Berlin Nursing And Rehabilitation Center
Inspection history, citations, penalties and survey trends for this long-term care facility in Berlin, Maryland.
- Location
- 9715 Healthway Drive, Berlin, Maryland 21811
- CMS Provider Number
- 215126
- Inspections on file
- 14
- Latest survey
- August 14, 2025
- Citations (last 12 mo.)
- 64
Citation history
Health deficiencies cited at Berlin Nursing And Rehabilitation Center during CMS and state inspections, most recent first.
A resident was not protected from a significant medication error due to a failure in the medication administration process.
Surveyors found three opened, unlabeled bags of bread and three unlabeled containers of seasoning base in the kitchen. The Dietary Manager confirmed that the bread should have been labeled and that two containers held chicken base transferred from a larger container. This failure to properly store and label food items did not meet professional standards.
Surveyors found that the facility did not develop or implement complete care plans for three residents with complex needs, including dialysis, constipation, diabetes, depression, chronic pain, anticoagulant use, and contractures. Key health conditions and therapy recommendations were omitted from care plans, and these omissions were confirmed through interviews and record reviews. The DON acknowledged that these care needs should have been addressed in the care plans.
Surveyors identified that staff failed to document medication administration in the MAR at the time medications were given, with multiple instances of late charting for several residents. In addition, a resident's nursing note was incorrectly filed under another individual's record, resulting in incomplete documentation during a hospital transfer. The DON and NHA confirmed these documentation lapses and acknowledged that they did not meet facility policy requirements.
Surveyors identified that several residents did not receive accurate MDS assessments, including incorrect coding of hearing loss, falls, and urinary continence. For example, a resident with severe hearing impairment was assessed as having only moderate loss, and two residents who experienced falls were not properly coded for these events. Another resident with a Foley catheter was incorrectly coded as occasionally incontinent. These discrepancies were confirmed by facility staff during the survey.
Two residents experienced physical abuse by GNAs, including being pushed and sustaining injuries. In both cases, the facility substantiated the abuse through investigation and interviews, but failed to report one of the incidents to the Maryland Board of Nursing as required by policy and regulation.
A resident with an indwelling Foley catheter was observed with a visible, uncovered drainage bag attached to the bed frame, despite a physician order and facility policy requiring a privacy barrier. The DON confirmed that nursing staff were responsible for ensuring privacy covers were used, but this was not done at the time of the surveyor's observation.
A resident did not receive scheduled showers as ordered, with records showing only one shower provided over several months. The resident's POA raised concerns, and review of POC documentation confirmed the lack of showers and no evidence of refusals. The DON verified that neither refusals nor missed showers were documented, and the care plan did not address refusals.
A resident's legal representative repeatedly requested the complete medical record, but only partial records were provided on two occasions. Facility staff could not confirm that the full record was ever sent, and documentation to verify transmission was lacking.
A resident admitted with Atherosclerotic Heart Disease, Dementia, and End Stage Renal Disease, and receiving hemodialysis three times weekly, did not have a Baseline care plan developed or provided within 48 hours of admission as required. The DON confirmed the absence of the care plan in the clinical record.
Surveyors identified that two residents did not have their care plans properly reviewed or revised to reflect current interventions, including one with a wound lacking specific care plan interventions and documentation, and another whose responsible party was not properly notified or documented for a care plan meeting. The DON and social worker confirmed these deficiencies in care plan management and documentation.
Two residents did not receive care in accordance with professional standards. One resident, after an unwitnessed fall resulting in a head laceration and wrist fracture, had no documented follow-up nursing care, including missing neuro and circulation checks. Another resident was left unattended, undressed, and calling for help, with soiled items left in the room and bathroom, and without privacy measures in place. The assigned GNA reported leaving the resident after a refusal of care and combative behavior.
A resident with dementia and end stage renal disease, dependent on staff for grooming, was repeatedly observed with unshaven facial hair due to staff being unaware of the care plan requirement for shaving assistance. The lack of communication in updating the resident's profile led to the omission of necessary care.
Two residents experienced deficiencies: one did not receive a physician order for splint use despite OT recommendations for contracture management, and another was transferred to the hospital without proper assessment or documentation of vital signs and without addressing a complaint of trouble breathing. The DON confirmed the lack of necessary orders and documentation.
A resident with documented bilateral hearing loss and moderate hearing difficulty, as assessed in the MDS, did not receive an audiology consultation or hearing aids since admission. The facility's only intervention was the use of a whiteboard for communication, and the Clinical Service Director confirmed that no audiology referral had been made.
Two residents requiring dialysis care did not receive proper monitoring and documentation as required by physician orders and facility policy. For one resident, vital signs and weights were often not recorded before and after dialysis, and communication sheets from the dialysis center were frequently missing or incomplete. For another resident, the clinical record lacked documentation of the type and location of the dialysis shunt, physician orders for shunt monitoring, and evidence of nursing assessment of the shunt site, despite policy requiring regular inspection.
A required annual performance review was not completed for a Geriatric Nursing Assistant, despite facility policy mandating yearly evaluations. The DON confirmed the omission after a review of personnel files.
A resident's monthly drug regimen reviews identified that physician orders for PRN pain medications lacked pain scale guidance and that a narcotic pain medication had not been used for 60 days, with recommendations for clarification and discontinuation made by the pharmacist. These recommendations were not addressed by the physician, and no documentation of response was found in the medical record.
Surveyors found that a CMA administered medication from a bottle of Senna Plus that was not labeled with the date it was opened, contrary to facility practice. Additionally, a medication cart was observed unlocked and unattended in a hallway, with staff later confirming it should have been secured according to policy.
