Stella Maris, Inc.
Inspection history, citations, penalties and survey trends for this long-term care facility in Timonium, Maryland.
- Location
- 2300 Dulaney Valley Road, Timonium, Maryland 21093
- CMS Provider Number
- 215117
- Inspections on file
- 18
- Latest survey
- July 23, 2025
- Citations (last 12 mo.)
- 8
Citation history
Health deficiencies cited at Stella Maris, Inc. during CMS and state inspections, most recent first.
The facility did not report multiple allegations of abuse, neglect, and injuries of unknown origin to the Office of Health Care Quality within the required 2-hour timeframe. Staff and administration delayed notifying the regulatory agency after learning of incidents involving rough handling, intimidation, and unexplained bruises among residents, including those with dementia. Documentation and interviews confirmed repeated late reporting and a lack of adherence to mandatory reporting protocols.
The facility did not conduct comprehensive investigations into multiple allegations of abuse, neglect, and unexplained injuries, often failing to interview other residents or staff who may have had relevant information. In several cases, residents with cognitive impairments or those who expressed fear were not adequately assessed, and investigations were limited to statements from the accused or the reporting individual, resulting in incomplete reviews of the incidents.
Surveyors observed that staff failed to maintain proper food temperatures during meal service, with hot foods served below 135°F and cold foods above 41°F. Food items in kitchen storage were found without required dates or labels, and unsanitary practices were noted in dining areas, including undated food, personal items on serving counters, and food left at room temperature. Staff interviews confirmed inconsistent adherence to food safety and infection control standards.
The facility did not maintain an effective pest control program, as evidenced by repeated findings of mice and droppings in several nursing units and the kitchen. Multiple residents and families reported mouse sightings, and staff interviews confirmed ongoing rodent issues, especially since construction began. Vendor logs documented frequent rodent activity, and identified structural issues were not addressed promptly due to communication lapses between facility staff.
Facility staff administered a new medication to a resident with severe cognitive impairment without first obtaining consent from the resident's representative. The psychiatric practitioner ordered Depakote for behavioral disturbances, but documentation showed no evidence that the representative was notified or involved in the decision prior to administration. This was confirmed by both the representative and the Assistant Director of Nursing.
A resident with dementia sustained a significant facial bruise and a gash, prompting a provider to order an ophthalmology consult. Despite the inability to secure the consult, staff did not notify the provider as expected, and there was no documentation of the consult or communication about the failure to obtain it. The DON confirmed the lack of documentation regarding physician notification.
A resident with significant medical and cognitive conditions was physically abused by an LPN, who slapped the resident in the face and used expletives during morning care after the resident became agitated. The incident was witnessed by a GNA, who delayed reporting due to fear of retaliation. The resident was medically evaluated and found to have no significant injuries. The LPN had a documented history of behavioral and disciplinary issues.
Facility staff did not accurately code MDS assessments for several residents, failing to document falls with injury, use of antifungal treatments, and the presence of hallucinations, despite these events being recorded in medical records and progress notes. The MDS Coordinator confirmed these errors during surveyor interviews.
Two residents with dementia and their representatives were not provided with baseline care plans or written summaries of initial goals, physician orders, and services within 48 hours of admission. Interviews confirmed that neither verbal meetings nor written documentation were given, and facility leadership acknowledged the absence of required documentation in the medical records.
Staff did not update the care plan for a resident who developed skin integrity issues, including a pressure ulcer and IAD. Although treatments were ordered and administered, the care plan only addressed immobility and a head laceration, lacking specific interventions for the new skin conditions. The care plan was not revised to reflect the resident's changing needs, as confirmed by staff and nursing leadership.
Facility staff did not administer prescribed eye medications to a resident with multiple eye conditions, failed to complete required neuro checks after falls for another resident, and did not timely obtain or follow physician orders for nephrostomy tube care for a third resident. These actions did not meet professional standards of practice.
Facility staff did not complete required weekly wound assessments with measurements for a resident who had a Stage IV sacral pressure ulcer. This lapse in documentation and monitoring was confirmed by the ADON and resulted in missed opportunities to track the wound's progress and ensure effective treatment.
