Towson Rehabilitation And Healthcare Center
Inspection history, citations, penalties and survey trends for this long-term care facility in Towson, Maryland.
- Location
- 509 East Joppa Road, Towson, Maryland 21286
- CMS Provider Number
- 215054
- Inspections on file
- 19
- Latest survey
- February 17, 2026
- Citations (last 12 mo.)
- 18
Citation history
Health deficiencies cited at Towson Rehabilitation And Healthcare Center during CMS and state inspections, most recent first.
The facility failed to timely implement and update wound care orders and consult recommendations for multiple residents with pressure and arterial ulcers. In one case, a resident’s new sacral skin impairment was noted without adequate description, and a wound consult ordered by the physician was not completed for nine days, at which point a Stage 3 coccyx wound was documented. For another resident, a sacral wound was identified and physician treatment instructions were obtained, but the corresponding wound care order was not entered and implemented until three days later. A third resident with a left dorsal foot arterial ulcer had an existing every-other-day NSS-based treatment order that was not revised after a wound consult recommended a different, daily wound care regimen and continuous offloading in a Prevalon boot while in bed. The DON acknowledged that wound consults and related orders are expected to be implemented immediately or by the next day.
Surveyors found that dietary staff failed to follow professional standards for food storage, labeling, and attire. A cook was observed preparing breakfast without a required hairnet. Multiple refrigerated items, including cottage cheese, prepared cheese, thickened juice, marinara sauce, fruit cocktail, chicken gravy, pre-made sandwiches, lettuce, and sliced onions, were either past their "Best If Used By" or "Used By" dates or lacked any open/expiration dates or proper labels. A staff member reported that all staff are responsible for checking and discarding expired items, and the food service director was informed of these observations.
A resident was observed in bed with bottles of Tylenol 500 mg, Tylenol PM, and TUMS on the bedside table, despite facility staff stating that medications should not be kept at the bedside. The admission assessment documented that the resident did not wish to self-administer medications, and the medical record lacked a physician’s order for Tylenol PM, any authorization for self-administration of Tylenol or TUMS, and a care plan confirming the resident’s capacity to self-administer. The DON confirmed that required steps for self-administration—provider order, assessment, locked storage, and documentation on the MAR and care plan—had not been completed for this resident.
A resident with multiple comorbidities, including hemiplegia, PVD, epilepsy, and type 2 DM, developed a new wound on the left great toe that was first identified by an LPN and treated with wound care and Doxycycline. Despite an order requiring every-shift appraisal and provider notification for changes in condition, documentation showed the order as completed but did not show that the provider or resident representative were notified when the wound was first observed. Weekly skin checks documented intact skin on one assessment and, on the next, described the left great toe wound and its treatment while still indicating no new skin alterations, and the DON later confirmed there was no documentation of provider notification at the time the wound was initially identified.
Surveyors found that two residents were admitted without completion of required baseline care plans (BLCPs) within 48 hours and without documentation that BLCP summaries and current medication lists were provided to them or their representatives. The DON reported that residents are supposed to receive a BLCP at admission, with a copy given within 48–72 hours, and that staff should document provision of the BLCP in a progress note. For these two residents, no BLCPs or BLCP summaries were found in the medical records, and there was no documentation that they or their representatives had received them.
A resident with DM, intellectual disabilities, and severely impaired cognition had physician orders for pre-meal blood glucose (BS) checks and subcutaneous Insulin Aspart that were not consistently followed or documented. Over several months, the MAR showed multiple BS entries recorded as “NA” with codes for refusal or “other/see nurses note,” one entry marked as no insulin required, and some time slots left completely blank with no BS or insulin documentation. The DON stated that staff are expected to obtain BS each shift, administer ordered insulin, encourage residents who refuse, notify the provider and responsible party, and document these actions, and acknowledged that these expectations were not met and that there was no documentation of provider notification when the resident refused.
A resident with visual impairment reported that bedside glasses did not work and that a requested ophthalmology visit had not occurred, while documentation showed earlier notes of adequate vision followed by entries indicating vision loss, need for assistance, and a provider recommendation for ophthalmology follow-up. Staff described a process for arranging ophthalmology services and acknowledged the resident’s partial blindness and non-functioning glasses, and an NP documented the resident’s complaints of difficulty seeing and dry eyes, noting attempts to schedule an ophthalmology appointment complicated by insurance questions. Despite these documented concerns and awareness by nursing, NP, and DON, there was no evidence that an ophthalmology evaluation was obtained or that the resident’s vision impairment was appropriately assessed and treated.
A resident receiving O2 at 2 L via nasal cannula was observed with undated oxygen tubing and no humidifier attached to the concentrator, despite reporting nasal dryness from the oxygen. An LPN confirmed that tubing should be changed and dated and that a humidifier is normally used per physician orders, but this resident only had an order for oxygen administration without any instructions for respiratory equipment care. The RN unit manager and DON both stated that oxygen therapy requires specific physician orders for equipment care, including scheduled tubing and humidifier changes, yet such orders had not been in place for several months prior to surveyor involvement.
Surveyors found that the facility did not ensure providers consistently responded to and acted on pharmacist Medication Regimen Review (MRR) recommendations for two residents receiving psychotropic medications, narcotics, antibiotics, and antidepressants. Although the DON described a process requiring providers to review MRRs within 7–10 days, check agree/disagree/other, provide rationale when disagreeing, and sign and date the forms, multiple MRRs were incomplete or not acted upon. For one resident, a naloxone co-prescribing recommendation was agreed to but never implemented, a GDR recommendation for an antipsychotic was marked as disagree without any documented rationale, a probiotic recommendation during IV antibiotic therapy was not addressed, and an entire month’s MRR was left unsigned and without any response. For another resident, a GDR recommendation for olanzapine was left completely blank on the MRR, and a trazodone GDR recommendation was marked disagree without any written rationale on the MRR or in progress notes.
Surveyors identified that the facility’s medication error rate exceeded 5% when an LPN failed to recognize a discrepancy between a prescribed 75 mg Methadone dose and a 74 mg labeled dose during preparation for a resident, and an RN administered an Anoro Ellipta inhaler to another resident with COPD without instructing the resident to rinse and expectorate afterward as ordered. These two observed errors, out of 37 opportunities, resulted in a calculated medication error rate of 5.41%.
A resident with COPD and heart failure was found to be keeping a rescue albuterol inhaler with medication in it in his/her pocket, stating an intention to self-determine when to use it rather than rely on nursing staff. The NHA acknowledged seeing a blue inhaler in the resident’s hand but did not check if it contained medication and was unsure whether there was an order allowing the resident to keep medications at the bedside. Medical record review showed the resident had an order for albuterol HFA inhaler PRN for wheezing, designated to be administered by a clinician, and an assessment indicating the resident did not want to self-administer medications, with no orders permitting self-administration. This established that the resident’s possession of the inhaler was not authorized and that medication was not stored in accordance with required locked-compartment standards.
