Westgate Hills Rehab & Healthcare Ctr
Inspection history, citations, penalties and survey trends for this long-term care facility in Baltimore, Maryland.
- Location
- 10 North Rock Glen Road, Baltimore, Maryland 21229
- CMS Provider Number
- 215299
- Inspections on file
- 19
- Latest survey
- December 31, 2025
- Citations (last 12 mo.)
- 10
Citation history
Health deficiencies cited at Westgate Hills Rehab & Healthcare Ctr during CMS and state inspections, most recent first.
Surveyors found that two residents did not receive care and treatment in accordance with professional standards, including lack of documentation before administering Nitroglycerin and inconsistent skin assessments leading to delayed wound care for a resident with MASD and a stage 3 pressure ulcer. Staff interviews confirmed documentation errors and delays in notifying practitioners and implementing wound care orders.
A resident with dementia and behavioral disturbances exhibited worsening agitation and wandering, but staff failed to assess or document these behaviors or implement behavior monitoring, relying instead on verbal reports. The DON confirmed that required documentation was missing from the medical record.
The facility did not ensure that the call bell system on the second floor was fully functional, resulting in the absence of an audible alert for staff when a resident activated the call bell. A resident with a tracheostomy reported extended wait times for assistance, and staff confirmed they could not hear the call bell sound. The deficiency was confirmed through observations, interviews, and review of complaints.
A resident with legal blindness reported being verbally abused by a GNA after a prolonged wait for assistance, with the incident witnessed by the resident's roommate. The facility's investigation was incomplete, lacking proper documentation of interviews with the alleged victim, witnesses, and staff, and no follow-up was conducted when another resident indicated awareness of abuse.
A facility failed to report an injury of unknown origin involving a resident to the State Agency within the required two-hour timeframe, instead reporting the incident nearly four hours after discovery. This delay was identified during a complaint survey through record review and staff interviews.
Facility staff did not thoroughly investigate allegations involving two residents, including concerns about care, hygiene, and verbal abuse. In both cases, not all issues raised by complainants were addressed, documentation was incomplete or missing, and required follow-up on potential abuse was not performed. The lack of comprehensive investigation and documentation resulted in unresolved allegations and inconclusive findings.
A resident dependent on staff for personal hygiene and incontinence care was left unbathed and soiled on multiple occasions. Documentation showed only two bed baths for the month instead of the scheduled nine, and there were significant gaps in incontinence care records. Staff interviews confirmed required documentation procedures were not followed, and the facility could not provide evidence that the resident received the necessary care as scheduled.
A resident developed a pressure injury on the right knee due to prolonged use of a knee brace without consistent skin assessments. Although the care plan called for regular skin checks under the immobilizer, documentation of these assessments was lacking for over a month, and staff interviews confirmed that such checks were expected regardless of specific orders. The deficiency was identified when the wound was discovered during a skin evaluation, revealing a lapse in preventive care.
A resident with a history of multiple falls and identified as high risk did not have all care plan fall prevention interventions in place. Observations showed the call pad was not within reach or on the correct side of the bed as required, and staff confirmed these interventions were not consistently implemented.
A resident experienced multiple incontinent episodes, but the GNA documented 'Not Applicable' for toileting hygiene instead of indicating whether care was provided or refused. The DON confirmed that staff should use the 'Resident Refused' option when care is declined, but the GNA reported being unable to do so and selected 'NA' instead, resulting in incomplete and inaccurate medical records.
Surveyors identified multiple instances of improper food storage and labeling, including unlabeled and unsecured food items in the kitchen refrigerator and freezer, as well as in the dry storage area. Additionally, the 2nd floor nourishment refrigerator contained a bag of deli meats without proper labeling or dating, despite staff-only access.
The facility failed to accurately document assessments for two residents. One resident's MDS assessment listed only a stage 3 pressure ulcer, despite wound care notes indicating both a stage 3 and a stage 2 ulcer. Another resident's discharge assessment incorrectly recorded a transfer to a hospital, while records showed the resident was discharged home. These errors were confirmed by MDS staff.
A newly admitted resident who had recently been hospitalized for an acute subdural hematoma did not receive a summary of the initial Baseline Care Plan (BCP) within 48 hours of admission. Although the BCP was developed and entered into the medical record, there was no evidence it was shared with the resident, who expressed concern about not receiving information on their diet and swallowing plan. Staff interviews confirmed the BCP was not presented as required.
Surveyors identified that two residents did not have comprehensive, individualized care plans addressing their specific needs, including incomplete documentation for medical conditions and delayed care planning for transfer assistance after a fall. Facility staff confirmed that care plans were either incomplete or not developed in a timely manner.
The facility did not hold care plan meetings after comprehensive assessments for two residents and failed to invite them to participate, with only their guardians being contacted. Documentation was lacking for both the meetings and the rationale for not including the residents.
A resident with significant medical and cognitive needs, confined to their room, was observed multiple times without engagement in meaningful activities, despite a care plan indicating the need for personalized interventions. Documentation revealed only three one-to-one activity visits over two months, and staff acknowledged the lack of ongoing, individualized activities for this resident.
A resident experienced decreased vision and was scheduled for a follow-up with an eye specialist, but there was no documentation that the appointment occurred. Interviews revealed that Medical Records staff, responsible for scheduling and transportation, were unaware of the appointment, resulting in the missed follow-up.
A resident with limited mobility and contractures did not receive prescribed knee extension braces and hand splints as ordered, and there was no documentation of their application. The DON confirmed that the orders were not transferred to the TAR, resulting in a lack of evidence that the treatments were provided.
