Complete Care At Laplata Llc
Inspection history, citations, penalties and survey trends for this long-term care facility in Laplata, Maryland.
- Location
- 1 Magnolia Drive, Laplata, Maryland 20646
- CMS Provider Number
- 215151
- Inspections on file
- 16
- Latest survey
- January 9, 2026
- Citations (last 12 mo.)
- 11
Citation history
Health deficiencies cited at Complete Care At Laplata Llc during CMS and state inspections, most recent first.
A resident with dementia, severe cognitive impairment, poor gait/balance, and incontinence experienced multiple falls, including two hip fractures, while staff failed to consistently update and individualize the fall care plan or implement ordered interventions. Although the care plan called for root cause review of each fall and a toileting program, several documented falls were never added to the care plan, no new interventions were implemented, and the toileting program was not carried out. The care plan lacked any intervention specifying the needed level of supervision, despite the resident’s impulsivity and frequent unassisted attempts to get up. After a fall resulting in a left hip fracture and subsequent readmission, the only new intervention was to place the wheelchair by the bed, which staff had already been doing, and there was still no documented fall analysis. Observation of the resident’s room revealed additional unaddressed hazards, including a high bed without fall mats, cluttered and low-lit areas, obstructed space preventing wheelchair placement by the bed, and a closed curtain that blocked staff visibility, all contributing to the cited deficiency in accident prevention and supervision.
Surveyors found that the facility failed to maintain a safe, clean, and homelike environment across multiple units and common areas. Hallways on several wings were lined with w/c, geriatric chairs, mechanical lifts, dressers, boxes, and other equipment, while handrails were used to store items such as gloves, trash bags, paper cups, paper towels, and hand sanitizer drip trays. A trash bag with linens was left on a resident room floor, and a bedside commode with an uncovered urine hat was stored at the end of a hallway. In the main dining room, large sheets of plastic were taped to the ceiling, partially covering vending machines and concealing building supplies. Shower rooms were used for storage of w/c, geriatric chairs, beds, clothing bags, and maintenance equipment, leaving only limited shower stalls accessible. An LPN confirmed that staff routinely store residents’ mobility devices in hallways, rooms, and shower areas.
A resident with a history of frequent refusals of medications, vitals, and nursing care had a care plan and physician order directing staff to notify the resident’s representative (RR) whenever treatments or procedures were refused. Despite ongoing daily medication refusals and two documented falls followed by ordered but refused x‑rays, labs, and imaging, records showed that while physicians were notified, the RR was not. Nursing notes later documented a change in the resident’s responsiveness, and the on‑call physician ordered continued monitoring and respect for the resident’s refusal of labs, yet there was still no documented contact with the RR as required by the care plan and orders. The resident was subsequently transferred to the hospital with a diagnosis of sepsis, and the DON could not provide documentation that the RR had been notified of these refusals or condition changes.
A resident repeatedly reported that current incontinence briefs were leaking more than previous ones, causing urine odor on clothing and leading to a missed facility event, along with concerns about missing medical shoe boots and bothersome construction odors. The first grievance was marked resolved without addressing the leaking brief issue, and a second grievance was closed after deciding to add a pad under the brief, without investigating the cause of the leakage or ensuring an effective intervention. The resident stated that staff were not responsive to these complaints, and the NHA, acting as Grievance Officer, acknowledged that the initial concern was not addressed and that the second grievance was not properly investigated.
An activity assistant asked a group of residents if they wanted to listen to music, then played it despite most declining, using music a resident described as derogatory, inappropriate, and excessively loud. This triggered a verbal confrontation between the assistant and a resident, escalating into yelling and cursing until a supervisor intervened and removed the staff member from the area. The recreation director reported prior complaints from this resident about the same staff member’s music, and the staff member’s file showed recent discipline for negative interactions in which a resident was singled out and became upset. Surveyors substantiated this as verbal abuse and failure to treat a resident with respect.
The facility failed to prevent misappropriation of controlled medications and to ensure proper destruction procedures were followed. A former unit manager RN removed and destroyed oxycodone from a med cart without a second licensed nurse present, then left early without notifying the nurse assigned to that cart. Later, another RN found the controlled substance destruction form on the former manager’s desk with signatures suggesting two staff had witnessed destruction, but one staff member reported he had only witnessed his own medications being wasted, not the additional narcotics listed. Surveyors reviewing Unit A narcotic logs found multiple days with missing entries, and the DON acknowledged that the facility’s investigation did not identify which residents’ medications were destroyed, did not verify whether medications documented as sent home or destroyed had actually been handled as recorded, and relied only on the fact that medications were signed off to conclude no other residents were affected.
The facility failed to meet required timeframes for reporting abuse allegations and misappropriation of medication to the SA and did not fully document when and to whom these concerns were reported. In one case, a resident’s family member reported during a care plan meeting that two male therapists had kicked the resident, but documentation of the time of the allegation, the chain of reporting, and the person notified was incomplete, and the report to the SA occurred later that day. In another case, staff reported concerns about misappropriation of a resident’s medication, but the SA was not notified until eight business days later, even though this incident was later classified as misappropriation of resident medication, a form of abuse.
The facility failed to thoroughly investigate and properly document multiple allegations of neglect, abuse, and misappropriation. One resident with chronic pain and no cognitive impairment reported not receiving pain meds for 24 hours, not getting preferred daily showers, and experiencing trauma triggers, yet the investigation lacked a resident statement, interviews with other residents or staff, and any documented inquiry into bathing preferences, pain control, or trauma screening. Another resident with a stroke and mild cognitive impairment alleged being kicked in the chest and stomach by two male staff, but the initial report omitted to whom the allegation was reported, the SSD’s statement lacked dates and times, and staff interviews were incomplete. In a separate incident, an RN unit manager destroyed two sheets of oxycodone without a witness, and the facility did not determine whose meds were destroyed or audit other narcotics documented as sent home or destroyed on that unit, relying only on the fact that medications were signed off.
Staff failed to consistently complete and sign end-of-shift narcotic count verifications for one medication cart on a unit, leaving multiple days without required two-nurse signatures despite facility policy requiring this process. A prior internal concern about alleged improper wasting of narcotics without a witness led surveyors to review narcotic logbooks and compare them with staff schedules, revealing that even when nurses worked double shifts, narcotic logs were often not signed between shifts. The DON acknowledged instructing staff working doubles to sign for both shifts, and facility policy required daily visual audits and spot checks of controlled substance documentation, but the shift-to-shift verification process was not maintained.
Surveyors observed a medication cart left unattended near a nursing station with insulin syringes, hypodermic needles, and a Budesonide inhaler on top, while the assigned RN was in a nearby bathroom and not supervising the cart. A ward clerk and unit manager were present in the area but were not responsible for the cart. During this period, two independently mobile residents were on the opposite side of the nursing station, out of direct staff view, including a resident with Alzheimer's disease and a care plan for eating and chewing inanimate objects. The unsecured medications and administration instruments on the unattended cart in proximity to these vulnerable residents constituted the cited deficiency.
The facility did not maintain three years of survey results for residents, families, and visitors to review. A surveyor’s review of the survey binder in the front lobby showed that it did not contain the required three years of survey reports. In an interview, the NHA confirmed he had reviewed the binder and stated that the facility’s standard was to keep only one year of survey results available, resulting in noncompliance with requirements for public access to survey findings.
A resident was transferred to the hospital without the required care plan goals or documentation being sent, as confirmed by medical record review and staff interviews. The DON made the transfer decision due to behavioral concerns, but the resident had not been assessed by psychiatric services or a physician, and the facility social worker was not involved in the process. Hospital staff reported receiving no paperwork or belongings with the resident.
A resident was transferred to the hospital due to behavioral issues without receiving the required discharge notice, care plan information, or documentation of appeal rights. The DON made the transfer decision without input from psychiatric services or the medical director, and hospital staff reported not receiving necessary paperwork or a bed hold notice.
A resident was transferred to the hospital without the required documentation, care plan goals, or belongings, and neither the resident nor their responsible party received necessary information prior to transfer. The transfer decision was made by the DON due to behavioral concerns, without assessment by a facility physician or psychiatric services, and hospital staff confirmed that no paperwork or bed hold notice was provided.
A resident was transferred to the hospital due to behavioral concerns without being provided a written bed hold notice or the required transfer documentation. Facility staff, including the DON and hospital liaison, confirmed that no paperwork or belongings were sent with the resident, and hospital social workers reported not receiving any bed hold notice or transfer information.
A resident was transferred to the hospital due to behavioral issues without being issued an involuntary discharge notice or having required transfer documentation and care plan information sent. The DON made the decision to transfer the resident, and hospital staff reported that no paperwork, belongings, or bed hold notice were provided, and the resident was not assessed by facility psychiatric services or a physician prior to transfer.
The facility failed to provide warm palatable food to residents, as evidenced by cold meals and inadequate measures to maintain food temperature. A resident confirmed the issue, and test trays showed food temperatures below acceptable levels. The facility lacked sufficient heated pellets and a pellet warmer, contributing to the deficiency.
