Sterling Care Rockville Nursing
Inspection history, citations, penalties and survey trends for this long-term care facility in Rockville, Maryland.
- Location
- 303 Adclare Road, Rockville, Maryland 20850
- CMS Provider Number
- 215107
- Inspections on file
- 15
- Latest survey
- January 14, 2026
- Citations (last 12 mo.)
- 8
Citation history
Health deficiencies cited at Sterling Care Rockville Nursing during CMS and state inspections, most recent first.
Facility staff failed to accurately code MDS assessments for several residents, omitting documented falls and high-risk medication use. One resident’s fall within the three-month look-back period was not recorded in the MDS falls section. Another resident had multiple unwitnessed falls and PRN Oxycodone and topical antibiotic use documented in the MAR and care plan, but these were not captured in the MDS falls and medication sections. A third resident received daily Aspirin and Gabapentin, and a fourth received scheduled Tramadol before therapy, yet their MDS assessments left the relevant high-risk drug class fields blank. The MDS Coordinator confirmed these discrepancies between clinical records and MDS coding.
Staff failed to maintain dignity for two residents with Foley catheters when their urinary drainage bags were observed hanging openly from bed frames without being placed in required privacy/dignity bags. One resident had a physician’s order specifying that a dignity Foley bag be used every shift, but this order was not followed. An RN acknowledged that the drainage bags should have been in privacy bags, confirming that expected practices to protect resident dignity were not implemented for these residents.
Facility staff failed to honor a resident representative’s decision to discharge a resident home by conditioning the discharge on the representative’s signature on an AMA form, despite documented physician certifications that the resident lacked decision-making capacity. Social Services staff told the representative that the resident could not leave unless discharge paperwork, including the AMA form, was signed and returned, and an email from staff reiterated that signed paperwork was required before discharge. The representative, who had already arranged transportation and wanted the resident home earlier than the therapy-planned discharge date, signed the AMA form only after being told the resident would not be discharged without it, and documented this concern directly on the form.
A resident with dementia, a history of repeated falls, multiple sclerosis, generalized weakness, and gait/balance problems had a care plan requiring that commonly used items, including the call bell and TV remote, be kept within easy reach. During multiple observations, the resident was found in bed with the call bell either hanging on the wall or lying on the floor out of reach, and the over-bed tray table with water, food, and the TV remote positioned away from the bedside. An LPN Unit Manager had to search for and reposition the call bell and tray table, and later observations again showed the call bell out of reach, demonstrating repeated noncompliance with the resident’s care plan.
A resident reported feeling uncomfortable with the way a staff member provided care and later stated that the staff member’s fingers were in the resident’s private area, constituting an allegation of sexual abuse. The facility’s investigation omitted a timely statement from the first staff member who received the report, delayed obtaining the resident’s statement until the next day, and failed to include an interview with the Dietitian, despite documentation that the resident had reported the allegation to the Dietitian. The investigation initially lacked ER documentation, which later showed the resident’s chief complaint of sexual assault by a male staff member, and the follow-up report submitted by the Administrator did not include the resident’s sexual abuse allegation, resulting in an incomplete investigation.
Facility staff did not develop or implement a comprehensive, measurable care plan for a resident with an indwelling Foley catheter, despite the resident having obstructive and reflux uropathy, malignant rectal neoplasm, and benign prostatic hyperplasia. Observation found the resident in bed with catheter tubing and a urinary drainage bag hanging at the bedside without a dignity bag. Medical record review showed no catheter-specific care plan, and an RN acknowledged that a catheter care plan should have been in place.
A resident with dementia, repeated falls, and multiple sclerosis had a care plan requiring commonly used items, including the call bell, to be within reach and a fall mat at the bedside when in bed unattended. Surveyors twice observed the resident in bed without fall mats in place and with the call bell out of reach—first hanging on the wall and the overbed tray with water, food, and TV remote positioned away from the bed, and later with the call bell on the floor and still no fall mats present. An LPN and other staff were shown these concerns, demonstrating that care-planned fall-prevention interventions were not consistently implemented.
The facility failed to maintain complete and accurate medical records and documentation for multiple residents. One resident’s room change was reflected in the census and in a psychotherapy note describing adjustment to the new room, but there was no corresponding documentation of the room change or roommate notification in either resident’s record, and the transfer form was found in the DON’s office instead of in the chart. A resident with a Foley catheter had a visible drainage bag without a dignity cover, even though the TAR contained a physician’s order for a dignity bag every shift and nurses had initialed that it was in use. Another resident’s record lacked any documentation of an emergency room visit related to an allegation of sexual abuse, and the ER record had to be obtained from an external health information exchange rather than being present in the resident’s chart.
The facility failed to maintain a safe and homelike environment, as evidenced by deficiencies in shower room maintenance and a broken handrail in a resident's bathroom. Surveyors found stained ceiling tiles, taped vents, and perforated walls in shower rooms, while a resident reported a broken handrail that had been in disrepair for weeks. The facility acknowledged ongoing repairs but had not addressed the issues promptly.
The facility failed to prevent abuse in two incidents. In one, a resident slapped another in the hallway, observed by staff. In another, a family member was seen pulling a resident's hair and tapping their head. The resident, with dementia and a BIMS score of 0.0, could not recall the incident. The facility's policy on abuse was reviewed, and the corporate nurse noted the regional team handles such cases.
The facility failed to report an alleged abuse and an injury of unknown origin to regulatory agencies. A resident reported feeling someone was trying to harm them, noted by a physician as delusions possibly due to medication changes. Another resident had a shoulder dislocation with no witnessed cause. The DON confirmed internal investigations but acknowledged the failure to report to the OHCQ.
A facility failed to maintain evidence of a thorough investigation into an injury of unknown origin for a resident. The investigation file lacked documentation of resident interviews and skin checks, and a statement from the GNA who identified the injury was missing. Although the DON confirmed skin checks were done, no interviews with capable residents were completed, indicating a deficiency in the investigation process.
A facility failed to update a resident's care plan after a change in the resident's use of hearing aids. Despite a family member's request to stop using the hearing aids, the care plan still included instructions for their daily application. The treatment log inaccurately documented the use of hearing aids, and the Unit Manager was unsure of the current status. The DON confirmed the need for updates to reflect the resident's current care needs.
The facility failed to ensure post-discharge home health services for two residents, leading to delays in care initiation. One resident, with a history of joint replacement and osteoarthritis, was discharged without proper contact details for the home care agency, resulting in a 13-day delay in services. Another resident faced an 8-day delay due to issues with securing a primary care doctor and the home health agency's inability to provide the requested hours of care.
A facility physician failed to review and acknowledge abnormal lab results for a resident with a history of UTIs and hydronephrosis. Despite a urinalysis indicating a Pseudomonas Aeruginosa infection, no treatment was ordered, and the lab results were not acknowledged. The lack of documentation and rationale for non-treatment led to a deficiency identified by the surveyor.
The facility failed to provide routine medications as ordered for two residents, leading to deficiencies in pharmaceutical services. A resident with diabetes did not receive Sitagliptin Phosphate on three occasions due to pharmacy delivery issues, and another resident missed doses of Keppra and Latanoprost due to similar issues. The DON was unable to provide an explanation for the unavailability of medications, and an incident report revealed that two nurses did not administer the medications over two shifts.
