Atlee Hill Health And Rehab Center
Inspection history, citations, penalties and survey trends for this long-term care facility in Westminster, Maryland.
- Location
- 297 Stoner Avenue, Westminster, Maryland 21157
- CMS Provider Number
- 215247
- Inspections on file
- 15
- Latest survey
- September 11, 2025
- Citations (last 12 mo.)
- 41
Citation history
Health deficiencies cited at Atlee Hill Health And Rehab Center during CMS and state inspections, most recent first.
A review of the facility's abuse policy and staff interviews revealed that the policy did not address all required elements, including misappropriation of resident property, abuse prevention, staff training, QAPI coordination, and timely reporting requirements. The policy also failed to prohibit retaliation for reporting suspected abuse, and there was no posted signage informing employees of their rights regarding retaliation.
The facility did not report multiple allegations of abuse, neglect, or theft to the state agency or law enforcement within the required timeframes. In several cases, residents reported incidents to staff, but there were delays in notifying facility leadership and external authorities, despite facility policy and regulatory requirements. Interviews confirmed that staff were aware of the reporting requirements, but documentation showed repeated failures to comply.
Surveyors found that the facility did not consistently develop or implement comprehensive, person-centered care plans for three residents. One resident's need for ADL assistance was not addressed in their care plan, another resident's discharge planning lacked documentation of assistance with ALF placement and necessary supplies, and a third resident's urinary incontinence was not included in their care plan despite assessment triggers. The DON and social services staff confirmed these omissions during interviews.
A resident exhibited increased confusion and agitation, including throwing a dinner tray, which was reported by an LPN to the resident's representative but not to the attending physician. The DON confirmed that this behavioral change should have prompted a change in condition assessment and provider notification, but documentation of these actions was lacking.
The facility failed to ensure accurate communication and documentation during resident transitions, including providing incomplete or inaccurate assessment information to a receiving ALF, not processing or documenting orders for medical equipment and home health services as discussed, and not providing required written transfer notices or bed hold policies to residents' representatives during transfers to acute care.
Two residents and their representatives did not receive a copy of the baseline care plan, including a summary of admission medications, within 48 hours of admission. In both cases, documentation was incomplete or missing, and staff interviews revealed uncertainty about responsibility for providing this information.
A resident who required staff assistance for showering did not receive the scheduled number of showers, with records showing only one shower provided over nearly two months. The resident expressed a desire for more frequent showers, and staff confirmed the lack of documentation for additional showers during this period.
Three residents experienced deficiencies in care: one received an incorrect dose of Carvedilol due to a transcription error and lack of proper admission checks, resulting in hypotension and hospitalization; another was given an antiemetic instead of prescribed nitroglycerin for chest pain, with no assessment or provider notification; and a third did not have required weights obtained or documented as ordered, with no explanation for the omissions.
A resident with a history of unstable angina did not receive prescribed Nitroglycerin for chest pain as ordered by the provider. Instead, staff administered an antiemetic (Zofran) when the resident complained of chest pain, and documentation did not show that the correct medication was given.
A resident was served breakfast with incorrect portion sizes for cereal and juice, as the items provided did not match the amounts listed on the meal ticket. The Dietary Director confirmed that staff were unaware the cups used for juice were smaller than required, resulting in residents not receiving the correct portions as specified on the menu.
Abuse Policy Lacks Required Components and Protections
Penalty
Summary
The facility failed to ensure its abuse policy addressed all required regulatory components, as determined by a review of the policy and interviews with staff. The policy lacked a date of initiation or review and, while it included definitions of various types of abuse and some signs of abuse, it did not address misappropriation of resident property. Additionally, the policy did not include provisions for abuse prevention, staff training, or coordination with the Quality Assurance Performance Improvement (QAPI) program. The reporting section of the policy did not meet federal requirements, as it did not specify that allegations of abuse must be reported immediately, but not later than two hours after the allegation is made, to the nursing home administrator and other officials. Furthermore, the policy failed to address the prohibition and prevention of retaliation against individuals reporting suspected abuse. Observations throughout the facility, including employee break areas, revealed that there was no posted signage informing employees of their rights related to protection from retaliation for reporting suspected crimes. The nursing home administrator confirmed the absence of such signage and acknowledged that the abuse policy provided to staff was incomplete in these areas.
