White Oak Rehabilitation And Nursing Center
Inspection history, citations, penalties and survey trends for this long-term care facility in Hyattsville, Maryland.
- Location
- 6500 Riggs Road, Hyattsville, Maryland 20783
- CMS Provider Number
- 215024
- Inspections on file
- 19
- Latest survey
- May 13, 2025
- Citations (last 12 mo.)
- 0
Citation history
Health deficiencies cited at White Oak Rehabilitation And Nursing Center during CMS and state inspections, most recent first.
A portion of a unit was locked following an elopement, resulting in multiple residents being unable to exit freely and requiring staff assistance to leave. Several cognitively intact residents confirmed they did not have the code to open the door, and there was no documentation supporting the need for these restrictions. One resident, distressed by the confinement, sustained fractures while attempting to exit the locked area.
Several residents with cognitive impairment and high risk for elopement or wandering were not properly supervised, resulting in unsupervised exits from the facility and repeated incidents of residents entering others' rooms. Additionally, residents who required supervision while smoking were observed smoking unsupervised and without required safety equipment, and care plans did not consistently address noncompliance or provide adequate interventions.
Four residents did not have Advance Directives or documentation that information about Advance Directives was offered in their medical records. A staff member confirmed that the process to provide and document this information had not been done consistently.
Surveyors identified multiple deficiencies in the facility's housekeeping and maintenance, including unsecured bathroom fixtures, unsealed toilets, foul-smelling substances, damaged walls, and unclean windows. A resident was found in a room with cobwebs and debris in the window, and another had duct tape on the chair railing near the bed. These conditions compromised the sanitary and homelike environment expected for residents.
Several residents did not have complete, individualized care plans addressing their specific needs, including dental care, hospice status, elopement risk, and smoking safety. For example, a resident requiring dental extractions had no care plan for dental issues, another on hospice care lacked an updated care plan, and residents at high risk for wandering or with smoking safety needs did not have appropriate interventions documented in their care plans.
Surveyors found that dry goods such as flour, rice, and sugar were stored past their labeled expiration dates, and an opened bag of frozen pepperoni in the kitchen freezer was not labeled with the date it was opened or its expiration date, contrary to facility policy and professional food safety standards.
A resident reported that the Business Office was holding mail for an extended period. Interviews confirmed that a backlog of undelivered mail had accumulated because the previous Business Office Manager worked remotely and was not present to distribute mail. The facility's policy requires prompt forwarding of mail to residents.
Two residents experienced loss of property and funds due to staff actions. In one case, a resident's controlled pain medication went missing after multiple LPNs failed to properly count and document controlled substances during shift changes. In another case, a resident loaned money to a GNA after an ATM withdrawal, but the GNA did not repay the loan and avoided further contact.
A resident was transferred to a hospital without receiving written notification of the facility's bed-hold policy, and staff confirmed that no such documentation was provided prior to the transfer.
A resident was observed uncovered in bed with an exposed brief and only a partially drawn privacy curtain, making them visible to others in the room. The GNA involved admitted the curtain should have been fully closed, and the resident stated that staff never close the curtain, demonstrating a lack of attention to privacy and dignity.
A resident with dementia and a history of elopement, who was assessed as high risk and had a wander guard in place, was not accurately coded for wandering behavior or the use of a wander guard in the MDS assessment. Despite documented interventions and observations, the MDS failed to reflect the resident's actual condition and care needs.
A resident was not offered the opportunity to participate in care planning meetings following multiple MDS assessments, as required. Record review and staff interviews confirmed that care plan meetings were not held after several quarterly and annual assessments, resulting in the resident and their representative not being included in the care planning process.
A resident admitted after a stroke did not have a cardiology follow-up appointment scheduled as ordered by the physician. Due to a breakdown in communication and process, the appointment was not scheduled within the required timeframe, resulting in a failure to meet professional standards of care.
A resident did not receive a prescribed dose of Lacosamide 150mg as ordered by the physician. Review of medication records and a controlled substance count revealed a discrepancy between the number of tablets in the blister pack and the count sheet, and staff confirmed the medication had not been administered during the shift.
A resident's controlled substance medication, Lacosamide 150mg, was not accurately reconciled when the number of tablets in the blister pack did not match the controlled substance count sheet. Staff signed off on the shift count without performing the required dual count with another nurse, and the medication was not administered as documented.
A resident who required multiple dental extractions and expressed difficulty eating was not provided with timely dental care, despite a Prosthodontist's evaluation and recommendation. Staff interviews revealed a lack of awareness and follow-up, with cost and insurance issues cited as reasons for the delay.
Multiple deficiencies were identified in the facility's medical record-keeping, including incorrect or incomplete cognitive assessments, inconsistent documentation of care such as bathing, and delayed or inaccurately recorded medication administration. These issues resulted in conflicting or missing information in residents' records, failing to meet professional standards for medical documentation.
A resident with a tracheostomy was repeatedly observed with their extension tubing and drainage bag stretched across the floor and connected to their trach collar. Staff and the infection preventionist confirmed that this was not in accordance with infection control protocols, but the issue continued despite being reported.
Surveyors observed that two resident bathrooms had maintenance issues, including a missing cove base and peeling paint on the floor. These deficiencies were confirmed during interviews with the NHA and ADON.