Facility staff did not obtain required weekly weights for a newly admitted resident with dementia, missing several scheduled weigh-ins. Despite a 10-pound weight loss over three weeks, there was no documented reassessment by the dietitian or evidence of further nutritional intervention, as confirmed by the DON.
A resident did not consistently receive prescribed topical medications, including A&D ointment and a topical analgesic, due to delays in reordering and supply issues. Documentation and staff interviews confirmed that medications were often unavailable, and there was a lack of timely notification to providers about these delays, resulting in missed doses and unmet pharmaceutical needs.
Surveyors observed multiple instances where medication carts were left unlocked and unattended, allowing unauthorized access to resident medications. In several cases, opened insulin pens were found in the carts without dates indicating when they were first used, contrary to policy and best practice. LPNs and other staff were not consistently ensuring medication security or proper labeling of opened medications.
A resident with dementia had a C. diff stool sample ordered by a Nurse Practitioner, but facility staff did not collect or send the specimen to the lab before the resident was discharged. The resident experienced ongoing diarrhea, prompting a request for hospital evaluation, and the Assistant DON confirmed the test was never completed.
Facility staff failed to secure timely outside professional consults for two residents: one with chronic kidney disease who did not receive a nephrology consult as ordered, and another with dementia and significant eye bruising who did not receive an ophthalmology evaluation after a provider's request.
A resident's medical record lacked required hospice documentation, including progress notes, assessments, and care plans, despite the resident being on hospice services. The DON confirmed the absence of these records during the survey.
Surveyors observed improper storage of clean and soiled linens, as well as patient care items, on two units. Clean linens and supplies were left uncovered on tray tables and soiled linen carts, and personal items were mixed with soiled materials. Staff confirmed these practices did not meet infection control standards.
Failure to Timely Report Alleged Abuse and Injuries of Unknown Origin
Penalty
Summary
The facility failed to report allegations of abuse, neglect, and injuries of unknown origin to the regulatory agency, the Office of Health Care Quality (OHCQ), within the required 2-hour timeframe. Multiple incidents were identified where staff either delayed notifying administration or failed to report to OHCQ promptly after becoming aware of alleged abuse or suspicious injuries. In several cases, staff members, including GNAs, LPNs, and other personnel, did not immediately escalate allegations or observations of potential abuse, resulting in late reporting to both facility administration and the regulatory agency. Specific events included residents and their families alleging rough handling, intimidation, and physical abuse by staff, as well as the discovery of unexplained bruises. In some cases, staff were aware of the incidents but delayed reporting due to fear or uncertainty, while in others, administration was not notified until days later. Documentation reviews revealed that initial reports to OHCQ were consistently submitted well beyond the 2-hour requirement, with some reports sent several hours or even a day after the incident was known to staff. Interviews with facility leadership confirmed these delays and lapses in timely reporting. Additionally, the facility failed to report multiple instances of bruises of unknown origin for a resident with dementia, despite documentation in the medical record. The lack of timely reporting was confirmed through interviews with the DON, ADON, and other staff, who acknowledged the delays and, in some cases, a misunderstanding of the regulatory requirements. The findings were evident for twelve residents reviewed during a complaint survey, highlighting a pattern of noncompliance with mandatory reporting protocols.
Failure to Thoroughly Investigate Alleged Abuse, Neglect, and Injuries of Unknown Origin
Penalty
Summary
The facility failed to thoroughly investigate multiple incidents of alleged abuse, neglect, and injuries of unknown origin involving several residents. In numerous cases, when allegations were made by residents or their families regarding rough handling, verbal abuse, or unexplained bruising, the facility's investigations were incomplete. Specifically, the investigations often lacked interviews with other residents who may have been under the care of the accused staff members, and in many instances, there were no additional staff interviews conducted to corroborate or refute the allegations. This pattern was observed across a range of incidents, including those involving residents with cognitive impairments such as dementia, who may have been unable to clearly communicate their experiences. For example, in one case, a resident expressed fear and alleged being hit by a GNA, but the facility did not interview other residents or staff to determine if there was a pattern of similar behavior. In another instance, a resident with a history of anxiety and fear of falling was found with bruising, but the facility attributed the injuries to the resident's own actions without conducting further interviews or assessments. There were also cases where residents reported being treated roughly or verbally abused by staff, yet the investigations were limited to statements from the accused staff or the reporting resident, with no broader inquiry into the experiences of other residents or staff on the unit. Additionally, the facility did not consistently assess or interview residents who were non-verbal or cognitively impaired to determine if they felt safe or had experienced similar issues. In several cases, the documentation of the investigation was limited to a few statements or medical notes, and there was a lack of comprehensive review or follow-up. The failure to conduct thorough investigations, including interviews with potentially affected residents and relevant staff, resulted in incomplete assessments of the alleged incidents and did not ensure that all possible concerns were identified and addressed.