Failure to Timely Report Allegations of Abuse, Neglect, or Theft
Penalty
Summary
The facility failed to report allegations of abuse, neglect, or theft in a timely manner for multiple residents, as evidenced by record review and staff interviews. In several cases, allegations were either not reported to the state agency within the required timeframe or not reported to law enforcement as appropriate. For example, one resident with complex medical needs, including hydrocephalus and chronic kidney disease, reported an incident involving a blood draw that was perceived as abusive. The DON was notified by the resident’s family, but the incident was not reported to the state agency until two days later, exceeding the required reporting window. Another instance involved a cognitively intact resident who reported theft of money to a receptionist, who then informed the DON. The DON initiated an internal investigation and interviewed staff, but the incident was not reported to the state office until the following day, and law enforcement was not notified. Additional cases included residents reporting abuse or missing money to staff, with delays in both internal notification to facility leadership and external reporting to the state agency. In one case, a resident’s allegation of abuse was reported to an LPN, but the NHA was not notified until two days later, and the state agency was not informed until four days after the initial report. Facility policy required allegations to be reported to the administrator within 24 hours and to state agencies as per regulations, which in some cases is within two hours. Interviews with the NHA and DON confirmed awareness of these requirements, but documentation and investigation records showed repeated failures to meet the mandated reporting timelines. These deficiencies were identified for five residents out of fifteen reviewed for abuse allegations.
Failure to Develop Comprehensive, Person-Centered Care Plans
Penalty
Summary
The facility failed to develop comprehensive, person-centered care plans for three residents, as evidenced by medical record reviews and staff interviews. One resident, who required assistance with activities of daily living (ADLs) as documented in the Minimum Data Set (MDS), did not have these needs addressed in their care plan. The Director of Nursing (DON) confirmed that the care plan was not comprehensive and did not capture the resident's ADL needs. Another resident, admitted for therapy and with a goal of discharge to an assisted living facility (ALF), had a care plan that only included staff discussing discharge needs with the family. There was no documentation in the care plan regarding assistance with identifying an appropriate ALF placement or obtaining necessary supplies and services for discharge, despite the responsible party's stated goals and the social worker's reported practices. A third resident, who was occasionally incontinent of urine according to the admission MDS assessment, had triggered a care area assessment (CAA) for urinary incontinence, with a decision to address this in a care plan. However, review of the care plans revealed that urinary incontinence was not addressed. The DON confirmed that the care plan did not include interventions for urinary incontinence, despite the CAA indicating it should be addressed. These findings demonstrate that the facility did not consistently develop or implement care plans that addressed all identified resident needs.
Failure to Notify Physician of Resident's Change in Condition
Penalty
Summary
A deficiency was identified when the facility failed to notify an attending physician of a documented change in a resident's condition. Specifically, a licensed practical nurse (LPN) observed that a resident was more confused and agitated, and reported this change in behavior, including the resident throwing a dinner tray, to the resident's representative. However, there was no evidence that the LPN completed a change in condition assessment or notified the resident's attending provider of these behavioral changes. The Director of Nursing (DON) confirmed that such a change in behavior should have triggered both an assessment and provider notification, but the records did not show that these actions were taken.
Deficiencies in Transition of Care Communication and Required Written Notifications
Penalty
Summary
The facility failed to ensure appropriate communication and documentation during resident transitions, resulting in deficiencies related to discharge planning and notification requirements. For one resident discharged to an assisted living facility (ALF), the care plan lacked documentation on facilitating the identification of an appropriate discharge location and assistance with obtaining necessary supplies and services. The Resident Assessment Tool (RAT) provided to the ALF contained inaccurate information regarding the resident's continence and psychosocial status, which did not align with the Minimum Data Set (MDS) and other clinical documentation. Additionally, there was no evidence that the facility processed orders for durable medical equipment or home health care as discussed in care plan meetings, and the discharge instructions form was incomplete regarding medical equipment arrangements. Further review revealed that although discharge orders for skilled nursing, physical and occupational therapy, and a home health aide were documented, there was no evidence that these orders or referrals were communicated to the receiving ALF. The facility also failed to document that discharge orders were sent to the ALF, and the Maryland Discharge Instructions form did not reflect the home health or therapy orders. Interviews with staff confirmed that some equipment orders were not placed as indicated, and home health services were not ordered because the ALF had its own therapy department, but this was not documented in the resident's record. In a separate incident, another resident was transferred to an acute care facility due to a change in condition. The resident's representative was notified by telephone, but there was no documentation that a written transfer notice or the facility's bed hold policy was provided as required. The admissions director stated that written notifications were only sent to short-stay residents' representatives, and the nursing home administrator confirmed that the facility had stopped mailing these documents to long-term care residents' representatives to avoid confusion. This resulted in a failure to provide required written notifications during the transfer process.
