Bay Harbor Post Acute Healthcare Center
Inspection history, citations, penalties and survey trends for this long-term care facility in Salisbury, Maryland.
- Location
- 200 Civic Avenue, Salisbury, Maryland 21804
- CMS Provider Number
- 215067
- Inspections on file
- 18
- Latest survey
- April 17, 2026
- Citations (last 12 mo.)
- 15 (2 serious)
Citation history
Health deficiencies cited at Bay Harbor Post Acute Healthcare Center during CMS and state inspections, most recent first.
A resident was subjected to verbal abuse when a staff member used abusive language while attempting to bring the resident inside from a smoking area. Witnesses reported that the staff member told the resident to come inside, sit down, and shut up, and the staff member later confirmed having a verbal exchange with the resident and telling the resident to shut up. The facility’s internal investigation verified that this interaction constituted verbal abuse.
Staff failed to secure a deceased resident’s personal belongings, resulting in the loss of the resident’s cell phone. After the resident’s death, multiple GNAs observed the phone in the room on different shifts, with one placing it in a bag left in the room rather than in a secure location. Another staff member reported that belongings are typically packed, labeled, and kept behind the nurse’s station, but also acknowledged there was no secure storage area for items awaiting family pickup. When the family arrived to collect belongings, the phone and charger were missing and could not be located despite a search, leading to a citation for misappropriation of property.
Nursing staff failed to meet professional standards when a CMA administered nighttime medications intended for a discharged resident to that resident’s former roommate without verifying identity or discharge status, as documented in the medical record and facility investigation. In a separate incident, an RN treated a resident’s hypoglycemic episode with Glucagon and documented that an on-call provider ordered a repeat glucose check and possible second dose, but no corresponding Glucagon order or follow-up fingerstick result was entered in the EHR. Additionally, staff reported performing ostomy appliance changes for a resident and stated this care was documented on the TAR, yet review of the TAR and EHR showed no documentation that ostomy care was provided despite an existing order for colostomy appliance care.
A medication administration error occurred when a resident was given Gabapentin, an anticonvulsant, without any active or discontinued order for the drug and without a documented clinical indication. After receiving the medication, the resident experienced dizziness. The DON later confirmed that the Gabapentin dose had been intended for a different resident, resulting in the wrong resident receiving an unprescribed medication.
Surveyors found that staff failed to serve meals according to printed meal tickets for two residents during a lunch service. One resident, who reported disliking most facility food and relying on milk as the only item they enjoyed, did not receive the 8 oz of whole milk listed on their ticket, a fact confirmed by the Regional Food Service Director. Another resident was served mashed potatoes instead of the pasta specified on their ticket. The Food Service Director stated that the end-of-line employee is responsible for ensuring that what is served matches the meal ticket and acknowledged that residents are to receive the items indicated.
Multiple incidents of alleged abuse, neglect, and injury were not reported or investigated in accordance with regulatory requirements. Staff were informed of allegations involving physical and sexual abuse, as well as injuries of unknown origin, but failed to notify the SSA within the required timeframe or submit follow-up investigation reports. These lapses involved residents with both intact and impaired cognition and included both staff-to-resident and resident-to-resident incidents.
Multiple allegations of abuse, including physical, sexual, and verbal incidents involving several residents, were not thoroughly investigated by facility staff. In each case, required steps such as suspending accused staff, conducting skin or trauma assessments, obtaining written statements, and interviewing all relevant parties were not completed, despite the facility's policies mandating comprehensive investigations.
Over a nine-month period, the facility did not adequately address repeated Resident Council concerns about staffing shortages and delayed call light responses. Residents reported long waits for assistance, especially on weekends and overnight shifts, and staff sometimes turned off call lights before needs were met. Observations confirmed delayed responses, and interviews with staff and leadership revealed a lack of clear policies or documentation of corrective actions.
A resident dependent on staff for toileting was not provided timely incontinence care before attending a group activity, despite requests from both the resident and their representative. Staff communicated that providing care would prevent the resident from attending the activity, resulting in the resident attending while soiled. The facility did not thoroughly investigate the grievance or communicate resolution efforts to those involved. Additionally, multiple residents and the Resident Council reported ongoing delays in call bell response over several months, with incomplete investigations and lack of follow-up or resolution documentation.
The facility did not follow its abuse prevention and reporting policies, failing to notify law enforcement and the ombudsman about multiple allegations of abuse, neglect, and injuries of unknown origin. Investigations into these incidents were incomplete, lacking required interviews and documentation from residents, staff, and witnesses. Leadership confirmed that expected procedures were not followed, and several cases showed a pattern of noncompliance with required reporting and investigation protocols.
Staff failed to consistently follow infection control protocols, including enhanced barrier precautions during wound care for a resident with MRSA and a central line, and proper hand hygiene and glove use during catheter care for two residents with indwelling catheters. Observations revealed that staff did not use required PPE, did not sanitize surfaces or use barriers, and did not change gloves or perform hand hygiene at appropriate times, contrary to facility policy.
Staff failed to promptly assist a resident with incontinence care, resulting in the resident attending a church service in a soiled brief after being told that receiving care would prevent participation in the activity. Additionally, a staff member entered a shared room without knocking or announcing herself, contrary to facility policy. Leadership confirmed that these actions did not meet expectations for resident dignity and privacy.
Two residents with severe cognitive impairment and behavioral issues were involved in a physical altercation over a pillow, resulting in a skin tear to one resident's forearm. An LPN witnessed the incident and intervened, but the facility failed to prevent the abuse as required by policy.
A resident with hemiplegia and muscle atrophy did not receive physical therapy as frequently as ordered by the physician, with two scheduled sessions missed in one week and no documentation provided to explain the absences. Interviews with the DOR and PTA confirmed the lack of documentation and communication regarding the missed therapy, which was not in accordance with facility policy or physician orders.
Three residents did not have complete or accurate medical records, including missing orders for catheter care, absent documentation of showers and ADLs, and lost paper records for personal care. Staff and administration confirmed that all care, including refusals and scheduled tasks, should be documented in the medical record.
Surveyors found deficiencies in food storage and temperature monitoring at the facility. Observations revealed expired, unlabeled, and improperly stored food items in the medication room and clean utility room refrigerators, along with incomplete temperature logs. In the kitchen, various food items were unlabeled and undated, and temperature logs for the freezer and dishwasher were not maintained. The assistant manager confirmed these findings and acknowledged the expectations for proper labeling and temperature recording.
The facility failed to maintain a clean and safe environment, with surveyors observing unsanitary conditions such as dried stool, strong urine odors, and overflowing trash in resident rooms. Residents reported unaddressed concerns about potential mold in the dining room, and missing light bulbs and dirty toilet seats were noted. Housekeeping duties were not consistently performed, and the administrator was unaware of some issues.
The facility failed to implement comprehensive care plans for three residents, leading to deficiencies in addressing their specific needs. A resident lacked an updated activities calendar, another did not have a specific care plan for nutrition despite suspected weight loss, and a third resident's care plan was missing essential communication and respiratory care details. Staff interviews confirmed these oversights.
The facility failed to implement physician orders and maintain proper documentation, affecting several residents. A resident with a PEG tube lacked management orders, while another's vital signs were inconsistently recorded. A resident's wound care was not documented, and another experienced significant weight loss without a care plan. Medication administration was delayed for two residents, impacting pain management. Weekly weight checks for a resident were not completed as ordered.
The facility failed to ensure monthly Medication Regimen Reviews (MRR) by a licensed pharmacist for three residents, leading to deficiencies in medication management. A resident had an incomplete physician order for Phenobarbital, risking incorrect dosage, while two other residents did not have MRRs conducted for several months. The DON acknowledged the oversight, and these issues were discussed with the administration team.
The facility failed to maintain a sanitary environment, with linen found on floors in multiple units and unsanitary conditions in a clean utility room. Maintenance issues included missing wallpaper and a damaged metal box. The DON confirmed these findings, and the NHA acknowledged challenges in addressing maintenance concerns due to ongoing renovations.
The facility failed to maintain resident dignity and proper care, as observed in several incidents. A resident's transfer was delayed due to a malfunctioning Hoyer lift, resulting in the resident bumping against a raised grab bar. Other issues included a resident with an uncovered Foley catheter bag, a resident with mucous secretions on their gown, and another with full and empty urinals on their bedside table. These deficiencies were acknowledged by the Director of Nursing.
The facility failed to ensure call bells were accessible for residents on Unit 4, with instances of call bells being out of reach or improperly placed. Additionally, the facility did not schedule a necessary follow-up orthopedic appointment for a resident, failing to document the appointment, transportation arrangements, or family contact.
