Waldorf Center
Inspection history, citations, penalties and survey trends for this long-term care facility in Waldorf, Maryland.
- Location
- 4140 Old Washington Highway, Waldorf, Maryland 20602
- CMS Provider Number
- 215273
- Inspections on file
- 15
- Latest survey
- January 23, 2026
- Citations (last 12 mo.)
- 5
Citation history
Health deficiencies cited at Waldorf Center during CMS and state inspections, most recent first.
Surveyors found that medical records containing PHI were stored in a shared warehouse used for general storage, where open and closed boxes of records had resident names, MRNs, and assessments freely visible on box exteriors and file covers. The warehouse was unlocked for surveyors by maintenance staff, and the Director of Maintenance reported that central supply, housekeeping, and dietary staff had access. The DON later confirmed that maintenance and environmental services did not need access to PHI, yet acknowledged that multiple non-clinical staff, including maintenance and environmental services leadership, had keys to the warehouse where these records were kept.
Surveyors identified multiple infection control failures, including an activities assistant placing a personal cell phone on a resident’s bed, improper storage and management of biohazard waste in a warehouse where clean medical supplies, gloves, drinking cups, and other items were stored without separation or off-floor protection, and disorganized handling of clean and soiled linens. In the clean laundry area, uncovered facility linens and unidentified resident garments were piled, leaning on walls, and in some cases touching the floor. In the soiled laundry area, overflowing unlined bins and containers held unbagged resident laundry and facility linens piled high against walls in an odorous room, with only one functioning washing machine contributing to the accumulation of soiled items.
Surveyors found that MDS assessments were inaccurately coded for tobacco use for two residents. Both residents told surveyors they were smokers, and facility smoking lists and prior Smoking Evaluations identified them as independent smokers. Despite this, their annual MDS assessments documented "No" for tobacco use in section J1300, indicating that known information about their smoking status was not accurately reflected in the MDS.
Surveyors found that the facility did not develop complete, person-centered care plans for a resident at risk for falls and two residents who were independent smokers. For the fall-risk resident with a history of CVA and impaired mobility, the care plan goal of avoiding falls with injury lacked specific, measurable interventions, including incomplete directions about fall mat use and which personal items should be kept within reach. For the two independent smokers, smoking assessments and goals for safe smoking were documented, but the care plans did not include any specific interventions or services to support those goals.
An LPN administered a PRN oxycodone dose to a resident for pain but failed to document the administration on the MAR, even though the narcotic control book showed the medication was signed out. In separate med pass observations, the same LPN gave multiple 9:00 AM scheduled medications, including metformin, Eliquis, antihypertensives, diuretics, GI meds, supplements, and inhaled therapy, to two residents more than an hour late, with the eMAR highlighting the overdue status. The LPN acknowledged the late administration and cited responsibility for two hallways of residents.
The facility failed to ensure proper cleaning and air drying of food preparation equipment, potentially affecting 103 residents. The AMD confirmed that the meat slicer had food remnants and several pans were stacked wet, contrary to facility policies requiring equipment to be cleaned and air dried before storage.
The facility failed to properly dispose of garbage in the dumpster area, affecting 110 residents and staff. An observation revealed an open dumpster and a ripped trash bag on the ground. The AMD confirmed that dumpsters should be closed and trash bags placed inside. The facility's policy requires trash to be contained in covered, leak-proof containers and disposed of in external receptacles, with the area kept free of debris.
The facility failed to provide residents with preplanned menus and alternative food options, resulting in residents not being able to choose their meals. Interviews and observations revealed that residents were not consistently informed of their meal options, especially those in isolation or unable to leave their rooms. Staff acknowledged the lack of a formal policy for menu distribution and preference collection, leading to meals not aligning with residents' preferences.
The facility failed to address resident council concerns about meal menus and food preferences. Residents reported that their requests for weekly meal menus and consideration of their food preferences were repeatedly ignored. Despite documentation of these issues in resident council meeting notes, no resolution was implemented. Interviews revealed a lack of communication and follow-up by the Activity Manager, District Dietary Manager, and Administrator, and the facility lacked a policy to address resident group concerns.
The facility failed to follow infection control measures for two residents, increasing the risk of COVID transmission. An LPN did not sanitize hands after removing PPE in a COVID-positive resident's room, and a GNA mishandled trash and soiled laundry. Another LPN did not perform hand hygiene between glove changes during wound care for a resident on Enhanced Barrier Precautions.
The facility failed to maintain a clean and comfortable environment, with issues such as unpainted walls, peeling laminate, and damaged wheelchairs observed. Additionally, a resident's gold ring went missing after being placed in a medication cart for safekeeping, leading to an investigation and the termination of an LPN for gross misconduct. The facility lacked a policy for protecting residents' property.
The facility failed to report allegations of abuse to the Office of Health Care Quality within the required 2-hour timeframe for two residents. In one instance, a staff member reported witnessing another staff member hitting a resident, but the report was delayed by seven days. In another case, a resident alleged that an LPN waved her finger in their face, but the report was delayed until the following day due to distractions from surveyors in the building.
The facility failed to thoroughly investigate an alleged abuse incident involving a resident. A staff member reported witnessing another staff member hitting a resident's hand, but the investigation was incomplete. It lacked the reporting staff's statement and did not include statements from other staff or residents who interacted with the accused staff member. The Administrator and DON confirmed the investigation's inadequacy.
The facility failed to hold quarterly care plan meetings and involve residents or their representatives in care planning. One resident had no care plan meetings in the past year, while another had only one meeting during their stay. The DON confirmed these deficiencies, and facility policies were not provided during the survey.
A facility failed to schedule a follow-up colonoscopy for a resident with gastrostomy status, GERD, and peptic ulcer, as ordered by a physician. A consultation report recommended a repeat colonoscopy due to poor colon preparation, but no documentation of the procedure was found. Staff interviews revealed that the responsibility for scheduling appointments lay with the unit manager or nurse, but the DON confirmed that the follow-up was not scheduled or performed.
A resident with a Stage IV pressure ulcer on the sacrum did not receive timely wound care as per physician orders. Upon admission and subsequent readmissions, there were significant delays in initiating the prescribed wound treatments, ranging from seven to ten days. These delays were confirmed by the DON, highlighting a pattern of non-compliance with wound care protocols.
A resident with a left second toe amputation did not receive proper wound care as ordered by the physician. The facility staff failed to cleanse and dress the surgical site on multiple occasions, and there were no nursing progress notes or wound notes to confirm that the care was provided. This deficiency was identified during a complaint survey.
A facility failed to administer prescribed respiratory inhalers for a resident with COPD/Asthma exacerbation, as indicated by blank spaces on the MAR for specific dates. The resident's care plan, which included administering aerosol treatments, was not followed. The DON confirmed that the nurse responsible no longer worked at the facility, and there was no documentation to confirm the treatments were provided.
A facility failed to document the administration of PRN Dilaudid (Hydromorphone) for a resident and did not monitor the resident's pain level or the medication's efficacy. The medication was removed from the controlled lock box on several occasions, but these administrations were not recorded on the MAR, as confirmed by the Administrator.
