Willowbrooke Ct Skilled Care Ctr At Bayleigh Chase
Inspection history, citations, penalties and survey trends for this long-term care facility in Easton, Maryland.
- Location
- 501 Dutchman's Lane, Easton, Maryland 21601
- CMS Provider Number
- 215137
- Inspections on file
- 14
- Latest survey
- January 29, 2025
- Citations (last 12 mo.)
- 0
Citation history
Health deficiencies cited at Willowbrooke Ct Skilled Care Ctr At Bayleigh Chase during CMS and state inspections, most recent first.
The facility failed to protect residents from abuse, with incidents involving physical assault by a GNA and inadequate investigations into allegations of abuse. Staff did not report incidents immediately, and the facility did not ensure all staff had required abuse training. Additionally, the administration dismissed allegations without thorough investigation, contributing to the facility's inability to protect residents.
A facility failed to conduct a root cause analysis for a resident with Alzheimer's Dementia who experienced multiple falls, one resulting in a hip fracture. Despite being identified as a high fall risk, the resident's care plan lacked updated interventions to prevent further falls. The facility's Fall Reduction and Management Policy was not fully adhered to, as confirmed by the DON, who noted that only monitoring was listed as an intervention and the Root Cause of Fall section was not completed.
The facility did not conduct annual performance reviews for GNAs, as required, since 2011. The DON, who joined in 2020, confirmed that evaluations were not performed for GNAs, only for the ADON. This oversight affects the facility's ability to provide targeted in-service education.
The facility failed to consistently monitor and document meal temperatures before serving, as required by policy. The Dietary Manager, new to the position, had not reviewed temperature logs until recently and was unaware that staff were not temping all food items. This oversight potentially affected all residents consuming food from the kitchen, except one resident who was NPO.
The QA committee at the facility failed to conduct a thorough Performance Improvement Project (PIP) as required by their QAPI program. The DON admitted that the PIP for increasing pressure ulcers was limited to collecting information and filling out a form, without tracking outcomes or conducting a root cause analysis. The Administrator acknowledged the lack of proper documentation, which hindered the ability to demonstrate the facility's efforts.
The facility administration failed to ensure effective oversight, resulting in incomplete investigations of injuries and abuse. The DON provided inadequate reports for residents with unwitnessed falls, lacking assessments and care plan updates. An abuse allegation was mishandled, with the alleged perpetrator not suspended and police not notified. Additionally, an LPN did not report an abuse incident immediately, and the facility could not verify required abuse training for agency staff.
The facility failed to ensure all nursing staff, including agency staff, received training on abuse reporting procedures. An LPN witnessed a GNA physically abusing a resident but delayed reporting the incident, allowing the GNA to continue working. The facility did not verify the LPN's abuse training, relying on the agency for documentation.
The facility failed to report several incidents of alleged abuse, neglect, or injuries of unknown origin to the OHCQ within the required timeframe. This included cases of unwitnessed falls, bruises, and abuse allegations that were not reported to local law enforcement or the state agency promptly. The facility's policy requires immediate reporting of such incidents, but this was not adhered to, and investigations were not conducted thoroughly.
The facility failed to thoroughly investigate multiple allegations of abuse and injuries of unknown origin, and did not protect residents from further harm. Incidents included unwitnessed falls resulting in fractures, unreported physical abuse, and dismissed verbal abuse allegations. Investigations were incomplete, lacking interviews with all relevant staff and residents, and failed to implement preventive measures.
The facility failed to administer and document pain medication for two residents with reported pain. One resident with severe cognitive impairment was found with hip pain, but the MAR did not reflect the administration of Tylenol as documented. Another resident with dementia and gait abnormalities experienced arm pain after a fall, but further doses of Tylenol were not recorded despite ongoing pain complaints and a physician's order. These issues were discussed with the facility's DON and NHA.
A facility failed to maintain accurate medical records for a resident who alleged abuse by an employee. The incident was reported, but the resident's medical records lacked documentation of the abuse allegation, assessment of injury, mental status, physician notification, or measures taken. Despite 17 nursing progress notes during the relevant period, none addressed the abuse incident.
A resident with a history of a left femur fracture and neuropathy did not have their lidocaine patches removed as per physician's orders, despite documentation indicating otherwise. The patches were found still on the resident during an observation, and the discrepancy was confirmed by the DON. The facility's policy on medication administration was not followed.