The facility did not report allegations of abuse and misappropriation of resident property within the required timeframes. In three reviewed incidents, including a resident's report of stolen money and two separate abuse allegations, notifications to the State Agency were delayed beyond regulatory requirements, and follow-up with the affected resident was not conducted.
Nurse staffing information was not posted in a location that was easily accessible to all residents and visitors on the Med Bridge unit. The staffing schedule was placed on the locked side of the unit, making it difficult for 17 residents on the unlocked side to view, and staff confirmed the information was not readily visible.
Involuntary Seclusion and Resident Harm Due to Locked Unit
Penalty
Summary
Residents in the Med Bridge unit were subjected to involuntary seclusion when a portion of the unit was locked, restricting their ability to move freely. This action was initiated following an elopement incident, and as a result, 15 residents were confined behind a locked door without documented clinical justification for such restriction. Among these, three residents with intact or moderately impaired cognition confirmed they did not have the code to exit and required staff assistance to leave the unit. There was no evidence in their records indicating a need for placement in a secure, locked environment. The remaining residents were not interviewable and also lacked documentation supporting the necessity for such confinement. One resident experienced significant distress due to the locked environment, resulting in self-inflicted physical harm while attempting to exit the unit. This resident was observed banging on the locked doors and subsequently sustained acute fractures, requiring hospital treatment. Staff interviews confirmed that the locked unit was established as a temporary measure for wandering residents, but no individualized assessments or documentation supported the restriction for the affected residents.
Failure to Prevent Accidents Due to Inadequate Supervision and Hazard Controls
Penalty
Summary
Multiple deficiencies were identified related to the facility's failure to ensure a safe environment free from accident hazards and to provide adequate supervision to prevent accidents. Several residents with cognitive impairments and high risk for elopement or wandering were not properly supervised or monitored. In one instance, a resident with severe cognitive impairment and a high elopement risk was able to exit the facility unsupervised due to malfunctioning wander guard systems and inadequate staff response to door alarms. Staff failed to confirm the resident's presence after an alarm was triggered, resulting in the resident being found offsite by emergency services and returned to the facility. The facility also failed to properly assess, supervise, and monitor residents during smoking activities. Residents who were identified as dependent smokers, or who had cognitive impairments, were observed smoking unsupervised in facility courtyards. In several cases, residents did not use required safety equipment such as smoking aprons/blankets, and independent smokers were observed assisting dependent smokers in violation of facility policy. Care plans for these residents did not consistently address noncompliance with smoking policies or provide adequate interventions for their supervision needs. Additionally, residents with known wandering behaviors were not effectively monitored or provided with updated care plan interventions following repeated incidents of entering other residents' rooms and engaging in altercations. Despite documented incidents of wandering and aggressive behavior, care plans were not revised to include additional safety measures. Staff interviews confirmed that expectations for monitoring were not consistently met, and multiple incidents occurred where residents with severe cognitive impairment wandered into unsafe situations or other residents' rooms without timely staff intervention.
Failure to Offer and Document Advance Directive Information
Penalty
Summary
The facility failed to ensure that four residents were offered information regarding Advance Directives, as required. During a record review, it was found that there was neither an Advance Directive nor documentation indicating that information about Advance Directives had been offered to these residents in their electronic medical records. When the surveyor inquired about the missing documentation, a staff member acknowledged that an audit had been started to identify residents needing Advance Directives and that outreach to residents and responsible parties had begun, but this process had not been performed consistently. The absence of both the Advance Directives and documentation of having offered the information was confirmed for the four residents reviewed.
Failure to Maintain Sanitary and Safe Resident Environment
Penalty
Summary
Surveyors observed multiple deficiencies related to the facility's failure to maintain a safe, clean, and homelike environment for residents. During observation rounds, several resident bathrooms were found with significant maintenance and cleanliness issues, including sinks loosely hanging from walls, toilets lacking proper seals with visible brown discoloration and holes at the base, bathroom floors with foul-smelling brown substances, ripped wallpaper, and separated door frames that compromised safe use. Additional concerns included brown stains on bathroom walls, missing drywall around exhaust fans, and marred walls under residents' TVs. These issues were identified in multiple rooms across both the east and west wing units. Further observations included the use of duct tape on chair railings near residents' beds and the presence of cobwebs, dead insects, and dirt between window screens and glass in resident rooms. Residents were present in the affected rooms at the time of the observations, and one resident reported a preference for keeping the window open, which revealed the unclean condition. The facility staff, including the Nursing Home Administrator, were made aware of these findings during the survey.
Failure to Develop and Implement Comprehensive, Person-Centered Care Plans
Penalty
Summary
The facility failed to develop and implement complete, person-centered care plans to address the medical, nursing, mental, and psychosocial needs of several residents. One resident expressed a desire for dental extractions and was evaluated by a prosthodontist, who recommended full mouth rehabilitation and surgical extractions. Despite this, the resident's care plan did not address their dental issues, and there was no evidence of a care plan to meet these needs. Another resident was admitted to hospice care, but their care plan was not updated to reflect their hospice status, as confirmed by staff and medical record review. For residents assessed as high risk for elopement or wandering, the facility did not consistently include appropriate interventions in their care plans. One resident with a high elopement risk and a physician order for a Wander Guard device did not have a care plan focus for wandering or exit-seeking behaviors. Another resident's care plan was not updated to reflect changes in monitoring orders for their wander prevention band, despite documentation of behavioral monitoring and device checks in the medical record. Additionally, a resident with ataxia and muscle weakness, who was identified as requiring supervision and a smoking apron/blanket while smoking, was repeatedly observed smoking without supervision and without the required protective equipment. The care plan for this resident did not include the need for a smoking apron/blanket, as indicated in the smoking safety screen. Staff interviews confirmed that residents were non-compliant with the smoking policy, and the care plan did not fully address the resident's safety needs during smoking activities.