The facility failed to consistently serve hot foods at appetizing temperatures, as reported by multiple residents who stated that hot foods were often not hot, sometimes arrived cold, and that taste was poor, with one resident attributing cold food to delays while waiting for feeding assistance. During a survey, the Food Service Director provided a test tray from the last lunch cart delivered to a unit, and staff were observed delivering all resident trays before removing the test tray. When the surveyor checked the test tray, temperatures of the candied sweet potatoes, fish, and vegetables were all below expected warm serving levels, and these low/abnormal temperatures were later reported to the DON.
A resident with depression and anxiety, who had been observed as irritable, agitated, and expressing a desire to leave, had physician orders for every-shift behavior monitoring with documentation of episode frequency, interventions, and outcomes. Review of the MAR showed that on two shifts staff marked that behaviors were present but did not record any description of the behaviors, their frequency, or the interventions provided. The DON later acknowledged that the behavioral documentation on those shifts was incomplete and not accurately completed.
Staff failed to follow required infection control practices for residents on Droplet Precautions and Enhanced Barrier Precautions. A resident on Droplet Isolation for RSV had clear signage requiring full face coverage and appropriate PPE, yet a GNA entered the room to remove a meal tray wearing only a mask and no gown or additional protective equipment, later stating she did not realize a gown was required. In a separate incident, a resident on EBP for a coccyx wound had a dressing change performed by an LPN who double-gloved, removed the old dressing, cleansed the wound, then removed only the outer gloves and applied the clean dressing without performing hand hygiene and changing to a fresh pair of gloves, contrary to the wound care steps described by facility leadership.
Staff did not document notification to a resident's responsible party regarding an increase in anti-anxiety medication and the addition of Hydroxyzine following ongoing behavioral issues. Although a timeline was later provided by the DON and ADON, there was no evidence in the medical record that the responsible party was informed at the time of the medication changes.
A resident's physician progress notes were not entered into the electronic medical record on the day of the visit, with several notes signed and uploaded several days after the actual visit. The physician interviewed stated that such delays were not typical for his documentation, and the NHA confirmed the issue during the survey.
A resident with multiple neuropsychiatric diagnoses was given Hydroxyzine on a scheduled basis instead of PRN due to a transcription error, and nursing staff failed to document specific behaviors, only marking checkboxes. Both the psych NP and DON confirmed the medication was intended as PRN and acknowledged the documentation issues.
A resident who experienced a fall resulting in a facial hematoma did not have complete or accurate medical record documentation regarding physician notification and follow-up. The medical record lacked confirmation of when the physician was notified, contained a progress note with an incorrect date, and referenced STAT labs that were neither ordered nor documented. Facility leadership confirmed the deficiencies in documentation.
A resident with severe cognitive and communication impairments reported to therapy staff that a GNA hurt their arm during care. Although the allegation was relayed to the DSW and Administrator, it was not reported to the state survey agency as required, because facility staff believed the incident was accidental. The facility maintained internal documentation but did not fulfill mandatory reporting obligations.
A resident with severe cognitive impairment and aphasia reported to therapy staff that a GNA hurt their arm during care. The facility did not report the allegation to the SSA, as staff believed the incident was accidental, and the investigation documentation was incomplete, lacking interviews with all relevant staff. The deficiency involved failure to follow policy for reporting and thoroughly investigating abuse allegations.
The facility failed to follow infection control protocols during wound care for three residents and PICC line management for one resident. An LPN did not use a clean field or barrier during wound care for two residents, and a resident's PICC line dressing was not changed as required. These actions were inconsistent with facility policies and could increase infection risk.
The facility failed to report an allegation of abuse to the State Agency within the required timeframe. A resident reported an abuse incident during a care plan meeting, which occurred three days prior. The RN was informed shortly after the report, and the Administrator was notified, but the report to the SA was delayed by several hours. The Nursing Home Administrator and DON did not provide a rationale for the late reporting.
A resident with Hidradenitis suppurativa and obesity was not adequately repositioned by staff, despite being at risk for pressure injuries and requiring full assistance. Observations showed the resident remained on their back for extended periods, and staff expressed fear of repositioning due to fall risks but did not report this. The Wound Care NP highlighted the potential for HS wounds to become pressure wounds, yet the Unit Manager was unaware of staff concerns.
The facility failed to maintain the cleanliness of an ice machine, with the filter grate covered in dust and the drain pan covered in rust and white substances. The Kitchen Dietary Manager and Maintenance Director confirmed the condition, but there was no cleaning schedule or maintenance log available. The Administrator was unaware of any policy for kitchen equipment maintenance.
A resident with Parkinson's, delirium, and dementia eloped from the facility undetected, despite having a wander guard. The resident was found by police hours later. The receptionist, unaware of the elopement binder, mistakenly allowed the resident to leave, thinking they were a visitor.
A resident's request for medical records was delayed due to a change in facility ownership. The request was forwarded to corporate, but no further action was taken, resulting in a failure to provide the records in a timely manner. The DON confirmed the deficiency.
A resident with congestive heart failure and atrial fibrillation experienced a significant weight loss due to the administration of Metolazone over several days, despite the physician's order for a one-time dose. The facility failed to notify the resident's family and physician of this change in condition, as confirmed by staff interviews and medical record reviews.
The facility failed to report allegations of abuse to the State Agency within the required time frame in three separate incidents. In one case, a suspected sexual assault was reported late, and in another, a resident's request for assistance was ignored, but the incident was not reported. Additionally, a resident alleged rough treatment, but the report was delayed by 7 days. The Director of Nursing could not provide explanations for these delays.
A resident reported multiple incidents of abuse by GNAs, including neglect and rough handling. The facility's investigations were incomplete, lacking statements from all relevant staff and residents, and some incidents were not reported to the State Agency. The DON failed to verify claims or take disciplinary action, and a staff nurse delayed reporting an incident, leading to unresolved allegations.
Two residents experienced deficiencies in care. One resident did not receive prescribed medication and necessary blood work on time, while another resident, on a blood thinner, did not receive timely assistance after cutting their toe and bleeding heavily. The DON confirmed these lapses.
A resident admitted for rehabilitation after spinal surgery did not receive siderails as ordered by a consulting physician to aid in mobility exercises. The facility did not document the provision of an alternative solution, such as a trapeze, nor did they communicate with the physician about the inability to use bed rails. Interviews confirmed the absence of siderails or alternative equipment, and the resident's representative also noted that no such aids were provided.
A resident with congestive heart failure and atrial fibrillation experienced significant weight loss due to an error in medication administration. The physician ordered Metolazone as a one-time dose, but it was administered for seven days, resulting in the resident's weight dropping from 221 lbs to 159 lbs. Facility staff confirmed the error during a complaint survey.
The facility failed to update its annual facility assessment, with documentation only covering 2020-2021. During a survey, it was found that the assessment binder lacked dated signatures for 2023 or the current year. This was confirmed by the corporate nurse and operations representative.
The facility failed to follow up with outside resources for two residents' care. One resident, admitted for rehabilitation, missed doses of IV antibiotics and had oral antibiotics discontinued without consulting the Infectious Disease physician. Another resident with dementia and a heel wound did not receive ordered podiatry and wound consults. The DON confirmed these lapses in communication and follow-up.