Two residents with indwelling medical devices did not receive proper infection control measures as required by facility policy. One resident with multiple wounds and a dialysis catheter was not placed on Enhanced Barrier Precautions, and there were no signs or supplies for EBP at the room entry. Another resident with a urinary catheter had the drainage bag lying on the floor, contrary to infection control standards.
Significant Medication Error Occurred
Penalty
Summary
Residents were not ensured to be free from significant medication errors. The report identifies that there was at least one instance where a resident experienced a significant medication error, indicating a failure in the medication administration process. Specific details regarding the actions or omissions that led to the error, as well as information about the resident's medical history or condition at the time, are not provided in the report.
Failure to Properly Store and Label Food Items
Penalty
Summary
During an initial kitchen tour, surveyors observed three opened, unlabeled bags of bread stored on a steel cart in the kitchen, as well as three 14-ounce containers of beef flavored base that were also unlabeled and stored with other seasonings. The Dietary Manager confirmed that the bread bags were expected to be labeled and that two of the containers actually contained chicken flavored base, which had been transferred from a larger container in the cooler. These observations indicated that the facility failed to properly store and label food items to maintain their integrity, as required by professional standards.
Failure to Develop and Implement Comprehensive Care Plans
Penalty
Summary
Surveyors identified that the facility failed to develop and implement comprehensive care plans for several residents, as required. For one resident with a history of constipation and undergoing dialysis three times a week, neither condition was included in the care plan despite documented complaints of constipation and ongoing dialysis treatments. The omission was confirmed through interviews and record reviews, which showed that the care plan was only updated after the issue was identified by surveyors. Another resident reported ongoing constipation and chronic pain, with a medical history including Type II Diabetes, Major Depressive Disorder, and use of anticoagulant medication. Despite these significant health concerns and active medication orders for each, the care plan did not address constipation, anticoagulant use, depression, diabetes, or chronic pain. The DON acknowledged that these issues should have been included in the care plan, but review of the updated care plan showed that only constipation was added, leaving other conditions unaddressed. A third resident was observed with contractures of the left elbow and both hands, and medical records confirmed these diagnoses along with recommendations from occupational therapy for splinting and positioning. However, there was no evidence that a care plan had been formulated to address the contractures since admission, despite documentation of therapy recommendations and care plan meeting notes referencing therapy involvement. The DON confirmed the absence of a care plan for contractures and stated that therapy recommendations were expected to be discussed in meetings.
Failure to Ensure Timely and Accurate Medical Record Documentation
Penalty
Summary
The facility failed to ensure timely and accurate documentation of medical records for several residents, as evidenced by interviews and record reviews. Multiple instances were identified where medications were administered but not documented in the Medication Administration Record (MAR) at the time of administration. For one resident, medications scheduled for 9 PM were consistently signed off as complete well after 11 PM, with notes indicating that charting was done late but medications were administered on time. The Director of Nursing confirmed that medications are expected to be administered and documented within a specific timeframe, and acknowledged that the documentation was not completed as required. Further review of other residents' MARs revealed similar patterns of late documentation. For another resident, both afternoon and evening medications, including insulin and other critical medications, were signed off several hours after the scheduled administration times, again with notes stating that charting was late. Another resident's MAR showed delayed documentation for antibiotics, with charting occurring hours after the scheduled dose. These findings were corroborated by the facility's own Medication Management Program Policy, which requires immediate documentation after medication administration. Additionally, a review of medical records for a resident who was admitted and then discharged to the hospital revealed a lack of appropriate nursing documentation. Only one progress note was found for the period in question, and a relevant nursing note was incorrectly filed under the record of the resident's spouse rather than the correct resident. Both the Nursing Home Administrator and the Director of Nursing confirmed the absence of proper documentation and acknowledged the error in record-keeping.
Failure to Ensure Accurate Resident Assessments
Penalty
Summary
The facility failed to ensure that residents received accurate and comprehensive assessments, as evidenced by multiple discrepancies found during interviews and record reviews. One resident with severe bilateral hearing loss, who could only communicate via a whiteboard, was incorrectly assessed on the Minimum Data Set (MDS) as having moderate hearing loss, despite documentation and staff interviews confirming a higher level of impairment. Another resident who experienced a fall was not accurately coded for this event on the quarterly MDS assessment, even though progress notes and care plans documented the fall. A third resident with an indwelling Foley catheter was discharged to the hospital, but the discharge MDS assessment inaccurately coded urinary continence as "occasionally incontinent" instead of "Not rated," which is the correct coding when a catheter is present. Additionally, a fourth resident who had a fall and was sent to the hospital was not coded for the fall on the subsequent quarterly MDS assessment, despite clinical records confirming the incident. In each case, the discrepancies were confirmed by facility staff, including the Director of Nursing and the MDS Coordinator, during interviews with surveyors. These findings demonstrate that the facility did not consistently ensure the accuracy of MDS assessments for residents, particularly in areas related to hearing loss, falls, and urinary continence. The inaccuracies were identified through direct review of medical records, care plans, and staff interviews, highlighting a pattern of incomplete or incorrect documentation in resident assessments.
