Wicomico Nursing Home
Inspection history, citations, penalties and survey trends for this long-term care facility in Salisbury, Maryland.
- Location
- 900 Booth Street, Salisbury, Maryland 21801
- CMS Provider Number
- 215007
- Inspections on file
- 19
- Latest survey
- February 5, 2026
- Citations (last 12 mo.)
- 13
Citation history
Health deficiencies cited at Wicomico Nursing Home during CMS and state inspections, most recent first.
A facility failed to submit the final investigation report of an alleged abuse incident to the OHCQ within the required timeframe. A resident was found with unexplained discoloration on her hands and forearm. Although the initial report was submitted within 24 hours, the final report was not submitted within 5 working days. The ADON confirmed the absence of documentation for the 5-day conclusion report.
A resident in an LTC facility was administered the antibiotic Cefepime twice daily instead of the prescribed once daily, over three days. This error was confirmed by the resident's physician and the facility pharmacy manager, highlighting a failure in medication administration and documentation.
A facility failed to maintain an accurate medical record for a resident, as a physician certification form was found with a date discrepancy and missing resident identification. The nurse practitioner could not explain the omission, and the issue was discussed with the facility's administration.
A facility failed to ensure resident safety during wheelchair transport and fall prevention, resulting in harm. A resident with osteoporosis was injured due to the absence of leg rests on their wheelchair, leading to a fracture. Another resident, at high risk for falls, experienced multiple falls without updates to their care plan. Additionally, a third resident was observed being transported without leg rests, contrary to facility policy. Staff interviews confirmed lapses in protocol adherence and documentation.
A resident experienced significant dental pain and weight loss due to the facility's failure to provide timely dental care. Despite being prescribed antibiotics and pain medication, the resident was not seen by the dental group due to time constraints and insurance issues. Interviews revealed a lack of communication and coordination among staff, contributing to the delay in treatment.
The facility failed to update and revise care plans for several residents after changes in their needs or incidents occurred. For example, a resident's care plan did not include the use of Geri-sleeves despite a physician's order, and another resident's care plan lacked updates after a fall, omitting the use of fall mats and leg rests. Interviews with staff revealed inconsistent documentation and updating of care plans, contributing to the deficiencies identified.
A resident was left completely exposed during a bed bath, with neither the privacy curtain nor the window curtain pulled, making her visible from the hallway and outside. The GNA confirmed the oversight, and the DON acknowledged the facility's expectation for privacy and dignity during care.
A resident with severe cognitive impairment was found in a bed with a wheelchair placed against the head of the bed, restricting movement and acting as a physical restraint. This setup was not part of the resident's care plan and was not listed as an appropriate restrictive device in the facility's policy. Staff interviews revealed that the wheelchair was placed to prevent falls, but it was not intended to be used as a restraint.
The facility failed to report allegations of abuse and injury within required timeframes. In one case, a resident with a bruise on the eye was not reported to OHCQ within 2 hours, and in another, a resident's injury was not reported within 24 hours. The DON acknowledged the delays, citing frequent bruising and medication use for one resident, but this did not justify the reporting failures.
The facility failed to thoroughly investigate two incidents involving residents. In one case, a resident's eye discoloration was not reported by staff until days after it was first noticed by the resident's daughter. In another case, a resident's fall was not fully investigated as interviews with the GNAs who found the resident were missing. The DON and ADON acknowledged the investigations were incomplete.
A resident's behaviors, including wandering and aggression, were not accurately coded in the MDS assessments, despite being documented in medical records. The social worker, overwhelmed by workload, had assistance from another individual who failed to code the behaviors correctly, leading to the deficiency.
Two residents' CPAP and nebulizer masks were left uncovered on dressers, increasing infection risk. A nurse confirmed the masks should have been bagged for infection control, but this was not done. The DON noted a lack of policy on mask storage, despite recent updates to cleaning procedures.
