Solomons Nursing And Rehab Center
Inspection history, citations, penalties and survey trends for this long-term care facility in Solomons, Maryland.
- Location
- 13325 Dowell Road, Solomons, Maryland 20688
- CMS Provider Number
- 215270
- Inspections on file
- 18
- Latest survey
- January 16, 2026
- Citations (last 12 mo.)
- 1
Citation history
Health deficiencies cited at Solomons Nursing And Rehab Center during CMS and state inspections, most recent first.
A resident with multiple comorbidities, moderate cognitive impairment, and high fall risk experienced a fall from bed. Despite facility policy requiring assessment, post-fall documentation, incident reporting, and notification of the physician, family, and oncoming staff, the assigned RN did not complete the required paperwork, did not document the fall, and was unsure if it was reported to the next shift. A GNA reported the resident’s leg as "wobbly" and, with a CMA, assisted the resident back to bed after being told the nurse had assessed the resident. The following day, another RN noted swelling, discoloration, and abrasions of the resident’s leg and ankle, and an LPN later requested physician evaluation, leading to hospital transfer where imaging revealed a comminuted fracture of the distal tibia and fibula.
A survey revealed that the facility failed to maintain a homelike environment in resident rooms, with issues such as missing towel hangers, damaged footboards, and bathroom fixture problems. These deficiencies were confirmed by the Administrator and Director of Maintenance.
The facility failed to ensure effective mechanical ventilation in resident bathrooms, affecting 5 out of 7 rooms reviewed. During a tour with the Administrator and the Director of Maintenance, it was observed that bathrooms in certain rooms did not have effective ventilation, as confirmed by a test using a thin piece of paper. The Director of Maintenance attributed the issue to likely nonfunctional motors in the rooftop ventilation units.
The facility failed to protect residents from abuse, as evidenced by grievances and interviews. A resident reported verbal abuse by a GNA/CMA, corroborated by a social worker's grievance. Another resident reported rough treatment and public embarrassment by the same GNA/CMA. A third resident alleged physical abuse by a GNA, which was documented but not investigated. The facility's grievance process was inadequate, leading to a failure to address and prevent abuse.
A resident with diabetes and neuropathy experienced harm due to inadequate foot care. Despite a podiatrist's recommendation for antibiotic ointment and monitoring, no orders were documented, and confusion about which toe was affected persisted. The resident's condition worsened, leading to a hospital transfer and partial amputation. The facility's failure to document and follow through with care recommendations contributed to the harm.
The facility failed to resolve grievances filed by residents, including verbal abuse, rough handling, and unresolved complaints about care and personal belongings. Despite grievances being logged and assigned to department supervisors, there was no documentation of resolution or follow-up. Interviews revealed a lack of communication and follow-up in the grievance process, leading to unresolved grievances and a failure to protect residents' rights.
The facility failed to report residents' allegations of theft and abuse in a timely manner. A resident reported missing money, but the facility delayed reporting to OHCQ. Another resident's abuse allegation was not investigated promptly. Multiple grievances about verbal abuse and rough treatment were documented but not resolved, indicating systemic issues in handling such complaints.
The facility failed to conduct thorough investigations and maintain documentation for multiple abuse allegations involving residents. Incidents included physical and verbal abuse by GNAs, with missing documentation of interviews and follow-ups. The NHA acknowledged the deficiencies, and the DON noted systemic issues in handling such allegations.
A facility failed to deliver meals at appropriate temperatures, as observed during a survey. A resident and families reported that food was lukewarm and not palatable. A test tray showed food temperatures below expected levels, with chicken at 119°F, rice at 126°F, potato at 117°F, and peas at 120°F.
The facility failed to store food according to professional standards, with unlabeled and expired items found in the kitchen and personal items in the freezer. Significant ice buildup was also observed, creating a slippery area. The Certified Dietary Manager confirmed these issues, indicating a lapse in following the facility's food labeling and dating procedures.
The facility failed to maintain accurate medical records and incident documentation for three residents. Two residents had conflicting MOLST forms in their charts, leading to potential confusion about their code statuses. Additionally, the facility did not properly document falls and related injuries for two residents, with one resident's fall protocol not completed immediately and another's pain management assessments failing to note a significant fracture and surgery.
A facility failed to notify a resident's medical Responsible Party (RP) about changes to the care plan, specifically the end of Medicare-covered services, contacting only the financial RP instead. Interviews revealed a misunderstanding of notification protocols, leading to the medical RP being uninformed on multiple occasions.
A resident's diet was changed from mechanical soft to pureed texture and chopped meats without prior notification to the Responsible Party (RP) or documented rationale. The LPN involved believed the change was due to dental needs, but there was no evidence of RP notification or documentation supporting the change, leading to a deficiency noted by the surveyor.