Failure to Protect Residents from Abuse and Report to Licensing Board
Penalty
Summary
The facility failed to protect residents from abuse, as evidenced by two separate incidents involving geriatric nursing assistants (GNAs) and residents. In the first incident, a resident reported being pushed by a GNA by the back of the neck, shoved onto the bed, and sustaining an arm injury. The investigation conducted by the acting DON confirmed the presence of a bruise consistent with the resident's account, and the GNA was found to have abused the resident. In the second incident, another resident accused a GNA of hitting their finger after the resident pointed at a meal tray and put their hand in the GNA's face. The facility's investigation substantiated that there was direct physical contact between the GNA and the resident, and the GNA admitted to pushing the resident's hand away. The incident was reported to local law enforcement, and the resident confirmed being physically abused. However, the facility did not file a required complaint with the Maryland Board of Nursing regarding the substantiated abuse by the GNA, as was mandated by facility policy and state regulations.
Failure to Maintain Resident Dignity by Not Covering Foley Catheter Drainage Bag
Penalty
Summary
Facility staff failed to ensure the dignity of a resident with an indwelling Foley catheter. During the initial facility tour, a surveyor observed that the resident's Foley catheter drainage bag was attached to the bed frame and was not covered with a privacy barrier, making the urine visible. The resident's electronic medical record indicated a physician order for both the indwelling Foley catheter and a privacy bag to be in place every shift. In an interview, the DON confirmed that the facility provided privacy barrier covers for Foley catheter drainage bags and that it was the nursing staff's responsibility to ensure these were used upon resident admission. The deficiency was identified when the resident was found without the required privacy barrier, despite facility policy and physician orders mandating its use.
Failure to Provide Scheduled Showers and Support Resident Self-Determination
Penalty
Summary
A deficiency was identified when a resident did not receive scheduled showers as ordered by their physician, with documentation showing only one shower provided over a period of more than three months. The resident's Power of Attorney reported concerns about the lack of routine showers. Review of the resident's physician orders confirmed a standing order for showers twice weekly on the day shift. Examination of the Point of Care (POC) documentation revealed that showers were not provided as scheduled, and there was no documentation indicating that the resident refused care or showers during this period. The Director of Nursing confirmed the lack of both shower provision and refusal documentation, and the resident's care plan did not address refusals of care or showers.
Failure to Provide Complete Medical Records Upon Request
Penalty
Summary
The facility failed to provide a complete set of medical records to a complainant who had requested them multiple times for a specific resident. Record reviews confirmed that only partial records were sent on two separate occasions, with 9 pages (including a cover page) faxed on one date and 14 pages (including a cover page) faxed on another. Despite repeated requests, including a formal letter requesting all medical records from the patient chart, there was no documentation or fax confirmation that the full medical record had ever been provided to the complainant. Interviews with facility staff revealed uncertainty regarding whether the complete medical record packet was ever sent. The medical records staff member was unable to confirm the transmission of the full records and needed IT assistance to retrieve email records, which were not immediately available. The DON later confirmed that only incoming emails had been retrieved, and there was no confirmation of outgoing emails to verify that the complete records were sent. As a result, the surveyor determined that the facility did not ensure timely and complete access to the resident's medical records as required.
Failure to Complete Baseline Care Plan for Hemodialysis Resident
Penalty
Summary
The facility failed to develop and implement a Baseline care plan within 48 hours of admission for a resident requiring hemodialysis treatments. Record review showed that the resident, admitted with diagnoses including Atherosclerotic Heart Disease, Dementia, and End Stage Renal Disease, did not have a Baseline care plan completed or provided to them or their responsible party, as required. The resident was receiving hemodialysis three times a week. During an interview, the DON confirmed that the Baseline care plan was missing from the clinical record and could not provide a reason for the omission.
Failure to Review and Revise Care Plans and Inadequate Documentation of Care Plan Meetings
Penalty
Summary
The facility failed to review and revise interdisciplinary care plans to accurately reflect interventions for residents, as evidenced by two cases. In the first case, a resident with a wound on the right thigh had been receiving daily dressing changes per physician order, but the care plan did not include specific interventions or approaches to manage the skin impairment. Additionally, the clinical record lacked a description or measurements of the wound, despite documentation by a nurse noting its presence and treatment. The Director of Nursing confirmed that the care plan was not updated to include the resident's actual skin impairment and that the clinical record did not contain a description of the affected area. In the second case, a resident's significant other reported not being invited to a care plan meeting following the resident's admission. The social worker confirmed that no care plan meeting had been scheduled and that invitations were typically sent within two weeks of admission, but there was no documentation indicating that the responsible party declined the invitation or that a meeting had occurred. The deficiency was identified when the surveyor found a lack of documentation in the medical record regarding the care plan meeting process for this resident.
Failure to Meet Professional Standards of Care and Ensure Resident Dignity
Penalty
Summary
The facility failed to ensure that care provided to two residents met professional standards of practice. For one resident, after an unwitnessed fall resulting in a forehead laceration and a left wrist fracture, there was no documented evidence of follow-up nursing care. The resident's medical record lacked documentation of neurological checks for the head injury, circulation checks for the fractured arm, and progress notes regarding the resident's condition following the fall and injuries. The Director of Nursing confirmed the absence of this required documentation during the surveyor's review. In a separate incident, another resident was observed unattended, lying naked in a high bed, calling for help, and holding onto the bed rail. A soiled disposable brief was found on the floor, and a feces-soiled washcloth was left in the bathroom sink with water running. The privacy curtain was not drawn, and no staff were present in the room for at least ten minutes. The assigned GNA later stated that the resident had refused care and become combative, so the GNA left the resident in that condition. The Unit Manager and Regional Clinical Services Director subsequently provided education to the GNA regarding safety, privacy, dignity, infection control, and handling of residents who refuse care.
