Snow Hill Rehabilitation & Healthcare Center
Inspection history, citations, penalties and survey trends for this long-term care facility in Snow Hill, Maryland.
- Location
- 430 West Market Street, Snow Hill, Maryland 21863
- CMS Provider Number
- 215121
- Inspections on file
- 17
- Latest survey
- February 4, 2026
- Citations (last 12 mo.)
- 5
Citation history
Health deficiencies cited at Snow Hill Rehabilitation & Healthcare Center during CMS and state inspections, most recent first.
Surveyors found that the facility failed to ensure a functioning call bell system on two nursing units, where call lights above resident rooms were illuminated but no audible alerts were heard by staff. On one unit, the call bell panel behind the nurse’s station had tape covering the enunciator speaker and was set to a low tone that was not audible to staff or residents. On the other unit, an illuminated call light corresponded with a panel that had tape over the enunciator speaker, a nonfunctional enunciator, and a missing low/high tone switch. The director of maintenance reported being unaware of these issues until informed by surveyors, and the administrator and DON were notified of the nonfunctioning systems during the survey.
Nursing staff failed to follow MD-ordered BP and pulse parameters before administering cardiac medications for two residents. For one resident deemed unable to make medical decisions, Midodrine was given despite SBP readings above the ordered threshold at multiple administrations. For another resident with ESRD on hemodialysis, osteomyelitis, and AFib, Amiodarone and Metoprolol were repeatedly administered even when SBP and/or HR were below the specified hold parameters, as shown in MAR and clinical record reviews conducted during a complaint survey.
Staff failed to immediately report an allegation of suspected abuse to law enforcement after a resident’s family reported that an LPN had told staff not to provide care and not to administer pain medication. The facility’s investigation documented that the resident, who had a BIMS score indicating adequate cognition, reported not receiving pain medication, but the facility concluded the allegation was unsubstantiated and that care and pain medication were provided as ordered. Despite an abuse policy requiring timely reporting of all alleged or suspected abuse to the State Agency and other required agencies, including law enforcement, the allegation was not reported to police or other state agencies, a fact confirmed by the administrator.
A resident with depression, a positive trauma screen, and a history of PTSD had physician orders for psychological/psychiatric evaluation and care plans addressing depression and behavior issues, including yelling out instead of using the call bell. After an alleged incident in which an LPN told staff not to provide care or pain medication to the resident, the facility conducted an abuse investigation and determined the resident should be referred to Geri-Psych services. Despite this determination and the existing order for psychiatric evaluation, the resident was never assessed by the facility’s Geri-Psych consultant, as confirmed by the DON.
A resident’s closed clinical record lacked complete and accurate documentation related to controlled substances and medication administration. During a complaint survey, staff were unable to produce certain controlled substance administration records, and the DON reported that the Oxycodone controlled substance record for a range of dates could not be located. Review of the Oxycodone 5 mg tablet MAR showed missing nurse signatures and assessments for multiple administered doses. The report emphasizes that documentation is an integral part of medication administration and that inaccurate documentation has the potential to place residents at significant risk of medication error and provide incomplete or inaccurate information for providers and caregivers.
Surveyors found that food items, including mashed potatoes, chicken, eggs, sausage, and bacon, were served below required temperatures, and frozen juice was placed on breakfast trays. Temperature logs were incomplete, and beverage temperatures were not consistently recorded, as confirmed by staff interviews and record review.
The facility designated the ADON as its Infection Preventionist without ensuring she had completed the required specialized infection control training. Documentation showed she had only recently enrolled in a training course and was still on the first module, with no other qualified staff available for the role.
Surveyors found that several dependent residents did not receive required ADL care, including oral hygiene, assistance with dressing, and shaving. Observations included a resident with a dry mouth and unbrushed teeth despite physician orders, another with soiled clothing left unchanged, and a resident with unshaven facial hair. Staff interviews and record reviews confirmed that these residents required substantial or total assistance with ADLs, but care was not provided as needed.
Surveyors found expired and undated medications on two medication carts, including expired tablets, suspensions, and injection pens, as well as multi-use medications that were opened but not dated. The consultant pharmacist confirmed these deficiencies, and the DON reported that routine checks for expired and unlabeled medications were not performed due to staffing changes.
Surveyors identified multiple deficiencies in food storage and preparation, including staff not wearing hair nets, incomplete temperature logs, opened and unlabeled food items, personal food stored with facility food, pest issues, and contamination in both refrigerators and freezers. Expired food and unsanitary conditions were also found in the nourishment room, with these issues confirmed by the Dietary Manager and DON.
