St. Elizabeth Rehabilitation & Nursing Center
Inspection history, citations, penalties and survey trends for this long-term care facility in Baltimore, Maryland.
- Location
- 3320 Benson Avenue, Baltimore, Maryland 21227
- CMS Provider Number
- 215044
- Inspections on file
- 16
- Latest survey
- August 29, 2025
- Citations (last 12 mo.)
- 14
Citation history
Health deficiencies cited at St. Elizabeth Rehabilitation & Nursing Center during CMS and state inspections, most recent first.
The facility failed to protect residents from all forms of abuse and neglect, including physical, mental, and sexual abuse, as well as physical punishment, by any individual.
A resident with severe cognitive and physical impairments, who required staff assistance for mobility, was injured after falling from a wheelchair that lacked leg rests during staff transport. The absence of leg rests, contrary to facility policy, allowed the resident's feet to become caught under the wheelchair, resulting in a forward fall and head injury. The facility did not complete a full investigation or root cause analysis following the incident.
Staff failed to respond to resident call bells within the facility's required timeframe, with numerous instances of delays exceeding 30 minutes and some over an hour. Additionally, a resident with a PEG tube did not receive prescribed site care, as the order was not documented on the TAR or MAR, and care was not provided as directed by the physician.
Facility staff did not determine if a resident had an advance directive upon admission, nor did they provide information or assistance regarding advance directives. Later, after the resident was found to lack decision-making capacity, the facility failed to document or identify a surrogate decision maker.
A resident with a history of blood clots was lowered to the floor by staff, who did not report the incident as a fall. The resident later exhibited swelling and inability to bear weight, leading to hospital transfer and diagnosis of a hip fracture. The responsible party was not notified of the incident until the resident was hospitalized.
A resident who was admitted for therapy and antibiotics did not receive assistance with changing out of a soiled brief during a night shift, leading the family to file a grievance alleging neglect by a GNA. Although the staff member was terminated, there was no documented follow-up with the resident or family, and the resident remained distressed and uncertain about the situation. The facility's grievance policy requires keeping residents informed and providing a written decision, but these steps were not documented.
Staff failed to promptly report incidents of suspected abuse and neglect, including not documenting or notifying responsible parties after a resident was lowered to the floor and later found with a hip fracture, and not reporting allegations of sexual abuse and neglect to authorities within required timeframes. In some cases, staff did not immediately escalate residents' distress or unusual behavior to supervisors, resulting in delayed investigations and notifications.
Facility staff did not conduct thorough investigations into allegations of abuse and neglect, including failing to perform timely physical assessments, interview other potentially affected residents, or ensure accurate documentation of care. In several cases, residents with cognitive impairment or those unable to be interviewed were not properly assessed, and staff statements lacked necessary details, resulting in incomplete investigations.
A resident's cognitive status was not accurately assessed on the MDS due to a documentation error, where another resident's information was entered under the wrong record. The BIMS section was left unassessed or unrated in all submitted MDS assessments, despite the resident being cognitively intact at admission.
Surveyors found that the facility did not develop individualized, measurable care plans for two residents with complex medical and psychiatric needs. One resident with multiple diagnoses and a PEG tube lacked a care plan addressing specific interventions for each condition, NPO status, and oral care needs. Another resident with psychiatric diagnoses had no care plan or interventions documented. These deficiencies were confirmed through record review and staff interviews.
A resident with bowel and bladder incontinence was not consistently changed and cleaned by nursing staff, as shown by documentation gaps across multiple shifts and days. The DON and Administrator confirmed that agency GNAs were unaware of proper documentation procedures. During a facility tour, a strong urine odor was noted and a resident complained about delays in being changed, with no response from the Administrator.
A resident who required maximal assistance for bathing did not receive scheduled showers for an extended period, with records indicating no showers were provided during one month and only two showers in nearly two months. The DON was unable to locate documentation to account for missed showers.
A resident who was dependent on staff for feeding experienced a significant decrease in oral intake over several days, with missed meals and no updated nutritional assessment. Facility staff did not alert the dietitian or reassess the resident despite documented reduced intake. The resident's condition worsened, leading to hospitalization for dehydration after staff were unable to establish IV access and reported decreased intake to the hospital.
Staff failed to maintain a complete and accurate medical record for a resident, as documentation of a physician-ordered PT evaluation for wheelchair and positioning was missing. Interviews with the PT Director and DON confirmed the absence of required information in the electronic medical record.
A resident with vascular dementia and impaired mobility eloped from a secure unit due to inadequate supervision and an unsecured gate. The resident left during an outdoor activity when the staff was assisting another resident, and the gate was left unlocked after a fire drill. The resident was found at a nearby hospital and returned without injuries.