Failure to Provide Grooming Assistance per Care Plan
Penalty
Summary
A deficiency was identified when a resident with diagnoses including atherosclerotic heart disease, dementia, and end stage renal disease, who was dependent on staff for grooming, was repeatedly observed with unshaven facial hair over several days. The resident stated that assistance was needed with shaving due to inability to perform the task independently. The resident's care plan, initiated months prior, documented limited ability to maintain grooming and specified that staff should provide assistance or full performance for facial hair care. Despite this care plan, a Geriatric Nursing Assistant (GNA) was unaware of the resident's need for shaving assistance and believed the resident was independent, only providing help upon request. This lack of awareness was traced to a failure to transfer the care plan intervention to the resident's profile, resulting in staff not being informed of the resident's grooming needs. The deficiency was confirmed through interviews and record review, as well as direct observation of the resident's unshaven condition.
Failure to Obtain Splint Orders and Inadequate Assessment Prior to Hospital Transfer
Penalty
Summary
The facility failed to obtain a physician order for the use of a splint and did not properly assess or address a resident's condition prior to hospital transfer. For one resident with contractures of the left elbow and both hands, observations revealed the absence of splints or braces despite occupational therapy recommendations for orthotic support and the use of towel rolls. The occupational therapist confirmed that recommendations were made and communicated verbally to staff, but no formal physician order was documented, and the Director of Nursing acknowledged the lack of orders to address the contractures. In a separate incident, another resident was transferred to the hospital after experiencing pain and trouble breathing. Documentation showed that only one progress note was written in the relevant timeframe, and there was no record of vital signs being obtained or documented prior to the transfer, despite facility expectations. While pain medication was administered, there was no documentation indicating that the complaint of trouble breathing was addressed. The Director of Nursing confirmed the absence of vital sign documentation and the lack of follow-up on the respiratory complaint.
Failure to Provide Audiology Services for Resident with Hearing Loss
Penalty
Summary
A resident with a diagnosis of unspecified bilateral hearing loss was observed to have significant difficulty hearing, requiring the use of a whiteboard for communication with staff. During interviews, the resident confirmed not having hearing aids and reported not having seen an audiologist since admission to the facility. Review of the resident's medical records and care plan confirmed the presence of hearing loss, with interventions limited to the use of a whiteboard for communication. Further review of the resident's Minimum Data Set (MDS) assessment indicated moderate hearing difficulty, yet there was no documentation of an audiology consultation since the resident's admission. The Clinical Service Director acknowledged that the facility had not ordered an audiology consult to assess the resident's hearing. This lack of referral and assessment resulted in the resident not receiving appropriate audiology services to address their hearing loss.
Failure to Ensure Proper Dialysis Care and Documentation
Penalty
Summary
The facility failed to provide safe and appropriate dialysis care and services for two residents requiring such care. For one resident receiving hemodialysis three times a week, there were multiple deficiencies in following physician orders and facility protocols. Orders required documentation of pre- and post-dialysis vital signs and weights, as well as the return and scanning of Dialysis Communication Sheets into the electronic medical record. However, vital signs and weights were frequently not documented, with staff often citing the resident's condition or absence for dialysis as reasons. Additionally, many Dialysis Communication Sheets were missing or not scanned into the system, and those that were available often lacked required information such as pre- and post-dialysis weights and blood pressures. For another resident with end stage renal disease and a dialysis shunt, the clinical record lacked essential information, including the type and location of the shunt, a physician's order to monitor the shunt site for infection, and documentation of nursing staff monitoring the site. The care plan also did not include interventions or approaches related to shunt care, despite facility policy requiring shunt site inspection every shift for signs of infection. Staff interviews confirmed the absence of these critical elements in the resident's record, and the infection preventionist was unable to identify the shunt location or find relevant orders in the chart. These deficiencies were identified through record reviews and staff interviews, which revealed that the facility did not consistently follow its own policies or physician orders regarding dialysis care and monitoring. The lack of documentation and incomplete communication between the dialysis center and facility staff contributed to the failure to ensure proper care for residents undergoing dialysis.
Missed Annual Performance Review for Geriatric Nursing Assistant
Penalty
Summary
Facility staff failed to conduct a required annual performance review for one Geriatric Nursing Assistant who had been employed for over eight years. A review of five Geriatric Nursing Assistants' personnel files revealed that the performance review for the calendar year 2023 was not completed for this staff member. The Director of Nursing confirmed that, despite facility policy requiring annual reviews, the documentation for the required review was missing for the specified period. This deficiency was identified during a surveyor's review of personnel files and was confirmed through an interview with the Director of Nursing, who acknowledged the absence of the annual performance review for the affected staff member.
Failure to Address Pharmacist Drug Regimen Review Recommendations
Penalty
Summary
The facility failed to act on recommendations made by the pharmacist during monthly drug regimen reviews for a resident reviewed for unnecessary medication use. Specifically, the pharmacist identified that the resident had physician orders for two PRN pain medications, Tylenol and Tramadol, but the orders did not specify the pain scale rating to guide nursing staff on when to administer each medication. The pharmacist recommended that the physician clarify the orders to include the pain scale rating, but this recommendation was not addressed by the physician. Additionally, a subsequent pharmacist review noted that Tramadol PRN had not been used in the past 60 days and recommended discontinuing the medication to reduce unnecessary drug storage and associated risks. This recommendation was also not acted upon by the physician. Interviews with the DON confirmed that both pharmacist recommendations were not addressed, and there was no documentation or physician response to the pharmacist's reports in the resident's medical record.
