Fairland Center
Inspection history, citations, penalties and survey trends for this long-term care facility in Silver Spring, Maryland.
- Location
- 2101 Fairland Road, Silver Spring, Maryland 20904
- CMS Provider Number
- 215015
- Inspections on file
- 19
- Latest survey
- November 20, 2025
- Citations (last 12 mo.)
- 4
Citation history
Health deficiencies cited at Fairland Center during CMS and state inspections, most recent first.
Surveyors found overflowing trash, dirty and stained carpeting, unclean resident equipment, and damaged flooring throughout one floor and a nursing unit. The second-floor shower room had black substance on vents, a warped door, broken tiles, a rusty radiator, and peeling paint, with one shower lacking hot water for over a year while still in use. Facility leadership acknowledged these issues, but no immediate corrective actions were observed during the survey.
Surveyors found multiple instances where medications were not properly labeled, secured, or stored, including unattended and unlocked med carts, an unlabeled bottle of eye drops for a resident, expired medical supplies, and a narcotic medication stored in a zip lock bag. Staff confirmed that these practices did not meet facility guidelines and expectations.
Surveyors found significant sanitation and food safety issues, including improper storage of ice scoops, unsanitary dining and kitchen areas, unlabeled food, broken refrigerator seals, and structural disrepair in food prep areas. Staff were unable to verify food expiration dates due to missing labels, and food was not consistently covered during transport. Facility leadership acknowledged these concerns during the survey.
Surveyors identified multiple infection control deficiencies, including unsanitary storage of linens and medical supplies, improper hand hygiene and PPE use by staff, lack of up-to-date TB clearance documentation for two employees, and repeated findings of soiled linens and shared personal care items in a shower room. Staff interviews confirmed awareness of proper procedures, but observations revealed ongoing lapses.
Surveyors identified a failure to maintain adequate ventilation on the second floor, where closets used for biohazard trash and linen storage lacked proper ventilation and were coated in black soot-like debris. Staff and residents reported ongoing concerns about air quality, and inspection revealed missing and clogged HVAC filters, leading to persistent debris accumulation in the area.
A resident was found without access to their call device, which was placed out of reach behind a box on a nightstand. The resident confirmed they could not reach the device, and an LPN was initially unable to locate it, stating the resident always calls them. The issue was observed and acknowledged by the ADON.
A state surveyor observed an agency GNA verbally abusing a resident by repeatedly calling the resident 'crazy' and blaming the resident for work delays. The GNA refused to identify herself and was not wearing a name tag. The incident was confirmed as abuse by facility administration.
A resident was found with a red mark on the forehead by a family member, who reported it to staff but was told it was not reportable. Staff, including a unit manager, LPN, and DON, were aware of the mark and discussed it, but the incident was not reported to authorities as required until prompted by surveyors.
A resident was found with a red mark on the forehead by a family member, who reported it to staff. Staff did not initially report or investigate the incident, and key personnel were not asked to provide written statements. The DON assumed the mark was caused by a TV remote without evidence, and the allegation was only reported and investigated after surveyor intervention.
A resident did not receive necessary oral care, as observed by a surveyor and reported by a family member. Staff interviews revealed confusion over whether nurses or respiratory therapists were responsible for oral care, with respiratory therapists stating they only performed suctioning. Despite a medical order for oral care every shift, documentation was missing for several shifts, indicating the care was not consistently provided.
Surveyors identified that two residents did not receive care according to physician orders and facility protocols. One resident was not provided with required positioning devices or consistent turning and repositioning, and did not receive the prescribed frequency of physical therapy sessions. Another resident receiving psychotropic medications was not monitored for side effects as ordered, with documentation missing for nearly all shifts reviewed. These findings were based on observations, staff interviews, and record reviews.
A closet containing a carpet cleaning chemical was found unlocked and accessible in a resident area by a surveyor during environmental rounds with the DON and Director of Maintenance. Both staff confirmed the unsecured chemical, and attempts to lock the closet were unsuccessful, allowing continued access to the chemical.
A review of employee files and interviews with facility leadership revealed that one GNA did not have documented completion of required abuse training. Despite the facility's use of HealthStream for staff education and the migration of prior training records, no evidence of abuse training was found in the GNA's file or transcripts, confirming the deficiency.
Several residents did not receive the required two showers per week, as confirmed by resident and family interviews and review of clinical records. The DON verified that shower logs matched the reported numbers.