A facility failed to consistently document ADL care for a dependent resident, who was frequently incontinent. Complaints indicated the resident was left soiled for hours. While nursing notes showed care was provided, GNA documentation was incomplete for several shifts. A unit supervisor confirmed regular rounds and assistance as needed. The issue was discussed with the interim DON during the survey.
Failure to Timely Implement and Update Wound Care Orders and Consult Recommendations
Penalty
Summary
The deficiency involves the facility’s failure to provide pressure ulcer and wound care in accordance with professional standards, specifically by not timely implementing physician orders for wound consults and treatments, and not updating treatment orders after wound consult recommendations. For one resident, a scheduled skin check identified new sacral redness on 01/04/2026, but the documentation did not further describe the skin impairment. A physician order for an in-house wound team consult was entered on 01/05/2026, yet the wound consult was not completed until 01/13/2026, nine days later, at which time a Stage 3 cluster wound on the coccyx was documented with specific measurements and tissue characteristics. For another resident, a change in condition note on 09/17/2025 identified a sacral skin wound/ulcer, and the physician provided specific wound care treatment instructions that same day, but the corresponding physician order for wound care to the left buttock pressure ulcer was not entered and implemented until 09/20/2025, three days after the wound was first identified and treatment was recommended. A third resident had a physician order dated 01/20/2026 for care of a left dorsal foot arterial ulcer, including cleansing with NSS, application of Xeroform, ABD pad, rolled gauze, and offloading in Prevalon boots every other day. A subsequent wound consult on 02/10/2026 for the same left dorsal foot ulcer recommended a different regimen: daily cleansing with soap and water, Xeroform, dry gauze/Kerlix, tape, and maintaining a Prevalon boot while in bed, per the surgeon’s request and facility protocol. However, the February 2026 treatment record still reflected the earlier every-other-day NSS-based order starting 01/22/2026 and was not updated to reflect the new daily treatment recommendations from the wound consult. In interviews, the DON confirmed that wound consult recommendations and physician orders are expected to be implemented immediately or by the following day, and the surveyors shared concerns regarding the timeliness of wound consult completion and implementation of wound-related physician orders.
Improper Food Storage, Labeling, and Staff Attire in Dietary Services
Penalty
Summary
Surveyors identified a deficiency in food service practices related to improper food storage, labeling, and staff attire during an initial kitchen tour. A cook was observed preparing breakfast without wearing a required hairnet. Inspection of the refrigerators revealed multiple food items that were expired, past their "Best If Used By" or "Used By" dates, or lacked any open or expiration dates. These included an open and an unopened 5 lb container of low-fat cottage cheese with a "Best If Used By" date already passed, prepared cheese labeled with a prep date and a "Used By" date that had expired, and an open box of thickened apple juice with a "Best If Used By" date that had passed. Additional items in the refrigerators were found without proper labeling or dating, including an open container of sliced strawberries, a large plastic container of marinara sauce, a container of fruit cocktail, a metal container of chicken gravy, and various pre-made sandwiches (grilled cheese, turkey and cheese, and peanut butter) that were not dated or properly labeled. A wilted head of lettuce and saran-wrapped sliced raw red onions were also observed with "Used By" stickers that were past due. In an interview, a staff member stated that everyone is responsible for checking dates to ensure items are used by the expiration date or discarded if unused. The food service director was later informed of these findings.
Failure to Assess and Authorize Resident Self-Administration of Medications
Penalty
Summary
Surveyors identified a failure to appropriately assess and determine the clinical appropriateness of self-administration of medications for one resident. During an observation, the resident was found lying in bed with multiple medication bottles on the bedside table, including Tylenol 500 mg tablets, Tylenol PM, and TUMS. A registered nurse stated that medication bottles should not be kept at the bedside and acknowledged that the resident had medications there. Record review for this resident showed that on the admission assessment, the resident had indicated they did not want to self-administer their own medications. The medical record did not contain a physician's order for Tylenol PM, any authorization for self-administration of Tylenol 500 mg or TUMS, or a care plan documenting the resident's capacity for self-administration. The DON confirmed that the facility’s process for self-administration requires a physician’s order, completion of an assessment, locked storage at the bedside, and documentation on the MAR and in the care plan, none of which were present for this resident.
Failure to Notify Provider and Representative of New Toe Wound
Penalty
Summary
The deficiency involves the facility’s failure to ensure timely and appropriate notification of a physician and resident representative regarding a change in a resident’s condition, specifically a new wound on the left great toe. A resident with diagnoses including hemiplegia and hemiparesis following cerebral infarction, peripheral vascular disease, epilepsy, and type 2 diabetes mellitus was admitted on a prior date and had an active order dated 8/1/25 to be appraised and observed every shift for changes in physical and mental condition, with instructions to notify the provider if changes were observed. On 2/10/26, an LPN identified a new wound on the resident’s left toe, and the Treatment Administration Record for that date showed that the every-shift appraisal order was marked as completed, but there was no documentation that the provider was notified of this new physical change. Further record review showed a Weekly Skin Check dated 2/4/26 documenting that the resident’s skin was intact, and a subsequent Weekly Skin Check dated 2/11/26 documenting "No New Skin Alterations" while also describing a left great toe wound with specific wound care orders, indicating the wound was present but not identified as a new skin impairment. The DON confirmed that the first documentation of the left toe wound was on the 2/11/26 Weekly Skin Check and acknowledged that the nurse should have documented it as a new skin impairment. The DON also confirmed there was no documentation that the provider was notified on 2/10/26 when the wound was first observed, despite an existing order to notify the provider of observed physical changes, and that an antibiotic (Doxycycline Hyclate 100 mg) had been ordered for the left great toe wound without corresponding documentation of provider notification on the date the wound was initially identified.
Failure to Complete and Provide Baseline Care Plans on Admission
Penalty
Summary
The deficiency involves the facility’s failure to complete and document baseline care plans (BLCPs), including current medication lists, within 48 hours of admission and to provide a summary of these BLCPs to the residents and/or their representatives. Surveyors reviewed the medical records of two residents and found that, although both had been admitted to the facility, there was no BLCP in their records and no evidence that a BLCP summary or current medication list had been given to them or their representatives. The regulatory expectation described in the report is that a BLCP must be completed within 48 hours of admission and must include initial goals based on admission orders, physician orders, dietary orders, therapy services, and social services, and that a summary of the BLCP and current medication list must be provided to the resident and/or representative and documented in the medical record. During an interview, the DON explained that residents are supposed to receive a BLCP when they are admitted and that a copy is typically given within 48–72 hours. She stated that the BLCP is not printed separately but is added to the comprehensive care plan, and staff are supposed to write a progress note indicating that the resident or representative received it. When the surveyor requested copies of the BLCPs and documentation that they were provided for the two residents in question, the DON acknowledged that there was no evidence in the medical records for these residents and confirmed she did not see any BLCP summaries in the records. The DON also stated that, according to facility policy, staff are supposed to write a note documenting that the BLCP was given, but this had not been done for these two residents.