Failure to Properly Label and Secure Medications
Penalty
Summary
Surveyor observations and staff interviews revealed that the facility failed to ensure proper labeling and storage of drugs and biologicals, as well as secure medication storage. During medication administration on the 300 unit, a Certified Medication Aide (CMA) was observed using a bottle of Senna Plus (sennosides-docusate sodium) that was not labeled with the date it was opened, despite the facility's practice requiring such labeling. The bottle was already opened and approximately half empty at the time of observation. The CMA confirmed that bottles should be dated when opened and proceeded to label the bottle after the surveyor's inquiry. The Regional Nurse Consultant, Licensed Nursing Home Administrator, and Director of Nursing were all notified of this finding. Additionally, a medication cart was found unlocked and unattended in a hallway, with all drawers accessible and no staff present nearby. A Geriatric Nursing Assistant (GNA) later locked the cart, stating the responsible nurse was assessing a patient elsewhere. The nurse later confirmed she had left the cart unlocked because she intended to return shortly, and the Director of Nursing acknowledged that the cart should have been locked when not in the nurse's view. Review of facility policy confirmed that medication carts are required to be locked when not in use and in direct line of sight.
Failure to Implement and Follow Infection Control Procedures for Residents with Indwelling Devices
Penalty
Summary
The facility failed to follow its own infection prevention and control policies and procedures, resulting in lapses in infection control for two residents. One resident with multiple wounds on the right foot, including a recent diagnosis of cellulitis and a dialysis catheter in the chest, was not placed on Enhanced Barrier Precautions (EBP) as required by facility policy. There were no EBP signs or infection control supplies at the entryway to the resident's room, and no order for EBP was present in the medical record at the time of observation and review. The infection control preventionist confirmed that residents with wounds and indwelling medical devices, such as central lines, should be on EBP, and the Director of Nursing agreed that EBP should have been implemented for this resident. Another resident with an indwelling urinary catheter and a history of urinary tract infections was observed with the catheter drainage bag lying flat and face down on the floor, rather than being properly hung on the bed. The Director of Nursing acknowledged that the drainage bag should not be on the floor, as this practice is inconsistent with infection control standards and increases the risk of contamination. Review of the facility's reference materials confirmed that catheter drainage bags should not be placed on the floor to prevent infection.
Latest citations in Maryland
Facility staff did not ensure that 2nd floor residents who could not use stairs were able to receive visitors when the only elevator was out of service for an extended period. Complaints indicated that some family members, who were themselves unable to ambulate stairs, could not visit their relatives on the 2nd floor during this time. The emergency plan directed non-ambulatory 2nd floor residents to remain on that floor unless there was an emergency and did not address how visitation would be maintained when the elevator was inoperable. The Administrator reported that visitors could use the stairs and that an emergency chair system could be used to move residents, but also stated that the chair system was not used for visitation and was unaware of any complaints, despite two having been filed.
Facility staff did not complete required quarterly smoking safety assessments for several residents identified as smokers, including some who had not been reassessed for many months and one who had never been assessed during their stay. This issue was discovered during a complaint survey after the facility’s only elevator was out of service for an extended period, affecting a group of residents on an upper floor who needed to reach a designated smoking area on a lower floor. Review of records and staff interviews, including with the DON and a unit manager, confirmed that the facility’s own practice of quarterly smoking safety assessments for smokers was not followed for half of the affected residents.
Facility staff failed to accurately code multiple MDS assessments for several residents, leading to discrepancies between MDS entries and MARs for pain management, falls, and high-risk drug classes. In several cases, scheduled pain management was coded as provided when MARs did not show daily pain medications, often because an LPN counted low-dose Aspirin ordered for cardiovascular prophylaxis or heart failure as pain medication, contrary to RAI guidance. One resident’s falls were underreported on the MDS despite two documented falls, and daily use of a topical analgesic and an antiplatelet (Aspirin) was not correctly captured. Other residents had MDS entries indicating use of hypnotic or antianxiety medications when MARs showed none, while actual antidepressant and hypoglycemic medications administered daily were omitted from Section N0415. These errors were confirmed by the involved LPNs during surveyor interviews.
Staff failed to conduct complete investigations into two residents’ abuse allegations. In one case, a resident reported that an employee poked their face and made an obscene gesture, but the investigation lacked a statement from the corporate representative who was first notified of the allegation. In another case, a resident reported that someone in blue clothing put a hand by their face and over their mouth, with a specific GNA identified as the alleged perpetrator; however, the investigation did not include statements from two GNAs who were on duty on the unit at the time of the alleged incident, despite leadership having the opportunity to ensure all relevant documents were present.
Staff failed to create person-centered care plans for two residents, one with mobility limitations and one receiving peritoneal dialysis. For the resident with mobility issues, the care plan did not address the resident’s refusal to use a Hoyer lift and preference for pivot transfers, despite therapy prohibiting pivot transfers and staff awareness of the resident’s resistance. For the resident on peritoneal dialysis, the care plan did not specify that the treatment was peritoneal dialysis, nor did it include the treatment schedule or cycle time frames; an LPN Unit Manager acknowledged using a generalized renal care plan without incorporating the specific dialysis prescription.
A resident’s medical record lacked documentation confirming that scheduled showers or bed baths were provided on multiple dates, and there was also no record of any refusals of care on those days. The DON and an LPN unit manager reported that showers were scheduled on specific shifts and that completed showers and refusals should be documented on shower/skin sheets and in the care plan, but the surveyor found gaps where no such entries existed. This resulted in incomplete ADL documentation and failure to maintain medical records according to accepted professional standards.
