South Mountain Rehab Center
Inspection history, citations, penalties and survey trends for this long-term care facility in Boonsboro, Maryland.
- Location
- 141 South Main Street, Boonsboro, Maryland 21713
- CMS Provider Number
- 215144
- Inspections on file
- 19
- Latest survey
- January 10, 2025
- Citations (last 12 mo.)
- 0
Citation history
Health deficiencies cited at South Mountain Rehab Center during CMS and state inspections, most recent first.
The facility failed to report abuse allegations to the State Agency within the required time frame for several residents. Incidents involving falls, inappropriate touching, and sexual abuse were reported late, with inadequate documentation and conflicting policy guidelines. These failures highlight a pattern of delayed reporting and inadequate documentation of abuse allegations.
The facility failed to conduct thorough investigations into abuse allegations involving several residents. For one resident, an injury investigation was incomplete as it did not assess other residents with similar conditions. Another resident's case lacked interviews with all relevant staff. Additionally, documentation was missing for a resident's abuse report, and no interview was conducted for another resident's allegation of being yelled at by staff. These deficiencies were confirmed by the DON.
The facility failed to maintain a safe and clean environment, with issues such as hair and stool in shower rooms, broken and missing tiles, and non-functional exhaust vents. The Maintenance Director acknowledged these problems, attributing some to building settling, but they remained unresolved, compromising the facility's sanitary conditions.
The facility failed to meet the personal hygiene and assistance needs of several residents. One resident had untrimmed nails and matted hair, while another reported unclean dentures. Two residents did not receive scheduled showers, and a resident requiring assistance with eating was left unattended. These deficiencies highlight a lack of adherence to care plans and inadequate support for residents' daily living activities.
The facility failed to ensure proper medication regimen review and implementation for two residents. One resident's physician did not address pharmacy recommendations for anticoagulant monitoring, and the Vitamin B12 order was incorrect. Another resident's medications were not discontinued timely despite pharmacy recommendations. Staff interviews revealed confusion about the process, and the facility's policy lacked defined timeframes.
The facility failed to ensure RN coverage 24/7 and maintain adequate staffing levels, with 8 out of 16 days lacking RN coverage and 13 out of 106 days with low staffing. Residents reported low staffing, especially on weekends. The facility's records showed HPPD below 3.0 on several dates, and dietary employees were inaccurately included in bedside care hours.
A resident with multiple medical conditions experienced significant changes, including emesis and low oxygen saturation. Despite these changes, the facility delayed notifying the resident's representative until later in the day, leaving a message for them to call back.
A facility failed to document a resident's hospital transfer, including the reason for transfer, notification of the physician and family, and the method of transfer. The resident had eloped and was hospitalized, returning in stable condition with abrasions. The required documentation was not provided during the survey.
The facility failed to administer medications and notify physicians as required for two residents. A resident on comfort care experienced seizures without proper documentation of medication effectiveness or physician notification. Another resident with uncontrolled diabetes did not receive insulin when glucose levels were high, and refusals of Trulicity were not reported to healthcare practitioners. The DON acknowledged these deficiencies.
A facility failed to inform a resident with cognitive decline about their right to formulate an advance directive. The social work assistant did not document any discussion of the advance directive during the resident's initial assessment or quarterly care plan meeting. The ADON confirmed the absence of an advance directive and mentioned contacting the resident's POA, but no documentation was provided to support this contact.
The facility failed to complete a Quarterly MDS assessment for a resident within the required time frame. The resident was admitted in June, and the admission MDS was completed later that month. However, the quarterly MDS due in September was not completed or submitted by December, resulting in a 174-day lapse. The corporate staff confirmed the oversight during an interview.
The facility failed to complete and submit MDS Discharge assessments for three residents who were discharged, as required by federal regulations. The MDS is a mandated tool for gathering resident information, and discharge assessments are necessary for quality monitoring. The corporate MDS person confirmed these omissions during an interview.
The facility failed to accurately document MDS assessments for two residents, affecting care planning and service provision. One resident with Multiple Sclerosis had MDS assessments that did not reflect their significant range of motion impairments, while another resident was incorrectly coded as discharged to a hospital instead of home. Staff confirmed the inaccuracies upon review.
A facility failed to ensure a resident's PASRR form accurately reflected their bipolar disorder diagnosis. The resident's initial nursing admission assessment documented the diagnosis, but the PASRR form completed later did not include it. The Social Service Assistant acknowledged the oversight, admitting that a new PASRR should have been completed. The DON was informed of this failure.