The facility failed to accurately assess residents' use of side rails and functional status on the MDS. A resident had side rails documented as 'not used' despite their presence, and another had a physician order for side rails, yet the MDS indicated 'not used'. Additionally, a third resident had family consent for side rails, but the MDS inaccurately reported 'not used'. These inaccuracies were noted during a survey and discussed with the DON.
Facility staff failed to follow CDC guidelines for PPE removal during a COVID-19 outbreak. A GNA was observed removing PPE in the hallway instead of inside the resident's room and did not sanitize hands afterward. The GNA also took two food trays into a room without changing gloves or gown between residents. Interviews revealed a lack of recent PPE training and monitoring of staff compliance with infection control protocols.
The facility failed to maintain safe and accessible hallways in Units A, B, and D, with clutter including wheelchairs, chairs, and carts obstructing pathways and handrails. This clutter, due to maintenance activities and insufficient room space, persisted over several days despite being reported to management, raising concerns about emergency evacuation and resident safety.
A facility failed to honor a resident's advance directive, which requested all life-extending measures, including a gastrostomy tube for nutrition. Despite the resident's repeated hospitalizations for aspiration pneumonia and dehydration, the MOLST form indicated no artificial nutrition, influenced by the healthcare agent's opposition. This discrepancy was not addressed, leading to a deficiency in care.
A resident reported being hit by staff members, but the facility delayed reporting the abuse allegation to the state agency by 5 hours, exceeding the required 2-hour timeframe. The incident was brought to the attention of the DON during a complaint survey.
A facility failed to thoroughly investigate an alleged abuse incident where a resident was reportedly struck by a receptionist. The investigation did not include interviews with the resident's roommate or other residents, and the Assistant Director of Nursing could not recall who was interviewed. The Director of Nursing was informed of these findings.
Two residents were unnecessarily monitored with elopement deterrent devices due to the facility's failure to reassess their elopement risk after significant changes in their conditions. Despite assessments indicating low risk, the residents continued to be monitored with wanderguards, a decision made by the DON and Unit Managers. Interviews revealed a lack of clarity on the necessity of these devices.
A resident's care plan was not updated after multiple incidents of g-tube dislodgement, despite the facility's protocol requiring updates following a change in status. The resident needed hospital transfers for g-tube replacement on several occasions, but the care plan was last updated in September 2023. Interviews confirmed that unit managers are responsible for such updates, but this was not done in 2024.
The facility failed to document ADL care for two residents dependent on staff for bowel and bladder care. One resident, requiring extensive assistance, had care documented only twice out of ten potential times. Another resident, dependent due to comorbidities, had no care documented over several shifts. Staff interviews confirmed that ADL records should not have blanks.
The facility did not ensure trauma-informed care for a resident with a history of trauma, as no assessment or care plan was completed upon admission. A social worker confirmed that trauma-informed care assessments were not administered at the time of admission, although they were part of the facility's protocol. An assessment and care plan were only implemented after a complaint investigation.
The facility failed to properly assess and reassess two residents for bed rail use, leading to deficiencies in care. One resident experienced multiple falls and injuries without a reassessment after a change in functional status, while another continued using bed rails against assessment recommendations, resulting in a forehead injury. Staff interviews confirmed the use of bed rails to prevent falls, but there was no evidence of alternative safety measures being considered.
A facility failed to administer medications in accordance with professional standards, resulting in a resident receiving medications late on multiple occasions. Medications such as Tylenol, Prednisone, Metoprolol Tartrate, and Finasteride were administered outside the prescribed 1-hour time frame, as revealed in a medication administration audit. These findings were confirmed through observation, record review, and interviews, and discussed with the DON.
A facility failed to notify a physician of lab results for a resident with multiple comorbidities, including diabetes and anemia. A repeat CBC was ordered by an NP, but the lab report was not available in the medical record, and no physician was notified of the results. The lab report, containing several flagged results, was only reviewed 13 days later during a subsequent visit. The Medical Director confirmed the delay, and the report had to be printed by the DON upon request.
A facility failed to ensure an ordered lab report was available on the chart for a resident with diabetes and anemia. A repeat CBC was ordered by the NP, but the lab report was not available for review when needed. The DON later provided the report, confirming it was not on the chart initially. The Medical Director noted a 13-day delay in follow-up, and the process for lab notification was discussed.
A resident's food preferences were not honored, as they were repeatedly served shrimp despite disliking it. The FSM and Dietician failed to document the resident's preferences in the system, and the GNA's attempts to rectify the situation by contacting the kitchen were unsuccessful. The Quarterly Nutrition Assessment also did not reflect the resident's dislikes, indicating a deficiency in the facility's documentation and communication processes.
A resident with Multiple Sclerosis, requiring assistance and modified drinkware, sustained burns from a hot drink provided by a family member without staff knowledge. The facility failed to provide surveyors with QA and risk management records following the incident, and interviews revealed that documentation of a root cause analysis was missing.
A resident with Multiple Sclerosis sustained burns after spilling hot chocolate provided by a family member without staff knowledge or use of modified drinkware. The facility failed to maintain QA and risk management records for five years post-discharge, as required. Interviews confirmed that a root cause analysis was conducted, but documentation was missing.
Failure to Analyze Recurrent Falls and Implement Adequate Supervision and Environmental Controls
Penalty
Summary
Facility staff failed to identify and evaluate factors contributing to a resident’s recurrent falls and did not ensure appropriate interventions were implemented to prevent future occurrences. The resident had dementia with severe cognitive impairment, poor gait and balance, poor safety comprehension, incontinence, and a history of falls, and was assessed as high risk for falls. A fall care plan initiated months earlier included environmental decluttering, adequate lighting, appropriate footwear, and fall mats, with a goal to keep the resident free of falls. After a right hip fracture from a fall, the care plan called for a toileting program and for each fall to be reviewed for root cause and for the cause to be removed. However, the care plan did not include any intervention specifying the level of supervision needed to prevent falls. Multiple subsequent falls were documented on Change in Condition (CIC) forms, but these events were not consistently incorporated into the care plan, and new interventions were often not added. Falls on 6/16/25 and 7/1/25 were not listed on the care plan, no new interventions were implemented, and there was no evidence that staff reviewed these falls to determine their causes, despite the care plan directive to do so. A toileting program ordered to prevent falls was not implemented, as confirmed by review of the physician’s orders, MAR, and TAR, and by interview with an LPN who stated the resident was not on a toileting program. A later fall on 12/23/25 was added to the care plan, but only one new intervention (ensuring the bed was locked and in low position) was documented, again with no evidence of a fall review or root cause analysis. On 12/31/25, the resident sustained another fall, was found on the floor near the bathroom doorway while staff were passing lunch trays and administering medications, and was subsequently diagnosed with a left hip fracture requiring surgical intervention. After readmission, the fall care plan was updated with only one intervention to place the wheelchair beside the bed, an action staff had already been performing per LPN interview, and there was still no documented review of the fall for root cause or any intervention addressing the level of supervision needed. Observation of the resident’s new room showed additional unaddressed hazards: the bed was too high, there were no fall mats, the wheelchair was not beside the bed and there was no space to place it there, the curtain was closed preventing staff from seeing the resident, the room was far from the nurses’ station, and the roommate’s side was cluttered with low lighting and items protruding into the walkway. These conditions, combined with the resident’s impulsivity, poor safety awareness, and frequent attempts to get up unassisted, reflected the facility’s failure to maintain an environment free from accident hazards and to provide adequate supervision to prevent accidents.
Cluttered Hallways, Shower Rooms, and Dining Area Undermine Homelike Environment
Penalty
Summary
The deficiency involves the facility’s failure to provide a safe, clean, comfortable, and homelike environment on all nursing units and in common areas. During a tour of the C and D units, surveyors observed a partially disassembled hand sanitizer dispenser lying on a PPE cart, wheelchairs, geriatric chairs, and mechanical lifts stored in multiple hallways, and paper cups and a plastic drip tray placed on handrails. Additional items, including a box of gloves and a green mesh bag containing trash bags, were also stored on handrails outside resident rooms. On the A and B units, surveyors observed a trash bag with linens on the floor beside a resident bed, multiple hand sanitizer drip trays and a partial roll of paper towels on handrails, and a mesh bag with trash bags hanging from a handrail. At the end of one hallway, a bedside commode with an uncovered urine hat was present, and the short A wing hallway contained multiple dressers, boxes, and a large trash can stored near the recreation room. Wheelchairs, geriatric chairs, and mechanical lifts were stored in each hallway on the unit. In the main dining room, where residents eat meals and participate in activities, large pieces of plastic were hanging from the ceiling, secured with blue painter’s tape, partially covering vending machines and concealing a large assortment of building supplies. On a subsequent tour, an open, uncovered linen cart with linens and wash basins was observed between resident rooms, along with a box of gloves on the handrail and additional wheelchairs, geriatric chairs, a room chair, and mechanical lifts lining the hallways. One wheelchair contained basins, bleach wipes, toiletries, and trash bags on the seat, and a housekeeper had difficulty maneuvering a cleaning cart between these items and a medication cart. An LPN reported that staff store residents’ wheelchairs and geriatric chairs in hallways, resident rooms, and shower rooms. In the C and D shower room, wheelchairs, geriatric chairs, and a shower bed with large trash bags of clothing and shoes occupied shower stalls, while other stalls contained shower chairs and stretchers. In the A and B shower room, men were moving a bed from the shower room, and the women’s side was full of maintenance equipment; another room had a bed with bags of clothing, and the men’s side had three geriatric chairs blocking a back shower stall, leaving only two shower stalls accessible.
