Denton Nursing And Rehab
Inspection history, citations, penalties and survey trends for this long-term care facility in Denton, Maryland.
- Location
- 420 Colonial Drive, Denton, Maryland 21629
- CMS Provider Number
- 215149
- Inspections on file
- 22
- Latest survey
- March 16, 2026
- Citations (last 12 mo.)
- 15
Citation history
Health deficiencies cited at Denton Nursing And Rehab during CMS and state inspections, most recent first.
A resident alleged that no staff provided care during an overnight (11p–7a) shift, and the facility’s follow-up investigation confirmed that the assigned GNA did not enter the room to provide care. Review of GNA task documentation for that shift showed no entries for bathing, bed mobility, oral hygiene, toileting, barrier cream after incontinence care, bowel and urinary incontinence care, or use of foam ankle boots in bed as tolerated. The DON stated that all care, including refusals, must be documented and that blank spaces indicate a lack of support that care was completed.
A resident reported to an Emergency Department that night-shift staff frequently left them sitting in urine and ignored call bells, prompting the resident to call 911. The ED note containing this neglect allegation was uploaded into the facility’s records, but the Administrator was unaware of the complaint and no investigation was identified. The DON stated the admitting nurse should have reviewed the hospital discharge paperwork and noted the complaint. In a separate facility-reported incident, the same resident alleged being left in soiled conditions for an extended period; however, only the initial report to the state was available, and the DON and Administrator could not locate the required investigation file or supporting documentation.
Surveyors identified that quarterly care plan meetings were not consistently held for a resident, with documented gaps where required meetings were missed despite the expectation for regular interdisciplinary review. In addition, a resident with documented ongoing inappropriate sexual behavior had a care plan intervention for 1:1 supervision that was not being implemented; the resident was observed without 1:1 supervision, an RN reported the behaviors occurred daily and that 1:1 supervision had not been provided for an extended period, and the DON confirmed the absence of the ordered supervision.
Surveyors identified that nursing staff failed to provide quality care when an LPN administered medications to residents without explaining the medications or offering information, and an RN administered medications without drawing the privacy curtain in a shared room, allowing a roommate to observe. Policy required privacy during medication administration, and the DON stated residents should be offered information about their medications to support choice and refusal. Surveyors also found urinals filled with urine left on a nightstand and a bed, and a trash can under a sink partially filled with coffee-colored water and trash for several days, despite the Lead GNA stating that GNAs are responsible for emptying urinals every two hours and as needed.
Two residents receiving Morphine Sulfate for pain management had discrepancies between the number of doses signed out and those documented as administered on the MAR, with several doses lacking documentation and no corresponding nursing assessments of effectiveness. Nursing staff were unaware of the missing documentation, and the facility's pain management policy requirements for documentation and monitoring were not met.
A dependent resident with quadriplegia and an above-the-knee amputation, who required two-person assistance for Hoyer lift transfers, was transferred by a single GNA. During the transfer, the Hoyer lift struck the bed, causing the resident to slip through the sling and fall, resulting in bilateral sacral fractures and an L2 compression fracture. Staff interviews and documentation revealed that short staffing contributed to the failure to follow the care plan, with GNAs sometimes performing Hoyer transfers alone.
A resident with quadriplegia suffered physical injury and worsened PTSD after a ceiling collapsed in their room when a pipe burst due to inadequate attic temperature control and lack of pipe insulation. The resident was trapped under water, insulation, and drywall until staff arrived, resulting in ongoing pain, a mild disc bulge, and increased psychological distress.
A resident with hemiplegia was found in bed without access to their call light, which was on the floor instead of within reach as required by their care plan. The resident stated that a staff member had removed the call bell due to frequent use, despite care plan instructions to keep it accessible and encourage its use for assistance.
Staff did not promptly notify a physician when a resident experienced a significant decline, resulting in delayed assessment and intervention. In a separate case, multiple medication changes for another resident were made without notifying the resident's representative, as confirmed by medical record review and facility leadership.
A resident with severe cognitive impairment was found with a swollen, bruised eye, and the facility did not report the injury of unknown origin to OHCQ within the required 2-hour window. The cause of the injury was unclear at the time it was discovered, and the delay in reporting was confirmed by facility leadership.
A resident alleged theft of money, a gift card, and gift certificates from their room. The facility's investigation included statements from GNAs, the previous DON, and leadership staff, but failed to obtain input from nurses, prior shift staff, housekeeping, maintenance, or dietary staff who had access to the room. The NHA and ADON acknowledged that more staff should have been interviewed.
Facility staff did not hold required quarterly care plan meetings for a resident, despite completing quarterly MDS assessments. The last documented care plan meeting was several months prior, and both staff and the resident confirmed that no meetings had occurred during the expected periods.
A resident with cardiac conditions received Metoprolol Tartrate on multiple occasions when either blood pressure or heart rate was below the physician-ordered parameters. Staff misunderstood the order, administering the medication when only one parameter was out of range, rather than holding it as directed. The physician later clarified the order should have been followed for either parameter.
A resident with a history of stroke and hemiplegia had incomplete and inaccurate medical records, including missing diagnoses and lack of documentation of care plan meetings and discussions about loss of nursing home level of care. Key information was not included in the official record, and some documentation was not properly uploaded.
The facility did not follow its plan of correction for three previously identified deficiencies, with one deficiency remaining out of compliance. Although monthly QA meetings were held, the QA team did not specifically discuss the citations or progress of the corrective actions, contrary to what was outlined in the plan. Ongoing concerns were also noted regarding a qualified social worker.
The facility failed to maintain sufficient staffing to meet the needs of its 81 residents, leading to issues such as delayed assistance with ADLs and call light responses. Residents and staff reported concerns about inadequate staffing, with some residents missing scheduled care and staff struggling to complete assignments. The DON and Regional Director acknowledged the staffing shortages and efforts to incentivize staff to cover shifts.
The facility did not complete annual performance reviews for five GNAs, potentially affecting the care of 80 residents. Personnel files showed that GNAs hired between September 2021 and March 2023 missed evaluations. Interviews with HR, administration, and nursing leadership confirmed the oversight, attributed to nurse leadership turnover.
The facility failed to serve food at a palatable and appetizing temperature, affecting all residents consuming meals from the kitchen. Residents with intact cognition reported dissatisfaction with the taste and temperature of meals, including unappetizing eggs and cold, tasteless food. Observations confirmed these issues, with meals lacking flavor and desserts being dry, contrary to the facility's policy on providing a nourishing and well-balanced diet.
The facility failed to maintain sanitary conditions in the kitchen, affecting food preparation and serving for all residents. Observations revealed unsanitary conditions around the ice machine and kitchen equipment, with a lack of adherence to cleaning schedules. Interviews indicated that maintenance tasks were not completed as required, and a dietary aide was found not wearing a facial hair restraint, violating FDA Food Code requirements.
The facility failed to maintain a sanitary garbage and refuse area, with disposable gloves and a trash bag with a hole found around dumpsters. The Dietary Manager, a housekeeper, and the Administrator had differing views on who was responsible for maintaining the area. The facility's policy required the area to be kept clean to minimize debris and pest attractions.
The facility failed to use appropriate PPE during catheter care for residents, with staff unaware of Enhanced Barrier Precautions (EBP) requirements. A resident with an indwelling urinary catheter and another with a drug-resistant UTI did not receive care with the necessary PPE, despite orders for EBP. Additionally, the facility lacked a water management program, increasing the risk of Legionella infection.
The facility did not provide the required 12 hours of in-service training for five GNAs, as mandated by their policy. Personnel files showed that GNAs with start dates from September 2021 to March 2023 had not completed the necessary training. Interviews with facility leadership confirmed the deficiency, which could affect the safety and care of 80 residents.
The facility failed to maintain a sanitary and comfortable environment, with black mold and structural damages observed in multiple rooms. Staff and residents reported that maintenance issues were not addressed, and the Regional Director of Maintenance confirmed the need for significant repairs.
The facility failed to implement its abuse policy for allegations involving a resident who reported rough care and threats by a GNA. The investigation was delayed, and the abuse was not reported immediately. Additionally, the facility could not account for missing narcotics involving two residents, with an incomplete investigation lacking resident and staff statements.
The facility failed to investigate allegations of abuse and missing narcotics for several residents. One resident reported rough treatment and threats from a GNA, but the investigation was delayed, and the GNA was not immediately removed from care. Missing narcotics for two residents were not thoroughly investigated, and a new injury for another resident was not investigated, leaving the cause undetermined.
A facility failed to notify a resident's responsible party when a new treatment was started for a Stage 3 pressure ulcer. The resident was readmitted with a pressure ulcer, and treatment orders were documented, but there was no record of notification to the responsible party. This was confirmed by the DON.
A resident was readmitted to the facility with a stage 3 pressure ulcer on the coccyx. Despite treatment orders being placed, the wound dressing was not started until several days later, resulting in a gap in care. This deficiency was confirmed by the DON.
The facility did not have a Registered Nurse (RN) on duty for at least 8 consecutive hours a day, 7 days a week, on four specific days. This deficiency was confirmed through staffing documentation and an interview with the Regional Director of Labor Management. Complaints from residents, staff, and families about low staffing were also reviewed during the survey.
The facility failed to maintain complete and accurate medical records for three residents, as care plan meetings were not included in their records despite being documented on paper. The Social Services Assistant admitted to keeping evidence of these meetings in her office and uploading them when possible, which was confirmed by the DON.
The facility failed to treat two residents with dignity and respect. A resident with cognitive intactness reported that staff did not knock or introduce themselves before entering her room, and a CMA was observed rolling her eyes at the resident. Another resident with severe cognitive impairment was left uncovered and exposed during care, despite expressing that she was cold. The Interim DON confirmed that staff should knock before entering rooms and cover residents during care.