The facility failed to promptly address concerns from the family council group for several months. Despite the NHA's claim of timely responses, evidence showed delays in addressing issues raised in meeting minutes from April, May, July, August, and September. The deficiency was identified through a complaint and confirmed by reviewing meeting minutes and interviews.
A resident with a history of diabetes and other conditions experienced a delay in receiving scheduled medication due to altered mental status. The medication, Glimepiride, was scheduled for administration at 8:30 AM but was not attempted until 10:40 AM, two hours late. The facility's policy requires medications to be given within one hour of the scheduled time, which was not followed in this instance.
The facility did not have the required Residents' Rights information, including contact details for the Maryland Long-Term Care Ombudsman and the state survey agency, posted in accessible locations. This was noted across all resident care areas, and staff confirmed the postings were removed during renovations. The NHA later provided the necessary poster for display.
The facility staff did not display the annual recertification survey results in an accessible location for residents, family members, and legal representatives. The survey results were initially kept in the NHA's office and were not available in the lobby or any open area. The NHA explained that the binder might have been removed due to renovations. Eventually, the survey results were placed in the reception area, but the most recent results were from 2019.
The facility failed to maintain copies of Advance Directives for three residents and did not address a resident's request to discontinue thickened liquid treatment. Despite acknowledging the presence of Advance Directives, the facility did not ensure they were included in medical records. Additionally, a resident's desire to stop a specific treatment was not discussed with relevant parties, leaving the request unaddressed.
The facility failed to provide written notification of hospital transfers to two residents and their representatives, as required by regulations. One resident was transferred twice without written notice, and another was transferred after becoming unresponsive, with no documentation of notification. The Director of Nursing was unaware if notifications were being done.
A resident with flaccid hemiplegia was observed without the prescribed arm support, despite a physician's order and care plan intervention for a Comfy Grip Splint to be worn during the daytime. A staff member confirmed the need for the splint and applied it after the surveyor's inquiry, highlighting a lapse in care.
The facility failed to maintain RN coverage for at least 8 consecutive hours a day, 7 days a week, as required. On four specific days, there was no RN coverage for 24 hours. The DON confirmed the absence of staffing waivers and acknowledged the issue, particularly on weekends. The Staff Scheduler noted challenges in securing weekend RN coverage, although a weekend supervisor who is an RN was expected to start soon.
The facility failed to prevent infection spread and maintain equipment standards. A resident with Covid-19 was found without droplet precaution signage, and another resident's oxygen equipment was improperly labeled and maintained. Staff acknowledged and addressed these deficiencies.
The facility failed to maintain the walk-in freezer in safe operating condition, resulting in ice buildup on the ceiling and floor, creating a slippery hazard. Despite a previous assessment attributing the issue to condensation, the problem persisted, and recent documentation of service calls was not provided. The deficiency highlights a failure to ensure essential equipment is working safely.
A facility failed to ensure a resident had a call bell within reach, as observed by a surveyor on two occasions, despite being informed by an LPN. Additionally, another resident with a history of surgical amputation and mobility issues was not provided with necessary bedrails in a timely manner, as the facility delayed ordering additional bedrails despite the identified need.
The facility failed to conduct timely care plan meetings and include necessary interventions for residents. A resident had no care plan meetings documented for quarterly assessments, while another resident's care plan lacked interventions for therapeutic activities. The scheduling process for care plan meetings was flawed, leading to missed meetings.
The facility failed to maintain good personal hygiene for two residents. One resident, requiring extensive ADL assistance, had inconsistent shower documentation, and the DON could not confirm showers were given. Another resident experienced a 52-minute delay in toileting assistance despite activating the call light. The DON acknowledged the need for timely response.
The facility failed to document wound care responses for a resident with a sacral wound, leading to unclear treatment effectiveness. Additionally, another resident requiring two-person assistance for transfers was moved by a single aide, resulting in shoulder pain. These deficiencies highlight lapses in documentation and adherence to care protocols.