The facility failed to maintain clean carpets, with surveyors observing sticky carpets in several rooms. The Maintenance Director attributed the issue to improper cleaning solution ratios. Numerous work orders for carpet cleaning were noted, and complaints about dirty carpets dated back to 2023. The NHA acknowledged the problem and mentioned plans for carpet replacement.
The facility failed to report the results of abuse investigations within the required five working days for four residents. An alleged abuse incident involving a resident occurred, and the final report was submitted late. Additionally, three residents alleged abuse by a GNA, and the final report was also submitted late. The DON confirmed awareness of the delays.
A facility failed to inform a resident about a new medication, Semaglutide, prescribed for diabetes control. Despite the resident being their own healthcare decision-maker and having a history of congestive heart failure, hypertension, and other conditions, there was no documentation that they were informed about the medication or its side effects. This deficiency was noted during a review of medical records and interviews.
The facility failed to protect residents from abuse, as one resident was observed hitting another in the face, and later kicked a different resident. The aggressor had adjustment problems and involuntary movements due to their condition. Despite being sent for psychiatric care, the facility could not relocate the aggressor until behavior management was achieved, leading to a failure in protecting residents.
A facility failed to suspend a GNA during an abuse investigation involving a resident who alleged being beaten by staff. The investigation could not substantiate the claim, but the GNA was only reassigned, not suspended. The DON admitted the GNA should have been suspended until the investigation concluded.
A resident discharged from a facility with planned home health services experienced a delay in receiving care due to incomplete documentation. The interdisciplinary team discharge form indicated the need for various home health services, but the home health agency required clearer documentation to start services. Despite efforts by the social worker and communication with the nursing home administrator, the necessary documentation was delayed, resulting in an eight-day gap before services began.
A resident with dementia and mobility issues was left unsupervised in the shower, resulting in a fall due to a broken chair. The care plan required staff assistance during bathing, which was not provided. Another resident with multiple medical conditions had incomplete documentation of wound care treatments, indicating potential lapses in care. The DON acknowledged the lack of supervision and unexplained missing documentation.
A facility failed to maintain resident privacy and dignity during medication administration. An RN was observed not closing the door or drawing the room divider curtain while assessing and treating residents. The RN acknowledged the oversight, stating awareness of the facility's privacy policy.
The facility did not notify the local Ombudsman of a resident's transfer to the hospital, as required. A resident was transferred to the emergency room for evaluation and treatment, but this discharge was not included in the report to the Ombudsman. The DON confirmed that the facility was not sending the Ombudsman copies of transfer or discharge notices.
A facility failed to accurately code a resident's behavioral symptoms on the MDS, despite documentation showing behaviors in the 7-day look-back period. The MDS Coordinator acknowledged the error after review.
A facility failed to maintain good personal hygiene for a dependent resident. A surveyor observed the resident in an incontinence brief, and records showed they received only four showers and one bed bath in 24 days, contrary to the facility's policy of twice-weekly showers. The NHA confirmed the discrepancy.
The facility did not update nurse staffing information daily, as observed on two occasions when the posted data was outdated. The Staffing Coordinator, responsible for posting, did not work weekends, and the nursing supervisor was tasked with updates during that time. The NHA was informed of the issue.
The facility failed to ensure that an account of all controlled drugs was completed, as 6 out of 14 Controlled Medication Shift Change Logs showed incomplete counts for 31 shifts. The policy requires incoming and outgoing nurses to count all controlled medications, a practice not followed, as confirmed by an LPN and the DON.
The facility was found deficient in securing medication carts and properly storing medications. Three medication carts were left unlocked and unattended, containing improperly labeled insulin pens. Additionally, two medication storage rooms had improperly stored and expired medications. Staff interviews confirmed these practices did not meet facility expectations.
A facility failed to ensure accurate entry of resident information for lab specimens, leading to the rejection of samples due to incorrect DOB entries. A resident's blood and stool samples were canceled by an outside lab because of this error, which was confirmed by the DON. The issue was systemic, as both samples obtained by the outside lab and the facility's nurse were affected.
The facility failed to properly store and label food, with surveyors finding undated and improperly wrapped items in the freezer, expired bologna in the refrigerator, and unlabeled food in the dining room. The Certified Dietary Manager acknowledged these issues, which contravened facility policy.
A facility failed to sanitize medical equipment between residents, as observed with an RN using a blood pressure cuff and monitor on multiple residents without cleaning them between uses. The RN acknowledged the oversight and confirmed that the facility's protocol required sanitization of shared equipment after each use.
The facility failed to notify responsible parties of medication changes for three residents, despite evaluations indicating the need for such notifications. This included changes in medications like Semaglutide, Aricept, and Remeron, without informing the designated health care agents or family members.
