Williamsport Health And Rehabilitation Center
Inspection history, citations, penalties and survey trends for this long-term care facility in Williamsport, Maryland.
- Location
- 154 North Artizan Street, Williamsport, Maryland 21795
- CMS Provider Number
- 215198
- Inspections on file
- 17
- Latest survey
- December 10, 2025
- Citations (last 12 mo.)
- 32 (1 serious)
Citation history
Health deficiencies cited at Williamsport Health And Rehabilitation Center during CMS and state inspections, most recent first.
Two residents with documented wishes for no CPR received resuscitation after staff failed to follow or locate the correct MOLST forms, resulting in conflicting code status orders and lack of a clear process for verifying advance directives. Staff confusion and inconsistent documentation contributed to the deficiency.
A resident's care plan meeting was conducted in their room with a roommate present, resulting in a breach of privacy when the roommate made comments indicating they were listening. Staff had adopted the practice of holding care plan meetings in residents' rooms since the COVID-19 pandemic and did not consider the lack of privacy on the LTC unit. The issue was confirmed by interviews with social services staff and was brought up by the resident's family at the end of the meeting.
Staff did not ensure a clean and homelike environment on Unit A, as surveyors observed soiled carpets, crumbs, and debris in resident rooms and hallways. The Environmental Director confirmed that housekeeping was responsible for these areas and identified ongoing issues with cleanliness due to poor time management by the assigned staff.
A resident requiring assistance with personal care did not receive appropriate incontinent care over multiple shifts, resulting in saturated briefs and bedding and a strong urine odor. Documentation was missing or indicated care was not provided, and staff failed to notify nursing or provide education when care was refused. The DON confirmed that lack of documentation meant the care was not completed.
Staff failed to maintain accurate and consistent code status information in medical records, resulting in two residents receiving unwanted CPR due to conflicting MOLST forms and physician orders. The facility did not ensure all staff were educated on the correct process, and the QAPI committee did not address or follow up on the identified deficiencies.
A resident's representative was wrongfully denied access to medical records after the resident's death, despite having a healthcare POA documented in the advanced directive. The request was denied by a third-party vendor due to missing documentation, which facility staff failed to review and provide, resulting in the representative's rights not being honored.
The facility failed to protect residents from various forms of abuse and neglect, including physical, mental, and sexual abuse, as well as physical punishment, by any individual.
The facility did not provide required annual performance reviews or 12 hours of in-service training for two GNAs, as confirmed by record review and staff interviews. Leadership acknowledged the lack of documentation for these requirements over multiple years.
A resident did not receive several prescribed medications at the correct times, including doses of hydroxyzine, doxycycline, Entresto, and trimethoprim, which were administered either late or too close together. Staff confirmed these deviations from physician orders and professional standards, as documented in medication administration records and through interviews.
Surveyors found that required daily nurse staffing information was not consistently posted, and records of these postings were not retained for the required period. The DON confirmed that postings were missing and that historical records were unavailable, affecting all nursing units.
The facility did not ensure that all grievances were investigated and responded to promptly. Two residents reported repeated concerns about long call light response times and staffing, but their complaints were not consistently documented, investigated, or addressed according to policy. Audit reports confirmed extended wait times, and staff interviews revealed lapses in grievance handling and communication.
A resident's personal funds were misappropriated when an agency LPN took possession of the resident's credit card and driver’s license while the resident was temporarily transferred out of the facility. The LPN admitted to making unauthorized charges, including the purchase of a $100 Amazon gift card, using the resident’s credit card.
A resident developed a blister on the right foot after nursing staff applied a warm compress and failed to monitor the skin condition afterward. The compress was secured with an ace bandage, and no immediate discomfort was noted, but lack of follow-up led to the injury. The DON confirmed that staff did not monitor the resident as required.
Insufficient nursing staff resulted in two residents experiencing prolonged call light response times, with waits ranging from 30 minutes to several hours for assistance with incontinence care, toileting, and meal-related needs. Staff interviews and call bell audits confirmed that low staffing levels contributed to these delays, and the DON was unable to justify the adequacy of staffing when presented with evidence of the extended response times.
Facility staff administered insulin to two non-diabetic residents, resulting in significant medication errors. One resident with a history of kidney/pancreas transplant and hypoglycemia monitoring was injected with insulin and required frequent glucose checks and glucose tablets. Another resident with multiple chronic conditions but no diabetes diagnosis also received insulin after being confused with another patient. The LPN admitted to mixing up residents, and the facility did not conduct an internal investigation or report the incident to the appropriate health authority.