Failure to Assess, Document, and Report Resident Fall and Resulting Injury
Penalty
Summary
The deficiency involves the facility’s failure to follow its fall prevention and post-fall procedures for a resident at high risk for falls. The facility’s Fall Prevention Program policy required that when any resident experiences a fall, staff must assess the resident, complete a post-fall assessment and incident report, notify the physician and family, review and update the care plan as indicated, document all assessments and actions, and obtain witness statements in the case of injury. Resident #2, admitted with heart failure, polyneuropathy, bone density disorders, protein-calorie malnutrition, and anemia, had moderate cognitive impairment and required substantial to maximal assistance with mobility and toileting. The resident’s care plan identified them as high risk for falls due to impaired mobility and poor safety awareness. Staff interviews and the facility’s own incident investigation revealed that the resident fell from bed at approximately 6:00 AM on 12/10/2025. Following this fall, RN #21 (also referenced as RN #2 in interview) stated she looked at the resident and did not observe any injuries but did not complete any of the required fall-related documentation, including the incident report, post-fall assessment, or documentation of the fall itself. She also stated she was not sure she reported the fall to anyone on the oncoming shift, and there was no evidence that the physician or responsible party were notified at that time. GNA #22 reported to RN #21 that the resident’s leg was “wobbly” on the morning of the fall and later asked a CMA to help place the resident back in bed, telling the CMA that the nurse had already assessed the resident. No pain was reported at that time. The next day at 6:00 AM, another RN noted swelling, pain with movement, purplish discoloration, and abrasions on the resident’s left lower leg and ankle. Later that morning, an LPN observed that the ankle appeared abnormal and discolored, requested a physician evaluation, and the resident was sent to the ER, where imaging showed a comminuted fracture of the distal tibia and fibula. The DON and Administrator both confirmed that the expected process—assessment, documentation, and notification of the provider, responsible party, and oncoming staff—was not followed for the 12/10/2025 fall.
Failure to Maintain Homelike Environment in Resident Rooms
Penalty
Summary
The facility failed to maintain a homelike environment in resident rooms, as observed during an environmental survey. The survey, conducted with the Administrator and the Director of Maintenance, revealed several deficiencies across seven resident rooms. These included the absence of towel hangers in bathrooms, damaged footboards with protective layers peeling away, and issues with bathroom fixtures such as a damaged gasket and exposed bolts on toilets. Additionally, some rooms had short pull cords for overhead lights, non-functional night lights, and loose toilet seats, which posed safety risks. The survey also identified a loose wall plate of the overhead sprinkler in one of the rooms. These deficiencies were confirmed by the Administrator and the Director of Maintenance during the tour. The report highlights the facility's failure to provide a safe, clean, comfortable, and homelike environment for its residents, as required by regulations.
Ineffective Mechanical Ventilation in Resident Bathrooms
Penalty
Summary
The facility failed to ensure effective mechanical ventilation in resident bathrooms, as observed during an environmental survey. This deficiency was identified in 5 out of 7 resident rooms reviewed for increased occupancy. During a tour conducted with the Administrator and the Director of Maintenance, it was noted that the bathrooms in rooms 18, 17, 32, 33, and 16 did not have effective ventilation. The effectiveness of the ventilation was tested by observing if a thin piece of paper was drawn towards and held against the ventilation intake on the ceiling, a test performed by the Director of Maintenance. The Director confirmed the ineffectiveness of the ventilation in these rooms and attributed the issue to likely nonfunctional motors in the rooftop ventilation units.
Failure to Protect Residents from Abuse
Penalty
Summary
The facility failed to protect residents from physical and verbal abuse, as evidenced by multiple grievances and interviews with residents and staff. Resident #58 reported being verbally abused by GNA/CMA #19, who allegedly screamed at the resident and invaded their personal space during a confrontation. This incident was corroborated by a grievance filed by the Director of Social Work, who witnessed the GNA/CMA yelling at the resident. Additionally, Resident #58 had previously filed a grievance about staff rushing and hollering during care, which was not adequately addressed by the facility. Resident #18 also reported rough treatment and verbal abuse by the same GNA/CMA, expressing a desire to move to a different unit to avoid further mistreatment. The resident felt embarrassed by the GNA/CMA's public reprimand regarding candy consumption. Despite these grievances being documented, there was no evidence of follow-up or resolution by the facility's administration, indicating a systemic failure to address and prevent abuse. Furthermore, Resident #291 alleged physical abuse by a GNA who roughly handled them, causing injury. This grievance was documented but not reported to the appropriate authorities, nor was an investigation conducted. The facility's grievance process was flawed, with grievances being logged but not followed up on, leading to a failure to protect residents from abuse and neglect.
Failure to Provide Adequate Foot Care Leads to Harm
Penalty
Summary
The facility failed to provide adequate treatment for a resident with a foot concern, resulting in harm. The resident, who had a medical history including type 2 diabetes mellitus with diabetic neuropathy, was seen by a podiatrist in February 2021. The podiatrist noted erythema on the right great toe and recommended the application of topical antibiotic ointment and continued monitoring. However, no order for the ointment or monitoring was documented in the Treatment Administration Record (TAR) for February, March, or April 2021. Additionally, there was confusion regarding which toe was affected, as the podiatrist's note included a diagram indicating the left toe, but no clarification was made in the medical record. In March 2021, a Psychiatric Nurse Practitioner assessed the resident as restless and irritable, recommending Depakote, but no order was documented. The resident was noted to have an abrasion on the toe after kicking a door, yet no treatment was ordered. By early April, a Licensed Practical Nurse observed redness, swelling, and an open area on the left great toe, and a fax was sent to the primary care physician. However, the fax was initially unsuccessful, delaying the response. A wound consult was eventually ordered, and the wound physician recommended antibiotics and an x-ray, but no antibiotics were ordered. By mid-April, the resident's condition worsened, with the left great toe showing erosion and bone exposure. The resident was transferred to the emergency room, where a bone scan confirmed osteomyelitis, leading to a partial amputation. The facility's failure to document and follow through with the podiatrist's recommendations, as well as the lack of timely treatment and communication, contributed to the resident's harm.