Failure to Provide Baseline Care Plan and Medication Summary to Residents/Representatives
Penalty
Summary
The facility failed to provide residents or their representatives with a copy of the baseline care plan, including a summary of admission medications, within 48 hours of admission as required. For one resident, the representative reported not receiving the baseline care plan or medication list, and record review confirmed that while a care plan was initiated and later marked as complete, it lacked both staff and representative signatures. There was no documentation to show that the representative had been given a copy of the care plan or medication summary. For another resident admitted for therapy after hospitalization, the baseline care plan was provided to the resident but not to the representative, as indicated by a blank signature area and lack of documentation in the medical record. The first care plan meeting with the family occurred 15 days after admission, which was the first time the level of care was communicated to them. Staff interviews revealed confusion about who was responsible for providing the baseline care plan to representatives, and no documentation was provided to confirm that the representative received the required information.
Failure to Provide Scheduled Showers for Dependent Resident
Penalty
Summary
A resident who required staff assistance with activities of daily living, specifically showering, was not provided with the scheduled number of showers. The resident, who had been in the facility since June 2025, expressed a desire for more frequent showers during an interview. Review of the Minimum Data Set (MDS) assessment confirmed the resident's need for staff assistance with showering. Documentation from July to August 2025 showed no showers in July and only one shower in August, despite the resident being scheduled for two showers per week. Staff interviews confirmed the resident's shower schedule and the lack of documentation for showers provided during this period. The Director of Nursing acknowledged that only one shower was documented between July 1 and August 25, 2025.
Failure to Provide Care According to Physician Orders and Professional Standards
Penalty
Summary
A deficiency occurred when a resident with a history of congestive heart failure, atrial fibrillation, and hypertension was admitted following a hospitalization for dyspnea. Upon admission, the facility transcribed a hospital order for Carvedilol incorrectly, entering it as 25 mg twice daily instead of the intended 12.5 mg (half tablet) twice daily. This error resulted in the resident receiving double the prescribed dose for four administrations, leading to hypotension, acute kidney injury, and a transfer to the hospital. The facility's admission process was not followed, as the required admission checklist and second nurse review were not completed, and the error was not identified by the pharmacist during the admission medication review. Another deficiency was identified when a resident with a history of unstable angina and an order for sublingual nitroglycerin for chest pain reported chest pain during the night. Instead of administering the prescribed nitroglycerin, staff gave the resident an antiemetic (Zofran) and did not assess the resident for a change in condition or notify the attending provider. The resident later requested transfer to the hospital for evaluation of a possible heart attack due to their medical history. A third deficiency involved a resident admitted after a hospitalization, for whom the facility failed to obtain and document weights as ordered. The resident's care plan and physician orders required weights to be taken on admission, on day two, and weekly for four weeks. Documentation showed that weights were not obtained or recorded on the required days, and there was no evidence that attempts were made to obtain the missing weights. The DON was unable to account for the missing documentation or explain why the required weights were not obtained.
Failure to Administer Prescribed Medication for Chest Pain
Penalty
Summary
A deficiency was identified when a resident with a medical history of chest pain secondary to unstable angina did not receive medication as ordered by the attending provider. The provider's order specified that Nitroglycerin Tablet Sublingual 0.4 MG should be administered sublingually every 5 minutes as needed for chest pain, up to three doses. Record review and staff interviews revealed that when the resident complained of chest pain during the night, staff administered an antiemetic (Zofran) instead of the prescribed Nitroglycerin. Documentation did not show that the Nitroglycerin was given, and both the RN and the Director of Nursing confirmed that the resident should have received the angina medication according to the provider's order.