Failure to Store and Label Food According to Professional Standards
Penalty
Summary
Surveyors observed that the facility failed to store food in accordance with professional standards for food service safety. During observation rounds with a dietary aide, sealed bins of white flour, white rice, brown rice, and sugar were found in the kitchen's dry goods storage room with expired use-by dates clearly labeled on them. Specifically, the white flour, white rice, brown rice, and sugar all had use-by dates that had already passed. Additionally, in the kitchen's freezer, an opened bag of frozen pepperoni was found without any labeling to indicate when it was opened or when it would expire. Interviews with the Dietary Director and Regional Food Service Director confirmed the presence of expired dry goods and the unlabeled opened frozen pepperoni. The facility's Food Storage Chart policy was reviewed and states that expiration dates printed by the manufacturer apply until the food product is opened, after which specific timeframes for safe use are outlined. The policy also requires that opened food items be labeled with the date they were opened to determine expiration, which was not followed in the case of the pepperoni.
Failure to Promptly Distribute Resident Mail
Penalty
Summary
The facility failed to ensure that residents received their mail in a timely manner, as required by facility policy. A complaint was reviewed indicating that a resident reported the Business Office was holding resident mail longer than appropriate. Interviews with the Business Office Manager revealed that when they began working at the facility, there was a backlog of undelivered resident mail due to the previous manager working remotely and not being present to distribute mail. The current Business Office Manager confirmed that they found and distributed the backed-up mail upon starting their position. Facility records, specifically the Resident Handbook, state that mail and other deliveries are to be promptly forwarded to residents.
Failure to Protect Residents' Property and Funds
Penalty
Summary
The facility failed to protect residents' property from loss in two separate incidents. In the first case, a resident's controlled pain medication, Oxycodone IR 5mg, was reported missing from the medication cart. The medication was received and signed for by an LPN, then handed off to other LPNs during shift changes. During these transitions, required counts of controlled medications were not performed, and the medication cart keys were exchanged without proper verification. The missing medication and its corresponding documentation were discovered the following morning when a nurse attempted to administer the medication and found it absent. In the second incident, a resident reported giving personal bank cards to a GNA to withdraw cash from an ATM. After returning the money and cards, the GNA requested and received a loan of $260 from the resident, with a verbal agreement to repay it. The GNA subsequently avoided contact and did not return the money as agreed. The incident was confirmed by facility staff during interviews.
Failure to Provide Written Bed-Hold Policy Notification Prior to Hospital Transfer
Penalty
Summary
The facility failed to provide written notification of its bed-hold policy to a resident or the resident’s representative prior to the resident’s transfer to a hospital. Medical record review showed that, before the resident was transferred in August 2024, there was no documentation indicating that the required written notification was given. Staff interviews confirmed that neither the resident nor the representative received the facility’s bed-hold policy paperwork or documentation before the transfer occurred.
Failure to Ensure Resident Privacy and Dignity During Care
Penalty
Summary
Facility staff failed to maintain a dignified and respectful environment for a resident during morning care. During observation rounds, the resident was found lying in bed with the bed raised to its highest position, uncovered, and with a yellow brief exposed. The privacy curtain was only partially drawn, allowing the resident to be visible to their roommate and anyone entering the room. When interviewed, the Geriatric Nursing Assistant acknowledged that the curtain should have been fully closed. The resident reported that staff never close the curtain, indicating a pattern of not ensuring privacy during care.
Inaccurate MDS Coding for Resident with Elopement Risk
Penalty
Summary
The facility failed to ensure the accuracy of Minimum Data Set (MDS) assessments for a resident with a history of elopement and high risk for wandering. The resident, who had dementia and impaired safety awareness, was observed multiple times wearing a wander guard and walking around the facility. Documentation confirmed that the resident had previously eloped from the facility and was subsequently assessed as high risk for elopement, with a care plan and interventions in place, including the use of a wander guard and regular monitoring by nursing staff. Despite these documented risks and interventions, the quarterly MDS assessment did not accurately reflect the resident's wandering behavior or the use of a wander guard. The assessment failed to code for wandering in Section E and did not indicate the use of a wander guard in Section P. This inaccuracy was confirmed by the MDS Coordinator during an interview, acknowledging that the resident's behaviors and interventions were not properly documented in the MDS assessment.
Failure to Hold Timely Care Plan Meetings After MDS Assessments
Penalty
Summary
The facility failed to ensure that residents were offered the opportunity to participate in their care planning process by not holding timely care plan meetings following comprehensive MDS assessments. Specifically, for one resident, care plan meetings were not conducted after quarterly and annual MDS assessments on three separate occasions, as confirmed by both record review and staff interviews. The care plan meetings are intended to involve the resident and/or their representative and are required to be held after each comprehensive assessment to summarize health conditions, care needs, and treatments. Interviews with the social worker revealed an ongoing issue with the timeliness of care plan meetings, with the staff member acknowledging that some meetings were overdue and in the process of being completed. Documentation reviewed by the surveyor confirmed the absence of care plan meetings for the resident following the specified MDS assessments, and no evidence was provided to show that the resident or their representative participated in the care planning process during those times.