The facility failed to provide baseline care plans to three residents and their representatives within 48 hours of admission. Reviews of records for these residents showed no documentation that the care plans were discussed or provided, and the DON confirmed the absence of such documentation.
A resident's activity preferences were not met, as they were observed with the TV on channels not aligned with their interests, and music was unavailable due to a non-functional remote. Staff interviews revealed a lack of communication and awareness of the resident's preferences, indicating a deficiency in meeting their activity needs.
The facility failed to prevent further decline in range of motion for two residents with limited mobility. One resident had a contracted right hand without any device, and another had impaired range of motion due to a stroke. Despite therapy evaluations noting impairments, there was no evidence of implemented treatment or services to prevent further decline after discharge from therapy.
The facility failed to maintain a safe smoking area during inclement weather, lacking necessary safety equipment in the alternate location used. Additionally, the facility did not consistently document the placement of a resident's wander guard as ordered, despite the resident's history of attempting to exit the facility unsupervised. The Director of Nursing acknowledged computer issues but could not provide alternative documentation.
A facility failed to obtain weekly weights for a resident who experienced significant weight loss, despite physician orders. The resident lost more than 20 pounds over several months, and weights were not recorded for multiple weeks as required. The unit nurse manager could not provide documentation for the missing weights, as the resident was on another unit during that time.
A facility failed to document pain assessments for a resident receiving PRN pain medications, leading to a deficiency. The resident, with a history of fractures and chronic pain, was given Hydromorphone and Tramadol without proper documentation of pain location and type. Staff interviews confirmed expectations for detailed documentation, which was not met.
A facility failed to provide trauma-informed care for a resident with PTSD. Despite a diagnosis and medication order, the care plan lacked details on the resident's PTSD triggers, essential for preventing re-traumatization. Interviews confirmed the absence of this critical information, hindering appropriate care.
The facility failed to ensure a CNA maintained current certification, as her certification had expired but she continued to work. The staffing coordinator was unaware of the expiration, and the DON acknowledged a breakdown in the monitoring process.
Two residents with hypertension received antihypertensive medications despite orders to hold them if systolic blood pressure (SBP) was below 120. The facility's MARs showed multiple instances where medications were administered contrary to these orders, confirmed by the ADON and an LPN.
A facility failed to monitor a resident's use of an antidepressant medication, resulting in a deficiency. The resident was prescribed the medication for depression, but staff did not document monitoring for changes in behavior or side effects. The care plan required monitoring every shift, but records showed no evidence of this from early November to mid-December. Interviews with staff confirmed the lack of documentation and monitoring.
A facility failed to maintain a medication error rate below 5%, as observed during a medication administration. An LPN administered seven medications to a resident but failed to give two scheduled antihypertensive medications, despite signing them as dispensed. This discrepancy was noted by a surveyor and discussed with the DON, indicating the facility's medication error rate was above the acceptable limit.
The facility failed to dispose of expired medications promptly, as observed in the second-floor medication storage room where a Tylenol 650 mg suppository had expired. Staff acknowledged the oversight, and the ADON confirmed that nurses are expected to discard expired medications and mark expiration dates. Despite weekly audits, the expired medication was not removed, and incorrect reports were made regarding the removal of expired medications.
A resident was not provided with adaptive eating equipment as recommended by therapy, leading to repeated spillage incidents during meals. Despite a therapy assessment recommending a 2-handled sippy cup, the device was not provided due to a communication error between therapy, nursing, and the kitchen. The deficiency was identified during survey observations.
The facility failed to accurately complete the resident matrix, leading to discrepancies such as marking two residents as having COVID infections when no outbreak was present. The DON acknowledged only addressing specific discrepancies without reviewing the entire matrix, resulting in continued inaccuracies.
The facility failed to ensure proper infection control practices for a resident with a PEG tube and during BP monitoring. Staff did not consistently wear required PPE for a resident on Enhanced Barrier Precaution, and an LPN did not disinfect BP equipment between residents. The DON was informed of these issues.
The facility failed to document that nurse aides received the required annual training in abuse prevention and dementia management. A review of staff files for five GNAs showed incomplete records, with no evidence of completed competencies. The ADON and DON could not provide adequate documentation or tracking methods for the training, relying only on sign-in sheets without a syllabus or curriculum.