Deficient Food Storage, Preparation, and Sanitation Practices Identified
Penalty
Summary
Facility staff failed to store, prepare, and serve food in accordance with professional standards, as evidenced by multiple observations during meal service and kitchen inspections. During a lunch meal service, hot foods such as minestrone soup, fried chicken, and broccoli were served below the required temperature of 135 degrees, while cold foods like pudding and milk were above the safe temperature of 41 degrees. These temperature discrepancies were confirmed by both the surveyor and facility staff. Additionally, food items in the kitchen freezer were found without expiration dates, and several items in the refrigerator, such as eggs, ground meat, and mashed potatoes, were not dated or labeled. Staff interviews revealed a lack of consistent understanding and application of food labeling and dating requirements. Further observations in nourishment and dining rooms on various units revealed unsanitary storage practices, including undated and unlabeled food and drink items, personal belongings such as cell phones and pocketbooks on food service counters, and food left out at room temperature. Staff interviews, including those with infection control nurses, confirmed that these practices posed sanitary and infection control concerns. The findings were reviewed with facility leadership, including the Administrator and Director of Nursing.
Failure to Maintain Effective Pest Control Program
Penalty
Summary
The facility failed to maintain an effective pest control program, as evidenced by ongoing and repeated sightings and findings of mice and mouse droppings in multiple nursing units (1P, 3P, 3S) and the kitchen. Facility pest control logs documented several incidents, including staff disposing of dead mice, finding significant mouse droppings, and receiving resident complaints about mice in their rooms. Vendor pest control logs further confirmed persistent rodent activity, with multiple dead mice found in the kitchen on numerous occasions, rodent droppings, and evidence of mice in other facility areas such as the chapel. Residents and their families also reported frequent mouse sightings, with one family providing video evidence of mice in a resident's room. Staff interviews revealed that mice had been a recurring issue, with increased activity noted since construction began. The Director of Environmental Services stated that the pest control vendor visits weekly, but vendor reports indicated that identified issues, such as gaps in floors and holes in walls, were not addressed in a timely manner. Communication lapses between the Director of Environmental Services and the Director of Facilities contributed to delays in addressing vendor-identified concerns, as the Director of Facilities was not consistently receiving vendor reports. These actions and inactions led to the facility's failure to prevent and control pest infestations as required.
Failure to Obtain Consent Before Administering New Medication
Penalty
Summary
Facility staff failed to obtain consent from a resident's representative prior to administering a new medication. The resident, who had a diagnosis including dementia and was assessed to have severe cognitive impairment with a BIMS score of 4 out of 15, was seen by a psychiatric practitioner who ordered Depakote for behavioral disturbances. Documentation indicated that the practitioner was unable to reach the resident's representative to discuss the treatment plan, and there was no evidence in the medical record that the representative was notified before the medication was given. The resident's representative later confirmed that medications were administered without a meeting to discuss the behavior or care plan. The Assistant Director of Nursing also confirmed that there was no evidence of notification prior to administration.
