Complete Care At Heritage Llc
Inspection history, citations, penalties and survey trends for this long-term care facility in Dundalk, Maryland.
- Location
- 7232 German Hill Road, Dundalk, Maryland 21222
- CMS Provider Number
- 215135
- Inspections on file
- 20
- Latest survey
- February 25, 2026
- Citations (last 12 mo.)
- 34
Citation history
Health deficiencies cited at Complete Care At Heritage Llc during CMS and state inspections, most recent first.
Staff failed to accurately code multiple MDS assessments, leading to missing and incorrect entries for medications, falls, behaviors, and treatments. Anticonvulsant and antianxiety medications documented on MARs were not captured in the high-risk drug classes section for several residents, while one resident was incorrectly coded as receiving hypoglycemic medication despite no such orders. A resident’s documented fall was not coded in the falls section, and another resident’s oxygen therapy was omitted from the special treatments section while hospice services and limited life expectancy were incorrectly coded without supporting documentation. In addition, a resident with clearly documented aggressive and combative behaviors was coded as having no physical or verbal behavioral symptoms on the MDS.
A resident who was alert and oriented reported that a nurse repeatedly entered the room despite the resident’s request to keep the door closed and to stop coming in. A GNA accompanied the resident back to the room and informed an LPN of the resident’s wishes, but the LPN stated he did not care and entered anyway to give meds to the roommate. The resident continued to ask the LPN to leave, the situation escalated into yelling, and both the resident and the LPN used expletive language. The LPN told the resident to hit him, stated the resident would not do anything, and threatened to beat the resident, which was witnessed and later confirmed as verbal abuse by supervisory staff and the administrator.
A resident who was alert, oriented, and able to express needs had standing orders for showers on specific days but, over a two‑month period, received only bed baths instead of the ordered showers. The resident and the responsible party both reported that no showers had been provided during this time, and facility documentation confirmed only bed baths with one documented refusal related to diarrhea. The resident was agreeable to occasional bed baths but expected to be offered showers on scheduled shower days, which did not occur.
A resident with acute prostatitis did not receive IV antibiotics as ordered by the physician. Hospital discharge instructions included daily Ertapenem through the end of the month, but the final scheduled dose was not administered according to the MAR. The antibiotic regimen was later changed to Meropenem every 8 hours, and a scheduled evening dose was also not documented as given. The DON confirmed that staff failed to administer these ordered antibiotic doses.
Two residents did not receive respiratory care in accordance with professional standards. One resident with obstructive sleep apnea had a hospital discharge summary directing continuation of BiPAP for sleep, but BiPAP was neither ordered nor documented as administered for the first three nights after admission. Another resident with COPD, asthma, chronic myeloid leukemia, and a history of acute on chronic hypoxic hypercapnic respiratory failure had intermittent oxygen use documented in vital signs, yet there were no physician orders for oxygen therapy, tubing changes, humidification, O2 saturation goals, or basic oxygen care, despite facility policy requiring a provider order specifying liter flow and delivery device; the DON confirmed the absence of related documentation on the MAR and TAR.
Facility staff did not provide necessary personal hygiene and bathing assistance to two totally dependent residents. One resident was found with neglected toenail care, and another had no documented showers or bed baths for several months, despite being fully dependent due to significant physical limitations. Documentation and staff interviews confirmed the lack of provided care and incomplete records.
Two residents experienced significant delays in receiving prescribed medications and wound care treatments. One resident's medications were repeatedly administered several hours late, primarily due to short staffing and reliance on agency staff, as confirmed by MAR review and staff interviews. Another resident did not receive wound care or IV antibiotics until days after admission, with no documentation of earlier treatment. Facility leadership acknowledged the lack of timely care and absence of supporting documentation.
A resident who was alert and oriented experienced severe, unrelieved pain for several hours without timely assessment or administration of pain medication. Although pain medications were reportedly ordered and administered, there was no documentation in the MAR to support this, and no pain assessment was recorded. Staff interviews confirmed that pain management and documentation protocols were not followed, resulting in a significant delay in addressing the resident's pain before hospital transfer.