Delayed Reporting of Abuse Allegations
Penalty
Summary
The facility failed to report allegations of abuse, neglect, or theft to the State Agency within the required time frame for several residents. For Resident #421, two falls occurred, one on 1/23/23 and another on 1/28/23, both resulting in injuries of unknown origin. The Director of Nursing was unaware if these incidents were reported to the state agency, and there was no record of such reports. Staff acknowledged that these incidents should have been reported as injuries of unknown origin. Resident #214 alleged inappropriate touching by a Geriatric Nursing Assistant on 2/16/23, but the report was not submitted to the state survey agency until 12/17/23. There was no documentation of who the resident initially reported the allegation to or any follow-up interview conducted. The facility's policy indicated a 24-hour reporting window for non-serious bodily injury, which conflicted with the expectation of immediate reporting for abuse allegations. For Resident #468, an alleged sexual abuse incident occurred between January and April 2023, but was not reported to the State Agency until 9/11/2023, outside the 2-hour requirement. Similarly, Resident #469's abuse allegation on 3/22/2024 was reported late, and no final report was submitted. Resident #264's abuse allegation on 2/27/2022 was also reported late, confirmed by the Director and Assistant Director of Nursing. These failures highlight a pattern of delayed reporting and inadequate documentation of abuse allegations.
Inadequate Investigation of Abuse Allegations
Penalty
Summary
The facility failed to conduct thorough investigations into multiple allegations of abuse involving residents. For Resident #416, an investigation into an injury of unknown origin was incomplete as it did not assess other residents with similar cognitive impairments and diagnoses. The Director of Nursing (DON) and Assistant DON acknowledged the oversight but did not provide additional information to support a comprehensive investigation. Similarly, for Resident #264, the facility did not interview all staff members who were present on the unit during the alleged abuse incident, despite the staffing schedule indicating more personnel were on duty. In the case of Resident #213, the facility's investigation documentation lacked a statement from the Business Office Manager who initially reported the abuse allegation, and there was no evidence of an interview with the resident until several days later. For Resident #44, who reported being yelled at by staff, the facility failed to document any attempt to interview the resident regarding the allegation. These deficiencies highlight a pattern of inadequate response and documentation in handling abuse allegations, as confirmed by the DON during the survey.
Facility Fails to Maintain Safe and Clean Environment
Penalty
Summary
The facility failed to maintain a safe, clean, and homelike environment for residents, as evidenced by multiple deficiencies observed during a survey. In the Antietam shower room, issues included hair on shower stall walls, a caked white substance on wooden seats, missing or peeling molding, and exposed netting on soap dishes. Additionally, a shower chair was found with dried stool, and broken tiles were noted. Similar issues were found in other units, including missing end caps exposing jagged metal, cracked tiles, and non-functional exhaust vents, which were reported to be part of a system that pulls exhaust for entire units. The Maintenance Director acknowledged these issues, attributing some to building settling and indicating plans to fix them. However, the survey revealed persistent problems, such as a urine odor in a hallway and missing tiles in a shower room, with no exhaust fan/vent identified in one unit. Despite a work history report indicating monthly inspections and cleaning of exhaust fans, the deficiencies remained unaddressed, compromising the sanitary and safe environment expected in the facility.
Deficiencies in Resident Care and Assistance
Penalty
Summary
The facility staff failed to meet the personal hygiene needs of several residents, as evidenced by observations and interviews. Resident #10 was found with long, dirty fingernails and matted hair, despite requiring assistance with personal hygiene. The care plan for Resident #10 indicated that staff should check and trim nails on bath days, but this was not done. Additionally, Resident #68 reported that their dentures had not been cleaned, and there was confusion regarding the documentation of denture care, indicating a lack of proper assistance and record-keeping. Resident #66 and Resident #62 both reported not receiving showers as scheduled. Resident #66, who has multiple sclerosis and requires extensive assistance, was documented to have received bed baths instead of showers on multiple occasions, with no record of refusal documented. Similarly, Resident #62, who requires substantial assistance due to a history of stroke, did not receive the scheduled number of showers, as evidenced by the shower records. This indicates a failure to adhere to the care plans and provide the necessary assistance for these residents. Resident #369, who was admitted with dementia and acute stroke, was observed with an untouched breakfast tray, despite requiring assistance with eating. The occupational and speech therapy evaluations confirmed the need for assistance, yet the resident was not helped during breakfast. This lack of assistance with meals further highlights the facility's failure to provide adequate care and support for residents' daily living activities, as required by their care plans.
