Sterling Care Bethesda
Inspection history, citations, penalties and survey trends for this long-term care facility in Bethesda, Maryland.
- Location
- 5721 Grosvenor Lane, Bethesda, Maryland 20814
- CMS Provider Number
- 215187
- Inspections on file
- 16
- Latest survey
- February 5, 2026
- Citations (last 12 mo.)
- 2
Citation history
Health deficiencies cited at Sterling Care Bethesda during CMS and state inspections, most recent first.
The facility failed to serve meals at posted mealtimes and in line with resident preferences, resulting in multiple cognitively intact residents waiting 40–45 minutes or more for lunch, with some leaving the dining room without being served and others reporting that food was often cold, especially on weekends. One resident with diabetes, pancreatitis, lung and kidney disorders, and mineral metabolism issues reported chronic delays in receiving lunch, another with a fracture, central cord syndrome sequela, and anxiety disorder described routinely late and cold meals and staff irritation when asked to reheat food, and a third resident council president with anxiety, depression, and hypo-osmolality reported six months of late, sometimes cold meals and negative staff demeanor when reheating was requested. Staff interviews cited dietary staffing shortages and logistics problems as reasons for late meal delivery, despite observations that sufficient nursing and non-nursing staff were available to assist.
Surveyors found that several residents, many with dementia, diabetes, CKD, incontinence, and dependence on staff for ADLs, were using bathrooms with toilets that had large rust stains, black mildew-like buildup around the base, missing caulk, instability, and active water leakage. A cognitively intact resident reported that the toilet had been stained and leaking for some time despite daily housekeeping, and another ambulatory resident using a walker reported a leaking toilet and concern about slipping. Housekeeping staff stated they clean bathrooms daily and report problems but admitted leaving stains they could not remove and not reporting them, while the EVS manager acknowledged only partial daily room checks. The maintenance supervisor reported noticing rust and caulking issues weeks earlier, directing housekeeping and a technician to address them but not following up, resulting in ongoing unsanitary and nonfunctional toilet conditions contrary to facility policies for a safe, clean, and homelike environment.
A resident with Alzheimer's and schizophrenia was physically abused by a geriatric nursing assistant, who was observed hitting the resident with a bag. The incident was substantiated by the facility's investigation, and the resident showed no signs of trauma. The nursing assistant was suspended and reported to the Maryland Board of Nursing.
Two residents were not provided adequate privacy, as one had an uncovered Foley catheter drainage bag visible from the hallway, and another had lower extremity dressings exposed to view by others. These lapses resulted in a failure to maintain resident dignity and privacy during care.
Surveyors found that several residents did not have advance directives documented in their medical records, and there was no evidence that they or their representatives had been given the opportunity to complete one. The Director of Social Services confirmed the absence of both the directives and related documentation.
Surveyors found that the facility failed to provide a clean, safe, and homelike environment, with issues such as marred walls, dirty floors, inaccessible trash cans, loose bathroom fixtures, broken toilet paper holders, stained ceiling tiles, and the presence of substances with strong odors in resident rooms and bathrooms. These deficiencies were observed in multiple resident areas and were reported to facility leadership.
Nursing staff did not follow professional standards by inaccurately documenting medication administration for two residents. One resident refused a prescribed medication, but it was recorded as given, while another did not receive several medications, including Zinc, which was marked as administered despite being unavailable. The MAR lacked proper documentation of medication unavailability, and the nurse confirmed signing off on medications that were not given.
A resident who had resumed a regular diet and was no longer using a PEG tube for nutrition repeatedly requested tube removal, but the facility failed to timely schedule the recommended MBSS to assess swallowing safety. Despite documentation of the resident's improved condition and notification to the DON and administrator, the assessment and removal process was delayed.
Staff failed to maintain a medication error rate below 5%, with an LPN administering an incorrect insulin dose until corrected, documenting medications as given when they were refused or unavailable, and recording administration of several medications that were not actually provided to two residents.
A nurse prepared and nearly administered 30 units of insulin to a resident with diabetes, instead of the ordered 24 units, before being corrected by a surveyor. The nurse, with one year of experience, adjusted the dose after intervention, and the resident's MAR confirmed the correct order.
Surveyors found expired intravenous drugs, a COVID self-test kit, and an insulin injection pen in a medication storage room, indicating that staff had not discarded these items as required. An LPN was present during the observation, and the ADON confirmed that expired medications should have been removed.