During a complaint survey, facility staff failed to keep medication and treatment carts locked when unattended. On the B wing, two medication carts were found unlocked and unattended, with accessible drawers containing resident medications. Additionally, a treatment cart was found unlocked on both the B and A wings, containing medicated ointments and other supplies. Staff members were informed but seemed unaware or indifferent to the issue. The facility's policy requires medication supplies to remain locked when not in use.
Facility staff failed to follow up with outside resources for a resident's oral surgery post-operative instructions. The resident had three teeth extracted and was given written instructions, but these were not documented in the medical record. An interview confirmed the lack of follow-up with the oral surgeon.
The facility lacked an effective pest control program, resulting in a widespread gnat problem. A resident complained about gnats in their wheelchair, and another resident's meal was affected by gnats. The issue was confirmed by a CMA and observed in the NHA's office. The NHA admitted the facility only recently secured a pest control contract.
A cognitively intact resident was not invited to their care plan meetings, despite having full decision-making capacity. The resident's mother attended the meetings instead, and discussions about the resident's care were held with her. Facility staff misunderstood the resident's competency status, leading to this oversight.
A facility failed to provide written notification of transfer to a resident or their family/representative. A resident, who was severely cognitively impaired and dependent on ADLs, was transferred to the emergency room after sustaining a head injury. The facility did not provide written notification of this transfer, and the Administrator confirmed that such notifications were not being issued.
A resident with mental disorders and intellectual disabilities did not receive a required PASARR Level II evaluation after remaining in the facility for over 40 days. The resident's medical records showed moderate cognitive impairment and impulsive behaviors, but the facility failed to request the necessary screening from the State Agency, as confirmed by staff interviews.
Two residents, both cognitively intact but dependent on staff for ADLs, were found with long and soiled fingernails. Despite being reliant on staff for personal hygiene, their nails remained untrimmed and dirty over several days. An LPN and the DON confirmed that GNAs were responsible for nail care, but the facility failed to provide a policy for ADL care upon request.
A resident with impaired range of motion in the left upper extremity did not consistently receive a prescribed hand splint, as observed during multiple checks. The resident was unable to apply the splint independently and staff were unaware of the order. The Director of Rehab confirmed the splint was missing, and the Director of Nursing stated that nursing staff were responsible for implementing the care plan, which was not followed.
A pharmacist failed to monitor adverse consequences and target behaviors for a resident prescribed Seroquel for agitation, despite the resident's severe cognitive impairment and Alzheimer's diagnosis. The Medication Regimen Review did not address the use of Seroquel or the need for monitoring, and the pharmacist could not provide specific information due to database access issues.
A facility failed to monitor the use of Seroquel for a resident with Alzheimer's and Parkinsonism, who was prescribed the medication for agitation despite no signs of distress. The care plan lacked specific monitoring for side effects or target behaviors, and observations showed the resident was calm. The DON confirmed the absence of adequate monitoring, violating the facility's medication management policy.
Unsecured Storage of Medical Records with Visible PHI in Shared Warehouse
Penalty
Summary
The facility failed to ensure privacy and confidentiality of medical records when surveyors observed resident medical records stored in an unsecured warehouse building. During a dual surveyor observation conducted in connection with a complaint investigation, the Director of Maintenance and Assistant Director of Maintenance unlocked the warehouse, where surveyors saw several open boxes of medical records in different areas of the warehouse with freely visible protected health information, including resident names and medical record assessments. In another area of the warehouse, surveyors observed approximately 11 closed boxes of medical records with papers affixed to the exterior showing visible resident names and medical record numbers, as well as medical record files sitting on top of the boxes with names and other information written on the outside of the files. During the same observation, the Director of Maintenance stated that the warehouse was used by "everybody" to put items in and that it served as additional storage. When surveyors asked who had access to the warehouse, the Director of Maintenance identified the central supply staff, housekeeping, and dietary staff as having access. In a subsequent interview, the DON confirmed that maintenance and environmental services staff did not need access to medical records or protected health information, yet reported that the Maintenance Director, Environmental Services Director, Medical Records/Supply person, and Maintenance Assistant all had keys or access to the warehouse where the medical information was stored. These observations and interviews established that medical records containing protected health information were stored in a location accessible to multiple non-clinical staff, with resident-identifying information openly visible.
Inadequate Infection Control in Warehouse Storage, Laundry Handling, and Resident Care Area
Penalty
Summary
The deficiency involves failures in basic infection prevention and control practices, beginning with improper handling of personal items in a resident care area. An activities assistant placed their personal cell phone directly onto a resident’s bed while accessing the resident’s furniture with a key. The assistant acknowledged that the phone was personal, and the concern was recognized by the facility’s Director of Nursing, who stated the assistant had been rushed and not thinking when placing the phone on the bed. Additional deficiencies were identified in the facility’s warehouse storage area during a dual surveyor observation conducted with the Director and Assistant Director of Maintenance. Surveyors observed biohazard waste stored in the same area as open boxes of clean medical gloves and other clean medical supplies, with boxed biohazard waste stacked against boxes of clean items. An opened box of drinking cups and cup lids was stored on the floor near a plastic container of used belongings, including a worn and cracked wheelchair armrest. Lancets, medical tape, and various expired syringes were present without separation of clean and dirty items, and boxed medical supplies such as gloves, incontinence briefs, wound cleanser, and dressing supplies were stored directly on the floor. The Infection Preventionist confirmed that these storage and biohazard management conditions were not acceptable and stated that biohazard waste should never be stored with clean items. Further infection control concerns were identified in the clean and soiled laundry processing areas. In the clean laundry area, surveyors observed an uncovered metal linen cart with facility blankets, towels, washcloths, and sheets piled high, leaning on the wall, and stored close to the floor. There was also an uncovered laundry basket with a pile of clean, unfolded, unidentified resident laundry overflowing and leaning against the wall, along with three additional uncovered containers of unidentified resident laundry under folding tables, one of which had items touching the floor. In the soiled laundry area, multiple unlined large trash bins were overflowing with unbagged resident laundry and facility linens piled high and touching the wall, along with additional containers and a tilt truck filled with bagged and unbagged soiled linens, and the room was described as odorous. The Environmental Services Manager and District EVS Manager confirmed these conditions and the associated infection control concerns, noting that only one of two washing machines was operational, contributing to the volume of soiled laundry present.
Inaccurate MDS Coding of Resident Tobacco Use
Penalty
Summary
The deficiency involves the facility’s failure to ensure that Minimum Data Set (MDS) assessments were accurately coded to reflect residents’ current tobacco use status. Two residents who were identified as smokers through interviews with the surveyor and facility documentation were coded as non-smokers on their annual MDS assessments. One resident reported to the surveyor that they were a smoker, and the facility’s smoking list and a prior Smoking Evaluation dated 9/2/2025 identified this resident as an independent smoker. However, the resident’s annual MDS assessment completed on 9/22/2025 documented “No” for tobacco use in section J1300. Similarly, another resident informed the surveyor that they were a smoker, and the facility’s smoking list and a Smoking Evaluation dated 12/3/2025 showed that this resident was also an independent smoker. Despite this, the resident’s annual MDS assessment completed on 12/06/2025 recorded “No” for tobacco use in section J1300. During interviews, the MDS Coordinator acknowledged that tobacco use should have been captured on the annual MDS for one of the residents, and the Corporate Clinical Lead was informed by the surveyor that the other resident’s annual MDS did not reflect current tobacco use. These findings demonstrate that existing information about residents’ smoking status was not accurately incorporated into their MDS assessments.