Failure to Submit Final Investigation Report to OHCQ
Penalty
Summary
The facility failed to report the final investigation of an incident of alleged abuse to the Office of Health Care Quality (OHCQ) as required. On December 19, 2024, a resident was observed with discoloration on her bilateral hands and left forearm by a staff member and the resident's family member. The resident was unable to explain how the discoloration occurred. The facility submitted the initial report to OHCQ within 24 hours of the allegation, but did not submit the final investigation report within the required 5 working days. During an interview on March 10, 2025, the Assistant Director of Nursing confirmed that the staff could not locate any documentation that the 5-day conclusion was reported to the State Survey Agency for the incident.
Medication Administration Error in LTC Facility
Penalty
Summary
The facility failed to ensure that a resident's medications were administered as ordered, leading to a significant medication error. This was identified during a complaint survey involving a resident who was prescribed the antibiotic Cefepime, 1 gram, to be administered intravenously every 24 hours for 7 days. However, the medication administration records revealed that the nursing staff administered the antibiotic twice daily on three consecutive days, contrary to the physician's order. This error was discovered during a review of the resident's closed medical record and was confirmed by both the resident's physician and the facility pharmacy manager. The resident's physician confirmed that the order was for a single daily dose, and the facility pharmacy manager corroborated that the pharmacy received the correct order. The error was brought to the physician's attention by a nurse, indicating a lapse in following the prescribed medication regimen. The report does not provide details on the resident's medical history or condition at the time of the deficiency, but it highlights a critical failure in medication administration and documentation, which could have significant implications for resident safety.
Inaccurate Medical Record Documentation
Penalty
Summary
The facility staff failed to maintain an accurate medical record for a resident, as identified during a complaint survey. The deficiency was noted in the medical record of one resident, where a completed physician certification form related to medical condition, decision making, and treatment limitations was dated incorrectly. The form, completed and signed by the facility nurse practitioner, was found in the resident's closed medical record with a date discrepancy. During an interview, the nurse practitioner was unable to explain why the signed certification form did not have the resident's name printed on it. The issue was discussed with the Administrator and Assistant Director of Nursing.
Failure to Ensure Resident Safety During Wheelchair Transport and Fall Prevention
Penalty
Summary
The facility failed to ensure the safety of a dependent resident during transportation to activities in a wheelchair, resulting in actual harm. Resident #28, who was non-ambulatory and had a history of osteoporosis and a previous tibial fracture, was being transported without leg rests on the wheelchair. The resident's legs became too heavy to hold up, causing them to drop and get caught under the wheelchair, leading to a fracture in the lower leg. The incident highlighted a lack of adherence to the facility's protocol for using leg rests during wheelchair transport, as confirmed by staff interviews and facility documentation. Additionally, the facility did not implement new fall interventions for a resident at high risk for falls, despite multiple incidents resulting in injuries. Resident #51, who was severely cognitively impaired and had a history of falls, experienced several falls without any updates to their care plan to address the risks. Staff interviews revealed a lack of communication and documentation regarding fall interventions, and the care plan had not been updated since February 2023, despite the resident's repeated falls and injuries. Furthermore, another resident, #57, was observed being transported in a wheelchair without leg rests, requiring them to hold their legs up. This was against the facility's policy, which mandates the use of leg rests during transport to prevent injury. Staff interviews confirmed that the policy was not followed, and the leg rests were not available in the resident's room. The facility's failure to adhere to its own safety protocols for wheelchair transport and fall prevention contributed to the deficiencies identified by the surveyors.