A resident with involuntary lower extremity movement and poor spatial awareness was not provided with a perimeter mattress as required by their care plan after a room change. The omission was confirmed through observation and staff interviews, and the resident experienced two falls from bed in the new room where the mattress was not in place.
A resident with neuropathic pain was readmitted from the hospital, and although hospital discharge instructions recommended continuing gabapentin, the medication was discontinued on the day of readmission. The NP's progress note initially indicated gabapentin should be continued, but there was no documentation or rationale for its discontinuation, and the NP later could not recall the reason for stopping the medication.
A resident with shortness of breath did not receive an additional 40 mg dose of furosemide as recommended by the provider. The medication was not documented as given, and staff could not provide evidence or a rationale for the omission. The DON confirmed that the nurse did not follow expected documentation practices.
A resident's medication regimen review reports completed by the pharmacist were not included in the medical record, and there was no process to ensure the primary care provider's review and documentation of actions taken. Staff interviews confirmed that while reports were reviewed and signed by the NP, they were not consistently filed in the resident's record, and the DON had to retrieve them from the pharmacist.
A surveyor found an unattended and unlocked medication cart in a hallway, with multiple drawers containing medications accessible. A nurse, who was responsible for the cart and managing two carts due to staff absence, confirmed the cart should have been locked and stated it was left open by accident.
A surveyor observed a significant buildup of plastic bags, leaves, pine needles, and plastic cups behind the dumpster used by kitchen staff, indicating improper disposal and maintenance of the outdoor garbage area. The Director of Maintenance confirmed that this accumulation should not be present.
Surveyors found that clean clothing belonging to residents who were hospitalized or had expired was stored in green bags within the dirty laundry room. The Environmental Director confirmed the clothes were clean, and the DON was notified of the risk for accidental contamination due to this storage practice, which did not minimize the potential spread of infection.
The facility failed to report several incidents of alleged abuse, neglect, and misappropriation of property to the Office of Health Care Quality (OHCQ) within the required two-hour timeframe. Incidents included a resident being threatened by a GNA, another resident alleging being hit, and a case of missing money. Additionally, an LPN allegedly yelled at a resident and refused to change a wound dressing, and an injury of unknown source was not reported promptly. The NHA confirmed delays in reporting and acknowledged staff education on timely reporting.
The facility failed to accurately code MDS assessments for four residents, missing documentation of falls, injections, surgeries, and required assessments for cognitive patterns, mood, and pain. Staff confirmed these errors during interviews.
A resident experienced chest pain that was not addressed by facility staff until the family intervened. The resident reported chest pain since the morning, but staff did not notify the physician or document the issue until late afternoon. Nitrostat was offered but refused, and the family requested ER evaluation. The NHA confirmed the lack of timely physician notification.
The facility failed to thoroughly investigate abuse allegations involving two residents. A resident's family member accused others of abuse, and the resident reported disrespectful and abusive behavior, including exposure by another resident. The investigation lacked statements from involved parties and witnesses, and the administrator confirmed the investigation was incomplete.
Facility staff failed to adhere to and update the care plan for a cognitively impaired resident with poor safety awareness. The resident, who had a history of falls, was observed without a required safety helmet, non-skid socks, and hip protectors, contrary to the care plan. The care plan had not been reviewed or revised following the resident's latest assessment, as confirmed by the DON.
A resident, dependent on staff for bathing, received inadequate assistance with activities of daily living, as only three showers were documented during an eight-week stay. The MDS assessment confirmed the resident's total dependence on staff for bathing, but the facility failed to provide the necessary care, as confirmed by the DON.
A facility failed to conduct required neuro checks for a resident after a fall, despite initial assessment showing a slight hematoma on the forehead. The protocol required frequent neuro checks following an unwitnessed fall or head injury, but no further checks were documented after the initial assessment. The ADON confirmed the lapse in following the protocol, leading to a deficiency in meeting the resident's health needs.
A resident with multiple wounds did not receive timely treatment for pressure ulcers upon admission and after returning from the hospital. Initial treatment for a stage II ulcer was delayed by a week, and a stage III ulcer was not treated until four days after documentation. Additional wounds were also left untreated for several days. The DON confirmed the lack of documentation and expected procedures were not followed.
A resident experienced significant weight loss due to the facility staff's failure to timely assess and evaluate nutritional needs. The resident's weight dropped from 285.1 pounds at admission to 252.4 pounds, with the staff failing to recognize and address the weight loss promptly. The DON confirmed the oversight in timely intervention.
A resident with seborrheic dermatitis was found to have three active orders for medicated shampoos, despite a dermatology consult indicating only one was necessary. The facility staff failed to ensure the resident's medication regimen was free from unnecessary drugs, as the resident was receiving Selsun Blue, Ketoconazole, and Ciclopirox shampoos concurrently.
A resident with urinary retention and poor ambulatory status attended a urology consultation, where a follow-up procedure was recommended. However, the resident was discharged without a follow-up appointment being scheduled. This oversight was confirmed by the DON.
The facility failed to maintain accurate medical records and medication documentation for two residents. One resident, who was cognitively impaired, had inconsistencies in the documentation regarding the use of a Wanderguard bracelet, while another resident's Medication Administration Record (MAR) showed blank entries for several medications, indicating a failure to document administration. Interviews with nursing staff confirmed expectations for proper documentation were not met.