The facility did not promptly address the resident council's recommendations on issues of resident care and life. Interviews with residents and staff, along with a review of council meeting minutes, revealed that 20 issues were consistently identified over several months, with most marked as 'Still an issue.' The DON and administrator were informed of these findings.
Facility staff failed to assess residents for advance directives and did not offer assistance with creating them. Six residents were not assessed or informed about their rights to have an advance directive, nor were they provided with written materials. The facility's policy requires inquiries and documentation of offers to assist residents, but no evidence was found to show these actions were taken.
The facility failed to address a resident's grievance regarding a missing jacket, with no follow-up or grievance filed. During a resident council meeting, multiple residents were unaware of the grievance process and feared reprisal. The Administrator could not provide documentation of addressed grievances, and ongoing issues were documented in council minutes.
The facility failed to meet professional standards of care, including not scheduling a follow-up appointment for a resident, lacking physician orders for PEG tube management, incomplete vital sign documentation for another resident, and discrepancies in narcotic counts. Additionally, discontinued controlled medications were not destroyed immediately as per policy.
The facility failed to ensure CNAs completed a state-approved GNA training program within four months of employment, affecting seven CNAs. The administrator was unaware of the four-month requirement, believing CNAs had 12 months to obtain certification. Additionally, the HR Director missed the expiration of a CNA's certification, assuming it was still active.
The facility failed to serve meals according to residents' menu tickets, as observed during a survey. Several residents did not receive the items listed on their meal tickets due to the kitchen running out of certain items. During a lunch tray line observation, it was noted that the facility ran out of several menu items, leading to substitutions not indicated on the meal tickets.
The facility failed to maintain food at an appetizing temperature during a lunch service. Due to a shortage of hot plates, the last 16 trays were delivered without proper temperature control. A test tray showed significant temperature drops, resulting in unpalatable food and room temperature coffee.
The facility failed to provide suitable and nourishing alternative meals and snacks for residents wishing to eat at non-traditional times. During a resident council meeting, all attendees reported issues with the availability and delivery of bedtime snacks, which were often unlabeled and lacked variety. A resident with special dietary needs also noted that these needs were not met. Staff interviews confirmed that snacks were sent in bulk and unlabeled, and the Senior Director of Operations stated this was standard practice.
The facility failed to document that five GNAs received screening, education, and the offering of the COVID-19 vaccination. A review of their records showed no documentation of these procedures. The IP confirmed the absence of such documentation during an interview.
The facility failed to regularly inspect bed frames, mattresses, and bed rails for potential entrapment risks, affecting five residents. Observations revealed that these residents had quarter-length bed rails raised on their beds. The facility's policy required routine inspections, but interviews with the DON and the Nursing Home Administrator confirmed that maintenance did not regularly check for entrapment risks, leading to the deficiency.
The facility failed to notify responsible parties of two residents about significant medical changes. One resident was transferred to the hospital without family notification, and another had a medication discontinued without informing the responsible party. These incidents highlight lapses in the facility's communication process.
A GNA in an LTC facility verbally threatened a resident after being physically assaulted by the resident. The incident was overheard by an RN, who reported it. The GNA admitted to making the remarks, and the facility's administrator confirmed the GNA was suspended and terminated. However, the Board of Nursing was not notified of the investigation results.
A facility failed to report an injury of unknown origin involving a resident to the state agency within the required two-hour timeframe. The incident was reported to an LPN by the resident, but the facility's Self Report Form was submitted late, and the DON and Administrator could not explain the delay.
A resident experienced two falls in one evening, which were not documented by the responsible LPN. The resident later complained of pain and was found to have a femur fracture upon hospital admission. The DON failed to retain documentation of the falls, the LPN's admission, and the disciplinary action taken. The GNA reported the falls to the LPN, but no documentation was made.
The facility failed to conduct interdisciplinary care plan meetings for two residents, resulting in a deficiency. One resident did not have a documented care plan meeting within the first week of admission, and another resident's meeting lacked full team participation. The Director of Social Services noted that team members were invited but did not attend.
A facility failed to document and provide consistent assistance with activities of daily living for a quadriplegic resident. The resident, who had limited hand mobility, was left without meal assistance and had not been out of bed for six months due to an unrepaired wheelchair. Documentation reviews revealed significant gaps in personal hygiene and showering records, and the resident had been hospitalized with a urinary tract infection and decubitus ulcers.
A facility failed to provide one-on-one activities for a resident who was observed without engagement on multiple occasions. The Life Enrichment Director confirmed that such activities should occur two to three times weekly, but documentation showed only one activity in December and none in November, highlighting a deficiency in resident engagement.
Facility staff failed to ensure safe transfer of a resident using a Hoyer lift, resulting in the resident bumping against a raised grab bar due to a malfunctioning battery. Additionally, another resident's environment was not kept safe, as a tangle of wires was found near their bed, contrary to their care plan for fall risk prevention.
A resident experienced multiple falls due to inadequate staffing at a facility. On one occasion, there was no nurse assigned to the resident's station, which contributed to the inability to prevent a fall. The DON confirmed the absence of a nurse during the shift, deviating from the usual staffing pattern.
The facility failed to properly store and label medications, as observed during a survey. Multiple medication carts contained opened house stock medications without date labels, and discontinued controlled medications were found in narcotic lock boxes. The facility's policy requires labeling with the date when medications are opened and immediate disposal of discontinued controlled substances, but these procedures were not followed.
The facility failed to maintain accurate and secure medical records, as evidenced by incomplete PASARR forms for two residents and a medication list mix-up involving another resident. The Director of Social Services acknowledged the oversight in reviewing forms, and the DON and Administrator were unaware of the medication list error until the survey.
The facility failed to protect two residents' personal property and did not investigate reports of missing items. One resident reported missing clothing after laundry, and another reported a missing jacket during Christmas. Despite informing staff, no follow-up or investigation was conducted.
A facility failed to accurately code a resident's Deep Tissue Injury (DTI) on the MDS assessment, despite documentation in the medical record. The MDS Coordinator confirmed reliance on medical records for coding, but the surveyor found the coding did not reflect the resident's status accurately.
The facility failed to provide adequate mobility support and basic hygiene care for two residents. A resident with quadriplegia was confined to bed for six months due to a broken wheelchair, with no alternative equipment provided. Another resident reported not receiving scheduled showers, and there was no documentation to verify shower provision. The DON and ADON acknowledged these issues, highlighting deficiencies in care and documentation.
A resident experienced significant weight loss over several months, dropping from 215.6 lbs to 165 lbs. Despite an order for weekly weights, there was no documentation of these being taken. The RD was aware of the weight loss but did not intervene until January, citing a history of weight fluctuations. The DON and PA were not informed of the weight loss in a timely manner, and established protocols for addressing significant weight changes were not followed.
The facility failed to obtain informed consent before using bed rails for five residents. Observations and document reviews showed that bed rails were used without documented consent or attempts to use alternatives, contrary to the facility's policy. The DON confirmed the lack of consent and alternative attempts.
A resident experienced significant weight loss over several months, dropping from 215.6 lbs to 165 lbs, without timely intervention or notification to the medical provider. The DON could not explain the lack of communication, and the PA was unaware of the issue until a recent meeting.
Failure to Protect a Resident From Verbal Abuse by Staff
Penalty
Summary
The facility failed to protect a resident from verbal abuse when a staff member directed abusive language toward the resident. Review of a facility-reported incident and investigation records showed that on the date in question, Staff #40 was attempting to get Resident #57 to come inside from the smoking area. When the resident stated they did not want to come inside, Staff #40 told the resident to “shut up” and come inside. A witness statement from Staff #21 documented that Staff #40 told the resident, “Just come inside, sit down, and shut up,” and the Activities Director (Staff #13) recalled being notified that Staff #40 was going back and forth with a resident and told the resident to shut up. During the facility’s investigation, the DON reported that Staff #40 confirmed having words back and forth with the resident and acknowledged stating “come inside and shut up,” and the facility verified the allegation of verbal abuse. The DON was subsequently notified that this constituted a concern related to the requirement to protect residents from all types of abuse, including verbal abuse.