A facility failed to maintain a safe and sanitary environment in a resident's room. A resident reported that the floors were not cleaned regularly due to a fall mat, and the surveyor observed debris, a dark substance on the privacy curtain, a removed ceiling tile, a falling chair rail, an exposed footboard edge, a faulty nightstand drawer, and brown staining on the toilet. An LPN confirmed the room had been cleaned earlier, and the Nursing Home Administrator acknowledged the issues.
A resident was left in bed with a soiled incontinence brief after requesting assistance, and staff entered the room without knocking or seeking permission. The resident, unable to get up independently, waited approximately ten minutes for care, and the Unit Manager confirmed that staff should have knocked before entering.
Surveyors found that two residents did not have proper access to the call bell system—one lacked a call bell entirely due to equipment limitations, while another was unable to activate the provided call bell because of its design. Staff and maintenance confirmed these issues during the survey.
A resident who was prescribed and receiving an anticoagulant medication was incorrectly coded as not receiving such medication on their quarterly MDS assessment. This discrepancy was identified through medical record review and confirmed by staff interview, indicating a failure to ensure accurate MDS documentation.
A resident's care plan did not reflect their expressed wishes to transfer to another facility and to participate in shopping outings, despite these preferences being documented in clinical notes and discussed with staff. The care plan instead indicated a long-term stay and focused on group activities, failing to address the resident's actual goals and requests.
A resident experienced a fall that was attributed to a broken toilet handrail, which was confirmed to be nonfunctional during surveyor observations. Despite a care plan for falls and monthly equipment checks by maintenance, the broken handrail was not promptly repaired, resulting in the resident relying solely on wall-mounted handrails for support.
A resident was given oxygen therapy following a change in condition and a verbal instruction from an NP, but no order for oxygen was entered into the EHR at the time. Multiple LPNs and the unit manager confirmed the absence of an order, despite the resident receiving oxygen, which was later verified by facility leadership.
The facility did not have an RN physically present for 8 consecutive hours on one reviewed day, as confirmed by staffing records and staff interviews. Although the ADON was on call by phone, no RN was scheduled or present in the building, and no staffing waivers were in place.
Physicians did not consistently document their review of pharmacist-identified medication irregularities or actions taken in response for two residents prescribed antidepressants. Although pharmacy recommendations were provided and reviewed, there was no clear process to ensure documentation in the medical record when recommendations were not acted upon, leading to incomplete records of medication regimen reviews.
A resident being treated for hypothyroidism received duplicate doses of levothyroxine sodium over four days, resulting in a higher than intended daily dose. The error was discovered through review of the Medication Administration Record and confirmed by the DON, following the resident's report of incorrect medication dosing.
A resident experienced significant delays in receiving ordered radiology services, including an ultrasound and MRI, due to poor coordination of transportation, scheduling issues, and lack of available services from the provider. Staff relied on verbal communication to determine transportation needs, which contributed to the delays and miscommunication.
A resident with bilateral below the knee amputations had an active physician's order to float heels for skin prevention, which staff documented as performed multiple times daily. An LPN confirmed the order was inaccurate since the resident did not have heels, yet the order remained active and was documented as completed.
The facility did not maintain an effective pest control program, as evidenced by reports from a resident and a family member about cockroach sightings, and pest management records indicating repeated issues with roaches. The NHA was unable to provide documentation of routine pest control visits or details on follow-up actions, highlighting gaps in pest management documentation and oversight.
Inaccurate MDS Coding for Falls and High-Risk Medications
Penalty
Summary
Facility staff failed to ensure that Minimum Data Set (MDS) assessments were accurately coded for multiple residents, as identified through medical record review and staff interview during a complaint survey. For one resident, an annual MDS with an assessment reference date (ARD) of 10/1/25 incorrectly coded Section J1800 (Falls) as having no falls in the prior three months, despite a care plan update note documenting an unwitnessed fall on 7/11/25. Another resident’s MDS with an ARD of 8/22/25 coded no falls since the last assessment in Section J1800, even though nursing progress notes and a care plan update documented unwitnessed falls on 7/30/25 and 7/31/25. A subsequent MDS for the same resident also failed to capture a fall that occurred during bathing on 9/15/25. Additional MDS coding errors involved medication use not being captured in Section J0100B and Section N0415 (High-Risk Drug Classes). For one resident, the August 2025 MAR and TAR showed administration of PRN Oxycodone and Bacitracin ointment, but the MDS coded no PRN pain medication use and left the antibiotic field blank. Another resident’s December 2025 MAR documented daily Aspirin (antiplatelet) and nightly Gabapentin (anticonvulsant), yet the corresponding MDS left the antiplatelet and anticonvulsant fields blank. A further resident’s February 2025 MAR showed scheduled Tramadol, an opioid, administered prior to therapy sessions on multiple days, but the MDS with an ARD of 2/14/25 did not code opioid use in Section N0415. The MDS Coordinator (RN #16) confirmed these MDS coding errors during interview.
Failure to Maintain Dignity for Residents With Foley Catheters
Penalty
Summary
Facility staff failed to honor residents’ rights to dignity and self-determination by not placing urinary catheter drainage bags in privacy/dignity bags as ordered and expected. During a complaint survey on 1/13/26 at 12:25 PM, Resident #14 was observed lying in bed with a Foley catheter drainage bag hanging off the left side of the bed frame, and the bag was not placed in a privacy/dignity bag to enhance the resident’s privacy. Review of Resident #14’s January 2026 Treatment Administration Record showed a physician’s order, written on 1/11/26, for catheter care specifying that a dignity Foley bag was to be in use every shift. At 12:27 PM on the same date, Resident #15 was observed lying in bed with a Foley catheter drainage bag hanging off the side of the bed, also not placed in a dignity bag. When informed of these findings at 12:35 PM, RN #15 acknowledged that the drainage bags should have been in privacy bags. These observations demonstrated that staff did not consistently follow physician orders or facility practice to maintain resident dignity for 2 of 5 residents reviewed for urinary catheters during the complaint survey.
Failure to Honor Resident Representative’s Discharge Wishes
Penalty
Summary
Facility staff failed to honor the wishes of a resident’s representative regarding discharge, despite the resident being determined unable to comprehend information and make decisions. The resident had been admitted from the hospital for rehabilitation, and two physician certifications documented the resident’s incapacity on two separate dates. A social services note recorded that the resident’s representative wanted the resident discharged earlier than the date set by the Director of Rehabilitation so the resident could be home, and the representative planned to follow up with Social Services about a discharge date. Subsequently, when the representative arranged transportation home and notified the facility, Social Services staff (Staff #6) informed the representative that discharge paperwork, including an Against Medical Advice (AMA) form, had to be signed and returned before the resident could leave on the requested date. Staff #6 acknowledged telling the representative that, because the resident could not sign, the representative needed to sign the AMA form for the resident to be discharged. The AMA form, later provided to the surveyor, contained a written statement by the representative that the facility had said the resident would not be allowed to leave unless the form was signed, and it was signed by both the representative and Staff #6. An email from Staff #6 to the representative stated that the facility could send discharge paperwork in advance but required the signed paperwork to discharge the resident on the requested day. The representative reported believing the facility could not hold the resident if the representative wanted the resident to go home, but signed and returned the AMA form after being told the resident could not be discharged without it. The corporate nurse later confirmed she had informed Staff #6 that the AMA form was not required, but this occurred after the representative had already signed the document.