The facility failed to respond to call bells promptly, affecting the care of multiple residents. One resident reported waiting over an hour for assistance, while another experienced a delay of hours for incontinent care. Call history reports confirmed multiple instances of excessive wait times, with staff not having pagers during some incidents. Additionally, a resident experienced a significant delay in response to a call light, coinciding with a medical emergency that required hospitalization. The NHA acknowledged the unacceptable response times.
Failure to Protect Residents from Abuse and Neglect
Penalty
Summary
A deficiency was identified regarding the facility's failure to protect each resident from all types of abuse, including physical, mental, sexual abuse, physical punishment, and neglect by any individual. The report documents that residents were not adequately safeguarded from these forms of mistreatment, indicating lapses in the facility's responsibility to ensure resident safety and well-being. Specific details about the actions or inactions that led to the deficiency, as well as information about the residents involved or their medical conditions at the time, are not provided in the report.
Failure to Prevent Avoidable Fall Due to Missing Wheelchair Leg Rests
Penalty
Summary
A deficiency was identified when a resident with dementia, polyarthritis, muscle contracture, and severe cognitive impairment experienced a fall resulting in actual harm. The resident was dependent on staff for activities of daily living, including mobility and personal care. The care plan indicated the need for staff assistance and escort to activities. On the day of the incident, the resident was being pushed in a wheelchair by a GNA after breakfast, when the resident fell forward from the wheelchair, sustaining a laceration to the forehead and requiring hospital evaluation. The medical record and staff interviews confirmed that the wheelchair did not have leg rests attached at the time of transport, contrary to facility policy and staff expectations for safe resident transport. Further review revealed that the facility did not complete a summary of the investigation, witness statements, or a root cause analysis for the fall. Interviews with the Director of PT and the DON confirmed the requirement for leg rests when staff transport residents in wheelchairs, but neither could recall the specific incident. The GNA involved could not remember if leg rests were in place and reported that the resident's feet went under the wheelchair, causing the fall. The lack of proper wheelchair equipment and supervision directly contributed to the resident's avoidable fall and subsequent injury.
Failure to Respond Timely to Call Bells and Provide PEG Tube Site Care
Penalty
Summary
Facility staff failed to provide timely responses to resident call bells and did not ensure proper gastrostomy tube (PEG) site care for a resident. Review of call bell logs over a one-week period revealed 114 instances where call bells were left unanswered for more than 30 minutes, with 31 of those occasions exceeding one hour. The facility's policy required all staff to respond to call lights within a reasonable timeframe, defined by the DON as within 15 minutes, or up to 25 minutes if staff were with another resident. Despite this policy, staff did not consistently meet these expectations, and the facility was unable to demonstrate effective monitoring or identification of trends related to call bell response times. Additionally, a resident with a PEG tube did not receive documented site care as ordered by the physician. The order to cleanse the PEG tube site with soap and water and cover with dry gauze every night shift was not transcribed onto the Treatment Administration Record (TAR) or Medication Administration Record (MAR) for July or August, and no new order was written upon the resident's return from the hospital. Interviews with nursing leadership confirmed that PEG tube care should have been documented and performed according to physician orders, but this was not done, resulting in the resident's PEG tube site being left uncleaned on multiple occasions.
Failure to Determine Advance Directive Status and Identify Decision Maker
Penalty
Summary
Facility staff failed to determine on admission whether a resident had an advance directive and did not provide information about the right to formulate one. The admission record for the resident showed the section for advance directives was left blank, and there was no documentation indicating that staff had informed the resident of their rights or offered assistance in establishing an advance directive. The resident was noted as being cognitively intact at admission, with a BIMS score of 14, and was listed as their own responsible party. Subsequently, the resident experienced increased confusion and was assessed by two physicians, who determined that the resident lacked capacity to make informed medical decisions. Despite this change in condition, the medical record did not identify who was responsible for making decisions on the resident's behalf or how a surrogate decision maker was determined. When requested, the facility administrator was unable to provide documentation regarding advance directives or the identification of a decision maker for the resident.
Failure to Notify Responsible Party After Resident Fall
Penalty
Summary
The facility failed to notify the responsible party after a resident experienced a fall. On 8/23/24, a staff member lowered the resident to the floor, but did not consider this a fall and therefore did not report the incident. The resident, who had a history of blood clots, was later observed by a family member to have a swollen left ankle and was unable to stand or put pressure on the foot. Medical assessments, including an x-ray and venous doppler, were performed, and the resident was eventually sent to the hospital where a left hip fracture was diagnosed and surgically repaired. The responsible party was not informed of the fall until several days later, when the resident was already at the hospital.