A resident's representative was not provided with written information or offered the opportunity to formulate an advance directive upon admission, despite the presence of a surrogate and certifications of incapacity in the medical record. Review of documentation and interviews with the DON confirmed that the required information and opportunity were not given or documented.
A resident was transferred to a hospital due to a change in condition, but the facility did not provide written notification of its bed hold policy to the resident or their representative as required. Staff interviews indicated inconsistent practices, and no documentation could be found to confirm that the policy was offered or provided at the time of transfer.
Two residents were not provided with summaries of their baseline care plans or medication lists within 48 hours of admission, and the required care plans were not completed on time. Staff interviews and medical record reviews confirmed that the process for timely completion and distribution of BLCPs was not followed or documented as required.
A resident's care plan was not reviewed or revised quarterly as required, with only the initial care plan present in the medical record and no evidence of interdisciplinary team review after admission. The facility's process for tracking care plan reviews did not prompt staff to complete the necessary updates.
A resident left the facility against medical advice, and although the NP notified the primary care provider and DON, the required physician discharge summary was not completed. The medical record lacked a recapitulation of the stay, final status summary, medication reconciliation, and post-discharge care plan, as confirmed by the DON.
A review of staff files revealed that several nurses and nurse aides lacked documentation of required training in areas such as behavioral health, tracheotomy care, ventilator care, resident rights, communication, and abuse prevention. Facility leadership confirmed that these records could not be found, indicating a failure to ensure all staff had completed necessary training prior to working on the units.
A resident with an order for depression symptom monitoring did not have the required behavioral monitoring documented for a month. Review of the clinical record revealed the monitoring was not completed because responsibility was incorrectly assigned to ancillary staff rather than nursing, preventing the task from appearing on the MAR for nursing staff documentation.
A resident's medication regimen review identified a discrepancy between the discharge summary and the active physician order for Lidocaine, with the pharmacist recommending verification and correction. The DON confirmed that the physician did not address this recommendation, and the incorrect order remained active.
Staff failed to follow physician-ordered parameters for medication administration for two residents, including giving antihypertensive and insulin medications outside of specified blood pressure and blood sugar ranges, and administering PRN oxycodone for pain scores below the ordered threshold. The DON confirmed these medications were not given as ordered.
A resident was administered trazodone for insomnia without a documented diagnosis of insomnia in the medical record. The DON confirmed that there was no evidence of the required diagnosis to support the psychotropic medication order, resulting in a deficiency for failure to ensure medications were only used for specific, documented conditions.
Facility staff did not ensure that QAA committee meetings were held quarterly as required, and minimum required members were absent from several meetings. The NHA confirmed that a quarterly meeting was missed and that required attendance was not met at multiple meetings.
A deficiency was identified when mouse droppings and roaches were found in the facility, and it was determined that there was no ongoing preventative pest control program in place. The Director of Maintenance reported that pest control services had lapsed due to a payment issue, and pest issues were only addressed after being observed, rather than through regular prevention.
Staff failed to keep nurse staffing whiteboards current and accurate, with outdated information, missing staffing ratios, and absent names of GNAs. Required staffing postings were also not displayed at the facility entrance, as confirmed by staff interviews including the DON.
The facility failed to maintain a sanitary and comfortable environment, with issues such as water leaks, mold, and damaged furniture observed across multiple units. Ceiling tiles were stained or improperly fitted, and several bathrooms had mold and non-functional bathtubs. Interviews revealed a lack of awareness and action regarding these maintenance issues, impacting residents' right to a safe and clean environment.
A resident in a LTC facility was unable to wear their own clothing due to facility staff's failure to ensure the clothing was clean and available. Despite the resident's preference for personal attire, they were observed in a hospital gown, with their clothing found balled up and wrinkled in the room. Staff interviews revealed a lack of awareness and adherence to procedures for handling residents' clothing.
A resident with a history of epilepsy was administered incorrect doses of Trileptal due to a transcription error in the MAR. The facility failed to notify the physician of this significant medication error, which occurred over several days. The Medical Director confirmed that the physician should have been informed, and the DON acknowledged the issue.
The facility failed to thoroughly investigate multiple incidents of alleged abuse, neglect, and misappropriation of property. In one case, a resident reported inadequate care, but the investigation was incomplete. Another resident was found outside unattended, but the investigation documentation was missing. Additionally, a resident alleged assault by a staff member, but no investigation records were found. In another instance, a resident reported mistreatment, but the facility did not obtain a direct statement from the resident.