A resident with lactose intolerance was repeatedly not provided with lactose-free milk as ordered, instead receiving regular milk or no milk at all. The resident reported this issue occurred often, and review of the menu sheet confirmed the correct order was not followed. Staff were made aware of the error, and the Dietary Manager later acknowledged the problem.
A strong, persistent ammonia urine-like odor was observed throughout the hallways and rooms of one unit. Staff and administration acknowledged the odor, but it remained present during multiple surveyor observations, resulting in an unsanitary and uncomfortable environment.
Failure to Serve Timely, Proper-Temperature Meals in Accordance With Resident Preferences
Penalty
Summary
The deficiency involves the facility’s failure to provide meals at regular, designated mealtimes in accordance with residents’ needs, preferences, and requests, as required by its own dietary policy on frequency of meals. The policy, last revised 10/2022, states that at least three daily meals will be provided at regular times comparable to normal community mealtimes and that the Dining Services Director will ensure each meal is served within the designated time frame. Surveyor observations in the Chesapeake dining room showed residents present from 12:10 PM to 1:00 PM for a posted lunch period of 12:15 PM to 12:30 PM, with several residents waiting without being served, some leaving the dining room and not returning, and one resident verbally expressing frustration about the delay. Interviews with cognitively intact residents confirmed that they had been waiting 40–45 minutes for lunch and that meals were not brought on time. Three sampled residents were specifically affected. One resident with type 2 diabetes mellitus with hyperglycemia, pancreatitis, lung disorder, acute kidney failure, and mineral metabolism disorder reported waiting over forty minutes for lunch and stated that staff never brought food on time. Another resident with a displaced fracture, central cord syndrome sequela, and anxiety disorder reported waiting over 45 minutes for lunch, stated that weekends were worse, and that food was usually cold by the time it was served; this resident also reported staff becoming upset when asked to reheat meals. A third resident, the Resident Council President with anxiety disorder, depression, and hypo-osmolality, reported that for the last six months meals had been served late, often cold, and that staff displayed negative or disrespectful demeanor when residents requested reheating. Staff interviews revealed that meals were frequently late due to dietary staffing shortages and logistics problems, while observations showed that there were sufficient nursing and non-nursing staff available to assist dietary staff when needed.
Unsanitary, Leaking Toilets and Poor Bathroom Maintenance for Multiple Residents
Penalty
Summary
The deficiency involves the facility’s failure to maintain a functional, sanitary, and comfortable bathroom environment for five residents whose rooms had toilets with rust, black mildew-like buildup, missing caulk/sealant, instability, and active water leakage. Facility policies on Resident/Patient Room Cleaning and Safe and Homelike Environment required regular cleaning and disinfection of restrooms, including toilets and surrounding areas, and provision of housekeeping and maintenance services as necessary to maintain a sanitary, orderly, and comfortable environment. Despite these policies, surveyors observed that the toilets in the rooms of five residents had a rust stain approximately five inches wide and seven inches long, black discoloration around the toilet seal resembling mildew, missing caulk/sealant, and unsteady commodes that shifted side to side, with water leaking from the base. The affected residents had multiple medical diagnoses and varying levels of cognitive function and dependence on staff for ADLs, including toileting. One resident had Type II diabetes, dysphagia, hyperlipidemia, depression, hypertension, GERD, and frequent bowel and bladder incontinence, and was cognitively intact and able to report that the toilet rust stain had been present for a while, that housekeeping cleaned daily but the stains remained, that the toilet moved and leaked where the caulking was missing, and that no one should live with a dirty bathroom. Another resident with dementia, hyperlipidemia, hypertension, GERD, major depressive disorder, dysphagia, and frequent incontinence, who used a walker and went to the bathroom independently, reported that the toilet leaked and expressed concern about slipping and falling, though they did not know how long the leakage had been occurring. Other residents involved had conditions such as dementia, chronic kidney disease, hemiplegia, aphasia, schizophrenia, bipolar disorder, COPD, and failure to thrive, and were dependent on staff for toileting and transfers, yet their toilets were also found with rust, mildew-like buildup, missing caulk, and leakage. Staff interviews revealed inactions and incomplete follow-through that contributed to the ongoing unsanitary and nonfunctional bathroom conditions. A housekeeper with 16 years of experience stated they clean the bathroom, including the toilet bowl and the area behind the toilet, and are expected to report room problems to a supervisor so a work order can be placed, but acknowledged they did not see the rust stain behind the toilet, could not remove a stain, and simply left it, planning only to inform the supervisor if it happened again. The Environmental Services Manager stated that rooms are expected to be cleaned daily and that only about 10% of rooms receive a complete daily check, and reported having seen caulk/sealant issues but not rust stains. The Maintenance Supervisor, in the role for two months, stated they noticed the rust stain two to three weeks earlier, notified housekeeping to clean again, and asked a technician to complete caulking, but did not perform any follow-up to ensure the work was completed. These actions and omissions allowed the rust, mildew-like buildup, missing caulk, toilet instability, and water leakage to persist in resident bathrooms in violation of facility policies and regulatory expectations for a safe, clean, and comfortable environment.