A resident with morbid obesity was not provided with the appropriate size of incontinent briefs, despite her repeated requests and visible discomfort. The facility staff measured her for a large size but supplied a smaller size, leading to pain and difficulty in sitting. Staff interviews confirmed the resident's need for a larger size, but the facility did not address the issue adequately.
A resident's grievance about another resident's behavior was not promptly resolved due to a lack of follow-up and communication among staff. The grievance, documented during a resident council meeting, was forgotten after being handed to a former DON, leading to unresolved issues and potential for further grievances.
A facility failed to transmit a Death in Facility MDS assessment for a resident within the required timeframe. Although the assessment was completed on time, the MDS Coordinator sent it to corporate offices for batch transmission, and the exact submission date was unknown. The CMS manual requires transmission within 14 days of the MDS death date, which was not met.
A facility failed to create a care plan for a resident with an indwelling urinary catheter, leading to its use for seven months without a discontinuation plan. The resident, cognitively intact, was unsure of the catheter's purpose. Initially ordered for one-day use due to urinary retention, the catheter remained due to a lack of follow-up and delayed urology consultation. The medical record lacked a care plan, and the DON confirmed this oversight.
A facility failed to integrate hospice care into a resident's care plan and did not include all necessary interdisciplinary team members in care planning meetings. Additionally, the facility missed quarterly care plan meetings for several residents, indicating a lack of coordination and adherence to care planning protocols.
A resident with dysphagia experienced significant weight loss, prompting a physician's order for weekly weights. However, the facility failed to document weights on two specified dates, as confirmed by the Interim DON.
The facility failed to provide necessary grooming services for two residents, resulting in inadequate ADL care. One resident, with morbid obesity, was not offered showers due to size limitations of the shower equipment, while another resident, with stroke-related paralysis, did not receive scheduled showers due to equipment issues and staffing shortages. Both residents were dependent on staff for bathing, and the facility's lack of communication and maintenance follow-up contributed to the deficiency.
A facility failed to ensure the safety of a designated smoking area for a resident, as required by its policy. Observations revealed no protective cover over the area and a metal container for ashtrays filled with trash. The resident, who was cognitively intact and smoked regularly, had not experienced any accidents, but the conditions were acknowledged by staff as non-compliant and potentially unsafe.
A facility failed to manage urinary catheter care for a resident, leading to multiple UTIs and delayed urology consults. The resident's catheter was not removed promptly despite physician orders, and a voiding trial was not conducted. Additionally, another resident received improper catheter care, as staff did not follow the facility's policy. These deficiencies were confirmed by the facility's Interim DON.
A facility failed to limit the use of PRN psychotropic medication for a resident with anxiety disorder and moderately impaired cognition. Lorazepam was prescribed beyond the 14-day limit without documented rationale, and the facility lacked a policy addressing this limitation. Despite a recommendation from the consultant pharmacy to discontinue the medication, it was overlooked, leading to a deficiency in the resident's medication regimen.
A resident with an indwelling urinary catheter experienced a seven-month delay in obtaining a urology consult, despite a physician's order. The catheter was initially placed due to urinary retention and possible neurogenic bladder. The delay resulted in continued catheter use without appropriate indication, leading to recurrent urinary tract infections. The resident, who was cognitively intact, was unsure of the catheter's purpose and had requested a delay in its removal. The catheter was eventually removed following a physician's order.
A resident reported her electric bed was broken, and inspection revealed the headboard and footboard were not securely attached, creating a safety hazard. The facility's maintenance system required monthly inspections, which had not been completed in over six months. The resident's cognition was intact, and the deficiency was confirmed by the Regional Director of Maintenance and the Administrator.
A resident with dementia was punched by another resident known for aggression, but the incident was not reported or investigated by the facility. Staff interviews revealed a lack of awareness and communication, and the facility's abuse reporting policy was not followed.
The facility failed to timely report allegations of abuse, neglect, and theft for several residents, increasing the risk of continued harm. A resident reported physical and verbal abuse by a GNA, but the DON delayed reporting to the state agency. Another resident with dementia alleged sexual abuse, but the police were not contacted. Unexplained bruising on a resident was reported late, and a resident's hand fracture was not investigated as a new injury. Additionally, a resident's missing bank card was not reported within the required timeframe.
Failure to Provide and Document Required Overnight Care Resulting in Resident Neglect
Penalty
Summary
The deficiency involves a failure to ensure that a resident remained free from neglect when required care was not provided during an overnight shift. A facility-reported incident submitted to the Office of Health Care Quality documented an allegation by Resident #75 that no staff provided care during the 11 p.m. to 7 a.m. shift on a specific date. A follow-up investigation form in the facility’s incident folder confirmed that the assigned Geriatric Nursing Assistant (GNA) did not enter the resident’s room to provide care during that shift. Review of the GNA task documentation for that night showed no entries for multiple care tasks, including bathing, bed mobility, oral hygiene, toileting, application of barrier cream after incontinence care, bowel elimination, urinary incontinence care, or use of foam ankle boots in bed as tolerated. During an interview, the Director of Nursing stated that care provided during a shift must be documented by the GNA, that there should not be blank spaces on the GNA task documentation, and that refusals and all care-related activities should be recorded. She acknowledged that if a task was not documented, there was no support to show it was completed, and confirmed that if care had been provided to the resident on that night shift, it should have been documented and not left blank.
Failure to Investigate and Document Resident Neglect Allegations
Penalty
Summary
The deficiency involves the facility’s failure to thoroughly investigate and respond to allegations of neglect made by a resident. Medical record review showed that a hospital consult report, uploaded into the resident’s chart on 12/13/2025, documented that the resident went to the Emergency Department and reported being constantly neglected by the 11 p.m. to 7 a.m. shift, frequently sitting in urine, and having call bells purposely ignored, leading the resident to call 911 for help. The Administrator stated he was not aware of this complaint or of any investigation related to it, despite confirming that such reports of neglect should be brought to his attention and investigated, and that the Emergency Department note had been uploaded by facility staff. The DON reported that the admitting nurse should have reviewed the discharge paperwork when the resident returned from the hospital and should have noted the resident’s complaint of neglect. A second deficiency component was identified through review of Facility Reported Incident #2690114, in which the same resident had reported an allegation of neglect and being left in soiled conditions for an extended period. The DON could only provide the initial incident report submitted to the Office of Health Care Quality and was unable to locate any additional documentation or an investigation file for this incident. She stated that a file containing interviews and evidence is normally maintained for each Facility Reported Incident and confirmed that such a folder should exist for this resident but could not be found. The Administrator similarly confirmed that investigation notes and interviews are kept in a folder in a file cabinet and that the previous DON had handled the investigation for this incident, but the investigation file could not be located.
Missed Care Plan Reviews and Failure to Implement 1:1 Supervision Intervention
Penalty
Summary
The facility failed to hold required quarterly care plan meetings for one resident and failed to implement a care plan intervention for another resident. For Resident #75, interview on 03/10/2026 revealed the resident denied having regular care plan meetings. Medical record review on 03/11/2026 showed documented care plan meetings on 12/04/2024, 09/17/2025, and 01/16/2026, with no additional meetings documented between 12/04/2024 and 09/17/2025. The Regional Social Worker confirmed on 03/11/2026 that no care plan meetings were held for this resident between 12/04/2024 and 09/17/2025 and acknowledged that meetings due in March and June 2025 were missed. For Resident #1, the facility did not implement a care plan intervention for inappropriate sexual behavior. Progress notes reviewed on 03/11/2026 documented multiple occasions of inappropriate sexual behavior. The resident’s care plan, reviewed the same day, included an intervention for 1:1 supervision related to this behavior. However, observation on 03/11/2026 at 10:33 AM found the resident on the unit without 1:1 supervision. In an interview on 03/10/2026, an RN stated the resident continued to display inappropriate behaviors with other residents daily and that 1:1 supervision had not been in place for “maybe 2 months.” On 03/13/2026, the DON acknowledged that the resident displayed inappropriate sexual behavior and did not currently have 1:1 supervision as specified in the care plan.
Failure to Provide Informed, Private Medication Administration and Basic Hygiene Care
Penalty
Summary
The deficiency involves failures in medication administration practices and basic care related to hygiene and environmental cleanliness. Surveyors observed an LPN administering medications to two residents without explaining the medications or offering the opportunity for the residents to be informed. In a separate observation, an RN administered medications to a resident in a shared room without providing privacy, as the privacy curtain was not drawn and the roommate was able to observe the process. Review of the facility’s medication administration policy showed that providing privacy is required, and the DON stated that staff are expected to offer residents the opportunity to be informed about their medications to support resident choice and the ability to refuse. Additional deficiencies were identified in the management of residents’ urinals and room cleanliness. Surveyors observed two urinals filled with urine on a nightstand in one resident’s room, and the resident reported that some aides empty the urinal and some do not, and that this situation happens all the time. In another room, a urinal filled with urine and a trash can were observed on the bed. During room rounds, a trash can under a sink was found to be approximately one-quarter full of coffee-colored water and trash, and a resident stated it had been there for a couple of days. The Lead GNA reported that GNAs are responsible for emptying residents’ urinals every two hours and as needed, confirming that ensuring urinals are emptied is part of their duties.
