St. Mary's Nursing Center Inc
Inspection history, citations, penalties and survey trends for this long-term care facility in Leonardtown, Maryland.
- Location
- 21585 Peabody Street, Leonardtown, Maryland 20650
- CMS Provider Number
- 215013
- Inspections on file
- 16
- Latest survey
- December 4, 2024
- Citations (last 12 mo.)
- 0
Citation history
Health deficiencies cited at St. Mary's Nursing Center Inc during CMS and state inspections, most recent first.
The facility was found deficient in maintaining a safe and homelike environment due to abraded wall markings behind bed headboards in five resident rooms on the 4th floor. The Facilities Director was unaware of these issues, despite a system for reporting maintenance concerns. Previous attempts to address the problem were unsuccessful.
A facility failed to transcribe a physician's order for a wound care consult for a resident with moisture-associated skin damage. The physician had ordered the resident to be turned every two hours and to obtain a wound care consult, but the consultation was not conducted. The DON confirmed that the nurse did not carry over the order, leading to the oversight.
Two residents experienced a lack of respect and privacy in a facility. One resident's call for assistance was ignored, leading to a delay in receiving help with a bedpan. Another resident's Foley drainage bag was left uncovered and visible from the hallway, compromising their privacy. These incidents highlight deficiencies in maintaining resident dignity and privacy.
The facility failed to invite two residents to participate in their care planning meetings, as revealed during a survey. One resident had not been invited since July 2023, and another was unaware of any meetings despite a recent MDS assessment. The social worker admitted to not documenting invitations, leading to a deficiency in resident involvement in care planning.
A facility failed to ensure resident safety during a transfer, resulting in a fall and hospitalization, and did not maintain proper seizure precautions for a resident with epilepsy. The resident fell when a GNA moved a wheelchair backward during a transfer, and another resident's bedrails were only partially padded despite an order for full padding as a seizure precaution.
The facility staff failed to accurately document the walk-in refrigerator temperatures, relying on an inaccurate outside thermometer instead of the correct inside thermometer. This led to consistent documentation of temperatures above the required 40 degrees, despite staff awareness of the correct temperature standards.
A resident was transferred to a hospital for emergency treatment and later denied readmission to the facility without prior notice to the resident or their representative. The facility's Administrator and DON cited unrealistic care expectations from the family as the reason for the decision, which was made after a care conference with the resident's POA.
A resident was not prepared for discharge from a facility, as the facility failed to provide notice to the resident or their representative. After being transferred for emergency treatment and admitted to a hospital for sepsis, the facility decided not to allow the resident's return, citing unrealistic care expectations from the family. The decision was confirmed by the Administrator and DON, despite a care conference where additional care interventions were requested.
A facility failed to allow a resident to return after hospitalization, citing unrealistic care expectations from the family. The resident was initially transferred for emergency treatment due to a suspected infection. Despite a care conference where the family requested changes to the care plan, the facility later refused readmission, stating they could not meet the family's expectations. The Administrator confirmed the decision, acknowledging the facility's capability to provide care but unwillingness to comply with the family's demands.
A resident was involuntarily discharged from a facility without prior notice, violating CMS regulations. The resident was transferred to a hospital for emergency treatment, and upon the family's request for a care conference, the facility initially agreed to consider changes to the care plan. However, the facility later refused to readmit the resident, citing unrealistic care expectations from the family, causing psychosocial harm to the resident.
A facility failed to document the discharge of a resident transferred for emergency treatment and later admitted to a hospital for sepsis. The resident's POA requested a care conference to discuss post-hospital care, but the facility later refused the resident's return, citing unrealistic care expectations. The facility did not document the discharge or provide notice, which was confirmed by the administration.
Facility Fails to Maintain Good Repair in Resident Rooms
Penalty
Summary
The facility failed to maintain a safe, clean, and homelike environment for its residents, as evidenced by the presence of abraded wall markings in five resident rooms on the 4th floor nursing unit. These observations were made on November 20, 2024, at various times throughout the day. The markings, which resembled scratch-like marks, were found behind the headboards of the beds in these rooms. The issue was consistent across multiple rooms, indicating a broader problem with the facility's maintenance practices. During an interview with the Facilities Director, it was revealed that staff members are expected to fill out maintenance slips for any concerns, which are checked hourly by maintenance staff. However, the Facilities Director was unaware of any maintenance issues on the 4th floor. He acknowledged that the facility has had ongoing issues with wall damage behind bed headboards due to staff pushing beds against the walls and adjusting bed heights, which causes scratches. Despite previous attempts to address this issue, the problem persisted, leading to the deficiency noted by the surveyor.