Failure to Serve Meals According to Menu and Portion Sizes
Penalty
Summary
The facility failed to serve meals to residents according to the predetermined menu and specified portion sizes, as required. During a surveyor's observation of the breakfast tray line, a test tray prepared for a resident did not contain the correct portion sizes for Cheerios and orange juice as listed on the resident's meal ticket. The Cheerios portion was measured at 5 oz instead of the required 6 oz, and the orange juice was measured at 4.5 oz instead of 6 oz. The Dietary Director confirmed that the cups used for serving juice were not the correct size, and staff were unaware of this discrepancy prior to the surveyor's intervention. This deficiency was identified through record review, observation, and staff interview, and it was determined that the practice had the potential to affect all residents.
Latest citations in Maryland
Facility staff did not ensure that 2nd floor residents who could not use stairs were able to receive visitors when the only elevator was out of service for an extended period. Complaints indicated that some family members, who were themselves unable to ambulate stairs, could not visit their relatives on the 2nd floor during this time. The emergency plan directed non-ambulatory 2nd floor residents to remain on that floor unless there was an emergency and did not address how visitation would be maintained when the elevator was inoperable. The Administrator reported that visitors could use the stairs and that an emergency chair system could be used to move residents, but also stated that the chair system was not used for visitation and was unaware of any complaints, despite two having been filed.
Facility staff did not complete required quarterly smoking safety assessments for several residents identified as smokers, including some who had not been reassessed for many months and one who had never been assessed during their stay. This issue was discovered during a complaint survey after the facility’s only elevator was out of service for an extended period, affecting a group of residents on an upper floor who needed to reach a designated smoking area on a lower floor. Review of records and staff interviews, including with the DON and a unit manager, confirmed that the facility’s own practice of quarterly smoking safety assessments for smokers was not followed for half of the affected residents.
Facility staff failed to accurately code multiple MDS assessments for several residents, leading to discrepancies between MDS entries and MARs for pain management, falls, and high-risk drug classes. In several cases, scheduled pain management was coded as provided when MARs did not show daily pain medications, often because an LPN counted low-dose Aspirin ordered for cardiovascular prophylaxis or heart failure as pain medication, contrary to RAI guidance. One resident’s falls were underreported on the MDS despite two documented falls, and daily use of a topical analgesic and an antiplatelet (Aspirin) was not correctly captured. Other residents had MDS entries indicating use of hypnotic or antianxiety medications when MARs showed none, while actual antidepressant and hypoglycemic medications administered daily were omitted from Section N0415. These errors were confirmed by the involved LPNs during surveyor interviews.
Staff failed to conduct complete investigations into two residents’ abuse allegations. In one case, a resident reported that an employee poked their face and made an obscene gesture, but the investigation lacked a statement from the corporate representative who was first notified of the allegation. In another case, a resident reported that someone in blue clothing put a hand by their face and over their mouth, with a specific GNA identified as the alleged perpetrator; however, the investigation did not include statements from two GNAs who were on duty on the unit at the time of the alleged incident, despite leadership having the opportunity to ensure all relevant documents were present.
Staff failed to create person-centered care plans for two residents, one with mobility limitations and one receiving peritoneal dialysis. For the resident with mobility issues, the care plan did not address the resident’s refusal to use a Hoyer lift and preference for pivot transfers, despite therapy prohibiting pivot transfers and staff awareness of the resident’s resistance. For the resident on peritoneal dialysis, the care plan did not specify that the treatment was peritoneal dialysis, nor did it include the treatment schedule or cycle time frames; an LPN Unit Manager acknowledged using a generalized renal care plan without incorporating the specific dialysis prescription.
A resident’s medical record lacked documentation confirming that scheduled showers or bed baths were provided on multiple dates, and there was also no record of any refusals of care on those days. The DON and an LPN unit manager reported that showers were scheduled on specific shifts and that completed showers and refusals should be documented on shower/skin sheets and in the care plan, but the surveyor found gaps where no such entries existed. This resulted in incomplete ADL documentation and failure to maintain medical records according to accepted professional standards.