Failure to Protect Residents from Abuse and Inadequate Investigation
Penalty
Summary
The facility failed to protect residents from abuse, as evidenced by multiple incidents involving staff and residents. In one case, a Geriatric Nursing Assistant (GNA) physically assaulted a resident by choking and punching them, which was witnessed by other staff members. Despite the severity of the incident, the abuse was not reported immediately, allowing the GNA to continue working for an additional 12 hours before being suspended. The facility also failed to ensure that all staff had the required abuse training, particularly agency staff, and did not conduct a Root Cause Analysis or involve the Quality Assessment Performance Improvement (QAPI) committee in addressing the incident. In another incident, a resident alleged that they were slapped by a staff member after a verbal altercation. The facility's investigation was inadequate, as it did not include statements from all staff who worked during the time of the alleged incident, and the police were not notified. Additionally, a staff member failed to report an allegation of abuse immediately, and the facility did not act on this information when it was brought to their attention. A third incident involved a resident alleging verbal and mental abuse by a GNA, who was not suspended during the investigation. The facility's administration dismissed the allegations without conducting a thorough investigation, relying on assumptions rather than interviewing the resident or staff. This lack of immediate action and failure to follow proper procedures contributed to the facility's inability to protect residents from abuse and neglect.
Removal Plan
- Resident #45 was interviewed by the social worker regarding his/her abuse claim. The facility reported the incident to the state. A 5-day investigation was completed and submitted. The conclusion was that alleged abuse could not be substantiated. GNA #1 was removed from resident #45's care. All residents in GNA #1's group were interviewed by the social worker with no concerns identified.
- All other residents in WillowBrooke Court will be interviewed by nursing and the social worker to ensure there is no suspected abuse or neglect.
- Training on Abuse, Neglect, Reporting & Investigation was conducted by the Regional Clinical Director to the Director of Nursing (DON) & Assistant Director of Nursing (ADON). All team members currently working were educated on Abuse & Neglect Policy and protocol focusing on report abuse as soon as possible, obtaining witness statements, suspension pending investigation, Acts policy and state regulations on Abuse & Neglect, & who the abuse coordinator of the community is by nursing management (DON/ADON). The rest of the team members working in WillowBrooke Court will complete training by nursing management (DON/ADON). For those team members not on the schedule to work the training will be conducted by the DON and ADON by phone.
- The management team (NHA, DON, & ADON) will round twice a week to randomly interview 5% of the current residents on different shifts and different times regarding the quality of their care and monitor team members' interaction with residents. Any issues identified will be corrected immediately. Any concern from the resident will be reported per regulation requirement. Any alleged team member will be suspended immediately pending investigation.
- Random interviews by the NHA, DON, & ADON will be audited until 100% compliance is achieved and findings will be discussed in monthly QAPI.
Failure to Conduct Root Cause Analysis for Resident Falls
Penalty
Summary
The facility failed to conduct a root cause analysis and thorough investigation for a resident who experienced multiple falls, one of which resulted in a left hip fracture requiring surgery. The resident, diagnosed with Alzheimer's Dementia, had severe cognitive impairment and was identified as a high fall risk. Despite this, the facility did not implement new interventions to prevent further falls between September 2023 and July 2024, even after the resident experienced 11 falls. The resident's care plan identified them as a fall risk due to deconditioning, gait/balance problems, incontinence, and unawareness of safety needs. However, the interventions listed in the care plan were not updated with new strategies to address the ongoing fall risk. The facility's Fall Reduction and Management Policy aimed to identify and mitigate fall risks, but the lack of new interventions and failure to complete the Root Cause of Fall section in the Fall Incident Reports indicated a gap in adherence to this policy. The Director of Nursing confirmed that the Fall Intervention Form only included monitoring as an intervention and acknowledged that the Root Cause of Fall section was not completed. This oversight potentially limited the facility's ability to develop effective fall prevention strategies, as no new interventions were identified or implemented following the resident's falls.
Failure to Conduct Regular Performance Reviews for GNAs
Penalty
Summary
The facility failed to ensure that Geriatric Nursing Assistants (GNAs) received a performance review at least once every 12 months, which has the potential to affect all residents. This deficiency was identified during a review of staff records and interviews with facility staff. Specifically, the employee file of one GNA was reviewed, revealing no performance reviews since 2011. The Director of Nursing (DON), who joined the facility in 2020, admitted to not conducting evaluations for GNAs, only for the Assistant Director of Nursing (ADON). The lack of performance reviews prevents the facility from providing regular in-service education based on these evaluations.