Failure to Document Assessments and Timely Wound Care Interventions
Penalty
Summary
Surveyors identified deficiencies related to the facility's failure to accurately document assessments and ensure residents received treatment and care in accordance with professional standards. For one resident, Nitroglycerin was administered on multiple occasions without documentation of symptoms or assessments prior to administration. Interviews with the DON and an LPN confirmed that any change in condition, such as chest pain, should be documented in the electronic medical record, and that all steps taken in response to unusual symptoms should be recorded. However, the medical record lacked this required documentation. Another resident was found to have inconsistencies in skin assessment documentation within 24 hours of readmission. The admitting nurse documented intact skin, while subsequent assessments by the wound care nurse and nurse practitioner identified a stage 3 pressure ulcer and Moisture Associated Skin Damage (MASD) on the left buttock. The wound care nurse later explained that there was a user error in documentation, resulting in inaccurate records. Additionally, there was no evidence that the facility notified the resident's primary care practitioner of the wound upon readmission or that wound care treatment was initiated at that time, despite recommendations from the nurse practitioner. Wound care orders were not implemented until several days after readmission. Review of the GNA flowsheet and interviews with staff revealed further discrepancies, as documentation indicated no skin impairment for several days, despite clinical notes to the contrary. The facility's process for admission and wound care assessment was described by staff, but the records showed that required assessments and timely interventions were not consistently completed or documented. The DON confirmed that the hospital discharge summary did not indicate a wound, yet the resident developed significant skin impairment shortly after readmission, with delayed initiation of appropriate wound care.
Failure to Assess and Document Behavioral Health Needs
Penalty
Summary
The facility failed to assess or document the behaviors of a resident diagnosed with dementia with behavioral disturbance. Despite the resident exhibiting worsening agitation, wandering, and behaviors such as entering other residents' rooms and touching their belongings, there was no documentation or behavior monitoring order in the medical record. The resident was prescribed medications for behavioral health needs upon admission, but the facility did not implement or record any behavior monitoring as required. Interviews with facility staff revealed that information about the resident's behavioral issues was communicated verbally rather than documented. The Psychiatric Nurse Practitioner confirmed awareness of the resident's aggressive behaviors through verbal reports only, and the DON acknowledged that behavior monitoring should have been documented in the Treatment Administration Record. Upon review, the DON verified the absence of any assessment or documentation of the resident's behaviors in the medical record.
Failure to Maintain Audible Call Bell System in Resident Areas
Penalty
Summary
The facility failed to maintain a fully functioning call bell system on the second floor, as evidenced by the lack of an audible call bell sound in the hallways and at the nurses' station. During the survey, the call bell light was observed to be on outside a resident's room, but no audible alert was heard by staff in the area. Staff confirmed that they did not hear any call bell sound, and the Maintenance Director later acknowledged that the sound on the second floor was significantly lower than on the first floor. The issue had not been previously reported to maintenance, and the problem was identified as new, with the last inspection showing no issues. A resident with a tracheostomy reported that they had called for a nurse to assist with suctioning and experienced long wait times for call bell responses, sometimes up to an hour. The surveyor observed staff present at the nurses' station who did not respond to the call bell light, further indicating that the system was not functioning as intended to alert staff to resident needs. The deficiency was identified through complaint review, direct observation, and staff and resident interviews.
Failure to Protect Resident from Verbal Abuse and Inadequate Investigation
Penalty
Summary
Facility staff failed to ensure that a resident was free from verbal abuse, as evidenced by an incident involving a resident with legal blindness who reported being verbally abused by a Geriatric Nursing Assistant (GNA). The resident stated that after waiting over two hours for assistance to use the bathroom, an argument ensued during which the GNA called the resident a derogatory name related to their blindness. The resident's roommate was present during the incident. The Social Service Director confirmed that neither the resident nor their roommate had a history of fabricating complaints or causing trouble. The facility's investigation into the incident was insufficient. The Administrator relied on staff and resident questionnaires, but did not conduct or document thorough interviews with the alleged victim, witnesses, or staff involved. Although another resident also indicated awareness of abuse, there was no documentation of follow-up to clarify this response. The Administrator acknowledged that interviews were not properly documented and was unable to provide evidence supporting staff denials of the abuse allegation.
Delayed Reporting of Injury of Unknown Origin
Penalty
Summary
The facility failed to report an injury of unknown origin to the State Agency (SA) within the required two-hour timeframe after discovering the incident. Record review showed that the facility became aware of a resident's injury at 7:20 AM and did not report it to the SA until 11:02 AM, resulting in a delay of approximately 3 hours and 42 minutes. This delay exceeded the regulatory requirement for timely reporting of such incidents. The deficiency was identified during a complaint survey and was confirmed through review of the facility's investigation packet and interviews with facility staff.
Failure to Conduct Thorough Investigations of Alleged Violations
Penalty
Summary
Facility staff failed to conduct thorough investigations into alleged violations involving two residents. In the first case, an email complaint was received by the Administrator and DON detailing concerns about a resident's care, including issues with medications, oxygen, nutrition, hydration, hygiene, and personal care. The investigation file was missing the original complaint email, and when it was later provided, it was found that not all concerns listed by the complainant were addressed in the facility's investigation. Documentation showed significant gaps in incontinence care, with records indicating the resident may have gone over 12 hours without being changed on multiple occasions. The facility was unable to provide additional documentation to confirm that care was provided more frequently than recorded, and did not investigate all concerns raised, such as those related to medication and oxygen. In the second case, a resident reported to the Social Service Director that a GNA was verbally aggressive during a specific shift. The investigation file indicated that interviews were conducted, but there was no documentation of these interviews except for the alleged perpetrator. Staff and resident questionnaires were used, but responses indicating possible abuse were not followed up as required. The resident involved, who is legally blind, described a delay in assistance and reported being verbally abused by the GNA, with a roommate present as a witness. The facility's investigation did not include documented interviews with all relevant staff, witnesses, or the alleged victim, and the Administrator acknowledged that interviews were not properly documented. In both cases, the facility's investigations were incomplete, lacking documentation and follow-up on all allegations and failing to address all concerns raised by complainants. The absence of thorough documentation and failure to investigate all aspects of the complaints led to inconclusive findings and unaddressed allegations regarding resident care and staff conduct.