Surveyors found that a resident's nebulization mask was left uncovered and unlabeled on a nightstand, and oxygen tubing with a nasal cannula was nearly touching the floor. Additionally, clean bed sheets were observed touching the floor during folding by both a housekeeper and a laundry aide, despite staff awareness of proper procedures. These incidents reflect lapses in infection prevention and control practices.
The facility failed to maintain records for abuse and neglect investigations for three residents, leading to deficiencies in addressing alleged violations. In one case, a resident was found with another resident's hand on their clothed thigh, but the facility did not investigate. In another, a family member grabbed a resident around the neck, but no investigation report was found. In the third case, the facility could not provide the investigation file for a reported incident of abuse or neglect.
Two residents were not informed of their shower schedules and expressed a lack of awareness despite repeated inquiries. Staff interviews revealed confusion about documentation and the location of completed shower sheets, and the ADON confirmed the issue when notified that residents were unaware of their scheduled shower days.
A resident was admitted without a baseline care plan being developed or provided within the required 48-hour timeframe. Staff interviews indicated that the DON or ADON were responsible for creating these plans, but the process was not completed as required, resulting in a deficiency.
A resident was observed receiving oxygen via nasal cannula, but no care plan addressing oxygen use was found in their records. The DON confirmed that while care plans are usually initiated and updated as needed, the required care plan for oxygen therapy was not developed or implemented for this resident.
A resident with multiple diagnoses, including dementia and muscle weakness, was admitted and assessed as needing assistance with ADLs such as toileting, dressing, and personal hygiene. Despite this, no care plan was in place to address these needs, as confirmed by the DON during a surveyor interview.
Surveyors found that the facility did not perform ordered lab tests for a resident, failed to administer insulin according to prescribed sliding scale orders for another resident, and did not set up required pacemaker monitoring equipment for a third resident. Nursing staff were unaware of the need for cardiac monitoring, and documentation for lab draws and medication administration was incomplete or inconsistent with physician orders.
Two residents with pressure ulcers did not receive necessary care as staff failed to implement and document recommended interventions such as frequent turning, use of pressure-relieving devices, and heel elevation. Despite having physician orders and care plans in place, staff did not consistently follow these protocols, as confirmed by observations, interviews, and record reviews. The lack of standard protocols and inconsistent implementation led to deficiencies in pressure ulcer management.
A resident identified as being at risk for dehydration was found without access to water at the bedside or on the meal tray during a meal. The only available beverage was not suitable for the resident, and staff confirmed that the water pitcher had not been delivered as per facility protocol, despite a care plan intervention to encourage fluid intake.
Surveyors found that multiple residents receiving oxygen therapy did not have their oxygen tubing or humidification bottles labeled with the date of use, and required signage indicating oxygen in use was missing from room entrances. Additionally, one resident was receiving oxygen without a physician order, despite facility policy requiring such orders. These deficiencies were confirmed by interviews with LPNs and review of medical records.
A resident received PRN pain medications, including acetaminophen and oxycodone, without specific pain parameters outlined in the physician orders. Nursing staff administered these medications based on individual judgment rather than standardized guidelines, resulting in inconsistent pain management practices. The DON confirmed that the facility lacked a system for specifying pain parameters in PRN orders, leading to variability in care.
Surveyors found that two GNAs did not have documentation of the required 12-hour annual in-service training in their employee files. The HRD confirmed the absence of current in-service records and stated that a new training program had not yet started.
The facility did not include all required information on the posted nurse staffing sheet, omitting the resident census and the total number and actual hours worked by each category of licensed and unlicensed nursing staff. Staff interviews confirmed that the posted sheet only showed assignments and not the actual hours worked, and the HR director acknowledged the missing information.
A resident with a history of trauma and at risk for post-traumatic syndrome did not receive necessary behavioral health care services. Although care plans identified the risk and outlined monitoring goals, there was no evidence of a PTSD evaluation or consistent behavior monitoring, as confirmed by interviews and record reviews.
A resident did not receive monthly Medication Regimen Reviews (MRRs) as required, and the facility failed to implement the pharmacist's recommendations to monitor the resident's A1C levels for diabetes management. The necessary lab orders were not completed, and the last A1C result was not current, as confirmed by the DON.
A resident prescribed Abilify for psychosis and Lexapro for depression did not have required behavior monitoring documented on the TAR, despite facility policy and an active care plan calling for such monitoring. The DON confirmed that behavior monitoring for psychotropic medications was not being performed for this resident.
Three residents were not screened for or offered pneumonia vaccinations, and there was no documentation of vaccine administration or refusal. Facility policy requires assessment and offering of pneumococcal immunization upon admission, but staff could not explain the lack of documentation or confirm if the outside pharmacy had provided the vaccines.