Incomplete Medication Documentation for Pain Management
Penalty
Summary
The facility failed to ensure that clinical records were complete and accurately documented for two residents, as evidenced by discrepancies between the controlled medication utilization records and the medication administration records (MAR) for Morphine Sulfate. For one resident with diagnoses including anxiety, dementia, and atrial fibrillation, the pain management care plan required administration and documentation of analgesic medications as ordered, with monitoring and documentation of side effects and effectiveness every shift. However, a review of the resident's records revealed that 34 doses of Morphine Sulfate were signed out in November, but only 26 doses were documented as administered on the MAR. Several specific dates were identified where doses were not documented, and there was no corresponding nursing assessment of the medication's effectiveness in the progress notes. Similarly, for another resident with chronic pain, lumbar back pain, repeated falls, and muscle wasting, who was also receiving hospice services, the controlled medication utilization record showed 35 doses of Morphine Sulfate signed out over a specified period, but only 14 doses were documented as administered on the MAR. Multiple dates were identified where documentation was missing, and there was no evidence in the MAR or nursing progress notes of any assessment regarding the effectiveness of the administered medication. Interviews with nursing staff revealed a lack of awareness regarding the missing documentation for both residents. The staff nurse interviewed was not aware of the failure to sign off on administered doses and confirmed the existence of both standing and as-needed orders for Morphine Sulfate. The facility's pain management policy required collaboration with healthcare professionals and documentation of interventions, but the records reviewed did not reflect compliance with these requirements.
Failure to Follow Two-Person Hoyer Transfer Protocol Results in Resident Injury
Penalty
Summary
Facility staff failed to follow the established plan of care for a dependent resident with quadriplegia and an above-the-knee amputation, resulting in significant injury during a transfer. The resident, who was totally dependent for all activities of daily living and required a Hoyer lift with assistance from two staff members for transfers, was instead transferred by a single geriatric nursing assistant (GNA). The GNA used the resident's own sling but did not have a second staff member present, as required by the care plan. During the transfer from bed to chair, the wheel of the Hoyer lift struck the end of the bed, causing the resident to slip through the sling and fall to the floor, landing on the buttocks. Following the fall, the resident complained of back pain and was subsequently transferred to the hospital, where imaging revealed bilateral sacral fractures and an L2 compression fracture. The resident was alert but not at full baseline, likely due to pain and lack of sleep after spending the night in the emergency room. Staff interviews confirmed that the GNA was working alone at the time of the transfer, despite the care plan's requirement for two-person assistance. Other staff members reported that short staffing was common, and it was not unusual for GNAs to perform Hoyer transfers alone when the facility was understaffed. Documentation and interviews indicated that the unit was short-staffed on the day of the incident, with GNAs assigned to multiple units and responsible for a high number of residents, many of whom required total care. The nurse on duty and other GNAs corroborated that the transfer was performed by one person, and that this practice had occurred previously due to staffing shortages. The failure to adhere to the resident's care plan and provide adequate supervision during the transfer directly resulted in the resident's injuries.
Ceiling Collapse Causes Physical and Psychosocial Harm Due to Environmental Failure
Penalty
Summary
The facility failed to maintain a safe and functional environment, resulting in both physical and psychosocial harm to a resident. On the date of the incident, a pipe burst in the attic above a resident's room due to inadequate temperature control and lack of pipe insulation, causing the ceiling to collapse onto the resident. The resident, who has quadriplegia and fully intact cognitive function, was unable to move independently and was covered in water, insulation, and drywall until staff arrived several minutes later to remove them from the room. Medical records indicate that the resident was sent to the emergency room, where they were evaluated for injuries and subsequently diagnosed with cervical spine and lumbar strain, leading to ongoing pain management with various medications, including Oxycodone and later Suboxone. The resident continued to experience significant lower back pain, which was later associated with a mild disc bulge found on MRI. The incident also exacerbated the resident's pre-existing PTSD, as documented in psychological and psychiatric evaluations, with the resident expressing ongoing fear and trauma related to the event. Interviews with staff confirmed that the ceiling collapse was sudden and involved a large section of drywall, insulation, and water falling directly onto the resident. Staff described the resident as visibly upset and shaken after the incident. The resident later requested counseling and physical therapy services from providers not affiliated with the facility, citing feelings of unsafety and worsened PTSD symptoms following the event. The deficiency was directly linked to the facility's failure to maintain appropriate environmental controls to prevent pipe freezing and rupture.
Call Light Not Accessible to Resident with Hemiplegia
Penalty
Summary
A deficiency was identified when a resident with hemiplegia was observed lying in bed without access to their call light, which was found on the floor in front of the oxygen concentrator. The resident reported that the call bell was usually placed on the bed but had been removed by a staff member because the resident was using it frequently. The resident's care plan included interventions to encourage the use of the call bell for assistance and specifically directed that the call light be kept within reach on the resident's right side. Despite these documented interventions, the call light was not accessible to the resident at the time of observation, and the resident had to request assistance from the surveyor to retrieve a personal item.
Failure to Notify Physician of Change in Condition and Representative of Medication Changes
Penalty
Summary
Facility staff failed to promptly notify a physician when a resident experienced a significant change in condition. One resident with a history of traumatic brain injury, heart failure, and renal failure was noted as difficult to arouse and lethargic by a nurse, but no timely assessment or notification to the physician occurred. Multiple staff members, including a registered nurse and a geriatric nursing assistant, observed the resident to be unresponsive and reported that the assigned LPN had not taken immediate action or obtained vital signs. The resident was eventually found to have critically low blood pressure and was transferred to the hospital after emergency measures were initiated, but only after a significant delay and repeated prompting by other staff members. Additionally, the facility failed to notify a resident's representative when there were multiple changes to the resident's medication regimen. Medical record review showed several instances where antipsychotic and anti-anxiety medications were initiated or had their dosages increased, but there was no documentation that the resident's representative was informed of these changes. The Assistant Director of Nursing confirmed the lack of documentation regarding representative notification for these medication changes.
Failure to Timely Report Injury of Unknown Origin
Penalty
Summary
The facility failed to report an injury of unknown origin within the required 2-hour timeframe to the regulatory agency, the Office of Health Care Quality (OHCQ). A staff nurse became aware of a resident with severe cognitive impairment who was found with a swollen, bruised left eye. The resident was unable to communicate the cause of the injury. The initial self-report to OHCQ was sent the following morning, more than 2 hours after the injury was discovered. Facility leadership confirmed that at the time, it was unclear whether the injury was due to a fall, being hit, or another cause.
Failure to Thoroughly Investigate Alleged Misappropriation of Property
Penalty
Summary
The facility failed to provide adequate documentation that an allegation of misappropriation of property was thoroughly investigated. Specifically, a resident reported that money, a gift card, and multiple gift certificates were stolen from their room during a specified time frame. The facility's investigation included written statements from three geriatric nursing assistants, the previous DON, and three other staff in leadership positions. However, the investigation did not include interviews or statements from nurses on duty, staff from previous shifts, housekeeping, maintenance, or dietary staff who also had access to the resident's room. During interviews, the NHA and ADON confirmed that additional staff should have been interviewed as part of the investigation process.
Failure to Hold Quarterly Care Plan Meetings
Penalty
Summary
Facility staff failed to conduct required quarterly care plan meetings for a resident, as evidenced by medical record review and staff interviews. The resident was admitted in November 2022, and while quarterly MDS assessments were completed in March and June 2025, there was no documentation or evidence of corresponding care plan meetings during those periods. The last recorded care plan meeting for the resident occurred in December 2024. Interviews with the Social Services Assistant and the Assistant Director of Nursing confirmed the absence of care plan meetings in March and June 2025. Additionally, the resident reported not having any care plan meetings during the year and had been requesting them.
Failure to Follow Physician-Ordered Parameters for Blood Pressure Medication Administration
Penalty
Summary
A deficiency occurred when a resident with multiple cardiac and vascular diagnoses, including non-rheumatic aortic stenosis, hypertension, atrial fibrillation, and heart disease, received Metoprolol Tartrate despite physician orders specifying parameters for administration. The physician's order directed staff to hold the medication if the resident's blood pressure was less than 110/65 or if the heart rate was less than 65. However, medical record review revealed multiple instances over several months where the medication was administered even when the resident's blood pressure or heart rate was below the specified thresholds. Staff interviews confirmed a misunderstanding of the physician's order, with staff indicating they would only hold the medication if both blood pressure and heart rate were below parameters, rather than either one. The physician clarified during the survey that the medication should have been held if either parameter was below the threshold. The facility's failure to follow the physician's order resulted in the resident receiving unnecessary medication doses outside of the prescribed parameters.
Incomplete and Inaccurate Medical Record Documentation
Penalty
Summary
The facility failed to maintain complete and accurate medical records for a resident with a history of cerebral infarction and hemiplegia. Upon review, it was found that the resident's medical record did not include all relevant diagnoses, specifically omitting hemiplegia on the information sheet submitted for nursing home level of care appeal. Instead, the documentation listed a diagnosis of no residual deficit, which did not accurately reflect the resident's condition. Additionally, the documentation provided for the appeal did not include all of the resident's diagnoses, and the information sheet was incomplete. Further review revealed that the facility did not maintain up-to-date records of care plan meetings and discussions regarding the resident's loss of nursing home level of care. There was no evidence in the medical record of a care plan meeting after April, nor documentation of discussions with the resident and their representative about the loss of level of care. Although a care plan meeting was held in July, the documentation was kept in the Social Services Assistant's office and had not been uploaded to the medical record, resulting in incomplete official records.
Failure to Follow Plan of Correction and Monitor Quality Deficiencies
Penalty
Summary
The facility failed to correct and monitor previously identified quality deficiencies, as evidenced by a revisit survey that found noncompliance with three specific deficiencies (F610, F842, and S1320). Record review and staff interviews revealed that the facility did not follow its plan of correction for these deficiencies, with S1320 remaining out of compliance. The Director of Nursing identified the Administrator as the Quality Assurance (QA) contact person, and the Administrator confirmed that QA meetings were held monthly. However, when questioned, the Administrator stated that the QA team did not specifically discuss the citations or the progress of the plan of correction, despite the plan indicating that the QAPI team would review all audits. The surveyor noted ongoing concerns related to a qualified social worker.