Failure to Schedule Cardiology Follow-Up as Ordered
Penalty
Summary
A deficiency was identified when a resident, who had been admitted to the facility following a hospitalization for a stroke, did not have a cardiology follow-up appointment scheduled as ordered by the physician. The physician's order, dated 2/15/2025, specified that the resident should follow up with a cardiologist in 12 weeks. Upon review of the resident's electronic medical record and interviews with staff, it was found that there was no documentation of the appointment being scheduled within the required timeframe. Interviews with the Assistant Director of Nursing (ADON) and the unit clerk revealed that the process for scheduling appointments relies on the unit manager to inform the unit clerk of any required appointments, as the unit clerk does not have access to the electronic health record to view orders. The unit clerk only became aware of the need for the cardiology appointment on 4/22/2025 and scheduled it for a later date, well after the original order. This failure to ensure timely scheduling of the follow-up appointment resulted in the facility not meeting professional standards of care for the resident.
Failure to Administer Medication as Ordered
Penalty
Summary
A deficiency was identified when a resident did not receive their prescribed medication, Lacosamide 150mg, as ordered by the physician. Medical record review showed an active order for the resident to receive Lacosamide 150mg by mouth twice daily. During observation and medication cart review, it was found that the controlled substance blister pack contained 8 tablets, while the facility's controlled substance count sheet indicated there should have been 7 tablets remaining after the previous dose was reportedly administered the night before. Staff interview confirmed that the resident had not yet received the medication during the current shift and that the blister pack count did not match the count sheet, indicating a failure to administer the medication as ordered.
Failure to Accurately Reconcile Controlled Substance Medication
Penalty
Summary
The facility failed to accurately reconcile a resident's controlled substance medication, specifically Lacosamide 150mg, as required. Medical record review showed a physician's order for the resident to receive Lacosamide 150mg twice daily. On review of the medication cart and the resident's blister pack, there were 8 tablets present, while the controlled substance count sheet indicated there should have been 7 tablets remaining after the last documented administration. The count sheet showed that staff had signed off that the medication was administered and the count was correct, but this did not match the actual number of tablets in the blister pack. Further investigation revealed that the shift count sheet for the controlled substances was signed off by one staff member without completing the count with another nurse, as required during shift changes. Staff interview confirmed that the count was incorrect and that the medication had not been administered as documented. The staff member also acknowledged that the shift count sheet should not have been signed without a dual count at the time of shift change.
Failure to Provide Timely Dental Care for Resident
Penalty
Summary
Facility staff failed to ensure that a resident received necessary dental care. The resident expressed to staff a desire to have teeth extracted due to only being able to eat soft foods. The resident had previously been evaluated by a Prosthodontist, who recommended several surgical extractions and noted the resident's strong interest in dental implants. Despite this, there was no evidence that the recommended dental procedures were arranged or provided in a timely manner. Interviews with facility staff revealed a lack of awareness and follow-up regarding the resident's dental needs. The unit manager acknowledged the resident's request but did not indicate any immediate action. The Administrator cited the high cost of the dental work and lack of insurance as reasons for the delay. The Business Office Manager was unaware of the dental issue until informed by the surveyor, indicating a breakdown in communication and coordination among staff regarding the resident's dental care needs.
Failure to Maintain Accurate and Complete Medical Records
Penalty
Summary
The facility failed to maintain accurate and complete medical records in accordance with accepted professional standards for multiple residents. In several cases, cognitive assessments such as the Brief Interview for Mental Status (BIMS) were either incorrectly scored or not completed properly, leading to inconsistent documentation of residents' cognitive status. For example, one resident's BIMS score was entered as 99, indicating the interview could not be completed, yet the assessment showed the resident was able to answer questions, suggesting severe impairment. Additionally, smoking safety screens for these residents contained conflicting or missing information regarding cognitive loss and dexterity, with some questions left blank or answered inaccurately. Another deficiency was identified in the documentation of care provided, such as bathing. For one resident, the electronic medical record indicated a shower was given, while the corresponding shower sheet documented a bed bath instead, showing a discrepancy in the records. This inconsistency in documentation raises concerns about the accuracy of care records and the facility's ability to track the actual care provided to residents. Medication administration records also revealed deficiencies. A resident reported not receiving medications on time or at all, and a review of the electronic medical record and medication administration audit showed that medications were often administered and documented at times significantly later than ordered. Despite the medication administration record indicating that medications were given, the audit revealed delays and inconsistencies in the timing of administration and documentation. These findings demonstrate a failure to maintain accurate, timely, and complete medical records for residents, as required by professional standards.
Tracheostomy Tubing and Drainage Bag Found on Floor
Penalty
Summary
Surveyors observed that a resident with a tracheostomy had their extension tubing and drainage bag stretched across the floor and connected to their trach collar on multiple occasions. These observations occurred during several visits to the resident's room, where the oxygen delivery system was located along the wall and the tubing and drainage bag were seen in direct contact with the floor. Staff interviews confirmed that the tracheostomy extension tubing and drainage bag should not be touching the floor, yet the issue persisted even after it was brought to the attention of a unit manager. The infection preventionist also acknowledged that the tubing and drainage bag should not be on the floor.