Failure to Provide and Document Required ADL and Incontinence Care
Penalty
Summary
Facility staff failed to provide adequate care and assistance with activities of daily living (ADLs) for a resident who was dependent on staff for personal hygiene and incontinence care. The deficiency was identified when it was found that the resident was left unbathed and soiled with urine and bowel movement on multiple occasions, as reported by a complainant. Documentation review revealed that the resident was scheduled to receive showers twice weekly, but records showed only two bed baths documented for the entire month when there should have been nine entries. Additionally, there were significant gaps in the documentation of incontinence care, with long periods between recorded care events. Interviews with facility staff, including a Geriatric Nursing Assistant (GNA) and the Assistant Director of Nursing (ADON), confirmed that staff are required to document showers, refusals, and incontinence care in both electronic records and shower logbooks, and to notify nursing staff of any refusals. However, the facility was unable to provide documentation verifying that the resident received the required care as scheduled. The lack of documentation and the observations of the resident being left soiled indicate that the facility did not ensure consistent provision and recording of necessary ADL and incontinence care for the resident.
Failure to Prevent Pressure Injury Under Orthopedic Device
Penalty
Summary
A deficiency was identified when a resident developed a pressure injury on the right lateral knee, attributed to the use of a knee brace. The resident had an order to wear a right hinge-knee brace locked in extension at all times, with no range of motion allowed. Although there was an initial order to assess the skin under the brace and report abnormalities, this order was discontinued after a few days, and no further documentation of skin assessments was found in the progress notes or treatment administration record for over a month. The care plan included an intervention to check the right knee skin under the immobilizer every shift and notify the medical provider of any abnormalities, but there was no evidence that this intervention was consistently implemented during the period in question. Staff interviews revealed that the standard practice was to assess the skin before and after placement of orthopedic devices, ideally every two to four hours, regardless of whether there was a specific order. However, in this case, the lack of documented skin checks and the absence of ongoing assessment orders contributed to the development of an avoidable pressure injury. The wound was first identified during a skin and wound evaluation, at which point recommendations were made to check the skin daily, consult orthopedics, and consider alternative bracing or additional padding.
Failure to Implement Fall Prevention Interventions
Penalty
Summary
A deficiency was identified when a facility failed to implement fall prevention interventions for a resident who had experienced multiple falls and was assessed as high risk for falls. The resident's care plan included specific interventions such as frequent rounding, bilateral fall mats, and ensuring a call pad was within reach and placed on the side of the bed where the resident was most likely to fall. Despite these documented interventions, observations by the surveyor on two separate occasions revealed that the call pad was not within the resident's reach and was not positioned on the correct side of the bed, as required by the care plan. Instead, the call pad was found on top of a suctioning container and, at another time, on top of an oxygen humidifier machine. Interviews with the resident's representative and facility staff, including the ADON, confirmed that the call pad was not consistently placed according to the care plan. The resident's representative provided photographic evidence of the improper placement, and the ADON acknowledged that the required interventions were not in place at the time of the observations. The administrator and DON were notified of these concerns regarding the lack of adherence to fall prevention measures for the resident.
Failure to Accurately Document Toileting Hygiene After Incontinent Episodes
Penalty
Summary
The facility failed to maintain accurate and complete medical records for a resident, as evidenced by discrepancies in documentation related to toileting hygiene following incontinent episodes. Specifically, the resident experienced bladder and bowel incontinence on several occasions during the night shift, but the Geriatric Nursing Assistant (GNA) documented 'Not Applicable' (NA) for the Toileting Hygiene task instead of indicating whether care was provided or refused. The Director of Nursing (DON) confirmed that the expectation is for GNAs to document if care was provided or if the resident refused care, using the 'Resident Refused' (RR) option when applicable. During interviews, the GNA responsible for the documentation stated that 'NA' was used when a task did not apply, but in this case, the GNA intended to document a refusal but was unable to do so and therefore selected 'NA.' This resulted in incomplete and inaccurate records regarding the resident's care after incontinent episodes, as the documentation did not accurately reflect whether hygiene care was provided or refused by the resident.
Improper Food Storage and Labeling Practices Identified
Penalty
Summary
Facility staff failed to properly store food in accordance with professional standards for food service and safety. During a kitchen inspection, surveyors observed two containers of cottage cheese in the refrigerator, both labeled with received and sell-by dates, and a small block of lunch meat labeled only with an opened and use-by date, but lacking product identification. Additionally, a package of hot dogs was found unsecured and open to air. In the freezer, a water bottle containing a dark liquid was present without a label, and a cut of meat was stored in a pan with cellophane that was not airtight, resulting in visible freezer burn. In the dry storage area, opened packages of ziti and long pasta were found without labels indicating when they were opened or when they should be used by. On a separate unit, the 2nd floor nourishment refrigerator was inspected and found to contain two plastic bags of deli meats. One bag was labeled with a resident room number, but the other lacked any label or date, making it unclear who it belonged to or how long it had been stored. Staff confirmed that only staff had access to the refrigerator and acknowledged that the unlabeled bag should have been properly identified and dated.