Failure to Provide Adequate Grievance Follow-Up After Alleged Neglect
Penalty
Summary
A resident was admitted to the facility for therapy and antibiotics. On a night shift, the resident repeatedly used the call-light to request assistance with changing out of a soiled brief, but did not receive help. The resident's family submitted a grievance alleging that a GNA failed to provide any activities of daily living during that shift. The grievance form indicated that the employee was terminated, but there was no documentation of follow-up with the resident or family regarding the resolution of the grievance. During an interview, the resident expressed ongoing distress and fear, stating they had not received any follow-up and were unsure if the staff member involved would return. The DON stated that follow-up had occurred, but was unable to provide documentation to support this. Review of the facility's grievance policy showed requirements for keeping residents informed of progress and issuing a written decision at the conclusion of the investigation, but these steps were not documented in this case.
Failure to Timely Report Suspected Abuse, Neglect, or Theft
Penalty
Summary
Facility staff failed to report incidents of suspected abuse, neglect, or theft within required timeframes for multiple residents. In one case, a resident was lowered to the floor by a staff member, but the incident was not documented or reported as a fall. The resident's responsible party was not notified until the resident was sent to the hospital days later with a hip fracture. There were no nursing notes or investigation conducted immediately after the incident, and the staff member involved did not report the event, believing it did not constitute a fall. In another instance, a resident reported possible sexual abuse to a family member, who then informed facility staff. However, the facility did not report the allegation to the state agency within the mandated two-hour window after becoming aware of it. Additional deficiencies included a delay in reporting an allegation of neglect involving another resident, where the facility was aware of the situation but did not notify the state agency until several days later, following a formal grievance by the family. In a separate case, a staff member observed a resident in distress and exhibiting unusual behavior suggestive of possible abuse but did not immediately report this to a nurse or supervisor. The facility's investigation later noted that such behavior was considered baseline for the resident, but there was no evidence of timely reporting or documentation at the time of the incident.
Failure to Conduct Thorough Investigations of Abuse and Neglect Allegations
Penalty
Summary
Facility staff failed to thoroughly investigate allegations of abuse and neglect involving multiple residents. In one case, a moderately cognitively impaired resident residing on a memory care unit reported a possible sexual abuse incident to a family member, which was then reported to facility staff. Although the facility's investigation included interviews with the resident, family, and staff, there was no evidence that a physical assessment was conducted at the time the allegation was reported. Additionally, no interviews were conducted with other residents on the same unit, nor were assessments completed for other vulnerable residents who may have been affected. In another incident, the DON was made aware of an allegation of neglect involving a resident found in a soiled brief with sacral excoriation. The ADON took a photograph and applied a moisture barrier cream, but there was no documented skin assessment of the excoriation. Further review revealed that the GNA responsible for the resident had documented care for several other residents during the same shift, despite evidence that care was not provided, and similar documentation patterns were found over three consecutive days. The DON and NHA were unaware of the extent of inaccurate documentation and lack of care provided by the GNA. A third incident involved an allegation of physical abuse reported by a resident's family member. The facility's investigation included staff statements, but most did not specify the relevant date or shift, and statements were missing from several staff who worked during the period in question. Of the 32-33 residents on the unit, only four were interviewed, and there were no physical assessments for residents who could not be interviewed. These deficiencies in the investigative process were acknowledged by facility leadership during interviews with surveyors.
Failure to Accurately Complete BIMS Assessment on MDS
Penalty
Summary
The facility failed to complete accurate assessments for a resident regarding the Brief Interview of Mental Status (BIMS) as part of the federally mandated Minimum Data Set (MDS) process. Medical record review showed that upon admission, the resident was identified as their own representative and was able to sign the admission contract. The social worker completed a BIMS assessment at admission, with the resident scoring a 13, indicating cognitive intactness. However, subsequent reviews of the resident's medical record revealed that all submitted MDS assessments for cognitive status since admission did not include the BIMS score, and the section was either not assessed or not rated as required. During an interview, the social worker responsible for completing the BIMS and MDS assessments was unable to recall the details and needed to review her notes. Upon follow-up, the social worker acknowledged an error in documentation, stating that another resident's information was entered under this resident, resulting in inaccurate MDS submissions for the BIMS section. This documentation error led to the failure to ensure an accurate assessment of the resident's cognitive status.
Failure to Develop Comprehensive, Individualized Care Plans
Penalty
Summary
The facility failed to develop and implement comprehensive, individualized care plans for residents with complex medical and psychiatric needs. For one resident with multiple diagnoses including dysphagia, pulmonary fibrosis, heart disease, diabetes, Parkinson's disease, and malnutrition, the care plan lacked specific, measurable objectives and did not address individualized interventions for each diagnosis. The plan also failed to include details regarding the resident's NPO (nothing by mouth) status, specific oral care needs, and the speech therapy interventions being provided, despite the resident having a PEG tube and receiving tube feedings. Additionally, the ADL care plan did not specify that the resident was only to receive oral intake during speech therapy sessions, nor did it address oral care needs related to NPO status. In a separate case, the facility did not establish a care plan for another resident with psychiatric diagnoses, omitting necessary interventions to address those needs. These deficiencies were identified through medical record review and staff interviews, and were confirmed with facility leadership. The lack of comprehensive, resident-centered care plans resulted in the failure to address the unique clinical and psychiatric needs of the residents as required.