Failure to Resolve Resident Grievances
Penalty
Summary
The facility failed to adequately address and resolve grievances filed by residents, leading to a deficiency in honoring residents' rights to voice grievances without discrimination or reprisal. Resident #58 filed grievances regarding verbal abuse and staff rushing care, which were documented by the Director of Social Work (SW) #17. Despite these grievances being logged and assigned to the appropriate department supervisors, there was no documentation of resolution or follow-up. Additionally, Resident #18 filed a grievance about rough treatment and embarrassment caused by a staff member, which was also not resolved or documented. Resident #291's grievances were similarly mishandled. The resident's family member complained about issues such as a non-working phone, therapy questions, and food concerns, but follow-up was only partially documented. Another grievance involved rough handling by a Geriatric Nursing Assistant (GNA), resulting in an injury, and being left in soiled diapers for an extended period. These grievances were not followed up on, and there was no documentation of resolution. Furthermore, a request to switch beds for accessibility reasons and missing clothes were not addressed, and there was no record of these grievances being resolved. Interviews with the Nursing Home Administrator (NHA) and SW #17 revealed a lack of communication and follow-up in the grievance process. The NHA acknowledged the grievances as potential abuse cases but confirmed that there was no documentation of resolution or follow-up. The facility's grievance procedure was not effectively implemented, leading to unresolved grievances and a failure to protect residents' rights.
Failure to Report and Address Allegations of Theft and Abuse
Penalty
Summary
The facility failed to ensure timely reporting of residents' allegations of theft and abuse to the appropriate authorities. In one instance, a resident reported $100 missing from their wallet, but the facility delayed reporting the incident to the Office of Health Care Quality (OHCQ) beyond the required 24-hour timeframe. Similarly, another resident's report of theft was not submitted to OHCQ within the mandated period. These delays in reporting indicate a failure in the facility's protocol for handling allegations of theft. Additionally, the facility did not adequately respond to and report allegations of abuse. A resident reported being roughly handled by a Geriatric Nursing Assistant (GNA), but the Nursing Home Administrator (NHA) was unaware of the allegation, and no investigation was conducted until much later. The social worker who documented the incident did not follow up or ensure the allegation was reported to the necessary authorities, highlighting a breakdown in communication and procedure within the facility. The facility also failed to address grievances related to verbal abuse and rough treatment by staff. Multiple grievances were filed by residents, including one where a staff member was witnessed yelling at a resident. Despite these grievances being documented and assigned to department supervisors, there was no evidence of follow-up or resolution. The NHA acknowledged the grievances as potential abuse but confirmed that no documentation of resolution or follow-up existed, indicating a systemic issue in handling and addressing resident grievances and allegations of abuse.
Inadequate Investigation and Documentation of Abuse Allegations
Penalty
Summary
The facility failed to conduct thorough investigations and maintain proper documentation for several allegations of abuse involving multiple residents. In one instance, an investigation into an allegation that a Geriatric Nursing Assistant (GNA) hit a resident on the head was incomplete, lacking documentation of interviews and statements from involved parties. Additionally, there was no evidence that the GNA was placed on leave during the investigation, although a time card indicated otherwise. The Nursing Home Administrator (NHA) acknowledged the missing documentation and confirmed that the abuse allegation was not reported to the police or the Office of Health Care Quality (OHCQ). Further deficiencies were noted in the handling of grievances related to verbal and physical abuse. A social worker documented incidents of a GNA yelling at a resident and another resident's complaint of rough treatment and embarrassment. Despite these grievances being logged and forwarded to the appropriate supervisors, there was no documentation of follow-up or resolution. The NHA admitted that these grievances met the definition of abuse and recognized a pattern of complaints involving the same GNA, yet no actions were documented to address these issues. The facility also failed to properly investigate and document incidents reported in the Facility Reported Incident (FRI) files. One resident reported rough treatment and neglect by a GNA, but the investigation lacked essential components such as staff interviews and resident assessments. Another incident involving a resident being hit by a GNA was reported, but the facility could not provide the investigation file. The Director of Nursing (DON) acknowledged that many FRI investigations were incomplete prior to her tenure, indicating systemic issues in the facility's handling of abuse allegations.