Failure to Follow and Document Insulin and Blood Glucose Orders
Penalty
Summary
The deficiency involves the facility’s failure to ensure physician orders for blood glucose monitoring and insulin administration were accurately carried out and documented for a resident with multiple complex diagnoses. The resident was admitted with schizophreniform disorder, bipolar disorder, generalized idiopathic epilepsy, type 2 DM with foot ulcer, and unspecified intellectual disabilities, and had an MDS BIMS score of 5 indicating severely impaired cognition. The physician’s order required subcutaneous Insulin Aspart before meals with a fingerstick blood sugar (BS) obtained prior to meals. Review of the MAR showed multiple instances over several months where BS values were documented as “NA” with chart codes indicating drug refusal or “other/see nurses note,” as well as one entry marked “X” with a code for “no insulin required,” without supporting documentation. There were also entries where BS and insulin administration boxes were left completely blank, with no BS, no insulin, and no explanatory documentation. During interviews, the DON stated that for residents with intellectual disabilities who refuse medications, staff are expected to encourage the resident, notify the physician and responsible party, and document these contacts as a change in condition or progress note, and that it would not be acceptable to simply mark a resident as sleeping and not administer medication. The DON further explained that “NA” had been used when BS was not obtained, and confirmed that BS should have been obtained for each shift where “NA” was documented and that sleeping was not an acceptable reason to omit BS checks. The DON acknowledged there was no documentation that the provider was notified when the resident refused, and confirmed that blank MAR boxes indicated no documentation was completed. She affirmed that the expectation was for nurses to carry out physician orders and document BS results, insulin administration, and insulin amounts, which did not occur as required for this resident.
Failure to Obtain Ophthalmology Evaluation for Resident With Vision Impairment
Penalty
Summary
The deficiency involves the facility’s failure to ensure that a resident with reported visual impairment received appropriate treatment and access to ophthalmology services to maintain vision abilities. During an interview, Resident #64 reported visual impairment, a need to see an ophthalmologist, and that this request had not been fulfilled, stating that the glasses at bedside did not work and that special glasses were needed. The admission MDS assessment documented the resident’s vision as adequate with glasses, and an earlier PCP note recorded vision as within normal limits, but a subsequent nutrition note indicated the resident required setup/clean-up assistance related to vision loss. A later PCP note specifically directed that ophthalmology follow-up appointments should be scheduled as necessary, with regular monitoring and evaluation by an ophthalmologist. Progress notes also documented the resident’s complaint of dry eyes and an order for artificial tears. Staff interviews and record review showed that the facility was aware of the resident’s vision issues but did not complete the process to obtain an ophthalmology visit. The unit manager described the standard process for arranging ophthalmology appointments but was initially unsure whether there was an in-house ophthalmologist and later stated that appointments depended on insurance qualification, with others referred out. A GNA reported the resident was partially blind and required assistance with care. An LPN acknowledged that the resident had glasses at the bedside that were reported as not working, though the LPN stated the resident had not specifically reported current vision issues to her. The NP reported that the resident had expressed difficulty seeing and requested eye wash, and that she could not prescribe eye wash without an ophthalmologist assessment; she stated she had been attempting to schedule an appointment but was unsure about insurance coverage. The DON reported the resident was being reviewed for an ophthalmologist assessment but was unsure of the conclusion. There was no documented evidence that the facility had appropriately assessed and/or treated the resident’s vision impairment issues or secured an ophthalmology evaluation, despite multiple indications of visual problems and provider recommendations for ophthalmology follow-up.
Failure to Provide Ordered Respiratory Equipment Care for Oxygen Therapy
Penalty
Summary
Surveyors identified a deficiency in the provision of necessary respiratory care related to oxygen therapy equipment for one resident receiving oxygen via nasal cannula. On 02/09/2026, the resident was observed in bed on 2 liters of oxygen via nasal cannula with oxygen tubing that was not dated and an oxygen concentrator that did not have a humidifier attached. The resident had a physician order, dated 11/20/2025, for oxygen at 2 liters via nasal cannula as needed, but there were no accompanying physician orders specifying care of the respiratory equipment, such as tubing changes or humidifier use. During an interview, the resident reported that his/her nose becomes dry from the oxygen. On 02/10/2026, an LPN stated that a physician's order is required to change the nasal cannula, that oxygen tubing is changed every 24 hours, and that staff date the humidifier bottle, and confirmed that the resident’s oxygen tubing was undated and no humidifier was in use. The RN Unit Manager explained that oxygen therapy requires a physician’s order that includes specific instructions for respiratory equipment care, including weekly changes and dating of oxygen tubing and humidifier bottles, and stated she expected such an order to be in place. The DON similarly confirmed that physician orders are required for respiratory equipment care, including weekly or as-needed oxygen tubing changes and humidifier care, and acknowledged that such orders for this resident’s oxygen equipment had not been in place for the three months prior to surveyor intervention.
Failure to Ensure Provider Response to Monthly Medication Regimen Review Recommendations
Penalty
Summary
The deficiency involves the facility’s failure to ensure that providers consistently responded to and acted upon monthly Medication Regimen Review (MRR) recommendations made by the consultant pharmacist. The facility’s policy requires that, upon receiving the MRR report, the attending physician review and respond to the pharmacist’s recommendations, document in the medical record that the recommendations were reviewed, and indicate what actions, if any, were taken. The DON stated that the pharmacist typically visits during the third week of the month, emails the MRRs to regional staff, the DON, and Unit Managers, and that the printed MRRs are physically handed to the provider, who is expected to check agree/disagree/other, provide rationale if disagreeing, and sign and date the form within 7–10 days. Despite this described process and policy, multiple MRRs for two residents were either not fully addressed, not acted upon, or not completed by the provider. For one resident reviewed for unnecessary medications, the pharmacist made several recommendations over multiple months. An MRR dated 8/22/25 recommended co-prescribing naloxone for a resident on routine oxycodone for lower extremity pain; the provider checked agree and signed and dated the MRR, but the resident did not have an active naloxone order in the medical record. An MRR dated 9/21/25 recommended a gradual dose reduction (GDR) of Uzedy for schizophreniform disorder and instructed that, if the recommendation was declined, the provider should select a rationale option and provide a brief clinical rationale note; the provider checked disagree and signed and dated the MRR but did not select any of the rationale options or document a brief clinical rationale on the MRR. An MRR dated 11/16/25 recommended adding a stop date for cefepime and adding a probiotic while on antibiotic therapy; the provider checked other and documented that the patient had a stop date of 12/3/25, thereby addressing the stop-date portion, but did not respond to or act on the probiotic recommendation on the MRR form. Further review for the same resident showed that the facility did not provide a complete set of MRRs for the requested six-month period. Initially, only August, September, and November 2025 MRRs were produced. The DON later stated there were no recommendations for December 2025 and that the resident was hospitalized during the January 2026 review, so no MRR was conducted then. However, the DON acknowledged that an October 2025 MRR existed and had been missed. When the October 10/26/25 MRR was produced, it was found that the provider had not completed it at all: there was no indication of agree, disagree, or other, no signature or date, and no documented action taken to address the pharmacist’s recommendation. The DON confirmed that this MRR had not been addressed and that, several months later, it still remained incomplete. For a second resident, the pharmacist’s MRRs also contained recommendations that were not fully reconciled by the provider. An MRR dated 10/26/25 included a psychiatry recommendation for a GDR of olanzapine 10 mg at bedtime for paranoid schizophrenia, stating the resident was due for a dose reduction to find the lowest effective dose. The MRR form for this recommendation was left entirely blank, with no box checked for agree, disagree, or other, and no provider signature or date, and there was no indication that the recommendation had been completed. Another MRR dated 1/19/26 contained a physician recommendation regarding trazodone 50 mg at bedtime for depression/insomnia, stating that if an antidepressant is used for sleep or to manage behavior, mood, or a psychiatric disorder, it must be reviewed for possible GDR and, if a reduction is clinically contraindicated, the rationale and risk–benefit should be documented. The provider checked disagree and signed and dated the form but did not write any brief clinical rationale note on the MRR. Review of the physician’s progress notes for this resident also failed to show any documented reason for disagreeing with the trazodone GDR recommendation, and there was no documentation that the olanzapine GDR recommendation had been addressed, demonstrating that the facility did not ensure provider response and action on the pharmacist’s MRR recommendations.