Failure to Consistently Change and Clean Incontinent Resident
Penalty
Summary
A deficiency was identified when a resident who is incontinent of bowel and bladder was not consistently changed and cleaned by nursing staff, as documented in the GNA Kardex. The records showed multiple instances across several days and shifts in June, July, and August where the resident was not changed, with specific dates listed for day, evening, and night shifts. During an interview, the DON and Administrator acknowledged that agency GNAs were unaware of where to document completed care. Additionally, during a facility tour, an area was noted to have a urine odor, and a resident complained about not being changed and experiencing long wait times for assistance. The Administrator did not respond to the complaint during the tour.
Failure to Provide Scheduled Showers for Resident Requiring Maximal Assistance
Penalty
Summary
Facility staff failed to ensure that a resident's personal hygiene needs were met by not offering or providing scheduled showers. Medical record review and staff interviews revealed that the resident, who required maximal assistance for bathing and had adequate cognitive ability, was scheduled to receive showers every Wednesday and Saturday. Documentation showed that from early December through late January, the resident only received two showers and did not receive any showers during the entire month of December. The Director of Nursing was unable to locate shower documentation sheets when questioned about the concern.
Failure to Monitor and Intervene for Resident's Decreased Intake Resulting in Hospitalization for Dehydration
Penalty
Summary
Facility staff failed to adequately monitor and respond to a resident's hydration and nutrition status, resulting in a significant change in the resident's condition. The resident, who was dependent on staff for feeding, experienced a marked decrease in oral intake over several days, with documentation showing missed meals and reduced intake from 3/1/25 to 3/5/25. Despite these changes, there was no evidence that the resident was assessed by the dietitian during this period, nor was there an updated nutritional assessment since 9/9/24. The resident's condition deteriorated to the point where they became nonverbal and unresponsive, requiring supplemental oxygen and an attempted IV, which could not be established by facility staff. The resident was subsequently transferred to a local hospital, where they were diagnosed and treated for dehydration. Hospital records confirmed that facility staff reported decreased oral intake prior to the transfer. Interviews with the facility dietitian revealed that reduced intake should have triggered an alert and a reassessment, but this did not occur. The Director of Nursing was informed of the failure to monitor the resident's intake and implement interventions to prevent dehydration.
Incomplete Medical Record Documentation for PT Evaluation
Penalty
Summary
Facility staff failed to maintain a complete and accurate medical record for a resident. A review of the resident's electronic medical record showed a physician order for physical therapy (PT) to evaluate wheelchair and positioning, but there was no documentation available to confirm whether the evaluation occurred. During interviews, the Director of PT was unable to confirm or deny if the evaluations took place due to the absence of information in the electronic medical record. The Director of Nursing also confirmed that the medical record was not maintained in its most complete form for the resident. This deficiency was identified through medical record review and staff interviews, which revealed that required documentation related to a physician-ordered PT evaluation was missing from the resident's record.
Failure to Supervise Resident Leads to Elopement
Penalty
Summary
The facility failed to provide adequate supervision and a secure environment for a resident residing in a secure unit, which led to the resident eloping and being at increased risk for serious harm. The resident, who had a history of vascular dementia and impaired mobility, was identified as an elopement risk with exit-seeking behaviors. Despite having care plans in place to address these risks, the resident was able to leave the facility unsupervised. The incident occurred when the resident attended an outdoor activity on the patio attached to the locked unit. During the activity, the staff member responsible for supervision was assisting another resident, allowing the resident to open the gate and leave the enclosed area. The gate's locking mechanism had been disarmed due to a fire drill conducted the previous day, which was not properly secured afterward. The resident was found at a nearby hospital and returned to the facility without injuries. Interviews with staff revealed that the protocol for outdoor activities was not followed, as the gate was not checked to ensure it was locked, and there was insufficient supervision. The facility's investigation confirmed these lapses in protocol, contributing to the resident's elopement.
Removal Plan
- An in-service was completed with the maintenance staff that included the education training to check all exits after fire drills.
- An in-service was completed for staff on the protocol for resident safety during outside activities on the locked unit.
- Directions to split up residents into two different groups with two staff members.
- Activity and nursing staff to check the gate prior to outside activities to ensure that it's locked during activities.
- Collaboration with nursing staff with a roll call at the beginning of an activity and the end of an activity to make sure all the residents are accounted for.