Failure to Secure Deceased Resident’s Personal Belongings
Penalty
Summary
Facility staff failed to protect a deceased resident’s personal belongings, specifically the resident’s cell phone, from misappropriation. The resident died on 03/17/26, and documentation noted that the family would come to collect the resident’s belongings. When the family arrived to pick up the belongings, the resident’s cell phone was missing. The resident’s daughter reported the missing phone to the Administrator on 03/20/26, and staff searched the laundry and the resident’s room but were unable to locate it. A nurse supervisor documented that when the phone could not be found, the police were notified. Multiple staff statements showed that the resident’s cell phone had been seen in the room after the resident’s death but was not secured. One GNA reported seeing the phone on 03/18/26 and placing it in a green Bay Harbor bag that was left in the room, even though the resident had passed and could no longer use the phone. Another GNA reported seeing the phone on the bedside table during the 11 pm–7 am shift on 03/17/26. The RN Unit Manager documented that when the family went into the room, there was no phone or charger present. One GNA stated that when a resident passes, belongings are usually packed, labeled, and kept behind the nurse’s station for a day or two before housekeeping takes them downstairs, and acknowledged there was no secure place for belongings until family retrieval. Another GNA stated they did not handle the belongings because they were not instructed to do so and were unsure of the policy. The cell phone was never located, and the facility was cited for misappropriation of property.
Medication Errors, Incomplete Hypoglycemia Documentation, and Missing Ostomy Care Records
Penalty
Summary
Nursing staff failed to meet professional standards by incorrectly administering medications and not properly identifying a resident prior to administration. A certified medication aide (CMA) gave nighttime medications intended for a discharged resident to that resident’s former roommate. The medical record documented a change in condition note stating that the roommate received the other resident’s nighttime medications, although no abnormal signs or symptoms were observed and the provider was notified. The facility’s internal investigation identified that the CMA did not verify the resident’s identity and did not confirm the discharged resident’s status before administering the medications, despite existing training that requires verification of unit census and resident identity and removal of medications from the cart after discharge. Nursing staff also failed to adhere to standards of practice regarding documentation of verbal orders and follow-up care during a hypoglycemic episode. A resident was noted to be difficult to arouse with a fingerstick blood glucose of 50 mg/dl, and an RN administered Glucagon to the resident’s left thigh. The RN documented that an on-call provider was notified and that an order was received to recheck the glucose in 10 minutes, give another dose of Glucagon, and notify the provider of the results. However, the electronic health record contained no written medication order for two doses of Glucagon and no documented follow-up fingerstick result, despite the RN later stating that the resident received one dose of Glucagon and that the follow-up fingerstick was 88 mg/dl. In addition, nursing staff failed to document ostomy care for a resident with an ostomy. An RN reported that they had wound care training, performed ostomy appliance changes as needed, and that this care was documented on the treatment administration record (TAR). Review of the TAR for the relevant month showed no documentation that the resident’s ostomy appliance was changed or that ostomy care was provided. Another RN stated that ostomy care should be ordered and documented on the TAR and signed when completed, and the wound care nurse was unable to locate documentation in the electronic health record verifying that the ordered colostomy appliance care was actually provided.
Medication Error: Unprescribed Gabapentin Administered to Resident
Penalty
Summary
A medication administration deficiency occurred when Gabapentin, an anticonvulsant, was given to Resident #54 without a clinical indication. A complaint was made alleging that the resident received Gabapentin inappropriately, and subsequent record review showed that the resident had no active or discontinued order for this medication. Documentation further revealed that the resident experienced side effects, including dizziness, after the administration of Gabapentin. During an interview, the Director of Nursing confirmed that a medication error had occurred and clarified that the Gabapentin dose administered to Resident #54 had been intended for a different resident. These findings demonstrate that the resident received a medication not prescribed for them and without a documented clinical indication, resulting in adverse effects.
Failure to Serve Meals According to Printed Meal Tickets
Penalty
Summary
Surveyors identified a deficiency in meal service when residents were not served food and beverages according to their printed meal tickets. During a lunch observation, one resident’s tray lacked the 8 oz of whole milk specified on the meal ticket, and the resident stated they did not like the facility’s food and looked forward to milk as the only item they enjoyed, confirming they had not received it. The Regional Food Service Director, present during this observation and interview, confirmed that milk was not served as ordered. In a separate observation minutes later, another resident was served mashed potatoes instead of pasta, which was listed on their meal ticket. The Facility Food Service Director reported that the employee at the end of the food line is responsible for ensuring that the meal ticket matches what is served and acknowledged that residents should receive what is indicated on their meal tickets. On the same day, the facility administrator was notified of these concerns, which demonstrated that the facility failed to follow residents’ meal tickets for at least two residents during the observed dining period.
Failure to Timely Report and Investigate Abuse Allegations
Penalty
Summary
The facility failed to ensure timely reporting of suspected abuse, neglect, or theft, and did not submit the results of investigations to the State Survey Agency (SSA) within the required timeframes for multiple residents. In several instances, staff were made aware of allegations of physical and sexual abuse, as well as injuries of unknown origin, but these were not reported to the SSA within two hours as required by facility policy and federal regulations. For example, one resident reported being physically abused by a registered nurse, and although staff notified the Director of Nursing (DON), the allegation was not reported to the SSA. Another resident alleged being pushed by a housekeeper, but the initial report to the SSA was delayed and the follow-up investigation was not submitted within five working days. Additionally, there were failures to report and investigate allegations of sexual abuse and retaliation between residents. One resident reported an incident involving another resident attempting to touch their genitals and subsequent feelings of intimidation and isolation. Staff were informed of these allegations, but the facility did not report them to the SSA as required. In another case, a resident with severely impaired cognition was found with discoloration on their arm, and while an initial report was submitted, the final investigation report was not provided to the SSA. The facility's own policy required immediate reporting of abuse allegations to the administrator and appropriate authorities, defining 'immediately' as within two hours for incidents involving abuse or serious bodily injury. Despite this, multiple incidents were either not reported, not reported timely, or not followed up with the required documentation to the SSA. These failures were identified through observation, interviews, record reviews, and policy reviews, and were determined to have caused, or were likely to cause, serious injury, harm, impairment, or death to residents.
Removal Plan
- Statements were obtained from involved residents #41, #22 and #33 by the Nurse manager.
- Resident #41, Resident #22, and Resident #33 were assessed to ensure no injuries, physical or psychological, were present by the nurse manager.
- RN #20 and Housekeeper #28 have been suspended by Regional Director of Operations.
- The administrator and director of nursing have been suspended by Regional Director of Operations.
- Statements were obtained from the accused employees #20 and #28 by Regional Nurse.
- Social Services has met with involved residents #41, #22 and #33 to address any psychosocial concerns.
- Residents #41 (allegation of physical abuse) and #33 (allegation of sexual abuse) responsible parties were made aware of the allegations by Nurse manager. Education provided for timely abuse reporting based on CMS regulation.
- Medical Directors were made aware of the allegations of physical and sexual abuse.
- Police were notified of the allegations of physical and sexual abuse. Maryland Department of Health was notified of the allegations of physical and sexual abuse.
- Medical Directors were notified of the allegations of physical and sexual abuse for residents #41 and #33.
- Ombudsman was notified of the allegations of physical and verbal abuse.
- Trauma informed evaluations completed for identified residents #41 and #33.
Failure to Thoroughly Investigate Abuse Allegations
Penalty
Summary
The facility failed to conduct thorough investigations into multiple allegations of abuse involving four residents. In one instance, a resident with intact cognition and a history of falls reported that a registered nurse physically abused them by grabbing their head and squeezing their arm after a fall. Although staff were informed and some statements were collected, the Director of Nursing (DON) did not initiate a comprehensive investigation, did not suspend the accused nurse, and did not report the incident to the State Survey Agency as required. Witnesses were not fully interviewed, and documentation was incomplete. Another resident alleged that a housekeeper pushed them, an incident witnessed by staff. However, the facility did not perform a skin audit or trauma assessment on the resident, nor did it obtain a written statement from the resident or interview other potential witnesses. The investigation relied on a summary of staff interviews and did not include direct input from the resident or other residents in the area at the time of the incident. A third resident reported that another resident attempted to touch them inappropriately and that subsequent retaliation occurred. Despite the resident self-isolating and reporting the incident to multiple staff members, the facility did not conduct an investigation into the allegation. Additionally, an allegation of verbal abuse made by another resident was not thoroughly investigated, as the facility failed to obtain written statements from staff or residents related to the claim. These failures were contrary to the facility's own policies, which require comprehensive investigation and documentation of all abuse allegations.