Medication Error Rate Exceeded Due to Methadone Dose Discrepancy and Inhaler Instructions Omission
Penalty
Summary
The facility failed to maintain a medication error rate below 5%, with 2 errors identified out of 37 medication administration opportunities, resulting in a 5.41% error rate. In the first instance, an LPN prepared Methadone for a resident with a physician order for Methadone HCl oral solution 75 mg by mouth twice daily for maintenance. During medication preparation, the LPN stated she was going to administer 75 mg and handed the Methadone container to the surveyor, who observed the bottle was labeled 74 mg. When prompted, the LPN read the bottle label as 74 mg and the electronic order as 75 mg but did not initially recognize the discrepancy between the ordered dose and the labeled dose. Only after further questioning by the surveyor did the LPN acknowledge that the Methadone container dosage did not match the physician’s order. In the second instance, an RN administered an Anoro Ellipta inhaler to another resident who had a physician order for one puff daily for COPD with instructions to rinse the mouth with water and expectorate after use. The surveyor observed the RN give the resident a puff of the Ellipta inhaler, after which the resident took a sip of water. The RN did not provide any instructions to the resident to rinse and spit out the water, and the resident did not perform the ordered mouth-rinsing and expectoration. When the surveyor later raised this concern, the RN acknowledged and understood that the resident had not followed the ordered post-inhalation mouth care instructions.
Unauthorized Resident Possession of Rescue Inhaler and Improper Medication Storage
Penalty
Summary
The facility failed to ensure medications were stored properly and that drugs were maintained in locked compartments as required, as evidenced by one resident keeping a rescue inhaler on his/her person without an order for self-administration. During an interview, the Nursing Home Administrator (NHA) stated that the resident was a hoarder and always had a safety inhaler in his/her pocket, and acknowledged seeing a blue inhaler in the resident’s hand but did not verify whether it contained medication. The NHA also stated that residents should only have medications at the bedside if there was an order, and she was unsure whether this resident had such an order. In a separate interview, the resident confirmed having an albuterol rescue inhaler with medication in it in his/her pocket and stated an intention to keep the medication on his/her person to use when he/she felt it was needed, rather than relying on nursing staff. Review of the medical record showed the resident had diagnoses including COPD with acute exacerbation, heart failure, and other abnormal lung findings, and that on an admission/readmission nursing evaluation the resident was documented as not wanting to self-administer medications. The record contained an order for albuterol sulfate HFA inhaler to be administered as 1 puff every 4 hours as needed for wheezing related to COPD, but there was no order for self-administration of any medications. The albuterol order specified that it was to be administered by a clinician, not by supervised or unsupervised self-administration, confirming that the resident’s possession and control of the inhaler was not authorized by provider orders or facility policy.
Failure to Serve Hot Foods at Appetizing Temperatures
Penalty
Summary
The facility failed to ensure that hot foods were served at an appetizing temperature, as evidenced by resident reports and a test tray evaluation during a recertification/complaint survey. On 02/09/2026 at 9:12 AM, one resident reported that hot foods were not hot, and another resident reported that food was sometimes served hot and sometimes not, and that the taste was poor. Later that same day at 12:46 PM, a different resident reported that food was being served cold and sometimes this occurred due to waiting for assistance with feeding. On 02/13/2026 at 8:50 AM, the Food Service Director was instructed to provide a test tray on the last food cart for lunch delivery to a specified unit. Observation of the last food cart delivery began at 12:30 PM, with lunch tray service starting at 12:36 PM, during which staff delivered all resident trays before removing the last tray designated as the test tray. At 12:44 PM, the surveyor pulled the test tray from the delivery cart, and at 12:53 PM recorded food temperatures using two thermometers, finding the candied sweet potatoes at 115.3°F/112.8°F, the fish at 108.5°F/107.7°F, and the vegetables at 108.1°F/105.0°F, which were identified as low/abnormal when reported to the DON at 2:13 PM. These findings show that residents experienced inconsistently heated meals and that, at the time of surveyor testing, multiple hot food items on a sample tray from the last delivered cart were below expected warm holding or serving temperatures.
Failure to Accurately Document Behavioral Monitoring and Interventions
Penalty
Summary
Surveyors identified a deficiency in the facility’s failure to maintain accurate and complete medical records related to behavioral monitoring for a resident with documented psychiatric conditions. The resident had a psychiatric evaluation indicating depression and anxiety, with a treatment plan calling for continuation of current treatment and routine monitoring of mood and behavior. A subsequent psychiatric progress note documented that the resident presented as frustrated, irritable, angry, and verbally expressed a desire to leave the facility, along with complaints of sleep difficulty and fatigue. During the survey, the resident was again observed to be irritable, easily agitated, and expressing a desire to leave immediately. Physician orders directed staff to perform behavior monitoring every shift and to document the frequency of behavioral episodes, the interventions used, and the outcomes, using specified intervention codes. Review of the January Medication Administration Record (MAR) showed that on two shifts, staff had indicated that behaviors were present, but there was no further description of the behaviors, no documentation of the frequency of episodes, and no record of any interventions or outcomes. When questioned, the DON stated she was unsure what the MAR documentation indicated and later confirmed that the documentation did not clarify staff findings. The DON agreed that when behaviors are identified, there should be additional description and documentation of what was observed and what treatment was provided, and acknowledged that the documentation was not accurately completed.