Environmental Safety and Maintenance Deficiencies in Resident Bathrooms
Penalty
Summary
Surveyors determined that the facility failed to maintain a safe and comfortable environment for residents, as evidenced by observations made during facility rounds. Specifically, in two resident bathrooms, one was found to have a missing cove base at the bottom of the wall, and another had peeling paint on the floor. These deficiencies were directly observed by surveyors and subsequently brought to the attention of the Nursing Home Administrator and the Assistant Director of Nursing during staff interviews. No information was provided regarding the medical history or condition of the residents using these bathrooms at the time of the deficiency.
Failure to Timely Report Abuse and Misappropriation Allegations
Penalty
Summary
The facility failed to timely report allegations of abuse, neglect, or misappropriation of resident property as required by regulations. In one instance, a resident reported that $20.00 was stolen from their room, but the facility did not follow up with the resident or report the incident to the Office of Health Care Quality or other appropriate agencies within 24 hours. Documentation showed that the facility was aware of the missing money on 10/03/24, but the incident was not reported until brought to the attention of staff by a surveyor several months later. Staff interviews confirmed that the report was not made in a timely manner. Additionally, the facility failed to report two separate allegations of abuse within the required two-hour timeframe. In one case, the Assistant Director of Nursing was notified of possible abuse at midnight, the Nursing Home Administrator was informed at 7am, but the initial report to the State Agency was not submitted until 3:15pm. In another case, the DON was made aware of an abuse allegation at 11am, the administrator at 11:30am, and the report was submitted at 4pm, all outside the mandated two-hour window. These failures were identified during a review of 19 facility-related incident reports, with three incidents not reported in accordance with regulatory requirements.
Failure to Prominently Post Nurse Staffing Information
Penalty
Summary
The facility failed to post the required daily nurse staffing information in a prominent and readily accessible location for all residents and visitors on the Med Bridge unit. During observation rounds, it was noted that the staffing information was posted on the locked side of the unit, visible only through a slim window, making it difficult for most ambulatory residents and visitors on the unlocked side to view. This deficiency affected 17 out of 32 residents who resided on the unlocked portion of the unit. Staff confirmed that the information was not easily accessible to all residents and explained that staff verbally inform residents of their assigned caregivers at the start of each shift.
Latest citations in Maryland
The facility did not ensure that its Infection Preventionist (IP) met required qualifications for managing the Infection Prevention and Control Program. The DON reported serving as the IP but acknowledged lacking the specialized infection control training required for the role, and confirmed that no other staff member was currently qualified. Records showed that the previously qualified IP left several months earlier, and the Administrator and DON confirmed they were still seeking a replacement, leaving the infection control program without a properly trained leader.
Staff failed to consistently secure medications and medical supplies across three units, including an oxygen tank left on the floor behind a resident’s bed without a supporting device, a treatment cart with Collagenase Santyl cream left on top while two residents in power wheelchairs passed by, an unattended and unlocked treatment cart at a nursing station, and another treatment cart with Diclofenac gel and dressings left on top, indicating repeated lapses in maintaining locked and secure storage for drugs, biologicals, and related supplies.
The facility failed to provide sufficient dietitian coverage and timely nutritional assessments for several residents with significant dietary needs. A resident admitted for diabetic management with a high A1C was placed on a regular diet instead of the recommended carb-controlled diet and had only one weight taken in the first two weeks, with no dietitian review of the record. Another resident with prior significant weight loss had no documented dietitian follow-up despite continued weight loss, and a resident admitted with severe protein-calorie malnutrition experienced further significant weight loss without any dietitian assessment. The dietitian reported working limited hours and prioritizing certain high-risk cases, resulting in delayed or missed evaluations for new admissions and residents with ongoing nutritional concerns.
The facility failed to maintain adequate linen and incontinence supplies and did not keep resident care areas in good repair, resulting in delays and alterations in incontinence care and substandard environmental conditions. Staff reported that towels and washcloths were used instead of wipes and then discarded due to heavy soiling, and that linen deliveries to units were late, leaving residents waiting for care. Observations showed very limited numbers of clean washcloths and other linens on units and in the laundry, with no stock of disposable wipes or backup washcloth supply despite repeated reports to housekeeping. Additional observations revealed recliner chairs blocking a dining-area handwashing sink and kitchenette, multiple resident and shared bathrooms with unfinished spackle, chipped paint, musty odors, black substances near showers, missing threshold molding, exposed cracks and nails, and eroded, rusted baseboard heaters. Hallway handrails on both units were worn, chipped, and splintered, and a shower room contained fecal odors, dried brown stains on the toilet, and deteriorated fixtures, all contributing to a failure to provide a safe, clean, and homelike environment.
Facility staff did not thoroughly investigate two separate abuse allegations involving a resident and an injury of unknown origin involving another resident. In both cases, investigations focused on the directly affected resident and included staff interviews, but there were no interviews of other residents on the unit or documented assessments of those residents for signs of abuse or injuries of unknown origin, including residents unable to communicate due to cognitive status.
Two residents who were dependent on staff for oral care, including one with a tracheostomy, were observed with thick, white or milky substances coating their mouths and teeth, indicating inadequate oral hygiene. One resident communicated that staff did not brush their teeth and that staff "need to." In another case, despite oral care supplies being present in the room, the resident’s mouth and teeth remained unclean on multiple observations, with a thick milky substance caking the teeth and stringing between them when the resident tried to open their mouth. These findings showed that staff did not consistently provide oral care to residents who relied on them for this ADL.