Removal Plan
- Obtain statements from involved residents #41, #22 and #33
- Assess residents #41, #22, and #33 to ensure no injuries, physical or psychological, are present
- Suspend RN #20 and Housekeeper #28
- Suspend the administrator and director of nursing
- Obtain statements from the accused employees #20 and #28
- Social Services to meet with involved residents #41, #22 and #33 to address any psychosocial concerns
- Notify responsible parties of residents #41 and #33 of the allegations
- Notify police of the allegations of physical and sexual abuse
- Notify Maryland Department of Health of the allegations of physical and sexual abuse
- Notify Medical Directors of the allegations of physical and sexual abuse for residents #41 and #33
- Notify Ombudsman of the allegations of physical and verbal abuse
- Complete trauma informed evaluations for identified residents #41 and #33
- Educate all current employees regarding investigation of abuse
- Educate nurse managers and social workers on abuse investigation
Failure to Address Resident Council Concerns on Staffing and Call Light Response
Penalty
Summary
The facility failed to adequately address ongoing concerns raised by the Resident Council regarding staffing levels and call light response times over a nine-month period. Resident Council minutes repeatedly documented complaints about insufficient staff on weekends, delayed responses to call lights, and staff not assisting residents with getting up or providing care during certain shifts. Despite these recurring concerns, the facility's responses were limited to general statements, requests for more specific information, or references to individual cases, without evidence of comprehensive investigation or resolution. Documentation such as call bell audits and records of supervisory rounds or spot checks, which were cited as part of the facility's response, were not provided for review. Observations during the survey confirmed that call lights were left unanswered for extended periods, and staff sometimes turned off call lights before residents' needs were met. For example, one resident's call light remained on and flashing for a prolonged time, and the resident reported that their need was not met even after the call light was answered. Another resident waited over an hour for acetaminophen after activating their call light. Staff interviews corroborated that call lights were not always answered promptly, often due to multiple simultaneous calls and insufficient staffing. Interviews with facility leadership revealed a lack of clear policies or targets for call light response times, and there was no evidence that the concerns raised by the Resident Council were systematically addressed through the facility's Quality Assurance and Performance Improvement (QAPI) process. The Regional Director of Operations and Regional Nurse Consultant were unable to provide documentation of corrective actions or performance improvement plans related to these issues. The facility's grievance policy required prompt investigation and resolution of complaints, but there was no documentation that this process was followed for the Resident Council's ongoing concerns.
Failure to Promptly and Consistently Resolve Resident Grievances Related to Incontinence Care and Call Bell Response
Penalty
Summary
The facility failed to ensure prompt and consistent efforts were made to resolve resident grievances, specifically in relation to incontinence care and call bell response times. In one instance, a resident with hemiplegia and hemiparesis, who was dependent on staff for toileting, experienced an episode of incontinence while preparing to attend church. The resident and their representative reported that staff informed the resident that if incontinence care was provided, the resident would not be able to attend church. As a result, the resident attended church in a soiled brief. Documentation showed that the Manager on Duty was informed of the incident well after lunch, and although the resident was eventually provided care, there was no thorough investigation or communication of the facility's efforts to resolve the grievance to the resident or their representative. Staff interviews revealed that key personnel were unaware of the grievance until much later, and statements were not collected in a timely manner. The facility also failed to address and resolve repeated grievances and concerns related to staff response to call bells, as reported by multiple residents and the Resident Council over a nine-month period. Grievance forms and Resident Council Meeting Minutes documented ongoing complaints about delayed call light responses, staff turning off call bells before needs were met, and staff being inattentive or unavailable. Investigations into these grievances were often incomplete, lacking documentation of whether actual delays occurred or what specific actions were taken. In several cases, there was no follow-up with residents or their families regarding the facility's efforts to resolve the grievances, and some grievances remained unresolved for extended periods. Observations and interviews further confirmed ongoing issues with call light response times. Residents reported waiting significant periods for assistance, and staff acknowledged challenges in responding promptly due to workload and staffing levels. Facility leadership and consultants were unable to specify targeted response times or provide evidence of systematic efforts to address the pattern of grievances. There was also no documentation that these concerns were addressed in the facility's Quality Assurance and Performance Improvement (QAPI) committee.
Failure to Implement Abuse Prevention and Reporting Policies
Penalty
Summary
The facility failed to implement its abuse prohibition and prevention policies for multiple residents, as evidenced by the lack of proper reporting and incomplete investigations into allegations of abuse, neglect, and injuries of unknown origin. In several cases, allegations made by residents or their representatives were not reported to required external agencies such as law enforcement and the ombudsman, despite facility policy mandating such notifications. For example, allegations involving rough care, physical abuse, and neglect were not communicated to the appropriate authorities, and documentation showed that notifications were either delayed or not made at all. Investigations into reported incidents were incomplete and did not follow facility policy. In multiple instances, investigation reports lacked statements from the residents who made the allegations, the staff members involved, and potential witnesses. For example, in one case, a resident alleged rough care by a GNA, but the investigation file did not include statements from the resident or the staff present during the incident. Similarly, another resident alleged that a housekeeper pushed them, but the investigation lacked statements from both the resident and the housekeeper, and there was no evidence that other residents or staff were interviewed as required by policy. Interviews with facility leadership confirmed that the expected procedures for thorough investigations and reporting were not followed. The Regional Director of Operations and the Regional Nurse Consultant acknowledged that interviews with all involved parties and timely notifications to external agencies were part of facility protocol, yet these steps were not consistently documented or performed. Additionally, review of initial reports for several other residents revealed that allegations of verbal abuse and injuries of unknown origin were not reported to required agencies, further demonstrating a pattern of noncompliance with abuse prevention and reporting policies.
Failure to Implement Infection Control Practices During Wound and Catheter Care
Penalty
Summary
The facility failed to ensure staff consistently and correctly implemented infection control practices, specifically regarding enhanced barrier precautions (EBP) during wound care and proper catheter care and hand hygiene. During wound care for a resident with a history of MRSA infection and a central line, an LPN performed hand hygiene and donned gloves but did not wear an isolation gown as required by the facility's EBP policy. The LPN was unable to state whether a gown was necessary and noted the absence of PPE setup outside the resident's room, despite a caddy with PPE being present. The resident's care plan and physician orders clearly indicated the need for EBP, including gown and glove use during high-contact care activities such as wound care. In two separate observations of catheter care, staff did not follow proper infection control protocols. For one resident with an indwelling catheter, a GNA failed to sanitize the bedside table or use a barrier before placing supplies, did not change gloves or perform hand hygiene during the procedure, and cleaned the catheter in the incorrect direction. The GNA acknowledged not changing gloves or performing hand hygiene and stated that gloves would only be changed if they ripped or became soiled. For another resident with an indwelling catheter, a different GNA also failed to sanitize the nightstand or use a barrier, did not change gloves or perform hand hygiene after providing catheter care, and continued to handle the resident's personal items and assist with grooming while still wearing the same gloves. This GNA was unaware of the need to change gloves and perform hand hygiene at specific points during the procedure. Interviews with the Infection Preventionist, Interim DON, and Regional Director of Operations confirmed expectations that staff should follow EBP and hand hygiene protocols. However, the Infection Preventionist admitted to only occasionally observing staff during wound and catheter care, and the staff involved were either unaware of or did not adhere to the required infection control practices. The facility's own policies on EBP, hand hygiene, and catheter care were not followed during the observed care activities, leading to the identified deficiencies.
Failure to Provide Dignified Care and Respect Resident Privacy
Penalty
Summary
Facility staff failed to treat three residents with dignity and respect as required by policy. One resident, who had a history of hemiplegia, hemiparesis, chronic heart failure, and chronic pain, was dependent on staff for toileting and hygiene. On the day of the incident, the resident experienced incontinence while preparing to attend church and requested assistance with hygiene. Staff informed the resident that if incontinence care was provided, the resident would not be able to attend church, leading the resident to attend the service in a soiled brief. The Manager on Duty was not informed of the incident until after lunch, and incontinence care had still not been provided by early afternoon. Multiple interviews confirmed that the resident and their representative reported the incident, and staff acknowledged the failure to provide timely care. Additionally, the facility failed to ensure privacy and dignity for two other residents sharing a room. During an observation, a staff member entered the shared room without knocking or announcing herself, despite the facility's policy requiring staff to knock and request permission before entering any resident's room. The staff member believed that knocking was unnecessary if the door was open, a misunderstanding not supported by facility leadership or policy. Interviews with facility leadership confirmed that the expectation was for staff to always knock or announce themselves before entering, regardless of whether the door was open. These incidents demonstrate that staff did not follow established policies designed to protect resident dignity, including prompt response to requests for incontinence care and respecting privacy by knocking before entering resident rooms. The failures were confirmed through interviews with residents, their representatives, and facility staff, as well as review of facility policies and grievance documentation.
Failure to Prevent Resident-to-Resident Physical Abuse
Penalty
Summary
The facility failed to protect a resident's right to be free from physical abuse by another resident. According to facility records and staff interviews, one resident with severe cognitive impairment and a history of psychosocial well-being issues was involved in a physical altercation with their roommate, who also had severe cognitive impairment, dementia, and a history of behavioral problems including aggression and poor impulse control. The incident occurred when the aggressive resident entered the other resident's bed and began fighting over a pillow, resulting in a skin tear on the affected resident's forearm. Staff observed the altercation and noted that the aggressive resident had their fingernails in the other resident's arm during the incident. Both residents had documented histories of cognitive impairment and behavioral concerns, with care plans indicating risks for negative interactions and physical behaviors. Progress notes and staff interviews confirmed that the altercation was witnessed by an LPN, who intervened to separate the residents. The facility's policies prohibit all forms of abuse and require recognition and prevention of such incidents, but the altercation still occurred, resulting in physical harm to one resident.