Surveyors identified that required in-service training, including dementia care and abuse prevention, was not documented as completed for several GNAs. The HR Director confirmed the incomplete records and acknowledged that a new training program had not yet started, with no further documentation provided during the survey.
Nonfunctional Call Bell System on Two Nursing Units
Penalty
Summary
The deficiency involves the facility’s failure to maintain a functioning, house-wide resident call bell system on both nursing units, resulting in call lights being illuminated without an accompanying audible alert to staff. During observation of the Cypress Unit, the surveyor noted resident call bell lights lit above rooms, but no audible signal was heard to indicate residents were requesting assistance. Closer inspection of the call bell panel behind the nurse’s station showed tape covering the enunciator speaker and the enunciator set to a low tone that, after several seconds, produced a sound that was not audible to the surveyor, staff, or residents on the unit. On the Federal Unit, the surveyor observed a resident call bell light illuminated above a room with no audible alert, and the call bell panel behind that unit’s nurse’s station had tape over the enunciator speaker, a nonfunctional enunciator, and a missing low/high tone switch. The director of maintenance stated that they were not aware of these call bell system issues until the surveyor raised the concern, and the administrator and DON were informed of the nonfunctioning call bell systems on both units during the survey. No specific resident medical histories or clinical conditions were described in the report, and the deficiency centers on the environmental and equipment failures related to the call bell system and the lack of prior awareness by facility leadership and maintenance staff.
Failure to Follow BP and Pulse Parameters for Cardiac Medications
Penalty
Summary
Nursing staff failed to follow physician-ordered blood pressure parameters for administration of Midodrine for one resident. The resident had been deemed incapable of making all medical decisions by two physicians and had a physician’s order dated 01/16/26 for Midodrine 10 mg orally three times a day, to be given only when the systolic blood pressure (SBP) was less than 100 mmHg and to be held when SBP was greater than 100. Review of the January 2026 MAR showed that staff administered Midodrine despite SBP readings above the ordered threshold, including doses given when SBP was documented as 102/57, 108/62, and 101/60. Nursing staff also failed to follow physician-ordered blood pressure and pulse parameters for administration of Amiodarone and Metoprolol for another resident with diagnoses including end stage renal disease on hemodialysis, difficulty walking, osteomyelitis, and atrial fibrillation, who had been deemed capable of making all medical decisions. A physician’s order for Amiodarone 200 mg orally every 12 hours directed staff to hold the medication if SBP was less than 110 or heart rate was less than 60, yet MAR review showed multiple doses given when SBP was below 110 and/or pulse was below 60. A separate order for Metoprolol 25 mg orally twice daily directed staff to hold the medication if SBP was less than 100 or heart rate was less than 60, but MAR review again showed multiple administrations when SBP and/or pulse were below the ordered hold parameters, including an instance with SBP 81/40. These findings were identified through review of closed and active clinical records and MARs during a complaint survey and shared with facility leadership at exit.
Failure to Report Alleged Abuse to Law Enforcement
Penalty
Summary
Facility staff failed to immediately report an allegation of suspected resident abuse to local law enforcement as required. On 08/31/25, a nursing staff member (LPN #1) allegedly told a resident’s nursing staff not to provide care and stated that pain medication would not be administered to the resident. The resident later informed his/her responsible party that nursing staff had not medicated him/her with pain medication. The responsible party reported this concern, and the facility initiated an investigation. The resident’s Brief Interview for Mental Status (BIMS) score was documented as 13/15 on 06/10/25, indicating the resident had the capacity to report concerns. The Office of Health Care Quality (OHCQ) received a facility-reported incident on 09/05/25 regarding these allegations. A 5-day follow-up investigation report dated 02/03/26 documented the allegation and the facility’s conclusion that the allegation was unsubstantiated, stating that the resident had received care and pain medication as ordered on 08/31/25. Review of the facility’s abuse policy showed that all alleged or suspected abuse, including verbal and mental abuse and neglect, must be reported to the State Agency and all other required agencies, including law enforcement, in a timely manner. Further review of the facility’s follow-up investigation revealed that the allegation was not reported to law enforcement or any other state agencies beyond OHCQ. During an interview on 02/04/26, the administrator confirmed that law enforcement had not been notified of the abuse allegation involving this resident.