Failure to Deliver Meals at Appropriate Temperatures
Penalty
Summary
The facility failed to ensure that food was delivered to residents at an appropriate and palatable temperature. This deficiency was identified during an observation and interview process conducted by the Surveyor. A resident reported that the food was lukewarm and not palatable, and similar complaints were received from resident families about the food being cold by the time it reached their loved ones. The issue was further substantiated during a test tray observation where the Surveyor noted that the food temperatures were below the expected levels for palatability. During the observation of the lunch tray line, it was noted that the first tray was prepared at noon, and the final tray was placed on the meal cart at 1:00 PM. The meal cart was then taken to the nursing unit, and the test tray was the last to be distributed. The temperature of the food items on the test tray was recorded as follows: chicken breast at 119 degrees Fahrenheit, rice at 126 degrees Fahrenheit, potato at 117 degrees Fahrenheit, and peas at 120 degrees Fahrenheit. These temperatures were below the expected levels for maintaining hot food palatability, indicating a failure in the facility's process to deliver meals at appropriate temperatures.
Deficiency in Food Storage Practices
Penalty
Summary
The facility failed to store food in accordance with professional standards of food service safety, as observed during a surveyor's inspection of the kitchen. In the main walk-in refrigerator, there was an opened and unlabeled 1-gallon tub of Sysco mayo, a 1-gallon tub of Sysco mustard with a received date, and a 1-gallon tub of Kens Homestyle Ranch with a received date. In the dry goods storage pantry, there were several opened and unlabeled food items, including a 28 oz box of Quaker Cream Of Wheat, Ralson Foods Quick oats, and a tub of Goldmetal Chocolate Fudge icing, among others. Additionally, the main walk-in freezer contained personal items such as a grocery bag with personal food items and a bouquet, alongside other frozen foods. There was also significant ice buildup in the freezer, with mounds of ice on the ceiling and floor, creating a slippery area. The Certified Dietary Manager (CDM) confirmed the surveyor's findings and acknowledged the presence of unlabeled and expired food items, as well as personal items in the freezer. The CDM also confirmed the issue of ice buildup in the walk-in freezer, stating that it required removal a couple of times a week. The facility's procedure for labeling and dating foods was reviewed, which mandates that opened packages be re-dated with the date of opening and used by the safe food storage guidelines or the manufacturer's expiration date. However, this procedure was not followed, leading to the deficiency in food storage practices.
Deficiencies in Medical Record Accuracy and Incident Documentation
Penalty
Summary
The facility failed to maintain complete and accurate medical records for three residents, as identified during an annual survey. For two residents, there were discrepancies in the Maryland Medical Orders for Life-Sustaining Treatment (MOLST) forms. One resident's chart contained two MOLST forms with conflicting code statuses: one indicating Do Not Resuscitate (DNR) and the other indicating Cardiopulmonary Resuscitation (CPR). Another resident's chart also had two MOLST forms, one with a DNR status and the other with a Do Not Intubate (DNI) status. The nursing staff was expected to void the old MOLST form and retain only the most recent one to prevent errors, but this procedure was not followed, leading to potential confusion regarding the residents' code statuses. Additionally, the facility failed to accurately document incidents and assessments related to falls for two residents. One resident's electronic medical record contained conflicting nursing notes about the timing of a fall, and the fall protocol was not completed immediately after the incident. Another resident's pain management assessments failed to document a significant injury—a left femoral fracture—sustained from a fall, despite the resident having undergone surgery for the fracture. The pain management notes inaccurately reported no recent acute incidents or trauma, indicating a lack of proper documentation and assessment of the resident's condition following the fall.
Failure to Notify Medical RP of Care Plan Changes
Penalty
Summary
The facility failed to notify the designated medical Responsible Party (RP) of a change to a resident's plan of care, specifically regarding the end date for Medicare-covered services. The resident, admitted in mid-2013, had a spouse/friend listed as the medical RP and a separate financial RP. Despite this clear distinction, the facility contacted only the financial RP about the cessation of Medicare services, neglecting to inform the medical RP. Interviews with the Director of Nursing (DON) and Social Worker #17 revealed a misunderstanding or misapplication of the facility's protocol for notifying RPs. The DON stated that both the medical and financial RPs should be contacted when Medicare services are stopped, while the social worker indicated that only the medical RP should be notified for medical decisions. This discrepancy led to the medical RP not being informed on three occasions, as the facility mistakenly involved only the financial RP.