Inaccurate Documentation of Resident Assessments
Penalty
Summary
The facility failed to accurately document assessments in the medical records of two residents. For one resident, the Minimum Data Set (MDS) assessment recorded only one stage 3 pressure ulcer, while a prior wound nurse note documented both a stage 3 sacral wound and a stage 2 left hip wound upon readmission. The discrepancy was confirmed during an interview with MDS staff, who acknowledged the error in documentation. For another resident, the MDS discharge assessment indicated a transfer to a short-term general hospital, but the discharge summary stated the resident was stable and discharged home with a spouse. This inconsistency was also confirmed by MDS staff, who stated the discharge location was documented in error.
Failure to Provide Baseline Care Plan Summary to New Admission
Penalty
Summary
The facility failed to inform a newly admitted resident of a summary of the initial Baseline Care Plan (BCP) within 48 hours of admission, as required. The BCP, which should include essential healthcare information to address immediate needs and reduce the risk of negative outcomes, was developed and entered into the medical record, but there was no evidence that the summary was shared or provided to the resident. The resident, who had recently been hospitalized for an acute subdural hematoma, expressed concern about not receiving information regarding their diet and swallowing plan of care. Interviews with staff revealed that the assigned social worker was a new hire and had only documented discharge planning, with no documentation of the BCP being presented to the resident. The Director of Nursing confirmed that the BCP was not shared as expected.
Failure to Develop Comprehensive, Person-Centered Care Plans for Residents at Risk for Falls
Penalty
Summary
The facility failed to develop comprehensive, person-centered care plans for two residents reviewed for falls. For one resident, the care plans initiated were incomplete and did not specify the reasons for the interventions, such as oral/dental health problems, use of anti-psychotic and anti-depressant medications, risk for respiratory complications, and the presence of an automatic implanted cardiac defibrillator. The care plans lacked individualized details and did not address the specific needs of the resident, as confirmed by the Director of Nursing during an interview. For another resident, there was a delay in developing a care plan related to transfer assistance following a fall that occurred while using a sliding board. Although the resident was initially deemed safe to use the sliding board independently with supervision, a re-evaluation later determined that one staff assist was required for transfers. The care plan reflecting this change was not developed until after the fall, and both the Director of Rehabilitation and the Unit Manager acknowledged that the care plan should have been created earlier.
Failure to Conduct Timely Care Plan Meetings and Involve Residents
Penalty
Summary
The facility failed to conduct care plan meetings following each comprehensive assessment and did not invite residents to participate in their care plan meetings. Specifically, for two out of four residents reviewed, there was no evidence that care plan meetings were held after their Minimum Data Set (MDS) assessments, nor was there documentation explaining why the residents were not invited to participate. In one case, a resident reported not being invited to a care plan meeting for an extended period, and attendance records confirmed the absence of the resident at previous meetings, with only the guardian participating via telephone. Further review of records showed that after the resident's MDS assessments, there were no attendance logs or documentation of care plan meetings being conducted. The Director of Social Services confirmed that no care plan meetings were held after the specified assessments and could not provide documentation for the lack of resident participation. This failure to conduct timely care plan meetings and involve residents as required was evident in the reviewed cases.
Failure to Provide Ongoing Personalized Activities for Room-Bound Resident
Penalty
Summary
A deficiency was identified when a resident, who was confined to their room due to a recent cerebral infarction resulting in a new tracheostomy and feeding tube, was observed on multiple occasions lying in bed, staring at the walls, and falling asleep without any activity staff present or nearby. The resident had a history of diabetes mellitus and depression, and their care plan indicated a need for more personalized activities due to a new low cognitive baseline and several chronic disease processes. Despite this, documentation showed that the resident received only three one-to-one activity visits over a two-month period. Interviews with the Activity Director confirmed that residents unable to participate in group or social activities were supposed to receive frequent, meaningful, ongoing personalized activities. However, after reviewing the activity records, the Activity Director acknowledged that there was a lack of meaningful one-to-one activities provided to this resident. The Director of Nursing was also made aware of this deficit in meeting the resident's needs for personalized activities.
Failure to Ensure Resident Attended Scheduled Eye Specialist Appointment
Penalty
Summary
A deficiency was identified when a resident reported decreased vision since admission, and a review of their medical records showed a missed follow-up appointment with an eye specialist. The resident was scheduled for an eye appointment, as documented in a progress note, but there was no evidence that the appointment occurred. Interviews with facility staff revealed that the Medical Records department was responsible for scheduling follow-up appointments and transportation, but the staff member in charge was unaware of the scheduled eye appointment. The Administrator confirmed the lack of documentation regarding the resident's attendance at the appointment.
Failure to Provide and Document Prescribed ROM Devices
Penalty
Summary
A deficiency was identified when a resident with limited mobility and a history of contractures was not provided with the prescribed treatments to maintain or improve range of motion. The resident had physician orders for bilateral knee extension braces to be worn for six hours daily as tolerated, and for resting hand splints to be applied to both hands for up to two hours at a time after hand hygiene. Multiple observations by the surveyor revealed that the resident was not wearing the prescribed braces or splints, and the resident was consistently seen with knees pulled to the chest and contracted fingers. A review of the resident's medical record showed no documentation that the splints or braces were applied as ordered. During interviews, the DON confirmed that the use of braces and splints should be documented, but acknowledged that the orders for these treatments were never transferred to the Treatment Administration Record (TAR), resulting in a lack of documentation and evidence that the treatments were provided as prescribed.