Failure to Keep Call Bell and Essential Items Within Reach for High-Fall-Risk Resident
Penalty
Summary
The deficiency involves the facility’s failure to ensure a resident’s call light and commonly used items were kept within reach as required by the individualized care plan. The resident was admitted with diagnoses including unspecified dementia, repeated falls, and multiple sclerosis, and had a care plan initiated in November 2024 identifying an actual fall and risk for falls related to generalized weakness and gait/balance problems. The care plan included an intervention to keep commonly used articles, such as the call bell and TV remote control, within easy reach. During an observation on 1/12/26 at 11:26 AM, the resident was found lying in bed with the call bell cord hanging on the wall, out of reach, and the over-bed tray table positioned by the window, also out of reach, with water, sandwiches, and the TV remote on it. When asked, the LPN Unit Manager had to look around the bed to locate the call bell on the wall and then placed it on the bed and moved the tray table within reach. On subsequent observations on 1/13/25 at 9:35 AM and 1/13/26 at 12:25 PM, the call bell cord with attached call bell was again found lying on the floor, out of the resident’s reach, and this concern was shown to staff and reported to an RN, demonstrating repeated failure to maintain the call bell within reach as care planned.
Failure to Thoroughly Investigate Resident’s Allegation of Sexual Abuse
Penalty
Summary
The deficiency involves the facility’s failure to thoroughly investigate an allegation of abuse reported by a resident. A facility-reported incident indicated that a resident told a staff member on one date that he/she was uncomfortable with the way another staff member had cared for him/her several days earlier, and the initial report to the state agency categorized the allegation as physical. The facility’s investigation lacked a statement from the staff member who first received the report, including what was reported and when. The resident’s own statement was not obtained until the following day, and when it was documented by the Social Services Assistant, the resident reported seeing the staff member’s fingers in his/her private area. Further review of the resident’s medical record showed that a Psychiatric Mental Health NP documented that the resident reported the allegation to the Dietitian on the same day the incident was reported to the state, but the facility’s investigation contained no statement from the Dietitian. The investigation provided to the surveyor also did not include emergency room documentation. Only after surveyor intervention was the ER record produced, which contained the resident’s chief complaint in his/her own words that he/she had been sexually assaulted by a male staff member on a prior Saturday evening. The Facility Reported Incident Follow-Up Investigation Report submitted by the Administrator did not include the resident’s statement alleging sexual abuse, and the Corporate Nurse confirmed that the investigation did not include necessary interviews, ER documentation, or a complete investigation of the allegation.
Failure to Develop Comprehensive Care Plan for Resident With Foley Catheter
Penalty
Summary
Facility staff failed to develop and implement a comprehensive, resident-centered care plan with measurable goals and interventions for a resident with an indwelling Foley catheter. During observation, the resident was noted lying in bed with Foley catheter tubing and a urinary drainage bag hanging on the side of the bed, and the drainage bag was not placed in a dignity bag. Medical record review showed the resident had been admitted with diagnoses including obstructive and reflux uropathy, malignant neoplasm of the rectum, and benign prostatic hyperplasia, conditions relevant to urinary function and catheter use. Further review of the medical record did not reveal any care plan addressing the Foley catheter, including measurable goals or specific interventions for catheter management, despite the resident’s clinical conditions and the presence of the indwelling catheter. Staff interview confirmed that the resident should have had a catheter care plan in place, and the RN acknowledged the absence of such a care plan in the record.
Failure to Maintain Call Bell Access and Fall Mats for High-Fall-Risk Resident
Penalty
Summary
Surveyors identified a deficiency in the facility’s failure to maintain a safe environment and provide adequate supervision to prevent accidents for a resident with a history of falls. The resident had been in the facility since November 2024 and had diagnoses including unspecified dementia, repeated falls, and multiple sclerosis. The resident’s care plan, initiated in November 2024 for actual falls and risk for falls related to generalized weakness and gait/balance problems, included interventions such as keeping commonly used items (call bell, TV remote, etc.) within easy reach and placing a fall mat at the bedside when the resident was in bed unattended, as tolerated. A prior unwitnessed fall on 7/11/25 had been documented, and the interdisciplinary team had decided to continue the existing plan of care. On 1/12/26 at 10:12 AM, record review confirmed the care plan interventions, and at 11:26 AM the resident was observed lying in bed with the call bell cord hanging on the wall, out of reach. The overbed tray table, holding water, sandwiches, and the TV remote, was positioned by the window and also out of the resident’s reach, and there were no fall mats on the floor next to the bed. When questioned, the unit manager LPN located the call bell on the wall and placed it on the bed, and then moved the tray table within reach. A subsequent observation on 1/13/26 at 12:25 PM again found the call bell cord with attached call bell lying on the floor out of the resident’s reach and no fall mats at the bedside. These repeated observations demonstrated that staff did not consistently implement the resident’s care-planned fall prevention interventions regarding call bell accessibility and use of fall mats.
Incomplete and Inaccurate Medical Records and Documentation
Penalty
Summary
The deficiency involves the facility’s failure to maintain complete and accurate medical records in accordance with accepted professional standards for multiple residents. For one resident who changed rooms, the census section showed a room switch on 9/18/25 and a psychotherapy note on 9/23/25 documented that the resident loved the new room and was adjusting well, but there was no documentation in the miscellaneous, assessment, or progress notes sections about the room change or the request to change rooms. The new roommate’s record also lacked any documentation of receiving a new roommate on that date, and the only roommate assessment forms for either resident were from prior years. A handwritten transfer form related to the room change was later found in the DON’s office rather than in the resident’s medical record, and both the social work assistant and the Interim DON acknowledged it should have been in the medical record. Another deficiency was identified when a resident with a Foley catheter was observed in bed with the drainage bag hanging on the side of the bed without a dignity bag, and urine was visible. The resident’s Treatment Administration Record contained a physician’s order for catheter care requiring use of a dignity Foley bag every shift, and the TAR showed nurses’ initials for several days indicating that a dignity bag was in use each shift, despite the observation that it was not in place. In a separate case, review of another resident’s record related to a complaint of an emergency room visit for an allegation of sexual abuse showed no documentation of the ER visit in the assessments, progress notes, or paper record. The Acting DON later obtained the ER documentation from a regional health information exchange and confirmed that there was no documentation of the ER visit in the resident’s medical record.
Deficiencies in Shower Room Maintenance and Bathroom Safety
Penalty
Summary
The facility failed to provide a safe, comfortable, and homelike environment as evidenced by deficiencies found in the shower rooms and a broken handrail in a resident's bathroom. During the annual survey, surveyors observed that the second-floor shower room had stained ceiling tiles, a taped-up vent with brown tape, and visible dark spots in the ceiling light covers. Two of the shower stalls appeared to be recently used, while the other two were dry and used for equipment storage. On the third floor, one shower stall was in use, while two had perforations in the walls covered with taped-on plastic, and a fourth stall was filled with equipment. The Nursing Home Administrator acknowledged that the second-floor showers had not worked in years and repairs were ongoing, with an outside company hired to work on the pipes. Additionally, a resident reported a broken handrail attached to the toilet, which had been in disrepair for weeks. Upon observation, the surveyor confirmed that the handrail on the right side of the toilet was broken at the connecting piece. Staff was notified, and the Maintenance Director stated that monthly checks are conducted, and repairs are prioritized by severity. However, the broken handrail had not been addressed promptly, and the handrails were removed for safety, with wall-mounted handrails provided as an alternative.