Failure to Notify Resident Representative of Treatment Refusals and Changes in Condition
Penalty
Summary
The deficiency involves the facility’s failure to notify a resident’s representative (RR) of changes in condition and refusals of treatment, despite a specific care plan and physician order requiring such notification. The RR had requested during a care plan meeting that staff call her whenever the resident refused medications, treatments, vitals, or procedures, and this request was incorporated into the care plan and entered as a physician order on the MAR to be acknowledged every shift from admission to discharge. Medical record review showed that the resident had ongoing, daily refusals of medications throughout the stay, and although the attending physician was notified, there was no documentation that the RR was informed of these refusals as required. Further review of the nursing progress notes showed that the resident experienced a fall in late summer, after which x‑rays and laboratory tests were ordered due to observed swelling; these tests were refused and never completed, and there was no documentation that the RR was notified. Later in the stay, the resident had another witnessed fall, and subsequent labs and imaging, including a urinalysis, were ordered and again refused in line with the resident’s documented history of refusals. The following day, nursing notes documented a change in condition with the resident being less responsive. The on‑call physician was notified and ordered monitoring and to respect the resident’s refusal of labs, with instructions to re‑offer if the condition changed or the resident became more agreeable. At no time, according to the record and interviews, was the RR notified or contacted to come in and assist, despite the existing care plan and orders. The resident was later transferred to the hospital for an extended stay with a diagnosis of sepsis, and the DON was unable to provide additional documentation showing that the RR had been notified of the refusals or changes in condition related to the falls and subsequent orders.
Failure to Adequately Investigate and Resolve Resident Grievances About Incontinence Care
Penalty
Summary
The deficiency involves the facility’s failure to adequately address and resolve a resident’s grievances related to incontinence care and other concerns. Record review showed that on 12/9/25 three concerns about Resident #10 were reported to social services: the resident’s incontinence briefs were leaking more than previous ones and their clothing smelled of urine more frequently, two medical shoe boots were missing, and construction odors were bothering the resident. The grievance form indicated that the Nursing Home Administrator (NHA) investigated the grievance and signed it as resolved on 12/10/25, but the written response did not address the concern about the leaking incontinence briefs. A second grievance dated 12/24/25, completed by Unit Manager #4, documented that the same resident again reported leaking incontinence briefs that caused urine odor on their clothing and led them to miss a facility event. The resident stated that the previous briefs did not leak and that they had been complaining without anyone listening. The follow-up section stated that the current brief was not new and that a pad would be added under the brief, and it was marked as resolved. However, there was no documented investigation into why the briefs were leaking or what intervention would prevent recurrence. During an interview, the resident reported ongoing feelings that staff were not responsive to their grievances. In a separate interview, the NHA, who served as Grievance Officer, acknowledged that the incontinence brief concern was not addressed when first reported and that the second grievance was not investigated to ensure an effective resolution for the resident.
Verbal Altercation and Disrespectful Conduct by Activity Staff Toward a Resident
Penalty
Summary
Facility staff failed to protect a resident from verbal abuse and to ensure the resident was treated with respect. During a scheduled smoke break in the courtyard, an activity assistant asked a group of residents if they wanted to listen to music. Although the majority of residents reportedly declined, the activity assistant played music anyway. The resident reported that the music selections were derogatory, inappropriate for public listening, and extremely loud, making it difficult for residents to hear one another. This led to escalating verbal exchanges between the resident and the activity assistant. According to the investigation statements, the interaction progressed into a verbal altercation involving yelling and cursing between the resident and the activity assistant until a supervisor arrived and escorted the staff member from the courtyard and out of the facility for the remainder of the day. The Recreation Program Director reported that the resident had previously complained about the music played by this same activity assistant, and that the activity assistant had also approached him about these prior conflicts. Review of the activity assistant’s employee file showed disciplinary action less than three weeks earlier for negative interactions with a resident, in which a resident was singled out and became upset. Surveyors substantiated abuse based on these findings.
Failure to Prevent Misappropriation and Ensure Proper Destruction of Controlled Medications
Penalty
Summary
The deficiency involves the facility’s failure to protect residents’ medications from misappropriation and to ensure proper controlled substance handling and documentation. A facility-reported incident described that the former Unit A manager (an RN) removed two sheets of oxycodone from a medication cart and destroyed them without following required procedures, including having a second licensed nurse witness the destruction. The RN then left work early without notifying the nurse responsible for that medication cart. When the assigned nurse later attempted to appropriately waste medications from the cart, she discovered the narcotics were already gone. She contacted another RN, who located the Controlled Dangerous Substance Destruction Report on the former unit manager’s desk, bearing signatures and initials of that RN and another staff member. When the other staff member was interviewed, he stated he was only aware of his own medications being wasted and not the additional two narcotics listed on the form. During the survey, narcotic logbooks on Unit A were reviewed and showed multiple days with missing entries (“holes”) in the logs. The current Unit A manager explained that the facility’s process required two licensed nurses to be present for the entire destruction process, from gathering the medications through signing paperwork and destroying the drugs. The DON acknowledged the prior incident involving the former unit manager and stated that the facility’s investigation could not determine which residents’ medications had been destroyed, although she noted that pharmacy could have been contacted using prescription numbers to obtain that information. Review of narcotic logs showed that some medications were documented as sent home with residents and others as destroyed, which the DON said was based on physician orders. When asked, the DON reported that the facility did not go back to verify whether narcotics were actually sent home or destroyed on Unit A during the former unit manager’s tenure and confirmed that the only step taken to determine whether other residents were affected was to verify that all medications were signed off in the records.
Failure to Timely Report Abuse Allegations and Misappropriation of Medication
Penalty
Summary
The deficiency involves the facility’s failure to timely report allegations of abuse and misappropriation of resident property to the state agency (SA) within required timeframes, and incomplete documentation of when and to whom the allegations were reported. For one resident, documentation showed a care plan meeting note initiated by a unit manager on one date was incomplete, and a late-entry care plan note by the Social Services Director (SSD) indicated the care plan meeting occurred earlier that same day. The facility’s investigation file for this incident documented that the resident accused two male therapists of kicking the resident in the chest and stomach, and that staff became aware of the allegation at 4:00 PM, but failed to document to whom it was reported. The final investigation report indicated the allegation was reported by a family member during a care plan meeting. The SSD’s written statement did not include the date and time she was told of the allegation, nor when and to whom she reported it. Email confirmation showed the allegation was reported to the SA at 5:55 PM that day. In interview, the ADON stated she documented the date and time she became aware of the allegation on the initial report form and acknowledged she should have documented the date and time the SSD was told of the allegation but did not. The SSD reported in interview that the care plan meeting occurred at 2:30 PM, lasted about 45 minutes, and that she reported the allegation to the ADON between 3:19 PM and 3:30 PM. A second deficiency involved the facility’s failure to timely report a misappropriation of resident medication, which is classified as a form of abuse. The facility-reported incident showed that staff member #4 made the facility aware of the concern on one date, but the SA was not notified until eight business days later at 6:00 PM. Initially, during interview, the DON stated this was considered an unusual circumstance; however, after surveyor review and interviews, the incident was classified as misappropriation of resident medication. The survey team requested email confirmations of submissions to verify reporting timeframes and reviewed concerns about reporting timeframes throughout the survey and again during exit.