Staffing Shortages Impact Resident Care
Penalty
Summary
The facility failed to ensure sufficient staffing to meet the needs of its 81 residents, as evidenced by multiple observations and interviews with residents and staff. Several residents, including those identified as R15, R44, and R55, reported issues related to inadequate staffing, such as not receiving timely assistance with activities of daily living (ADLs) and delayed response to call lights. R15, who required assistance from two staff members, expressed concerns about the lack of staff, while R44 noted that she sometimes missed her scheduled baths due to insufficient staffing. R55 also highlighted difficulties in getting assistance on weekends. These issues were corroborated by the facility's Minimum Data Set (MDS) assessments, which indicated that these residents were cognitively intact and aware of the staffing deficiencies. Staff interviews further confirmed the staffing inadequacies, with Geriatric Nurse Aides (GNAs) and a Registered Nurse (RN) expressing concerns about their ability to complete assignments and ensure resident safety. GNAs reported being unable to monitor all residents effectively, especially when only one aide was assigned to a unit. The RN mentioned working double shifts and being the only nurse on duty during certain shifts, which heightened his anxiety about resident safety. The Director of Nursing (DON) and the Regional Director of Labor Management acknowledged the staffing shortages, noting efforts to incentivize staff to cover shifts, but admitted that the facility was struggling to maintain adequate staffing levels.
Failure to Conduct Annual GNA Performance Reviews
Penalty
Summary
The facility failed to conduct annual performance reviews for five Geriatric Nurse Aides (GNAs), which could potentially impact the safety and care of all 80 residents. Personnel files revealed that GNAs with start dates ranging from September 2021 to March 2023 had not received their required annual evaluations. Interviews with the Human Resources Director, Administrator, Director of Nursing, Chief Nursing Officer, and President of Clinical Operations confirmed that the evaluations were not completed due to nurse leadership turnover. The Chief Nursing Officer had implemented a directive for annual evaluations in January 2024, but it was not followed, leading to the deficiency.
Deficiency in Food Temperature and Palatability
Penalty
Summary
The facility failed to ensure that food was served at a palatable and appetizing temperature, as observed during two meal tray observations. This deficiency potentially affected all 80 residents who consumed food prepared by the facility's kitchen. During the initial screening, several residents expressed dissatisfaction with the taste and temperature of the food. Interviews with residents revealed specific complaints about the quality of meals, including unappetizing eggs, hard meat, and half-baked toast. These residents had intact cognition, as indicated by their BIMS scores, which ranged from 13 to 15 out of 15. Further observations during a group meeting and review of resident council minutes highlighted ongoing issues with food quality. Residents consistently reported that meals were cold and tasteless. A tray observation revealed that while some items were warm, they lacked flavor, and the dessert was dry. The facility's policy on Food and Nutrition Services, revised in October 2017, stated that each resident should receive a nourishing, palatable, well-balanced diet, considering their preferences. However, the facility did not adhere to this policy, as evidenced by the residents' complaints and the observations made during the survey.
Sanitation Deficiencies in Kitchen and Food Handling
Penalty
Summary
The facility failed to maintain sanitary conditions in the kitchen, affecting the preparation and serving of food to all 80 residents. During an initial kitchen tour, it was observed that the ice machine compressor was covered with a white powdery substance, and the floor around it was littered with trash, debris, and spider webs. The ice scoop holder contained water with a brown, gritty appearance, and the ice chest had a blackish-brown substance. Additionally, the floor and baseboards around kitchen equipment were covered with a greasy, dark sticky substance, and the tile grout appeared discolored. The hood vent had not been cleaned since February 2024, despite being due for cleaning in August 2024, and had a visible buildup of grease. Interviews with the Dietary Manager and the Regional Director of Maintenance revealed a lack of adherence to cleaning schedules and maintenance responsibilities. The Dietary Manager stated that the maintenance director was responsible for the ice machine's cleanliness, while the Regional Director of Maintenance acknowledged that scheduled maintenance tasks were not completed as required. Furthermore, during a tray line observation, a dietary aide was found not wearing a facial hair restraint, contrary to FDA Food Code requirements. The facility's policy on ice machines emphasized the need for proper cleaning and maintenance to prevent microbial contamination, which was not being followed.
Improper Disposal of Garbage and Refuse
Penalty
Summary
The facility failed to ensure proper disposal of garbage and refuse, as observed during a kitchen tour with the Dietary Manager (DM). Three green dumpsters were located on a grass pad, surrounded by disposable gloves and a clear plastic trash bag with a hole, containing gloves, napkins, and food wrappers. The DM indicated that maintaining the garbage area was a housekeeping task, although dietary staff would pick up trash if found. The cleaning schedule for dietary staff did not include responsibility for the garbage area. A housekeeper believed maintenance was responsible, but all staff should clean around the dumpsters. The Administrator thought both dietary staff and housekeeping were responsible. The facility's policy stated that the surrounding area should be kept clean to minimize debris and insect/rodent attractions, and garbage should not accumulate outside the dumpster.
Inadequate PPE Use and Lack of Water Management Program
Penalty
Summary
The facility failed to adhere to proper infection prevention and control protocols, specifically in the use of personal protective equipment (PPE) during catheter care for residents. Resident 65, who was readmitted with a diagnosis of obstructive and reflux uropathy, was observed receiving catheter care without the appropriate PPE. The Geriatric Nursing Assistant (GNA) 4 only wore gloves and did not don a gown, contrary to the facility's Enhanced Barrier Precautions (EBP) policy. The Interim Director of Nursing (DON) confirmed that the necessary PPE was not available outside Resident 65's room, and staff were not aware of the EBP requirements for residents with indwelling urinary catheters. Similarly, Resident 11, who had a physician's order for EBP due to an indwelling urinary catheter, did not have the required signage or PPE available. Licensed Practical Nurse (LPN) 3 and GNA17 provided care without wearing gowns, and there was confusion about the status of the EBP order. Resident 33, diagnosed with a drug-resistant urinary tract infection, had signage and PPE available, but GNA6 did not use a gown during care, indicating a lack of awareness about the resident's infection control needs. Additionally, the facility lacked a water management program, which is crucial for preventing Legionella infections. The Regional Director of Maintenance confirmed the absence of such a program and was unaware of any concerns related to Legionella. This oversight places all residents at risk, highlighting significant gaps in the facility's infection control measures.
Failure to Provide Required In-Service Training for GNAs
Penalty
Summary
The facility failed to provide the required 12 hours of in-service training for five Geriatric Nurse Aides (GNAs), which is necessary to ensure their continuing competencies. This deficiency was identified through interviews, personnel files review, and policy review. The facility's policy mandates that 12 hours of in-service training be provided annually based on the employment date. However, the personnel files of GNAs with start dates ranging from September 2021 to March 2023 revealed that they had not completed the required training. Interviews with the Human Resources Director, Administrator, Director of Nursing, Chief Nursing Officer, and the President of Clinical Operations confirmed that the training was not being provided. This lapse had the potential to impact the safety and care of 80 residents in the facility.
Facility Maintenance and Sanitation Deficiencies
Penalty
Summary
The facility staff failed to maintain a sanitary, orderly, and comfortable environment, as evidenced by the presence of black mold and other maintenance issues across multiple rooms. During an environmental tour, several deficiencies were observed, including black mold in rooms 408, 410, 400, 307, and 205, as well as structural damages such as unpainted spackle, holes in walls, and missing base molding. Additionally, there were issues with rusted fixtures, chipped counters, and missing covers for smoke detectors and ventilation fans. These conditions were confirmed by the Regional Director of Maintenance during a tour. Interviews with staff and residents revealed that maintenance issues had been reported but not addressed. A staff member indicated that the maintenance personnel had not performed their duties the previous week, and a resident reported that complaints about mold were ignored by the Maintenance Director. The resident had even marked the mold location with a sticky note, highlighting the lack of response to maintenance requests. The Regional Director of Maintenance acknowledged the findings and the need for significant repairs.
Failure to Implement Abuse Policy and Investigate Missing Narcotics
Penalty
Summary
The facility failed to fully implement its abuse policy in response to allegations of physical and verbal abuse, as well as misappropriation of property, involving three residents. One resident reported that a Geriatric Nursing Assistant (GNA) was rough during care and made threatening statements regarding the resident's diaper. The resident, who was cognitively intact and dependent on staff for toileting, expressed fear and reported soreness in his arms and neck. Despite the resident's report, the facility's investigation was delayed, and the abuse allegation was not reported immediately as required by the facility's policy. The investigation into the abuse allegation was initiated after a written statement was found under the Director of Nursing's (DON) door. The DON was informed of the incident via text message the previous evening but did not take immediate action to report the allegation. The investigation included obtaining statements from the involved staff, but the facility was unable to substantiate the abuse claims due to contradictory statements and lack of physical evidence. The resident was placed on daily safety checks, but the investigation did not include comprehensive interviews with all potential witnesses or other residents. In a separate incident, the facility failed to account for missing narcotics involving two residents. The investigation into the missing medications was incomplete, lacking written statements from the affected residents or other staff. The facility conducted an audit and background checks but was unable to determine the cause of the missing narcotics. The administrative staff involved in the incident were no longer employed at the facility, and the Interim DON was unfamiliar with the case, indicating a lack of continuity in addressing the issue.
Failure to Investigate Abuse and Missing Narcotics
Penalty
Summary
The facility failed to investigate allegations of physical and verbal abuse, as well as misappropriation of property, in a timely and thorough manner for several residents. One resident reported an incident where a Geriatric Nursing Assistant (GNA) was rough during care and made threatening remarks. Despite the resident being cognitively intact and dependent on staff for toileting, the facility did not initiate a care plan for behaviors upon admission. The investigation was delayed, and the alleged perpetrator was not immediately removed from the resident's care, leaving the resident and others at risk. In another incident, the facility did not adequately investigate missing narcotics for two residents. The medications were unaccounted for, and the facility was unable to determine what happened. The investigation lacked written statements from the involved residents or staff, and the administrative staff at the time of the incident were no longer employed, leaving gaps in the investigation process. Additionally, the facility failed to investigate a new injury for a resident who was found with a hairline fracture and bruising on the hand. Despite the physician's documentation indicating no known cause for the injury, the facility did not conduct an investigation, as they believed it was related to a previous fall. This lack of investigation left the cause of the injury undetermined.