Failure to Follow Droplet and Enhanced Barrier Precautions During Resident Care
Penalty
Summary
The deficiency involves failures in the facility’s infection prevention and control practices related to Droplet Precautions and Enhanced Barrier Precautions (EBP). A resident with an active order for Droplet Isolation Precautions for RSV had a Droplet Precautions sign posted on the room door instructing everyone to clean their hands and ensure eyes, nose, and mouth were fully covered before entry, and to remove face protection before exit. Despite this, a GNA entered the resident’s room to remove a meal tray wearing only a mask and no gown or additional required PPE. In an interview immediately afterward, the GNA acknowledged knowing the resident was on Droplet Precautions but stated she did not know a gown was required unless performing direct care such as washing the resident, and she was unsure if there was a designated Infection Preventionist. The deficiency also includes improper infection control technique during wound care for a resident on EBP for a coccyx wound. EBP signage on the door indicated staff must wear gowns and gloves during high-contact care activities. During an observed dressing change, an LPN placed two pairs of gloves on their hands, entered the room, removed the old dressing, cleansed the wound, then removed only the top pair of gloves and proceeded to apply the new dressing without performing hand hygiene or changing to a completely new single pair of gloves as described by facility leadership. The resident’s medical record confirmed an order for EBP every shift and specified the wound care steps, including cleansing the coccyx cluster and applying santyl, calcium alginate, barrier cream to the periwound, and covering with bordered foam daily and as needed.
Failure to Notify Responsible Party of Medication Changes
Penalty
Summary
Facility staff failed to notify a resident's responsible party regarding changes in the resident's medication regimen. The resident, who had diagnoses including metabolic encephalopathy, unspecified dementia with behavioral disturbances, anxiety disorder, depression, and altered mental status, experienced increased anxiety and restlessness. Following a psychiatric evaluation, Buspar was initially ordered and the caregiver was notified and authorized the medication. Subsequently, the resident continued to display agitation and aggression, leading to an increase in the Buspar dosage and the addition of Hydroxyzine for escalating anxiety and agitation. There was no documentation in the medical record that the responsible party was notified of the increase in the anti-anxiety medication or the addition of Hydroxyzine. The DON stated that the ADON verbally informed someone, but could not specify who was notified. A signed timeline indicating family notification was provided to the surveyor, but this documentation was created after the surveyor began investigating and was not present in the medical record at the time of the medication changes.
Delayed Physician Documentation in Medical Records
Penalty
Summary
A deficiency was identified when a physician's progress notes were not present in the resident's electronic medical record on the day the resident was seen. Medical record review showed that several physician visit notes were dated earlier in the month but were not signed or uploaded into the resident's record until several days later. Additionally, one physician note was not signed and uploaded until five days after the visit. During an interview, the physician stated that he typically entered notes within 24 hours and indicated that the delayed notes were not his. The Nursing Home Administrator confirmed these findings during the survey.
Unnecessary Drug Administration and Inadequate Behavior Monitoring
Penalty
Summary
A deficiency was identified when a resident with diagnoses including metabolic encephalopathy, unspecified dementia with behavioral disturbances, anxiety disorder, depression, and altered mental status was administered Hydroxyzine 10 mg twice daily on a routine basis, despite the medication being ordered as PRN (as needed) for escalating anxiety and agitation. The medication was started following a psychiatric evaluation for increased anxiety, restlessness, and impulsive behaviors. However, the medication administration record showed that Hydroxyzine was given at scheduled times rather than in response to specific symptoms, due to a transcription error. Additionally, behavior monitoring documentation was incomplete, as nursing staff only marked checkboxes without providing descriptions of the resident's behaviors. This lack of detailed documentation failed to demonstrate the necessity for the PRN medication and did not provide adequate information about the resident's behavioral symptoms. Both the psych nurse practitioner and the DON confirmed the medication was intended to be PRN and acknowledged the documentation and transcription errors.
Incomplete and Inaccurate Medical Record Documentation Following Resident Fall
Penalty
Summary
The facility failed to maintain complete and accurate medical records in accordance with accepted professional standards for one resident who experienced a fall. After the resident sustained a hematoma and facial discoloration following the fall, the change in condition note indicated that the physician could not be notified at the time, and there was no subsequent documentation in the medical record confirming that the physician was later notified. Although an email from the Medical Director later stated that the physician was notified about the fall, the time of notification was not documented in the medical record. Additionally, the physician's progress note was incorrectly dated, referencing an event that occurred after the date on the note, and no addendum was made to correct the date. Further review revealed that the physician's note called for STAT labs due to the hematoma, but there was no documentation in the medical record that these labs were ordered or completed. The physician later clarified that the STAT order was an error and that the resident was clinically stable, so labs could be done on the regular schedule. The Director of Nursing and Nursing Home Administrator confirmed the incomplete and inaccurate documentation regarding physician notification and follow-up in the resident's medical record.
Failure to Report Alleged Abuse to State Agency
Penalty
Summary
The facility failed to report an allegation of abuse to the state survey agency as required by its own policy and federal regulations. A resident with severe cognitive impairment, aphasia, and hemiplegia reported to therapy staff that a geriatric nursing assistant hurt their arm during care. The Director of Social Work (DSW) interviewed the resident, who described the incident as the table hitting their arm during care, but was unclear if it was intentional or accidental. The DSW also interviewed the assigned staff and other residents, found no additional concerns, and provided the information to the Administrator. However, the incident was not reported to the state survey agency because the DSW and Administrator believed it was accidental and not abuse. Multiple staff interviews confirmed that the resident initially alleged rough treatment by staff, but later changed their account, suggesting the injury may have been accidental. Despite this, the Director of Rehabilitation reported the allegation as required, but was unaware if it was escalated to the state. The Administrator later acknowledged that the resident's statement should have been considered an allegation of abuse and reported, but this was not done at the time. The facility maintained internal documentation of the incident but did not fulfill the mandatory reporting requirement.
Failure to Report and Thoroughly Investigate Alleged Abuse
Penalty
Summary
The facility failed to ensure that an allegation of abuse involving a resident was properly reported to the state survey agency (SSA) and that the investigation documentation was thorough. The facility's policy required immediate investigation and reporting of any suspicion or report of abuse, neglect, or exploitation, including interviewing all involved persons and providing complete documentation. In this case, a resident with severe cognitive impairment, aphasia, and hemiplegia reported to a therapy staff member that a geriatric nursing assistant (GNA) hurt their arm during care. The Director of Social Work (DSW) interviewed the resident, who described an incident involving impact with a bedside table but was unclear if it was intentional or accidental. The DSW interviewed the assigned GNA and several other residents, finding no additional concerns, and submitted the information to the Administrator. However, the facility did not report the allegation to the SSA, as the DSW believed the incident was accidental. The Administrator confirmed that the decision not to report was based on the belief that not every negative statement constituted abuse. The facility maintained a "soft file" with statements from the DSW, the GNA, and documentation of interviews with other residents, but did not include statements from the therapy staff member who initially received the allegation or other potentially knowledgeable staff. Further interviews revealed that the Director of Rehabilitation (DOR), who first heard the allegation, was not asked for a statement until much later, and her account indicated the resident had repeatedly stated the staff was rough and hit their arm. The Director of Nursing (DON) stated that all abuse allegations should be reported and investigated. The Administrator later acknowledged that the allegation should have been reported and that the investigation did not include interviews with all relevant staff members. The documentation did not reflect a complete or thorough investigation as required by facility policy.