The facility failed to assist two residents with activities of daily living (ADLs). One resident was left in a soiled brief for several hours, including during breakfast, despite being dependent on staff for toileting. Another resident, who required assistance with personal hygiene, had excessively long nails with substances under them, as staff did not provide the necessary care. These actions were against the facility's policy of providing timely and adequate ADL assistance.
A resident with Alzheimer's and a history of wandering eloped from the facility despite wearing a wanderguard. The resident exited through an open side door and was found outside by staff. The facility failed to conduct a thorough investigation into the incident, and key staff were unavailable for interviews.
A resident with cerebral palsy and seizures was administered an incorrect dose of Trileptal due to multiple orders in the MAR, leading to extra doses being given. A DDR conducted by the pharmacist failed to identify this irregularity, and the issue was later acknowledged by the DON.
A resident with epilepsy and cerebral palsy was administered an incorrect dose of Trileptal due to conflicting medication orders, resulting in significant medication errors. The facility failed to notify the physician or investigate the error, as confirmed by the Medical Director and DON. No interventions were documented to prevent recurrence.
Facility staff failed to secure treatment carts, leaving them unlocked and unattended in a hallway accessible to residents. An LPN confirmed the carts were unlocked without explanation, and the Regulatory Compliance Advisor acknowledged the issue.
A facility failed to accurately document a resident's use of a wander/elopement alarm on the MDS, despite physician orders and nursing documentation indicating the use of such a device. The discrepancy was identified during a review of the resident's medical record.
The facility failed to ensure accurate medical records, as staff inaccurately documented a resident's wanderguard placement and functionality. Despite the wanderguard being discontinued, multiple LPNs documented it as functional and in place, which was confirmed as an error by the DON.
Failure to Maintain Safe, Clean, and Comfortable Resident Environment
Penalty
Summary
Surveyors identified multiple failures by the facility to maintain a safe, clean, and comfortable environment for residents. On several occasions, overflowing trash cans with bagged trash and cardboard were observed in a hallway closet, accompanied by strong, unpleasant odors. The trash cans and closet walls were dirty, with visible drip marks and black matter. Dirty carpeting with numerous dark stains, pieces of trash on the floor, and brown stains and drip marks on walls and handrails were also noted in resident hallways. Additionally, resident mobility equipment was found in an unclean condition with staining and debris, and furniture in a resident's room was missing drawer knobs. Further observations revealed significant maintenance issues. Multiple areas of damaged laminate flooring were present in main areas leading to the dining area and nursing station. The second-floor shower room had extensive deficiencies, including black substance on vents, a warped and damaged door, broken tiles, a rusty radiator touching the floor, peeling paint on the ceiling, and brown marks around light fixtures. Despite signage indicating a shower stall was out of order due to lack of hot water, the issue had persisted for over a year and a half, and the shower room continued to be used for resident bathing. Throughout the survey, these concerns were acknowledged by facility leadership, including the Director of Nursing, Director of Maintenance, and Regional Director of Nursing. However, no immediate corrective actions were observed during the survey period, and the environmental and maintenance deficiencies remained unaddressed, affecting the overall cleanliness and comfort of the resident environment.
Failure to Properly Label, Secure, and Store Medications
Penalty
Summary
Facility staff failed to ensure that drugs and biologicals were properly labeled, secured, and stored according to accepted professional standards. Surveyors observed three unattended and unlocked medication carts on one wing, and an unlabeled bottle of Azelastine HCl 0.05% eye drops prescribed for a resident, which lacked an open date. Additionally, a plastic container with oxycodone 20mg tablets, labeled with the names of recently admitted residents, was found in an old zip lock bag. An expired Nisus NPWT Canister was also found in the medication storage room. Staff interviews confirmed that multi-use eye drops should be discarded 28 days after opening, and the findings of unlabeled, expired, and improperly stored medications were acknowledged by nursing staff and the DON. On another wing, a round white pill was found on the resident hallway floor, and an LPN disposed of it in the medication cart trash can. Surveyors also observed an unattended and unlocked medication cart on this wing, which was acknowledged by the Regional DON and the nurse assigned to the cart. The nurse confirmed that the facility's expectation is for medication carts to be locked when not in use.