Failure to Notify Physician of Inability to Obtain Ophthalmology Consult After Resident Injury
Penalty
Summary
Facility staff failed to notify the physician when they were unable to obtain an ophthalmology consult for a resident who had sustained a significant bruise and a small gash to the left peri-orbital region. The resident, who had dementia and was unable to follow instructions, was found with facial bruising and initially gave conflicting accounts of how the injury occurred. Medical documentation indicated that an ophthalmology consultation was ordered to further evaluate the injury, but there was no evidence in the medical record that the consult was ever completed. Despite the provider's expectation that they would be notified if an ophthalmology appointment could not be secured promptly, there was no documentation that the nurse practitioner was informed of the failure to obtain the consult. The Director of Nursing confirmed the absence of such documentation. This lack of communication and follow-through on the consult order constituted the deficiency identified during the complaint survey.
Resident Physically Abused by LPN During Morning Care
Penalty
Summary
A deficiency occurred when a resident with paraplegia, epilepsy, intellectual disability, aphasia, and multiple co-morbidities was subjected to physical abuse by an LPN during morning care. The incident took place while a GNA was assisting the resident, who became agitated and attempted to swing at the GNA. The LPN entered the room, closed the door, and then slapped the resident hard on the right side of the face, accompanied by yelling and the use of expletives. The resident was left holding their face, which appeared red, and became quiet following the incident. The GNA who witnessed the event did not immediately report the abuse due to fear of retaliation, as the LPN was described as confrontational and intimidating. The GNA reported the incident the following day to another nurse and then to administration, expressing emotional distress over the event. Another GNA corroborated the hostile behavior of the LPN, noting previous instances of yelling at residents. Documentation and staff interviews confirmed the sequence of events and the delay in reporting. Medical evaluation of the resident following the incident included a physician's assessment for headache and a referral to the emergency room to rule out head injury. The resident underwent a CT scan of the head and C-spine, which were unremarkable, and no significant injuries were found. The LPN involved had a documented history of behavioral issues, including previous write-ups for insubordination, inappropriate language, and harsh interactions with residents.
Inaccurate MDS Coding for Falls, Treatments, and Symptoms
Penalty
Summary
Facility staff failed to ensure the accuracy of Minimum Data Set (MDS) assessments for multiple residents, as evidenced by medical record reviews and staff interviews. In several cases, significant clinical events and treatments were not properly coded in the MDS. For example, one resident experienced an unwitnessed fall resulting in a head laceration requiring staples, but the MDS did not capture the fall with injury. Additionally, the same resident received antifungal powder for a rash, but this treatment was not documented in the relevant MDS section. Another resident with a history of visual hallucinations, including seeing snakes, had these symptoms documented in both progress notes and a physician's history and physical, but the admission MDS failed to capture the presence of hallucinations. In a separate case, a resident who was found on the floor after attempting to walk was not recorded as having had a fall in the MDS, despite clear documentation in the progress notes. A further incident involved a resident with chronic inflammatory demyelinating polyneuritis who was assisted by staff after sliding from a wheelchair. The resident was placed on the floor and then transferred using a Hoyer lift, with the event witnessed by a family member. However, the MDS assessment did not reflect that a fall had occurred. In each instance, the MDS Coordinator confirmed the errors in coding during interviews with surveyors.
Failure to Provide Baseline Care Plans Within 48 Hours of Admission
Penalty
Summary
The facility failed to implement a process to ensure that baseline care plans were provided to residents and their representatives within 48 hours of admission. Specifically, for two residents with dementia, there was no evidence in the medical records that a baseline care plan, including initial goals, physician orders, therapy, dietary, and social services, was reviewed or given to the residents or their representatives. Interviews with the residents' representatives confirmed that they were not given a baseline care plan or had a meeting with facility staff to discuss the plan. Further interviews with the Assistant Director of Nursing (ADON) and Director of Nursing (DON) revealed that the facility's current process involved discussing goals with the resident and family within 72 hours of admission, but nothing was provided in writing to the resident or their representative. The DON confirmed that there was no documentation in the medical record showing that the baseline care plans were reviewed and provided to the residents or their representatives.