Failure to Monitor and Document Meal Temperatures
Penalty
Summary
The facility failed to ensure that meal temperatures were consistently taken and documented before each meal was served, which is a critical step in maintaining food safety standards. The Dietary Manager (DM) reviewed the food temperature logs and found that from January 1 to January 9, temperatures were not documented for all three meals or all hot food items prepared for each meal. The DM, who had been in the position for four months, admitted to not reviewing the temperature logs until the week of the survey and was unaware that staff were not temping all food items prepared for each meal. During interviews, both the DM and the Director of Nursing (DON) expressed their expectations that food should be served at the correct temperature and that staff should ensure this is done in a timely manner. The facility's policy on food temperatures, revised in January 2013, states that food temperatures should be obtained and recorded prior to meal service, and any inappropriate temperatures should be corrected. However, the lack of consistent documentation and monitoring of food temperatures indicates a failure to adhere to this policy, potentially affecting all residents consuming food from the kitchen, except for one resident who was nothing by mouth (NPO).
Inadequate Performance Improvement Project Documentation
Penalty
Summary
The Quality Assurance (QA) committee at the facility failed to conduct a comprehensive Performance Improvement Project (PIP) that included continuous improvement of processes, measured outcomes, developed and implemented action plans, and conducted a root cause analysis. This deficiency was identified through interviews and a review of facility documentation. The facility's Quality Assurance, Performance Improvement (QAPI) and Compliance Program document, dated October 2022, outlined the purpose of QAPI as a proactive, systematic, interdisciplinary, comprehensive, and data-driven approach to improve the quality of life, care, and services for residents. However, the QA committee did not adhere to these guidelines, as evidenced by the lack of thorough documentation and analysis in their PIP efforts. During an interview, the Director of Nursing (DON) revealed that each department could fill out a form to report areas of concern or improvement, and residents could report concerns through the Resident Council or to any nurse or employee. The Infection Preventionist (IP) identified an issue with increasing pressure ulcers, prompting a PIP. However, the DON admitted that the PIP consisted merely of collecting information from the IP and filling out a form, without tracking outcomes, developing and implementing action plans, conducting a root cause analysis, or measuring the success of actions. The Administrator acknowledged that while work was being done, it was not being documented properly, resulting in a lack of proof to demonstrate the facility's efforts.
Facility Fails to Investigate and Address Abuse and Injuries
Penalty
Summary
The facility administration failed to provide effective oversight to ensure resources were used effectively to meet the health and safety needs of residents. This was evidenced by the lack of a system to complete investigations related to injuries of unknown origin, failure to address abuse, and failure to ensure all staff received required training for abuse. The Director of Nursing (DON) provided incomplete investigation reports for incidents involving residents with unwitnessed falls resulting in fractures. These reports lacked essential information such as resident assessments, witness statements, and care plan updates. The DON admitted to not conducting root cause analyses for incidents and only discussing them without proper documentation. The facility did not report or investigate several incidents involving residents with falls and injuries of unknown origin. Additionally, a staff member identified in an abuse allegation was not suspended upon notification, and the facility failed to conduct thorough investigations into these incidents. The DON and Nursing Home Administrator (NHA) were unable to identify who was responsible for the final review of investigations prior to submission. An abuse allegation against a GNA was not handled appropriately, as the alleged perpetrator was not suspended and continued working on the same unit. The facility also failed to notify the police of a previous abuse allegation and did not expand the investigation to include all potential witnesses. Furthermore, an LPN witnessed an abuse incident but did not report it immediately, and the facility could not verify the required abuse training for this agency staff member.
Failure to Ensure Abuse Training for Agency Staff
Penalty
Summary
The facility failed to ensure that all nursing staff received training on abuse, including procedures for reporting incidents of abuse, neglect, exploitation, and misappropriation of resident property. This deficiency was identified during the review of a facility-reported incident involving a resident who was physically abused by a Geriatric Nursing Assistant (GNA). The incident was witnessed by an LPN, who did not report it until nearly 19 hours later, allowing the GNA to continue providing care to residents during that time. The Director of Nursing confirmed that the LPN, who was an agency staff member, had not received the required abuse training from the facility, as the facility relied on the agency to provide necessary documentation, excluding abuse training verification.