A resident with multiple fractures and chronic pain was receiving an opioid-based pain regimen, including PRN hydromorphone. The resident was later found unresponsive and "out of it" by an LPN, who located an order for Narcan and administered it, with the resident responding to the medication. A physician note documented an opioid overdose treated with Narcan. Review of the medical record showed no documentation that the resident’s representative was notified of this significant change in condition and emergency intervention, and staff interviews confirmed that notification likely did not occur, despite the DON’s expectation that the responsible party should have been informed.
Staff failed to follow updated wound care orders and to document an opioid overdose event and Narcan use for two residents. One resident with venous and arterial lower extremity wounds did not receive the prescribed change from oil emulsion to daily skin prep on one foot wound, and did not receive ordered skin prep on a new plantar wound for several days after the wound physician revised the treatment plan. Another resident with multiple fractures and chronic pain, receiving multiple opioid and adjunct analgesics, reportedly experienced an opioid overdose; an LPN found the resident unresponsive, located an existing Narcan order, administered Narcan, and observed the resident return to baseline, but did not complete or document a change-in-condition assessment, vital signs, or the Narcan administration in the medical record.
Surveyors substantiated a deficiency when disinfectant wipes, labeled for storage in areas inaccessible to children and not for personal cleansing, were observed sitting openly on a wire shelf in the dining room of a locked dementia unit while cognitively impaired residents waited for breakfast. A GNA and an LPN present on the unit stated that staff used the wipes to clean tables and that residents were never left alone in the dining room and had not been seen using the wipes. The ICP reported being unaware that the wipes’ placement in the dining room was a concern, and the NHA and DON stated they had not previously been informed about the issue, though the DON acknowledged understanding the concern.
A resident’s medical record showed multiple instances where Hydromorphone, a controlled narcotic, was documented as signed out and given on the Controlled Drug Administration Record but was not documented on the MAR on the same dates and times. An LPN reported signing only the narcotic sheet and not the MAR, while the DON acknowledged awareness that nurses were signing the narcotic sheet without completing the MAR, and a unit manager stated they were unaware this was occurring and that both records should be completed. The NHA and DON agreed with the surveyor’s findings after the issue was identified.
Failure to Ensure Visitation Rights During Elevator Outage
Penalty
Summary
Facility staff failed to ensure that residents residing on the 2nd floor who could not safely ambulate using stairs were able to exercise their right to have visitors when the facility’s only elevator malfunctioned. Complaint reviews showed that family members were unable to visit their relatives on the 2nd floor when the elevator was inoperative, and these family members themselves were unable to use the stairs. An incident report documented that the facility’s only elevator was malfunctioning for an extended period, from 3/28/26 to 4/23/26. During this time, residents who could not use the stairs remained on the 2nd floor, and some of their family members could not access them due to the lack of elevator service. Review of the facility’s emergency plan revealed that it instructed that 2nd floor residents who could not safely use the stairs should remain on the 2nd floor unless there was an emergency, and it did not include any provisions for maintaining visitation when the elevator was inoperable. In an interview, the Administrator stated that visitors could use the stairs to visit 2nd floor residents and that residents could be transported using an emergency chair system to meet visitors who could not use the stairs. However, the Administrator acknowledged that the emergency chair system was not used for visitation purposes during the elevator outage and reported being unaware of any complaints about the inoperative elevator, despite two complaints having been received by OHCQ. No additional documentation was provided to show a plan to support visitation for 2nd floor residents during the elevator malfunction.
Failure to Complete Required Quarterly Smoking Safety Assessments
Penalty
Summary
Facility staff failed to update smoking safety assessments at least once every three months for multiple residents identified as smokers. During a complaint survey focused on smoking safety, surveyors reviewed an incident involving the facility’s only elevator being inoperative for nearly a month, which affected residents who lived on the 2nd floor and needed to access the 1st-floor smoking area. The facility’s investigation identified a group of 10 residents on the 2nd floor who smoked and required additional accommodations to safely ambulate to the designated smoking area. Review of these residents’ medical records showed that 5 of the 10 did not receive quarterly smoking safety assessments as required by the facility’s practice. Specifically, four residents had not received a smoking assessment since May 2025, and one resident had no documented smoking assessment at any time during their stay. During interviews, the Unit Manager stated that residents identified as smokers are to be assessed quarterly for smoking safety. When the surveyor pointed out the missing assessments, the DON reviewed the records and confirmed that these residents had not received the required quarterly smoking assessments. This lack of timely reassessment occurred in the context of an extended elevator outage that necessitated special consideration for safe smoking access for residents residing on the 2nd floor.