Facility Fails to Prevent Resident Abuse in Two Incidents
Penalty
Summary
The facility failed to prevent resident abuse, as evidenced by two incidents involving residents. In the first incident, a resident was observed by a registered nurse and a certified medication aide to have approached and slapped another resident who was sitting in a wheelchair in the hallway. This incident was documented in the facility report, and the policy on abuse was reviewed, which clearly stated that physical abuse includes slapping. The Director of Nursing acknowledged the concern but did not provide further details about the incident. In the second incident, a staff member witnessed a family member of a resident with dementia and a BIMS score of 0.0 pulling the resident's hair and tapping their head. This occurred in the hallway outside the resident lounge during lunchtime. The family member claimed there was no malintent and was trying to get the resident to eat. The resident, due to their cognitive condition, was unable to recall the incident. The corporate nurse mentioned that the regional corporate team handles such allegations, but no additional documentation was provided to support the investigation.
Failure to Report Alleged Abuse and Injury of Unknown Origin
Penalty
Summary
The facility staff failed to report an allegation of abuse and an injury of unknown origin to the regulatory agencies and the Office of Health Care Quality (OHCQ). In the first case, a resident recounted an alleged abuse incident where they felt someone was trying to harm them by holding their nose closed during the night. This incident was noted in a progress note by a palliative care physician, who also mentioned the resident's delusions and a recent medication change. However, the Director of Nursing (DON) was unaware of this allegation until the surveyor's inquiry and confirmed that an investigation would be initiated. In the second case, another resident experienced a right shoulder dislocation, which was discovered after initial x-rays for discomfort showed no fracture. The injury was classified as of unknown origin, as no fall or incident was witnessed. The previous DON documented the resident's position in a wheelchair but could not determine the cause of the dislocation. The current DON confirmed that the investigation was conducted internally and acknowledged that the facility failed to report and submit the investigation to the OHCQ.
Investigation Deficiency in Injury of Unknown Origin
Penalty
Summary
The facility failed to maintain evidence of a thorough investigation into an injury of unknown origin for a resident. The investigation file reviewed by the surveyor on January 21, 2025, listed several steps taken, including a head-to-toe assessment of the resident, notifying the family, interviewing residents in the hall, notifying the Director of Nursing (DON) and the Ombudsman, conducting staff interviews, notifying the police, and filing a self-report. However, the investigation file lacked documentation of resident interviews and skin checks, and a statement from the GNA who identified the injury was missing. During interviews with the DON, it was revealed that while skin checks were conducted, no interviews with capable residents were completed. The statement from the GNA was found in the concern forms documentation but was not included in the investigation file. The surveyor noted that the facility reported completing all steps for a thorough investigation, yet two components were missing from the investigation file, indicating a deficiency in the facility's investigation process.
Failure to Update Care Plan for Hearing Aid Use
Penalty
Summary
The facility failed to review and revise a resident's care plan after a change in the resident's situation, specifically regarding the use of hearing aids. A family member of a resident expressed concern that it was not communicated that the resident was hard of hearing. The family member had requested the facility to stop using the hearing aids as the resident frequently removed them, risking loss. Despite this request, the care plan still included instructions to apply bilateral hearing aids daily, and the treatment log for January 2025 showed documentation of hearing aid placement and removal as if they were still in use. The surveyor's review and interviews revealed that the care plan had not been updated since March 2021, and the Unit Manager was unsure about the current use of hearing aids by the resident. The Director of Nursing confirmed that both the care plan and treatment sheet needed updates to accurately reflect the resident's current care needs. This oversight indicates a failure in the facility's process to ensure care plans are reviewed and revised in response to changes in a resident's condition or care preferences.
Failure to Confirm Post-Discharge Home Health Services
Penalty
Summary
The facility failed to confirm and implement post-discharge care for residents requiring home health services, as evidenced by the cases of two residents. Resident #81, who had a history of joint replacement surgery, muscle weakness, and osteoarthritis, was discharged with instructions indicating the need for home health services, including nursing, aide, PT, and OT. However, the discharge instructions lacked contact details for the home care agency, and the facility did not ensure that the necessary documents were sent to the agency. Consequently, the first home care visit occurred 13 days after discharge, as the agency had not received the required documentation to initiate services. Similarly, Resident #132 was discharged without ensuring that home health services were in place. The resident was referred to a home health agency, but the agency could not provide the requested hours of care due to the lack of a primary care doctor in the community. Social Services attempted to resolve the issue by coordinating with the resident's friend and the facility's PCP, but the first home health visit did not occur until eight days after discharge. These deficiencies highlight the facility's failure to establish and confirm post-discharge care arrangements, leading to delays in the initiation of necessary home health services.
Failure to Review and Acknowledge Abnormal Lab Results
Penalty
Summary
The facility physician failed to acknowledge and review laboratory results for a resident, leading to a deficiency in care. The resident, admitted in September 2021, had a medical history of elevated white blood cell count, overactive bladder, pyelonephritis, UTIs, and hydronephrosis. On October 28, 2021, a urinalysis and culture and sensitivity test were ordered, revealing an E. coli infection. The resident was prescribed antibiotics on November 4, 2021. However, a subsequent urinalysis on November 22, 2021, indicated a Pseudomonas Aeruginosa infection, but no treatment was ordered, and the lab results were not acknowledged by the physician. The surveyor noted that the progress notes from the resident's providers did not document a review of the abnormal lab results or provide a rationale for the lack of treatment. The Director of Nursing and Regional Clinical Nurse Staff were unable to provide documentation confirming the review of the abnormal labs. The Medical Director's review, conducted much later, suggested that treatment was not necessary according to the Center for Disease Criteria, but there was no documentation at the time of the incident to support this decision. This lack of documentation and acknowledgment of the lab results led to the deficiency identified by the surveyor.
Failure to Administer Routine Medications
Penalty
Summary
The facility failed to provide routine medications as ordered for two residents, leading to deficiencies in pharmaceutical services. Resident #82, with a history of diabetes mellitus type 2, did not receive Sitagliptin Phosphate on three occasions in May 2022 due to pharmacy delivery issues. The medication administration record indicated that the medication was marked as 'see progress notes' on specific dates, with notes stating that the medication was reordered and awaiting delivery. The Director of Nursing (DON) was unable to provide an explanation for the unavailability of the medication at the time of the survey. Resident #99 also experienced missed doses of medications, specifically Keppra and Latanoprost, due to pending pharmacy delivery. A care plan note from August 2021 indicated that the resident missed three doses, but no seizure activities or changes were noted. The Medical Doctor and Resident Representative were informed. An incident report revealed that two nurses did not administer the medications over two shifts, and staff received education on ordering medications from the pharmacy if not available in the facility.