Failure to Obtain Psychiatric Evaluation After Abuse Allegation and Positive Trauma Screen
Penalty
Summary
Facility staff failed to obtain a psychiatric consultation for Resident #3 despite multiple indicators and orders requiring such services. The resident had diagnoses including muscle atrophy, lack of coordination, difficulty walking, depression, gout, and osteomyelitis, and had been deemed capable of making medical decisions by the physician. On 12/06/24, the resident screened positive for a history of trauma and past PTSD, and a depression care plan was initiated the same day, identifying the resident as at risk for depression with a positive trauma screen. Interventions in the care plan directed staff to notify the provider for any risk of harm to self or others and to observe for signs of depression such as hopelessness, anxiety, sadness, tearfulness, and repetitive anxious or health-related complaints. On 03/26/25, a physician’s order instructed nursing staff to obtain a psychological/psychiatric evaluation upon admission and as needed due to the positive trauma screen. On 08/31/25, an incident occurred in which an LPN allegedly told other nursing staff not to provide care to Resident #3 and stated that pain medication would not be administered. Following this, the facility conducted an abuse investigation related to these allegations. The resident also had a behavior care plan initiated on 09/02/25 for yelling out for assistance instead of using the call bell, with interventions including discussing the behavior with the resident when reasonable, explaining why the behavior was inappropriate, anticipating and meeting needs, monitoring episodes of behavior, and documenting behaviors and potential causes. Despite the physician’s order for psychological/psychiatric evaluation and the facility’s determination during its follow-up investigation that the resident should be referred to the facility Geri-Psych service provider, the DON confirmed that the resident was never assessed by the Geri-Psych consultant after the abuse allegation was brought to the facility’s attention.
Incomplete Controlled Substance and MAR Documentation for a Resident
Penalty
Summary
The deficiency involves the facility’s failure to maintain complete and accurate clinical records for a resident, specifically related to controlled substances and medication administration documentation. During a complaint survey, a nurse surveyor reviewed the closed medical record of Resident #3 and requested all closed paper documents and access to the electronic medical record. Several documents were found to be missing from the clinical record, and facility staff were unable to produce certain documentation, including medication administration records (MARs) and controlled medication records. The nursing staff did not document the number of Oxycontin 10 mg tablets destroyed on the resident’s controlled substance administration record on 09/21/25. In an interview on 02/04/26, the DON stated they were unable to locate the resident’s Oxycodone controlled substance administration record for dates between 09/05/25 and 09/24/25. Additionally, a review of the resident’s Oxycodone 5 mg tablet MAR for August and September 2025 showed missing nursing administration signatures and nursing assessments for doses that were given on specific dates and times, including 08/25/25 at 4 pm, 09/01/25 at 10:30 pm, and 09/02/25 at 1:15 pm and 6:15 pm. The report notes that documentation is an integral part of medication administration and that inaccurate medication documentation has the potential to place residents at significant risk of medication error and provide incomplete or inaccurate information for providers and caregivers to evaluate.
Failure to Serve Food and Beverages at Safe and Appetizing Temperatures
Penalty
Summary
Surveyors observed that the facility failed to ensure food and beverages were served at safe and appropriate temperatures. During multiple kitchen observations, hot foods such as mashed potatoes, mechanical ground chicken, fried chicken, pureed eggs, ground sausage, and bacon were found to be below the required internal temperatures for safe consumption. The Dietary Manager and staff were seen attempting to reheat some items, but even after reheating, several foods still did not reach the necessary temperatures. Additionally, food temperature logs were incomplete, with missing entries for certain dates and meals. Surveyors also noted that frozen cranberry juice was placed on residents' breakfast trays and served to residents, rather than being at an appropriate temperature for consumption. Review of the Meal Service Checklist revealed that juice temperatures were not recorded for several weeks. These deficiencies were confirmed through observation, interviews with dietary staff and the DON, and review of facility records.
Infection Preventionist Lacks Required Training
Penalty
Summary
The facility failed to ensure that its designated Infection Preventionist (IP) met the mandatory qualifications for the position. The Assistant Director of Nursing (ADON), who was serving as the IP, confirmed during an interview that although she holds a college degree in nursing, she had not completed specialized training in infection control as required. Documentation reviewed included an email and a computer screenshot showing that the ADON had only recently registered for an Infection Prevention and Control course and was currently on the first module. The Director of Nursing (DON) also confirmed that the ADON was the only individual currently serving as the IP and that no one else in the facility was qualified for the position.
Failure to Provide ADL Care to Dependent Residents
Penalty
Summary
The facility failed to provide necessary activities of daily living (ADL) care to dependent residents, as evidenced by multiple observations and record reviews. One resident, who was dependent on staff for all ADLs due to upper and lower extremity impairment and was NPO, was repeatedly observed with a dry mouth, yellow teeth, and a thick coating on the tongue. Clinical records confirmed a physician's order for oral care every shift, but interviews and observations revealed that oral care had not been completed as required. Another resident was observed lying in bed with dried food particles on the gown, which remained unaddressed for an extended period despite staff being notified. This resident required maximum assistance for dressing and personal hygiene according to the admission assessment. Additionally, a resident requiring assistance with ADLs was observed with significant facial hair and reported not receiving help with shaving since admission. Staff confirmed that shaving assistance should have been provided but was not. A further resident with dentures, requiring substantial to maximal assistance for oral hygiene, was found to have an unused toothbrush still in its packaging. Both the resident and a family member reported that oral care had not been provided since admission. Staff interviews revealed a lack of awareness regarding which residents required assistance with dentures, and repeated observations confirmed that oral care was not performed as needed.