- Activity staff and nursing staff have been educated on the steps to protect our patients from leaving the facility unaccompanied during outside therapeutic activities.
Failure to Maintain Clean Carpets
Penalty
Summary
The facility failed to maintain clean carpets, which was evident in several carpeted areas. On multiple occasions, surveyors observed sticky carpets in specific rooms, with shoes sticking to the floor. The Maintenance Director explained that the stickiness resulted from staff using an incorrect cleaning solution ratio. A review of the facility's work orders revealed numerous requests for carpet cleaning by staff. Additionally, complaints were received about dirty and sticky carpets in certain rooms dating back to 2023. The Nursing Home Administrator acknowledged the carpet issues and mentioned plans for replacement during upcoming renovations.
Failure to Timely Report Abuse Investigation Results
Penalty
Summary
The facility failed to report the results of an alleged abuse investigation within the required five working days to the Office of Health Care Quality. This deficiency was identified during a review of a facility-reported incident involving four residents. For Resident #375, an alleged abuse incident occurred on November 28, 2023, and the facility initiated an investigation and submitted a self-report on November 29, 2023. However, the final investigation report was not submitted until December 12, 2023, which exceeded the five-working-day requirement. The Director of Nursing confirmed the late submission during an interview with the surveyor. Additionally, on May 21, 2024, three residents alleged verbal and physical abuse by a geriatric nursing assistant. The facility submitted the initial report to the Office of Health Care Quality within 24 hours, as required. However, the final report was not submitted until May 31, 2024, again failing to meet the five-working-day deadline. The Director of Nursing and Unit Manager acknowledged the delay during an interview with the surveyor, confirming awareness of the late submission.
Failure to Inform Resident of New Medication
Penalty
Summary
The facility failed to inform a resident in advance of changes to their treatment plan, specifically regarding the initiation of a new medication. The deficiency was identified during a review of the medical records and interviews conducted as part of the complaint portion of the annual survey. The resident in question, admitted in 2021, has a medical history that includes congestive heart failure, hypertension, paroxysmal atrial fibrillation, and altered mental status. Despite being alert and oriented with some confusion, the resident remains their own healthcare decision-maker. On March 7, 2024, an order was written for a new medication, Semaglutide, to be administered weekly for diabetes control. However, there was no documentation in the medical record indicating that the resident was informed about the new medication or its potential side effects. Even after a visit from the medical team on March 15, 2024, there was no mention of the new medication or updates to the resident's plan of care.
Failure to Protect Residents from Abuse
Penalty
Summary
The facility failed to protect residents from abuse and neglect, as evidenced by incidents involving two residents. One resident was observed hitting another resident in the face, leading to the aggressor being sent to the hospital for emergency evaluation. In another incident, the same aggressor kicked a different resident in the face, although no injuries were noted, and the residents were immediately separated. The Director of Nursing acknowledged that the aggressor had adjustment problems managing behavior upon arrival at the facility and had involuntary movements due to their condition. Despite obtaining an Emergency Petition and transferring the aggressor for psychiatric care, the facility was unable to place the aggressor in another facility until behavior management was achieved, resulting in a failure to protect residents from abuse.
Failure to Suspend Staff During Abuse Investigation
Penalty
Summary
The facility failed to suspend a staff member during an ongoing abuse investigation, which was a deficiency identified by surveyors. The incident involved a resident whose responsible party reported an allegation of abuse, claiming the resident was beaten by staff. The facility conducted an investigation but was unable to substantiate the allegation. Despite this, the Geriatric Nursing Assistant (GNA) implicated in the allegation was not suspended; instead, they were reassigned and did not work with the resident in question. The Director of Nursing acknowledged that the GNA should have been suspended until the investigation was complete.
Incomplete Documentation Delays Home Health Services for Discharged Resident
Penalty
Summary
The facility failed to ensure complete and appropriate documentation in the medical record to meet the discharge needs of a resident. The deficiency involved a resident who was planning to return home with their daughter and required home health services, including physical therapy, occupational therapy, a home nurse, social work, and a home health aide. The interdisciplinary team discharge form indicated these services, and the resident signed the form. However, the home health agency later contacted the facility, stating that the physician notes did not reflect the need for home health care, delaying the start of services. The social worker set up home health services before the resident's discharge, but the home health agency requested clearer documentation to support the need for home care. Despite the social worker's efforts to obtain the necessary documentation from providers, there was a delay in response, leading to a gap in services for the resident. The nursing home administrator was involved in the communication with the home health agency, but the updated documentation was not provided until eight days after the resident's discharge, resulting in a delay in the initiation of home health services.