Facility Fails to Maintain Sanitary Environment in Resident Room
Penalty
Summary
The facility failed to maintain a safe, functional, and sanitary environment for a resident, as observed in one of the resident rooms. During an interview, a resident reported that the floors in the back corner of their room were not cleaned regularly due to a fall mat alongside the bed. The surveyor observed debris on the floor, a dark substance on the privacy curtain, a removed ceiling tile above an unoccupied bed, a chair rail falling down behind the resident's bed, an edge of the footboard sticking out, a top drawer of the bedside nightstand falling out when pulled, and brown staining along the side of the resident's toilet. These conditions were confirmed by a Licensed Practical Nurse (LPN) who stated that the rooms had been cleaned earlier in the morning. The Nursing Home Administrator acknowledged the issues and stated that the facility was working on fixing the identified concerns.
Failure to Maintain Resident Dignity During Incontinent Care
Penalty
Summary
A deficiency was identified when a resident was observed lying in bed with an open incontinence brief after having requested assistance for incontinent care. The resident reported that a staff member had entered the room, turned off the call light, and stated they would get the assigned caregiver, but did not provide immediate assistance. Approximately ten minutes later, a Geriatric Nursing Assistant entered the resident's room without knocking or asking permission, contrary to facility protocol. The resident was unable to get up independently and had a full incontinence brief at the time of the observation. The Unit Manager confirmed that staff are expected to knock before entering a resident's room.
Failure to Provide Accessible and Appropriate Call Bells
Penalty
Summary
The facility failed to ensure that residents had access to and appropriate use of call bells, as observed during the recertification survey. In one instance, a resident did not have a call bell in their room due to the need for a splitter to accommodate two call bells for both roommates. Staff confirmed the absence of the call bell and acknowledged the need for corrective action, but the resident remained without a call bell for a period of time during the surveyors' observations. In another case, a resident reported that staff did not respond to their call bell earlier in the day. Upon further observation, the resident was unable to physically activate the provided push pad style call bell. Staff and maintenance confirmed the resident's inability to use the call bell and identified the need for a different type of call bell that the resident could operate. The deficiency was noted due to the lack of accessible and appropriate call bell systems for these residents.
Inaccurate Coding of Anticoagulant Use on MDS Assessment
Penalty
Summary
Surveyors determined that the facility failed to accurately code a resident's status on the Minimum Data Set (MDS) assessment. Specifically, a review of the medical record revealed that a resident had a physician's order for Apixaban, an anticoagulant (AC) medication, and the resident's care plan documented the use of AC medication. However, the quarterly MDS assessment for this resident was coded as 'no' for AC medication under section N, despite evidence in the medical record and care plan indicating otherwise. During interviews, the MDS Coordinator confirmed that the quarterly MDS assessment was incorrectly coded and acknowledged the error. The deficiency was identified through both medical record review and staff interview, demonstrating that the resident's MDS assessment did not accurately reflect their medication status as required.
Failure to Develop Person-Centered Care Plan Reflecting Resident Preferences
Penalty
Summary
The facility failed to develop a comprehensive, person-centered care plan for one resident, as evidenced by discrepancies between the resident's expressed preferences and the documented care plan. The resident communicated a desire to transfer to another facility closer to shopping and metro access, as well as an interest in going shopping outside the facility. These preferences were documented in progress notes by psychiatric and psychological staff, who also noted the resident's requests and assessed their capacity and safety for such activities. However, these expressed goals and preferences were not reflected in the resident's care plan, which instead indicated the resident anticipated a long-term stay and focused on participation in group activities within the facility. Interviews with staff, including the Social Service Director and DON, confirmed that the resident's requests for transfer and shopping outings were known and discussed, with some documentation in emails and typed statements. Despite this, the care plan was not updated to include the resident's goals regarding discharge planning or preferred activities outside the facility. The lack of alignment between the resident's expressed wishes and the care plan demonstrates a failure to ensure the care plan was comprehensive and person-centered, as required.
Failure to Maintain Functional Safety Equipment Leads to Resident Fall
Penalty
Summary
A deficiency was identified when a resident reported a recent fall, which they attributed to a broken handrail on the toilet in their room. During an interview and observation, it was confirmed that the handrail attached to the left side of the toilet was broken. The issue was brought to the attention of staff, who indicated this was the first notification of the problem. A subsequent observation the following day revealed that the handrail remained broken. The resident's records showed a fall had occurred when the resident attempted to use the restroom, and a care plan for falls was in place, revised after the incident to include anticipating the resident's needs. Further investigation revealed that the facility's maintenance director conducts monthly checks of safety equipment and addresses repairs as they are reported, prioritizing based on severity. The maintenance director keeps a personal log of concerns and records repair dates upon completion. In this case, the broken handrail was removed for safety, and the resident was left with only the wall-mounted handrails for support. The deficiency centers on the failure to ensure that safety equipment was maintained in working condition, which contributed to the resident's fall.
Oxygen Administered Without Physician Order
Penalty
Summary
Surveyors found that a resident was administered oxygen via nasal cannula through an oxygen concentrator without a corresponding order in their electronic health record (EHR). The resident had experienced low oxygen saturations, and a nurse practitioner was contacted, who verbally instructed staff to start oxygen at 3 liters. However, no written or electronic order for oxygen administration was present in the resident's chart at the time of the surveyors' review. Multiple staff members, including LPNs and the unit manager, confirmed that there was no order for oxygen in the EHR, despite the resident receiving oxygen therapy. The deficiency was identified through direct observation of the resident on oxygen, review of the medical record, and staff interviews. The expectation among staff was that an order should be present in the EHR for any resident receiving oxygen. The absence of a documented order for oxygen administration was confirmed by both nursing staff and facility leadership during the survey.
Failure to Provide RN Coverage for 8 Consecutive Hours
Penalty
Summary
The facility failed to provide a Registered Nurse (RN) on duty for 8 consecutive hours on one of the 21 days reviewed during the recertification survey. Review of staffing records, including the Payroll Based Journal (PBJ) and daily nursing staffing sheets, revealed that on 1/1/2025, there was no RN scheduled or present for the night, day, or evening shifts. The facility did not have any staffing waivers in place at the time of the survey, as confirmed by the Nursing Home Administrator. Interviews with the Director of Nursing (DON), Assistant Director of Nursing (ADON), and Staffing Coordinator confirmed that no RN was physically present in the building on the identified date. The ADON reported being on call and available by phone but was not present in the facility. Review of staff punch-in sheets corroborated that no RN clocked in on that day, and the Staffing Coordinator acknowledged that the facility's expectation is to have an RN in the building for 8 consecutive hours daily, which did not occur on the date in question.
Failure to Document Physician Review of Pharmacist Medication Recommendations
Penalty
Summary
The facility failed to ensure that physicians documented their review of pharmacist-identified medication irregularities and failed to document actions taken or not taken in response to these irregularities. This deficiency was identified for two residents who were prescribed antidepressant medications, including Trazodone, Sertraline, and Mirtazapine. Pharmacist reviews of these residents' medication regimens were conducted on multiple occasions, and recommendations were made regarding their drug regimens. Interviews with facility staff, including the DON and Medical Director, revealed that while providers are expected to review pharmacy recommendations in a timely manner, there was no consistent process for documenting whether the recommendations were reviewed or acted upon, especially when no changes were made. Staff confirmed that if a provider agreed with a recommendation, changes would be made and documented, but if no changes were made, there was often no documentation in the resident's chart to indicate the recommendation was reviewed or considered.