Failure to Properly Label and Store Medications
Penalty
Summary
Surveyors identified that the facility failed to ensure medications were properly labeled and stored, as required by professional standards. During observations of two medication carts, expired medications and opened medications without dates were found. Specific examples included expired tablets, suspensions, cough suppressants, injection pens, and inhalation aerosols. Additionally, several multi-use medications, such as insulin pens and ophthalmic solutions, were found opened but not dated, making it impossible to determine their expiration. These deficiencies were confirmed through interviews with the consultant pharmacist, who stated that expired medications should be removed and multi-use medications should be dated upon opening. The facility's own Medication Storage Document indicated that consultant pharmacists are responsible for routinely inspecting for discontinued, outdated, or improperly labeled medications. However, the Director of Nursing reported that the Night Charge Nurse, who typically checks medication carts for expired and unlabeled medications, had been reassigned to direct care duties and was unable to perform this supervisory role. The pharmacy was noted to conduct monthly audits, but expired and undated medications were still present at the time of the survey.
Deficient Food Storage and Sanitation Practices Identified
Penalty
Summary
Surveyors observed multiple deficiencies in the facility's food storage and preparation practices. During a kitchen tour, staff members were seen preparing food without wearing hair nets. Temperature logs for both the reach-in fridge and beverage refrigerator were not completed daily, with several days missing entries. Inside the reach-in fridge, multiple opened food items were found unlabeled, including sliced turkey, cheese, and vegetables, as well as personal food items that should not have been stored there. A container of mozzarella cheese with a broken lid and an outdated label was also found. In the dry storage area, several food items such as peanut butter, instant mashed potatoes, noodles, and bread were found opened and undated, and the Dietary Manager acknowledged ongoing pest issues in the facility. Further observations revealed additional concerns in the freezer, where an unknown substance had dripped onto food items, contaminating an open bag of ice and waffles. Multiple opened and unlabeled food items were found, including leftovers and personal beverages. The outside freezer had water icicles dripping onto food due to a faulty gasket, causing temperature fluctuations. In the nourishment room, expired milk and sandwiches were found, along with personal food in the fridge and a dirty ice scoop holder. These findings were confirmed by the Dietary Manager and DON during the survey.
Deficiencies in Infection Control: Improper Storage of Respiratory Equipment and Laundry Handling
Penalty
Summary
Surveyors identified deficiencies in the facility's infection prevention and control program related to the handling and storage of respiratory equipment and the management of clean laundry. For one resident, a nebulization mask was observed left uncovered and unlabeled on a nightstand when not in use, contrary to facility expectations that such devices be stored in a clean, labeled bag. Additionally, the same resident's oxygen tubing was seen hanging from the concentrator with the nasal cannula exposed and nearly touching the floor. These observations were confirmed by nursing staff during the survey. In a separate incident, clean bed sheets were observed touching the floor during the folding process in the laundry room on multiple occasions. Both a housekeeper and a laundry aide were seen allowing sheets to contact the floor while folding, with the laundry aide acknowledging awareness of the proper procedure but citing difficulty due to her height. The housekeeping supervisor confirmed that clean laundry should not touch the floor and that folding should be done on a table.
Failure to Maintain Abuse and Neglect Investigation Records
Penalty
Summary
The facility failed to maintain records for abuse and neglect investigations for three residents, leading to deficiencies in addressing alleged violations. In the first case, a resident was found with another resident's hand on their clothed thigh, but the facility did not investigate the incident. The resident involved had a diagnosis of dementia and was adjusting to a new environment. Despite the incident being reported to the Office of Health Care Quality, the facility could not provide documentation of an investigation, and staff members were unaware of the incident. In the second case, a staff member observed a family member grab a resident around the neck after the resident refused a kiss. The facility was unable to locate the investigation report for this incident, and the current Nursing Home Administrator, who was not employed at the time, could not find any documentation. An activities aide reported the incident to her supervisor and the NHA at the time, but no evidence of a thorough investigation was provided. The third case involved a reported incident of abuse or neglect, but the facility could not provide the investigation file. The current NHA, who was not in the position at the time of the incident, was unable to locate the file or any documentation of staff in-services on abuse and neglect. The facility's policy required prompt investigation and documentation of such incidents, but no evidence was found to support compliance with this policy.