Inaccurate MDS Coding for Pain Management, Falls, and High-Risk Drug Classes
Penalty
Summary
Facility staff failed to ensure that Minimum Data Set (MDS) assessments were accurately coded for multiple residents, based on medical record review and staff interviews. For one resident with cerebrovascular disease, an MDS with an Assessment Reference Date (ARD) of 3/2/26 coded Section J0100A (scheduled pain management) as "yes," but the March Medication Administration Record (MAR) did not show daily pain medication administration. An LPN stated she coded it that way because the resident received Aspirin 81 mg daily, although the physician’s order showed the Aspirin was prescribed as prophylaxis for cardiovascular events, and the RAI Manual specifies that medications not primarily intended for pain relief should not be coded as pain management. Another resident with cerebral infarction, congestive heart failure, and vascular dementia had two documented falls in progress notes between the prior assessment and the ARD of 2/4/26, but Section J1900 (number of falls since admission or prior assessment) captured only one fall. The same MDS coded Section J0100A (scheduled pain management) as "no" despite the February MAR documenting daily use of Diclofenac topical gel for pain. The MAR also showed daily Aspirin 81 mg for coronary artery disease, but Section N0415 (high-risk drug classes) did not capture the use of an antiplatelet medication. The responsible LPN confirmed missing the second fall and the Aspirin coding error. Additional residents had similar discrepancies: one resident’s MDS repeatedly coded use of hypnotic medications in Section N0415 when MARs showed no hypnotics administered, and failed to capture an antidepressant (Sertraline) that was given; the LPN reported coding Clonazepam as a hypnotic based on dual use, though reference guidelines did not classify it as such. Further inaccuracies were identified for other residents in pain management and high-risk drug class coding. One resident’s MDS with an ARD of 1/8/26 coded receipt of PRN pain medication in Section J0100A, but the January MAR showed no PRN pain medications given; a later MDS for the same resident coded use of an antianxiety medication in Section N0415, while the April MAR showed no such medication administered. Another resident with traumatic subarachnoid hemorrhage, type 2 diabetes with neuropathy, atrial fibrillation, and atherosclerotic heart disease had an MDS with an ARD of 2/3/26 that coded scheduled pain medication as "yes" and PRN pain medication as "no," although the MAR showed intermittent PRN Tylenol for pain and no daily pain medication, and also documented daily Aspirin 81 mg for heart failure and daily Rybelus for diabetes; the MDS failed to capture PRN pain use, incorrectly coded daily pain medication, and did not code hypoglycemic medication in Section N0415. Another resident with a history of stroke and right-sided hemiplegia/hemiparesis had two MDS assessments in February coded as receiving scheduled pain medication, but the February MAR did not show daily pain medication; the LPN reported coding based on daily prophylactic Aspirin 81 mg, which was not ordered for pain.
Incomplete Investigations of Resident Abuse Allegations
Penalty
Summary
Facility staff failed to complete thorough investigations of two separate resident allegations that were reported to the state agency. For the first incident, a resident alleged that on a specific date and time an employee poked two fingers into their face and showed them their middle finger. The five-day follow-up documented the allegation, but the investigation file did not clearly identify who was the first point of contact for the report. During interview, the Administrator stated that a corporate representative was initially made aware of the alleged incident, but there was no statement from this corporate representative included in the investigation file. The Administrator described their usual investigation process as interviewing involved parties, identifying and interviewing witnesses, reviewing staffing for the date of the alleged incident, and interviewing the resident’s roommate and other nearby residents if there were no direct witnesses. In the second incident, a resident reported that during a specific shift someone wearing blue put a hand by their face and over their mouth, and a particular GNA was identified as the alleged perpetrator. Review of the staffing sheet for the time of the alleged incident showed that two GNAs were working on the unit where the incident was reported to have occurred. However, the investigation file contained no statements or interviews from these two GNAs. Prior to the surveyor’s review of the investigation, the DON and a regional nurse were given the opportunity to review the investigation to ensure all necessary documents were available, yet the statements from the two GNAs remained absent. These omissions demonstrated that the facility did not conduct complete investigations into the reported allegations.