Failure to Provide Care Planned Fall Prevention Intervention
Penalty
Summary
The facility failed to implement a necessary intervention for a resident identified as a fall risk. The resident had a care plan in place due to involuntary movement of both lower extremities and unawareness of personal boundaries, which included the use of a perimeter mattress for spatial awareness and border definition. After the resident was moved to a new room, the perimeter mattress was not provided, despite being listed as a required intervention in the care plan. Observations confirmed the absence of the perimeter mattress, and staff interviews revealed uncertainty about why the mattress did not transfer with the resident. The resident experienced two documented falls from bed in the new room where the perimeter mattress was not in use. The spouse of the resident reported multiple falls and noted that the special mattress had previously helped keep the resident in bed. The Director of Nursing confirmed the resident was not provided with the perimeter mattress as care planned and was unaware of the reason for this omission. The deficiency was identified through observations, staff interviews, and review of the resident's medical record and fall history.
Failure to Accurately Review and Prescribe Medications After Resident Readmission
Penalty
Summary
A deficiency occurred when the facility failed to ensure that a medical provider thoroughly reviewed and accurately prescribed medications following a resident's readmission from the hospital. The resident, who had a history of neuropathic pain, was readmitted on the same day that their gabapentin order was discontinued. Hospital discharge paperwork recommended continuing gabapentin for neuropathic pain, but the medication was not listed among those to be continued, discontinued, or newly started. Upon readmission, the nurse practitioner's progress note indicated gabapentin should be continued, but there was no subsequent documentation or rationale for discontinuing the medication. Further review revealed that the nurse practitioner could not recall the reason for discontinuing gabapentin and stated that the resident did not report pain during assessment, nor was there any communication about uncontrolled pain. The omission of gabapentin was later identified as a missed order, but at the time of the deficiency, the medication was not provided as recommended in the hospital discharge instructions and as indicated in the provider's initial progress note.
Failure to Administer Ordered Medication and Document Administration
Penalty
Summary
A deficiency occurred when a resident experiencing shortness of breath did not receive an additional 40 mg dose of furosemide as recommended by the provider. The recommendation was documented in an SBAR note, but a review of the medication administration record showed no evidence that the medication was administered. When requested, facility staff were unable to provide documentation or a rationale for the omission. Interviews with the Administrator and DON confirmed that the medication was not given and that the nurse responsible did not follow the facility's expected practice for documenting administered medications.
Failure to Document and Track Medication Irregularity Reports in Resident Record
Penalty
Summary
The facility failed to ensure that a process was in place for medication irregularity reports generated by the pharmacist to be reviewed by the primary care physician and for the actions taken based on those recommendations to be documented in the resident's medical record. Specifically, for one resident, pharmacy medication regimen reviews were completed on three separate occasions, but the corresponding reports were not found in the resident's electronic medical record. The Director of Nursing (DON) had to obtain these reports directly from the pharmacist, indicating they were not properly filed or accessible as part of the resident's official record. Interviews with facility staff revealed that the process involved the DON or a nurse printing the pharmacist's reports and providing them to the nurse practitioner (NP) for review. The NP would review, document decisions, and sign the reports before returning them to the DON or nurse for implementation of any indicated orders. However, there was no clear process for ensuring that these reports and the responses to them were incorporated into the resident's medical record, as confirmed by both the NP and the DON.
Unsecured Medication Cart Found Unlocked in Hallway
Penalty
Summary
A surveyor observed an unlocked medication cart in the hallway between two resident rooms during a random observation on the second floor. The surveyor was able to open the top drawer and found multiple medications and supplies, as well as access all seven other drawers containing medications. Staff confirmed that the cart was the responsibility of a nurse who was working with two medication carts due to a Certified Medication Aide calling out sick and a subsequent reassignment of duties. The nurse acknowledged that the cart should not have been left open and stated it was left unlocked by accident.
Improper Maintenance of Outdoor Garbage Storage Area
Penalty
Summary
The facility failed to maintain the outdoor garbage storage area in a sanitary manner to prevent the harboring of pests. During an observation, a surveyor noted a significant accumulation of plastic bags, leaves, pine needles, and plastic cups, approximately six inches high, located between the dumpster and the concrete wall behind it. This accumulation was found in the area used by kitchen staff for garbage disposal, just outside the kitchen receiving doors. In an interview, the Director of Maintenance acknowledged that the accumulation should not be present in that area.
Improper Storage of Clean Resident Clothing in Laundry Room
Penalty
Summary
During the recertification survey's infection control investigation, surveyors observed six green bags containing clean clothes stored in the facility's dirty laundry room. Staff interviews confirmed that these clothes belonged to residents who were either hospitalized or had expired. The Environmental Director acknowledged that the clothes in the bags were clean, and the Director of Nursing was informed of the potential risk for accidental contamination due to the storage method. The facility failed to ensure that clean residents' clothing was stored in a manner that minimized the potential spread of infection, as required by infection prevention and control protocols.