Failure to Inform and Support Resident Choice in Shower Scheduling
Penalty
Summary
The facility failed to provide residents with the opportunity to choose or be informed about their shower schedules, as evidenced by interviews and record reviews. Two residents reported not knowing their shower schedules, with one stating they had been in the facility for several weeks and had repeatedly asked staff for information without receiving an update. Another resident expressed a desire to know their schedule. Review of physician orders showed that one resident had scheduled shower days, while the other did not have an order in place. Staff interviews revealed that GNAs received assignments with highlighted shower days at the start of their shifts, but there was confusion regarding the location and availability of completed shower sheets. A GNA was unable to provide completed documentation, and the LPN stated that alert and oriented residents were aware of their schedules, though this was contradicted by resident interviews. The ADON confirmed the lack of accessible shower sheets and acknowledged awareness of the issue when informed that residents were not aware of their shower days.
Failure to Develop Baseline Care Plan Within 48 Hours of Admission
Penalty
Summary
The facility failed to develop a baseline care plan for a newly admitted resident within 48 hours of admission, as required. Record review showed that the resident was admitted on 1/31/25, but there was no evidence in the medical record that a baseline care plan was created or provided to the resident. Interviews with staff revealed that the DON or ADON were typically responsible for developing baseline care plans, while nurses would add interventions in the electronic health record. The DON confirmed that the baseline care plan was not completed in a timely manner for this resident.
Failure to Develop and Implement Oxygen Therapy Care Plan
Penalty
Summary
The facility failed to develop and implement a comprehensive care plan for a resident who was receiving oxygen therapy via nasal cannula at 2 liters per minute. During the recertification survey, it was observed that the resident was using oxygen, but a review of the care plan revealed no documentation or evidence that a care plan addressing oxygen use had been created. Interviews with the DON confirmed that care plans are typically initiated upon admission and updated as needed, but in this case, the necessary care plan for oxygen therapy was not present. The deficiency was identified through direct observation, record review, and staff interview.
Failure to Develop Care Plan for ADL Needs
Penalty
Summary
The facility failed to develop or revise a care plan to address the activities of daily living (ADL) needs for one resident. The resident was admitted with multiple diagnoses, including hypotension, diabetes, dementia, and muscle weakness. According to the Minimum Data Set (MDS) admission assessment, the resident required assistance with ADLs such as toileting, dressing, showering, and personal hygiene. However, a review of the clinical records revealed that there was no care plan in place to address these specific needs. During an interview, the Director of Nursing (DON), who also served as the MDS coordinator, acknowledged responsibility for initiating care plans and confirmed that a care plan for ADLs should have been established for the resident. The absence of a care plan was identified during the surveyor's review, indicating that the facility did not meet the requirement to develop or revise care plans to address the resident's assessed needs.
Failure to Follow Physician Orders for Labs, Medication Administration, and Cardiac Monitoring
Penalty
Summary
The facility failed to ensure that physician laboratory orders were performed as ordered for a resident who required weekly CBC and CMP blood tests. Despite an active order for these labs to be drawn every Tuesday for four weeks, the medical records showed that the tests were not performed for three consecutive weeks. Documentation revealed that while other blood tests were marked and drawn, the CBC and CMP were not, and the phlebotomist's signature was crossed out for those tests, confirming they were missed. Additionally, the facility did not administer medications as ordered for a resident requiring insulin based on blood glucose levels. The Medication Administration Record (MAR) lacked documentation of the resident's blood glucose level on a day when insulin was held, making it unclear if the medication was withheld appropriately. On another occasion, the MAR showed a blood glucose level of 470, but the insulin dosage administered did not match the physician's sliding scale order, which required a higher dose for such elevated levels. The facility also failed to provide proper cardiac monitoring for a resident with a pacemaker. The resident and family reported that the pacemaker monitoring system had not been set up since admission several months prior, and observations confirmed the equipment remained unused in the resident's closet. Interviews with assigned nursing staff revealed a lack of awareness regarding the resident's pacemaker and the need for bedside monitoring, despite care plans and medical records indicating the presence of a pacemaker and the requirement for monitoring.