Failure to Update Care Plan for Altered Skin Integrity
Penalty
Summary
Facility staff failed to develop and implement a comprehensive, resident-centered care plan addressing altered skin integrity for one resident. The resident was noted to have erythema and a rash on the buttocks and thighs, for which antifungal powder was ordered and administered. Subsequent documentation revealed the development of incontinence-associated dermatitis (IAD) and a pressure injury, with additional topical treatments ordered for wound care. Despite these changes in the resident's skin condition and the initiation of new treatments, the care plan was not updated to reflect these developments. The existing care plan only addressed the potential for skin impairment related to immobility and a head laceration, with interventions limited to encouraging range of motion exercises and weight-bearing mobility. No specific interventions were included to address the resident's evolving skin integrity issues, such as the documented pressure ulcer and IAD. Staff interviews confirmed that the care plan was initiated by the admitting nurse and relied on the electronic medical record system to autotrigger updates, but the care plan remained incomplete and was not revised to address the resident's changing needs.
Failure to Provide Care and Treatment According to Orders and Standards
Penalty
Summary
Facility staff failed to provide treatment and care in accordance with professional standards of practice for three residents. For one resident with legal blindness and diagnoses of glaucoma, entropion, and dry eye, the eye doctor ordered specific eye ointment and drops to be administered regularly. However, a review of the medication administration records over several months showed that these medications were neither ordered nor administered as prescribed. Another resident with a history of falls experienced unwitnessed falls on two occasions. Post-fall neurological assessments were incomplete, with missing documentation of the COMA scale, vital signs, and hand grip assessments at various required intervals. Additionally, some scheduled neuro checks were not documented at all, as confirmed by facility leadership. A third resident, who had a nephrostomy tube placed following hospitalization for septic shock and pyelonephritis, requested tube flushes upon return to the facility. There was no documentation that this request was communicated to a physician in a timely manner, resulting in a delay before an order was obtained. Furthermore, the nephrostomy tube was flushed by nursing staff prior to obtaining a physician's order, contrary to facility policy requiring such an order for nephrostomy care.
Failure to Complete Weekly Wound Assessments for Pressure Ulcer
Penalty
Summary
Facility staff failed to provide appropriate treatment and services to prevent and heal pressure ulcers for a resident with a history of a Stage IV sacral pressure ulcer. The resident was admitted with this condition and later readmitted following a hospitalization. Medical record review revealed that staff did not complete required weekly wound assessments with measurements on multiple occasions, specifically on 12/23/22, 12/30/22, 1/13/23, 2/17/23, and 3/3/23. The absence of these weekly wound assessments impeded the ability to monitor the wound's progress, identify any issues that could affect healing, and ensure the effectiveness of the treatment plan. This deficiency was confirmed during an interview with the Assistant Director of Nursing, who acknowledged the lack of documented weekly wound assessments for the resident's sacral pressure ulcer.
Failure to Obtain Weekly Weights and Address Significant Weight Loss
Penalty
Summary
Facility staff failed to obtain weekly weights for a resident with dementia who was newly admitted. According to the facility's weight policy, newly admitted LTC residents are to be weighed on admission, weekly for four weeks, and then monthly. The resident's medical record showed weights were only documented on admission, and then at two subsequent points, with missing weekly weights on three occasions. The initial nutritional assessment by the dietitian indicated that weekly weights were to be initiated to evaluate the need for further intervention. Additionally, the resident experienced a 10-pound weight loss over a three-week period, but there was no documentation that the resident was reassessed by the dietitian or that further interventions were considered. The DON confirmed that the required weekly weights were not obtained and that no further assessment was documented after the significant weight loss.
Failure to Provide Timely Pharmaceutical Services and Medication Administration
Penalty
Summary
The facility failed to provide timely pharmaceutical services to meet the needs of a resident, as evidenced by inconsistent administration and delayed reordering of prescribed topical medications. Specifically, an order for A&D ointment to be applied every shift for skin protection was not consistently fulfilled. Documentation in the Medication Administration Record (MAR) showed multiple instances where the ointment was not administered, with progress notes indicating it was on order, awaiting delivery, or being reordered. Staff interviews confirmed that the ointment was sometimes unavailable due to delays in reordering and supply, and that the process of obtaining the medication could take time, especially when only small tubes were available and frequent use was required. Additionally, a prescribed topical analgesic (Biofreeze) for knee pain was not available for several days after being ordered, and there was a lack of timely physician notification regarding its unavailability. The order for the analgesic was eventually changed after six days, but during that period, nursing notes repeatedly documented that the medication was on order or awaiting delivery. Interviews with nursing leadership acknowledged that staff did not act quickly enough to reorder medications or notify providers about the delays, resulting in the resident not receiving prescribed treatments as ordered.