Incomplete and Non-Specific Care Plans for Fall Risk and Independent Smokers
Penalty
Summary
Surveyors identified that the facility failed to develop and implement comprehensive, individualized care plans for multiple residents. For one resident reviewed for change in condition, the care plan included a focus of risk for falls related to CVA and impaired mobility, with a goal of no falls with injury for 90 days. However, specific interventions were left incomplete: the intervention for fall mats did not indicate the number or sides to be used, and the intervention directing staff to place personal items within reach did not specify which personal items. During review, the DON acknowledged that this care plan was not sufficiently personalized or specific to the resident’s needs. For two residents reviewed for accidents who were identified as independent smokers, the facility failed to develop complete person-centered care plans that included specific interventions. Both residents had smoking evaluations indicating they were independent smokers, and each had a care plan focus stating that the resident may smoke independently per smoking assessment, with goals that the resident would smoke safely by the next review or for 90 days. Despite this, the care plans did not include any detailed interventions describing the specific care and services to be implemented to meet the stated goals for safe smoking. This lack of defined interventions for independent smokers was confirmed during record review and staff interview.
Failure to Document PRN Narcotic and Late Administration of Scheduled Medications
Penalty
Summary
The deficiency involves failure to follow professional standards of practice during medication administration and documentation. During an observation, an LPN removed and administered a 5 mg oxycodone tablet to a resident who complained of an upset stomach and headache, signing the narcotic control book when removing the medication from the narcotic drawer. Subsequent medical record review showed the resident had a PRN order for oxycodone 5 mg by mouth every four hours as needed for pain rated 4–6, but the medication administration record (MAR) did not show that the oxycodone dose was documented as administered, despite confirmation in the narcotic book that it had been signed out for that resident. Additional deficiencies were identified during medication pass observations for two other residents when an LPN administered multiple scheduled medications significantly later than the ordered time. For one resident, medications including metformin, Eliquis, aspirin, metoprolol, amlodipine, cetirizine, furosemide, omeprazole, a multivitamin, and fluticasone inhalation were scheduled for 9:00 AM but were administered at 10:30 AM, with the electronic MAR screen highlighted in pink to indicate they were not given at the scheduled time. For another resident, medications and supplements including protein liquid, amlodipine, metoprolol, a multivitamin with minerals, sodium bicarbonate, Vitron-C, and omeprazole were also scheduled for 9:00 AM but were administered at 10:45 AM, again with the computer screen highlighted in pink. The LPN acknowledged in both cases that the medications were given outside the scheduled ordered time and explained she was responsible for two hallways of residents.
Improper Cleaning and Drying of Kitchen Equipment
Penalty
Summary
The facility failed to ensure proper cleaning and air drying of food preparation equipment, which could potentially increase the risk of foodborne illness for 103 of the 110 residents receiving dietary services. During an observation, the Account Manager Dietary (AMD) confirmed that the meat slicer blade had food remnants on it and needed cleaning before use. The AMD stated that it was expected for the meat slicer to be properly cleaned after each use, as per the facility's policy, which mandates that all food contact equipment be cleaned and sanitized after each use. Additionally, during another observation, the AMD confirmed that several pans, which were cleaned and stacked for use, were still wet and had not been allowed to air dry before storage. The facility's policy requires all cookware and service ware to be air dried prior to storage. These deficiencies in cleaning and drying procedures were observed and confirmed by the AMD, highlighting a failure to adhere to the facility's established policies for maintaining sanitary conditions in food preparation areas.
Improper Garbage Disposal in Dumpster Area
Penalty
Summary
The facility failed to ensure proper disposal and containment of garbage in the dumpster area, affecting 110 residents and staff. During an observation, it was noted that one of the two dumpsters used for trash and recycling was left open, and a large trash bag was found ripped open on the ground between the dumpsters. The Account Manager Dietary (AMD) confirmed that dumpsters should be closed and trash bags should be placed inside the dumpsters, not left on the ground. The facility's policy, dated September 2017, mandates that all trash be contained in covered, leak-proof containers to prevent cross-contamination and be properly disposed of in external receptacles, with the surrounding area kept free of debris.
Failure to Provide Meal Choice and Menu Information
Penalty
Summary
The facility failed to provide preplanned menus and a list of alternative foods to residents, resulting in a lack of opportunity for residents to choose their meals. This deficiency was observed in four residents, all of whom were cognitively intact and capable of making their own meal choices. The residents reported not being asked about their meal preferences and not being informed of the available menu options. This led to residents receiving meals that did not align with their preferences, such as one resident preferring oatmeal but receiving scrambled eggs instead. Interviews with staff revealed a lack of a formal policy for distributing menus and collecting residents' meal preferences. The District Manager of Dietary and the Director of Nursing both acknowledged that there was no established process for ensuring residents were informed of their meal options. The nursing department was supposed to distribute menus and collect preferences, but this was not consistently done, especially for residents in isolation or those unable to leave their rooms. Observations further confirmed the inconsistency in meal service. Residents in isolation did not receive menus during their isolation period, and some residents received meals that did not match the menu or their preferences. The dietary manager stated that menus were posted in common areas, but this did not address the needs of residents who remained in their rooms. The facility's failure to ensure residents were informed of their meal options and preferences contributed to the deficiency.
Failure to Address Resident Council Concerns on Meal Preferences
Penalty
Summary
The facility failed to address the concerns and requests of the resident council regarding meal menus and food preferences. Five residents who regularly attended the resident council meetings expressed that their requests for weekly meal menus and consideration of their food preferences had been repeatedly ignored. During a group interview, residents reported that they had not received any rationale for their unmet requests, and their concerns were documented in the resident council meeting notes over several months without resolution. The Activity Manager (AM) had documented plans to address these issues, such as providing menus and surveying residents for meal preferences, but these actions were not implemented. Interviews with facility staff revealed a lack of communication and follow-up on the residents' grievances. The AM acknowledged awareness of the residents' requests but could not provide documentation of any communication with the dietary department. The District Dietary Manager (DM) was aware of the concerns but had not acted on proposed solutions, such as the mock plate discussion. The Administrator was also aware of the issues but had not ensured that the dietary staff responded to the resident council's concerns. The facility lacked a policy to address resident group concerns, contributing to the ongoing deficiency.
Infection Control Deficiencies in Resident Care
Penalty
Summary
The facility failed to adhere to infection control measures for two residents, increasing the risk of COVID transmission and cross-contamination. For Resident 31, a physician ordered strict isolation and droplet precautions due to a COVID-positive diagnosis. However, during wound treatment, an LPN did not sanitize or wash her hands after removing PPE in the resident's room, citing a non-functional sanitizer dispenser. Additionally, a GNA improperly handled trash and soiled laundry from the resident's room, placing them on the hallway floor and failing to label the laundry for separate washing, which was confirmed by the laundry worker and the Infection Preventionist. For another resident, R1, who was on Enhanced Barrier Precautions due to a feeding tube, urinary catheter, and non-healing pressure ulcers, an LPN failed to perform hand hygiene between glove changes during wound care. The LPN changed gloves multiple times without sanitizing her hands, even after touching the dresser and bed rails. This was verified by another LPN assisting with the procedure and the Infection Preventionist, who confirmed that hand hygiene was expected between all glove changes.