Failure to Thoroughly Investigate and Document Abuse, Neglect, and Misappropriation Allegations
Penalty
Summary
The deficiency involves the facility’s failure to conduct thorough investigations and maintain complete written records for abuse, neglect, and misappropriation allegations. For one resident with no cognitive impairment, chronic pain syndrome, and a documented preference for choosing between a shower or bed bath, the record did not show that staff determined or documented the resident’s bathing preference or frequency. When this resident later reported neglect concerns about pain medication not being given for 24 hours, not receiving daily showers as preferred, and experiencing trauma triggers related to stress and being in a nursing home, the facility’s investigation file lacked key elements. The initial report did not identify to whom the concerns were reported, and the final report did not include a resident statement, interviews with other residents about showers or trauma care, or staff statements. A census sheet used as part of the investigation had check marks and a note about residents having no concerns with pain medications but lacked dates, times, and the name or signature of the interviewer. There was no evidence that staff investigated why the resident was not receiving daily showers, why the resident’s pain was not controlled, or how trauma triggers had not been identified during trauma screening. For another resident with a history of stroke and mild cognitive impairment, the facility failed to fully document and investigate an allegation of physical abuse by staff. The resident’s physician documented a need for PT and OT, and care plan meeting notes were entered by the unit manager and social services director on different times and as a late entry. The initial abuse report documented that the resident accused two male therapists of kicking the resident in the chest and stomach, and that staff became aware of the allegation at a specific time, but did not state to whom it was reported. The final investigation report stated that a family member reported the allegation during a care plan meeting and that the resident said two staff members kicked the resident in the stomach on a prior evening. The abuse was deemed unsubstantiated because the alleged perpetrators were not identified and the resident could not clearly describe the incident, and it was noted there was only one male therapist in the facility. The SSD’s written statement did not include the date and time she was told of the allegation or when and to whom she reported it. Although statements were obtained from two male staff who cared for the resident that evening and from the male therapist, the facility did not obtain statements from other staff who worked that evening/night. In a separate incident involving potential misappropriation of narcotics, the facility failed to complete a thorough investigation and maintain adequate documentation. The initial information provided to surveyors consisted only of the initial report to the state agency and the Board of Nursing regarding an RN who had been a unit manager. According to these documents, the RN removed two sheets of oxycodone from a medication cart and destroyed them without following required procedures, including having a witness present. The DON stated that they were unable to determine whose medications were destroyed, although a call to the pharmacy with the prescription number could have clarified this. Review of narcotic logs showed that narcotics were sometimes documented as sent home with residents at discharge and sometimes as destroyed. The DON acknowledged that, during the investigation, they did not verify whether narcotics documented as sent home or destroyed on that unit during the RN’s tenure were accurate, and that their only verification was that all medications were signed off. No additional investigative information was provided to surveyors before exit.
Failure to Maintain Two-Nurse Narcotic Count Verification Between Shifts
Penalty
Summary
Facility staff failed to ensure that end-of-shift narcotic count verifications were consistently completed and signed by two nurses for one of two medication carts on the A wing. Review of the A wing narcotic logbooks on 1/7/26, prompted by a prior facility report from August 2025 regarding alleged improper wasting of narcotics by a former unit manager without a witness, showed multiple days between August 2025 and December 2025 where two-nurse verification at shift change was not documented. The A unit manager stated that two nurses are supposed to sign each shift and that staff working a double shift are to complete the narcotic count with the shift supervisor. She was informed of multiple gaps in the narcotic log, and copies of the logs from August through December were requested. The DON reported that her practice was to instruct staff working a double shift to sign their initials for both shifts, which she suggested could explain missing signatures. However, comparison of staff schedules for selected time frames with the narcotic logs and corresponding signatures, conducted with the DON on 1/8/26, revealed that staff still failed to consistently sign the narcotic log between shifts even when working double shifts. Review of the facility’s Controlled Substance Administration and Accountability policy, last revised 3/2023, showed that the controlled drug record is intended to document both narcotic disposition and patient administration, and that the charge nurse or designee is to conduct a daily visual audit of controlled substance documentation with spot checks for proper destruction documentation and physician orders for removed medications. Despite these policy requirements, the narcotic log shift-to-shift verification process was not maintained, as noted throughout the survey and again at exit on 1/9/26.
Unattended Medication Cart with Unsecured Medications and Needles Near Mobile Residents
Penalty
Summary
Facility staff failed to keep medications and related supplies secured from residents when a medication cart was left unattended and accessible near the C/D unit nursing station. During a tour at 4:20 PM, a surveyor observed a medication cart pushed up against the nursing station with 2 insulin syringes, 2 hypodermic needles, and a Budesonide steroid inhaler on top. A ward clerk was seated at the desk and the C/D unit manager was in her office, but neither was assigned to or in charge of the medication cart. The Nurse Practice Educator (NPE) arrived shortly thereafter, independently observed the same unsecured items on the cart, and began looking for the nurse responsible for the cart. The NPE was informed by staff at the nursing desk that the nurse assigned to the cart was in the bathroom. Moments later, a staff member exited a bathroom across from the nursing station and returned to the unattended medication cart, and it was verified that this was her cart and that she was an RN who had previously worked at the facility. During this time, two independently mobile residents were observed on the opposite side of the nursing station, in an area where they would not be visible to staff if they approached the cart. Review of the medical record for one of these residents showed a diagnosis of Alzheimer's disease and a care plan for eating and chewing inanimate objects. The unsecured medications and administration instruments on the unattended cart in the vicinity of these vulnerable residents were reported to the DON and discussed again with the facility at exit.
Failure to Provide Three Years of Survey Results for Public Review
Penalty
Summary
The facility failed to make the last three years of survey results available for residents, family members, and visitors to review. On 01/07/2026 at 12:18 PM, surveyors reviewed the survey binder located on a table in the front lobby and found that it did not contain the required three years of survey results. During an interview on 01/07/2026 at 12:20 PM, the Nursing Home Administrator stated that he had reviewed the binder and that the facility’s standard was to have only one year of survey results available in the binder, confirming that the facility was not maintaining three years of survey results for public review as required.
Failure to Provide Required Transfer Documentation to Hospital
Penalty
Summary
The facility failed to ensure that required information was sent to the hospital when a resident was transferred. Medical record review showed that the resident was admitted to the facility and later transferred to the hospital, but there was no documentation indicating that the resident's care plan goals or other required information were sent with the resident. Interviews with facility staff, including the DON and hospital liaison, confirmed that the transfer occurred without the necessary paperwork or belongings being provided to the hospital. The hospital social workers also stated that they did not receive any paperwork or a bed hold notice for the resident upon transfer. Further review revealed that the facility's social worker was not involved in the discharge process and did not attempt to find alternative placement for the resident. The DON made the decision to send the resident back to the hospital due to behavioral concerns, but the resident had not been assessed by facility psychiatric services or a physician prior to transfer. The facility hospital liaison communicated with the hospital social worker about the transfer, but did not provide the required documentation. The medical director was not involved in the decision to transfer the resident.
Failure to Provide Timely Discharge Notification and Required Documentation
Penalty
Summary
The facility failed to provide timely notification of discharge to a resident, their representative, and the ombudsman prior to or during the resident's transfer back to the hospital. Medical record review showed no documentation that the required discharge notice or care plan goals were sent to the hospital at the time of transfer. Additionally, there was no evidence that the education provided included a review of the specific information required to be sent to the receiving facility. The resident was transferred due to behavioral issues, including wandering, aggression, and combativeness, but had not been assessed by facility psychiatric services or a facility physician prior to the transfer. Interviews with facility staff and hospital personnel confirmed that the resident was sent back to the hospital without the necessary paperwork, belongings, or a bed hold notice. The DON made the decision to transfer the resident and communicated with the hospital, but the hospital social workers reported not receiving any documentation or notification of appeal rights. The facility hospital liaison and medical director were not directly involved in the decision or the transfer process, and the required notifications and documentation were not provided as mandated.
Failure to Provide Required Documentation and Information During Resident Transfer
Penalty
Summary
The facility failed to provide required documentation and information to a resident or their responsible party prior to transferring the resident to the hospital. Medical record review showed that the resident was admitted to the facility and later transferred to the hospital, but there was no documentation indicating that the resident's care plan goals or other necessary information were sent to the hospital at the time of transfer. Additionally, there was no evidence that the resident or their responsible party received education or review of the specific information required to be sent to the receiving facility. The resident's belongings were also not sent with them, and no bed hold notice was provided. Interviews with facility staff, including the DON, hospital liaison, and medical director, revealed that the decision to transfer the resident was made by the DON due to behavioral concerns, but the resident had not been assessed by a facility physician or psychiatric services prior to transfer. Communication between facility staff and the hospital was limited to verbal notification, and the hospital social workers confirmed that no paperwork or belongings accompanied the resident. The medical director stated they had no input in the transfer decision.
Failure to Provide Bed Hold Notice and Required Transfer Documentation
Penalty
Summary
The facility failed to provide a written bed hold notice to a resident or the resident’s representative prior to the resident’s transfer to the hospital. Medical record review showed no documentation that a bed hold notice was given, nor was there evidence that the required care plan goals or specific transfer information were sent to the hospital at the time of transfer. Interviews with facility staff, including the DON and hospital liaison, confirmed that the resident was transferred due to behavioral issues without being seen by facility psychiatric services or a facility physician, and that no paperwork or belongings accompanied the resident to the hospital. Further interviews with hospital social workers revealed that the hospital did not receive any paperwork or a bed hold notice for the resident upon transfer. The DON acknowledged making the decision to send the resident back to the hospital and confirmed that the resident was not under involuntary discharge. The facility hospital liaison and medical director also confirmed a lack of involvement in the transfer decision and absence of required documentation, resulting in the deficiency.
Failure to Issue Involuntary Discharge Notice and Provide Required Transfer Documentation
Penalty
Summary
The facility failed to issue an involuntary discharge notice to a resident prior to transferring the resident to the hospital, which resulted in the resident not being informed of their legal rights as required for residents in long-term care. The resident, who had been admitted to the facility and later transferred to the hospital due to behaviors such as wandering, aggression, and combativeness, did not have documentation in their medical record indicating that care plan goals or required transfer information were sent to the hospital. Additionally, there was no evidence that the resident was assessed by facility psychiatric services or a facility physician prior to the transfer. Interviews with facility staff, including the DON and hospital liaison, revealed that the decision to send the resident back to the hospital was made by the DON, and the hospital was informed that the resident would not be returning to the facility. The hospital social workers confirmed that no paperwork, belongings, or bed hold notice accompanied the resident upon transfer, and the facility medical director stated they had no input in the decision. The lack of proper documentation and communication regarding the resident's transfer and discharge process led to the deficiency.