Unattended and Unlocked Medication Carts; Undated Opened Medications
Penalty
Summary
Facility staff failed to ensure that medication carts were kept locked when unattended and that medications were properly dated when opened. During random observations on three of seven nursing units, surveyors found multiple instances of unattended and unlocked medication carts containing resident medications. On one unit, a medication cart was left unlocked outside a resident's room while the LPN was inside the room. On another unit, a medication cart was left unlocked at the nurse's station while the LPN and unit secretary were occupied with other tasks, allowing the surveyor to access medications, including a Heparin vial. On a third unit, a medication cart was left unlocked in the hallway with the keys on top, and the surveyor was able to access insulin pens in the top drawer after the nurse walked away. Additionally, several insulin pens belonging to different residents were found in the unlocked cart without dates indicating when they were opened, despite the requirement that insulin pens are only good for 28 days after opening. The LPN present was unable to accurately date the insulin pens, as she was not the one who had administered them. The facility's medication storage policy requires that medication carts be locked or attended by authorized personnel at all times, but this was not followed during the observations.
Failure to Obtain Ordered Laboratory Test for C. diff
Penalty
Summary
Facility staff failed to obtain laboratory services as ordered for a resident admitted with dementia. The medical record showed that a Nurse Practitioner ordered a C. difficile (C. diff) stool sample for the resident, but no specimen was collected or sent to the laboratory from the time of the order until the resident's discharge. During this period, a change of condition was documented, noting that the resident's representative requested hospital evaluation due to ongoing diarrhea lasting over two weeks. The Assistant Director of Nursing confirmed in an interview that the ordered C. diff specimen was never sent.
Failure to Obtain Timely Outside Professional Consults
Penalty
Summary
Facility staff failed to obtain timely outside professional services for two residents as required. For one resident with chronic kidney disease stage IV, a physician ordered a nephrology consult upon admission in December 2024. However, as of early April 2025, the resident had not been seen by a nephrologist nor had an appointment scheduled. This was confirmed by both the Director of Nursing and Assistant Director of Nursing, who acknowledged that staff did not schedule the necessary consult. In a separate incident, another resident with dementia developed significant bruising and swelling around the left eye, with a small gash to the eyebrow. The nurse practitioner requested an ophthalmology consult to evaluate the injury, but review of the medical record showed that no such consult was obtained following the incident. Although the resident had a preplanned retinal specialist appointment a month after the injury, this was unrelated to the acute event. The DON agreed that the resident could have been sent to an eye clinic or emergency room for timely evaluation, but this did not occur.
Failure to Maintain Complete Hospice Documentation in Medical Record
Penalty
Summary
The facility failed to maintain complete and accurate medical records in accordance with accepted professional standards for one resident. Medical record review showed that the resident was admitted to the facility in August 2023 and began receiving hospice services in June 2024. However, the resident's medical record did not contain any documentation from hospice, such as progress notes, assessments, or care plans. This lack of hospice documentation was confirmed during an interview with the Director of Nursing, who acknowledged that the records were missing at the time of review.
Failure to Follow Infection Control Guidelines for Linen and Patient Care Item Storage
Penalty
Summary
Surveyors identified that the facility failed to implement effective infection control practices during the handling and storage of linens and patient care items. On two separate units, soiled linen carts were observed with clean patient care items, such as gloves, cleanser, ointment, and a beverage bottle, improperly stored on top. Additionally, a list containing resident names and weights, along with a pen, was found on a soiled linen cart. Clean linens, including sheets, towels, and diapers, were observed uncovered on over-bed tray tables and on carts in hallways. These items were not protected from potential contamination, and clean and soiled items were not kept separate as required by infection control guidelines. Staff interviews confirmed that these practices were not acceptable and did not align with infection control standards.
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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