Failure to Notify Responsible Party of Pressure Ulcer Treatment
Penalty
Summary
The facility failed to notify a resident's responsible party when a new treatment was initiated for a pressure ulcer. This deficiency was identified during a review of the medical records and staff interviews, specifically concerning a resident who had been readmitted to the facility after a hospital stay. Upon readmission, the nursing admission assessment noted the presence of a pressure ulcer on the coccyx, but the length, width, depth, and stage were initially undetermined. Subsequent documentation on a wound note indicated that the resident had a Stage 3 pressure ulcer, and treatment orders were placed to cleanse the area with a wound cleanser, apply medical-grade honey and calcium alginate to the base of the wound, secure it with bordered gauze, and change it daily. However, the medical record did not contain documentation that the responsible party was informed of the Stage 3 pressure ulcer and the treatment plan. This oversight was confirmed during an interview with the Director of Nursing.
Failure to Provide Timely Pressure Ulcer Treatment
Penalty
Summary
The facility failed to provide timely treatment and services to prevent or heal pressure ulcers for Resident #65. Upon review of the medical records and staff interviews, it was found that Resident #65 was readmitted to the facility with a pressure ulcer on the coccyx, which was initially unable to be determined in terms of length, width, depth, and stage. A subsequent wound note on 10/25/23 documented that the ulcer was a stage 3 pressure ulcer present on admission, and treatment orders were placed to cleanse the area with a wound cleanser, apply medical grade honey, calcium alginate to the base of the wound, secure with a bordered gauze, and change the dressing daily. However, the review of Resident #65's October 2023 Treatment Administration Record (TAR) revealed that the wound dressing treatment was not initiated until 10/28/23, indicating a gap in treatment from 10/17/23 to 10/28/23. This lapse in care was confirmed during an interview with the Director of Nursing on 10/31/24. The failure to provide timely treatment for the pressure ulcer represents a deficiency in the facility's care for Resident #65.
Failure to Maintain Required RN Staffing Levels
Penalty
Summary
The facility failed to maintain the required staffing levels by not having a Registered Nurse (RN) on duty for at least 8 consecutive hours a day, 7 days a week. This deficiency was identified during an annual survey, where it was found that on four specific days, the facility did not have RN coverage as required. The days without RN coverage were January 26, 2024, January 28, 2024, October 5, 2024, and October 20, 2024. This was confirmed through a review of staffing documentation provided by the Regional Director of Labor Management and an interview with the same individual, who acknowledged the lack of RN coverage on these dates. Numerous complaints regarding low staffing from residents, staff, and families were also reviewed during the survey, highlighting the ongoing issue of inadequate RN staffing.
Incomplete Medical Records for Residents
Penalty
Summary
The facility failed to maintain complete and accurate medical records for three residents, as required by accepted professional standards. For Resident #19, the care plan meetings held in March and July 2024 were not included in the resident's medical record, despite evidence of these meetings being available on paper. The Social Services Assistant admitted to keeping evidence of care plan meetings in her office and uploading them to the medical record when possible. This was confirmed by the Director of Nursing, who acknowledged the omission of the March and July 2024 care plan meetings from the medical record. Similarly, for Resident #45, the June 2024 care plan meeting was not documented in the resident's medical record, although evidence was available on paper. The Social Services Assistant again stated that she keeps evidence of care plan meetings in her office and uploads them when she can. The Director of Nursing confirmed the failure to include the June 2024 care plan meeting in the medical record. For Resident #62, the September 2024 care plan meeting was missing from the medical record, despite being documented on paper. The Social Services Assistant's practice of keeping evidence in her office and uploading it when possible was again noted, and the Director of Nursing confirmed the omission of the September 2024 care plan meeting from the medical record.
Failure to Uphold Resident Dignity and Respect
Penalty
Summary
The facility failed to ensure that residents were treated with dignity and respect, as evidenced by the treatment of two residents. Resident 14, who was cognitively intact with a BIMS score of 15 out of 15, reported that staff did not knock or introduce themselves before entering her room. During an interview, a Certified Medicine Aide (CMA) entered Resident 14's room without knocking and placed a lunch tray without introduction. Additionally, Resident 14 expressed frustration over the CMA's behavior, including rolling her eyes, which was observed by surveyors. The Interim Director of Nursing confirmed that staff are expected to knock and wait for permission before entering a resident's room and should not roll their eyes at residents. Resident 65, who had a BIMS score of zero indicating severe cognitive impairment, was left uncovered and exposed during a bath and catheter care by a Geriatric Nursing Assistant (GNA). Despite Resident 65 expressing that she was cold multiple times, the GNA did not cover her with a blanket or sheet, leaving her exposed throughout the care process. The Interim Director of Nursing stated that staff are expected to cover residents during care to prevent exposure. These incidents demonstrate a failure to uphold the facility's policy on promoting and maintaining resident dignity.
Failure to Provide Appropriate Incontinent Briefs
Penalty
Summary
The facility failed to honor a resident's right to self-determination by not allowing her to choose the appropriate size of incontinent briefs, which led to discomfort and potential skin issues. The resident, who was readmitted with a diagnosis of morbid obesity, expressed that the current size of briefs was too tight and painful, causing difficulty in sitting up. Despite being cognitively intact, as indicated by a perfect score on the Brief Interview for Mental Status, the resident's repeated requests for a larger size over two months were not addressed by the facility. Interviews with staff revealed that the resident was initially measured for a large size, but was provided with a 3x size, which was deemed insufficient by the resident and some staff members. The Medical Records/Central Supply staff decided against providing a larger size after a trial, assuming the resident did not complain further. However, observations confirmed the resident's discomfort, and staff acknowledged the need for a larger size due to the resident's condition as a heavy wetter. The Interim DON acknowledged the issue but did not provide a reason for the failure to supply the correct size.
Failure to Resolve Resident Grievance Promptly
Penalty
Summary
The facility failed to promptly resolve a grievance voiced by a resident, R4, during a resident council meeting. R4, who was cognitively intact with a BIMS score of 15, expressed concerns about another resident, R34, being rude due to the toilet not being cleaned properly after use. The grievance was documented on a Council Concern/Recommendation Form, but the form was undated and unsigned, indicating a lack of follow-up. The Activities Director stated that the concern was forgotten because the Director of Nursing, who received the concern, was no longer employed at the facility. Interviews revealed that the Social Services Assistant, who was responsible for ensuring grievances were followed up on, had given the form to the former Director of Nursing and had not seen it since. The Administrator, who oversees all grievances, confirmed that she had not seen the concern from R4 and acknowledged that there should have been more follow-up. This lack of action and communication led to the grievance not being resolved, which had the potential to cause further grievances to remain unresolved for other residents in the facility.
Delayed Transmission of MDS Assessment for Deceased Resident
Penalty
Summary
The facility failed to ensure timely transmission of a Minimum Data Set (MDS) assessment for one resident, identified as Resident 75, out of 31 sampled assessments. The resident was admitted to the facility and subsequently died there. The Death in Facility MDS was completed on time, but the transmission of this assessment was delayed. The MDS Coordinator confirmed that assessments are sent to corporate offices for batch transmission, and she was unaware of the exact submission date, although she sent it immediately. According to the CMS Long-term Care Facility Assessment Instrument 3.0 User's Manual, the transmission should occur no later than 14 days after the MDS death date. The facility's policy also mandates adherence to federal and state submission timeframes.
Failure to Develop Care Plan for Indwelling Urinary Catheter
Penalty
Summary
The facility failed to develop a comprehensive care plan for a resident with an indwelling urinary catheter, resulting in the catheter being in place for seven months without a plan for its discontinuation. The resident, who was cognitively intact, was unsure of the reason for the catheter's placement. The initial physician's order was for a one-day use due to urinary retention, but the catheter remained in place due to a lack of follow-up and a delayed urology consultation. The medical record lacked a care plan addressing the catheter's use and discontinuation, and the Director of Nursing confirmed the absence of such a plan. The resident's medical records indicated a history of urinary retention and recurrent urinary tract infections, with a urology consult initially ordered but not completed until seven months later. The attending physician and medical director acknowledged the lack of medical justification for the prolonged use of the catheter and the delay in attempting a voiding trial. The failure to develop a care plan with specific interventions and goals for the catheter's use and discontinuation was verified by the Director of Nursing, highlighting a significant oversight in the resident's care management.
Deficiencies in Care Planning and Coordination
Penalty
Summary
The facility failed to ensure that a resident receiving hospice care had an integrated care plan, as required by their policies. The resident, identified as R32, was readmitted with a diagnosis of dementia and was under hospice care. However, the care plan did not reflect hospice involvement, and the interdisciplinary team (IDT) meetings did not include all necessary members, such as a hospice nurse and a nurse aide. Interviews with facility staff confirmed these omissions, indicating a lack of coordination and communication in care planning. Additionally, the facility did not conduct quarterly care plan meetings for several residents, including Resident #19, #45, and #65. Resident #19's last care plan meeting was in July 2024, missing the October 2024 meeting. Resident #45 missed multiple quarterly meetings, with no documentation of attempts to hold these meetings without the resident's presence. Resident #65's care plan meetings were not held for nearly a year, with missed opportunities to reschedule when the family was unavailable. These deficiencies highlight a pattern of inadequate care planning and coordination within the facility, potentially affecting the quality of care provided to residents. The lack of timely and comprehensive care plan meetings, as well as the failure to include all relevant parties in the planning process, suggests systemic issues in adhering to care planning protocols.