Failure to Implement and Document Pressure Ulcer Prevention and Treatment Interventions
Penalty
Summary
The facility failed to ensure that residents with pressure ulcers received the necessary treatment and that recommended interventions were implemented. For one resident, wound clinic recommendations included the use of a low air-loss mattress, turning and repositioning every two hours, floating heels at all times, and using pillow boots to offload pressure. However, a review of active physician orders showed that these pressure-relieving interventions were not written or implemented. Interviews with nursing staff and the DON confirmed that there were no standing orders or standard protocols for pressure ulcer management, and that interventions were handled on a case-by-case basis or only after wound clinic visits. Another resident with an unstageable pressure ulcer on the coccyx was observed not being turned or repositioned as required, and their heels were not floated despite orders and care plan interventions specifying these actions. The resident and their family member both reported that necessary tasks such as turning, repositioning, and heel elevation were not being performed. Observations confirmed that the heel floating device was not in use and was instead stored under the sink, and the resident had not been assisted out of bed as ordered. Record reviews for both residents showed that appropriate orders and care plan interventions were in place, including frequent turning, use of specialized cushions, and heel elevation. Despite these documented interventions, staff failed to consistently implement them, as evidenced by direct observation, resident and family interviews, and staff interviews. This failure resulted in the residents not receiving the necessary care to promote healing and prevent the development or worsening of pressure ulcers.
Failure to Provide Bedside Water for Resident at Risk of Dehydration
Penalty
Summary
A deficiency was identified when a resident, who was care planned as being at risk for dehydration, was observed without access to drinking water at the bedside or on the meal tray during lunch. The resident expressed to the surveyor that the only available beverage was too sweet and that water was not provided. Upon further inquiry, a Geriatric Nursing Assistant (GNA) confirmed that water is typically provided in pitchers at the bedside, filled by the night shift, but acknowledged that the resident in question did not have a water pitcher delivered. The Charge Nurse also confirmed the absence of water and explained that water is not placed on meal trays because it is assumed to be available at the bedside. Review of the resident's clinical record showed an active care plan intervention to encourage fluid intake due to dehydration risk. The Director of Nursing (DON) confirmed the facility's practice of providing water pitchers at the bedside and stated that it is the responsibility of GNAs and Charge Nurses to ensure pitchers are refilled. The deficiency was substantiated by direct observation and staff interviews, which revealed a lapse in the delivery of water to the resident, despite facility protocols and the resident's identified risk for dehydration.
Failure to Label Oxygen Equipment and Ensure Physician Orders for Oxygen Therapy
Penalty
Summary
Surveyors identified that the facility failed to provide necessary respiratory care services for residents requiring oxygen therapy. Specifically, oxygen administration equipment such as tubing and humidification bottles were not labeled with the date they were put into use or when they should be replaced for multiple residents. Additionally, there was no signage placed outside the residents' rooms to indicate that oxygen was in use, as required by facility policy. These deficiencies were observed during multiple visits and confirmed through interviews with nursing staff, who acknowledged that labeling and signage were expected practices. Further review revealed that one resident was receiving oxygen therapy without a corresponding physician order, contrary to the facility's policy that oxygen must be administered under a physician's direction. The affected residents had significant respiratory diagnoses, including acute respiratory failure with hypoxia, chronic obstructive pulmonary disease, and chronic respiratory failure. Despite the presence of physician orders for oxygen therapy for some residents, the lack of proper labeling, absence of required signage, and missing physician order for one resident constituted a failure to adhere to established protocols for safe and appropriate respiratory care.
Failure to Specify Pain Parameters for PRN Pain Medication Orders
Penalty
Summary
The facility failed to ensure that pain medications were administered according to professional standards of practice for a resident requiring pain management. Record review showed that the resident had active and discontinued PRN orders for acetaminophen and oxycodone, but none of these orders specified pain parameters to guide administration. Medication administration records indicated that the resident received both Tylenol and oxycodone on multiple occasions, with pain ratings documented at the time of administration. However, there was no clear guidance in the orders regarding which medication should be given at specific pain levels. Interviews with nursing staff revealed inconsistency in practice, as some nurses relied on their own judgment to determine which PRN pain medication to administer when parameters were not specified. The LPN interviewed stated that she would give oxycodone for pain ratings above 7 and Tylenol for pain ratings below 5, but this was not based on any written protocol. The DON confirmed that the facility did not have standardized pain parameters in place for PRN pain medications and that the process depended on individual physician orders, which were not always present. This lack of clear parameters led to inconsistent pain management practices for the resident.
Failure to Complete Required Annual GNA In-Service Training
Penalty
Summary
The facility failed to ensure that Geriatric Nursing Assistants (GNAs) completed the required 12 hours per year of in-service training, as evidenced by a review of two GNA employee files. During the survey, it was found that neither of the two GNA files contained documentation of current annual in-service training. The Director of Human Resources confirmed that the required in-service training had not been completed and that a new training program had not yet been initiated. No documentation of the required in-service training was provided to the surveyor at the time of exit.