Staff failed to maintain complete and accurate medical records for multiple residents, including missing and inconsistent documentation of wound care, delayed pain assessment after discovery of an injury of unknown origin in a cognitively impaired resident, and inaccurate recording of a PPD test result that was documented as negative despite no evidence the injection was administered and no supporting nurse’s note. Residents reported not receiving certain treatments, while MAR entries either lacked signatures for completion or contained conflicting information about whether care was provided.
Surveyors found that the facility failed to consistently implement and communicate correct transmission-based precautions and PPE use. One resident with a Foley catheter related to wounds had no precaution signage posted, while another resident in a double room had a contact precautions sign at the door, yet the NP entered without PPE and the GNA provided high-contact care wearing only gloves. Staff in that room stated the resident was not on contact precautions and later reversed the sign to show no PPE requirement. Therapy staff reported they rely solely on posted signs to determine PPE, and surveyors identified broader issues with inaccurate signage and staff awareness of which residents required contact precautions.
Surveyors found that MDS assessments were inaccurately coded for two residents. In one case, a resident sustained a femoral neck fracture after a fall, but the subsequent significant change MDS did not code the fall as a major injury and failed to capture prn Tylenol use documented on the MAR within the look-back period. In the other case, a quarterly MDS indicated opioid use for a resident, but the MAR for the same period showed no prescribed opioid, indicating incorrect coding of high-risk drug classes.
A resident who had recently been admitted and experienced a fall received multiple doses of the narcotic analgesic Tramadol, but the facility failed to accurately document all administered doses on the Medication Administration Record (MAR). Review showed only one Tramadol dose recorded on the MAR, while the Controlled Drug Receipt/Record/Disposition Form on the med cart reflected three doses given over two days. In interview, the DON stated staff are expected to document narcotic administration on the MAR and confirmed that two administered doses were not recorded there, resulting in an incomplete and inaccurate medical record.
Unqualified Infection Preventionist Overseeing Infection Control Program
Penalty
Summary
The facility failed to ensure that its designated Infection Preventionist (IP) met the mandatory qualifications for overseeing the Infection Prevention and Control Program. During an interview on 3/24/26 at 10:00 AM, the DON confirmed that she/he was serving as the facility’s IP but had not completed the specialized training in infection control required for the position. The DON further stated that no other staff member currently met the qualifications to serve as IP. Record review showed that the previously qualified IP left the facility in October 2025, and as of the survey date, the position remained unfilled by a qualified individual. At 1:30 PM on the same day, the Administrator and DON confirmed they were still in the process of finding a qualified IP for the facility, leaving the Infection Prevention and Control Program without a properly trained and qualified leader. No specific residents, medical histories, or clinical conditions were described in relation to this deficiency.
Unsecured Medications, Treatment Carts, and Oxygen Equipment
Penalty
Summary
Facility staff failed to ensure that drugs, biologicals, and related medical supplies were securely stored and properly maintained on multiple units. On one unit, an oxygen tank assigned to a resident was observed sitting on the floor behind the resident’s bed without any supporting device. On another unit, a treatment cart was observed with a tube of Collagenase Santyl cream labeled for a specific resident left on top of the cart, while residents in power wheelchairs passed by and staff were present at the nursing station. These observations showed that medications and oxygen equipment were not consistently secured as required. Further observations on additional units revealed an unattended and unlocked treatment cart at a nursing station, and on a separate occasion, a treatment cart with Diclofenac gel labeled for a resident left on top along with multiple packs of dressings. These incidents occurred across three units and on more than one date, demonstrating repeated failures to keep medications and treatment supplies in locked compartments or otherwise secured from unauthorized access.
Insufficient Dietitian Coverage and Delayed Nutritional Assessments
Penalty
Summary
The deficiency involves the facility’s failure to employ sufficient food and nutrition staff, including adequate dietitian coverage, to ensure timely assessment and appropriate diets for residents with significant nutritional and diabetic needs. A resident admitted over two weeks earlier with multiple comorbidities and an A1C of 11.5% had a hospital discharge recommendation for a carbohydrate-controlled diet, but was placed on a regular diet at admission with no acknowledgment of the recommended diet until one week later, when the resident requested larger portions. As of the survey date, the dietitian had not yet seen or reviewed this resident’s medical record, and the resident reported not having seen a dietitian and being very frustrated with the meals. During the first two weeks after admission, only one weight was obtained for this resident, despite physician notes stating the resident’s weight was “stable.” Further review of other residents showed additional failures in timely dietitian assessment and follow-up. One resident, readmitted in January and previously seen by the dietitian in September for a 6.4 lb weight loss over 30 days, had no documented follow-up despite continued weight loss totaling 22 lbs since the last dietitian review. Another resident admitted at the end of February with severe protein-calorie malnutrition had not been seen by the dietitian after about a month in the facility, despite a documented 14 lb (7%) weight loss over two weeks. The dietitian reported working only 12 hours per week at the facility and stated that she must prioritize which residents to see, focusing first on residents with tube feedings and those identified in risk meetings, resulting in delayed or absent assessments for new admissions and residents with ongoing weight loss and malnutrition diagnoses.