Failure to Conduct Weekly Weights for Resident
Penalty
Summary
The facility failed to ensure that a resident, identified as R3, received weekly weight monitoring as ordered by the physician. R3 was readmitted to the facility with a diagnosis of dysphagia and had experienced a significant weight loss of 14 pounds (11%) over 30 days. The Registered Dietitian recommended weekly weights for closer monitoring, starting on 10/14/24. However, a review of the electronic medical record (EMR) revealed that there was no documentation of weights being taken on 10/14/24 and 10/21/24, as required. This was confirmed during an interview with the Interim Director of Nursing, who acknowledged that the weekly weights were not completed as ordered.
Failure to Provide Adequate ADL Care for Residents
Penalty
Summary
The facility failed to provide necessary grooming services for two residents, R15 and R33, as part of their activities of daily living (ADL) care. R15, who was readmitted with a diagnosis of morbid obesity, was observed with greasy hair and white flakes, indicating a lack of proper hair washing. Despite being dependent on staff for bathing and hygiene, R15 was not offered showers due to her size exceeding the capacity of the available shower chair and bed. The Interim Director of Nursing confirmed that R15 had not been offered a shower in the past month, and there was no evidence in the Plan of Coordination that showers were offered or declined. Resident R33, who was admitted with a history of stroke and left-side paralysis, was also not receiving showers as per the facility's schedule. The resident's medical records indicated total dependence on staff for bathing, yet documentation showed only bed baths were provided from June to October 2024. Interviews with staff revealed issues with the availability and functionality of bariatric shower beds and slings, contributing to the lack of showers. R33 expressed fear of falling during the shower process and noted that staff often cited short staffing as a reason for not providing showers. The facility's failure to provide adequate ADL care was further highlighted by the broken shower bed pin, which was not promptly addressed. Staff interviews revealed a lack of communication and follow-up regarding maintenance issues, with the broken pin only being fixed during the surveyor's visit. The DON was informed of the situation, and R33 reiterated a preference for showers during the day shift due to perceived excuses from the evening shift about staffing shortages.
Deficiency in Smoking Area Safety Measures
Penalty
Summary
The facility failed to ensure the designated smoking area was safe for a resident who was the only smoker in the facility. The facility's policy required that the smoking area be protected from weather conditions and have accessible metal containers with self-closing covers for ashtrays. However, during observations, it was noted that there was no protective cover over the smoking area, and the metal container intended for ashtrays was full of trash. This was confirmed by the Regional Director of Labor, the Maintenance Director, and the Administrator in Training, who acknowledged that the conditions did not comply with the facility's smoking policy and could be unsafe when the area was in use. The resident involved, who was cognitively intact and safe to smoke with or without supervision, reported smoking six cigarettes per day at designated smoking times. Despite the lack of accidents related to smoking, the absence of a protective cover and the presence of trash in the metal container were identified as deficiencies. The Administrator also confirmed these observations, agreeing that the metal container should be free of trash before the resident smoked, indicating a failure to adhere to the facility's safety measures for the smoking area.
Deficiencies in Urinary Catheter Management and Care
Penalty
Summary
The facility failed to appropriately manage the urinary catheter care for a resident, identified as R11, who experienced multiple urinary tract infections (UTIs) while having an indwelling urinary catheter. Despite a physician's order to discontinue the catheter and monitor voiding, the catheter was not removed until a later date. The resident had a history of urinary retention and was initially given a catheter due to complaints of not being able to empty the bladder. However, a voiding trial was not attempted earlier, and a urology consult was delayed for several months, which contributed to the prolonged use of the catheter and recurrent UTIs. Additionally, the facility did not provide a policy for urinary catheter use when requested by surveyors. The medical records revealed multiple instances of UTIs treated with antibiotics, and the attending physician expressed concerns about antibiotic resistance. The Medical Director noted that there was no medical indication for the prolonged use of the catheter and that a voiding trial should have been conducted earlier. In another instance, the facility failed to provide proper catheter care for another resident, identified as R65. During an observation, a Geriatric Nursing Assistant (GNA) did not follow the facility's catheter care policy, which included not cleaning the labia area properly and not changing the direction of the washcloth. This was confirmed by the Interim Director of Nursing, who acknowledged that the staff did not adhere to the correct procedures for catheter care.
Failure to Limit PRN Psychotropic Medication Use
Penalty
Summary
The facility failed to ensure that a resident's medication regimen was free from unnecessary medications, specifically regarding the use of PRN psychotropic medications. A resident with a diagnosis of anxiety disorder and moderately impaired cognition was prescribed Lorazepam to be taken as needed every six hours for anxiety. The medication was administered on three occasions in September 2024. However, the facility did not have a policy limiting PRN orders for psychotropic drugs to 14 days, and the medication was prescribed beyond this period without documented rationale. Interviews with the Director of Nursing and the Medical Director revealed that the facility overlooked a recommendation from the consultant pharmacy to discontinue the PRN Lorazepam, which should have been limited to 14 days. The facility's Medication Regimen Review policy required monthly reviews by a licensed pharmacist, but the oversight occurred despite this policy. The deficiency was identified during a review of the resident's electronic medical record and the facility's policies.
Delayed Urology Consult for Resident with Indwelling Catheter
Penalty
Summary
The facility failed to obtain a timely urology consult for a resident with an indwelling urinary catheter, which was initially placed due to urinary retention and possible neurogenic bladder. Despite a physician's order for a urology consult on 03/07/24, the consult did not occur until 10/01/24, resulting in the continued use of the catheter without appropriate indication. The resident, who was cognitively intact, was unsure of the reason for the catheter placement and had expressed a desire to delay its removal until feeling better. The delay in obtaining the urology consult was verified by the Director of Nursing and acknowledged by the attending physician, who was unaware of the reason for the seven-month delay. The medical director also confirmed that the consult should not have taken so long. The resident experienced recurrent urinary tract infections, which the urologist attributed to the chronic use of the indwelling catheter. The catheter was eventually removed on 10/29/24, following a physician's order.
Failure to Maintain Resident's Bed Safety
Penalty
Summary
The facility failed to ensure the safety and maintenance of a resident's bed, which was identified as a deficiency during a survey. A resident reported that her electric bed was broken, and upon inspection, it was found that the headboard and footboard were not securely attached, creating a gap of approximately three to five inches between the mattress and the bed frame. The resident's electronic medical record indicated that her cognition was intact, with a BIMS score of 15 out of 15. The Regional Director of Maintenance confirmed that the loose headboard and footboard posed a safety hazard and acknowledged that the facility's maintenance management system, TELS, required monthly inspections of electric beds, which had not been completed in over six months. The Administrator also confirmed that the beds were to be inspected monthly to prevent safety hazards.
Failure to Report Resident-to-Resident Altercation
Penalty
Summary
The facility failed to protect a resident's right to be free from physical abuse, as evidenced by an incident involving two residents. Resident 39, who has diagnoses including dementia and anxiety disorder, was involved in an altercation with Resident 63, who has Alzheimer's disease and vascular dementia. Resident 63, known to be physically aggressive, punched Resident 39 in the face after Resident 39 wandered into Resident 63's room. Despite the altercation, Resident 39 did not sustain any injuries. The incident was not reported to the facility administration or the State Agency, and no internal investigation was conducted. Interviews with facility staff revealed a lack of awareness and communication regarding the incident. The Administrator and Nurse Practitioner were unaware of the altercation, and the Director of Nursing, who was new to the position, confirmed that no investigation had been initiated. A Registered Nurse and a Geriatric Nursing Assistant witnessed or were informed of the incident but did not ensure it was reported according to facility policy. The facility's policy on reporting abuse was not followed, resulting in a failure to protect the resident from abuse and to take appropriate action following the incident.
Failure to Timely Report Abuse and Neglect Allegations
Penalty
Summary
The facility failed to timely report allegations of physical and verbal abuse for five residents, increasing the risk of continued abuse. Resident 233 reported an incident of physical and verbal abuse by a Geriatric Nursing Assistant (GNA) to a Registered Nurse (RN), who then informed the Director of Nursing (DON) via text message. Despite being notified, the DON did not report the abuse allegation to the state agency until the following morning, exceeding the required two-hour reporting timeframe. The facility's investigation could not substantiate the allegations due to contradictory statements and lack of visible injuries. Resident 32, who has dementia, reported an allegation of sexual abuse to a hospice nurse. The facility conducted interviews and assessments but did not contact the police, which was confirmed by the interim DON as a failure in procedure. Additionally, Resident 28 was found with unexplained bruising, which was not reported to the state agency until several days later. The facility's investigation suggested an unwitnessed fall, but the delay in reporting and lack of immediate investigation were noted as deficiencies. Resident 65 had a hairline fracture and bruising on the hand, which was not reported as a new injury due to a previous fall. The Nursing Home Administrator (NHA) acknowledged that an investigation should have been conducted. Lastly, Resident 62 reported a missing bank card, but the facility failed to report the misappropriation within the required timeframe. These incidents highlight the facility's repeated failures to adhere to timely reporting protocols for abuse, neglect, and theft allegations.
Latest citations in Maryland
Facility staff did not ensure that 2nd floor residents who could not use stairs were able to receive visitors when the only elevator was out of service for an extended period. Complaints indicated that some family members, who were themselves unable to ambulate stairs, could not visit their relatives on the 2nd floor during this time. The emergency plan directed non-ambulatory 2nd floor residents to remain on that floor unless there was an emergency and did not address how visitation would be maintained when the elevator was inoperable. The Administrator reported that visitors could use the stairs and that an emergency chair system could be used to move residents, but also stated that the chair system was not used for visitation and was unaware of any complaints, despite two having been filed.