Delayed Reporting of Abuse and Neglect Incidents
Penalty
Summary
The facility failed to report several incidents of alleged abuse, neglect, and misappropriation of property to the Office of Health Care Quality (OHCQ) within the required two-hour timeframe. In one instance, a resident reported being threatened by a geriatric nursing assistant at 3:00 AM, but the report was not submitted to OHCQ until 9:27 AM. The Nursing Home Administrator (NHA) confirmed the delay, stating he reported it as soon as he became aware. Another incident involved a resident who alleged being hit in the back, but the staff failed to report this to the NHA immediately, resulting in a delayed report to OHCQ. In another case, a resident reported being abused by staff members, but the allegation was not reported until several days later. The NHA confirmed that the staff involved were educated on timely reporting, but the delay in reporting was acknowledged. Additionally, an incident involving a Licensed Practical Nurse (LPN) allegedly yelling at a resident and refusing to change a wound dressing was not reported to the NHA until nearly two weeks later. The NHA noted that the staff involved were reprimanded for failing to report the incident promptly. Further deficiencies were noted in the reporting of a misappropriation of property, where a resident reported missing money, but the facility did not report the allegation to the state agency within the required timeframe. Similarly, an injury of unknown source was observed on a resident, but the report to the state agency was delayed. The NHA was unable to recall the exact timeline of events for this incident, indicating uncertainty about the reasons for the delay in reporting.
Inaccurate MDS Assessments and Documentation Failures
Penalty
Summary
The facility staff failed to ensure that Minimum Data Set (MDS) assessments were accurately coded for four residents during a complaint survey. For Resident #36, the facility did not document multiple falls that occurred on specific dates, nor did they capture an injection that was administered. The errors were confirmed by MDS coordinators during an interview. Resident #37's medical record review revealed that the facility did not capture a fall that occurred at home prior to admission, nor did they document a major surgery that the resident underwent during a hospital stay. The error was acknowledged by Staff #10, who admitted to forgetting to ask the resident about the fall. For Resident #42, the facility failed to conduct and document required assessments for cognitive patterns, mood, and pain, despite indications that these assessments should have been conducted. Additionally, a fall was not captured in the MDS. Staff #11 confirmed these omissions and noted issues with social work completing the MDS on time. Resident #34 also had a fall that was not documented in the MDS, as confirmed by Staff #11 and the Assistant Director of Nursing.
Failure to Promptly Notify Physician of Resident's Chest Pain
Penalty
Summary
The facility staff failed to promptly notify the physician of a resident's change in condition, specifically regarding chest pain. The resident, admitted in August 2023 for rehabilitation due to debility, reported experiencing chest pain since 10:00 AM on September 2, 2023. However, the staff did not address the complaint until the resident's family arrived at the facility at 4:40 PM and insisted on calling 911. The nursing notes documented the chest pain at 5:56 PM, and although Nitrostat was offered to the resident, it was refused. The responsible party requested the resident be transferred to the ER for evaluation. The Nursing Home Administrator (NHA) and the previous Director of Nursing (DON) acknowledged the delay in addressing the resident's chest pain. The primary nurse, Staff #45, claimed to have been informed of the chest pain at 3:50 PM and offered Nitrostat, but there was no documentation of physician notification at that time. The grievance report provided to the surveyor lacked an attached statement, and the NHA confirmed the absence of documentation supporting timely physician notification.
Incomplete Investigation of Abuse Allegations
Penalty
Summary
The facility failed to thoroughly investigate allegations of abuse involving two residents during a complaint survey. In one incident, a family member of a resident accused other residents of abusing their relative. The resident's medical record indicated that a psychologist documented the resident's claim that another resident had been disrespectful and verbally abusive. The resident also alleged that another resident had exposed themselves in the doorway. However, the facility's investigation did not include a statement from the resident who made the allegations, nor from the resident accused of the behavior, or any staff who might have witnessed the event. The surveyor's review revealed that the facility's investigation was incomplete, as it did not address the allegations made by the resident to the psychologist. The administrator confirmed that the facility staff did not conduct a thorough investigation into the allegations of abuse. This deficiency was evident in two out of fifty facility-reported incidents reviewed during the survey.
Failure to Follow and Update Resident Care Plan
Penalty
Summary
The facility staff failed to follow and update the care plan for a resident who was cognitively impaired and independently ambulatory with poor safety awareness. The resident had an unwitnessed fall resulting in a laceration and swelling above the right eye. The care plan, initiated after the incident, required the resident to wear a safety helmet when out of bed. However, during an observation, the resident was seen sitting in a chair without the helmet, indicating non-compliance with the care plan. Additionally, the care plan included interventions for the resident to wear non-skid socks and hip protectors at all times, except during care. During the same observation, the resident was not wearing the required non-skid socks or hip protectors. The medical record review showed no documentation that the care plan had been reviewed or revised following the resident's most recent quarterly assessment. These failures were confirmed by the Director of Nurses during the survey.
Failure to Provide Adequate Assistance with Activities of Daily Living
Penalty
Summary
The facility staff failed to provide necessary activities of daily living for a resident who was dependent on assistance with personal care. The deficiency was identified during a complaint survey, where it was found that a resident, admitted in August 2022 and discharged in October 2022, only received three documented showers during their eight-week stay. The resident's MDS assessment indicated total dependence on staff for bathing. However, documentation showed showers were only provided on three occasions, with no additional records found in the nursing notes. The Director of Nursing confirmed the lack of documentation for additional showers, corroborating the complaint that the resident received only two showers in a six-week period.