Failure to Prevent Resident Abuse by Staff
Penalty
Summary
The facility failed to protect a resident from physical abuse, as evidenced by an incident involving a geriatric nursing assistant. The incident occurred when the Business Office Director and the Admission Director observed the nursing assistant hitting a resident with a small, gray bag. The resident involved in the incident had a medical history of Alzheimer's Disease and schizophrenia and was non-verbal during the surveyor's interview. The abuse was substantiated by the facility's investigation. The incident was reported to the Maryland Board of Nursing, and the nursing assistant was suspended and subsequently terminated following the investigation. The resident was assessed after the incident and showed no signs of pain, trauma, skin discoloration, or psychological trauma. The deficiency highlights a failure in the facility's responsibility to prevent abuse and ensure the safety and well-being of its residents.
Failure to Ensure Resident Privacy and Dignity
Penalty
Summary
The facility failed to treat residents with dignity by not ensuring privacy for two residents during daily care. One resident with a Foley catheter had their urinary drainage bag uncovered and visible from the hallway, as it was attached to the side of the bed facing the open door. The contents of the bag were observable to anyone passing by, compromising the resident's privacy and dignity. Another resident was observed with lower extremity dressings exposed to the hallway while lying in bed near the room entrance. The dressings, dated from the previous shift, were visible to other residents and visitors. Despite staff being notified of the issue, the resident continued to have their dressings exposed during subsequent observations, and the resident reported that staff never covered their feet, allowing others to see them.
Failure to Offer Opportunity to Formulate Advance Directives
Penalty
Summary
Surveyors determined that the facility failed to provide residents and/or their representatives with the opportunity to formulate an advance directive. During record reviews, it was found that three residents did not have advance directives documented in their medical records. Additionally, there were no progress notes indicating that these residents or their representatives had been presented with the option to complete an advance directive. The Director of Social Services confirmed that these residents did not have advance directives in place and that there was no documentation showing that the opportunity to complete one had been offered.
Failure to Maintain Clean, Safe, and Homelike Resident Environment
Penalty
Summary
Surveyors identified multiple deficiencies related to the facility's failure to maintain a clean, safe, and homelike environment for residents. Observations included marred and scraped walls, large unpainted spackled areas, and dirty floors with food and trash present in resident rooms. In one instance, a resident was unable to reach their trash can due to its placement. Additional issues included a loose bathroom faucet and separated baseboard, as well as bathrooms with dried rust-colored and brown substances around toilets and on walls. Broken fixtures, such as a toilet paper holder, and stained ceiling tiles were also noted. In one room, two cups containing a clear yellow substance with a strong ammonia, urine-like odor were found on the floor near a resident's bed. These deficiencies were observed in the rooms and bathrooms of several residents, with some residents directly reporting maintenance issues to surveyors. The findings were communicated to facility leadership, including the Administrator and DON, during the survey process. The report documents the specific environmental and cleanliness concerns that were present at the time of the survey, as observed and reported by both residents and staff.
Failure to Accurately Document and Administer Medications
Penalty
Summary
Nursing staff failed to follow professional standards of practice during medication administration for two residents. In one instance, a resident refused a physician-ordered Lidocaine Patch during the medication pass, but the medication administration record (MAR) inaccurately documented the patch as given rather than refused. In another case, a nurse prepared multiple tablets for a resident but stated that Zinc 220mg was unavailable and could not be administered. Despite this, the MAR indicated that the Zinc was given, and also showed documentation for several other medications as administered, even though the surveyor did not observe these medications being given. The MAR lacked documentation that the medication was unavailable, including the required date, initials, and time. During an interview, the nurse confirmed that she had signed off on medications as given when, in fact, they were not administered. These actions resulted in inaccurate documentation of medication administration for both residents.