Facility staff did not complete required quarterly smoking safety assessments for several residents identified as smokers, including some who had not been reassessed for many months and one who had never been assessed during their stay. This issue was discovered during a complaint survey after the facility’s only elevator was out of service for an extended period, affecting a group of residents on an upper floor who needed to reach a designated smoking area on a lower floor. Review of records and staff interviews, including with the DON and a unit manager, confirmed that the facility’s own practice of quarterly smoking safety assessments for smokers was not followed for half of the affected residents.
Facility staff failed to accurately code multiple MDS assessments for several residents, leading to discrepancies between MDS entries and MARs for pain management, falls, and high-risk drug classes. In several cases, scheduled pain management was coded as provided when MARs did not show daily pain medications, often because an LPN counted low-dose Aspirin ordered for cardiovascular prophylaxis or heart failure as pain medication, contrary to RAI guidance. One resident’s falls were underreported on the MDS despite two documented falls, and daily use of a topical analgesic and an antiplatelet (Aspirin) was not correctly captured. Other residents had MDS entries indicating use of hypnotic or antianxiety medications when MARs showed none, while actual antidepressant and hypoglycemic medications administered daily were omitted from Section N0415. These errors were confirmed by the involved LPNs during surveyor interviews.
Staff failed to conduct complete investigations into two residents’ abuse allegations. In one case, a resident reported that an employee poked their face and made an obscene gesture, but the investigation lacked a statement from the corporate representative who was first notified of the allegation. In another case, a resident reported that someone in blue clothing put a hand by their face and over their mouth, with a specific GNA identified as the alleged perpetrator; however, the investigation did not include statements from two GNAs who were on duty on the unit at the time of the alleged incident, despite leadership having the opportunity to ensure all relevant documents were present.
Staff failed to create person-centered care plans for two residents, one with mobility limitations and one receiving peritoneal dialysis. For the resident with mobility issues, the care plan did not address the resident’s refusal to use a Hoyer lift and preference for pivot transfers, despite therapy prohibiting pivot transfers and staff awareness of the resident’s resistance. For the resident on peritoneal dialysis, the care plan did not specify that the treatment was peritoneal dialysis, nor did it include the treatment schedule or cycle time frames; an LPN Unit Manager acknowledged using a generalized renal care plan without incorporating the specific dialysis prescription.
A resident’s medical record lacked documentation confirming that scheduled showers or bed baths were provided on multiple dates, and there was also no record of any refusals of care on those days. The DON and an LPN unit manager reported that showers were scheduled on specific shifts and that completed showers and refusals should be documented on shower/skin sheets and in the care plan, but the surveyor found gaps where no such entries existed. This resulted in incomplete ADL documentation and failure to maintain medical records according to accepted professional standards.
A resident with multiple fractures and chronic pain was receiving an opioid-based pain regimen, including PRN hydromorphone. The resident was later found unresponsive and "out of it" by an LPN, who located an order for Narcan and administered it, with the resident responding to the medication. A physician note documented an opioid overdose treated with Narcan. Review of the medical record showed no documentation that the resident’s representative was notified of this significant change in condition and emergency intervention, and staff interviews confirmed that notification likely did not occur, despite the DON’s expectation that the responsible party should have been informed.
Staff failed to follow updated wound care orders and to document an opioid overdose event and Narcan use for two residents. One resident with venous and arterial lower extremity wounds did not receive the prescribed change from oil emulsion to daily skin prep on one foot wound, and did not receive ordered skin prep on a new plantar wound for several days after the wound physician revised the treatment plan. Another resident with multiple fractures and chronic pain, receiving multiple opioid and adjunct analgesics, reportedly experienced an opioid overdose; an LPN found the resident unresponsive, located an existing Narcan order, administered Narcan, and observed the resident return to baseline, but did not complete or document a change-in-condition assessment, vital signs, or the Narcan administration in the medical record.
Surveyors substantiated a deficiency when disinfectant wipes, labeled for storage in areas inaccessible to children and not for personal cleansing, were observed sitting openly on a wire shelf in the dining room of a locked dementia unit while cognitively impaired residents waited for breakfast. A GNA and an LPN present on the unit stated that staff used the wipes to clean tables and that residents were never left alone in the dining room and had not been seen using the wipes. The ICP reported being unaware that the wipes’ placement in the dining room was a concern, and the NHA and DON stated they had not previously been informed about the issue, though the DON acknowledged understanding the concern.
A resident’s medical record showed multiple instances where Hydromorphone, a controlled narcotic, was documented as signed out and given on the Controlled Drug Administration Record but was not documented on the MAR on the same dates and times. An LPN reported signing only the narcotic sheet and not the MAR, while the DON acknowledged awareness that nurses were signing the narcotic sheet without completing the MAR, and a unit manager stated they were unaware this was occurring and that both records should be completed. The NHA and DON agreed with the surveyor’s findings after the issue was identified.
Failure to Ensure Visitation Rights During Elevator Outage
Penalty
Summary
Facility staff failed to ensure that residents residing on the 2nd floor who could not safely ambulate using stairs were able to exercise their right to have visitors when the facility’s only elevator malfunctioned. Complaint reviews showed that family members were unable to visit their relatives on the 2nd floor when the elevator was inoperative, and these family members themselves were unable to use the stairs. An incident report documented that the facility’s only elevator was malfunctioning for an extended period, from 3/28/26 to 4/23/26. During this time, residents who could not use the stairs remained on the 2nd floor, and some of their family members could not access them due to the lack of elevator service. Review of the facility’s emergency plan revealed that it instructed that 2nd floor residents who could not safely use the stairs should remain on the 2nd floor unless there was an emergency, and it did not include any provisions for maintaining visitation when the elevator was inoperable. In an interview, the Administrator stated that visitors could use the stairs to visit 2nd floor residents and that residents could be transported using an emergency chair system to meet visitors who could not use the stairs. However, the Administrator acknowledged that the emergency chair system was not used for visitation purposes during the elevator outage and reported being unaware of any complaints about the inoperative elevator, despite two complaints having been received by OHCQ. No additional documentation was provided to show a plan to support visitation for 2nd floor residents during the elevator malfunction.
Failure to Complete Required Quarterly Smoking Safety Assessments
Penalty
Summary
Facility staff failed to update smoking safety assessments at least once every three months for multiple residents identified as smokers. During a complaint survey focused on smoking safety, surveyors reviewed an incident involving the facility’s only elevator being inoperative for nearly a month, which affected residents who lived on the 2nd floor and needed to access the 1st-floor smoking area. The facility’s investigation identified a group of 10 residents on the 2nd floor who smoked and required additional accommodations to safely ambulate to the designated smoking area. Review of these residents’ medical records showed that 5 of the 10 did not receive quarterly smoking safety assessments as required by the facility’s practice. Specifically, four residents had not received a smoking assessment since May 2025, and one resident had no documented smoking assessment at any time during their stay. During interviews, the Unit Manager stated that residents identified as smokers are to be assessed quarterly for smoking safety. When the surveyor pointed out the missing assessments, the DON reviewed the records and confirmed that these residents had not received the required quarterly smoking assessments. This lack of timely reassessment occurred in the context of an extended elevator outage that necessitated special consideration for safe smoking access for residents residing on the 2nd floor.
Inaccurate MDS Coding for Pain Management, Falls, and High-Risk Drug Classes
Penalty
Summary
Facility staff failed to ensure that Minimum Data Set (MDS) assessments were accurately coded for multiple residents, based on medical record review and staff interviews. For one resident with cerebrovascular disease, an MDS with an Assessment Reference Date (ARD) of 3/2/26 coded Section J0100A (scheduled pain management) as "yes," but the March Medication Administration Record (MAR) did not show daily pain medication administration. An LPN stated she coded it that way because the resident received Aspirin 81 mg daily, although the physician’s order showed the Aspirin was prescribed as prophylaxis for cardiovascular events, and the RAI Manual specifies that medications not primarily intended for pain relief should not be coded as pain management. Another resident with cerebral infarction, congestive heart failure, and vascular dementia had two documented falls in progress notes between the prior assessment and the ARD of 2/4/26, but Section J1900 (number of falls since admission or prior assessment) captured only one fall. The same MDS coded Section J0100A (scheduled pain management) as "no" despite the February MAR documenting daily use of Diclofenac topical gel for pain. The MAR also showed daily Aspirin 81 mg for coronary artery disease, but Section N0415 (high-risk drug classes) did not capture the use of an antiplatelet medication. The responsible LPN confirmed missing the second fall and the Aspirin coding error. Additional residents had similar discrepancies: one resident’s MDS repeatedly coded use of hypnotic medications in Section N0415 when MARs showed no hypnotics administered, and failed to capture an antidepressant (Sertraline) that was given; the LPN reported coding Clonazepam as a hypnotic based on dual use, though reference guidelines did not classify it as such. Further inaccuracies were identified for other residents in pain management and high-risk drug class coding. One resident’s MDS with an ARD of 1/8/26 coded receipt of PRN pain medication in Section J0100A, but the January MAR showed no PRN pain medications given; a later MDS for the same resident coded use of an antianxiety medication in Section N0415, while the April MAR showed no such medication administered. Another resident with traumatic subarachnoid hemorrhage, type 2 diabetes with neuropathy, atrial fibrillation, and atherosclerotic heart disease had an MDS with an ARD of 2/3/26 that coded scheduled pain medication as "yes" and PRN pain medication as "no," although the MAR showed intermittent PRN Tylenol for pain and no daily pain medication, and also documented daily Aspirin 81 mg for heart failure and daily Rybelus for diabetes; the MDS failed to capture PRN pain use, incorrectly coded daily pain medication, and did not code hypoglycemic medication in Section N0415. Another resident with a history of stroke and right-sided hemiplegia/hemiparesis had two MDS assessments in February coded as receiving scheduled pain medication, but the February MAR did not show daily pain medication; the LPN reported coding based on daily prophylactic Aspirin 81 mg, which was not ordered for pain.