Failure to Conduct Neuro Checks After Resident Fall
Penalty
Summary
The facility failed to provide adequate care for Resident #27 following a fall, as evidenced by the lack of documented neuro checks after the initial assessment. On 1/20/23, Resident #27 was found on the floor beside their wheelchair with a slight hematoma on the forehead after attempting to transfer themselves to bed. A comprehensive multisystem assessment was completed, and neuro checks were initiated with normal results initially. However, no further neuro checks were documented in the medical record, despite the physician's orders to continue monitoring and report any abnormalities. An interview with the Assistant Director of Nursing (ADON) confirmed that the facility staff did not complete the required neuro checks as per the protocol for unwitnessed falls or head injuries. The ADON stated that the protocol required an initial neuro check followed by checks every 15 minutes for the first hour, every 30 minutes for the next hour, every hour for four hours, and then every shift for 24 hours. The failure to adhere to this protocol resulted in a deficiency in meeting the resident's physical, mental, and psychosocial health needs.
Failure to Provide Timely Pressure Ulcer Care
Penalty
Summary
The facility failed to provide timely treatment and services to prevent and heal pressure ulcers for a resident admitted with multiple wounds. Upon admission in May 2023, the resident had a healing wound above the sacrum and a pressure ulcer near the left inner thigh. A subsequent note documented a stage II pressure ulcer on the buttock, but treatment for this ulcer was not initiated until a week later, on May 17, 2023. The resident was discharged to the hospital on May 29, 2023, and upon return on June 2, 2023, refused assessment. By June 6, 2023, a stage III pressure ulcer was documented on the left buttock, yet no treatment was recorded until June 7, 2023. Further review revealed that upon the resident's return from the hospital on June 16, 2023, there were additional wounds on the right and left buttocks and a suspected deep tissue injury on the right heel. However, treatment for these wounds was not documented until June 21, 2023. The Director of Nursing confirmed the lack of documentation and stated that the expectation was for the charge nurse to assess the resident upon admission, notify the physician, and obtain orders for immediate treatment, which was not done in this case.
Failure to Timely Address Resident's Weight Loss
Penalty
Summary
The facility staff failed to assess and evaluate the nutritional needs of a resident in a timely manner, leading to significant weight loss. Upon admission, the resident's weight was documented as 285.1 pounds, and a nutritional assessment was completed three days later, setting goals to maintain nutritional status and consume at least 50% of meals and supplements daily. However, the resident was not reweighed until 15 days after admission, showing a weight loss of 6.4 pounds. By December 2, the resident's weight had dropped to 252.4 pounds, indicating a total weight loss of 32.7 pounds since admission. The facility staff did not recognize the weight loss documented on November 16 and December 2 until December 7, and failed to reweigh the resident in a timely manner after the weight loss was identified. The resident was not reweighed until December 16, 14 days after the dietitian's note, at which point the weight was documented as 270 pounds. The Director of Nursing confirmed that the facility staff failed to recognize and intervene in the resident's weight loss in a timely manner.
Unnecessary Medication in Resident's Drug Regimen
Penalty
Summary
The facility staff failed to ensure that a resident's medication regimen was free from unnecessary medication. This was identified during a review of a complaint regarding a resident with seborrheic dermatitis, a common skin condition causing dandruff. The resident was initially prescribed Ketoconazole shampoo twice a week and had a dermatology appointment scheduled. Following the dermatology consultation, the physician prescribed Ciclopirox shampoo weekly and Derma smooth scalp oil for itching, with a follow-up in two months. However, a review of the resident's January 2025 Treatment Administration Record (TAR) and Medication Administration Record (MAR) revealed that there were three active orders for medicated shampoos being implemented to treat the resident's condition. These included Selsun Blue shampoo, Ketoconazole shampoo, and Ciclopirox shampoo, despite the dermatology consult indicating only Ciclopirox was necessary. The Director of Nurses (DON) was informed of the discrepancy and confirmed that only one medicated shampoo should have been ordered, as per the dermatologist's recommendation.
Failure to Schedule Follow-Up Urology Appointment
Penalty
Summary
The facility staff failed to ensure a follow-up appointment with a consultant physician for a resident who was admitted with a diagnosis that included retention of urine. The resident, who had poor ambulatory status and required a wheelchair that could not clear doorways due to bariatric size, attended a urology consultation. The consulting physician recommended rescheduling at an ambulatory surgery center for a local cystoscopy and Foley catheter change. However, the resident was discharged home without a follow-up appointment being scheduled with urology. This deficiency was confirmed during an interview with the Director of Nursing.
Inaccurate Medical Records and Medication Documentation
Penalty
Summary
The facility staff failed to maintain complete and accurate medical records for two residents during a complaint survey. For Resident #50, who was cognitively impaired and at risk for wandering, there was a discrepancy in the documentation regarding the use of a Wanderguard bracelet. The resident's medical record indicated that the Wanderguard was worn on various shifts, but there was no order for the device, and the resident was observed not wearing it. The Director of Nurses (DON) confirmed that the resident did not require a Wanderguard, highlighting inconsistencies in the documentation. For Resident #1, the facility failed to document the administration of several medications as required. The resident, who had a history of cerebral infarction and bipolar type schizoaffective disorder, had multiple medications listed in their Order Recap Report. However, the Medication Administration Record (MAR) for October 2024 showed blank entries for several medications on specific dates, indicating a failure to document whether the medications were administered. Interviews with the Assistant Director of Nursing (ADON) and the DON revealed that the expectation was for medications to be administered and documented as ordered. These deficiencies indicate a lack of adherence to professional standards in maintaining accurate medical records and ensuring the proper administration and documentation of medications. The discrepancies in documentation and failure to follow established protocols for medication administration and monitoring devices contributed to the identified deficiencies.
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.