Failure to Provide Warm Palatable Food to Residents
Penalty
Summary
The facility staff failed to implement measures to provide warm palatable food to residents, as evidenced by observations and interviews. A complaint was reviewed regarding cold meals, and during an interview, a resident confirmed that their food was sometimes not warm. A test tray was requested during lunch service, and it was found that the food was only slightly warm. The tray lacked a heated base or pellet, which are typically used to maintain food temperature. Additionally, trays were observed being delivered on an open rack without any means to keep the food warm. Further interviews revealed that the facility had insufficient heated pellets and no pellet warmer, which contributed to the issue. The Food Service Manager (FSM) was unaware of how long it had been since heated pellets were used and did not know if a pellet warmer had been ordered. Another test tray during lunch service showed food temperatures well below acceptable levels, with a chicken thigh at 85°F, corn at 98°F, and roasted potatoes at 82°F. These findings were reviewed with the Administrator and Director of Nursing.
Inaccurate MDS Assessments for Side Rails and Functional Status
Penalty
Summary
The facility failed to complete accurate assessments for residents regarding the use of side rails and the functional use of extremities on the quarterly and annual Minimum Data Set (MDS). For Resident #29, the MDS inaccurately coded the use of bed rails as 'not used' across multiple assessments, despite observations and documentation indicating the presence of 1/2 size side rails. Additionally, the MDS inaccurately reported 'no impairment' in the resident's extremities, contradicting nursing documentation and observations. MDS staff acknowledged that information is primarily gathered electronically, with occasional resident observations to confirm electronic records. For Resident #5, a physician order for 1/4 side rails as enablers was documented, yet the MDS inaccurately coded 'not used' for bed rails in several assessments. Similarly, Resident #30 had a family consent for side rails, and observations confirmed their presence, but the MDS inaccurately reported 'not used' for side rails in both annual and quarterly assessments. These discrepancies were discussed with the facility's Director of Nursing, highlighting a pattern of inaccurate MDS assessments related to side rail usage and functional status.
Improper PPE Removal During COVID-19 Outbreak
Penalty
Summary
Facility staff failed to adhere to the Centers for Disease Control's guidelines for removing personal protective equipment (PPE) during a COVID-19 outbreak. Observations revealed that a Geriatric Nursing Assistant (GNA) exited a resident's room wearing a gown, gloves, mask, and shield, and removed the gown and gloves in the hallway instead of inside the room. The GNA did not sanitize his hands after removing the PPE and was observed touching his mask and face shield multiple times. Additionally, the GNA took two food trays into a resident's room simultaneously without changing gloves or gown between residents, which is against infection control practices. Interviews with the Unit Manager and Infection Control Preventionist highlighted a lack of recent PPE training and monitoring of staff compliance with infection control protocols. The Unit Manager acknowledged that staff should have intervened when witnessing improper PPE removal. The Infection Control Preventionist admitted that the last PPE training was conducted three months prior and that no additional training had been provided since the COVID-19 outbreak began. The facility's infection control practices were not aligned with CDC guidelines, as PPE was not consistently removed and discarded before leaving the resident's room.
Cluttered Hallways Compromise Safety in Nursing Units
Penalty
Summary
The facility failed to maintain a safe environment for residents across three of its four nursing units, specifically Units A, B, and D. On Unit A, the hallway was cluttered with various items including wheelchairs, dining room chairs, isolation carts, and even a bedpan with a toilet plunger, leaving less than three feet of maneuverable space. This clutter was due to maintenance activities that required moving furniture from rooms into the hallway. The Unit Manager was unaware of the clutter and had not addressed it, raising concerns about emergency evacuation procedures. On Unit B, the hallway was similarly obstructed with Geri chairs, wheelchairs, medication carts, and breakfast carts, making handrails inaccessible and the hallway crowded. The DON was informed of these issues, which persisted over several days. On Unit D, the hallway was obstructed by reclining chairs, wheelchairs, and dining room chairs, reportedly due to insufficient space in resident rooms for GNAs to provide morning care. Despite being informed of the safety concerns, the clutter remained over multiple days, indicating a systemic issue with maintaining clear and accessible hallways.
Failure to Honor Resident's Advance Directive
Penalty
Summary
The facility failed to adhere to the wishes of a resident as outlined in their advance directive, which specified that all measures should be taken to extend their life, including the use of a gastrostomy tube for nutrition if necessary. Despite this, the MOLST form on file indicated that artificially administered nutrition should not be given, a decision that was influenced by the resident's healthcare agent who opposed the use of a feeding tube. This discrepancy between the advance directive and the MOLST form was not addressed by the facility, leading to a failure in honoring the resident's documented preferences. The resident, who had multiple comorbidities including dementia and dysphagia, experienced repeated hospitalizations due to aspiration pneumonia and dehydration. During these hospitalizations, evaluations indicated a high risk of aspiration and recommended that the resident be NPO pending further assessments. Despite these recommendations and the resident's significant weight loss, the facility did not implement the use of a feeding tube as per the advance directive, due to the healthcare agent's opposition. Interviews with facility staff, including the nurse practitioner and social worker, revealed that there was an assumption that the healthcare agent's decisions overrode the advance directive. The facility's Director of Nursing acknowledged the issue and indicated that they were contacting the healthcare agent for further consultation. However, the failure to align the MOLST with the advance directive and to follow the resident's stated wishes constituted a deficiency in the facility's care practices.
Failure to Timely Report Allegation of Abuse
Penalty
Summary
The facility staff failed to report an allegation of abuse in a timely manner to the State Agency. This deficiency was identified during a complaint survey involving a resident who reported being hit on the cheeks by a male and female staff member. The incident occurred at approximately 3:00 AM and was reported to a Licensed Practical Nurse at 5:30 PM on the same day. However, the facility did not report the allegation to the state agency until 10:30 PM, which was 5 hours after the staff became aware of the incident, instead of the required 2-hour timeframe. The Director of Nursing was informed of these findings during the survey.
Incomplete Investigation of Alleged Resident Abuse
Penalty
Summary
The facility staff failed to thoroughly investigate an allegation of resident abuse involving a resident who was reportedly struck on the hand by a receptionist. The incident was reported by a family member, who also mentioned that the resident's roommate confirmed the event. The facility's investigation included an assessment of the resident and statements from staff, but it was unable to conclude whether the alleged abuse occurred. However, the investigation was incomplete as it did not include interviews with the resident's roommate or other residents who might have had relevant information. During an interview, the Assistant Director of Nursing, who was responsible for the investigation, admitted to not remembering who was interviewed and failed to provide evidence of interviews with the roommate or other residents. Initially, she claimed the roommate was not alert, then changed her statement to say the roommate was alert but not oriented. The investigation file lacked documentation of any resident interviews, highlighting a significant gap in the investigation process. The Director of Nursing was informed of these findings.
Failure to Reassess Residents' Elopement Risk
Penalty
Summary
The facility staff failed to properly assess two residents after significant changes in their conditions, leading to unnecessary monitoring with elopement deterrent devices. Resident #22, who had previously eloped from the facility, was assessed multiple times in 2024 and found to be a low elopement risk. Despite this, the resident continued to be monitored with a wanderguard, a decision attributed to the Director of Nursing and Unit Managers. Interviews with facility staff confirmed that the resident was no longer considered an elopement risk, yet the monitoring device remained in use until it was eventually removed. Similarly, resident #28, who also had a history of elopement, was not reassessed for elopement risk after the initial incident in 2022. The only subsequent assessment in 2023 indicated a low risk, yet the resident continued to be monitored with a wanderguard. Interviews with the Assistant Director of Nursing and the Director of Nursing revealed a lack of clarity on the necessity of the monitoring device, highlighting a failure to reassess the resident's condition appropriately.
Failure to Update G-Tube Care Plan After Change in Status
Penalty
Summary
The facility failed to update a resident's care plan following a change in status, specifically concerning the care of the resident's g-tube. The resident experienced multiple incidents where the g-tube became dislodged, necessitating hospital transfers for replacement on several occasions, including in August 2022, September 2023, July 2024, and October 2024. Despite these incidents, the facility did not update the care plan with new interventions after the dislodgements in July and October 2024, with the last update occurring in September 2023. Interviews with facility staff, including the C/D Unit Manager and the Nurse Educator, confirmed that the responsibility for updating care plans after a change in status lies with the unit managers. However, the C/D Unit Manager did not update the care plan following the incidents in 2024. The Director of Nursing was informed of this failure by the surveyor, highlighting a lapse in the facility's protocol for maintaining current and effective care plans for residents experiencing changes in their medical status.