Deficiencies in Medication Regimen Review and Implementation
Penalty
Summary
The facility failed to ensure that the attending physician addressed irregularities identified in the pharmacy recommendations for two residents. For one resident, the attending physician did not respond to the pharmacy's recommendation to initiate monitoring for anticoagulant use, and the Vitamin B12 order did not match the physician's written response. The Assistant Director of Nursing (ADON) confirmed these discrepancies during an interview. Additionally, the facility's Medication Regimen Review (MRR) policy lacked defined timeframes for the process steps, which was acknowledged by the ADON. For another resident, the facility did not discontinue medications as recommended by the pharmacy in a timely manner. The healthcare practitioner agreed to discontinue Vitamin B12 and Zofran, but the medications remained on the medication administration record for over a month. Staff interviews revealed uncertainty about the pharmacy review process and communication of recommendations. The Director of Nursing was informed of these findings, but no further information was provided by the facility at the time of the survey exit.
Failure to Maintain RN Coverage and Adequate Staffing Levels
Penalty
Summary
The facility failed to comply with State and Local Laws and Professional Standards by not ensuring a registered nurse (RN) was on duty 24 hours a day, 7 days a week. This deficiency was evident for 8 out of 16 days reviewed for RN coverage. Specifically, there was no RN on duty for the night shifts on several dates in November and December 2024. The staffing coordinator confirmed that the facility's goal is to have at least one RN for each shift, but they are not meeting this goal every day. Additionally, surveyors received multiple reports from residents about low staffing, particularly on weekends. The facility also failed to maintain Hours Per Patient Day (HPPD) above 3.0, as evidenced by 13 out of 106 days reviewed for low staffing. The Payroll Based report indicated low weekend staffing, and the facility's records showed HPPD was less than 3.0 on several dates in July, August, September, and December 2024. The Business Office Manager and staffing coordinator initially reported these hours only included nurses and geriatric nursing assistants, but later provided additional documentation indicating more than 3.0 PPD for some dates. However, they included dietary employees in the total number of bedside hours of care, which was confirmed to be inaccurate as dietary workers do not bring trays directly to residents.
Failure to Timely Notify Resident's Representative of Condition Change
Penalty
Summary
The facility failed to notify a resident's representative in a timely manner following a significant change in the resident's condition. The resident, who was admitted with an acute embolic stroke, expressive and receptive aphasia, paralysis in the extremities, a new feeding tube, and a Foley catheter, experienced a large amount of emesis on the morning of 02/28/22. Despite the charge nurse being informed and the tube feeding being stopped, the on-call physician did not answer the phone call, and the night shift nursing supervisor was notified. However, there was no progress note from the night shift supervisor regarding the incident. Further review of the resident's medical record indicated that the resident had an oxygen saturation level of 88% while receiving oxygen, a heart rate of 115 beats per minute, was anxious and agitated, had a distended and firm abdomen with hypoactive bowel sounds, and had emesis seven times during the shift. Despite these significant changes, the resident's representative was not contacted until 1:08 PM, when a message was left for them to call the facility staff. This delay in communication with the resident's representative constitutes a deficiency in the facility's obligation to promptly inform the resident's family of significant changes in their condition.
Failure to Document Hospital Transfer for a Resident
Penalty
Summary
The facility failed to ensure proper documentation for a resident's transfer to the hospital, as required by their own hospital transfer checklist. The deficiency was identified during a review of medical records and staff interviews, which revealed that there was no documentation of the transfer, the reason for the transfer, or any indication that the physician and the resident's family were notified. Additionally, there was no record of how the resident was transferred to the hospital. The incident involved a resident who had eloped from the facility and was subsequently hospitalized. Upon returning to the facility, the resident was noted to be in stable condition with abrasions on both lower extremities. Despite this, the facility's records did not include a hospital transfer note or any of the required documentation outlined in the Sterling-Care South Mountain Hospital Transfer Document Checklist. The Assistant Director of Nursing was unable to provide the necessary documents during the survey, and no additional information was provided by the end of the survey.
Failure to Administer Medications and Notify Physicians
Penalty
Summary
The facility failed to provide appropriate treatment and care according to orders and professional standards for two residents. Resident #110, who was on comfort care without hospitalization, experienced seizures from October 11 to October 14, 2024, which worsened until death. A physician's order from July 10, 2024, prescribed Midazolam for seizure activity, but lacked documentation on frequency or actions if ineffective. On October 11, 2024, the first dose was ineffective, yet there was no documentation of physician notification or clarification on medication administration frequency. Subsequent doses were administered without proper documentation of effectiveness or drug control sheets to verify medication supply. Resident #21, treated for uncontrolled type 2 diabetes, had a physician's order for sliding scale insulin to be administered if glucose levels exceeded 350, with a requirement to notify the physician. On November 19, 2024, the resident's glucose level was 369, but insulin was not administered, and there was no documentation of physician notification. Additionally, the resident refused Trulicity on multiple occasions, but there was no documentation of healthcare practitioner notification. The Director of Nursing (DON) acknowledged the concerns regarding both residents. The lack of documentation and failure to follow physician orders for medication administration and notification of healthcare practitioners contributed to the deficiencies identified during the survey process.