Deficiencies in Facility Maintenance and Resident Property Protection
Penalty
Summary
The facility staff failed to maintain a sanitary, orderly, and comfortable environment in two of the three nursing units and the dining room. Observations revealed unpainted spackled areas, peeling laminate on dresser drawers, and stained privacy curtains in resident rooms. Additionally, wheelchairs in the dining room had missing or damaged armrests, exposing the padding underneath. The Maintenance Director acknowledged the issues with the wheelchairs and stated that audits are conducted every two months, but the Nursing Home Administrator could not provide invoices for replacement parts. The facility also failed to protect a resident's personal property from loss or theft. A grievance was filed by a family member regarding a missing gold ring belonging to a deceased resident. The ring was initially secured by the facility but was later reported missing after being placed in a medication cart for safekeeping. The investigation revealed that the last known staff member to have possession of the ring failed to inform the oncoming nurse of its location, leading to its disappearance. The facility was unable to determine if the staff member took the ring, but he was terminated for gross misconduct. The facility did not provide a policy related to protecting residents' property, and the investigation into the missing ring involved staff interviews and re-education on handling personal property. The incident was reported to local law enforcement, the State Agency, and the Long-Term Care Ombudsman. Despite these actions, the facility was unable to locate the missing ring, and the family was informed of the situation.
Failure to Timely Report Allegations of Abuse
Penalty
Summary
The facility failed to report allegations of abuse, neglect, or injury of unknown origin to the regulatory agency, the Office of Health Care Quality (OHCQ), within the required 2-hour timeframe. This deficiency was identified during an annual survey for two residents. In the first case, a staff member reported witnessing another staff member hitting a resident's hand, but the incident was reported to OHCQ seven days later. The Director of Nursing and Administrator confirmed the delay in reporting. In the second case, a resident alleged that an LPN waved her finger in the resident's face. The allegation was reported to the Nursing Home Administrator by a surveyor, but the report to OHCQ was delayed until the following day. The Nursing Home Administrator attributed the delay to being distracted by surveyors in the building.
Incomplete Investigation of Alleged Abuse
Penalty
Summary
The facility failed to thoroughly investigate an allegation of abuse involving a resident. On 8/14/24, a review of a facility-reported incident revealed that a staff member reported witnessing another staff member hitting a resident's hand on 5/19/22. The facility's investigation was found to be incomplete as it did not include the name or statement of the reporting staff member, nor did it contain statements from other staff who were present on the day of the alleged incident, except for the accused staff member. Additionally, the facility did not obtain statements from other residents who received care from the accused staff member to determine if there were further concerns of abuse. An interview with the Administrator and Director of Nursing confirmed that the facility staff failed to complete a thorough investigation of the alleged abuse incident.
Failure to Conduct Quarterly Care Plan Meetings
Penalty
Summary
The facility failed to conduct quarterly care plan meetings for residents and did not invite residents or their representatives to participate in the development of their care plans. This deficiency was identified for three residents during the review. For one resident, admitted with diagnoses including nontraumatic intracranial hemorrhage and chronic kidney disease, there was no record of any care plan conference being held, despite the availability of baseline and comprehensive care plans. A family member confirmed not being invited to any care plan meetings, and the Social Services Coordinator acknowledged that care plan meetings had not been held for this resident in the past year. Additionally, another resident had only one care plan meeting during their stay, and a third resident had no care plan meetings after an initial one, until their discharge. The Director of Nursing confirmed the absence of quarterly care plan meetings for these residents. Facility policies regarding care plans and meetings were requested but not provided during the survey.
Failure to Schedule Follow-Up Colonoscopy
Penalty
Summary
The facility failed to schedule a follow-up colonoscopy for a resident as per the physician's orders. The resident, admitted in August 2022, had diagnoses including gastrostomy status, GERD, and peptic ulcer. A consultation report dated April 19, 2023, indicated poor colon preparation and recommended a repeat colonoscopy in one month. The report included a note to schedule the procedure, but there was no documentation of the follow-up colonoscopy being performed. Interviews with staff revealed that the responsibility for scheduling such appointments lay with the unit manager or nurse on the unit. However, the Director of Nursing confirmed that no follow-up colonoscopy was scheduled or performed, and the last recorded visit to the GI office was in December 2023 for G-tube removal.
Failure to Provide Timely Wound Care for Resident
Penalty
Summary
The facility staff failed to provide appropriate treatment and services to prevent and heal pressure ulcers for a resident with a Stage IV pressure ulcer on the sacrum. Upon admission to the facility, the resident had a physician's order for wound treatment twice daily, but the treatment was not initiated until seven days after admission. This delay in treatment was documented in the resident's Treatment Administration Record (TAR) for December 2023. Further deficiencies were noted upon the resident's readmissions from hospital stays. On two separate occasions, the facility staff failed to begin the ordered wound treatment for the sacral wound in a timely manner. After a hospital stay in April 2024, the treatment was delayed by seven days, and following another hospital stay at the end of April 2024, the treatment was delayed by ten days. These delays were confirmed by the Director of Nursing during an interview, indicating a pattern of non-compliance with physician orders for wound care.
Failure to Provide Proper Foot Care
Penalty
Summary
The facility staff failed to provide proper foot care and treatment for a resident, which was identified during a complaint survey. The resident was admitted with a diagnosis of amputation of the left second toe. On 8/16/23, a physician ordered specific wound care instructions for the surgical site, including cleansing with wound cleanser, patting dry, and covering with a dry dressing daily during the day shift. However, medical records revealed that on multiple dates, including 8/16, 8/18, 8/20, 8/23, and 8/26, the surgical site was not cleaned and dressed as ordered by the physician. An interview with the Director of Nursing on 8/20/24 confirmed that there were no nursing progress notes or wound notes in the medical record to indicate that the wound care was performed according to the physician's orders. This lack of documentation and adherence to the prescribed wound care regimen led to the deficiency identified in the report.
Failure to Administer Respiratory Inhalers as Ordered
Penalty
Summary
The facility failed to administer respiratory inhalers as ordered for a resident who required respiratory treatment. This deficiency was identified during a review of a complaint, medical records, and staff interviews. The resident in question had a history of respiratory failure secondary to COPD/Asthma exacerbation and was admitted to the facility from the hospital. The resident was prescribed Budesonide and Ipratropium-Albuterol inhalers to be administered twice daily for shortness of breath and wheezing. However, the Medication Administration Record (MAR) for March and April 2023 showed that the inhalers were not administered on specific dates, as indicated by blank spaces on the MAR. The care plan for the resident, which included administering aerosol treatments as ordered, was not followed. During an interview with the Director of Nursing (DON), it was revealed that the nurse responsible for administering the inhalers on the dates in question no longer worked at the facility, and there was no documentation in the nurse's notes to confirm that the respiratory treatments were provided. This lack of documentation and failure to administer the prescribed inhalers as ordered led to the identified deficiency.