Failure to Provide Therapy Services as Ordered and Document Reasons for Missed Sessions
Penalty
Summary
The facility failed to provide physical therapy (PT) services in accordance with physician orders for one resident who had a history of hemiplegia and hemiparesis following a cerebral infarction, as well as muscle wasting and atrophy. The resident was admitted with significant deficits in activities of daily living (ADLs) and had orders for PT evaluation and treatment five times a week for 30 days, with subsequent recertifications to continue therapy at the same frequency. Documentation showed that during one week, the resident received PT only three times instead of the five times ordered, with no explanation documented for the missed sessions. Interviews with the Director of Rehabilitation and the Physical Therapy Assistant confirmed that the resident was scheduled for therapy on the missed days, but there was no documentation as to why therapy was not provided. The facility's policy required care and services to be provided and documented in accordance with physician orders and professional standards. The lack of documentation for the missed therapy sessions and absence of communication regarding the reasons for not providing therapy constituted a failure to follow physician orders and facility policy.
Failure to Maintain Complete and Accurate Medical Records
Penalty
Summary
The facility failed to maintain complete and accurate medical records for three residents, as required by professional standards and facility policy. For one resident with a history of cirrhosis and ascites, who was admitted with an indwelling urinary catheter, there was no documented order for catheter care in the medical record, despite the care plan and nursing documentation indicating that catheter care was being provided every shift. Interviews with nursing staff and administration revealed that orders for catheter care should have been entered upon admission, but there was no evidence that this occurred. Another resident, admitted with hemiplegia and muscle wasting, required substantial assistance with activities of daily living (ADLs), including showering and personal hygiene. Documentation for scheduled showers was missing for two specific dates, and staff interviews confirmed that care such as showers and ADLs should be documented in the electronic record, including refusals or if the resident was not present. The interim DON and Regional Director of Operations both stated that they expected staff to document all care provided in the resident's medical record. A third resident, with diagnoses including aphagia, dysphagia, and vascular dementia, was dependent on staff for all ADLs and was noted to be resistive to care. Family concerns were raised regarding missed showers, and the DON was unable to locate shower documentation for two months. The DON confirmed that shower care was documented on paper forms during that period, but these records were missing from the resident's medical record. The interim DON reiterated that such documentation should be included in the resident's record, and the RDO expected all care to be documented.
Deficiencies in Food Storage and Temperature Monitoring
Penalty
Summary
The facility was found to have deficiencies in food storage and temperature monitoring practices. During an inspection, surveyors observed that the medication room and clean utility room refrigerators contained expired, unlabeled, and improperly stored food items. The medication room refrigerator was dirty, with dried food stains and sticky residues, and contained a cup of pudding with an outdated label. In the clean utility room refrigerator, there were several food items, including bologna, cheese, and milk, that were either expired, unlabeled, or opened without proper labeling. The temperature log for this refrigerator was also incomplete, lacking documentation of freezer or refrigerator temperatures. In the kitchen, similar issues were noted with food storage and labeling. The kitchen refrigerator contained various unlabeled and undated food items, such as eggs, lunch meat, raw meat, and cooked chicken. The dry storage room had prepped cereal bowls that were undated. Additionally, the kitchen freezer's temperature log had not been updated since a previous date, and the dishwasher temperature records were incomplete. The assistant manager confirmed these findings and acknowledged that the expectation was for staff to label food with preparation and discard dates and to record equipment temperatures each shift.
Inadequate Housekeeping and Maintenance in LTC Facility
Penalty
Summary
The facility failed to maintain a safe, clean, and comfortable environment for its residents, as evidenced by multiple observations of inadequate housekeeping and maintenance services. During the survey, a shower room was found with dried stool on the floor, and a cotton-tipped swab was left unattended in a resident's bathroom for several days. Additionally, a resident's bathroom wall was in need of painting, and another resident reported that their room had not been cleaned for two consecutive days, resulting in food and trash scattered throughout the room and a foul-smelling substance in the bathroom. Further observations revealed several rooms with strong urine odors, sticky floors, and overflowing trash cans. The main dining room had ceiling tiles with dark brown spots and wall columns with a dark black substance, which residents suspected might be mold. Despite residents voicing concerns about these issues to the administrative staff over the past four months, no action had been taken until the surveyor's visit. The survey also noted missing light bulbs, dirty toilet seats, and other unsanitary conditions in several resident rooms. The Environmental Services Director confirmed that housekeepers were responsible for cleaning the rooms daily, but the surveyor's findings indicated a lack of adherence to these duties. The facility's administrator was unaware of the missing light bulbs, highlighting a communication gap between staff and management regarding maintenance and housekeeping responsibilities.
Deficiencies in Comprehensive Care Planning
Penalty
Summary
The facility failed to implement a comprehensive, person-centered care plan for three residents, leading to deficiencies in addressing their specific needs. Resident #150 was not provided with an updated activities calendar, resulting in a lack of awareness about daily and special events. Despite the care plan indicating that the resident should receive a monthly activity calendar and be invited to special activities, the Life Enrichment Director confirmed that daily activity calendars were not posted in resident rooms, and the Main Events calendar was missing. Resident #116 did not have a specific care plan for nutrition or weight loss, even though the resident was receiving a nutritional supplement and had a suspected weight loss. The Registered Dietician acknowledged that a weight loss care plan should have been in place, but the weight was not confirmed, and interventions were not included in the care plan. Additionally, Resident #179 lacked a specific care plan for communication and respiratory care, with the respiratory care plan missing essential information about the tracheostomy tube. The Director of Nursing explained that the resident communicated through gestures and eye movements, with their spouse assisting in communication, but the care plan did not reflect these specifics.
Deficiencies in Implementing Physician Orders and Documentation
Penalty
Summary
The facility failed to ensure that physician's orders were implemented and completed, which affected several residents. Resident #178 was admitted with a PEG tube, but there were no documented physician orders for its management, such as flushing or dressing changes. The Director of Nursing (DON) confirmed the absence of these orders. Additionally, Resident #297's vital signs were not consistently documented as per the physician's order, which required monitoring every shift for seven days post-admission. The DON acknowledged that the nursing staff should have implemented the orders as directed. Resident #150 reported that their sacral wound dressing was not changed as ordered. The medical record confirmed that the wound care was not documented as completed on a specific evening shift, and there was no explanation for this omission. Resident #116 experienced significant weight loss without a care plan in place to address it. The Registered Dietician (RD) noted that a reweigh was requested but not completed due to an oversight, and the resident's intake was inconsistent. Medication administration issues were also identified. Resident #193 reported unmanaged pain due to delayed medication administration, and the audit revealed a pattern of late documentation for pain medications. Similarly, Resident #188, who was on comfort care, had medications documented late, which included those critical for pain management. Resident #107's weekly weight checks were not completed as ordered, and the Nurse Unit Manager could not provide an explanation for this oversight.
Failure in Conducting Monthly Medication Regimen Reviews
Penalty
Summary
The facility failed to ensure that a licensed pharmacist conducted a monthly Medication Regimen Review (MRR) for three residents, leading to deficiencies in medication management. For Resident #133, a physician order for Phenobarbital was incomplete, missing the milligram dosage, which could have resulted in the administration of an incorrect number of tablets. Despite this, a pharmacy review conducted on January 8, 2025, reported no irregularities. This indicates a failure in identifying and reporting medication-related issues. Additionally, the facility did not conduct MRRs for Resident #107 for the months of September, October, November, and December 2024. The Director of Nursing (DON) was unable to locate these reviews and acknowledged the requirement for monthly MRRs. Similarly, Resident #150's medical records showed that the pharmacy did not complete the monthly drug regimen reviews for September, October, and December 2024. These oversights were discussed with the administration team during the exit meeting on January 17, 2025.
Sanitation and Maintenance Deficiencies
Penalty
Summary
The facility failed to maintain a sanitary environment, as evidenced by observations on three of the four units. On multiple occasions, linen was found on the floor in various locations, including outside bathrooms and in resident rooms. The Director of Nursing confirmed these observations, and the Unit 2 & 3 Manager stated that the expectation is for staff to place soiled linen in designated carts or rooms. Additionally, a large area of missing wallpaper was observed in the Unit 2 hallway, and a metal box with a missing corner exposing rough edges was noted behind the nurses' station. The Director of Maintenance indicated that staff are expected to report maintenance concerns using an online platform, but the Nursing Home Administrator acknowledged the difficulty in addressing all maintenance issues promptly due to ongoing renovations and resource limitations. Further observations revealed unsanitary conditions in the clean utility room at Station #1, where a dark substance was noted around the faucet, and dirty items were improperly stored. The Director of Nursing verified these findings and took immediate action to clean the area. The Administrator was informed of these concerns, highlighting the facility's failure to ensure a clean and safe environment for residents, staff, and the public.