A nurse, unfamiliar with the facility and distracted during medication pass, administered Methadone to a resident instead of the prescribed Methylphenidate by failing to verify the medication name, dose, and form. The nurse did not follow the five rights of medication administration, and the error was only discovered after the medication was given. The resident was later found unresponsive and the incident was reported to the Medical Examiner.
Inaccurate MDS Coding for Medications, Falls, Behaviors, and Treatments
Penalty
Summary
Facility staff failed to ensure that Minimum Data Set (MDS) assessments were accurately coded for multiple residents, resulting in omissions and inaccuracies in several MDS sections. For one resident receiving Gabapentin every eight hours for neuropathy, the anticonvulsant was not captured in Section N0415 (High-Risk Drug Classes) on two separate MDS assessments. Another resident experienced a documented fall, noted in the medical record as being found on the floor in a sitting position, but this fall was not coded in Section J1800 (any falls since admission/entry or prior assessment). A third resident had hypoglycemic medication use coded in Section N0415, despite the November MAR showing no hypoglycemic medications administered during that period. Additional inaccuracies were identified for a resident who received Lorazepam, an antianxiety medication, which was not captured in Section N0415 on a discharge MDS, and whose use of oxygen via nasal cannula was not coded in Section O (Special Treatments, Procedures, and Programs). The same resident was incorrectly coded in Section O as receiving hospice services and in Section J1400 as having a condition with a life expectancy of less than six months, despite no documentation supporting hospice services or such a prognosis. Another resident with documented aggressive and combative behavior, including agitation, psychosis, throwing objects at staff, and destroying property, was coded as having no physical or verbal behavioral symptoms in Section E0200. This resident was also receiving Gabapentin three times per day per the MAR, but the anticonvulsant was not captured in Section N0415. The MDS Coordinator confirmed these errors and noted that other staff had been filling in on MDS assessments during the primary coordinator’s leave.
Failure to Protect Resident From Verbal Abuse by Nursing Staff
Penalty
Summary
Facility staff failed to protect a resident from verbal abuse by a staff member. An alert and oriented resident, admitted in 2025, approached the nursing station and reported that a nurse kept entering the resident’s room despite the resident’s request to keep the door closed and to stop coming into the room. A geriatric nursing assistant accompanied the resident back to the room and informed the nurse of the resident’s request. The nurse stated he did not care and entered the room anyway, stating he needed to administer medications to the roommate. The resident repeatedly told the nurse to leave the room, but the nurse refused, leading the resident to begin yelling. The geriatric nursing assistant reported that the situation became heated, with the nurse and the resident speaking to each other “like they were on the streets” and both using expletive language. The nurse told the resident to hit him and stated that the resident was not going to do anything, and that he would “beat the [expletive]” out of the resident. The nursing supervisor, after being notified by the geriatric nursing assistant, went to the scene and personally heard the nurse threaten to beat the resident. The supervisor stated that the nurse was being abusive and that he was afraid the situation was going to become physical. The facility’s administrator later confirmed that the facility substantiated verbal abuse of the resident by the nurse.
Failure to Provide Ordered Showers and Honor Resident Bathing Preferences
Penalty
Summary
The facility failed to provide showers as ordered for a resident who required assistance with activities of daily living (ADLs). The resident had physician orders to receive showers on Tuesdays and Fridays during January and February 2026, but interviews and record review showed that these ordered showers were not provided. On 2/20/26, the resident’s responsible party reported that the resident had not received a shower in the prior two months, and the resident, who was alert, oriented, and able to express needs, confirmed not having had a shower during that period and expressed a desire for one. Documentation in the treatment and GNA records showed that the resident had only received bed baths, with one documented refusal of a shower/bed bath on a single occasion due to diarrhea, and there was no documentation that showers were offered on the scheduled shower days as ordered. The resident stated they were not opposed to receiving a bed bath occasionally but expected to be offered a shower on designated shower days rather than being given only bed baths. The surveyor’s review of records corroborated that showers were not provided in accordance with the care plan and orders for the months reviewed, and that the resident’s preference for showers on scheduled days was not honored, except for the one documented refusal related to diarrhea.