Failure to Document and Monitor PRN Pain Medication Administration
Penalty
Summary
The facility failed to consistently document the administration of an as-needed (PRN) pain medication, Dilaudid (Hydromorphone), for a resident, as evidenced during a complaint survey. The resident's primary physician had ordered the medication to be given every six hours as needed for pain. However, a review of the Controlled Medication Utilization Record showed that the medication was removed from the controlled lock box on several occasions in December 2023 and January 2024, but the administration was not documented on the Medication Administration Record (MAR). Additionally, the resident's pain level and the efficacy of the medication were not monitored. An interview with the Administrator confirmed that the facility staff failed to ensure the medication was given as needed for pain.
Unattended and Unlocked Medication and Treatment Carts
Penalty
Summary
Facility staff failed to keep medication and treatment carts locked when unattended, as observed during a complaint survey. On the B wing nursing unit, an unlocked and unattended medication cart was found in the hallway outside the clean utility room. This cart remained unlocked and unattended for at least 13 minutes, during which time the surveyor was able to open all drawers containing resident medications. Another medication cart in the same hallway was also found unlocked and unattended, with accessible drawers containing medications. Licensed Practical Nurse (LPN) #1 was informed of the situation but seemed unaware of the issue. Additionally, an unlocked and unattended treatment cart was observed on the opposite hallway of the B wing nursing unit, containing medicated ointments and treatment modalities. Registered Nurse (RN) #2 was informed of the unlocked carts. On the A wing nursing unit, another unlocked and unattended treatment cart was found, containing scissors, bandages, prescription ointments, creams, and medicated dressings. LPN #9 was informed and responded with indifference. The facility's Medication Storage Policy, reviewed by the surveyor, clearly stated that medication supplies should remain locked when not in use or attended by authorized personnel. The Director of Nursing (DON) was informed of these observations.
Failure to Follow Up on Oral Surgery Post-Op Instructions
Penalty
Summary
The facility staff failed to follow up with outside resources for the care of a resident, specifically regarding oral surgery post-operative instructions. This deficiency was identified during a complaint survey involving one of the 45 residents reviewed. The resident was transported to an oral surgeon by a friend and had three teeth extracted. Although the resident was given written post-operative instructions, these instructions were not documented in the resident's medical record. An interview with the Administrator confirmed that the facility staff did not follow up with the oral surgeon to obtain the post-operative instructions.
Ineffective Pest Control Program
Penalty
Summary
The facility failed to maintain an effective pest control program, as evidenced by the presence of numerous gnats throughout the building. During a complaint survey, gnats were observed in one of the three nursing units and public areas. A resident complained about gnats in their wheelchair, with at least ten gnats flying around the seat. A Certified Medicine Aide confirmed the gnat problem was widespread in the facility. In the dining room, another resident's lunch tray was observed with gnats flying on the fruit cocktail and BBQ sandwich. Additionally, gnats were seen in the Nursing Home Administrator's office, where surveyors were stationed for six days. The Nursing Home Administrator admitted that the facility did not have a pest control contract prior to the recent engagement of a new pest control company. Pest control logs were requested, but it was revealed that the facility had only secured a pest control contract in the past month, indicating a lack of prior pest management measures.
Failure to Include Competent Resident in Care Plan Meetings
Penalty
Summary
The facility failed to invite a cognitively intact resident, identified as Resident 41, to participate in their care plan meetings. Despite having a Brief Interview for Mental Status (BIMS) score of 15 out of 15, indicating full cognitive capacity, the resident was not informed or invited to the care plan meeting. Instead, the resident's mother attended the meeting, and discussions regarding the resident's care, including a referral to the rehab department and full code status, were held with her. Interviews with facility staff revealed a misunderstanding regarding the resident's competency status. The Social Services Coordinator incorrectly assumed the resident was not competent, despite documentation showing the resident had adequate decision-making capacity. The Director of Nursing confirmed that competent residents should be invited to their care plan meetings. The facility's policies on determining decision-makers and care plan meetings were requested but not provided by the time of the survey exit.
Failure to Provide Written Transfer Notification
Penalty
Summary
The facility failed to provide a written notice of transfer to a resident or their family/representative, which was identified during a review of one of three residents hospitalized among 31 sampled residents. The resident in question, identified as R471, was severely cognitively impaired and dependent on all Activities of Daily Living (ADLs) except eating. On 10/07/23, a nurse's note documented that R471 was found with a head injury, bleeding from the forehead, after reportedly rolling over and hitting their head on the side rail. The resident was sent to the emergency room for further evaluation and returned to the facility without being admitted to the hospital. Upon reviewing the electronic medical record (EMR) and the resident's hard chart, it was found that no written notification of the transfer was provided to the family. During an interview, the facility's Administrator confirmed that the facility had not been providing written notifications of transfers to residents and/or their representatives. This oversight had the potential to leave residents or their representatives unaware of the transfer details and their rights to appeal.
Failure to Conduct PASARR Level II Evaluation
Penalty
Summary
The facility failed to ensure an accurate pre-admission screening and resident review (PASARR) Level II evaluation for a resident with mental disorders or intellectual disabilities. The resident, identified as R81, was admitted with diagnoses including moderate intellectual disabilities, bipolar disorder, schizoaffective disorder, unspecified psychosis, and anxiety disorder. Despite these conditions, the facility did not request a PASARR Level II screening from the State Agency after the resident remained in the facility for more than 40 days, as required by the exempted hospital discharge screening. The resident's medical records indicated a moderate cognitive impairment with a Brief Interview for Mental Status (BIMS) score of six out of 15. The care plan documented impulsive behaviors and impaired communication, highlighting the need for a comprehensive evaluation. Interviews with the Social Worker and Administrator confirmed the oversight, acknowledging the lack of a PASARR Level II evaluation and the absence of a facility policy related to PASARR, which contributed to the deficiency.
Failure to Provide Adequate Nail Care for Dependent Residents
Penalty
Summary
The facility failed to provide adequate nail care for two residents, both of whom were cognitively intact but dependent on staff for activities of daily living (ADLs). The first resident, who had multiple sclerosis and functional quadriplegia, was observed with fingernails half an inch long and soiled with a black substance. Despite being totally dependent on staff for all ADLs, the resident's nails remained untrimmed and dirty over several days. The Licensed Practical Nurse (LPN) and Unit Manager confirmed the condition of the nails and stated that Geriatric Nursing Aides (GNAs) were responsible for nail care, as outlined in the GNA Plan of Care. Similarly, the second resident, who had limited mobility and was also dependent on staff for ADLs, was observed with fingernails half to one inch long and soiled. The resident expressed frustration over the condition of their nails. Observations over multiple days showed no improvement until the final day when the nails were trimmed and cleaned. The Director of Nursing (DON) confirmed that GNAs were responsible for nail care during resident showers or baths. The facility did not provide a policy for ADL care upon request before the survey exit.