Failure to Notify Responsible Party of Diet Change
Penalty
Summary
The facility failed to inform a resident's Responsible Party (RP) in advance of a change in the resident's plan of care, specifically regarding a diet change. This deficiency was identified during a review of the medical records and interviews conducted by the surveyor. The resident in question had a medical history that included muscle weakness, malnutrition, dementia, and dysphagia. On a specific date, a Licensed Practical Nurse (LPN) documented an incident where the resident was found on the floor, and the RP was notified. However, a subsequent order was placed to change the resident's diet from mechanical soft to pureed texture and chopped meats without any documented reason or prior notification to the RP. During interviews, the Director of Nursing (DON) confirmed that any change in the plan of care should involve notifying the RP. The LPN involved believed the diet change was due to a dental need, as the resident refused to use denture cream and did not want new dentures. Despite this belief, there was no documentation to support the rationale for the diet change or evidence that the RP was informed prior to the change. The lack of documentation and communication with the RP led to the deficiency noted by the surveyor.
Delayed Response to Family Council Concerns
Penalty
Summary
The facility failed to promptly respond to concerns raised by the family council group (FCG) for several months. The Nursing Home Administrator (NHA) was responsible for addressing these concerns, which were communicated through monthly meeting minute notes sent via email. Despite the NHA's assertion that he responded to the FCG's concerns before the next meeting, evidence showed that responses for April, May, July, August, and September 2023 were delayed. Specifically, the responses for April and May were only documented in June, while the responses for July, August, and September were not addressed until October. The deficiency was identified through a complaint received by the Office of Health Care Quality (OHCQ) and was corroborated by interviews and a review of the meeting minutes. The complainant provided documented evidence of timely email communication of the meeting minutes to the NHA. The surveyor's review confirmed the lack of prompt responses, highlighting a failure in the facility's process for addressing family council concerns. The NHA and the Director of Nursing (DON) were informed of these findings during the survey and at the exit conference.
Failure to Administer Medications Timely
Penalty
Summary
The facility failed to provide timely administration of medications for Resident #298, as evidenced by a review of medical records and interviews. Resident #298, who was admitted in early April 2021, has a medical history that includes type 2 diabetes, disorientation, epilepsy, and acute cystitis. On April 17, 2021, a progress note by LPN #29 indicated that the resident was nearly unresponsive and had not been responsive enough to eat breakfast. The Medication Administration Record (MAR) showed that a scheduled 6 AM medication was administered at 6:18 AM, but the next medication, Glimepiride, scheduled for 8:30 AM, was not administered due to the resident's altered mental status and subsequent transfer via Emergency Medical Service. The Director of Nursing confirmed that the facility's policy is to administer medications within one hour before or after the scheduled time. However, the surveyor noted that LPN #29 did not attempt to administer the scheduled medication until 10:40 AM, which was two hours after the scheduled time. This delay in medication administration was acknowledged by the Director of Nursing, indicating a failure to adhere to the facility's medication administration policy.
Failure to Post Residents' Rights Information
Penalty
Summary
The facility failed to ensure that information related to the Residents' Rights, including contact information for Maryland's Long-Term Care Ombudsman program and a statement informing residents of their right to file a complaint with Maryland's Survey Agency, was posted in easily viewed and accessible locations. This deficiency was observed on all units and halls with resident care areas. During a tour, the surveyor noted the absence of these postings in the Chesapeake, Patuxent, The Lodge, and Rehab areas. Staff #10 acknowledged that the postings were removed during renovations that began a year ago. The Nursing Home Administrator later provided the notice of Resident Rights poster to the survey team, indicating it would be posted in the hallway between two units, opposite the main dining area.
Failure to Display Survey Results in Accessible Location
Penalty
Summary
The facility staff failed to display the results of the annual recertification survey and plan of correction in a location that was easily accessible to residents, family members, and legal representatives. During observations on two separate days, surveyors noted the absence of the survey inspection results in the lobby or any other open area within the facility. An interview with the Director of Nursing (DON) revealed that the Survey Results binder was kept in the Nursing Home Administrator's (NHA) office, and the DON confirmed that the staff did not place the survey results in an accessible location. The NHA later provided the survey team with the binder, explaining that it might have been removed from the reception area due to renovations. Eventually, the survey results were observed in a binder on a table in the reception area, but the most recent survey results available were from a recertification survey conducted in 2019.