Supervision and Treatment Deficiencies in Resident Care
Penalty
Summary
The facility staff failed to maintain supervision of a resident, leading to a fall incident. Resident #224, who had a history of dementia, impaired balance, and limited mobility, was left unsupervised in the shower room, resulting in an unwitnessed fall. The resident's care plan required assistance by one staff member during bathing or showering, and the facility's policy explicitly stated that residents should not be left unattended during baths. The fall occurred due to a broken shower chair, which had not been reported as broken prior to the incident. The Director of Nursing (DON) acknowledged the oversight in supervision and the failure to investigate the incident as a lack of supervision. Additionally, the facility staff failed to provide treatments according to a resident's plan of care. Resident #382, who had a history of congestive heart failure, hypertension, atrial fibrillation, diabetes, and an open wound on the left foot, had multiple wound care treatments ordered. However, the Treatment Administration Record (TAR) showed several instances where wound treatments were not documented as completed, and the DON could not explain the missing documentation. Although refusals were documented, the lack of documentation for completed treatments suggested that the dressing changes were not performed as ordered.
Failure to Maintain Resident Privacy During Medication Administration
Penalty
Summary
The facility failed to uphold the residents' right to privacy and dignity during medication administration. This deficiency was observed when a Registered Nurse (RN) did not close the patient door or draw the room divider curtain while assessing residents, providing treatments, and administering medications. This lack of privacy was evident for three residents during the medication administration process. The RN acknowledged the oversight during an interview, stating that he usually closes the door during such procedures and was aware of the facility's policy on maintaining residents' privacy and dignity.
Failure to Notify Ombudsman of Resident Transfer
Penalty
Summary
The facility failed to notify the local Ombudsman of a facility-initiated resident discharge or transfer, as required. This deficiency was identified during an annual survey when reviewing the case of a resident who had physician orders to be transferred to the emergency room for evaluation and treatment. The resident was discharged to the hospital and later returned to the facility. However, the discharge was not included in the report provided to the Ombudsman for the specified period. During an interview, the Director of Nursing confirmed that the facility was not sending the Ombudsman copies of notices of transfer or discharge provided to residents or their representatives.
Inaccurate MDS Coding for Resident Behavior
Penalty
Summary
The facility staff failed to accurately code a resident's status on the Minimum Data Set (MDS) assessment, which is a federally mandated tool used to gather information on each resident's strengths and needs. This inaccuracy was identified for one resident during the annual survey. Specifically, the MDS for this resident incorrectly indicated the absence of behavioral symptoms in the 7-day look-back period, despite documentation in the resident's record showing the presence of such behaviors. The MDS Coordinator acknowledged the error upon review and indicated that the coding should have been different.
Failure to Maintain Personal Hygiene for Dependent Resident
Penalty
Summary
The facility failed to provide necessary services to maintain good personal hygiene for a dependent resident. On October 3, 2024, a surveyor observed a resident sitting at the edge of their bed wearing only an incontinence brief. The resident's medical record indicated they were dependent on assistance for bathing. A review of the shower records from September 8 to October 7, 2024, showed the resident received only four showers and one complete bed bath in 24 days, despite the facility's policy of providing showers twice per week. The Nursing Home Administrator confirmed the discrepancy in the shower schedule during an interview.
Failure to Post Daily Nurse Staffing Information
Penalty
Summary
The facility failed to post updated nurse staffing information daily, as required. During a survey, it was observed that on two separate occasions, the staffing information displayed in the front lobby was outdated. On September 30th, the posted information was from September 27th, and on October 7th, it was from October 4th. The surveyor interviewed the Staffing Coordinator, who stated that she was responsible for posting the staffing information but did not work on weekends. She indicated that the nursing supervisor was supposed to update the information during weekends. The Nursing Home Administrator was informed of these findings, which highlighted a lapse in maintaining current staffing information over the weekends.
Failure to Complete Controlled Medication Counts
Penalty
Summary
The facility failed to ensure that an account of all controlled drugs was completed, as evidenced by the review of the Controlled Medication Shift Change Logs. During an observation of the medication cart, surveyors and an LPN identified that 6 out of 14 logs showed that a count of the controlled medications was not completed for 31 shifts. The facility's policy requires the incoming and outgoing licensed nurses to complete a count of all controlled medications locked in the medication cart. This deficiency was confirmed during interviews with the LPN and the Director of Nursing, who acknowledged the failure to adhere to the facility's policy.
Medication Storage and Security Deficiencies
Penalty
Summary
The facility failed to maintain a secure system for medication storage, as observed during a survey of the 2nd floor nursing unit. Three out of ten medication carts were found unlocked and unattended, containing various medications including insulin pens, which were improperly labeled or not labeled at all. The surveyor noted that the medication cart should be locked when not attended by authorized staff, a standard acknowledged by the Charge Nurse and the Director of Nursing during interviews. Additionally, the surveyor observed two medication storage rooms where medications were improperly stored and not disposed of correctly. On the third floor, a bag of individual medications was found in a drawer, which included various tablets and capsules that should have been disposed of in a red biohazard bag. Similarly, on the second floor, expired Heparin Flush pre-filled syringes were found mixed with unexpired ones, indicating a failure in proper medication management and disposal. These observations highlight the facility's deficiencies in securing medication carts and ensuring proper storage and disposal of medications. The staff interviews confirmed that the facility's expectations were not met, as medication carts were left unlocked and medications were not disposed of according to protocol.