A resident with multiple fractures and chronic pain was receiving an opioid-based pain regimen, including PRN hydromorphone. The resident was later found unresponsive and "out of it" by an LPN, who located an order for Narcan and administered it, with the resident responding to the medication. A physician note documented an opioid overdose treated with Narcan. Review of the medical record showed no documentation that the resident’s representative was notified of this significant change in condition and emergency intervention, and staff interviews confirmed that notification likely did not occur, despite the DON’s expectation that the responsible party should have been informed.
Staff failed to follow updated wound care orders and to document an opioid overdose event and Narcan use for two residents. One resident with venous and arterial lower extremity wounds did not receive the prescribed change from oil emulsion to daily skin prep on one foot wound, and did not receive ordered skin prep on a new plantar wound for several days after the wound physician revised the treatment plan. Another resident with multiple fractures and chronic pain, receiving multiple opioid and adjunct analgesics, reportedly experienced an opioid overdose; an LPN found the resident unresponsive, located an existing Narcan order, administered Narcan, and observed the resident return to baseline, but did not complete or document a change-in-condition assessment, vital signs, or the Narcan administration in the medical record.
Surveyors substantiated a deficiency when disinfectant wipes, labeled for storage in areas inaccessible to children and not for personal cleansing, were observed sitting openly on a wire shelf in the dining room of a locked dementia unit while cognitively impaired residents waited for breakfast. A GNA and an LPN present on the unit stated that staff used the wipes to clean tables and that residents were never left alone in the dining room and had not been seen using the wipes. The ICP reported being unaware that the wipes’ placement in the dining room was a concern, and the NHA and DON stated they had not previously been informed about the issue, though the DON acknowledged understanding the concern.
A resident’s medical record showed multiple instances where Hydromorphone, a controlled narcotic, was documented as signed out and given on the Controlled Drug Administration Record but was not documented on the MAR on the same dates and times. An LPN reported signing only the narcotic sheet and not the MAR, while the DON acknowledged awareness that nurses were signing the narcotic sheet without completing the MAR, and a unit manager stated they were unaware this was occurring and that both records should be completed. The NHA and DON agreed with the surveyor’s findings after the issue was identified.
Failure to Ensure Visitation Rights During Elevator Outage
Penalty
Summary
Facility staff failed to ensure that residents residing on the 2nd floor who could not safely ambulate using stairs were able to exercise their right to have visitors when the facility’s only elevator malfunctioned. Complaint reviews showed that family members were unable to visit their relatives on the 2nd floor when the elevator was inoperative, and these family members themselves were unable to use the stairs. An incident report documented that the facility’s only elevator was malfunctioning for an extended period, from 3/28/26 to 4/23/26. During this time, residents who could not use the stairs remained on the 2nd floor, and some of their family members could not access them due to the lack of elevator service. Review of the facility’s emergency plan revealed that it instructed that 2nd floor residents who could not safely use the stairs should remain on the 2nd floor unless there was an emergency, and it did not include any provisions for maintaining visitation when the elevator was inoperable. In an interview, the Administrator stated that visitors could use the stairs to visit 2nd floor residents and that residents could be transported using an emergency chair system to meet visitors who could not use the stairs. However, the Administrator acknowledged that the emergency chair system was not used for visitation purposes during the elevator outage and reported being unaware of any complaints about the inoperative elevator, despite two complaints having been received by OHCQ. No additional documentation was provided to show a plan to support visitation for 2nd floor residents during the elevator malfunction.
Failure to Complete Required Quarterly Smoking Safety Assessments
Penalty
Summary
Facility staff failed to update smoking safety assessments at least once every three months for multiple residents identified as smokers. During a complaint survey focused on smoking safety, surveyors reviewed an incident involving the facility’s only elevator being inoperative for nearly a month, which affected residents who lived on the 2nd floor and needed to access the 1st-floor smoking area. The facility’s investigation identified a group of 10 residents on the 2nd floor who smoked and required additional accommodations to safely ambulate to the designated smoking area. Review of these residents’ medical records showed that 5 of the 10 did not receive quarterly smoking safety assessments as required by the facility’s practice. Specifically, four residents had not received a smoking assessment since May 2025, and one resident had no documented smoking assessment at any time during their stay. During interviews, the Unit Manager stated that residents identified as smokers are to be assessed quarterly for smoking safety. When the surveyor pointed out the missing assessments, the DON reviewed the records and confirmed that these residents had not received the required quarterly smoking assessments. This lack of timely reassessment occurred in the context of an extended elevator outage that necessitated special consideration for safe smoking access for residents residing on the 2nd floor.