Failure to Honor Residents' Advance Directives for CPR Due to Inadequate MOLST Management
Penalty
Summary
The facility failed to have a process in place to ensure that residents' choices regarding cardiopulmonary resuscitation (CPR), as documented in their Maryland Orders for Life-Sustaining Treatment (MOLST) forms, were honored. This deficiency was identified through record review and staff interviews, which revealed that staff were unclear about where to locate the active MOLST forms in the electronic medical record. Multiple staff members reported different methods for determining code status, including checking the information bar, reviewing uploaded documents, or referencing daily assignment sheets. However, there was no standardized procedure, and it was noted that retrieving the correct information could be time-consuming. For one resident, two active MOLST forms were found in the medical record: one indicating full code status and another, more recent, indicating no CPR. The older form was not voided, and conflicting physician orders were present in the system. When the resident was found unresponsive, CPR was initiated by staff, and it was only after EMS arrived and reviewed the paperwork that the resident's wish for no CPR was discovered. Staff failed to document the time CPR was started, and interviews revealed a lack of recall about the incident and confusion regarding the correct code status at the time of the event. An audit following the incident identified other residents with multiple active MOLST forms and conflicting code status orders. A similar incident occurred with another resident who had an active MOLST indicating no CPR, but this document was not uploaded into the record until after a conflicting full code order had been entered and remained active. When the resident coded, CPR was initiated despite the resident's documented wishes. Staff interviews and review of statements failed to clarify where the nurse checked for code status before starting CPR, and it was confirmed that two active MOLST forms were present in the record at the time. These failures led to the declaration of Immediate Jeopardy due to the facility's inability to ensure residents' advance directives were followed.
Removal Plan
- The facility completed audit of all MOLST forms and code status orders to ensure they matched.
- Any discrepancies identified were corrected upon discovery.
- The audit was completed by the Assistant Director of Nursing.
- All clinical nursing staff in the facility, including agency staff, were educated on ensuring that when a code event occurs, they are to look in Point Click Care under documents and filter for category MOLST for the active MOLST.
- Any staff not available will be educated prior to beginning their next scheduled shift to include active agency staff.
Failure to Ensure Privacy During Care Plan Meetings
Penalty
Summary
Facility staff failed to ensure the privacy of residents' personal and medical information by conducting care plan meetings in residents' rooms while roommates were present. In one instance, a care plan meeting was held in a resident's room on the LTC unit with the roommate present, and the roommate made a comment indicating they were listening to the discussion. The staff had pulled the curtain for privacy, but this did not prevent the roommate from overhearing the meeting. The practice of holding care plan meetings in residents' rooms had been adopted since the COVID-19 pandemic, and staff did not consider the lack of privacy when the resident was placed on the LTC unit. Interviews with the Director of Social Services and Social Services staff confirmed that care plan meetings were routinely held in residents' rooms, and that the privacy of the meetings was not always ensured, especially when a roommate was present. The Director of Social Services acknowledged that the room layout did not provide sufficient privacy for such meetings, particularly on the LTC unit. The issue was brought to the attention of staff by the resident's family, but only at the end of the meeting.
Failure to Maintain Clean and Homelike Environment on Unit A
Penalty
Summary
Facility staff failed to maintain a clean and homelike environment for residents on Unit A, as evidenced by multiple observations of visibly soiled and debris-laden floors in resident rooms and hallways. On two separate occasions, surveyors noted carpeted floors near doorways that were visibly soiled, as well as crumbs and debris under beds and in hallways. Additional debris, such as a cup lid, was found near the door to the room with the ice chest. The Environmental Director confirmed that housekeeping staff were responsible for keeping these areas clean and acknowledged ongoing issues with cleanliness on Unit A, attributing the problem to a lack of time management skills by the assigned housekeeper.
Failure to Provide and Document Incontinent Care
Penalty
Summary
The facility failed to provide appropriate incontinent care for a resident who required assistance with personal care. On two consecutive days, a complaint was received that the resident had not been changed, resulting in a strong odor of urine and saturated briefs and bedding. Review of assignment sheets showed limited staffing during the relevant shifts, and documentation for incontinent care was either missing or indicated that care was not provided. Specifically, there was no record of incontinence care being performed on several shifts, and on one occasion, the resident was documented as refusing care without any evidence that the nurse was notified or that education was provided to the resident. Medical record review confirmed that the resident needed thorough skin care for each incontinent episode, as recommended by a nurse practitioner treating the resident's wounds. The Director of Nursing, in the presence of the Nursing Home Administrator, acknowledged concerns regarding the lack of documentation and agreed that if staff did not sign off on the task, it was considered not done. The findings were based on both documentation review and interviews, confirming that incontinent care was not consistently provided or properly documented for the resident in question.