Failure to Inform Resident of Advance Directive Rights
Penalty
Summary
The facility failed to inform and provide written information to all residents concerning their right to formulate an advance directive, as evidenced by the case of a resident with cognitive decline. Upon review of the medical records, it was found that the resident did not have an advance directive documented. The social work assistant responsible for the resident's initial social assessment did not have any documentation indicating that the discussion about an advance directive took place during the assessment or in the resident's quarterly care plan meeting. Furthermore, the assistant director of nursing confirmed the absence of an advance directive for the resident and mentioned that the resident's Power of Attorney (POA) had been contacted regarding this matter. However, there was no documentation provided to support the claim that the POA was contacted. The lack of documentation and communication regarding the resident's advance directive rights led to the deficiency identified during the survey.
Failure to Complete Quarterly MDS Assessment
Penalty
Summary
The facility failed to complete the Quarterly Minimum Data Set (MDS) assessment for a resident within the required regulatory time frames. This deficiency was identified for one resident, who was admitted to the facility in June 2024. The resident's admission MDS assessment was completed on June 28, 2024, and the facility was required to complete a quarterly MDS assessment by September 26, 2024. However, as of the review conducted on December 19, 2024, the facility had not completed or submitted the required quarterly MDS assessment, resulting in a lapse of 174 days since the last assessment was completed. During an interview on December 19, 2024, the corporate staff responsible for MDS confirmed that the facility missed the deadline for completing the quarterly MDS for the resident. This oversight indicates a failure in maintaining the current assessment record and facilitating appropriate care planning for the resident.
Failure to Complete MDS Discharge Assessments
Penalty
Summary
The facility failed to complete and submit Minimum Data Set (MDS) Discharge assessments for residents who were discharged from the facility, as required by federal regulations. This deficiency was identified during a review of records for four residents, where it was found that three residents did not have completed discharge assessments. The MDS is a federally mandated tool used by nursing home staff to gather information on each resident, and discharge assessments are necessary for quality monitoring and reporting. Specifically, Resident #105 was admitted in October 2024 and discharged to another facility on December 9, 2024, but lacked a discharge assessment. Resident #112 was admitted from the hospital and left the facility against medical advice, yet no discharge assessment was completed. Similarly, Resident #64, admitted in September 2024 and discharged on September 25, 2024, also did not have a discharge assessment. The corporate MDS person confirmed these omissions during an interview, indicating a failure in the facility's process for completing required assessments.
Inaccurate MDS Assessments for Two Residents
Penalty
Summary
The facility failed to ensure accurate documentation of Minimum Data Set (MDS) assessments for two residents, leading to deficiencies in care planning and service provision. For one resident, who had been residing in the facility since September 2022 with diagnoses including Multiple Sclerosis and spastic paraparesis, the MDS assessments inaccurately recorded no functional limitation in range of motion despite multiple occupational therapy evaluations and a neurology consult indicating significant impairments. The corporate MDS person confirmed the inaccuracies in the MDS assessments, which were inconsistent with the resident's documented physical limitations. Another resident, who resided at the facility for a little over a month, was inaccurately coded in the MDS assessment as being discharged to a hospital, when in fact, the resident was discharged to home with family. The LPN responsible for completing the MDS assessment acknowledged the error after reviewing the resident's medical records, which contained no documentation of a hospital discharge. The Director of Nursing and Assistant DON were informed of the failure to accurately complete the MDS assessment, acknowledging the concern.
Inaccurate PASRR Form for Resident with Bipolar Disorder
Penalty
Summary
The facility failed to ensure that the Preadmission Screening and Resident Review (PASRR) form for a resident accurately reflected their diagnosis of bipolar disorder. The initial nursing admission assessment on June 20, 2019, documented the resident's diagnosis of bipolar disorder. However, the PASRR form completed on February 14, 2020, did not indicate this mental illness in Section C, which is designated for identifying major mental disorders. During an interview on December 17, 2024, the Social Service Assistant acknowledged that the resident's bipolar diagnosis was active as of February 10, 2020, but was not recorded on the PASRR form. She admitted that a new PASRR should have been completed to reflect the diagnosis, but this was not done. The Director of Nursing was informed of this oversight on December 20, 2024, highlighting the facility's failure to ensure the PASRR form accurately represented the resident's mental health condition.