Failure to Develop Person-Centered Care Plans for Mobility and Peritoneal Dialysis Needs
Penalty
Summary
Facility staff failed to develop and implement person-centered care plans that addressed all identified needs for two residents, one with mobility limitations and one receiving peritoneal dialysis. For the resident with mobility limitations, the care plan included interventions for resistance to care and adjustment issues, but did not address the resident’s specific resistance to use of a Hoyer lift and the resident’s insistence on pivot transfers from bed to wheelchair. The Unit Manager confirmed that the resident was resistant to care, did not like the Hoyer lift, and preferred pivot transfers, but also stated that physical therapy had prohibited pivot transfers. Despite this known conflict between the resident’s preferences and therapy restrictions, the care plan lacked individualized interventions related to the resident’s resistance to the Hoyer lift and continued request for pivot transfers. For the resident receiving peritoneal dialysis, review of the electronic health record showed an order for peritoneal dialysis, but the resident’s care plans did not include a person-centered care plan specific to this treatment. The existing dialysis care plan did not specify the type of dialysis treatment being provided, did not document when the resident was scheduled to receive the treatment, and did not include time frames for the dialysis cycles. During an interview, the LPN Unit Manager stated that they do not place the dialysis prescription details into the care plan and instead use a generalized renal care plan by selecting standard items, confirming that the care plan was not individualized to the resident’s ordered peritoneal dialysis regimen.
Failure to Document Resident Showers and Refusals
Penalty
Summary
Facility staff failed to maintain complete and accurate documentation of bathing care for a resident, specifically regarding showers and refusals of showers. During a complaint survey, the surveyor requested verification that Resident #5 was receiving scheduled showers. The DON stated that the resident was scheduled for showers on the 3 pm–11 pm shift on Tuesdays and Fridays, and provided shower sheets for several dates in October and early November. However, there was no documentation to verify that the resident received a shower or bed bath on 10/17/25, 10/21/25, and 10/24/25. The DON explained that when a resident receives a shower it is documented on a skin sheet, and that refusals of showers should be documented both in the plan of care and on the shower sheet. Despite this, the surveyor did not receive any documentation indicating that the resident either received bathing care or refused showers on the missing dates. This lack of documentation showed that the facility did not safeguard resident-identifiable information and maintain medical records in accordance with accepted professional standards, as there was no record confirming whether the resident’s scheduled showers or refusals occurred on the identified dates.
Failure to Notify Responsible Party After Narcan Administration for Suspected Opioid Overdose
Penalty
Summary
The deficiency involves the facility’s failure to notify a resident’s responsible party when there was a significant change in the resident’s medical status requiring emergency medication. A complaint alleged that there was no communication with the responsible party when Narcan (naloxone) was administered to a resident for an alleged opioid overdose. Medical record review showed the resident was admitted in March 2026 with multiple fractures, including a nondisplaced zone 1 sacral fracture, a nondisplaced fracture of the posterior column of the right acetabulum, a fracture of the right pubis, and other chronic pain. The resident’s pain regimen included multiple opioids and other pain medications, including Hydromorphone 6 mg every 4 hours PRN, Hydromorphone 4 mg every 4 hours PRN, Tylenol, Lidocaine cream, Methocarbamol, Celebrex, and Gabapentin. A physician’s note dated 4/8/26 documented that the resident reportedly had an opioid overdose earlier that morning and responded well to Narcan administration by nursing, with the note listing chronic pain and opioid overdose status post Narcan. Further review of the resident’s medical record did not show any documentation that the resident’s representative was notified of this overdose event and Narcan administration. During interviews, an agency LPN stated that the resident was “out of it and not responding” during rounds, prompting the LPN to check for and then administer Narcan, after which the resident responded. Another LPN reported that Narcan was given because the resident appeared to be having an overdose and that the physician saw the resident afterward, but stated, “I don’t think anyone was notified, but should have been.” The DON also stated that she would have expected the responsible party to be notified. These findings confirmed that the facility failed to notify the resident’s responsible party of a significant change in condition and emergency treatment.