Failure to Provide Timely Dental Care
Penalty
Summary
The facility failed to provide timely and adequate dental care for a resident, identified as R55, who experienced significant dental pain and weight loss. R55 was admitted with multiple diagnoses, including hip and knee contractures, congestive heart failure, and adjustment disorder with anxiety. Despite being assessed as moderately cognitively impaired and on a regular diet with no initial dental concerns, R55 began experiencing tooth pain, which was documented in the nursing progress notes. The facility's care plan did not address changes in dental pain, and interventions for weight loss due to poor food intake did not consider dental issues. R55's dental pain was first noted on 07/24/24, with a decayed and chipped tooth identified. Although a dental consult was ordered, the resident was not seen by the 360 dental group due to time constraints and insurance issues. The resident continued to experience pain, affecting their ability to eat, leading to a downgraded diet and significant weight loss. Despite being prescribed antibiotics and pain medication, the facility failed to ensure R55 received the necessary dental care, resulting in ongoing pain and discomfort. Interviews with facility staff revealed a lack of communication and coordination in addressing R55's dental needs. The Medical Records/Social Services staff and the Director of Nursing were aware of the resident's pain but did not take effective action to secure timely dental care. The facility's reliance on the 360 dental group and the misunderstanding of the resident's eligibility for services contributed to the delay in treatment. The facility did not have a policy addressing dental concerns, leading to confusion and inadequate response to R55's acute dental issue.
Failure to Update and Revise Care Plans
Penalty
Summary
The facility staff failed to update care plans when there were changes in resident needs or preferences, and did not thoroughly evaluate and revise resident plans of care after each assessment. This deficiency was identified during a complaint survey involving six residents. For instance, Resident #40's care plan was not updated to include the use of Geri-sleeves despite a physician's order, and Resident #27's care plan lacked updates after a fall, failing to include the use of fall mats and leg rests. Resident #34's care plan was not revised to include increased rounding and frequent toileting after a fall incident. Similarly, Resident #28's care plan did not reflect the need for wheelchair leg rests after sustaining an injury during transport. Resident #504's care plan was not updated with additional interventions despite multiple falls and a change in medical status, and it also lacked details on oxygen use and inhaler administration. Resident #505's care plan was not updated with new interventions following a fall that resulted in a fracture. Interviews with facility staff, including the Assistant Director of Nursing, Director of Nursing, and MDS Coordinator, revealed a lack of consistent documentation and updating of care plans. The MDS Coordinator acknowledged that while interventions were being implemented, they were not documented in the care plans. The Director of Nursing stated that care plans should be updated after incidents, but this was not consistently done, leading to the deficiencies identified in the survey.
Failure to Ensure Privacy During Resident Bed Bath
Penalty
Summary
The facility failed to provide visual privacy during a bed bath for a resident, identified as R56, who was totally dependent on staff for bathing and was cognitively intact with a BIMS score of 13 out of 15. During a facility tour, a surveyor observed R56 lying completely naked and exposed on her bed while a Geriatric Nurse Aide (GNA) was providing a bed bath. The privacy curtain was not pulled, and the resident was visible from the hallway. Additionally, the window curtain was not drawn, exposing the resident to anyone walking outside past her ground-level room. Interviews conducted with the GNA and the Director of Nursing (DON) confirmed the lack of privacy measures during the bed bath. The GNA acknowledged that the curtains were not pulled and the resident was not covered. The DON stated that the facility's expectation is to ensure privacy and dignity during care, which includes pulling both the privacy and window curtains and covering the resident during a bath. The resident expressed discomfort at the thought of being seen by a man while exposed.
Failure to Maintain Restraint-Free Environment
Penalty
Summary
The facility failed to maintain a restraint-free environment for a resident identified as R51, who was reviewed for physical restraints. The resident, who was severely cognitively impaired with a BIMS score of 99, was observed in a low bed with a fall mat and a quarter side rail. The left side of the bed was against the wall, and a wheelchair was placed against the head of the bed, effectively preventing the resident from getting out of bed. This setup was not listed as an appropriate restrictive device in the facility's policy, and the use of the wheelchair in this manner was not included in the resident's care plan for falls. During interviews, a Geriatric Nurse Aide (GNA) admitted to placing the wheelchair against the bed to prevent the resident from falling out. A Registered Nurse (RN) on duty acknowledged seeing the wheelchair against the bed but did not take action to move it or inquire about its placement. The Infection Control Nurse/Staff Development nurse confirmed that the wheelchair acted as a barrier, and the Director of Nursing verified that the wheelchair should not have been placed against the bed. These actions and inactions contributed to the deficiency, as the facility did not adhere to its policy of maintaining a restraint-free environment.