Duplicate Administration of Levothyroxine Sodium
Penalty
Summary
Facility staff failed to ensure that a resident's medication regimen was free from unnecessary drugs, as evidenced by the administration of duplicate doses of levothyroxine sodium. Medical record review revealed that the resident, who is being treated for hypothyroidism, received two separate doses of levothyroxine sodium 88 micrograms on four consecutive days, resulting in a combined daily dose of 188 micrograms. The error was identified through review of the Medication Administration Record and confirmed by staff interview, with documentation showing the medication was administered at both 6:30 AM and 9:00 AM on the affected days. The resident reported concerns about not receiving the correct medication doses during an interview, which prompted further investigation. The Director of Nursing confirmed that the duplicate administrations were not intended and were given in error.
Delayed and Poorly Coordinated Radiology Services
Penalty
Summary
The facility failed to ensure that radiology services were arranged and provided in a timely manner to meet the needs of a resident. The resident initially complained of left knee pain, and an X-ray was performed, which showed joint effusion but no fracture. Following this, a physician ordered an orthopedic surgery consultation, which led to further orders for an ultrasound and an MRI of the knee. However, the scheduling and completion of these radiology services were delayed due to a series of coordination issues. On the date the ultrasound and MRI were first scheduled, the procedures could not be completed because of an improper sling on the resident's wheelchair. The appointments were rescheduled, but the MRI was later canceled due to a physician's order indicating the resident could not tolerate the procedure, and the radiology provider did not offer ultrasound services. Efforts to reschedule the ultrasound continued, and the MRI was eventually completed at a later date. Additionally, staff interviews revealed that communication regarding transportation needs for radiology appointments relied on verbal exchanges between staff and unit managers. There was an expectation that the information provided by unit managers would be accurate, but the process lacked formal documentation or verification, contributing to the delays and miscoordination in arranging timely radiology services for the resident.
Inaccurate Medical Record Order for Resident with Bilateral BKA
Penalty
Summary
Surveyors identified that the facility failed to maintain accurate medical records for a resident with bilateral below the knee amputations (BKA). The resident's medical record included an active physician's order to 'float heels when in bed as tolerated every shift for preventative skin measures,' and staff documented this intervention as performed three times daily over a period of nearly two weeks. However, upon review, it was confirmed by a licensed practical nurse that the order was not accurate, as the resident did not have heels due to the bilateral BKA. The inaccurate order remained active in the resident's chart and was being documented as completed, despite being inapplicable to the resident's condition.
Failure to Maintain Effective Pest Control Program
Penalty
Summary
The facility failed to maintain an effective pest control program, as evidenced by multiple reports and documentation of cockroach sightings on one of three floors. A resident reported seeing cockroaches in a drawer several months prior, which led to the facility calling an exterminator for treatment. Another family member also observed a cockroach in their relative's room. Review of the facility's pest management records revealed several service dates where roaches were noted as a problem, and a special agreement document described a roach treatment service for multiple rooms, but lacked a date and signature. The Nursing Home Administrator was unable to provide documentation of routine pest control visits or details on actions taken or recommendations made after each visit, confirming a lack of comprehensive records and follow-up regarding pest management.
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The facility did not ensure that its Infection Preventionist (IP) met required qualifications for managing the Infection Prevention and Control Program. The DON reported serving as the IP but acknowledged lacking the specialized infection control training required for the role, and confirmed that no other staff member was currently qualified. Records showed that the previously qualified IP left several months earlier, and the Administrator and DON confirmed they were still seeking a replacement, leaving the infection control program without a properly trained leader.
Staff failed to consistently secure medications and medical supplies across three units, including an oxygen tank left on the floor behind a resident’s bed without a supporting device, a treatment cart with Collagenase Santyl cream left on top while two residents in power wheelchairs passed by, an unattended and unlocked treatment cart at a nursing station, and another treatment cart with Diclofenac gel and dressings left on top, indicating repeated lapses in maintaining locked and secure storage for drugs, biologicals, and related supplies.
The facility failed to provide sufficient dietitian coverage and timely nutritional assessments for several residents with significant dietary needs. A resident admitted for diabetic management with a high A1C was placed on a regular diet instead of the recommended carb-controlled diet and had only one weight taken in the first two weeks, with no dietitian review of the record. Another resident with prior significant weight loss had no documented dietitian follow-up despite continued weight loss, and a resident admitted with severe protein-calorie malnutrition experienced further significant weight loss without any dietitian assessment. The dietitian reported working limited hours and prioritizing certain high-risk cases, resulting in delayed or missed evaluations for new admissions and residents with ongoing nutritional concerns.
The facility failed to maintain adequate linen and incontinence supplies and did not keep resident care areas in good repair, resulting in delays and alterations in incontinence care and substandard environmental conditions. Staff reported that towels and washcloths were used instead of wipes and then discarded due to heavy soiling, and that linen deliveries to units were late, leaving residents waiting for care. Observations showed very limited numbers of clean washcloths and other linens on units and in the laundry, with no stock of disposable wipes or backup washcloth supply despite repeated reports to housekeeping. Additional observations revealed recliner chairs blocking a dining-area handwashing sink and kitchenette, multiple resident and shared bathrooms with unfinished spackle, chipped paint, musty odors, black substances near showers, missing threshold molding, exposed cracks and nails, and eroded, rusted baseboard heaters. Hallway handrails on both units were worn, chipped, and splintered, and a shower room contained fecal odors, dried brown stains on the toilet, and deteriorated fixtures, all contributing to a failure to provide a safe, clean, and homelike environment.
Facility staff did not thoroughly investigate two separate abuse allegations involving a resident and an injury of unknown origin involving another resident. In both cases, investigations focused on the directly affected resident and included staff interviews, but there were no interviews of other residents on the unit or documented assessments of those residents for signs of abuse or injuries of unknown origin, including residents unable to communicate due to cognitive status.
Two residents who were dependent on staff for oral care, including one with a tracheostomy, were observed with thick, white or milky substances coating their mouths and teeth, indicating inadequate oral hygiene. One resident communicated that staff did not brush their teeth and that staff "need to." In another case, despite oral care supplies being present in the room, the resident’s mouth and teeth remained unclean on multiple observations, with a thick milky substance caking the teeth and stringing between them when the resident tried to open their mouth. These findings showed that staff did not consistently provide oral care to residents who relied on them for this ADL.
Staff failed to maintain complete and accurate medical records for multiple residents, including missing and inconsistent documentation of wound care, delayed pain assessment after discovery of an injury of unknown origin in a cognitively impaired resident, and inaccurate recording of a PPD test result that was documented as negative despite no evidence the injection was administered and no supporting nurse’s note. Residents reported not receiving certain treatments, while MAR entries either lacked signatures for completion or contained conflicting information about whether care was provided.
Surveyors found that the facility failed to consistently implement and communicate correct transmission-based precautions and PPE use. One resident with a Foley catheter related to wounds had no precaution signage posted, while another resident in a double room had a contact precautions sign at the door, yet the NP entered without PPE and the GNA provided high-contact care wearing only gloves. Staff in that room stated the resident was not on contact precautions and later reversed the sign to show no PPE requirement. Therapy staff reported they rely solely on posted signs to determine PPE, and surveyors identified broader issues with inaccurate signage and staff awareness of which residents required contact precautions.