Failure to Provide Baseline Care Plans to Residents
Penalty
Summary
The facility failed to provide residents and their representatives with a summary of the baseline care plan within 48 hours of admission, as required. This deficiency was identified for three residents during a review of baseline care plans. For Resident #34, there was no documentation in the medical record indicating that a baseline care plan was given to the resident or their representative. The Director of Nursing (DON) confirmed the absence of such documentation during an interview. Similarly, for Resident #74, the review of records showed no evidence that the baseline care plan was discussed or provided to the resident or their representative, and the DON was unable to provide documentation to confirm otherwise. For Resident #101, the baseline care plan review also revealed no indications that the care plan was discussed with the resident or their representative. The DON confirmed the lack of documentation during an interview. These findings indicate a systemic issue in the facility's process for ensuring that baseline care plans are communicated to residents and their representatives promptly upon admission.
Failure to Provide Activities According to Resident Preferences
Penalty
Summary
The facility failed to provide activities according to a resident's preferences, as observed during a survey. A long-term resident was frequently observed in their room with the television on channels that did not align with their stated preferences, such as news and movies, rather than game shows, which they enjoy. Additionally, the resident was not provided with music, despite it being noted as somewhat important to them. The resident's care plan indicated a preference for word searches and game shows, yet these activities were not facilitated. Interviews with staff revealed a lack of communication and awareness regarding the resident's activity preferences. The Activity Director could not explain how the GNA staff were informed of the resident's preferences beyond the care plan. Furthermore, a staff member reported that the remote for the music had been non-functional for a long time, preventing the resident from listening to music. Another staff member, familiar with the resident's care, was unaware of the resident's TV programming preferences or the availability of music in the room. These observations and interviews indicate a deficiency in meeting the resident's activity needs as per their preferences.
Failure to Prevent Decline in Range of Motion
Penalty
Summary
The facility failed to provide adequate treatment and services to prevent further decline in range of motion for residents with limited mobility. Resident #66, who had been residing in the facility since September 2022, was observed with a contracted right hand and fingers pressed into the palm without any device. Despite an occupational therapy evaluation in September 2023 noting impairments in range of motion, there was no evidence of implemented treatment or services to prevent further decline after discharge from therapy. By May 2024, the resident's condition had worsened, yet there was still no documentation of preventive measures. Similarly, Resident #62, admitted with a history of stroke and left-sided weakness, was noted to have impaired range of motion in the right upper extremities. An occupational therapy evaluation in April 2024 indicated functional limitations due to contracture, but the responsibility for managing the contracture was deferred to nursing staff without evidence of follow-through. The Director of Rehab acknowledged the lack of a system to ensure the prescribed range of motion exercises were performed, contributing to the deficiency.
Deficiencies in Smoking Area Safety and Wander Guard Checks
Penalty
Summary
The facility failed to maintain a safe designated smoking area for residents in various weather conditions. During a survey, it was observed that residents were smoking in a covered patio area instead of the designated smoking area due to rain. The maintenance director confirmed that the designated smoking area was uncovered and lacked necessary safety equipment such as a cigarette tray, fire extinguisher, and smoking fire blanket in the alternate location being used. The facility's smoking policy required these safety items to be present in designated smoking areas, but they were not available in the covered patio area used during inclement weather. Additionally, the facility did not adhere to a physician's order to check the placement of a resident's wander guard every shift. The resident had a history of attempting to exit the facility unsupervised. A review of the treatment administration record (TAR) revealed that documentation of the wander guard's placement was missing for several months, despite a space being available for this purpose. The Director of Nursing acknowledged that there were computer issues preventing documentation, but no alternative documentation was provided to confirm compliance with the physician's order.
Failure to Monitor Resident's Weight as Ordered
Penalty
Summary
The facility failed to ensure that weekly weights were obtained as ordered by the physician for a resident who experienced significant weight loss. Resident #24 had a documented weight loss of more than 20 pounds from June to August 2024, and a further 7.5% weight loss from September to December 2024. Despite physician orders for weekly weight monitoring starting on September 9, 2024, there were no weights recorded for the 2nd, 3rd, or 4th weeks of September, nor for the 2nd week of October. The unit nurse manager was unable to provide documentation for the missing weights, as the resident was on another unit during September. This lack of documentation and monitoring contributed to the deficiency identified by the surveyors.