Failure to Post Complete Nurse Staffing Information
Penalty
Summary
The facility failed to ensure that the posted nurse staffing information on the nursing unit included all required elements. During a tour of the nursing unit, the surveyor observed that the daily staffing sheet, while displaying the facility name, staff names, assignments, date, and shift, did not include the resident census or the total number and actual hours worked by each category of licensed and unlicensed nursing staff responsible for resident care per shift. This omission was confirmed through interviews and review of the posted staffing sheet. Staff interviews revealed that the posted sheet was primarily used to indicate staff assignments for the shift, but did not provide information on the actual hours worked by each staff member. Both a Geriatric Nursing Assistant and an LPN confirmed that the sheet did not display the required details regarding hours worked. The Director of Human Resources, responsible for staffing and scheduling, also acknowledged that the posted sheet was missing the resident census and the total number and actual hours worked by each staff category.
Failure to Provide Behavioral Health Services for Trauma History
Penalty
Summary
A resident with a documented history of trauma and at risk for post-traumatic syndrome did not receive necessary behavioral health care services. The resident reported a lack of behavioral services for their trauma history. Record reviews showed that the resident's care plan identified risks for post-trauma syndrome and mood problems, with goals to monitor and report symptoms such as sadness, loss of interest, and changes in behavior. However, there was no evidence that a specific evaluation for PTSD was completed, despite the resident's risk factors and self-reported trauma history. Interviews with facility staff revealed that the process for residents identified as at risk for PTSD included a trauma screening and scheduling a psychiatric evaluation. Despite this, the resident's psychology consult notes did not document a PTSD evaluation, and behavior monitoring was not recorded on the Treatment Administration Record for the past six months. The deficiency was identified through interviews and record reviews, confirming the facility failed to provide necessary behavioral health care services for the resident.
Failure to Complete Monthly Medication Regimen Reviews and Implement Pharmacist Recommendations
Penalty
Summary
The facility failed to ensure that a licensed pharmacist performed a monthly Medication Regimen Review (MRR) for a resident, as required. Record review showed that MRRs were not completed every month, with gaps in the documented review dates. Additionally, the facility did not implement the pharmacist's recommendations from the MRRs regarding the monitoring of the resident's Hemoglobin A1C (A1C) levels, which are important for diabetes management. The pharmacist had recommended checking the resident's A1C immediately and every 3-6 months, and the physician agreed to these recommendations, but the necessary lab orders were not completed as directed. Further review of the resident's records revealed that the last A1C lab value was obtained several months prior, and subsequent lab collections did not include the A1C test as recommended. The Director of Nursing confirmed that the expectation was for the MRR to be completed monthly, indicating that the facility did not follow its own policies and procedures for medication review and follow-up on pharmacist recommendations.
Failure to Monitor Behaviors for Resident on Psychotropic Medications
Penalty
Summary
The facility failed to provide adequate behavior monitoring for a resident who was prescribed psychotropic medications, specifically Abilify for psychosis and Lexapro for depression. Record review showed that although a care plan was in place to address the use of these medications, including interventions such as discussing ongoing need with the physician and family and reviewing behaviors and alternative therapies, there was no evidence on the Treatment Administration Record (TAR) that behaviors were being monitored as required. The Director of Nursing confirmed that behavior monitoring for psychotropic medications was not being conducted for this resident, despite facility policy stating that such monitoring should occur and be documented each shift. This deficiency was identified during a recertification survey and was evident for one of four residents reviewed for unnecessary medications.
Failure to Screen and Offer Pneumonia Vaccinations
Penalty
Summary
The facility failed to screen and offer pneumonia vaccinations to three out of five residents reviewed for immunizations. Medical record review revealed that these residents had no documentation indicating they were screened for, offered, received, or refused the pneumonia vaccine. The facility's policy requires that each resident be assessed for pneumococcal immunization upon admission and be offered the vaccine unless medically contraindicated or previously immunized. During staff interviews, the Assistant Director of Nursing (ADON) acknowledged that the vaccines should have been offered and administered as appropriate, but was unable to explain why this did not occur for the affected residents. The ADON also reported that vaccination services had previously been performed by an outside pharmacy, but she did not have access to those records and was unable to locate documentation for the three residents in question, even after further searching.
Incomplete In-Service Training Documentation for GNAs
Penalty
Summary
The facility failed to ensure that required in-service training for Geriatric Nursing Assistants (GNAs) was completed, as evidenced by incomplete documentation in all five GNA employee files reviewed. During a record review, the surveyor found that none of the files for the selected GNAs contained complete records of the mandated in-service training, including education in dementia care and abuse prevention. The Director of Human Resources confirmed the lack of documentation and acknowledged that a new in-service training program had not yet been initiated. No additional documentation was provided to demonstrate completion of the required training for these GNAs by the time of the survey exit. The deficiency was identified through both employee record reviews and interviews, with the facility unable to provide evidence that the GNAs had received the necessary in-service education as required.
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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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