Failure to Apply Hand Splint for Resident
Penalty
Summary
The facility failed to consistently apply a hand splint for a resident, identified as R72, who was at risk of further contractures due to impaired range of motion in the left upper extremity. The resident's electronic medical record indicated a physician's order for a left hand roll splint to be worn for four consecutive hours during the day shift, as well as a care plan for restorative splint assistance. However, during multiple observations, R72 was seen without the splint, and the resident reported not knowing where the splint was and being unable to put it on independently. Staff members, including a Geriatric Nurse Aide (GNA) and a Licensed Practical Nurse (LPN), were unaware of the splint order and could not locate the splint. The Director of Rehab confirmed that the splint could not be found, necessitating a reevaluation by therapy. The Director of Nursing verified that the nursing staff, particularly the GNAs, were responsible for implementing the restorative nursing care plan interventions, including the application of splints. The facility's policy on restorative nursing indicated that such programs should be coordinated by nursing or in collaboration with rehabilitation, with a licensed nurse supervising the activities. Despite these guidelines, the failure to apply the splint as ordered increased the risk of further loss of mobility and contractures for the resident.
Pharmacist's Failure to Monitor Antipsychotic Use
Penalty
Summary
The pharmacist failed to identify and monitor adverse consequences and target behaviors for a resident receiving antipsychotic medication. The resident, who was severely cognitively impaired with a BIMS score of three out of 15, was admitted with diagnoses including Alzheimer's disease and Parkinsonism, without any hallucinations, delusions, or aggressive behaviors. Despite this, a physician's order was placed for Seroquel, an antipsychotic medication, to address agitation. However, there was no consistent monitoring of the target behavior of agitation or adverse consequences associated with Seroquel use, especially given the resident's Alzheimer's diagnosis. The Medication Regimen Review conducted on a later date failed to address the use of Seroquel for agitation or the need for monitoring adverse consequences and target behaviors. The pharmacist only recommended discontinuing a Lidocaine patch due to nonuse. During an interview, the pharmacist was unable to provide specific information about the resident due to a lack of access to his computer database. The facility's policy required the attending physician and consultant pharmacist to re-evaluate psychotropic medication use and monitor for effectiveness and potential adverse consequences, which was not adhered to in this case.
Failure to Monitor Psychotropic Medication Use
Penalty
Summary
The facility failed to adequately monitor and manage the use of psychotropic medication for a resident, identified as R107, who was severely cognitively impaired with Alzheimer's disease and Parkinsonism. Despite the absence of hallucinations, delusions, or aggressive behaviors, R107 was prescribed Seroquel, an antipsychotic medication, for agitation. The facility's care plan, initiated after the medication was prescribed, lacked specific side effects or target behaviors to monitor, and there was no plan for non-pharmacological interventions prior to using the antipsychotic medication. Observations and interviews with family members and staff indicated that R107 did not exhibit signs of agitation or distress during the review period. However, the facility's records, including the Medication Administration Record and Progress Notes, showed inconsistent monitoring of the target behavior of agitation and potential adverse effects of Seroquel. The Director of Nursing confirmed the lack of specific monitoring for adverse side effects or behaviors associated with the medication, which was contrary to the facility's medication management policy.
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The facility did not ensure that its Infection Preventionist (IP) met required qualifications for managing the Infection Prevention and Control Program. The DON reported serving as the IP but acknowledged lacking the specialized infection control training required for the role, and confirmed that no other staff member was currently qualified. Records showed that the previously qualified IP left several months earlier, and the Administrator and DON confirmed they were still seeking a replacement, leaving the infection control program without a properly trained leader.
Staff failed to consistently secure medications and medical supplies across three units, including an oxygen tank left on the floor behind a resident’s bed without a supporting device, a treatment cart with Collagenase Santyl cream left on top while two residents in power wheelchairs passed by, an unattended and unlocked treatment cart at a nursing station, and another treatment cart with Diclofenac gel and dressings left on top, indicating repeated lapses in maintaining locked and secure storage for drugs, biologicals, and related supplies.
The facility failed to provide sufficient dietitian coverage and timely nutritional assessments for several residents with significant dietary needs. A resident admitted for diabetic management with a high A1C was placed on a regular diet instead of the recommended carb-controlled diet and had only one weight taken in the first two weeks, with no dietitian review of the record. Another resident with prior significant weight loss had no documented dietitian follow-up despite continued weight loss, and a resident admitted with severe protein-calorie malnutrition experienced further significant weight loss without any dietitian assessment. The dietitian reported working limited hours and prioritizing certain high-risk cases, resulting in delayed or missed evaluations for new admissions and residents with ongoing nutritional concerns.
The facility failed to maintain adequate linen and incontinence supplies and did not keep resident care areas in good repair, resulting in delays and alterations in incontinence care and substandard environmental conditions. Staff reported that towels and washcloths were used instead of wipes and then discarded due to heavy soiling, and that linen deliveries to units were late, leaving residents waiting for care. Observations showed very limited numbers of clean washcloths and other linens on units and in the laundry, with no stock of disposable wipes or backup washcloth supply despite repeated reports to housekeeping. Additional observations revealed recliner chairs blocking a dining-area handwashing sink and kitchenette, multiple resident and shared bathrooms with unfinished spackle, chipped paint, musty odors, black substances near showers, missing threshold molding, exposed cracks and nails, and eroded, rusted baseboard heaters. Hallway handrails on both units were worn, chipped, and splintered, and a shower room contained fecal odors, dried brown stains on the toilet, and deteriorated fixtures, all contributing to a failure to provide a safe, clean, and homelike environment.
Facility staff did not thoroughly investigate two separate abuse allegations involving a resident and an injury of unknown origin involving another resident. In both cases, investigations focused on the directly affected resident and included staff interviews, but there were no interviews of other residents on the unit or documented assessments of those residents for signs of abuse or injuries of unknown origin, including residents unable to communicate due to cognitive status.
Two residents who were dependent on staff for oral care, including one with a tracheostomy, were observed with thick, white or milky substances coating their mouths and teeth, indicating inadequate oral hygiene. One resident communicated that staff did not brush their teeth and that staff "need to." In another case, despite oral care supplies being present in the room, the resident’s mouth and teeth remained unclean on multiple observations, with a thick milky substance caking the teeth and stringing between them when the resident tried to open their mouth. These findings showed that staff did not consistently provide oral care to residents who relied on them for this ADL.
Staff failed to maintain complete and accurate medical records for multiple residents, including missing and inconsistent documentation of wound care, delayed pain assessment after discovery of an injury of unknown origin in a cognitively impaired resident, and inaccurate recording of a PPD test result that was documented as negative despite no evidence the injection was administered and no supporting nurse’s note. Residents reported not receiving certain treatments, while MAR entries either lacked signatures for completion or contained conflicting information about whether care was provided.
Surveyors found that the facility failed to consistently implement and communicate correct transmission-based precautions and PPE use. One resident with a Foley catheter related to wounds had no precaution signage posted, while another resident in a double room had a contact precautions sign at the door, yet the NP entered without PPE and the GNA provided high-contact care wearing only gloves. Staff in that room stated the resident was not on contact precautions and later reversed the sign to show no PPE requirement. Therapy staff reported they rely solely on posted signs to determine PPE, and surveyors identified broader issues with inaccurate signage and staff awareness of which residents required contact precautions.
Surveyors found that MDS assessments were inaccurately coded for two residents. In one case, a resident sustained a femoral neck fracture after a fall, but the subsequent significant change MDS did not code the fall as a major injury and failed to capture prn Tylenol use documented on the MAR within the look-back period. In the other case, a quarterly MDS indicated opioid use for a resident, but the MAR for the same period showed no prescribed opioid, indicating incorrect coding of high-risk drug classes.