Surveyors found that MDS assessments were inaccurately coded for two residents. In one case, a resident sustained a femoral neck fracture after a fall, but the subsequent significant change MDS did not code the fall as a major injury and failed to capture prn Tylenol use documented on the MAR within the look-back period. In the other case, a quarterly MDS indicated opioid use for a resident, but the MAR for the same period showed no prescribed opioid, indicating incorrect coding of high-risk drug classes.
A resident who had recently been admitted and experienced a fall received multiple doses of the narcotic analgesic Tramadol, but the facility failed to accurately document all administered doses on the Medication Administration Record (MAR). Review showed only one Tramadol dose recorded on the MAR, while the Controlled Drug Receipt/Record/Disposition Form on the med cart reflected three doses given over two days. In interview, the DON stated staff are expected to document narcotic administration on the MAR and confirmed that two administered doses were not recorded there, resulting in an incomplete and inaccurate medical record.
Unqualified Infection Preventionist Overseeing Infection Control Program
Penalty
Summary
The facility failed to ensure that its designated Infection Preventionist (IP) met the mandatory qualifications for overseeing the Infection Prevention and Control Program. During an interview on 3/24/26 at 10:00 AM, the DON confirmed that she/he was serving as the facility’s IP but had not completed the specialized training in infection control required for the position. The DON further stated that no other staff member currently met the qualifications to serve as IP. Record review showed that the previously qualified IP left the facility in October 2025, and as of the survey date, the position remained unfilled by a qualified individual. At 1:30 PM on the same day, the Administrator and DON confirmed they were still in the process of finding a qualified IP for the facility, leaving the Infection Prevention and Control Program without a properly trained and qualified leader. No specific residents, medical histories, or clinical conditions were described in relation to this deficiency.
Unsecured Medications, Treatment Carts, and Oxygen Equipment
Penalty
Summary
Facility staff failed to ensure that drugs, biologicals, and related medical supplies were securely stored and properly maintained on multiple units. On one unit, an oxygen tank assigned to a resident was observed sitting on the floor behind the resident’s bed without any supporting device. On another unit, a treatment cart was observed with a tube of Collagenase Santyl cream labeled for a specific resident left on top of the cart, while residents in power wheelchairs passed by and staff were present at the nursing station. These observations showed that medications and oxygen equipment were not consistently secured as required. Further observations on additional units revealed an unattended and unlocked treatment cart at a nursing station, and on a separate occasion, a treatment cart with Diclofenac gel labeled for a resident left on top along with multiple packs of dressings. These incidents occurred across three units and on more than one date, demonstrating repeated failures to keep medications and treatment supplies in locked compartments or otherwise secured from unauthorized access.
Insufficient Dietitian Coverage and Delayed Nutritional Assessments
Penalty
Summary
The deficiency involves the facility’s failure to employ sufficient food and nutrition staff, including adequate dietitian coverage, to ensure timely assessment and appropriate diets for residents with significant nutritional and diabetic needs. A resident admitted over two weeks earlier with multiple comorbidities and an A1C of 11.5% had a hospital discharge recommendation for a carbohydrate-controlled diet, but was placed on a regular diet at admission with no acknowledgment of the recommended diet until one week later, when the resident requested larger portions. As of the survey date, the dietitian had not yet seen or reviewed this resident’s medical record, and the resident reported not having seen a dietitian and being very frustrated with the meals. During the first two weeks after admission, only one weight was obtained for this resident, despite physician notes stating the resident’s weight was “stable.” Further review of other residents showed additional failures in timely dietitian assessment and follow-up. One resident, readmitted in January and previously seen by the dietitian in September for a 6.4 lb weight loss over 30 days, had no documented follow-up despite continued weight loss totaling 22 lbs since the last dietitian review. Another resident admitted at the end of February with severe protein-calorie malnutrition had not been seen by the dietitian after about a month in the facility, despite a documented 14 lb (7%) weight loss over two weeks. The dietitian reported working only 12 hours per week at the facility and stated that she must prioritize which residents to see, focusing first on residents with tube feedings and those identified in risk meetings, resulting in delayed or absent assessments for new admissions and residents with ongoing weight loss and malnutrition diagnoses.
Linen Shortages and Poor Environmental Maintenance Compromise Resident Care and Comfort
Penalty
Summary
The deficiency involves the facility’s failure to maintain an adequate supply of clean linens and appropriate incontinence wipes, resulting in delays and alterations in residents’ incontinence care, as well as the use of towels and washcloths in place of disposable wipes. During the initial tour, the surveyor observed that the linen supply on one nursing unit hallway was low. Complaint reviews included concerns about delays in incontinence care and bed linens not being changed regularly, with residents left without clean bedding. A complainant reported that there was not enough clean linen available for residents. Staff interviews confirmed that towels, sheets, and washcloths were being used to wipe residents for incontinence care due to the absence of wipes, and that many of these linens were being thrown away when soiled. Staff also reported a shortage of linen, that linen deliveries to the units were late, and that residents who preferred to get up before breakfast had to wait for care when linen was delayed. Further observations showed that the clean supply room contained no disposable wipes or cloths for incontinence care, and a resident reported that staff did not use wipes, that the resident had to purchase their own, and that heavily soiled towels or washcloths were discarded. A tour of all nursing unit linen carts and closets revealed only six clean washcloths and limited supplies of towels, gowns, and bed linens. In the laundry room, only three washcloths were present, and the laundry assistant stated that there were only three washcloths available for each nursing unit that morning, that the facility was short on linen supply, and that these concerns had been repeatedly reported to the Director of Housekeeping over the preceding month and again that morning. The laundry assistant confirmed there was no additional laundry in process. The DON stated that wipe squares should be used for incontinence care, but no such wipes were found in the clean medical supply room, and no backup supply of washcloths was present in the emergency linen supply. The Director of Housekeeping confirmed there was no backup supply of washcloths. The deficiency also includes environmental and maintenance issues affecting resident bathrooms, handrails, and common areas. In the main dining area, a recliner chair was observed positioned directly in front of the handwashing sink, and two recliner chairs were stored in front of the nutrition area kitchenette. Multiple resident bathrooms and shared bathrooms were repeatedly observed over several days with unfinished spackle on walls that needed resurfacing and painting, chipped paint around sinks, uneven boards nailed to walls under sinks that appeared to partially cover holes, musty odors, black substances between shower bases and walls, missing threshold transition molding exposing cracks, missing tiles, and a nail, as well as eroded and chipped paint on baseboard heaters with exposed dark brown metal and rust-like material. Hallway handrails on both nursing units were observed to be worn, with chips, splintering, holes, and areas where the wood finish had worn off. A shower room was observed with a foul fecal odor, dried brown stains on the back of the toilet seat and in the toilet bowl, and a baseboard heater with eroded, chipped paint and rust-like material, along with chipped paint on the handrail. These conditions were acknowledged by the Director of Maintenance and other leadership, and some areas were noted to be in the process of renovation, but the observed deficiencies remained present during the survey period. Overall, the facility did not maintain a safe, clean, comfortable, and homelike environment in good repair across both nursing units and the dining area. The lack of adequate linen and incontinence supplies, combined with the poor condition of resident bathrooms, handrails, and certain common areas, constituted the basis for the cited deficiency. The observations and staff and resident reports consistently described shortages of essential hygiene supplies, delayed care related to linen availability, and multiple unresolved environmental and maintenance issues in resident care areas and shared spaces.