Failure to Maintain Resident Dignity and Proper Care
Penalty
Summary
The facility failed to maintain the dignity of several residents, as observed during a survey. One incident involved a resident who was being transferred using a Hoyer lift. The process was delayed due to a malfunctioning battery, requiring multiple replacements and assistance from the Maintenance Director. During the transfer, the resident was observed bumping against a raised grab bar, which should have been lowered. Additionally, the resident was noted to have a large wet area on their bottom, indicating a lack of timely incontinent care. The GNA involved admitted to forgetting to lower the grab bar due to the repeated battery issues. Other observations included a resident with an undated, cloudy suction canister and dried tube feeding on the floor, a resident with full and empty urinals on their bedside table, and a resident with mucous secretions on their gown and a saturated tracheostomy dressing. Another resident was found with a yellow stain and brown matter on their bed sheet. Additionally, a resident with a Foley catheter was repeatedly observed without a cover on the catheter bag, despite the expectation that it should be covered. These observations were discussed with the Director of Nursing, who acknowledged the issues.
Failure to Ensure Call Bell Accessibility and Timely Medical Follow-Up
Penalty
Summary
The facility staff failed to ensure that residents on Unit 4 had their call bells readily available, which is crucial for residents to request assistance when needed. During observation rounds, it was noted that one resident's call bell was on the floor, another resident's call bell was initially inaccessible due to limited arm mobility, and a third resident's call bell was found inside a slipper. These observations indicate a lack of consistent verification by staff to ensure call bells are within reach for residents, which is a fundamental aspect of accommodating their needs and preferences. Additionally, the facility did not accommodate a resident's medical needs by failing to schedule a follow-up orthopedic appointment in a timely manner. The resident was admitted with a discharge summary from the hospital that included orders for a follow-up appointment with orthopedic surgery. However, the facility was unable to provide documentation verifying that the appointment was scheduled, transportation was arranged, or that the family was contacted regarding the appointment. This oversight highlights a breakdown in the process of managing and documenting follow-up care for residents after hospital discharge.
Facility Fails to Address Resident Council Concerns
Penalty
Summary
The facility failed to promptly address the recommendations of the resident council concerning issues of resident care and life in the facility. This deficiency was identified through interviews with residents and staff, as well as a review of resident council meeting minutes. During an interview with 10 residents, including members of the resident council, numerous concerns were voiced, many of which were also identified by surveyors. The Life Enrichment Director provided copies of the resident council minutes for November 2024, December 2024, and January 2025, but not for October 2024. The minutes revealed that 20 issues were consistently identified by the resident council over these months, with 18 of the 20 issues in November and all 20 issues in December and January marked as 'Still an issue.' The DON and administrator were informed of these findings during a review of the resident council minutes and an earlier meeting.
Failure to Assess and Assist Residents with Advance Directives
Penalty
Summary
Facility staff failed to assess residents for advance directives and did not offer assistance with creating them. This deficiency was identified for six residents during a survey. Medical record reviews revealed no evidence that these residents or their representatives were assessed for an advance directive, informed of their rights to have one, or provided with written material regarding advance directives. The facility's policy requires that prior to or upon admission, the social director or designee should inquire about the existence of any written advance directives and document any offer to assist the resident in creating one. Despite the policy, the facility did not have documentation showing that the residents or their representatives were offered assistance with creating an advance directive at the time of admission. The Director of Social Services acknowledged the lack of evidence for such offers. The surveyor requested documentation from both the Administrator and the Director of Social Services, but neither could provide evidence that the required inquiries and offers of assistance were made for the residents in question.
Failure to Address Resident Grievances and Missing Property
Penalty
Summary
The facility failed to honor residents' rights to voice grievances without fear of discrimination or reprisal, as evidenced by the case of a resident whose personal property went missing. The resident and their family reported the missing jacket to facility staff, but no follow-up was conducted, and no grievance was filed. The Director of Nursing acknowledged the lack of a grievance record and follow-up, despite the facility's policy that nursing staff or the DON should assist residents in filing grievances and follow up after investigations. Additionally, during a resident council meeting, multiple residents expressed concerns about the grievance process, with many unaware of how to file grievances or where to find information. Some residents feared reprisal if they were to file grievances. The resident council minutes from previous months documented ongoing unresolved issues, and staff interviews confirmed that residents' concerns were not being addressed. The Administrator claimed that grievances were addressed but could not provide documentation, and the Activities Director confirmed the accuracy of the council meeting minutes but could not produce records of resolved grievances.
Deficiencies in Nursing Care and Controlled Substance Management
Penalty
Summary
The facility failed to provide nursing care within professional standards of practice for several residents. Resident #178 was admitted with a requirement for an orthopedic follow-up appointment, which was not scheduled by the facility. Additionally, the resident had a PEG tube in place, but there were no physician's orders for its management, such as flushing or dressing care, during the resident's stay at the facility. Resident #297 had a physician's order for vital signs to be taken on admission and every shift for seven days thereafter. However, the facility did not document complete vital signs for certain shifts, indicating a failure to adhere to the physician's orders. This lack of documentation suggests that the facility did not consistently monitor the resident's vital signs as required. The facility also demonstrated deficiencies in the management of controlled drugs. There were discrepancies in the narcotic counts for several residents, including Resident #150 and Resident #447, where the actual medication count did not match the recorded count on the Controlled Drug Receipt/Record/Disposition forms. Additionally, there were instances where discontinued controlled medications were not destroyed immediately as per facility policy, as observed with Resident #158 and Resident #150. These issues highlight a lack of adherence to protocols for controlled substance management.
Failure to Ensure Timely GNA Certification for CNAs
Penalty
Summary
The facility leadership staff failed to ensure that certified nursing assistants (CNAs) completed a state-approved geriatric nursing assistant (GNA) training program within four months of employment. This deficiency was identified in seven actively employed CNAs. A review of employee records revealed that several CNAs had been working at the facility beyond the four-month timeframe required to obtain their GNA certification. Specifically, CNA #29 had completed their CNA training and received their certificate from the Maryland Board of Nursing, but continued working past the four-month period without obtaining the GNA certification. The facility's administrator was unaware of the four-month requirement, mistakenly believing that CNAs had 12 months to obtain their GNA certification. Additionally, the Human Resources Director confirmed that CNA #77's certification had expired, and they had last worked at the facility on a specific date. The HR Director, scheduling coordinator, and Director of Nursing were responsible for verifying staff licenses and certifications but failed to notice the expiration. This oversight was due to an assumption that CNA #77's certificate was still active, despite receiving monthly emails listing upcoming expiring licenses and certifications.
Failure to Serve Meals According to Menu Tickets
Penalty
Summary
The facility failed to serve meals according to the residents' menu tickets, as observed during a survey. Several residents, including six randomly observed during meals, did not receive the items listed on their meal tickets. For instance, one resident's breakfast tray was missing extra gravy, hot cereal, orange juice, and coffee or hot tea. Another resident's tray lacked hot cereal, orange juice, and coffee or hot tea. Staff interviews revealed that the kitchen ran out of certain items, such as orange juice and coffee, leading to these discrepancies. Additionally, during a lunch tray line observation, it was noted that the facility ran out of several menu items, including Au Gratin Potatoes, apple cake slices, and meatloaf. As a result, residents received substitutions that were not indicated on their meal tickets, such as mashed potatoes instead of Au Gratin Potatoes, baked apple slices instead of apple cake, and baked fish instead of meatloaf. These observations highlight a failure in the facility's ability to provide meals as planned and documented on the residents' menu tickets.
Failure to Maintain Food Temperature
Penalty
Summary
The facility failed to provide palatable food at an appetizing temperature, as observed during a survey. On January 15, 2025, the surveyor noted that during the lunch tray line in the kitchen, staff were placing food onto hot plates to maintain an appealing serving temperature. However, the Director of Operations (Staff #58) indicated that they ran out of hot plates, resulting in the last 16 resident plates being placed on trays without a hot plate underneath. These trays were then delivered to the unit without the necessary temperature control. A test tray was requested by the surveyor, and the temperatures of the food items were measured before and after delivery. Initially, the fish entree was at 138.1 degrees Fahrenheit, and the mashed potatoes were at 144 degrees Fahrenheit. After delivery, the temperatures dropped to 124.8 degrees Fahrenheit for the entree and 114.1 degrees Fahrenheit for the mashed potatoes. The surveyors found the food to be unpalatable and not at an appetizing temperature, with the coffee on the tray being room temperature.