Infection Control Deficiencies in Wound Care and PICC Line Management
Penalty
Summary
The facility failed to adhere to its infection prevention and control program during wound care for three residents. For Resident 91, the Licensed Practical Nurse (LPN) did not use a clean field or place a barrier under the resident during sacral wound care, contrary to the facility's policy. The LPN was unaware of the requirement to use a clean field and had not received education on this aspect of wound care. Resident 91 was cognitively intact and had a sacral wound requiring specific treatment orders. Resident 298, who was cognitively intact and had a central line catheter for chemotherapy, did not have a PICC line dressing change as required. The dressing was observed to be loose and had not been changed since the resident's last hospital visit. The facility staff were only flushing the PICC line, and the Director of Nursing (DON) confirmed that the dressing should have been changed weekly. Additionally, during wound care for Resident 298's thigh wound, the LPN placed supplies on an unclean bedside table without using a clean field. Resident 82, who had severe cognitive impairment and a stage three pressure ulcer, also received wound care without the use of a protective barrier. The LPN placed wound care supplies directly on the resident's bed. The LPN acknowledged the oversight in not using a protective barrier. These actions were inconsistent with the facility's policies and had the potential to increase contamination and the spread of infection.
Failure to Timely Report Allegation of Abuse
Penalty
Summary
The facility failed to report an allegation of abuse to the State Agency (SA) within the required timeframe. This deficiency was identified during a review of the facility's investigation file for a reported incident involving a resident. The incident report was dated September 10, 2024, at 12:44 PM, indicating that the resident reported an allegation of abuse that occurred on September 7, 2024, during a care plan meeting. The facility documented that a Registered Nurse (RN) was informed of the allegation on September 10, 2024, at 12:45 PM, and subsequently reported it to the Administrator at 12:50 PM. However, the initial report to the SA was not sent until 3:15 PM on the same day, resulting in a delay. The Nursing Home Administrator and Director of Nursing were informed of this issue at the time of the survey exit, but they did not provide any explanation for the late reporting.
Failure to Reposition Resident at Risk for Pressure Injuries
Penalty
Summary
The facility failed to adequately turn and reposition a resident at risk for pressure injuries, as observed during a survey. Resident #72, who is obese and suffers from Hidradenitis suppurativa (HS), was observed multiple times lying on their back without being repositioned, despite requiring maximum to full dependence on staff for movement. The geriatric nursing assistants (GNAs) assigned to the resident were aware of the need to reposition the resident every two hours but failed to do so effectively. One GNA demonstrated an incorrect method of repositioning that did not relieve pressure on the resident's bottom, and another GNA expressed fear of turning the resident due to the risk of falling, but did not report this concern to the nurse. Interviews with the staff, including a Licensed Practical Nurse (LPN) and a Wound Care Nurse Practitioner (NP), confirmed the importance of repositioning the resident to prevent pressure wounds, especially given the resident's current HS outbreak. The NP noted that the HS wounds could potentially develop into pressure wounds. Despite these concerns, the Unit Manager was unaware of the staff's fear of repositioning the resident. The Nursing Home Administrator and Director of Nursing were informed of these issues at the time of the survey exit.
Ice Machine Maintenance Deficiency
Penalty
Summary
The facility failed to maintain the cleanliness of an ice machine, which had the potential to impact all 104 residents. During an observation, the filter grate of the ice machine was found to be covered in yellow-tinged dust, and the drain pan was covered with rust and white substances. The Kitchen Dietary Manager confirmed the condition of the ice machine and stated that the maintenance department was responsible for the filter, while the kitchen staff was responsible for cleaning the drain pan. However, there was no schedule available for cleaning the drain pan. The Maintenance Director confirmed the dirty condition of the ice machine's filter grate and mentioned that the machine was due for cleaning. Despite this, there was no maintenance log available for the ice machine. The Administrator was unaware of any facility policy addressing the maintenance of kitchen equipment. The manual for the ice machine recommended cleaning the drain pan weekly, but this was not being followed, leading to the observed deficiency.
Failure to Prevent Resident Elopement
Penalty
Summary
The facility failed to prevent a known wandering resident from eloping, which resulted in an Immediate Jeopardy situation. The incident involved a resident with a diagnosis of Parkinson's disease, delirium, and dementia with behavioral disturbances, who had been refusing medication. Despite having a wander guard placed upon admission, the resident was able to leave the facility undetected and was found by police five hours later at a hotel approximately 14 miles away. The wander guard was checked upon the resident's return and was found to be functioning, as it alarmed upon reentry, but it did not alarm when the resident left the facility. The incident report revealed that the receptionist, who was unaware of the elopement binder containing the resident's picture and information, mistakenly thought the resident was a visitor and allowed them to leave with other visitors. This oversight contributed to the resident's ability to elope. The receptionist had been educated on the facility's elopement procedures, including the use of the elopement binder, upon hire, but this knowledge was not applied during the incident.
Removal Plan
- A new wander guard was placed on Resident #18's ankle.
- The care plan was updated.
- Staff education related to elopement procedures.
- Staff re-education on the elopement process and procedures.
- Education related to the elopement binder at the front desk.
- Checks on the exit doors.
- Operation of the door monitors and patient wandering systems are checked.
Delay in Providing Medical Records
Penalty
Summary
The facility staff failed to provide a resident with a copy of their medical records in a timely manner. The issue was identified during a complaint survey involving a resident who had been discharged from the facility. The resident's representative had requested the medical records on 3/28/24, but as of 5/17/24, the records had not been received. The request was initially received by a staff member in the medical records department, who forwarded it to the corporate office due to a change in facility ownership. However, no further action was taken to fulfill the request, resulting in a delay in providing the records. The Director of Nursing confirmed the failure to provide the requested records in a timely manner.
Failure to Notify Physician and Family of Significant Weight Loss
Penalty
Summary
The facility failed to notify the resident representative and physician of a significant change in condition for one of the residents. The deficiency was identified during a complaint investigation concerning a resident who experienced a significant weight loss while residing in the facility. The resident had medical diagnoses including congestive heart failure and atrial fibrillation, and there was an initial order to notify the physician for a weight gain of 5 lbs or more. On a specific date, the resident's physician ordered Metolazone, a diuretic, to be administered as a one-time dose due to weight gain and shortness of breath. However, the medication was administered for several days, resulting in a weight loss from 221 lbs to 159 lbs. Interviews with facility staff, including the dietitian, revealed that the physician's order for Metolazone was intended as a one-time dose, but it was administered over a period of days. The staff acknowledged that there were no dietary notes or change in condition reports documenting the significant weight loss or any notification to the family or physician. The deficiency was confirmed through a review of the medical records and interviews with staff, highlighting a failure in communication and documentation regarding the resident's condition.