Inaccurate MDS Coding for Pain Management, Falls, and High-Risk Drug Classes
Penalty
Summary
Facility staff failed to ensure that Minimum Data Set (MDS) assessments were accurately coded for multiple residents, based on medical record review and staff interviews. For one resident with cerebrovascular disease, an MDS with an Assessment Reference Date (ARD) of 3/2/26 coded Section J0100A (scheduled pain management) as "yes," but the March Medication Administration Record (MAR) did not show daily pain medication administration. An LPN stated she coded it that way because the resident received Aspirin 81 mg daily, although the physician’s order showed the Aspirin was prescribed as prophylaxis for cardiovascular events, and the RAI Manual specifies that medications not primarily intended for pain relief should not be coded as pain management. Another resident with cerebral infarction, congestive heart failure, and vascular dementia had two documented falls in progress notes between the prior assessment and the ARD of 2/4/26, but Section J1900 (number of falls since admission or prior assessment) captured only one fall. The same MDS coded Section J0100A (scheduled pain management) as "no" despite the February MAR documenting daily use of Diclofenac topical gel for pain. The MAR also showed daily Aspirin 81 mg for coronary artery disease, but Section N0415 (high-risk drug classes) did not capture the use of an antiplatelet medication. The responsible LPN confirmed missing the second fall and the Aspirin coding error. Additional residents had similar discrepancies: one resident’s MDS repeatedly coded use of hypnotic medications in Section N0415 when MARs showed no hypnotics administered, and failed to capture an antidepressant (Sertraline) that was given; the LPN reported coding Clonazepam as a hypnotic based on dual use, though reference guidelines did not classify it as such. Further inaccuracies were identified for other residents in pain management and high-risk drug class coding. One resident’s MDS with an ARD of 1/8/26 coded receipt of PRN pain medication in Section J0100A, but the January MAR showed no PRN pain medications given; a later MDS for the same resident coded use of an antianxiety medication in Section N0415, while the April MAR showed no such medication administered. Another resident with traumatic subarachnoid hemorrhage, type 2 diabetes with neuropathy, atrial fibrillation, and atherosclerotic heart disease had an MDS with an ARD of 2/3/26 that coded scheduled pain medication as "yes" and PRN pain medication as "no," although the MAR showed intermittent PRN Tylenol for pain and no daily pain medication, and also documented daily Aspirin 81 mg for heart failure and daily Rybelus for diabetes; the MDS failed to capture PRN pain use, incorrectly coded daily pain medication, and did not code hypoglycemic medication in Section N0415. Another resident with a history of stroke and right-sided hemiplegia/hemiparesis had two MDS assessments in February coded as receiving scheduled pain medication, but the February MAR did not show daily pain medication; the LPN reported coding based on daily prophylactic Aspirin 81 mg, which was not ordered for pain.
Incomplete Investigations of Resident Abuse Allegations
Penalty
Summary
Facility staff failed to complete thorough investigations of two separate resident allegations that were reported to the state agency. For the first incident, a resident alleged that on a specific date and time an employee poked two fingers into their face and showed them their middle finger. The five-day follow-up documented the allegation, but the investigation file did not clearly identify who was the first point of contact for the report. During interview, the Administrator stated that a corporate representative was initially made aware of the alleged incident, but there was no statement from this corporate representative included in the investigation file. The Administrator described their usual investigation process as interviewing involved parties, identifying and interviewing witnesses, reviewing staffing for the date of the alleged incident, and interviewing the resident’s roommate and other nearby residents if there were no direct witnesses. In the second incident, a resident reported that during a specific shift someone wearing blue put a hand by their face and over their mouth, and a particular GNA was identified as the alleged perpetrator. Review of the staffing sheet for the time of the alleged incident showed that two GNAs were working on the unit where the incident was reported to have occurred. However, the investigation file contained no statements or interviews from these two GNAs. Prior to the surveyor’s review of the investigation, the DON and a regional nurse were given the opportunity to review the investigation to ensure all necessary documents were available, yet the statements from the two GNAs remained absent. These omissions demonstrated that the facility did not conduct complete investigations into the reported allegations.
Failure to Develop Person-Centered Care Plans for Mobility and Peritoneal Dialysis Needs
Penalty
Summary
Facility staff failed to develop and implement person-centered care plans that addressed all identified needs for two residents, one with mobility limitations and one receiving peritoneal dialysis. For the resident with mobility limitations, the care plan included interventions for resistance to care and adjustment issues, but did not address the resident’s specific resistance to use of a Hoyer lift and the resident’s insistence on pivot transfers from bed to wheelchair. The Unit Manager confirmed that the resident was resistant to care, did not like the Hoyer lift, and preferred pivot transfers, but also stated that physical therapy had prohibited pivot transfers. Despite this known conflict between the resident’s preferences and therapy restrictions, the care plan lacked individualized interventions related to the resident’s resistance to the Hoyer lift and continued request for pivot transfers. For the resident receiving peritoneal dialysis, review of the electronic health record showed an order for peritoneal dialysis, but the resident’s care plans did not include a person-centered care plan specific to this treatment. The existing dialysis care plan did not specify the type of dialysis treatment being provided, did not document when the resident was scheduled to receive the treatment, and did not include time frames for the dialysis cycles. During an interview, the LPN Unit Manager stated that they do not place the dialysis prescription details into the care plan and instead use a generalized renal care plan by selecting standard items, confirming that the care plan was not individualized to the resident’s ordered peritoneal dialysis regimen.
Failure to Document Resident Showers and Refusals
Penalty
Summary
Facility staff failed to maintain complete and accurate documentation of bathing care for a resident, specifically regarding showers and refusals of showers. During a complaint survey, the surveyor requested verification that Resident #5 was receiving scheduled showers. The DON stated that the resident was scheduled for showers on the 3 pm–11 pm shift on Tuesdays and Fridays, and provided shower sheets for several dates in October and early November. However, there was no documentation to verify that the resident received a shower or bed bath on 10/17/25, 10/21/25, and 10/24/25. The DON explained that when a resident receives a shower it is documented on a skin sheet, and that refusals of showers should be documented both in the plan of care and on the shower sheet. Despite this, the surveyor did not receive any documentation indicating that the resident either received bathing care or refused showers on the missing dates. This lack of documentation showed that the facility did not safeguard resident-identifiable information and maintain medical records in accordance with accepted professional standards, as there was no record confirming whether the resident’s scheduled showers or refusals occurred on the identified dates.