Failure to Provide Suitable Bedtime Snacks
Penalty
Summary
The facility staff failed to provide suitable and nourishing alternative meals and snacks to residents who wished to eat at non-traditional times or outside of scheduled meal service times, as per the resident plan of care. This deficiency was identified during a resident council meeting attended by 10 residents, where all attendees expressed dissatisfaction with the availability and delivery of bedtime snacks. The residents reported that snacks were often not delivered to their rooms, were unlabeled, and lacked variety, with only one choice available. Additionally, a resident with special dietary needs stated that these needs were not met by the evening snacks provided. The issue of inadequate bedtime snacks was consistently documented in the resident council minutes for several months, indicating a persistent problem. Interviews with various staff members, including those from different units and the dietary department, confirmed that snacks were sent to the units in bulk and unlabeled. The Senior Director of Operations for food services acknowledged this practice and stated that it was a standard procedure across the facilities he managed, without addressing how personal preferences and dietary considerations were accommodated.
Lack of COVID-19 Vaccination Documentation for Staff
Penalty
Summary
The facility failed to provide documentation indicating that five Geriatric Nursing Assistants (GNAs) received screening, education, and the offering of the current COVID-19 vaccination. This deficiency was identified during a review of facility records and staff interviews. On January 17, 2025, at 1:17 PM, the records of GNAs #64, #65, #66, #67, and #68 were reviewed, revealing a lack of documentation in their personnel records regarding COVID-19 vaccination procedures. Subsequently, at 1:44 PM, the Infection Preventionist (IP) staff #4 was interviewed and confirmed the absence of documentation for these five GNAs, indicating they had not received the necessary screening, education, and offering of the COVID-19 vaccination.
Failure to Conduct Regular Bedrail Inspections
Penalty
Summary
The facility failed to conduct regular inspections of bed frames, mattresses, and bed rails to identify potential entrapment risks. This deficiency was observed in five residents during the initial phase of the survey. Each of these residents was found in bed with two quarter-length bed rails raised on either side of the top end of their beds. The facility's policy on Bed Safety and Bed Rails required maintenance staff to routinely inspect all beds and related equipment for risks, including potential entrapment hazards. During an interview with the Director of Nursing, it was revealed that the maintenance logs for bedrail entrapment risk were not routinely checked. The Nursing Home Administrator confirmed that maintenance did not regularly inspect bedrails for entrapment risks, although staff assessed all resident bedrails the night before the surveyor's inquiry. This lack of routine inspection and documentation led to the deficiency identified by the surveyors.
Failure to Notify Responsible Parties of Medical Changes
Penalty
Summary
The facility failed to notify the responsible parties of two residents regarding significant changes in their medical conditions and care. In the first case, a family member of a resident was not informed about the resident's transfer to the hospital due to chest pain. The family member discovered the transfer incidentally while inquiring about the resident's whereabouts with a nurse. Both responsible parties listed on the resident's face sheet confirmed they were not notified of the transfer, indicating a lapse in communication from the facility. In the second case, a resident's medication was discontinued without notifying the responsible party. The responsible party only became aware of the discontinuation when another family member inquired about the medication with the doctor. The Director of Nursing explained that the nurse or provider is responsible for documenting and notifying the family about medication changes, but this procedure was not followed. The progress notes confirmed the medication discontinuation, yet the family was not informed, highlighting a failure in the facility's notification process.
Verbal Abuse Incident by GNA
Penalty
Summary
The facility failed to prevent verbal abuse of a resident by an employee. During the survey, it was determined that a GNA was overheard by an RN making threatening remarks towards a resident. The incident occurred when the GNA attempted to move the resident, who then became verbally and physically aggressive. The GNA responded by stating that she would harm the resident if not for the resident's mental condition. The GNA admitted in a written statement to making these remarks after being physically assaulted by the resident. The facility's administrator confirmed that the GNA was suspended and subsequently terminated following the investigation. However, the Board of Nursing was not notified of the investigation results, which the administrator acknowledged should have been done.
Failure to Timely Report Injury of Unknown Origin
Penalty
Summary
The facility failed to report an injury of unknown origin in a timely manner to the state agency, which was evident for one resident reviewed for abuse during the survey. The incident involved a resident who reported an injury of unknown origin to an LPN on May 18, 2024, at 4:20 pm. The facility's Self Report Form was submitted to the State Agency on May 19, 2024, without a time indicated by the DON, and the report was received by the State Agency on May 20, 2024, at 12:34 pm. During an interview with the DON and the Administrator, both were unable to explain why the incident was not reported within the required two-hour timeframe.
Failure to Document and Report Resident Falls
Penalty
Summary
The facility failed to retain documentation related to the delayed reporting of a resident fall, which was evident for one resident reviewed for falls during the survey. On June 1, 2024, a resident fell twice, once sliding from a wheelchair and later falling from a bed around 10 PM. The LPN responsible did not document the completion of an assessment or the occurrence of the falls. The resident later complained of pain and was admitted to the hospital on June 3, 2024, where a fracture of the right femur was discovered. The facility's report to the OHCQ on June 23, 2024, did not include documentation of the falls or the LPN's failure to report them. The Director of Nursing (DON) admitted to not typing up the LPN's statement regarding the falls and failing to report the LPN to the Maryland Board of Nursing. Additionally, the DON could not provide a copy of the disciplinary action form that led to the LPN's termination on June 26, 2024. A GNA reported observing the falls and notifying the LPN, but the LPN did not document these incidents. The deficient practice was discussed with the administrator and DON during the survey.
Deficiency in Interdisciplinary Care Plan Meetings
Penalty
Summary
The facility staff failed to conduct care plan meetings with the interdisciplinary care team for two residents, leading to a deficiency in care planning. For one resident, there was no documentation of a multidisciplinary care plan meeting within the first seven days of admission, as required. The resident did not recall participating in any care plan meetings, and the facility's records lacked evidence of an interdisciplinary team meeting to inform the resident about their anticipated plan of care. The Director of Social Services explained the process of inviting residents to care plan meetings, but there was no discipline assessment or interdisciplinary care conference attendance record to verify team involvement. For another resident, the Director of Social Services stated that emails were sent to the interdisciplinary team to invite them to care plan meetings, but the team did not attend. The resident's quarterly Interdisciplinary Care Conference Attendance Record showed that only a few members, including the Director of Nursing, MDS Coordinator, Social Service, and Occupational Therapy, attended the meeting. This lack of full interdisciplinary team participation in care plan meetings indicates a failure to provide comprehensive care planning for the resident.
Deficiency in Documenting and Assisting with ADLs for Quadriplegic Resident
Penalty
Summary
The facility failed to consistently document and provide necessary assistance with activities of daily living for a resident diagnosed with C5-C7 quadriplegia, resulting from a motor vehicle accident. During an observation, the surveyor noted that the resident was left with a breakfast tray without assistance, despite having limited hand mobility. The GNA responsible for the resident's care admitted to not offering assistance unless explicitly requested by the resident, despite being aware of the resident's condition. The resident expressed concerns about insufficient staffing, long wait times for assistance, and not being out of bed for six months due to an unrepaired wheelchair. The surveyor's review of the facility's documentation revealed significant gaps in the records of personal hygiene, showering, and meal assistance for the resident over several months. The documentation showed numerous instances marked as 'N/A' or with no documentation at all, indicating a lack of consistent care. Additionally, the resident had been admitted to the hospital with a urinary tract infection and stage two decubitus ulcers, further highlighting the neglect in care. The DON acknowledged the issues with the resident's wheelchair but did not provide evidence of regular personal care or showering for the resident.
Failure to Provide One-on-One Activities for a Resident
Penalty
Summary
The facility failed to provide one-on-one activities for a resident, as observed during a survey. On two separate occasions, the resident was observed either lying in bed asleep or sitting up in bed with no activities being provided. During these observations, no activity staff were seen entering the resident's room to engage in one-on-one activities. The Life Enrichment Director (LED) confirmed that residents who do not participate in group activities should receive one-on-one activities two to three times per week. However, documentation showed only one such activity for the resident in December 2024, and none for November 2024, indicating a lack of consistent engagement. The LED acknowledged the absence of documentation and activities, confirming the deficiency in providing adequate one-on-one activities for the resident.