Failure to Follow Wound Care Orders and Document Narcan Administration
Penalty
Summary
Facility staff failed to provide treatment and care in accordance with professional standards and physician orders for two residents. For one resident admitted after hospitalization with acute systolic heart failure and peripheral edema, a wound physician initially ordered daily oil emulsion dressings for venous wounds on the right shin, left medial foot, and left second toe. At a follow-up assessment, the wound physician changed the treatment for the left medial foot from oil emulsion to daily skin prep and ordered daily skin prep for a newly identified arterial wound on the left plantar foot. Review of the March 2026 medication and treatment administration records showed staff did not discontinue the oil emulsion or initiate the ordered skin prep to the left medial foot, and did not administer skin prep to the left plantar foot wound from the date of the new orders until the resident was sent to the hospital. The DON confirmed that treatments were not administered per the updated wound care orders during this period. For another resident admitted with multiple pelvic and sacral fractures and chronic pain, the record showed extensive opioid and adjunct pain medication orders, and a physician note documented that the resident reportedly experienced an opioid overdose and responded well to Narcan administration by nursing. However, the medical record contained no nursing assessment of the resident at the time of the event, no documentation of the resident’s condition or vital signs, and no record of Narcan administration or the resident’s response afterward. An agency LPN reported finding the resident unresponsive or "out of it" during rounds, knowing the resident was on significant pain medications, and, after checking for an existing order, administering Narcan, after which the resident returned to baseline. The LPN acknowledged not completing or documenting a change-in-condition assessment, and both the DON and unit manager stated they would have expected an assessment and vital signs to be documented in this situation.
Disinfectant Wipes Left Accessible in Dementia Unit Dining Room
Penalty
Summary
The deficiency involves the facility’s failure to keep the environment free from accident hazards on one locked dementia unit. During a complaint survey regarding unsecured cleaning supplies and the potential for residents to use cleaning wipes for personal use, a surveyor observed disinfectant wipes stored openly on a wire shelf in the dining room of the Seagull Unit, a locked dementia unit. The product labeling on the container directed that it be stored in areas inaccessible to children and specifically stated it was not to be used as a diaper wipe or for personal cleansing and that it was not a baby wipe. At the time of the observation, residents with cognitive impairment were present in the dining room awaiting breakfast. A GNA was in the dining room with the residents during the observation, and the unit manager, an LPN, accompanied the surveyor. The surveyor expressed concern about the wipes being accessible in a public area where cognitively impaired residents were present. The LPN reported she had never seen residents use or attempt to use the wipes and stated staff used them to wipe down tables before and after meals. The GNA stated she was always present when residents were in the dining room, that residents were never left alone there, and that she had never seen a resident use a wipe. The Infection Control Nurse stated she was not aware the disinfectant wipes in the dining room were a concern because no residents had gone near them and confirmed they were intended for staff use to clean tables. The NHA and DON reported they had not been made aware of the concern with the wipes, though the DON stated she understood the concern.
Incomplete Documentation of Narcotic Administration on MAR
Penalty
Summary
The deficiency involves the facility’s failure to maintain complete and accurate medical records in accordance with accepted professional standards for one resident. Review of the resident’s April 2026 Medication Administration Record (MAR) and the Controlled Drug Administration Record showed multiple discrepancies for Hydromorphone, a narcotic medication. On several specific dates in April, the Controlled Drug Administration Record documented that Hydromorphone doses were signed out and given by licensed nursing staff at various times, but the corresponding MAR entries for those same dates and times were left blank, indicating no documentation of administration on the MAR. During interviews, an LPN stated that they sign out the medication on the narcotic sheet but do not document it on the MAR. The DON acknowledged awareness that nurses were signing off on the narcotic sheet but not on the MAR, and a unit manager reported not being aware that nurses were failing to sign the MAR when also signing the narcotic sheet, stating that documentation should occur on both records. The NHA and DON later stated they were not aware of the concern until it was identified by the surveyor and agreed with the findings. These observations and interviews demonstrate that the facility did not ensure that all medication administrations were consistently and accurately documented on the MAR for this resident.
Trusted data from CMS and state health departments
Every citation, penalty and Plan of Correction is sourced from public CMS records (latest release June 24, 2026) and official state health department websites — never guesswork.
Trusted by long-term care providers and associations.