Failure to Notify Responsible Party After Narcan Administration for Suspected Opioid Overdose
Penalty
Summary
The deficiency involves the facility’s failure to notify a resident’s responsible party when there was a significant change in the resident’s medical status requiring emergency medication. A complaint alleged that there was no communication with the responsible party when Narcan (naloxone) was administered to a resident for an alleged opioid overdose. Medical record review showed the resident was admitted in March 2026 with multiple fractures, including a nondisplaced zone 1 sacral fracture, a nondisplaced fracture of the posterior column of the right acetabulum, a fracture of the right pubis, and other chronic pain. The resident’s pain regimen included multiple opioids and other pain medications, including Hydromorphone 6 mg every 4 hours PRN, Hydromorphone 4 mg every 4 hours PRN, Tylenol, Lidocaine cream, Methocarbamol, Celebrex, and Gabapentin. A physician’s note dated 4/8/26 documented that the resident reportedly had an opioid overdose earlier that morning and responded well to Narcan administration by nursing, with the note listing chronic pain and opioid overdose status post Narcan. Further review of the resident’s medical record did not show any documentation that the resident’s representative was notified of this overdose event and Narcan administration. During interviews, an agency LPN stated that the resident was “out of it and not responding” during rounds, prompting the LPN to check for and then administer Narcan, after which the resident responded. Another LPN reported that Narcan was given because the resident appeared to be having an overdose and that the physician saw the resident afterward, but stated, “I don’t think anyone was notified, but should have been.” The DON also stated that she would have expected the responsible party to be notified. These findings confirmed that the facility failed to notify the resident’s responsible party of a significant change in condition and emergency treatment.
Failure to Follow Wound Care Orders and Document Narcan Administration
Penalty
Summary
Facility staff failed to provide treatment and care in accordance with professional standards and physician orders for two residents. For one resident admitted after hospitalization with acute systolic heart failure and peripheral edema, a wound physician initially ordered daily oil emulsion dressings for venous wounds on the right shin, left medial foot, and left second toe. At a follow-up assessment, the wound physician changed the treatment for the left medial foot from oil emulsion to daily skin prep and ordered daily skin prep for a newly identified arterial wound on the left plantar foot. Review of the March 2026 medication and treatment administration records showed staff did not discontinue the oil emulsion or initiate the ordered skin prep to the left medial foot, and did not administer skin prep to the left plantar foot wound from the date of the new orders until the resident was sent to the hospital. The DON confirmed that treatments were not administered per the updated wound care orders during this period. For another resident admitted with multiple pelvic and sacral fractures and chronic pain, the record showed extensive opioid and adjunct pain medication orders, and a physician note documented that the resident reportedly experienced an opioid overdose and responded well to Narcan administration by nursing. However, the medical record contained no nursing assessment of the resident at the time of the event, no documentation of the resident’s condition or vital signs, and no record of Narcan administration or the resident’s response afterward. An agency LPN reported finding the resident unresponsive or "out of it" during rounds, knowing the resident was on significant pain medications, and, after checking for an existing order, administering Narcan, after which the resident returned to baseline. The LPN acknowledged not completing or documenting a change-in-condition assessment, and both the DON and unit manager stated they would have expected an assessment and vital signs to be documented in this situation.
Disinfectant Wipes Left Accessible in Dementia Unit Dining Room
Penalty
Summary
The deficiency involves the facility’s failure to keep the environment free from accident hazards on one locked dementia unit. During a complaint survey regarding unsecured cleaning supplies and the potential for residents to use cleaning wipes for personal use, a surveyor observed disinfectant wipes stored openly on a wire shelf in the dining room of the Seagull Unit, a locked dementia unit. The product labeling on the container directed that it be stored in areas inaccessible to children and specifically stated it was not to be used as a diaper wipe or for personal cleansing and that it was not a baby wipe. At the time of the observation, residents with cognitive impairment were present in the dining room awaiting breakfast. A GNA was in the dining room with the residents during the observation, and the unit manager, an LPN, accompanied the surveyor. The surveyor expressed concern about the wipes being accessible in a public area where cognitively impaired residents were present. The LPN reported she had never seen residents use or attempt to use the wipes and stated staff used them to wipe down tables before and after meals. The GNA stated she was always present when residents were in the dining room, that residents were never left alone there, and that she had never seen a resident use a wipe. The Infection Control Nurse stated she was not aware the disinfectant wipes in the dining room were a concern because no residents had gone near them and confirmed they were intended for staff use to clean tables. The NHA and DON reported they had not been made aware of the concern with the wipes, though the DON stated she understood the concern.
Incomplete Documentation of Narcotic Administration on MAR
Penalty
Summary
The deficiency involves the facility’s failure to maintain complete and accurate medical records in accordance with accepted professional standards for one resident. Review of the resident’s April 2026 Medication Administration Record (MAR) and the Controlled Drug Administration Record showed multiple discrepancies for Hydromorphone, a narcotic medication. On several specific dates in April, the Controlled Drug Administration Record documented that Hydromorphone doses were signed out and given by licensed nursing staff at various times, but the corresponding MAR entries for those same dates and times were left blank, indicating no documentation of administration on the MAR. During interviews, an LPN stated that they sign out the medication on the narcotic sheet but do not document it on the MAR. The DON acknowledged awareness that nurses were signing off on the narcotic sheet but not on the MAR, and a unit manager reported not being aware that nurses were failing to sign the MAR when also signing the narcotic sheet, stating that documentation should occur on both records. The NHA and DON later stated they were not aware of the concern until it was identified by the surveyor and agreed with the findings. These observations and interviews demonstrate that the facility did not ensure that all medication administrations were consistently and accurately documented on the MAR for this resident.
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