Deficiency in Pain Management Documentation
Penalty
Summary
The facility failed to adequately document the administration of as-needed (PRN) pain medications for a resident, leading to a deficiency in pain management. Resident #97, who was admitted with diagnoses including left hip fracture, left elbow fracture, chronic pain syndrome, and arthritis, was prescribed Hydromorphone and Tramadol for pain relief. However, the medical records for November 2024 showed that while the resident received these medications for reported pain levels, there was a lack of documentation regarding the pain assessment, including the location and type of pain, before and after medication administration. Interviews with facility staff revealed that non-pharmacological interventions were provided, but there was no documentation to support ongoing pain management efforts. The assistant director of nursing confirmed that staff were expected to document detailed pain assessments, which was not done in this case. This lack of documentation and assessment led to the deficiency being identified during the survey.
Failure to Provide Trauma-Informed Care for Resident with PTSD
Penalty
Summary
The facility failed to provide trauma-informed care for a resident with a history of post-traumatic stress disorder (PTSD). The resident's social history, dated September 10, 2024, indicated a diagnosis of PTSD, and an order for an antidepressant medication was made on November 5, 2024, to address this condition. However, the resident's care plan did not include information on the specific triggers related to their PTSD, which is essential to prevent re-traumatization. Interviews with the social services assistant and the assistant director of nursing confirmed that the care plan lacked details on the resident's PTSD triggers, which are necessary for staff to provide appropriate care.
Failure to Maintain Current CNA Certification
Penalty
Summary
The facility failed to maintain an effective system to ensure that staff certifications and licensures were current, as evidenced by the case of a Certified Nursing Aide (CNA), Staff #41. A review of Staff #41's employment record revealed that her CNA certification had expired, yet she continued to work in the facility. The Maryland Board of Nursing registry confirmed the expiration of her certification. Despite this, Staff #41 was found to be working as a CNA, as indicated by her timesheet information. The staffing coordinator, GNA#37, was unaware of the expired certification and stated that the human resources department was responsible for monitoring certifications. The Director of Nursing (DON) acknowledged the breakdown in the process to monitor training and licensure, noting that a new human resource staff member was in training.
Failure to Adhere to Antihypertensive Medication Orders
Penalty
Summary
The facility failed to ensure that residents' drug regimens were free from unnecessary medications by not adhering to the attending physician's orders regarding the administration of antihypertensive medications. Resident #97, diagnosed with hypertension, was prescribed Prazosin and Metoprolol with specific instructions to hold these medications if the systolic blood pressure (SBP) was less than 120. However, the medication administration records (MARs) revealed that these medications were administered on multiple occasions when the resident's SBP was below the specified threshold. The assistant director of nursing confirmed that the medications were given contrary to the orders. Similarly, Resident #102, also diagnosed with hypertension, was prescribed four antihypertensive drugs with the same parameter to hold the medications if the SBP was less than 120. The MARs showed that these medications were administered on several occasions when the resident's SBP was below 120. A licensed practical nurse acknowledged that the medications should not have been given under these circumstances, and the assistant director of nursing confirmed that staff did not adhere to the provider's orders.
Failure to Monitor Psychotropic Medication Use
Penalty
Summary
The facility failed to ensure that a resident's medication regimen was free from unnecessary psychotropic medication use. Specifically, the facility did not adequately monitor a resident for behaviors, side effects, or adverse consequences related to the use of psychotropic medication. This deficiency was identified for one resident who had been prescribed an antidepressant medication due to depression. The resident received the medication daily as prescribed, but there was no evidence that the facility staff monitored the resident for changes in behavior or side effects related to the medication. The care plan for the resident included interventions to monitor and document side effects and effectiveness every shift, as well as to monitor and report any adverse reactions to the antidepressant therapy. However, the facility's records did not show any monitoring of the resident's behaviors from the beginning of November to mid-December. Interviews with the unit manager and the assistant director of nursing confirmed the lack of documentation and monitoring, despite the expectation that staff would monitor and document the resident's behaviors and any adverse effects of the psychotropic medication every shift.
Medication Error Rate Exceeds Acceptable Threshold
Penalty
Summary
The facility failed to maintain a medication error rate of less than 5%, as evidenced by two errors identified out of 28 opportunities for error. During a medication administration observation, an LPN was observed administering medications to a resident. The LPN confirmed that she had given seven medications to the resident, but the surveyor noted that two antihypertensive medications, Metoprolol 200mg and Amlodipine 5mg, which were scheduled to be given at 0900, were not observed being administered. Despite the LPN signing off that these medications were given, the surveyor's observation did not corroborate this. The discrepancy was discussed with the director of nursing, highlighting that the facility's medication error rate exceeded the acceptable threshold. The failure to administer the prescribed antihypertensive medications as per the resident's medication administration record contributed to the facility's medication error rate being over 5%. This oversight in medication administration was identified during the surveyor's review and interviews with the involved staff.
