disposition Form, kept on the nurse’s medication cart and not in the medical record, showed that Tramadol 25 mg was administered three times between 3/8/26 and 3/9/26: at 11:00 AM and 9:00 PM on 3/8/26, and at 9:00 AM on 3/9/26. In interview, the DON stated that staff are expected to document narcotic administration on the MAR and confirmed that only one of the three Tramadol doses reflected on the controlled drug record was documented on the resident’s MAR. This discrepancy between the controlled substance record and the MAR, with missing documentation of two administered doses of Tramadol on the official medical record, constituted the failure to maintain a complete and accurate medical record for the resident.
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