Failure to Thoroughly Investigate Abuse Allegations and Injuries of Unknown Origin
Penalty
Summary
Facility staff failed to thoroughly investigate allegations of potential abuse involving one resident and an injury of unknown origin involving another resident. For one resident, there were two separate allegations of abuse occurring on different days in early February. The facility’s investigation packets included interviews with staff who cared for or were scheduled to work with this resident on the days of the alleged incidents, and the investigations focused solely on this resident. However, there were no interviews conducted with other residents on the unit to inquire about abusive or neglectful treatment by the staff who were working during the times of the allegations. The surveyors noted that, although the allegations were not validated, there was no documentation that other residents were interviewed, if able, or assessed for signs or symptoms of injury. In a separate incident, another resident was identified on March 4 with a new bruise on the right eye, documented as a change in condition at 4:09 AM. This resident had a BIMS score of 99, indicating the resident was unable to complete an interview and therefore could not report how the injury occurred. The facility’s investigation identified a potential cause of the injury but did not reach a definitive resolution. Additionally, there were no interviews of other residents on the unit regarding possible abuse, nor were there documented assessments of other residents for injuries of unknown origin, particularly for those unable to speak for themselves, as in this resident’s case.
Failure to Provide Oral Care to Dependent Residents
Penalty
Summary
The deficiency involves the facility’s failure to provide oral care to residents who were dependent on staff for activities of daily living, specifically oral hygiene. One resident with a tracheostomy was observed with a thick, sticky white substance in the mouth and was noted to intermittently chew on nearby bedding. This resident made good eye contact and, when asked if staff brushed their teeth, shook their head no and mouthed that staff “need to.” According to the resident’s Minimum Data Set (MDS) dated 2/11/26, the resident was dependent on staff for oral care. Another resident, also dependent on staff for oral care per the 3/11/26 MDS, was observed sitting propped up in bed and able to respond with smiles. During the initial observation, the inside of this resident’s lips and upper and lower teeth had a thick, clear, white milky substance visible when the resident tried to open their mouth to smile. Oral care supplies were present in the nightstand, but the resident’s mouth and teeth were not clean. On a subsequent observation with the DON, NHA, and Corporate VP of clinical services, the same resident again had a thick, clear, milky substance between the lips and caking the teeth, which would string between the teeth when the resident attempted to open their mouth, demonstrating a lack of consistent oral care for residents dependent on staff for this ADL.
Incomplete and Inaccurate Medical Record Documentation for Treatments and Assessments
Penalty
Summary
Facility staff failed to maintain complete and accurate medical records and documentation for multiple residents. For one resident with wound care needs, review of the MAR showed that wound care and related treatments were signed as completed on the dates initially reported, despite the resident’s ongoing complaints that wound dressings were not being changed. When additional dates were reviewed, there were missing staff signatures for wound care on two specific dates, as well as three instances where application of A&D ointment to the resident’s feet was not signed off out of 24 days reviewed. Another resident with severe cognitive impairment, as evidenced by a BIMS score of 00, was found to have an injury of unknown origin (a bruise on the left hand). Documentation showed that a change in condition was initiated late in the morning, but a formal pain evaluation was not initiated and completed until that night, and the resident was unable to explain how the injury occurred or verbalize pain using a standard pain scale. For a third resident, documentation related to the admission PPD test was inconsistent and incomplete. The MAR contained an entry indicating “9” for the administration date, meaning “see nurse’s note,” but there was no corresponding nurse’s note. Despite the absence of a signed administration of the PPD injection, staff documented the PPD result as “negative” on the scheduled read date. The resident reported never receiving the PPD injection, and the DON confirmed that the facility had been out of PPD solution at the time, so the test would not have been administered. These findings demonstrate failures in accurate documentation of treatments and assessments, including wound care, pain assessment, and TB screening, as well as missing or incomplete supporting notes in the medical record.
Failure to Implement and Communicate Correct Transmission-Based Precautions
Penalty
Summary
Surveyors identified a deficiency in the facility’s infection prevention and control program related to inconsistent and incorrect implementation of transmission-based precautions and PPE use. During a complaint investigation focused on residents on transmission-based precautions, one resident with a visible Foley catheter was observed in the room with physical therapy, but there were no signs posted indicating any need for PPE, despite the resident being a new admission with a Foley catheter placed related to wounds. In another double-occupancy room, a contact precautions sign was posted at the doorway, but the nurse practitioner was in the room on a personal phone with no PPE, and the assigned GNA was repositioning the resident in bed while wearing only gloves. When questioned, the NP, RN, and GNA all stated that the resident in the room was not on contact precautions, and the GNA reported that signs were hanging at all doors and that this particular resident’s sign was “just wrong.” The surveyor observed the GNA later return to the room and turn the sign around to indicate no PPE requirement. Subsequent interviews revealed that therapy staff relied on posted signage to determine PPE use and that if the sign was wrong, the PPE used would be wrong. Overall, surveyors found problems with signage accuracy and staff awareness of which residents required contact precautions, as well as observed failures to follow appropriate PPE use for residents who should have been on contact precautions.
Inaccurate MDS Coding for Falls, Pain Management, and High-Risk Medications
Penalty
Summary
Facility staff failed to ensure Minimum Data Set (MDS) assessments were accurately coded for two residents reviewed during a complaint survey. For one resident, a facility-reported incident showed that the resident was found seated on the floor beside the bed and was diagnosed with a non-displaced femoral neck impaction fracture of the left hip following an x-ray. Despite this fall with a major injury, the subsequent significant change MDS dated 11/4/25 did not code the fall with major injury in Section J1900C. Review of the resident’s Medication Administration Records for October and November 2025 showed administration of Tylenol on 10/31/25 at 9:30 PM, which fell within the 5-day look-back period for the MDS, but Section J0100 (prn pain) of the same significant change MDS did not capture the use of Tylenol. For another resident, review of a quarterly MDS with an assessment reference date of 10/15/25 showed that Section N0415 (High-Risk Drug Classes) documented the use of an opioid medication. However, review of the resident’s October 2025 Medication Administration Record did not show that the resident had been prescribed an opioid during that period. In both cases, MDS staff later confirmed that these were errors in MDS coding, demonstrating that the assessments did not accurately reflect the residents’ clinical status and medication use as documented in their medical records.
Incomplete Documentation of Narcotic Administration on MAR
Penalty
Summary
The facility failed to maintain complete and accurate medical records in accordance with accepted professional standards for one resident receiving narcotic medication. The resident, admitted in March 2026, had a fall on 3/6/26 and was sent to the hospital on 3/9/26. Review of the March 2026 Medication Administration Record (MAR) showed documentation of a single 25 mg dose of Tramadol administered on 3/8/26 at 9:23 AM. However, review of the resident’s Controlled Drug Receipt/Record/Disposition Form, kept on the nurse’s medication cart and not in the medical record, showed that Tramadol 25 mg was administered three times between 3/8/26 and 3/9/26: at 11:00 AM and 9:00 PM on 3/8/26, and at 9:00 AM on 3/9/26. In interview, the DON stated that staff are expected to document narcotic administration on the MAR and confirmed that only one of the three Tramadol doses reflected on the controlled drug record was documented on the resident’s MAR. This discrepancy between the controlled substance record and the MAR, with missing documentation of two administered doses of Tramadol on the official medical record, constituted the failure to maintain a complete and accurate medical record for the resident.
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