Failure to Timely Report Abuse and Neglect Incidents
Penalty
Summary
The facility administration failed to report several incidents of alleged abuse, neglect, or injuries of unknown origin to the Office of Health Care Quality (OHCQ) within the required timeframe. This deficiency was evident in multiple cases, including a resident with Alzheimer's and osteoporosis who experienced an unwitnessed fall resulting in a fracture, which was reported to the OHCQ approximately 10 hours after the incident. Another resident with breast cancer, dysphagia, and dementia had multiple documented injuries of unknown origin that were not reported to the OHCQ, including bruises and an unwitnessed fall. In another case, a resident with dementia and Parkinson's disease was found on the floor with a fracture, but the incident was not reported to the OHCQ. Additionally, an allegation of abuse involving a resident being slapped by an employee was not reported to local law enforcement, and the facility's investigation revealed that staff failed to report the incident immediately. Furthermore, a resident reported being physically abused by a Geriatric Nursing Assistant, but the incident was not reported to the OHCQ or local law enforcement in a timely manner. The facility's policy requires immediate reporting of suspected abuse, neglect, or crimes to the appropriate authorities, but this was not adhered to in several instances. The Director of Nursing and the Administrator were aware of the allegations but failed to report them to the state agency or conduct thorough investigations. In one case, the Administrator concluded there was no validity to an allegation without interviewing the resident or staff involved. These failures to report and investigate incidents in a timely manner highlight significant deficiencies in the facility's handling of abuse and neglect allegations.
Inadequate Investigations and Resident Protection Failures
Penalty
Summary
The facility staff failed to thoroughly investigate allegations of abuse and injuries of unknown origin, and failed to protect residents from further abuse. This was evident in several cases, including Resident #902, who experienced an unwitnessed fall resulting in a nondisplaced elbow fracture. The investigation into this incident was inadequate, as it only included an interview with the GNA assigned to the resident and lacked new interventions to prevent future falls. Resident #903 also suffered from an unwitnessed fall, resulting in a hip fracture. The investigation was limited to interviews with the nurse and GNA caring for the resident, and there was no documentation of corrective actions regarding a faulty bed alarm that may have contributed to the fall. Similarly, Resident #904 experienced multiple unwitnessed falls, with one resulting in a subdural hematoma and facial fractures. The investigation did not include interviews with staff or residents, and assumptions were made about the cause of the falls without thorough investigation. In another case, Resident #901 reported being slapped by an employee, but the facility's investigation was insufficient, as it did not expand to include all potential witnesses. Additionally, GNA#7 was not immediately removed from duty after being accused of physically abusing Resident #905, and the facility failed to conduct a comprehensive investigation into the incident. Furthermore, the facility did not adequately investigate an injury of unknown origin for R24, and R45's allegations of verbal abuse by a GNA were dismissed without proper investigation or reporting to the state.
Failure to Administer and Document Pain Management
Penalty
Summary
The facility failed to administer and document pain medication for residents with reported pain, as evidenced by the cases of two residents. Resident #903, who had severe cognitive impairment and was diagnosed with unspecified dementia and abnormalities of gait, was found on the bathroom floor with complaints of left hip pain. Although nursing staff documented that Tylenol was administered for the pain, the medication administration record (MAR) did not reflect this, despite the resident's pain being documented as a '6' prior to hospital transfer. Similarly, Resident #902, also diagnosed with unspecified dementia and abnormalities of gait, was found with a swollen arm and pain after a fall. Although the MAR indicated that Tylenol was administered initially, no further doses were recorded despite ongoing complaints of pain and a physician's order for medication every six hours as needed. Additionally, on a separate occasion, Resident #902 complained of leg pain and had a bruise, but no pain medication was documented as administered until several hours later. These deficiencies were discussed with the facility's Director of Nursing (DON) and Nursing Home Administrator (NHA).
Failure to Document Abuse Allegation and Assessment
Penalty
Summary
The facility staff failed to maintain complete and accurate medical records for a resident involved in an abuse allegation. The incident involved a resident who reported to their daughter that an employee had physically assaulted them after being called a derogatory name. The Director of Nursing (DON) reported the incident to the state agency and initiated an investigation. However, a review of the resident's medical records revealed that there was no documentation of the abuse allegation, no assessment specific to the allegation, and no record of any evidence of injury, the resident's mental status, physician notification, or measures implemented in response to the incident. This lack of documentation was evident despite the presence of 17 nursing progress notes within the relevant timeframe, none of which addressed the abuse allegation or related assessments.
Failure to Follow Physician's Orders for Medication Administration
Penalty
Summary
The facility failed to ensure that physician's orders for a resident's medication were followed, specifically regarding the removal of lidocaine patches. The resident, who was cognitively intact and had a history of a left femur fracture and neuropathy, was prescribed two lidocaine patches to be applied in the morning and removed at bedtime. However, during an observation, it was found that the patches had not been removed as per the physician's orders, despite documentation indicating otherwise. The incident involved a registered nurse who documented the removal of the patches without actually performing the task. This was confirmed during interviews with the nurse and the Director of Nursing, who acknowledged the discrepancy between the documentation and the actual practice. The facility's policy on medication administration and management, which requires accurate documentation of medication administration, was not adhered to in this instance.
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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