Failure to Maintain Advance Directives and Address Resident Treatment Preferences
Penalty
Summary
The facility failed to ensure that copies of residents' Advance Directives were obtained and maintained in their medical records. This deficiency was identified for three residents. For one resident, the facility's Social Worker acknowledged that the resident had an Advance Directive and a Durable Power of Attorney (DPOA) but did not follow up to obtain a copy for the medical record. The Director of Nursing later retrieved the DPOA from the resident's representative and placed it in the medical record. Another resident's medical record review revealed the presence of a Maryland Medical Orders for Life-Sustaining Treatment (MOLST) but lacked a copy of the Advance Directive. The Social Worker documented that the resident had an Advance Directive during the initial assessment, but no attempt was made to obtain the document for the medical record. The Director of Nursing was unable to provide a copy of the Advance Directive when notified of its absence. For the third resident, the facility did not address the resident's expressed desire to discontinue thickened liquid treatment, despite the resident's capability to make informed decisions. The resident's medical record lacked documentation of any discussion or meeting with the primary care physician or interdisciplinary team to address this request. The Nursing Home Administrator was aware of the resident's wishes but did not take steps to discuss the matter with Risk Management or the facility's Medical Director.
Failure to Provide Written Transfer Notices
Penalty
Summary
The facility failed to provide written notification of hospital transfers to residents and their representatives, as required by regulations. This deficiency was identified during a review of medical records and interviews with facility staff. Resident #8 was transferred to the hospital on two occasions, once in January and again in June, without any documentation or evidence that the resident or their representative was notified in writing of the reasons for these transfers. Although the Ombudsman was notified, there was no written notice provided to the resident or their representative. The Director of Nursing was unaware if the written notifications were being done. Similarly, Resident #20 was transferred to the hospital in June after becoming unresponsive during breakfast, but there was no documentation indicating that the resident or their representative received written notification of the transfer. The facility was unable to provide any evidence of written notice for this hospitalization. These findings highlight a failure in the facility's process for notifying residents and their representatives of hospital transfers, as required by regulations.
Failure to Provide Prescribed Arm Support for Resident
Penalty
Summary
The facility failed to provide appropriate treatment to maintain a resident's limited range of motion. A surveyor observed a resident with a flaccid right arm sitting in a wheelchair using their left hand to stabilize the right arm. The resident was not provided with the necessary arm support as prescribed. A staff member confirmed that the resident should have an arm support and subsequently retrieved and applied a splint to the resident's right arm. The resident's medical record indicated a physician's order for the resident to wear a Comfy Grip Splint during the daytime due to flaccid hemiplegia affecting the right dominant side. Additionally, a care plan intervention was in place to apply a splint for contracture management, with instructions to assess the skin prior to application and upon removal for skin breakdown. Despite these orders, the resident was observed without the splint, indicating a lapse in care.
Deficiency in RN Coverage on Weekends
Penalty
Summary
The facility failed to ensure that a Registered Nurse (RN) was on duty for at least 8 consecutive hours a day, 7 days a week, as required. This deficiency was identified during the annual survey, where it was found that on four specific days, there was no RN coverage for 24 hours. The Director of Nursing (DON) confirmed the absence of any Federal or State nursing staffing waivers and acknowledged the issue of insufficient RN coverage, particularly on weekends. The daily staffing sheets reviewed by the Surveyor revealed that on 7/28/2024, 8/10/2024, 8/11/2024, and 8/17/2024, there was no RN coverage for the entire day. Interviews with the Staff Scheduler and the DON highlighted the challenges in securing RN coverage for weekend shifts, although a weekend supervisor who is an RN was expected to start soon.
Infection Control and Equipment Labeling Deficiencies
Penalty
Summary
The facility failed to maintain a safe and sanitary environment to prevent the spread of infections, as evidenced by two specific incidents involving residents. Resident #72, who was diagnosed with Alzheimer's Disease and other conditions, tested positive for Covid-19 and was placed on droplet precautions. However, during an observation, Resident #72 was found lying on a mat in the dayroom with the door open and no signage indicating droplet precautions. Another resident without a Covid-19 diagnosis was present in the same room, and neither resident was wearing a mask. This oversight was acknowledged by staff, who then took immediate action to rectify the situation. In another incident, Resident #22, who had multiple diagnoses including Dementia and Chronic Diastolic Heart Failure, was observed with a nasal cannula lying on the floor while the oxygen concentrator was in use. The nasal cannula and humidifier bottle were not dated or labeled with the resident's name, contrary to the facility's policy. Staff confirmed these findings and removed the equipment for replacement. The facility's policy requires that such equipment be changed weekly and properly labeled, which was not adhered to in this case.
Ice Buildup in Walk-In Freezer
Penalty
Summary
The facility failed to maintain the walk-in freezer in a safe operating condition, leading to ice buildup, including ice frozen to the floor. During a follow-up tour of the kitchen, a surveyor observed ice mounds on the ceiling and floor of the freezer, particularly around the condenser fan unit and a pipe. This ice accumulation created a slippery surface, posing a safety hazard. The Certified Dietary Manager confirmed the surveyor's findings and mentioned that ice buildup had to be removed multiple times a week. A repairman had assessed the freezer a year prior, attributing the issue to condensation, but the problem persisted. The facility's administrator informed the surveyor that Southern Maryland Refrigeration was responsible for repairs, and the last assessment was conducted about a year ago. Despite requests, the administrator did not provide recent documentation of service calls or repairs before the surveyor's visit. The Director of Maintenance indicated that a work order for the freezer had been submitted and was in the process of being serviced. However, the lack of timely documentation and persistent ice buildup indicated a deficiency in maintaining essential equipment in safe working condition.