Failure to Document ADL Care for Dependent Residents
Penalty
Summary
The facility failed to document care provided to residents who were dependent on staff for activities of daily living (ADL), specifically related to bowel and bladder care. For Resident #11, who was coded as requiring extensive assistance and frequently incontinent, there were multiple days where staff did not document the provision of bowel and bladder care. During a specific period, care was documented only twice out of a potential ten times. This lack of documentation was confirmed through interviews with facility staff, who acknowledged that ADL records should not have any blanks. Similarly, for Resident #16, who was dependent on staff for ADL care due to multiple comorbidities and was frequently incontinent, there was a lack of documentation for incontinence care over several shifts. The records showed no documentation of care provided during specific evening and night shifts, and no bowel movements were recorded over 11 shifts. Interviews with staff confirmed that documentation should occur every shift, highlighting a consistent failure in maintaining accurate records of care provided.
Failure to Provide Trauma-Informed Care
Penalty
Summary
The facility failed to develop and implement a process to ensure that residents with a history of trauma received appropriate trauma-informed care. This deficiency was identified during a review of the medical records and interviews, specifically for one resident out of three reviewed for trauma-informed care. The medical record review revealed that the resident was admitted to the facility without an assessment or care plan to ensure trauma-informed care was provided. An interview with a social worker indicated that trauma-informed care assessments were conducted on admission and annually, but at the time of the resident's admission, the facility was not administering these assessments. It was noted that a trauma-informed care assessment was eventually completed, and a care plan was implemented after a complaint investigation.
Failure to Properly Assess and Reassess Bed Rail Use
Penalty
Summary
The facility failed to properly assess and reassess residents for the use of bed rails, leading to deficiencies in care. For Resident #26, there was a lack of documentation regarding attempted interventions or alternatives to bed rails, despite a significant change in the resident's functional status. The resident had a history of falls and injuries, including a fractured nasal bone, yet the facility did not conduct a reassessment after these incidents. Observations showed the resident using half side rails, contrary to the documented use of quarter side rails, and there was no follow-up assessment after the noted decrease in the resident's extremity functionality. For Resident #3, the facility also failed to adhere to the assessment recommendations. Despite an assessment on 3/27/24 advising against the use of bed rails, the resident continued to use them, resulting in a discoloration on the forehead from resting against the rail. Interviews with staff confirmed the continued use of bed rails to prevent falls, but there was no evidence of reassessment or consideration of alternative safety measures following the change in the resident's condition.
Failure to Administer Medications Timely
Penalty
Summary
The facility failed to ensure that residents were free from significant medication errors, as evidenced by the staff's failure to administer medications in accordance with professional standards. This deficiency was identified for one resident who was reviewed for medication administration. The resident's medication administration audit for November 2023 revealed that medications were consistently administered late, outside the 1-hour time frame specified. Specifically, Tylenol, Prednisone, Metoprolol Tartrate, and Finasteride were all administered outside the prescribed time frames on multiple occasions. These findings were confirmed through observation, record review, and interviews, and were discussed with the Director of Nursing.
Failure to Notify Physician of Lab Results
Penalty
Summary
The facility failed to ensure that a physician was notified of lab results for a resident with multiple comorbidities, including uncomplicated diabetes and anemia. The resident was seen by a Nurse Practitioner (NP) who ordered a repeat CBC due to leukocytosis noted in previous labs. However, the lab report from the ordered test was not available in the resident's medical record, and there was no documentation indicating that any physician was notified of the results. The lab report contained several flagged high and low results, which were not addressed until 13 days later when the NP saw the resident again. The Medical Director confirmed that the lab results were reviewed only during the subsequent visit by the NP, and a repeat CBC was ordered at that time. The surveyor noted that the lab report was not on the chart and had to be printed by the Director of Nursing (DON) upon request. This delay in reviewing and addressing the lab results highlights a deficiency in the facility's process for ensuring timely notification and follow-up on lab results.
Lab Report Unavailability on Chart
Penalty
Summary
The facility failed to ensure that an ordered lab report was available on the chart for review, as evidenced during a complaint survey. The medical record review for a resident with multiple comorbidities, including uncomplicated diabetes and anemia, revealed that a repeat CBC was ordered by the Nurse Practitioner (NP) on a specific date. However, the lab report and results for this test were not available on the chart when reviewed by the surveyor. The Director of Nursing (DON) later provided the lab report, confirming that it was not on the chart or available for review at the time it was needed. The Medical Director confirmed that the lab was followed up on 13 days after the initial order when the NP saw the resident again, and a repeat CBC was ordered. The process of notification for labs was discussed, and it was noted that the lab should have been on the chart for review and signed by the physicians/NPs. The deficiency was identified as the lab report not being available on the chart, which delayed the review and follow-up of the flagged results.
Failure to Honor Resident's Food Preferences
Penalty
Summary
The facility staff failed to honor a resident's food preferences, specifically regarding the resident's dislike of shrimp. During a complaint survey, it was found that the resident did not have their food preferences accurately documented in the facility's system. The Food Service Manager (FSM) and the Dietician were responsible for identifying and entering these preferences, but no dislikes were listed for the resident in question. The resident confirmed that they did not like shrimp and had been served it multiple times, despite staff efforts to provide alternatives. Interviews with staff revealed that the Geriatric Nursing Assistant (GNA) was aware of the resident's dislike for shrimp and had contacted the kitchen several times to request an alternative meal. However, the issue persisted, indicating a breakdown in communication and documentation processes. The most recent Quarterly Nutrition Assessment did not identify the resident's food preferences or dislikes, further highlighting the deficiency in the facility's system for managing resident dietary needs.
Failure to Provide QA and Risk Management Records After Resident Burn Incident
Penalty
Summary
The facility administration failed to provide a surveyor with quality assurance (QA) and risk management records following an incident where a resident sustained burns from hot liquid. This deficiency was identified during a complaint survey involving a resident who had been admitted to the facility due to complications from Multiple Sclerosis (MS). The resident required extensive assistance and modified drinkware/utensils due to numbness in their hands and fingers. On a specific date, the resident suffered burns on their thighs and chest after spilling a hot drink, which was given to them by a family member without the facility staff's knowledge and without using the modified drinkware/utensils. Interviews with the Nurse Educator/Former Unit B Manager confirmed the incident and indicated that a risk management investigation and QA activities were completed following the burn incident. However, during interviews with the Director of Nursing (DON) and the Executive Director, it was revealed that the facility could not locate any documentation of a root cause analysis, risk management, or QA activities related to the incident. Both the DON and the Executive Director acknowledged that such analyses and assessments would typically be conducted to determine if the incident posed a potential problem for other residents.
Failure to Maintain QA and Risk Management Records
Penalty
Summary
The facility administration failed to maintain quality assurance (QA) and risk management records for five years after a resident was discharged, as required by professional standards. This deficiency was identified during a complaint survey involving a resident who sustained burns from spilling a hot drink. The incident occurred when a family member provided the resident with hot chocolate without the facility staff's knowledge, and without using the resident's modified drinkware/utensils. The resident, who had Multiple Sclerosis and required extensive assistance due to numbness in hands and fingers, was unable to handle the hot liquid safely, resulting in burns on the thighs and chest. Interviews with the Nurse Educator/Former Unit B Manager, the Director of Nursing (DON), and the Executive Director confirmed that a risk management investigation and QA activities were conducted following the incident. However, the facility was unable to locate the root cause analysis or any related documentation for the incident. Both the DON and the Executive Director acknowledged that such analyses and assessments would have been conducted to determine if the incident posed a potential problem for other residents, but the absence of these records indicates a failure to maintain necessary documentation as per regulatory requirements.
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Facility staff did not ensure that 2nd floor residents who could not use stairs were able to receive visitors when the only elevator was out of service for an extended period. Complaints indicated that some family members, who were themselves unable to ambulate stairs, could not visit their relatives on the 2nd floor during this time. The emergency plan directed non-ambulatory 2nd floor residents to remain on that floor unless there was an emergency and did not address how visitation would be maintained when the elevator was inoperable. The Administrator reported that visitors could use the stairs and that an emergency chair system could be used to move residents, but also stated that the chair system was not used for visitation and was unaware of any complaints, despite two having been filed.
Facility staff did not complete required quarterly smoking safety assessments for several residents identified as smokers, including some who had not been reassessed for many months and one who had never been assessed during their stay. This issue was discovered during a complaint survey after the facility’s only elevator was out of service for an extended period, affecting a group of residents on an upper floor who needed to reach a designated smoking area on a lower floor. Review of records and staff interviews, including with the DON and a unit manager, confirmed that the facility’s own practice of quarterly smoking safety assessments for smokers was not followed for half of the affected residents.
Facility staff failed to accurately code multiple MDS assessments for several residents, leading to discrepancies between MDS entries and MARs for pain management, falls, and high-risk drug classes. In several cases, scheduled pain management was coded as provided when MARs did not show daily pain medications, often because an LPN counted low-dose Aspirin ordered for cardiovascular prophylaxis or heart failure as pain medication, contrary to RAI guidance. One resident’s falls were underreported on the MDS despite two documented falls, and daily use of a topical analgesic and an antiplatelet (Aspirin) was not correctly captured. Other residents had MDS entries indicating use of hypnotic or antianxiety medications when MARs showed none, while actual antidepressant and hypoglycemic medications administered daily were omitted from Section N0415. These errors were confirmed by the involved LPNs during surveyor interviews.