Failure to Address Conflicting Code Status Orders Resulting in Unwanted CPR
Penalty
Summary
The facility failed to implement corrective action after identifying that staff maintained inaccurate and inconsistent code status information in residents' medical records. This deficiency resulted in residents receiving unwanted Cardiopulmonary Resuscitation (CPR). In one instance, a resident's medical record contained two active Maryland Orders for Life Sustaining Treatment (MOLST) forms with conflicting code statuses—one indicating full code and another indicating no CPR. When the resident was found unresponsive, CPR was initiated despite the resident's documented wish not to receive it. The medical record also lacked documentation of the time CPR was started. A subsequent audit revealed additional residents with more than one active MOLST and conflicting code status physician orders. The process for updating and voiding MOLST forms and corresponding orders was not consistently followed, and not all nursing staff received education on the correct procedures. Despite the identification of these issues, the facility's Quality Assurance Performance Improvement (QAPI) committee meeting minutes over an eleven-month period did not document discussion or follow-up on the performance improvement plan (PIP) created to address the problem. In another case, a resident with an active MOLST indicating no CPR had conflicting physician orders in the medical record, including an order for full code that remained active until the resident coded. The resident received unwanted CPR for twelve minutes. The DON did not fully investigate the incident to determine the cause or ensure corrective action was taken. The QAPI committee failed to review or address this system breakdown in their meetings, and there was no evidence of actions taken to prevent recurrence.
Failure to Provide Resident Records to Authorized Representative
Penalty
Summary
The facility failed to honor a resident representative's right to access the resident's personal and medical records following the resident's death. The representative completed a medical records request form at the facility, but later received a phone call from staff stating the request was denied without further explanation. The medical records coordinator reported that requests are sent to a third-party company, Rytes, for determination. In this case, Rytes denied the request, citing a lack of supporting documentation to prove the representative's authority. However, the resident's medical record contained an advanced directive appointing the representative as the healthcare power of attorney, which was not reviewed or provided to Rytes by the facility staff. The medical records coordinator admitted to not reviewing resident records and relying solely on Rytes to determine eligibility for record release. Both the coordinator and Rytes had access to the resident's medical record, which included the necessary advanced directive. The failure to review the resident's file and provide the required documentation resulted in the wrongful denial of the records request. The deficiency was confirmed through interviews and record reviews, which showed that the facility did not follow proper procedures to ensure the representative's right to access the records was honored.
Failure to Protect Residents from Abuse and Neglect
Penalty
Summary
A deficiency was identified regarding the facility's failure to protect each resident from all types of abuse, including physical, mental, sexual abuse, physical punishment, and neglect by any individual. The report notes that residents were not adequately safeguarded from these forms of mistreatment, indicating lapses in the facility's responsibility to ensure resident safety and well-being. No specific details about the residents involved, their medical history, or their condition at the time of the deficiency are provided in the report.
Failure to Provide Annual Performance Reviews and In-Service Training for GNAs
Penalty
Summary
The facility failed to ensure that Geriatric Nursing Assistants (GNAs) received required annual performance reviews and at least 12 hours per year of in-service training, as identified through record review and staff interviews. Specifically, two GNAs did not have documentation of annual performance appraisals or the mandated in-service education for the years 2022-2025. The Director of Nursing (DON) and the Staff Development Coordinator (SDC) confirmed that tracking of training compliance was their responsibility, and acknowledged the absence of required documentation in the employee files. These findings were based on a review of six employee training records and interviews with facility leadership.
Failure to Administer Medications as Ordered by Physician
Penalty
Summary
A deficiency was identified when a resident did not receive medications as ordered by the physician. Document review and staff interviews revealed that multiple medications, including hydroxyzine HCL, doxycycline monohydrate, Entresto, and trimethoprim, were not administered at the prescribed times. For example, hydroxyzine was given more than two hours late for one dose and less than two hours apart for another, contrary to the physician's orders. Other medications, such as doxycycline and Entresto, were also administered several hours later than scheduled, with some doses given late at night instead of in the morning as ordered. Staff interviews confirmed that these administration times did not meet professional standards, with the Assistant Director of Nursing acknowledging that medications given more than one hour before or after the scheduled time constituted a medication error. The Director of Nursing also confirmed that the medications listed were not administered as ordered. These findings were based on a review of medication administration records and staff interpretations, and were substantiated by a complaint from a county agency regarding the resident not receiving medications on time.
Failure to Post and Retain Daily Nurse Staffing Information
Penalty
Summary
Surveyors determined that the facility failed to post daily nursing staffing information and did not retain 18 months of posted nursing data, as required. Upon entering the facility, surveyors observed that the nursing staffing document displayed at the receptionist's desk was outdated by several days. When questioned, the receptionist provided an updated posting within the hour. An interview with the DON confirmed that the daily posting for the observed day was missing and that the staff scheduler, who was responsible for posting, did not work weekends. The DON also acknowledged that the facility did not keep records of daily nursing staff postings for the previous six months and that records from previous ownership were not accessible. These findings were consistent across all five nursing units reviewed.