Failure to Administer Ordered IV Antibiotics as Prescribed
Penalty
Summary
Facility staff failed to administer ordered IV antibiotics as prescribed for a resident with acute prostatitis. The resident was admitted in December 2025 with a diagnosis including acute prostatitis, and the hospital discharge summary ordered Ertapenem 1 gm IV daily through 1/30/26. Review of the January 2026 Medication Administration Record showed the resident did not receive the ordered Ertapenem dose on 1/30/26. The resident’s antibiotic regimen was later changed by the physician to Meropenem 2 gm IV every 8 hours on 2/4/26. Review of the February 2026 Medication Administration Record revealed no evidence that the resident received the scheduled Meropenem dose on 2/15/26 at 10:00 PM. In an interview on 2/25/26 at 8:30 AM, the Director of Nursing confirmed that facility staff failed to administer the ordered antibiotic medications on both 1/30/26 and 2/15/26.
Failure to Provide Ordered BiPAP and Properly Order/Document Oxygen Therapy
Penalty
Summary
The deficiency involves the facility’s failure to provide respiratory services in accordance with professional standards of practice for two residents who required such care. One resident was admitted with a diagnosis that included obstructive sleep apnea and had a hospital discharge summary directing continuation of BiPAP for sleep. Review of the resident’s December Treatment Administration Record showed that the BiPAP was not ordered or documented as administered until three days after admission, resulting in three nights without the prescribed BiPAP therapy. In an interview, the Administrator confirmed that facility staff did not administer the resident’s BiPAP during those three nights following admission. For another resident, admitted with COPD, asthma, and chronic myeloid leukemia, the medical record documented use of oxygen at 3 LPM via nasal cannula and a history and physical noting acute on chronic hypoxic hypercapnic respiratory failure, COPD, asthma, and home oxygen use of 2–3 liters, as well as recent community-acquired pneumonia and acute hypoxic respiratory failure while hospitalized prior to admission. The vital sign section of the electronic medical record showed intermittent use of oxygen; however, review of the December and January physician’s orders revealed no orders for oxygen therapy, tubing changes, humidification, oxygen saturation goals, or basic care related to oxygen therapy. The facility’s oxygen therapy policy required verification of a medical doctor order including liter flow and type of O2 delivery device. During an interview, the DON confirmed that the MAR and TAR contained no documentation of oxygen usage, tubing changes, or humidification for this resident.
Failure to Provide Personal Hygiene and Bathing Assistance to Dependent Residents
Penalty
Summary
Facility staff failed to provide necessary personal hygiene services to residents who were totally dependent on staff for activities of daily living (ADL). In one instance, a resident was observed to have long, yellowed, thickened, and misshapen toenails, with one toenail having fallen off. The resident’s Minimum Data Set (MDS) indicated total dependence on staff for personal hygiene. Interviews with staff revealed that toenail care was the responsibility of nurses or podiatry, but the resident had not been seen by podiatry until after the surveyor’s intervention, indicating a lack of timely care. Another resident, who was dependent for all ADLs due to diagnoses including muscular dystrophy and Friedreich ataxia, was reported by a family member to have not received a shower in years and to have a layer of filth on their head. Review of the resident’s medical record and facility documentation showed no evidence of showers or bed baths being provided over several months. The facility’s documentation systems, including Point of Care (POC) and paper shower sheets, lacked records of bathing or showering for this resident, except for two instances where refusal was documented. Staff interviews confirmed that showers were scheduled and assigned, but documentation was incomplete or missing. Both residents had care plans indicating total dependence on staff for personal hygiene and bathing, with goals for their ADL needs to be met. However, the lack of documented care and observations of poor hygiene demonstrated that the facility did not provide the required assistance with personal hygiene and bathing for these dependent residents.
Delayed Medication and Wound Care Administration
Penalty
Summary
The facility failed to provide timely medication administration and wound care treatment to two residents, as identified during a recertification and complaint survey. For one resident, multiple medications were administered 2-4 hours late on various days throughout the month, as confirmed by a review of the Medication Administration Records (MAR). The resident attributed the delays to agency staff frequently used by the facility, and a registered nurse confirmed that short staffing and lack of medication aides were common reasons for late medication passes. The Director of Nursing acknowledged awareness of the issue and stated that medication times had been adjusted in an attempt to address the problem, but late administration persisted. Another resident experienced a delay in wound care and IV antibiotic administration following admission. The wound treatment order was not placed until two days after admission, and there was no documentation of wound care prior to that order. Additionally, the resident's IV antibiotic, vancomycin, was ordered a day after admission, with the first dose administered later that day, and no evidence of earlier administration. Both the Director of Nursing and the Nursing Home Administrator confirmed there were no additional orders or documentation to support earlier treatment or medication administration.