Staff failed to conduct complete investigations into two residents’ abuse allegations. In one case, a resident reported that an employee poked their face and made an obscene gesture, but the investigation lacked a statement from the corporate representative who was first notified of the allegation. In another case, a resident reported that someone in blue clothing put a hand by their face and over their mouth, with a specific GNA identified as the alleged perpetrator; however, the investigation did not include statements from two GNAs who were on duty on the unit at the time of the alleged incident, despite leadership having the opportunity to ensure all relevant documents were present.
Staff failed to create person-centered care plans for two residents, one with mobility limitations and one receiving peritoneal dialysis. For the resident with mobility issues, the care plan did not address the resident’s refusal to use a Hoyer lift and preference for pivot transfers, despite therapy prohibiting pivot transfers and staff awareness of the resident’s resistance. For the resident on peritoneal dialysis, the care plan did not specify that the treatment was peritoneal dialysis, nor did it include the treatment schedule or cycle time frames; an LPN Unit Manager acknowledged using a generalized renal care plan without incorporating the specific dialysis prescription.
A resident’s medical record lacked documentation confirming that scheduled showers or bed baths were provided on multiple dates, and there was also no record of any refusals of care on those days. The DON and an LPN unit manager reported that showers were scheduled on specific shifts and that completed showers and refusals should be documented on shower/skin sheets and in the care plan, but the surveyor found gaps where no such entries existed. This resulted in incomplete ADL documentation and failure to maintain medical records according to accepted professional standards.
A resident with multiple fractures and chronic pain was receiving an opioid-based pain regimen, including PRN hydromorphone. The resident was later found unresponsive and "out of it" by an LPN, who located an order for Narcan and administered it, with the resident responding to the medication. A physician note documented an opioid overdose treated with Narcan. Review of the medical record showed no documentation that the resident’s representative was notified of this significant change in condition and emergency intervention, and staff interviews confirmed that notification likely did not occur, despite the DON’s expectation that the responsible party should have been informed.
Staff failed to follow updated wound care orders and to document an opioid overdose event and Narcan use for two residents. One resident with venous and arterial lower extremity wounds did not receive the prescribed change from oil emulsion to daily skin prep on one foot wound, and did not receive ordered skin prep on a new plantar wound for several days after the wound physician revised the treatment plan. Another resident with multiple fractures and chronic pain, receiving multiple opioid and adjunct analgesics, reportedly experienced an opioid overdose; an LPN found the resident unresponsive, located an existing Narcan order, administered Narcan, and observed the resident return to baseline, but did not complete or document a change-in-condition assessment, vital signs, or the Narcan administration in the medical record.
Surveyors substantiated a deficiency when disinfectant wipes, labeled for storage in areas inaccessible to children and not for personal cleansing, were observed sitting openly on a wire shelf in the dining room of a locked dementia unit while cognitively impaired residents waited for breakfast. A GNA and an LPN present on the unit stated that staff used the wipes to clean tables and that residents were never left alone in the dining room and had not been seen using the wipes. The ICP reported being unaware that the wipes’ placement in the dining room was a concern, and the NHA and DON stated they had not previously been informed about the issue, though the DON acknowledged understanding the concern.
A resident’s medical record showed multiple instances where Hydromorphone, a controlled narcotic, was documented as signed out and given on the Controlled Drug Administration Record but was not documented on the MAR on the same dates and times. An LPN reported signing only the narcotic sheet and not the MAR, while the DON acknowledged awareness that nurses were signing the narcotic sheet without completing the MAR, and a unit manager stated they were unaware this was occurring and that both records should be completed. The NHA and DON agreed with the surveyor’s findings after the issue was identified.
Failure to Ensure Visitation Rights During Elevator Outage
Penalty
Summary
Facility staff failed to ensure that residents residing on the 2nd floor who could not safely ambulate using stairs were able to exercise their right to have visitors when the facility’s only elevator malfunctioned. Complaint reviews showed that family members were unable to visit their relatives on the 2nd floor when the elevator was inoperative, and these family members themselves were unable to use the stairs. An incident report documented that the facility’s only elevator was malfunctioning for an extended period, from 3/28/26 to 4/23/26. During this time, residents who could not use the stairs remained on the 2nd floor, and some of their family members could not access them due to the lack of elevator service. Review of the facility’s emergency plan revealed that it instructed that 2nd floor residents who could not safely use the stairs should remain on the 2nd floor unless there was an emergency, and it did not include any provisions for maintaining visitation when the elevator was inoperable. In an interview, the Administrator stated that visitors could use the stairs to visit 2nd floor residents and that residents could be transported using an emergency chair system to meet visitors who could not use the stairs. However, the Administrator acknowledged that the emergency chair system was not used for visitation purposes during the elevator outage and reported being unaware of any complaints about the inoperative elevator, despite two complaints having been received by OHCQ. No additional documentation was provided to show a plan to support visitation for 2nd floor residents during the elevator malfunction.
Failure to Complete Required Quarterly Smoking Safety Assessments
Penalty
Summary
Facility staff failed to update smoking safety assessments at least once every three months for multiple residents identified as smokers. During a complaint survey focused on smoking safety, surveyors reviewed an incident involving the facility’s only elevator being inoperative for nearly a month, which affected residents who lived on the 2nd floor and needed to access the 1st-floor smoking area. The facility’s investigation identified a group of 10 residents on the 2nd floor who smoked and required additional accommodations to safely ambulate to the designated smoking area. Review of these residents’ medical records showed that 5 of the 10 did not receive quarterly smoking safety assessments as required by the facility’s practice. Specifically, four residents had not received a smoking assessment since May 2025, and one resident had no documented smoking assessment at any time during their stay. During interviews, the Unit Manager stated that residents identified as smokers are to be assessed quarterly for smoking safety. When the surveyor pointed out the missing assessments, the DON reviewed the records and confirmed that these residents had not received the required quarterly smoking assessments. This lack of timely reassessment occurred in the context of an extended elevator outage that necessitated special consideration for safe smoking access for residents residing on the 2nd floor.
Inaccurate MDS Coding for Pain Management, Falls, and High-Risk Drug Classes
Penalty
Summary
Facility staff failed to ensure that Minimum Data Set (MDS) assessments were accurately coded for multiple residents, based on medical record review and staff interviews. For one resident with cerebrovascular disease, an MDS with an Assessment Reference Date (ARD) of 3/2/26 coded Section J0100A (scheduled pain management) as "yes," but the March Medication Administration Record (MAR) did not show daily pain medication administration. An LPN stated she coded it that way because the resident received Aspirin 81 mg daily, although the physician’s order showed the Aspirin was prescribed as prophylaxis for cardiovascular events, and the RAI Manual specifies that medications not primarily intended for pain relief should not be coded as pain management. Another resident with cerebral infarction, congestive heart failure, and vascular dementia had two documented falls in progress notes between the prior assessment and the ARD of 2/4/26, but Section J1900 (number of falls since admission or prior assessment) captured only one fall. The same MDS coded Section J0100A (scheduled pain management) as "no" despite the February MAR documenting daily use of Diclofenac topical gel for pain. The MAR also showed daily Aspirin 81 mg for coronary artery disease, but Section N0415 (high-risk drug classes) did not capture the use of an antiplatelet medication. The responsible LPN confirmed missing the second fall and the Aspirin coding error. Additional residents had similar discrepancies: one resident’s MDS repeatedly coded use of hypnotic medications in Section N0415 when MARs showed no hypnotics administered, and failed to capture an antidepressant (Sertraline) that was given; the LPN reported coding Clonazepam as a hypnotic based on dual use, though reference guidelines did not classify it as such. Further inaccuracies were identified for other residents in pain management and high-risk drug class coding. One resident’s MDS with an ARD of 1/8/26 coded receipt of PRN pain medication in Section J0100A, but the January MAR showed no PRN pain medications given; a later MDS for the same resident coded use of an antianxiety medication in Section N0415, while the April MAR showed no such medication administered. Another resident with traumatic subarachnoid hemorrhage, type 2 diabetes with neuropathy, atrial fibrillation, and atherosclerotic heart disease had an MDS with an ARD of 2/3/26 that coded scheduled pain medication as "yes" and PRN pain medication as "no," although the MAR showed intermittent PRN Tylenol for pain and no daily pain medication, and also documented daily Aspirin 81 mg for heart failure and daily Rybelus for diabetes; the MDS failed to capture PRN pain use, incorrectly coded daily pain medication, and did not code hypoglycemic medication in Section N0415. Another resident with a history of stroke and right-sided hemiplegia/hemiparesis had two MDS assessments in February coded as receiving scheduled pain medication, but the February MAR did not show daily pain medication; the LPN reported coding based on daily prophylactic Aspirin 81 mg, which was not ordered for pain.