A resident who had recently been admitted and experienced a fall received multiple doses of the narcotic analgesic Tramadol, but the facility failed to accurately document all administered doses on the Medication Administration Record (MAR). Review showed only one Tramadol dose recorded on the MAR, while the Controlled Drug Receipt/Record/Disposition Form on the med cart reflected three doses given over two days. In interview, the DON stated staff are expected to document narcotic administration on the MAR and confirmed that two administered doses were not recorded there, resulting in an incomplete and inaccurate medical record.
Unqualified Infection Preventionist Overseeing Infection Control Program
Penalty
Summary
The facility failed to ensure that its designated Infection Preventionist (IP) met the mandatory qualifications for overseeing the Infection Prevention and Control Program. During an interview on 3/24/26 at 10:00 AM, the DON confirmed that she/he was serving as the facility’s IP but had not completed the specialized training in infection control required for the position. The DON further stated that no other staff member currently met the qualifications to serve as IP. Record review showed that the previously qualified IP left the facility in October 2025, and as of the survey date, the position remained unfilled by a qualified individual. At 1:30 PM on the same day, the Administrator and DON confirmed they were still in the process of finding a qualified IP for the facility, leaving the Infection Prevention and Control Program without a properly trained and qualified leader. No specific residents, medical histories, or clinical conditions were described in relation to this deficiency.
Unsecured Medications, Treatment Carts, and Oxygen Equipment
Penalty
Summary
Facility staff failed to ensure that drugs, biologicals, and related medical supplies were securely stored and properly maintained on multiple units. On one unit, an oxygen tank assigned to a resident was observed sitting on the floor behind the resident’s bed without any supporting device. On another unit, a treatment cart was observed with a tube of Collagenase Santyl cream labeled for a specific resident left on top of the cart, while residents in power wheelchairs passed by and staff were present at the nursing station. These observations showed that medications and oxygen equipment were not consistently secured as required. Further observations on additional units revealed an unattended and unlocked treatment cart at a nursing station, and on a separate occasion, a treatment cart with Diclofenac gel labeled for a resident left on top along with multiple packs of dressings. These incidents occurred across three units and on more than one date, demonstrating repeated failures to keep medications and treatment supplies in locked compartments or otherwise secured from unauthorized access.
Insufficient Dietitian Coverage and Delayed Nutritional Assessments
Penalty
Summary
The deficiency involves the facility’s failure to employ sufficient food and nutrition staff, including adequate dietitian coverage, to ensure timely assessment and appropriate diets for residents with significant nutritional and diabetic needs. A resident admitted over two weeks earlier with multiple comorbidities and an A1C of 11.5% had a hospital discharge recommendation for a carbohydrate-controlled diet, but was placed on a regular diet at admission with no acknowledgment of the recommended diet until one week later, when the resident requested larger portions. As of the survey date, the dietitian had not yet seen or reviewed this resident’s medical record, and the resident reported not having seen a dietitian and being very frustrated with the meals. During the first two weeks after admission, only one weight was obtained for this resident, despite physician notes stating the resident’s weight was “stable.” Further review of other residents showed additional failures in timely dietitian assessment and follow-up. One resident, readmitted in January and previously seen by the dietitian in September for a 6.4 lb weight loss over 30 days, had no documented follow-up despite continued weight loss totaling 22 lbs since the last dietitian review. Another resident admitted at the end of February with severe protein-calorie malnutrition had not been seen by the dietitian after about a month in the facility, despite a documented 14 lb (7%) weight loss over two weeks. The dietitian reported working only 12 hours per week at the facility and stated that she must prioritize which residents to see, focusing first on residents with tube feedings and those identified in risk meetings, resulting in delayed or absent assessments for new admissions and residents with ongoing weight loss and malnutrition diagnoses.
Linen Shortages and Poor Environmental Maintenance Compromise Resident Care and Comfort
Penalty
Summary
The deficiency involves the facility’s failure to maintain an adequate supply of clean linens and appropriate incontinence wipes, resulting in delays and alterations in residents’ incontinence care, as well as the use of towels and washcloths in place of disposable wipes. During the initial tour, the surveyor observed that the linen supply on one nursing unit hallway was low. Complaint reviews included concerns about delays in incontinence care and bed linens not being changed regularly, with residents left without clean bedding. A complainant reported that there was not enough clean linen available for residents. Staff interviews confirmed that towels, sheets, and washcloths were being used to wipe residents for incontinence care due to the absence of wipes, and that many of these linens were being thrown away when soiled. Staff also reported a shortage of linen, that linen deliveries to the units were late, and that residents who preferred to get up before breakfast had to wait for care when linen was delayed. Further observations showed that the clean supply room contained no disposable wipes or cloths for incontinence care, and a resident reported that staff did not use wipes, that the resident had to purchase their own, and that heavily soiled towels or washcloths were discarded. A tour of all nursing unit linen carts and closets revealed only six clean washcloths and limited supplies of towels, gowns, and bed linens. In the laundry room, only three washcloths were present, and the laundry assistant stated that there were only three washcloths available for each nursing unit that morning, that the facility was short on linen supply, and that these concerns had been repeatedly reported to the Director of Housekeeping over the preceding month and again that morning. The laundry assistant confirmed there was no additional laundry in process. The DON stated that wipe squares should be used for incontinence care, but no such wipes were found in the clean medical supply room, and no backup supply of washcloths was present in the emergency linen supply. The Director of Housekeeping confirmed there was no backup supply of washcloths. The deficiency also includes environmental and maintenance issues affecting resident bathrooms, handrails, and common areas. In the main dining area, a recliner chair was observed positioned directly in front of the handwashing sink, and two recliner chairs were stored in front of the nutrition area kitchenette. Multiple resident bathrooms and shared bathrooms were repeatedly observed over several days with unfinished spackle on walls that needed resurfacing and painting, chipped paint around sinks, uneven boards nailed to walls under sinks that appeared to partially cover holes, musty odors, black substances between shower bases and walls, missing threshold transition molding exposing cracks, missing tiles, and a nail, as well as eroded and chipped paint on baseboard heaters with exposed dark brown metal and rust-like material. Hallway handrails on both nursing units were observed to be worn, with chips, splintering, holes, and areas where the wood finish had worn off. A shower room was observed with a foul fecal odor, dried brown stains on the back of the toilet seat and in the toilet bowl, and a baseboard heater with eroded, chipped paint and rust-like material, along with chipped paint on the handrail. These conditions were acknowledged by the Director of Maintenance and other leadership, and some areas were noted to be in the process of renovation, but the observed deficiencies remained present during the survey period. Overall, the facility did not maintain a safe, clean, comfortable, and homelike environment in good repair across both nursing units and the dining area. The lack of adequate linen and incontinence supplies, combined with the poor condition of resident bathrooms, handrails, and certain common areas, constituted the basis for the cited deficiency. The observations and staff and resident reports consistently described shortages of essential hygiene supplies, delayed care related to linen availability, and multiple unresolved environmental and maintenance issues in resident care areas and shared spaces.