Failure to Transcribe Physician's Order for Wound Care Consult
Penalty
Summary
The facility failed to transcribe a physician's order for a wound care consult for a resident, leading to a deficiency. The resident had a documented change in skin condition, specifically moisture-associated skin damage between the buttocks, noted on 10/5/24. The physician ordered that the resident be turned every two hours and a wound care consult be obtained. However, upon review of the medical record on 11/20/24, it was found that the wound consultation had not been conducted. An interview with the Director of Nursing revealed that the nurse did not carry over the order for the wound consultation, resulting in the oversight.
Failure to Respect Resident Dignity and Privacy
Penalty
Summary
The facility failed to ensure that residents were treated with respect and dignity, as evidenced by two specific incidents involving residents. In the first incident, a resident's call light was activated, indicating a need for assistance. Environmental Services Staff entered the room but did not provide the necessary help, as the resident urgently needed a bedpan. The resident's call light was activated again, and despite the presence of a GNA in the hallway, the resident's request was dismissed as a control issue. Eventually, the Unit Manager intervened to assist the resident, but the delay in response highlighted a lack of respect for the resident's needs. In the second incident, a resident with a Foley drainage bag attached to their bed was observed with the bag uncovered and visible from the hallway. This lack of privacy was noted on two separate occasions, and the LPN acknowledged that the bag should have been covered. The visibility of the drainage bag from the hallway without a privacy cover demonstrated a failure to maintain the resident's dignity and privacy.
Failure to Invite Residents to Care Plan Meetings
Penalty
Summary
The facility failed to ensure that residents were offered the opportunity to participate in their care planning process by being invited to their care plan meetings. This deficiency was identified for two residents during the survey. Resident #31 was unaware of care plan meetings and expressed a desire to participate. A review of the resident's medical records revealed that they had not been invited to any care plan meetings since July 2023. The social worker acknowledged that the resident had not been invited and admitted that improvements could be made in inviting residents to these meetings. Similarly, Resident #12 was also unaware of any care plan meetings. A review of their medical records showed that the last documented care plan meeting was in March 2024, despite a recent MDS assessment in October 2024. The social worker confirmed that there was no documentation of Resident #12 being invited to care plan meetings and admitted to not documenting when residents are invited. The surveyor noted this concern at the time of exit, highlighting the facility's failure to ensure resident participation in care planning.
Deficiencies in Resident Safety and Seizure Precautions
Penalty
Summary
The facility failed to ensure the safety of a resident during a transfer, which resulted in a fall and subsequent hospitalization. The resident, who was cognitively intact and dependent on staff for mobility transfers, reported that a Geriatric Nursing Assistant (GNA) spun them too fast during a transfer from the toilet, leading to the fall. The investigation revealed that the GNA unlocked the wheelchair wheels and moved it backward, causing the resident to lean forward and fall, despite the GNA's attempt to grab the resident by the gait belt. Additionally, the facility did not maintain proper seizure precautions for another resident with epilepsy. The resident's medical record indicated an active order for padded side rails as a seizure precaution, but observations showed that the bedrails were only partially covered with cushions, leaving a portion near the head of the bed exposed. Interviews with staff confirmed that the bedrails should have been fully padded, but they were not. These deficiencies highlight the facility's failure to maintain adequate safety measures during resident transfers and to ensure proper seizure precautions, as evidenced by the observations and staff interviews conducted by the surveyors.
Inaccurate Temperature Documentation in Walk-In Refrigerator
Penalty
Summary
The facility staff failed to ensure accurate documentation of the walk-in refrigerator temperatures, as observed during an environmental kitchen food services inspection. On the initial inspection, the temperature logs were not found near the refrigerator but were instead kept in a book near the dietician's office. The thermometer inside the refrigerator showed a temperature of 38 degrees, while the logs documented a temperature of 42 degrees for the same morning. The dietician acknowledged that the thermometer inside the refrigerator was accurate, whereas the one outside was sometimes inaccurate. Further inspection revealed that the outside thermometer was malfunctioning, as it was blinking and not registering a temperature, while the inside thermometer read 39 degrees. The temperature logs showed consistent documentation of temperatures above the required 40 degrees, with several entries at 45 degrees. The cook staff confirmed that she documented the temperature from the outside thermometer, despite knowing the correct temperature should be 40 degrees or less. The dietician admitted that the dietary staff were documenting incorrect temperatures from the outside thermometer instead of the accurate readings from the inside thermometer.