Failure to Ensure Accurate Entry of Resident Information for Lab Specimens
Penalty
Summary
The facility failed to ensure accurate entry of resident information for laboratory specimens, resulting in the rejection and cancellation of samples for a resident. On September 3, 2024, a resident was ordered to have blood samples for a Comprehensive Metabolic Panel (CMP), Lipid Panel, Complete Blood Count (CBC) with differential, and a stool sample for Clostridioides difficile (C-diff). However, the outside laboratory company rejected these samples due to incorrect Date of Birth (DOB) information on the specimen tubes and cup, which was not corrected despite confirmation with the nurse. Further review revealed that on September 23, 2024, another blood sample for a CBC with differential was also rejected for the same reason. The Director of Nursing (DON) confirmed that the facility used an outside company for laboratory results and that nurses were responsible for entering orders into a web-based system, including the resident's DOB. The DON acknowledged that both samples, one obtained by the outside lab and the other by the facility's nurse, were discarded due to the same error, indicating a systemic issue in the process of labeling and entering resident information for laboratory specimens.
Deficiency in Food Storage and Labeling
Penalty
Summary
The facility failed to store food in accordance with professional standards of food service safety, as observed during a survey. In the walk-in freezer, a frozen pork loin was found partially unwrapped with freezer burn and undated, along with a partial package of Polish Pork sausage in an opened plastic bag, also undated. The walk-in refrigerator contained nine packages of bologna past their expiration date and lacked an internal thermometer. In the dry storage room, three boxes of bananas were wrapped in plastic with condensation inside the bags, and nine boxes of Baker's Source Cake Mix were undated. Additionally, during a tour of the third-floor dining room, food stored in the Nursing Nutrition Refrigerator was found unlabeled. The Certified Dietary Manager acknowledged these issues, noting that facility policy requires securely wrapping and labeling food with open and expiration dates once opened.
Failure to Sanitize Medical Equipment Between Residents
Penalty
Summary
The facility failed to ensure proper sanitization of medical equipment between residents, as observed during a medication administration session. Registered Nurse (RN) #20 was seen using a blood pressure cuff and monitor on multiple residents without sanitizing the equipment between uses. Specifically, the RN did not sanitize the blood pressure cuff and monitor after using it on Resident #111, and continued this practice with Residents #424, #114, and #426. During an interview, RN #20 acknowledged the failure to sanitize the equipment and confirmed that the facility's protocol required sanitization of shared medical equipment after each use and between residents.
Failure to Notify Responsible Parties of Medication Changes
Penalty
Summary
The facility failed to properly identify and notify the responsible party (RP) of changes in the residents' medical conditions and treatments. This deficiency was identified during the facility's annual and complaint survey for three residents. For one resident, despite a decisional capacity evaluation indicating the resident was incapable of making healthcare decisions, there was no documentation that the RP was notified of an increase in medication dosage. The resident had a history of congestive heart failure, hypertension, and other conditions, and a health care agent was in place to make decisions on their behalf. In another case, a resident's daughter, who was the RP, reported that medication changes were made without her being informed. The facility's records did not show any notification to the RP regarding changes to the resident's Aricept medication. Similarly, for a third resident, the RP was not notified about the initiation of Remeron. The Assistant Director of Nursing acknowledged the lack of notification and emphasized the expectation that medication changes should be discussed with the RP, highlighting a systemic issue in communication within the facility.
Delayed Call Bell Responses Lead to Care Deficiencies
Penalty
Summary
The facility failed to respond to call bells in a timely manner, affecting the care of several residents. Resident #81 reported waiting over an hour for assistance, while Resident #106 experienced a delay of hours for incontinent care. The call history reports confirmed multiple instances where the call bell response times exceeded the facility's expectation of 10 minutes, with wait times ranging from 41 minutes to 2 hours. The facility's procedure mandates timely responses to residents' requests, but the review revealed that staff did not have their pagers during some of these incidents, contributing to the delays. Additionally, Resident #382 experienced a significant delay in response to a call light, which was activated during the evening into the morning shift and was not canceled until over an hour later. This delay coincided with a medical emergency that required the resident to be sent to the hospital. The Nursing Home Administrator acknowledged that the response time was unacceptable, indicating a failure to meet the facility's standards for call bell response times.
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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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