Failure to Provide Call Bell and Mobility Accommodations
Penalty
Summary
The facility failed to ensure that a resident had a call bell within reach and was able to use it if desired. During a tour of the facility, a surveyor observed a resident lying in bed with the call bell on the floor at the foot of the bed. Despite the surveyor expressing this concern to an LPN, the issue persisted the following day when the call bell was again found on the floor. The LPN confirmed that the resident should have had the call bell within reach, indicating a failure to accommodate the resident's needs for communication and assistance. Additionally, the facility did not provide reasonable accommodations for another resident to assist with mobility. The resident, who had a history of surgical amputation and required assistance with personal care, was identified as needing bedrails to aid in bed mobility and activities of daily living. Although an order for bedrails was placed, the facility did not have any available at the time, and the order for additional bedrails was not placed until several weeks later. This delay in providing necessary equipment further demonstrates the facility's failure to accommodate the resident's needs for mobility assistance.
Failure to Conduct Timely Care Plan Meetings and Include Interventions
Penalty
Summary
The facility failed to conduct care plan meetings after each Resident Assessment and hold quarterly care plan meetings for residents, as required. This deficiency was evident in three out of four residents reviewed for care planning. For Resident #290, there were no care plan meeting notes for the quarterly MDS assessments conducted on two occasions. The Director of Nursing (DON) and Social Worker #17, who were not in their positions at the time of the assessments, could not provide documentation that the meetings were held. The process for scheduling care plan meetings was flawed, as it relied on the Responsible Party to initiate the meeting, which was not happening. For Resident #8, there was no evidence of care plan meetings held around the time of the quarterly or annual MDS assessments. The last documented care plan meeting was in December of the previous year, and the resident's name did not appear on the care plan meeting log for the following months. Additionally, Resident #72's care plan for therapeutic activities lacked interventions to achieve the stated goal. The DON was unaware of the missing interventions until notified by the surveyor, and the care plan was later updated.
Deficiencies in Personal Hygiene and Timely Assistance
Penalty
Summary
The facility failed to provide necessary services to maintain good personal hygiene for two residents, as evidenced by the surveyor's findings. Resident #291, who requires extensive assistance with activities of daily living (ADLs) due to conditions such as dysphagia, dysphonia, muscle weakness, and unsteadiness, did not have consistent documentation of showers being provided. The facility's policy requires at least two full baths or showers per week, but records showed gaps in documentation, and the Director of Nursing (DON) could not confirm that showers were given without the necessary records. Additionally, Resident #45, who has ADL limitations and is at risk for bladder/bowel incontinence, experienced a delay in assistance for toileting needs. The resident's call light was activated, and a staff member entered the room but did not assist with the request to use the bathroom. It took 52 minutes and a second call light activation for the resident's needs to be addressed. The DON acknowledged that the resident's needs should have been addressed promptly after the first request.
Documentation and Transfer Assistance Deficiencies
Penalty
Summary
The facility failed to adequately document responses to treatment of skin conditions for Resident #291. The resident, admitted in January 2023, had a medical history including dysphagia, dysphonia, muscle weakness, and unsteadiness of feet, requiring assistance with personal care. On February 20, 2023, an LPN documented an open area on the resident's coccyx, while an RN noted only blanchable redness. Despite treatment orders for daily dressing changes, documentation was inconsistent, with missing entries on several dates in March and April 2023. The facility's policy required weekly assessments and documentation of wound characteristics, which were not consistently followed, leading to a lack of clarity on the wound's status and treatment effectiveness. The facility also failed to provide the required two-person assistance for Resident #29 during transfers, compromising the resident's safety. The resident, with a history of hemiplegia, hemiparesis, and an above-knee amputation, reported pain in the left shoulder after a rough transfer by a single aide. The resident's care plan and physician's orders specified the need for two-person assistance due to limited mobility and arthritis. However, the incident on June 15, 2024, where the resident was transferred by one person, resulted in shoulder pain, although an X-ray showed no fracture. The Director of Nursing was informed of both deficiencies, highlighting the lack of proper documentation for Resident #291's wound care and the failure to adhere to the two-person transfer requirement for Resident #29. These deficiencies indicate lapses in following established care protocols and documentation practices, which are essential for ensuring resident safety and effective treatment.
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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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