Expired Medication Not Disposed of Promptly
Penalty
Summary
The facility failed to ensure the prompt disposal of expired medications in accordance with the manufacturer's specifications. During an observation of the medication storage room refrigerator on the second floor, a Tylenol 650 mg suppository was found to have expired on 7/20/2024. Staff #49 acknowledged the oversight and reported it to the Unit Manager, Staff #7. The Assistant Director of Nursing (ADON) confirmed that nurses are expected to discard expired medications and mark expiration dates on packages upon receipt from the pharmacy. However, despite weekly audits conducted by Staff #7, the expired medication was not removed, and Staff #7 incorrectly reported that all expired medications had been removed in November and December 2024.
Failure to Provide Adaptive Eating Equipment
Penalty
Summary
The facility failed to provide adaptive eating equipment to a resident as recommended by therapy, leading to repeated incidents of spillage during meals. Observations on multiple occasions revealed that the resident was unable to control a regular cup, resulting in liquid spills on the floor and under the resident's chair. Despite a therapy assessment conducted on 9/04/2024, which recommended a 2-handled sippy cup for the resident to prevent spillage, the adaptive device was not provided until after the survey observations. The deficiency was attributed to a communication error between the therapy department, nursing staff, and the kitchen. The Certified Dietary Manager (CDM) reported not receiving any orders or notifications from therapy or nursing regarding the need for a 2-handled sippy cup for the resident. The Director of Nursing confirmed that the expected process of filling out an order and notifying the kitchen was not followed, resulting in the resident not receiving the necessary adaptive device until the issue was identified during the survey.
Inaccurate Resident Matrix Completion
Penalty
Summary
The facility failed to accurately complete the resident matrix, a form that lists residents' names, room numbers, and care categories. This deficiency was identified during a survey when discrepancies were found in the matrix for two out of three residents reviewed. Specifically, the matrix inaccurately marked two residents as having COVID infections, despite staff, including the Director of Nursing (DON), confirming that the facility was not experiencing a COVID outbreak. One of these residents was observed participating in activities, indicating they were not in isolation due to infection. Upon being informed of the discrepancies, the DON provided an updated matrix, but it still contained errors, such as the omission of a recently admitted resident. The DON acknowledged that she only corrected the specific discrepancies pointed out by the survey team and did not review the entire matrix for accuracy. This oversight led to the continued presence of inaccuracies in the resident matrix, which is crucial for reflecting the current status of all residents in the facility.
Infection Control Lapses in PEG Tube and BP Monitoring
Penalty
Summary
The facility failed to ensure appropriate infection control practices were followed for a resident with a percutaneous endoscopic gastrostomy (PEG) tube. The resident was on Enhanced Barrier Precaution (EBP) isolation, which required staff to wear gowns and gloves when providing care. However, observations revealed that a Licensed Practical Nurse (LPN) and a Registered Nurse (RN) did not consistently wear the required personal protective equipment (PPE) when accessing the resident's PEG tube. Despite a sign on the resident's door indicating the need for EBP, the LPN was observed without any PPE, and the RN was seen wearing only gloves. The resident's care plan highlighted the risk of infection due to the PEG tube, yet the staff did not adhere to the necessary precautions. Additionally, the facility did not maintain proper infection control practices during blood pressure (BP) monitoring. An LPN was observed failing to disinfect the BP equipment between residents. The LPN used the same equipment on multiple residents without cleaning it and even picked up a BP cuff from the floor to use on another resident without wiping it down. When questioned, the LPN admitted to not wiping down the equipment as required. The Director of Nursing (DON) was informed of these lapses in infection control practices.
Deficiency in Nurse Aide Training Documentation
Penalty
Summary
The facility failed to provide documented evidence that all nurse aides received the required 12 hours of annual training, including abuse prevention and dementia management, as well as training necessary to provide competent care. This deficiency was identified for five randomly selected Geriatric Nursing Aides (GNAs) whose records were reviewed. During interviews, one GNA could not recall when she last received training, indicating a lack of consistent training practices. The surveyor's review of staff files revealed incomplete records, with no documentation to confirm the completion of annual competencies for the selected GNAs. The Assistant Director of Nursing (ADON) and the Director of Nursing (DON) were unable to provide adequate documentation or tracking methods for the required training. The facility relied on sign-in sheets for course training, but there was no evidence of a syllabus or curriculum to verify the content covered. The ADON admitted that while training was conducted, there was no clear system to track or ensure that all staff training was up-to-date. The DON acknowledged the deficiency in tracking training, confirming that the facility did not have a reliable method to ensure staff competency 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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