Failure to Provide Timely Pain Management and Documentation
Penalty
Summary
A deficiency was identified when a resident experienced severe, unrelieved pain for an extended period without timely assessment or intervention. The resident, who was alert and oriented with a BIMS score of 15/15, began experiencing severe bilateral leg pain, rated at 10/10, starting in the evening and continuing into the following morning. Despite the resident's ongoing complaints and visible distress, there was no documented pain assessment or administration of pain medication during this time. Progress notes later indicated that pain medications and a lidocaine patch were ordered and reportedly administered, but the Medication Administration Record (MAR) did not reflect any such administration on the date in question. Staff interviews revealed that pain assessments are expected to be conducted every shift, and the DON confirmed that pain should be managed immediately with all interventions documented in the MAR. However, there was a five-hour gap between the initial documentation of severe pain and the resident's transfer to the hospital, during which no pain assessment or medication administration was documented. This failure to provide timely pain management and proper documentation constituted the identified deficiency.
Significant Medication Error: Methadone Administered Instead of Methylphenidate
Penalty
Summary
A significant medication error occurred when a registered nurse (RN), who was working their first shift at the facility as an agency nurse, administered Methadone to a resident instead of the prescribed Methylphenidate. The resident had been admitted with diagnoses including narcolepsy, muscle weakness, and recurrent falls, and was scheduled for discharge. The error happened when the RN, while administering medications, saw the letters 'M-E-T-H' on the medication administration record and assumed the medication was Methadone, without verifying the medication name, dosage, or form. The RN did not compare the medication pulled from the cart to the resident's medication administration record, did not confirm the medication, and did not check if the medication was in the correct form, resulting in the administration of a liquid Methadone dose instead of the prescribed tablet form of Methylphenidate. After realizing the error about an hour later, the RN assessed the resident, found them to be sleepy but with stable vital signs, and reported the incident to the nursing supervisor. The supervisor instructed the RN on documentation, contacting the on-call physician, and notifying the resident's family. The on-call provider was informed but was unable to obtain critical information from the RN, such as the resident's name, date of birth, and the exact dose of Methadone administered. The provider was told that the Methadone had been intended for another resident who was not currently admitted, and the RN could not locate the empty bottle or confirm the dose given. The provider relied on the RN's report that the resident was stable and did not recommend hospital transfer at that time. The RN admitted to not following the five rights of medication administration and reported being heavily distracted during the medication pass. The resident was found pulseless and without respirations by nursing staff later that evening, and the death was reported to the Medical Examiner's office. The facility's failure to ensure the resident was free from significant medication errors resulted in the identification of an Immediate Jeopardy situation by the Maryland Office of Health Care Quality.
Removal Plan
- Education of all nurses on medication administration with focus on the six-rights medication administration, opioid management, signs of opioid overdose, and in-house escalation protocol.
- Medicine Pass evaluations and competencies will be completed for all licensed nurses. Each nurse will undergo a thorough assessment of their medication administration skills. Any identified areas for improvement will be addressed through additional training, and successful completion will be documented in the employee's personnel file.
- Staff will be quizzed on their understanding of the opioid overdose management policy post education. The quizzes will cover key topics, including recognizing the signs and symptoms of opioid overdose, appropriate response protocols, and steps for escalation. Results will be reviewed, and any areas of concern will be addressed through additional training or clarification.
- Nursing staff will be quizzed on their understanding of the medication administration policy post education. The quiz will focus on the rights of medication administration. Any knowledge gaps identified will be addressed through additional training and support.
- Ongoing monthly medication evaluations will be conducted for all licensed nurses and Certified Medicine Aides by DON/designee. Each nurse will undergo a thorough assessment of their medication administration skills. Any identified areas for improvement will be addressed through additional training, and successful completion will be documented in the employee's personnel file.
- The results will be reported by the DON to the Quality Assurance Performance Improvement Committee until 100% compliance is achieved.
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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