Linen Shortages and Poor Environmental Maintenance Compromise Resident Care and Comfort
Penalty
Summary
The deficiency involves the facility’s failure to maintain an adequate supply of clean linens and appropriate incontinence wipes, resulting in delays and alterations in residents’ incontinence care, as well as the use of towels and washcloths in place of disposable wipes. During the initial tour, the surveyor observed that the linen supply on one nursing unit hallway was low. Complaint reviews included concerns about delays in incontinence care and bed linens not being changed regularly, with residents left without clean bedding. A complainant reported that there was not enough clean linen available for residents. Staff interviews confirmed that towels, sheets, and washcloths were being used to wipe residents for incontinence care due to the absence of wipes, and that many of these linens were being thrown away when soiled. Staff also reported a shortage of linen, that linen deliveries to the units were late, and that residents who preferred to get up before breakfast had to wait for care when linen was delayed. Further observations showed that the clean supply room contained no disposable wipes or cloths for incontinence care, and a resident reported that staff did not use wipes, that the resident had to purchase their own, and that heavily soiled towels or washcloths were discarded. A tour of all nursing unit linen carts and closets revealed only six clean washcloths and limited supplies of towels, gowns, and bed linens. In the laundry room, only three washcloths were present, and the laundry assistant stated that there were only three washcloths available for each nursing unit that morning, that the facility was short on linen supply, and that these concerns had been repeatedly reported to the Director of Housekeeping over the preceding month and again that morning. The laundry assistant confirmed there was no additional laundry in process. The DON stated that wipe squares should be used for incontinence care, but no such wipes were found in the clean medical supply room, and no backup supply of washcloths was present in the emergency linen supply. The Director of Housekeeping confirmed there was no backup supply of washcloths. The deficiency also includes environmental and maintenance issues affecting resident bathrooms, handrails, and common areas. In the main dining area, a recliner chair was observed positioned directly in front of the handwashing sink, and two recliner chairs were stored in front of the nutrition area kitchenette. Multiple resident bathrooms and shared bathrooms were repeatedly observed over several days with unfinished spackle on walls that needed resurfacing and painting, chipped paint around sinks, uneven boards nailed to walls under sinks that appeared to partially cover holes, musty odors, black substances between shower bases and walls, missing threshold transition molding exposing cracks, missing tiles, and a nail, as well as eroded and chipped paint on baseboard heaters with exposed dark brown metal and rust-like material. Hallway handrails on both nursing units were observed to be worn, with chips, splintering, holes, and areas where the wood finish had worn off. A shower room was observed with a foul fecal odor, dried brown stains on the back of the toilet seat and in the toilet bowl, and a baseboard heater with eroded, chipped paint and rust-like material, along with chipped paint on the handrail. These conditions were acknowledged by the Director of Maintenance and other leadership, and some areas were noted to be in the process of renovation, but the observed deficiencies remained present during the survey period. Overall, the facility did not maintain a safe, clean, comfortable, and homelike environment in good repair across both nursing units and the dining area. The lack of adequate linen and incontinence supplies, combined with the poor condition of resident bathrooms, handrails, and certain common areas, constituted the basis for the cited deficiency. The observations and staff and resident reports consistently described shortages of essential hygiene supplies, delayed care related to linen availability, and multiple unresolved environmental and maintenance issues in resident care areas and shared spaces.
Failure to Thoroughly Investigate Abuse Allegations and Injuries of Unknown Origin
Penalty
Summary
Facility staff failed to thoroughly investigate allegations of potential abuse involving one resident and an injury of unknown origin involving another resident. For one resident, there were two separate allegations of abuse occurring on different days in early February. The facility’s investigation packets included interviews with staff who cared for or were scheduled to work with this resident on the days of the alleged incidents, and the investigations focused solely on this resident. However, there were no interviews conducted with other residents on the unit to inquire about abusive or neglectful treatment by the staff who were working during the times of the allegations. The surveyors noted that, although the allegations were not validated, there was no documentation that other residents were interviewed, if able, or assessed for signs or symptoms of injury. In a separate incident, another resident was identified on March 4 with a new bruise on the right eye, documented as a change in condition at 4:09 AM. This resident had a BIMS score of 99, indicating the resident was unable to complete an interview and therefore could not report how the injury occurred. The facility’s investigation identified a potential cause of the injury but did not reach a definitive resolution. Additionally, there were no interviews of other residents on the unit regarding possible abuse, nor were there documented assessments of other residents for injuries of unknown origin, particularly for those unable to speak for themselves, as in this resident’s case.
Failure to Provide Oral Care to Dependent Residents
Penalty
Summary
The deficiency involves the facility’s failure to provide oral care to residents who were dependent on staff for activities of daily living, specifically oral hygiene. One resident with a tracheostomy was observed with a thick, sticky white substance in the mouth and was noted to intermittently chew on nearby bedding. This resident made good eye contact and, when asked if staff brushed their teeth, shook their head no and mouthed that staff “need to.” According to the resident’s Minimum Data Set (MDS) dated 2/11/26, the resident was dependent on staff for oral care. Another resident, also dependent on staff for oral care per the 3/11/26 MDS, was observed sitting propped up in bed and able to respond with smiles. During the initial observation, the inside of this resident’s lips and upper and lower teeth had a thick, clear, white milky substance visible when the resident tried to open their mouth to smile. Oral care supplies were present in the nightstand, but the resident’s mouth and teeth were not clean. On a subsequent observation with the DON, NHA, and Corporate VP of clinical services, the same resident again had a thick, clear, milky substance between the lips and caking the teeth, which would string between the teeth when the resident attempted to open their mouth, demonstrating a lack of consistent oral care for residents dependent on staff for this ADL.