Failure to Thoroughly Investigate Abuse Allegations and Injuries of Unknown Origin
Penalty
Summary
Facility staff failed to thoroughly investigate allegations of potential abuse involving one resident and an injury of unknown origin involving another resident. For one resident, there were two separate allegations of abuse occurring on different days in early February. The facility’s investigation packets included interviews with staff who cared for or were scheduled to work with this resident on the days of the alleged incidents, and the investigations focused solely on this resident. However, there were no interviews conducted with other residents on the unit to inquire about abusive or neglectful treatment by the staff who were working during the times of the allegations. The surveyors noted that, although the allegations were not validated, there was no documentation that other residents were interviewed, if able, or assessed for signs or symptoms of injury. In a separate incident, another resident was identified on March 4 with a new bruise on the right eye, documented as a change in condition at 4:09 AM. This resident had a BIMS score of 99, indicating the resident was unable to complete an interview and therefore could not report how the injury occurred. The facility’s investigation identified a potential cause of the injury but did not reach a definitive resolution. Additionally, there were no interviews of other residents on the unit regarding possible abuse, nor were there documented assessments of other residents for injuries of unknown origin, particularly for those unable to speak for themselves, as in this resident’s case.
Failure to Provide Oral Care to Dependent Residents
Penalty
Summary
The deficiency involves the facility’s failure to provide oral care to residents who were dependent on staff for activities of daily living, specifically oral hygiene. One resident with a tracheostomy was observed with a thick, sticky white substance in the mouth and was noted to intermittently chew on nearby bedding. This resident made good eye contact and, when asked if staff brushed their teeth, shook their head no and mouthed that staff “need to.” According to the resident’s Minimum Data Set (MDS) dated 2/11/26, the resident was dependent on staff for oral care. Another resident, also dependent on staff for oral care per the 3/11/26 MDS, was observed sitting propped up in bed and able to respond with smiles. During the initial observation, the inside of this resident’s lips and upper and lower teeth had a thick, clear, white milky substance visible when the resident tried to open their mouth to smile. Oral care supplies were present in the nightstand, but the resident’s mouth and teeth were not clean. On a subsequent observation with the DON, NHA, and Corporate VP of clinical services, the same resident again had a thick, clear, milky substance between the lips and caking the teeth, which would string between the teeth when the resident attempted to open their mouth, demonstrating a lack of consistent oral care for residents dependent on staff for this ADL.
Incomplete and Inaccurate Medical Record Documentation for Treatments and Assessments
Penalty
Summary
Facility staff failed to maintain complete and accurate medical records and documentation for multiple residents. For one resident with wound care needs, review of the MAR showed that wound care and related treatments were signed as completed on the dates initially reported, despite the resident’s ongoing complaints that wound dressings were not being changed. When additional dates were reviewed, there were missing staff signatures for wound care on two specific dates, as well as three instances where application of A&D ointment to the resident’s feet was not signed off out of 24 days reviewed. Another resident with severe cognitive impairment, as evidenced by a BIMS score of 00, was found to have an injury of unknown origin (a bruise on the left hand). Documentation showed that a change in condition was initiated late in the morning, but a formal pain evaluation was not initiated and completed until that night, and the resident was unable to explain how the injury occurred or verbalize pain using a standard pain scale. For a third resident, documentation related to the admission PPD test was inconsistent and incomplete. The MAR contained an entry indicating “9” for the administration date, meaning “see nurse’s note,” but there was no corresponding nurse’s note. Despite the absence of a signed administration of the PPD injection, staff documented the PPD result as “negative” on the scheduled read date. The resident reported never receiving the PPD injection, and the DON confirmed that the facility had been out of PPD solution at the time, so the test would not have been administered. These findings demonstrate failures in accurate documentation of treatments and assessments, including wound care, pain assessment, and TB screening, as well as missing or incomplete supporting notes in the medical record.
Failure to Implement and Communicate Correct Transmission-Based Precautions
Penalty
Summary
Surveyors identified a deficiency in the facility’s infection prevention and control program related to inconsistent and incorrect implementation of transmission-based precautions and PPE use. During a complaint investigation focused on residents on transmission-based precautions, one resident with a visible Foley catheter was observed in the room with physical therapy, but there were no signs posted indicating any need for PPE, despite the resident being a new admission with a Foley catheter placed related to wounds. In another double-occupancy room, a contact precautions sign was posted at the doorway, but the nurse practitioner was in the room on a personal phone with no PPE, and the assigned GNA was repositioning the resident in bed while wearing only gloves. When questioned, the NP, RN, and GNA all stated that the resident in the room was not on contact precautions, and the GNA reported that signs were hanging at all doors and that this particular resident’s sign was “just wrong.” The surveyor observed the GNA later return to the room and turn the sign around to indicate no PPE requirement. Subsequent interviews revealed that therapy staff relied on posted signage to determine PPE use and that if the sign was wrong, the PPE used would be wrong. Overall, surveyors found problems with signage accuracy and staff awareness of which residents required contact precautions, as well as observed failures to follow appropriate PPE use for residents who should have been on contact precautions.
Inaccurate MDS Coding for Falls, Pain Management, and High-Risk Medications
Penalty
Summary
Facility staff failed to ensure Minimum Data Set (MDS) assessments were accurately coded for two residents reviewed during a complaint survey. For one resident, a facility-reported incident showed that the resident was found seated on the floor beside the bed and was diagnosed with a non-displaced femoral neck impaction fracture of the left hip following an x-ray. Despite this fall with a major injury, the subsequent significant change MDS dated 11/4/25 did not code the fall with major injury in Section J1900C. Review of the resident’s Medication Administration Records for October and November 2025 showed administration of Tylenol on 10/31/25 at 9:30 PM, which fell within the 5-day look-back period for the MDS, but Section J0100 (prn pain) of the same significant change MDS did not capture the use of Tylenol. For another resident, review of a quarterly MDS with an assessment reference date of 10/15/25 showed that Section N0415 (High-Risk Drug Classes) documented the use of an opioid medication. However, review of the resident’s October 2025 Medication Administration Record did not show that the resident had been prescribed an opioid during that period. In both cases, MDS staff later confirmed that these were errors in MDS coding, demonstrating that the assessments did not accurately reflect the residents’ clinical status and medication use as documented in their medical records.
Incomplete Documentation of Narcotic Administration on MAR
Penalty
Summary
The facility failed to maintain complete and accurate medical records in accordance with accepted professional standards for one resident receiving narcotic medication. The resident, admitted in March 2026, had a fall on 3/6/26 and was sent to the hospital on 3/9/26. Review of the March 2026 Medication Administration Record (MAR) showed documentation of a single 25 mg dose of Tramadol administered on 3/8/26 at 9:23 AM. However, review of the resident’s Controlled Drug Receipt/Record/Disposition Form, kept on the nurse’s medication cart and not in the medical record, showed that Tramadol 25 mg was administered three times between 3/8/26 and 3/9/26: at 11:00 AM and 9:00 PM on 3/8/26, and at 9:00 AM on 3/9/26. In interview, the DON stated that staff are expected to document narcotic administration on the MAR and confirmed that only one of the three Tramadol doses reflected on the controlled drug record was documented on the resident’s MAR. This discrepancy between the controlled substance record and the MAR, with missing documentation of two administered doses of Tramadol on the official medical record, constituted the failure to maintain a complete and accurate medical record for the resident.
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