Incomplete Investigations of Resident Abuse Allegations
Penalty
Summary
Facility staff failed to complete thorough investigations of two separate resident allegations that were reported to the state agency. For the first incident, a resident alleged that on a specific date and time an employee poked two fingers into their face and showed them their middle finger. The five-day follow-up documented the allegation, but the investigation file did not clearly identify who was the first point of contact for the report. During interview, the Administrator stated that a corporate representative was initially made aware of the alleged incident, but there was no statement from this corporate representative included in the investigation file. The Administrator described their usual investigation process as interviewing involved parties, identifying and interviewing witnesses, reviewing staffing for the date of the alleged incident, and interviewing the resident’s roommate and other nearby residents if there were no direct witnesses. In the second incident, a resident reported that during a specific shift someone wearing blue put a hand by their face and over their mouth, and a particular GNA was identified as the alleged perpetrator. Review of the staffing sheet for the time of the alleged incident showed that two GNAs were working on the unit where the incident was reported to have occurred. However, the investigation file contained no statements or interviews from these two GNAs. Prior to the surveyor’s review of the investigation, the DON and a regional nurse were given the opportunity to review the investigation to ensure all necessary documents were available, yet the statements from the two GNAs remained absent. These omissions demonstrated that the facility did not conduct complete investigations into the reported allegations.
Failure to Develop Person-Centered Care Plans for Mobility and Peritoneal Dialysis Needs
Penalty
Summary
Facility staff failed to develop and implement person-centered care plans that addressed all identified needs for two residents, one with mobility limitations and one receiving peritoneal dialysis. For the resident with mobility limitations, the care plan included interventions for resistance to care and adjustment issues, but did not address the resident’s specific resistance to use of a Hoyer lift and the resident’s insistence on pivot transfers from bed to wheelchair. The Unit Manager confirmed that the resident was resistant to care, did not like the Hoyer lift, and preferred pivot transfers, but also stated that physical therapy had prohibited pivot transfers. Despite this known conflict between the resident’s preferences and therapy restrictions, the care plan lacked individualized interventions related to the resident’s resistance to the Hoyer lift and continued request for pivot transfers. For the resident receiving peritoneal dialysis, review of the electronic health record showed an order for peritoneal dialysis, but the resident’s care plans did not include a person-centered care plan specific to this treatment. The existing dialysis care plan did not specify the type of dialysis treatment being provided, did not document when the resident was scheduled to receive the treatment, and did not include time frames for the dialysis cycles. During an interview, the LPN Unit Manager stated that they do not place the dialysis prescription details into the care plan and instead use a generalized renal care plan by selecting standard items, confirming that the care plan was not individualized to the resident’s ordered peritoneal dialysis regimen.
Failure to Document Resident Showers and Refusals
Penalty
Summary
Facility staff failed to maintain complete and accurate documentation of bathing care for a resident, specifically regarding showers and refusals of showers. During a complaint survey, the surveyor requested verification that Resident #5 was receiving scheduled showers. The DON stated that the resident was scheduled for showers on the 3 pm–11 pm shift on Tuesdays and Fridays, and provided shower sheets for several dates in October and early November. However, there was no documentation to verify that the resident received a shower or bed bath on 10/17/25, 10/21/25, and 10/24/25. The DON explained that when a resident receives a shower it is documented on a skin sheet, and that refusals of showers should be documented both in the plan of care and on the shower sheet. Despite this, the surveyor did not receive any documentation indicating that the resident either received bathing care or refused showers on the missing dates. This lack of documentation showed that the facility did not safeguard resident-identifiable information and maintain medical records in accordance with accepted professional standards, as there was no record confirming whether the resident’s scheduled showers or refusals occurred on the identified dates.
Failure to Notify Responsible Party After Narcan Administration for Suspected Opioid Overdose
Penalty
Summary
The deficiency involves the facility’s failure to notify a resident’s responsible party when there was a significant change in the resident’s medical status requiring emergency medication. A complaint alleged that there was no communication with the responsible party when Narcan (naloxone) was administered to a resident for an alleged opioid overdose. Medical record review showed the resident was admitted in March 2026 with multiple fractures, including a nondisplaced zone 1 sacral fracture, a nondisplaced fracture of the posterior column of the right acetabulum, a fracture of the right pubis, and other chronic pain. The resident’s pain regimen included multiple opioids and other pain medications, including Hydromorphone 6 mg every 4 hours PRN, Hydromorphone 4 mg every 4 hours PRN, Tylenol, Lidocaine cream, Methocarbamol, Celebrex, and Gabapentin. A physician’s note dated 4/8/26 documented that the resident reportedly had an opioid overdose earlier that morning and responded well to Narcan administration by nursing, with the note listing chronic pain and opioid overdose status post Narcan. Further review of the resident’s medical record did not show any documentation that the resident’s representative was notified of this overdose event and Narcan administration. During interviews, an agency LPN stated that the resident was “out of it and not responding” during rounds, prompting the LPN to check for and then administer Narcan, after which the resident responded. Another LPN reported that Narcan was given because the resident appeared to be having an overdose and that the physician saw the resident afterward, but stated, “I don’t think anyone was notified, but should have been.” The DON also stated that she would have expected the responsible party to be notified. These findings confirmed that the facility failed to notify the resident’s responsible party of a significant change in condition and emergency treatment.
Failure to Follow Wound Care Orders and Document Narcan Administration
Penalty
Summary
Facility staff failed to provide treatment and care in accordance with professional standards and physician orders for two residents. For one resident admitted after hospitalization with acute systolic heart failure and peripheral edema, a wound physician initially ordered daily oil emulsion dressings for venous wounds on the right shin, left medial foot, and left second toe. At a follow-up assessment, the wound physician changed the treatment for the left medial foot from oil emulsion to daily skin prep and ordered daily skin prep for a newly identified arterial wound on the left plantar foot. Review of the March 2026 medication and treatment administration records showed staff did not discontinue the oil emulsion or initiate the ordered skin prep to the left medial foot, and did not administer skin prep to the left plantar foot wound from the date of the new orders until the resident was sent to the hospital. The DON confirmed that treatments were not administered per the updated wound care orders during this period. For another resident admitted with multiple pelvic and sacral fractures and chronic pain, the record showed extensive opioid and adjunct pain medication orders, and a physician note documented that the resident reportedly experienced an opioid overdose and responded well to Narcan administration by nursing. However, the medical record contained no nursing assessment of the resident at the time of the event, no documentation of the resident’s condition or vital signs, and no record of Narcan administration or the resident’s response afterward. An agency LPN reported finding the resident unresponsive or "out of it" during rounds, knowing the resident was on significant pain medications, and, after checking for an existing order, administering Narcan, after which the resident returned to baseline. The LPN acknowledged not completing or documenting a change-in-condition assessment, and both the DON and unit manager stated they would have expected an assessment and vital signs to be documented in this situation.
Disinfectant Wipes Left Accessible in Dementia Unit Dining Room
Penalty
Summary
The deficiency involves the facility’s failure to keep the environment free from accident hazards on one locked dementia unit. During a complaint survey regarding unsecured cleaning supplies and the potential for residents to use cleaning wipes for personal use, a surveyor observed disinfectant wipes stored openly on a wire shelf in the dining room of the Seagull Unit, a locked dementia unit. The product labeling on the container directed that it be stored in areas inaccessible to children and specifically stated it was not to be used as a diaper wipe or for personal cleansing and that it was not a baby wipe. At the time of the observation, residents with cognitive impairment were present in the dining room awaiting breakfast. A GNA was in the dining room with the residents during the observation, and the unit manager, an LPN, accompanied the surveyor. The surveyor expressed concern about the wipes being accessible in a public area where cognitively impaired residents were present. The LPN reported she had never seen residents use or attempt to use the wipes and stated staff used them to wipe down tables before and after meals. The GNA stated she was always present when residents were in the dining room, that residents were never left alone there, and that she had never seen a resident use a wipe. The Infection Control Nurse stated she was not aware the disinfectant wipes in the dining room were a concern because no residents had gone near them and confirmed they were intended for staff use to clean tables. The NHA and DON reported they had not been made aware of the concern with the wipes, though the DON stated she understood the concern.
Incomplete Documentation of Narcotic Administration on MAR
Penalty
Summary
The deficiency involves the facility’s failure to maintain complete and accurate medical records in accordance with accepted professional standards for one resident. Review of the resident’s April 2026 Medication Administration Record (MAR) and the Controlled Drug Administration Record showed multiple discrepancies for Hydromorphone, a narcotic medication. On several specific dates in April, the Controlled Drug Administration Record documented that Hydromorphone doses were signed out and given by licensed nursing staff at various times, but the corresponding MAR entries for those same dates and times were left blank, indicating no documentation of administration on the MAR. During interviews, an LPN stated that they sign out the medication on the narcotic sheet but do not document it on the MAR. The DON acknowledged awareness that nurses were signing off on the narcotic sheet but not on the MAR, and a unit manager reported not being aware that nurses were failing to sign the MAR when also signing the narcotic sheet, stating that documentation should occur on both records. The NHA and DON later stated they were not aware of the concern until it was identified by the surveyor and agreed with the findings. These observations and interviews demonstrate that the facility did not ensure that all medication administrations were consistently and accurately documented on the MAR for this resident.
Trusted data from CMS and state health departments
Every citation, penalty and Plan of Correction is sourced from public CMS records (latest release June 24, 2026) and official state health department websites — never guesswork.
Trusted by long-term care providers and associations.