Failure to Timely Report Allegations of Abuse and Injury
Penalty
Summary
The facility failed to report allegations of an injury of unknown source within the required 2-hour timeframe to the Office of Health Care Quality (OHCQ). This was evident in the case of a resident who was found with a discoloration/bruise on the outer corner of the right eye. The incident was discovered on a Thursday morning, but the initial report was not sent until later that afternoon, exceeding the 2-hour requirement. The resident's daughter had noticed the discoloration four days earlier but did not report it, and the nursing staff also failed to report it until the day of discovery. The Director of Nursing (DON) acknowledged the delay and attributed it to the resident's frequent bruising due to combative behavior and medication use, but this did not justify the failure to report promptly. In another incident, the facility did not submit a report within the required 24-hour timeframe after a resident allegedly punched a staff member, resulting in a laceration on the resident's hand. The initial report was submitted several days after the incident, and the DON confirmed the delay. These failures to report in a timely manner were identified during a complaint survey and involved inadequate communication and documentation by the facility's staff, leading to non-compliance with regulatory requirements.
Incomplete Investigations of Resident Incidents
Penalty
Summary
The facility failed to thoroughly investigate incidents of injuries of unknown origin for two residents during a complaint survey. In the first case, a resident was noted to have a discoloration to the outer corner of the right eye, which was first noticed by the resident's daughter on a Sunday. However, the facility staff did not report the discoloration until the following Thursday. The facility's investigation included interviews with some staff members but failed to include interviews with ten additional staff members who worked during the period when the discoloration was first noticed. The Director of Nursing was unable to explain why the staff who worked with the resident during that time did not report the discoloration. In the second case, a resident sustained a fall and was found on the floor near a wheelchair with a spilled cup of coffee. The facility's investigation included an incident report, a nurse's statement, an x-ray report, hospital documentation, and the resident's medication list. However, it lacked interviews with the two GNAs who found the resident and any other staff who may have seen the resident before the fall. The Assistant Director of Nursing acknowledged that the investigation was incomplete, as it did not include expected statements from the GNAs or others who saw the resident prior to the fall.
Inaccurate MDS Coding for Resident Behaviors
Penalty
Summary
The facility staff failed to ensure that Minimum Data Set (MDS) assessments were accurately coded for a resident during a complaint survey. The resident exhibited behaviors such as wandering, verbal aggression, and exit-seeking, which were documented in the medical records. However, these behaviors were not accurately reflected in the MDS assessments. For instance, the MDS with an assessment reference date of June 7, 2023, incorrectly documented that the resident did not exhibit verbal behavioral symptoms or wandering, despite multiple notes indicating otherwise. The inaccuracies in the MDS assessments were attributed to the social worker's workload, as they were working two jobs and had enlisted help from another individual. This helper documented the behaviors in progress notes but failed to code them correctly on the MDS. The social worker eventually stopped the helper from completing further MDS assessments upon realizing the errors. This oversight led to the deficiency in accurately assessing and documenting the resident's needs and behaviors.
Improper Storage of Respiratory Masks
Penalty
Summary
The facility failed to properly store CPAP and nebulizer masks for two residents, increasing the potential for respiratory infections. Resident 5, who was cognitively intact with a BIMS score of 13, had a CPAP mask left uncovered on the dresser beside their bed during multiple observations. Similarly, Resident 26, who was moderately cognitively impaired with a BIMS score of 8, had a nebulizer mask left uncovered on the dresser beside their bed during the same observation periods. These observations were confirmed by Registered Nurse 4, who acknowledged the masks should have been stored in bags for infection control. The Director of Nursing (DON) acknowledged that the facility's policy for CPAP masks had been recently updated due to issues with cleaning during the 3-11 shift. However, there was no policy regarding the storage of these masks. The DON confirmed that the masks should have been stored in plastic bags and changed weekly for infection control, but this was not being done, leading to the deficiency noted by the surveyors.
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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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.
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