Delay in Addressing Resident Request for Feeding Tube Removal
Penalty
Summary
A deficiency was identified when a resident with a percutaneous enteral gastric (PEG) feeding tube expressed a desire to have the tube removed after successfully tolerating a regular diet with nectar thick liquids for several months. The resident reported to staff and the surveyor that the feeding tube was no longer being used for nutrition, only for hydration, and that he had been waiting for three months for its removal. Despite the resident's repeated requests and the fact that he was eating well by mouth, the facility did not schedule the recommended modified barium swallow study (MBSS) in a timely manner to assess the resident's eligibility for tube removal. Medical record reviews confirmed that the resident had completed speech therapy with positive results and had a previous MBSS indicating improved swallowing function, with a recommendation for a repeat study within two months. However, there was no evidence that the facility scheduled this follow-up MBSS until after the surveyor's inquiry. Documentation showed that the resident's ability to swallow was unimpaired and that the DON and administrator had been notified of the resident's wishes, but the necessary assessment to proceed with tube removal was delayed.
Medication Error Rate Exceeds Regulatory Threshold
Penalty
Summary
Facility staff failed to maintain a medication error rate below 5 percent, as evidenced by 6 errors out of 29 observed medication administration opportunities. During medication administration, an LPN prepared an insulin injection for a resident and initially drew up 30 units instead of the ordered 24 units. The error was corrected only after surveyor intervention, and the correct dose was administered. In another instance, a resident refused a prescribed lidocaine patch, but the LPN documented the medication as administered on the medication administration record (MAR). Further observations revealed that the same LPN prepared medications for another resident but did not administer several ordered medications, including zinc, fluocinonide ointment, protein liquid, refresh teardrops, and Ocusoft lid scrub. Despite this, the LPN documented on the MAR that these medications were given. The LPN later confirmed during an interview that the medications were not administered as documented and acknowledged the insulin dosing error. These actions contributed to a medication error rate exceeding the regulatory threshold.
Significant Medication Error in Insulin Administration
Penalty
Summary
During a medication administration observation, a nurse prepared an insulin injection for a resident with diabetes by drawing 30 units of insulin from a prefilled insulin pen into a syringe, despite the provider's order specifying 24 units. The nurse was questioned by the surveyor about the correct dosage, at which point she acknowledged the error and adjusted the dose to 24 units before administering the medication. The resident's medication administration record confirmed the order for 24 units of Basaglar Tempo insulin to be given subcutaneously in the morning. The nurse involved reported having one year of nursing experience.
Expired Medications Found in Storage Room
Penalty
Summary
Surveyors observed that the facility failed to properly store medications in accordance with accepted professional principles. During an inspection of one medication storage room, two bags of intravenous drugs, a COVID self-test kit, and an insulin injection pen were found with expiration dates that had already passed. The expired items were present in the storage area at the time of observation, indicating that staff had not discarded them as required. The assistant director of nursing confirmed during an interview that staff are expected to dispose of expired medications, but these items had not been removed prior to the surveyor's visit.
Failure to Provide Lactose-Free Milk to Resident with Dietary Intolerance
Penalty
Summary
A resident with lactose intolerance was not provided with lactose-free milk as required by their dietary needs. During an observation, the resident reported receiving 2% milk instead of the Lactaid milk specified on their menu sheet, and stated that this error occurred frequently. The menu sheet confirmed that Lactaid milk was ordered, but the incorrect milk was served. On a subsequent day, the resident did not receive any milk, and the milk choice was crossed out on the menu sheet, which was verified by the surveyor. The issue was brought to the attention of a Geriatric Nursing Aide, and the Dietary Manager later acknowledged the problem, attributing it to a possible supply issue.
Persistent Unsanitary Odor in Facility Unit
Penalty
Summary
Surveyors observed a persistent, strong ammonia urine-like odor throughout the hallways and residents' rooms on one unit of the facility during multiple observation rounds. Staff, including the unit manager, nursing home administrator, and director of nursing, were interviewed and acknowledged the presence of the odor. Despite being made aware of the issue, the odor remained present during subsequent observations, indicating that the environment was not maintained in a sanitary or comfortable condition for residents, staff, and the public. No specific residents or their medical histories were mentioned in relation to the deficiency. The deficiency was limited to one of five units observed during the survey.
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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Every citation, penalty and Plan of Correction is sourced from public CMS records (latest release May 27, 2026) and official state health department websites — never guesswork.
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