Failure to Investigate and Respond to Resident Grievances Timely
Penalty
Summary
The facility failed to ensure that all resident grievances were investigated and responded to in a timely manner, as required by policy. For one resident, repeated complaints about extended call light response times and concerns about staffing were reported multiple times to staff, but no formal grievance was documented or investigated by the DON. Call bell audit reports confirmed that this resident experienced wait times ranging from 30 minutes to 3 hours for call light responses. The DON acknowledged that a grievance was not written for these concerns, as she believed immediate resolution negated the need for formal documentation, despite the ongoing nature of the complaints. Another resident submitted grievances regarding long call light response times, including an incident where the call light was unanswered for two hours, prompting the resident to call out for assistance. Although staff education was provided to the involved staff member, there was no evidence that the incidents were fully investigated to determine root causes or that a plan of correction was implemented. Review of the grievance logs and interviews with facility staff revealed inconsistencies in the handling and documentation of grievances, with some forms not being completed or routed appropriately, and no timely responses provided to the residents involved.
Failure to Protect Resident from Misappropriation of Funds by Staff
Penalty
Summary
A facility failed to protect a resident from the misappropriation of personal funds by a staff member. The incident involved a resident who was transferred out of the facility for a change in condition, with the expectation of returning, so their belongings—including a credit card and driver’s license—remained at the facility. During this period, a Licensed Practical Nurse (LPN) employed through an agency took possession of the resident’s credit card and driver’s license. The LPN admitted to making unauthorized charges on the resident’s credit card, specifically purchasing a $100 Amazon gift card. This admission was made during an interview with the county sheriff’s office. The facility became aware of the misappropriation after the incident was reported, and the matter was investigated, confirming the unauthorized use of the resident’s funds by the staff member.
Failure to Monitor Resident After Warm Compress Application Resulting in Burn
Penalty
Summary
Facility staff failed to provide adequate supervision to prevent an accident involving a resident who requested a warm compress. Nursing staff applied the warm compress to the resident's right foot and secured it with an ace bandage. After application, there were no immediate observed issues with the resident's skin or complaints of discomfort. However, staff did not monitor the condition of the resident's skin following the application of the compress. Subsequently, a blister measuring 2.5 cm x 1.2 cm was observed on the resident's right lateral foot. The facility's investigation included an admission from nursing staff that they failed to monitor the resident's skin after the compress was applied. The Director of Nursing confirmed that this lack of monitoring occurred, which resulted in the resident sustaining a blister/burn injury.
Failure to Provide Adequate Staffing Leads to Delayed Call Light Responses
Penalty
Summary
The facility failed to provide sufficient nursing staff to meet the needs of residents, resulting in extended call light response times. Two residents reported waiting from 30 minutes up to several hours for assistance, particularly for incontinence care and toileting. One resident described waiting so long for help that accidents occurred, and another reported being left on the toilet for extended periods. Additionally, residents experienced delays in receiving assistance with meals and had bed linens left unchanged on shower days due to staff being unable to complete all required tasks. Staff interviews confirmed that staffing levels were often inadequate, with only one GNA assigned to each floor and a float GNA who was sometimes reassigned elsewhere. The Director of Nursing acknowledged that the ideal staffing level was not always met and could not provide a rationale for the prolonged call light response times when presented with audit data. Call bell audits and staffing schedules reviewed for specific periods showed consistent understaffing, correlating with the reported delays in resident care.
Significant Medication Errors: Insulin Administered to Non-Diabetic Residents
Penalty
Summary
Facility staff failed to ensure that residents were free from significant medication errors by inappropriately administering insulin to two residents who were not diabetic. One resident, who had a history of kidney/pancreas transplant and was legally blind, was monitored for hypoglycemia but did not have a diabetes diagnosis and was not prescribed insulin. This resident reported being injected with a needle without warning and was told by the LPN that insulin had been administered. The resident's glucose levels were subsequently monitored hourly, and glucose tablets were provided to address low blood sugar. The resident also indicated that another individual had experienced a similar incident. A second resident, with diagnoses including COPD, anemia, dysphagia, and heart disease but no diabetes, also received an insulin injection. This resident reported receiving a shot in the stomach and was unsure of its contents. Glucose monitoring was initiated, and the resident's blood sugar was checked and treated as needed. The LPN involved admitted to confusing residents and administering insulin to the wrong individual. The facility did not complete an internal investigation or report the incident to the Office of Health Care Quality, only notifying the Board of Nursing regarding the LPN's actions.
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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