Incomplete and Inaccurate Medical Record Documentation for Treatments and Assessments
Penalty
Summary
Facility staff failed to maintain complete and accurate medical records and documentation for multiple residents. For one resident with wound care needs, review of the MAR showed that wound care and related treatments were signed as completed on the dates initially reported, despite the resident’s ongoing complaints that wound dressings were not being changed. When additional dates were reviewed, there were missing staff signatures for wound care on two specific dates, as well as three instances where application of A&D ointment to the resident’s feet was not signed off out of 24 days reviewed. Another resident with severe cognitive impairment, as evidenced by a BIMS score of 00, was found to have an injury of unknown origin (a bruise on the left hand). Documentation showed that a change in condition was initiated late in the morning, but a formal pain evaluation was not initiated and completed until that night, and the resident was unable to explain how the injury occurred or verbalize pain using a standard pain scale. For a third resident, documentation related to the admission PPD test was inconsistent and incomplete. The MAR contained an entry indicating “9” for the administration date, meaning “see nurse’s note,” but there was no corresponding nurse’s note. Despite the absence of a signed administration of the PPD injection, staff documented the PPD result as “negative” on the scheduled read date. The resident reported never receiving the PPD injection, and the DON confirmed that the facility had been out of PPD solution at the time, so the test would not have been administered. These findings demonstrate failures in accurate documentation of treatments and assessments, including wound care, pain assessment, and TB screening, as well as missing or incomplete supporting notes in the medical record.
Failure to Implement and Communicate Correct Transmission-Based Precautions
Penalty
Summary
Surveyors identified a deficiency in the facility’s infection prevention and control program related to inconsistent and incorrect implementation of transmission-based precautions and PPE use. During a complaint investigation focused on residents on transmission-based precautions, one resident with a visible Foley catheter was observed in the room with physical therapy, but there were no signs posted indicating any need for PPE, despite the resident being a new admission with a Foley catheter placed related to wounds. In another double-occupancy room, a contact precautions sign was posted at the doorway, but the nurse practitioner was in the room on a personal phone with no PPE, and the assigned GNA was repositioning the resident in bed while wearing only gloves. When questioned, the NP, RN, and GNA all stated that the resident in the room was not on contact precautions, and the GNA reported that signs were hanging at all doors and that this particular resident’s sign was “just wrong.” The surveyor observed the GNA later return to the room and turn the sign around to indicate no PPE requirement. Subsequent interviews revealed that therapy staff relied on posted signage to determine PPE use and that if the sign was wrong, the PPE used would be wrong. Overall, surveyors found problems with signage accuracy and staff awareness of which residents required contact precautions, as well as observed failures to follow appropriate PPE use for residents who should have been on contact precautions.
Inaccurate MDS Coding for Falls, Pain Management, and High-Risk Medications
Penalty
Summary
Facility staff failed to ensure Minimum Data Set (MDS) assessments were accurately coded for two residents reviewed during a complaint survey. For one resident, a facility-reported incident showed that the resident was found seated on the floor beside the bed and was diagnosed with a non-displaced femoral neck impaction fracture of the left hip following an x-ray. Despite this fall with a major injury, the subsequent significant change MDS dated 11/4/25 did not code the fall with major injury in Section J1900C. Review of the resident’s Medication Administration Records for October and November 2025 showed administration of Tylenol on 10/31/25 at 9:30 PM, which fell within the 5-day look-back period for the MDS, but Section J0100 (prn pain) of the same significant change MDS did not capture the use of Tylenol. For another resident, review of a quarterly MDS with an assessment reference date of 10/15/25 showed that Section N0415 (High-Risk Drug Classes) documented the use of an opioid medication. However, review of the resident’s October 2025 Medication Administration Record did not show that the resident had been prescribed an opioid during that period. In both cases, MDS staff later confirmed that these were errors in MDS coding, demonstrating that the assessments did not accurately reflect the residents’ clinical status and medication use as documented in their medical records.
Incomplete Documentation of Narcotic Administration on MAR
Penalty
Summary
The facility failed to maintain complete and accurate medical records in accordance with accepted professional standards for one resident receiving narcotic medication. The resident, admitted in March 2026, had a fall on 3/6/26 and was sent to the hospital on 3/9/26. Review of the March 2026 Medication Administration Record (MAR) showed documentation of a single 25 mg dose of Tramadol administered on 3/8/26 at 9:23 AM. However, review of the resident’s Controlled Drug Receipt/Record/Disposition Form, kept on the nurse’s medication cart and not in the medical record, showed that Tramadol 25 mg was administered three times between 3/8/26 and 3/9/26: at 11:00 AM and 9:00 PM on 3/8/26, and at 9:00 AM on 3/9/26. In interview, the DON stated that staff are expected to document narcotic administration on the MAR and confirmed that only one of the three Tramadol doses reflected on the controlled drug record was documented on the resident’s MAR. This discrepancy between the controlled substance record and the MAR, with missing documentation of two administered doses of Tramadol on the official medical record, constituted the failure to maintain a complete and accurate medical record for the resident.
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