Failure to Timely Report Allegations of Abuse
Penalty
Summary
The facility failed to report allegations of abuse to the State Agency within the required 2-hour time frame and did not ensure that the final report was sent within 5 business days. This deficiency was evident in three separate incidents. In the first incident, a police officer informed the facility of a suspected sexual assault based on a physician's exam, but the facility delayed reporting to the State Agency by 5 hours and 45 minutes. There was no evidence of when the final investigation report was sent. The Director of Nursing could not provide a rationale for the delay. In the second incident, a resident reported that an aide ignored their request for assistance, leading to a verbal altercation. Despite the investigation, the facility did not report the allegation to the State Agency, as the Nursing Home Administrator did not determine it as abuse. In the third incident, a resident alleged rough treatment by a GNA, but the facility delayed reporting the incident to the State Agency by 7 days. The Director of Nursing confirmed involvement in the investigation but offered no explanation for the late reporting.
Incomplete Investigations into Allegations of Abuse
Penalty
Summary
The facility failed to conduct thorough investigations into allegations of abuse involving Resident #19. In one instance, the resident reported that a GNA turned off the call light without providing assistance when the resident was coughing and needed water. The investigation file contained incomplete documentation, lacking statements from all staff on duty and other residents who might have witnessed the incident. The Director of Nursing (DON) did not verify if the resident had water at the bedside, as claimed by the GNA, and the incident was not reported to the State Agency (SA). In another case, Resident #19 alleged that a GNA threw a dirty gown in their face and was rough during care. The facility's investigation was incomplete, as it did not include interviews with all relevant staff and residents. The assignment sheet for the day in question was altered, and there was no documentation of care provided to the resident. The DON admitted to not being aware of the resident's preference for not being turned on their right side and could not provide evidence of disciplinary action against the GNA involved. Additionally, Resident #19 reported an incident where a GNA allegedly threw a box of tissue at them. This was reported to a staff nurse who failed to report it to the facility or DON in a timely manner. The DON did not file a complaint with the agency that employed the GNA and did not attempt to identify the GNA involved. The lack of timely reporting and follow-up resulted in no statement being obtained from the GNA, and the incident remained unresolved.
Failure to Follow Physician Orders and Provide Timely Care
Penalty
Summary
The facility staff failed to follow physician orders for Resident #15 in a timely manner. The resident, admitted for rehabilitation following spinal surgery, was ordered to start Clindamycin on 12/8/22 after a follow-up appointment. However, the medication was not administered until 12/10/22, two days later. Additionally, the resident was supposed to have blood work done every two weeks as per a physician's order on 1/17/23, but the required blood work was not completed on 2/6/23. The Director of Nursing confirmed these lapses in care during an interview. Resident #30 experienced a failure in receiving timely care when in distress. On 1/28/24, the resident accidentally cut their left big toe while cutting toenails, causing significant bleeding. Despite using the call bell multiple times, no nursing staff responded. The resident, who was on a blood thinner, had to call the receptionist and subsequently EMS for assistance. EMS found the resident with a large amount of blood and managed to stop the bleeding. The receptionist did not recall the incident, and the Director of Nursing was unaware of the situation until informed by EMS.
Failure to Provide Ordered Siderails for Resident Rehabilitation
Penalty
Summary
The facility staff failed to provide siderails as ordered by the consulting physician for a resident who was admitted for rehabilitation following spinal surgery. The resident's medical record indicated a recommendation from an orthopedic consultation to apply bed rails to assist with mobility exercises such as pulling up or rolling. However, the facility did not implement this recommendation, and there was no documentation of an alternative solution, such as a trapeze, being provided. Interviews with the Director of Rehabilitation and the Director of Nursing confirmed that siderails were not installed, and there was no evidence of communication with the consulting physician regarding the facility's inability to use bed rails or to seek approval for alternative equipment. Additionally, the resident's representative confirmed that neither a trapeze nor siderails were provided to the resident.
Medication Administration Error Leads to Significant Weight Loss
Penalty
Summary
The facility staff failed to appropriately order and administer a medication for a resident with congestive heart failure and atrial fibrillation. The resident was initially ordered to notify the physician for a weight gain of 5 lbs or more. On a specific date, the resident's physician ordered Metolazone, a diuretic, to be administered as a one-time dose due to an identified weight gain and shortness of breath. However, the medication administration record revealed that Metolazone was administered for seven consecutive days instead of the ordered single dose. This error in medication administration resulted in a significant weight loss for the resident, whose weight dropped from 221 lbs to 159 lbs over a short period. Interviews with facility staff, including the dietitian and the Director of Nursing, confirmed that the physician's order was for a one-time dose, yet the medication was given for an extended period. This oversight was identified during a complaint survey, highlighting a failure in following the physician's medication order accurately.
Outdated Facility Assessment Documentation
Penalty
Summary
The facility failed to maintain an updated annual facility assessment necessary for determining the resources required to care for residents competently during both routine operations and emergencies. During an extended survey conducted on May 21, 2024, it was discovered that the facility's assessment documentation was outdated, only covering the years 2020-2021. This deficiency was identified through a review of facility documents and interviews with staff. The current Nursing Home Administrator and the facility governing body representative had signed the assessment binder, but the signature page lacked a date, and no documents for the year 2023 or the current year were found. This issue was brought to the attention of the facility's corporate nurse and corporate operations representative, who confirmed the absence of updated documentation.
Failure to Follow Up with Outside Resources for Resident Care
Penalty
Summary
The facility staff failed to appropriately follow up with outside resources for the care of two residents, leading to deficiencies in their treatment. Resident #15, admitted for rehabilitation following spinal surgery, was supposed to continue IV antibiotics as per the hospital discharge summary. However, the facility staff stopped the IV antibiotic without consulting the Infectious Disease physician on 12/4/22, and the resident missed doses on 12/4, 12/5, 12/6, and 12/7/22. Additionally, the facility staff discontinued the oral antibiotic Clindamycin on 1/20/23 without consulting the outside facility, despite instructions to continue until further notice. The Director of Nursing confirmed these lapses in communication and follow-up with the outside physician. Resident #14, diagnosed with unspecified dementia and adult failure to thrive, had a 'dark/black' area on the right heel upon admission. Despite physician orders for podiatry and wound consults on 11/16/22, these were never implemented, as confirmed by the progress notes and medication administration records. The Director of Nursing acknowledged that there was no record of the podiatrist seeing the resident, nor was there a wound consult completed, indicating a failure to follow through with necessary external consultations for the resident's care.
Failure to Document ADL Care for Dependent Resident
Penalty
Summary
The facility failed to consistently document activities of daily living (ADL) care provided to a dependent resident, identified as Resident #32. This deficiency was discovered during a review of complaints regarding the resident being left in bed and soiled with urine and stool for extended periods. The medical record review revealed that Resident #32 was frequently incontinent of bowel and bladder, as documented in the minimum data set (MDS) Kardex. However, the geriatric nursing assistant (GNA) documentation for toileting and bowel and bladder care was incomplete, with multiple shifts lacking records of care provided, particularly on a day identified in the complaint. Despite this, nursing progress notes and the medication administration record indicated that care was provided, and a staff member interacted with the resident throughout the day. An interview with a unit supervisor confirmed that rounds were conducted to ensure staff checked on residents, and assistance was provided as needed. The issue of missing documentation for ADL care in March was discussed with the interim Director of Nursing during the survey and at the exit meeting.
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.
Trusted data from CMS and state health departments
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.
Trusted by long-term care providers and associations.