Incomplete Investigations of Resident Abuse Allegations
Penalty
Summary
Facility staff failed to complete thorough investigations of two separate resident allegations that were reported to the state agency. For the first incident, a resident alleged that on a specific date and time an employee poked two fingers into their face and showed them their middle finger. The five-day follow-up documented the allegation, but the investigation file did not clearly identify who was the first point of contact for the report. During interview, the Administrator stated that a corporate representative was initially made aware of the alleged incident, but there was no statement from this corporate representative included in the investigation file. The Administrator described their usual investigation process as interviewing involved parties, identifying and interviewing witnesses, reviewing staffing for the date of the alleged incident, and interviewing the resident’s roommate and other nearby residents if there were no direct witnesses. In the second incident, a resident reported that during a specific shift someone wearing blue put a hand by their face and over their mouth, and a particular GNA was identified as the alleged perpetrator. Review of the staffing sheet for the time of the alleged incident showed that two GNAs were working on the unit where the incident was reported to have occurred. However, the investigation file contained no statements or interviews from these two GNAs. Prior to the surveyor’s review of the investigation, the DON and a regional nurse were given the opportunity to review the investigation to ensure all necessary documents were available, yet the statements from the two GNAs remained absent. These omissions demonstrated that the facility did not conduct complete investigations into the reported allegations.
Failure to Develop Person-Centered Care Plans for Mobility and Peritoneal Dialysis Needs
Penalty
Summary
Facility staff failed to develop and implement person-centered care plans that addressed all identified needs for two residents, one with mobility limitations and one receiving peritoneal dialysis. For the resident with mobility limitations, the care plan included interventions for resistance to care and adjustment issues, but did not address the resident’s specific resistance to use of a Hoyer lift and the resident’s insistence on pivot transfers from bed to wheelchair. The Unit Manager confirmed that the resident was resistant to care, did not like the Hoyer lift, and preferred pivot transfers, but also stated that physical therapy had prohibited pivot transfers. Despite this known conflict between the resident’s preferences and therapy restrictions, the care plan lacked individualized interventions related to the resident’s resistance to the Hoyer lift and continued request for pivot transfers. For the resident receiving peritoneal dialysis, review of the electronic health record showed an order for peritoneal dialysis, but the resident’s care plans did not include a person-centered care plan specific to this treatment. The existing dialysis care plan did not specify the type of dialysis treatment being provided, did not document when the resident was scheduled to receive the treatment, and did not include time frames for the dialysis cycles. During an interview, the LPN Unit Manager stated that they do not place the dialysis prescription details into the care plan and instead use a generalized renal care plan by selecting standard items, confirming that the care plan was not individualized to the resident’s ordered peritoneal dialysis regimen.
Failure to Document Resident Showers and Refusals
Penalty
Summary
Facility staff failed to maintain complete and accurate documentation of bathing care for a resident, specifically regarding showers and refusals of showers. During a complaint survey, the surveyor requested verification that Resident #5 was receiving scheduled showers. The DON stated that the resident was scheduled for showers on the 3 pm–11 pm shift on Tuesdays and Fridays, and provided shower sheets for several dates in October and early November. However, there was no documentation to verify that the resident received a shower or bed bath on 10/17/25, 10/21/25, and 10/24/25. The DON explained that when a resident receives a shower it is documented on a skin sheet, and that refusals of showers should be documented both in the plan of care and on the shower sheet. Despite this, the surveyor did not receive any documentation indicating that the resident either received bathing care or refused showers on the missing dates. This lack of documentation showed that the facility did not safeguard resident-identifiable information and maintain medical records in accordance with accepted professional standards, as there was no record confirming whether the resident’s scheduled showers or refusals occurred on the identified dates.
Failure to Notify Responsible Party After Narcan Administration for Suspected Opioid Overdose
Penalty
Summary
The deficiency involves the facility’s failure to notify a resident’s responsible party when there was a significant change in the resident’s medical status requiring emergency medication. A complaint alleged that there was no communication with the responsible party when Narcan (naloxone) was administered to a resident for an alleged opioid overdose. Medical record review showed the resident was admitted in March 2026 with multiple fractures, including a nondisplaced zone 1 sacral fracture, a nondisplaced fracture of the posterior column of the right acetabulum, a fracture of the right pubis, and other chronic pain. The resident’s pain regimen included multiple opioids and other pain medications, including Hydromorphone 6 mg every 4 hours PRN, Hydromorphone 4 mg every 4 hours PRN, Tylenol, Lidocaine cream, Methocarbamol, Celebrex, and Gabapentin. A physician’s note dated 4/8/26 documented that the resident reportedly had an opioid overdose earlier that morning and responded well to Narcan administration by nursing, with the note listing chronic pain and opioid overdose status post Narcan. Further review of the resident’s medical record did not show any documentation that the resident’s representative was notified of this overdose event and Narcan administration. During interviews, an agency LPN stated that the resident was “out of it and not responding” during rounds, prompting the LPN to check for and then administer Narcan, after which the resident responded. Another LPN reported that Narcan was given because the resident appeared to be having an overdose and that the physician saw the resident afterward, but stated, “I don’t think anyone was notified, but should have been.” The DON also stated that she would have expected the responsible party to be notified. These findings confirmed that the facility failed to notify the resident’s responsible party of a significant change in condition and emergency treatment.
Failure to Follow Wound Care Orders and Document Narcan Administration
Penalty
Summary
Facility staff failed to provide treatment and care in accordance with professional standards and physician orders for two residents. For one resident admitted after hospitalization with acute systolic heart failure and peripheral edema, a wound physician initially ordered daily oil emulsion dressings for venous wounds on the right shin, left medial foot, and left second toe. At a follow-up assessment, the wound physician changed the treatment for the left medial foot from oil emulsion to daily skin prep and ordered daily skin prep for a newly identified arterial wound on the left plantar foot. Review of the March 2026 medication and treatment administration records showed staff did not discontinue the oil emulsion or initiate the ordered skin prep to the left medial foot, and did not administer skin prep to the left plantar foot wound from the date of the new orders until the resident was sent to the hospital. The DON confirmed that treatments were not administered per the updated wound care orders during this period. For another resident admitted with multiple pelvic and sacral fractures and chronic pain, the record showed extensive opioid and adjunct pain medication orders, and a physician note documented that the resident reportedly experienced an opioid overdose and responded well to Narcan administration by nursing. However, the medical record contained no nursing assessment of the resident at the time of the event, no documentation of the resident’s condition or vital signs, and no record of Narcan administration or the resident’s response afterward. An agency LPN reported finding the resident unresponsive or "out of it" during rounds, knowing the resident was on significant pain medications, and, after checking for an existing order, administering Narcan, after which the resident returned to baseline. The LPN acknowledged not completing or documenting a change-in-condition assessment, and both the DON and unit manager stated they would have expected an assessment and vital signs to be documented in this situation.
Disinfectant Wipes Left Accessible in Dementia Unit Dining Room
Penalty
Summary
The deficiency involves the facility’s failure to keep the environment free from accident hazards on one locked dementia unit. During a complaint survey regarding unsecured cleaning supplies and the potential for residents to use cleaning wipes for personal use, a surveyor observed disinfectant wipes stored openly on a wire shelf in the dining room of the Seagull Unit, a locked dementia unit. The product labeling on the container directed that it be stored in areas inaccessible to children and specifically stated it was not to be used as a diaper wipe or for personal cleansing and that it was not a baby wipe. At the time of the observation, residents with cognitive impairment were present in the dining room awaiting breakfast. A GNA was in the dining room with the residents during the observation, and the unit manager, an LPN, accompanied the surveyor. The surveyor expressed concern about the wipes being accessible in a public area where cognitively impaired residents were present. The LPN reported she had never seen residents use or attempt to use the wipes and stated staff used them to wipe down tables before and after meals. The GNA stated she was always present when residents were in the dining room, that residents were never left alone there, and that she had never seen a resident use a wipe. The Infection Control Nurse stated she was not aware the disinfectant wipes in the dining room were a concern because no residents had gone near them and confirmed they were intended for staff use to clean tables. The NHA and DON reported they had not been made aware of the concern with the wipes, though the DON stated she understood the concern.
Incomplete Documentation of Narcotic Administration on MAR
Penalty
Summary
The deficiency involves the facility’s failure to maintain complete and accurate medical records in accordance with accepted professional standards for one resident. Review of the resident’s April 2026 Medication Administration Record (MAR) and the Controlled Drug Administration Record showed multiple discrepancies for Hydromorphone, a narcotic medication. On several specific dates in April, the Controlled Drug Administration Record documented that Hydromorphone doses were signed out and given by licensed nursing staff at various times, but the corresponding MAR entries for those same dates and times were left blank, indicating no documentation of administration on the MAR. During interviews, an LPN stated that they sign out the medication on the narcotic sheet but do not document it on the MAR. The DON acknowledged awareness that nurses were signing off on the narcotic sheet but not on the MAR, and a unit manager reported not being aware that nurses were failing to sign the MAR when also signing the narcotic sheet, stating that documentation should occur on both records. The NHA and DON later stated they were not aware of the concern until it was identified by the surveyor and agreed with the findings. These observations and interviews demonstrate that the facility did not ensure that all medication administrations were consistently and accurately documented on the MAR for this resident.
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