Deficiencies in Resident Transfer and Environmental Safety
Penalty
Summary
The facility staff failed to use appropriate safety measures while transferring a resident using a Hoyer lift, leading to a deficiency in accident prevention. During a transfer of a resident, the staff encountered issues with the Hoyer lift's battery, which was replaced multiple times. Despite the presence of three GNAs, the transfer was not conducted safely as the resident was observed bumping against a raised grab bar, which should have been lowered during the transfer. The GNAs were unable to complete the transfer smoothly due to the malfunctioning lift, and the resident was left in a compromised position for an extended period. Additionally, the facility failed to maintain a safe environment for another resident who was at risk for falls. A large tangle of wires was found in front of the resident's bed, contrary to the care plan's intervention to keep the floor clear of clutter. Although the resident had been moved to the room a few days prior, the wires were not addressed until after the surveyor's observation. This oversight in maintaining a clutter-free environment posed a potential hazard to the resident's safety.
Inadequate Staffing Leads to Resident Falls
Penalty
Summary
The facility failed to ensure adequate nursing staff to properly monitor residents, specifically affecting one resident who experienced multiple falls. On a particular day, the resident's family member reported concerns about the resident being neglected due to staffing issues. It was revealed that on the day of one of the falls, there was no nurse assigned to the resident's station, which was confirmed by the Director of Nursing (DON). The resident was generally placed in the dining area to maximize supervision, but the lack of a nurse on duty contributed to the inability to prevent the fall. Interviews with facility staff, including a geriatric nursing assistant and the nurse manager, highlighted the staffing patterns and the incident where the resident attempted to stand and fell. The nurse manager witnessed the fall but was unable to reach the resident in time. The DON acknowledged the absence of a nurse on the resident's station during the shift when the fall occurred, which was a deviation from the usual staffing pattern where each station is supposed to have at least one nurse assigned.
Medication Storage and Labeling Deficiency
Penalty
Summary
The facility failed to ensure that all medications and biologicals were stored and labeled properly, as observed during a survey. Three medication carts were reviewed, and it was found that house stock medication bottles, including Melatonin, Aspirin, Acetaminophen, and Vitamin D, were opened and not labeled with the date they were opened. This was observed across multiple medication carts at different nurses' stations. The Licensed Practical Nurse (LPN) acknowledged the oversight and mentioned that the facility policy requires labeling with the date when a new house stock medication is opened. Additionally, the surveyor found discontinued controlled medications, such as Hydrocodone-Acetaminophen and Amphetamine-Dextroamphet ER blister packs, in the narcotic lock boxes of the medication carts. The facility's policy mandates that upon resident discharge or discontinuation of a controlled medication, two nurses must destroy the medication and document it on the Destruction Report immediately. The Director of Nursing (DON) confirmed the requirement for labeling and immediate disposal of controlled substances after discontinuation. However, these procedures were not followed, leading to the deficiency.
Deficiencies in Medical Record Accuracy and Security
Penalty
Summary
The facility failed to ensure that residents' medical records were accurate, complete, and protected, as evidenced by deficiencies found during a survey. For two residents, the Preadmission Screening and Resident Review (PASARR) forms were incomplete, specifically missing the section on Exempted Hospital Discharge. This section is supposed to be filled out before completing the rest of the form, but it was not reviewed again after the initial completion at the time of admission. This oversight was acknowledged by the Director of Social Services, who admitted that the forms were not reviewed for completion after admission. Additionally, a family member of another resident was mistakenly given a medication list for a different resident by an RN. This error was confirmed when the family member provided a photo of the incorrect document. The Director of Nursing (DON) and the Administrator were unaware of this incident until it was brought to their attention during the survey. These findings indicate lapses in the facility's processes for maintaining accurate and secure medical records.
Failure to Protect Residents' Personal Property
Penalty
Summary
The facility failed to protect residents from the misappropriation of personal property and did not adequately investigate reports of missing items. This deficiency was identified during a survey involving four residents, with two residents reporting missing belongings. Resident #38 reported that some of their clothing was missing after being laundered by the facility. Despite informing the Nursing Home Administrator about the grievance, no grievance summary was completed, and the Environmental Director was unaware of the issue. Similarly, Resident #76 and their family reported a missing jacket during the week of Christmas. Although the incident was reported to facility staff, no follow-up was conducted. Even after the surveyor informed the Director of Nursing about the missing property, no action was taken to address the issue. The lack of follow-up and investigation into these reports highlights the facility's failure to protect residents' personal property.
Inaccurate MDS Coding for Resident's Wound
Penalty
Summary
The facility staff failed to accurately code a resident's status on the Minimum Data Set (MDS) assessment, which is a federally mandated tool used to gather information on each resident's strengths and needs. This deficiency was identified for one resident during a survey of 40 sampled residents. The MDS assessments are crucial for ensuring that residents receive the care they need, and inaccuracies can lead to inappropriate care planning decisions. The specific issue involved a resident who had a Deep Tissue Injury (DTI) on the sacrum, as documented in a Wound Care Progress Note and a skin and wound evaluation, both dated the same day as the MDS assessment. Despite the presence of these notes in the resident's medical record, the MDS assessment failed to reflect the wound in Section M - Skin Conditions. During an interview, the MDS Coordinator confirmed that the staff relied on the resident's medical record, including progress notes and wound evaluation notes, to complete the MDS sections. However, the surveyor's review with the MDS Coordinator revealed that the coding did not accurately reflect the resident's status, and the coordinator agreed that the coding was inaccurate.
Deficiencies in Mobility Support and Hygiene Care
Penalty
Summary
The facility failed to provide adequate mobility support and basic activities of daily living for two residents. Resident #130, diagnosed with C5-C7 quadriplegia, had been confined to bed for six months due to a broken electric wheelchair. Despite the resident's expressed desire to be out of bed daily, the facility did not offer alternative equipment to facilitate mobility. The Director of Nursing (DON) was aware of the wheelchair issue but did not provide documentation of any interim solutions or confirm whether the resident had been routinely assisted out of bed. An assessment for a new wheelchair was initiated, but there was no evidence of its completion before the survey exit. Resident #116 reported not receiving scheduled showers, only wash-ups. A review of the electronic medical record (EMR) showed no documentation of showers being provided, nor any notes indicating refusal by the resident. The Assistant Director of Nursing (ADON) confirmed that the resident was scheduled for showers twice a week but acknowledged the lack of documentation. This indicates a failure in the facility's system to ensure and record the provision of basic hygiene care.
Failure to Monitor and Address Resident's Nutritional Needs
Penalty
Summary
Facility staff failed to adequately monitor and address the nutritional needs of a resident who experienced significant weight loss. The resident's weight decreased from 215.6 lbs in September 2024 to 165 lbs by January 2025, reflecting a substantial and continuous decline. Despite an order for weekly weights starting in December 2024, there was no documentation to confirm that these weights were taken. The Registered Dietician (RD) was aware of the weight loss but did not implement any interventions until January 2025, citing the resident's history of weight fluctuations as a reason for inaction. However, the RD acknowledged the steady weight loss when it was pointed out by the surveyor. The Director of Nursing (DON) and Physician Assistant (PA) were not informed of the resident's significant weight loss in a timely manner. The DON explained that the protocol for significant weight loss includes ordering weekly weights and notifying the resident's medical provider and family, which was not done in this case. The PA was unaware of the weight loss until an interdisciplinary meeting in January 2025, despite having seen the resident multiple times during the period of weight decline. This lack of communication and failure to follow established protocols contributed to the deficiency in care for the resident.
Failure to Obtain Informed Consent for Bed Rail Use
Penalty
Summary
The facility failed to obtain informed consent prior to the initiation of bed rails for five residents. During the survey, it was observed that these residents were using bed rails without documented evidence of informed consent or attempts to use alternatives. The facility's policy requires that bed rails should not be used unless criteria are met, including the exploration of alternatives and obtaining informed consent. However, the documentation for these residents did not reveal any such attempts or consents. The surveyor's observations and subsequent document reviews highlighted that the facility did not adhere to its own policy regarding bed rail use. Interviews with the Director of Nursing confirmed the absence of consent and alternative attempts for the residents involved. This deficiency was evident for all five residents reviewed for physical restraints, indicating a systemic issue in the facility's process for bed rail implementation.
Failure to Address Significant Weight Loss
Penalty
Summary
The facility staff failed to ensure proper physician supervision for a resident experiencing significant weight loss. The resident's weight decreased from 215.6 lbs in September 2024 to 175 lbs by January 2025, with a further drop to 165 lbs by mid-January 2025. Despite this significant weight loss, no interventions were ordered until January 13, 2025. The Director of Nursing was unable to explain why the resident's medical provider was not informed of the weight loss. Progress notes from various medical professionals did not mention weight concerns until January 7, 2025, and the Physician Assistant was unaware of the issue until an interdisciplinary meeting the previous week.
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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.
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