Failure to Provide Adequate Discharge Notice
Penalty
Summary
The facility failed to provide adequate notice to a resident and their representative prior to discharge. The incident involved a resident who was transferred from the facility for emergency treatment due to symptoms of a urinary tract infection leading to sepsis. The resident was admitted to a local hospital for observation. Despite a care conference held with the resident's power of attorney (POA), the facility later informed the POA that the resident would not be allowed to return after hospital discharge, citing the family's unrealistic care expectations. This decision was made without prior notice to the resident or their representative, as required. Interviews with the facility's Administrator and Director of Nursing (DON) confirmed the refusal to readmit the resident, attributing the decision to the family's changing and immediate care expectations. The Administrator expressed a willingness to accept regulatory penalties rather than accommodate the family's demands. The surveyor noted the facility's failure to provide the required notice, which was acknowledged by the Administrator and DON.
Failure to Prepare Resident for Discharge
Penalty
Summary
The facility failed to prepare a resident for discharge, as evidenced by the lack of notice provided to the resident or their representative prior to discharge. The resident was initially transferred from the facility for emergency treatment after being observed moving slower than usual, and was subsequently admitted to a local hospital for observation due to sepsis caused by a urinary tract infection. Despite a care conference being held with the resident's power of attorney (POA), the Administrator, Director of Nursing (DON), and a Social Worker, where additional interventions to the resident's care plan were requested, the facility later informed the POA that the resident would not be allowed to return after hospital discharge. The Administrator and DON confirmed the decision to refuse the resident's return, citing unrealistic care expectations from the family. The Administrator expressed a willingness to accept regulatory penalties rather than readmit the resident under the family's expectations. The DON noted a history of frequent visits and criticisms from the POA regarding the care provided. The surveyor highlighted the facility's failure to adequately prepare the resident or their representative for discharge, which the Administrator and DON acknowledged.
Facility Refusal to Readmit Resident Post-Hospitalization
Penalty
Summary
The facility failed to allow a resident to return after being transferred for emergency treatment, which was identified during a complaint survey. The resident was initially transferred to a hospital for observation due to a suspected systemic infection caused by a urinary tract infection. The facility did not provide the resident or their representative with notice prior to the discharge decision. The resident's power of attorney (POA) requested a care conference to discuss the resident's care post-hospitalization, which was attended by the facility's Administrator, Director of Nursing (DON), and a social worker. During this meeting, the POA requested additional interventions to the resident's care plan, which the Administrator said would be considered. Later, the facility informed the POA that they would not allow the resident to return, citing the family's unrealistic care expectations. The Administrator confirmed the refusal to readmit the resident, despite acknowledging that the facility could provide the necessary care. The DON provided context on the history of interactions with the POA, noting frequent visits and criticisms of the care provided. The Administrator expressed a willingness to accept regulatory penalties rather than readmit the resident under the family's expectations.
Failure to Provide Notice for Involuntary Discharge
Penalty
Summary
The facility's administration failed to provide leadership to ensure compliance with CMS regulations regarding the involuntary discharge of a resident. This deficiency was identified during a complaint survey involving a resident who was transferred to a hospital for emergency treatment due to a suspected systemic infection. Upon review, it was found that the facility did not provide the required notice to the resident or their representative prior to the discharge, which is a violation of the regulations. The situation escalated when the resident's power of attorney (POA) requested a care conference to discuss the resident's care plan after hospital discharge. During the conference, the POA requested additional interventions, which the facility initially agreed to consider. However, later that day, the facility informed the POA that they would not allow the resident to return, citing unrealistic care expectations from the family. The facility's decision not to readmit the resident without prior notice caused psychosocial harm to the resident, as the facility was deemed to have the appropriate staff and environment to meet the resident's needs. Interviews with the Administrator and DON confirmed the refusal to readmit the resident and acknowledged the lack of leadership in handling the situation appropriately.
Failure to Document Resident Discharge and Provide Notice
Penalty
Summary
The facility failed to document the discharge of a resident who was transferred for emergency treatment and subsequently admitted to a local hospital for observation due to sepsis caused by a urinary tract infection. Upon review of the resident's medical records, there was no documentation indicating that the facility discharged the resident or provided notice to the resident or their representative prior to discharge. This deficiency was identified during a complaint survey involving five residents. An interview with the resident's power of attorney (POA) revealed that a care conference was requested to discuss the resident's care post-hospital discharge. During the conference, the POA requested additional interventions to the care plan, which the facility agreed to consider. However, later that day, the facility informed the POA that they would not allow the resident to return, citing unrealistic care expectations. The facility's administrator confirmed the decision, stating they could provide care but not at the level expected by the POA. The surveyor noted the lack of discharge documentation, and the facility's administration acknowledged the oversight.
Latest citations in Maryland
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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