Widespread Sanitation and Food Safety Deficiencies in Food Service Areas
Penalty
Summary
Surveyors identified multiple failures in the facility's food service and sanitation practices. Observations included ice scoops being stored improperly, such as inside or on top of plastic bags on ice carts, and dirty dishes and utensils being placed on the same carts as clean ice and disposable cups. The dining area was found to be unsanitary, with overflowing trash cans, trash and debris on the floor, sticky surfaces, and dirty utensils and dishes left out. Additionally, the kitchen was observed to have a broken refrigerator seal, unlabeled ready-to-eat food, and structural issues such as damaged windows, a ceiling with black debris, cracks, and peeling paint above food prep areas. The kitchen floor was also noted to have crumbs, debris, sticky areas, and pooled water. Further, food transported through resident hallways was not consistently covered, as plate lids did not fit securely. The kitchen window area had makeshift repairs with splintered wood and bent metal, and a food cutting board was stored inappropriately against the window sill. Staff interviewed were unable to provide information on food expiration due to lack of labeling. These deficiencies were acknowledged by various facility staff, including the Food Services Director and the Director of Nursing, during the survey process.
Infection Control Failures and Unsanitary Conditions Identified
Penalty
Summary
The facility failed to maintain a sanitary environment and implement appropriate infection prevention and control practices across multiple areas. Surveyors observed storage closets and supply rooms containing a mix of clean linens, care products, and various forms of trash, including used medical gloves, open and uncapped ointments, personal items, and soiled incontinence briefs in disarray. Some items, such as incontinence briefs, were found touching visibly stained walls, and clean linens were stored on floors coated with black debris and cobwebs. Additionally, respiratory and medical supplies were stored directly on the floor or uncovered on shelves, and personal items were mixed with medical supplies, further compromising sanitation. Staff were observed failing to follow proper infection control protocols, including hand hygiene and the use of personal protective equipment (PPE). In one instance, a nurse donned PPE but handled a personal cell phone and case with gloved hands before entering a resident's room, only correcting the error after surveyor intervention. Another nurse entered a resident's room and handled the resident's bed covers without performing hand hygiene before or after the interaction. There was also a lack of appropriate signage to indicate necessary precautions for residents requiring special infection control measures, such as those with tracheostomies and tube feedings. The facility did not maintain up-to-date documentation confirming that all employees were free from communicable tuberculosis (TB). Two employees' files lacked current evidence of TB clearance, with one file missing any documentation and another containing only an outdated chest x-ray report. Additionally, the 2nd floor shower room was repeatedly found in unsanitary condition, with soiled linens, used personal care items, and open bottles of soap left in the room. Staff interviews confirmed that residents should have individual bathing items, but shared and improperly stored items were observed on multiple occasions.
Failure to Maintain Adequate Ventilation and Air Quality
Penalty
Summary
The facility failed to ensure adequate ventilation on the second floor, as observed during a recertification and complaint survey. A closet used for biohazard trash was found with a ventilation cover on the floor and an uncovered ceiling vent, with no detectable air circulation. Another closet storing backup linens was observed to have no ventilation and contained linens coated in black soot-like debris, along with cobwebs covered in the same material. Staff confirmed that this black soot was a recurring issue in the hallway and had been present for several months. Interviews with facility staff revealed that both staff and residents had reported concerns about breathing in black debris in the affected area. Upon inspection, the Director of Maintenance discovered that HVAC units servicing the area were missing filters on the evaporator side, and the return air filters were heavily clogged with dust and had not been changed for an extended period. Although filters were eventually replaced and cleaned, the Director of Maintenance noted that debris had already accumulated within the ductwork, resulting in ongoing complaints from residents and families about belongings becoming covered in debris after only a few days.
Resident Call Device Not Accessible
Penalty
Summary
A deficiency was identified when a resident did not have access to their call device to request staff assistance. During an observation, the resident's call device was found behind a cardboard box on a nightstand several feet away, making it unreachable from the resident's bed. The resident confirmed in an interview that they could not reach the call device. When the Assistant Director of Nursing (ADON) and a Licensed Practical Nurse (LPN) were involved, the LPN was initially unable to locate the call device and indicated that the resident always calls them directly. The call device was ultimately found and the issue was acknowledged by the ADON.
Failure to Protect Resident from Verbal Abuse by Agency Staff
Penalty
Summary
Facility staff failed to protect a resident from verbal abuse, as evidenced by an incident observed by a state surveyor. During the incident, an agency Geriatric Nursing Assistant (GNA), identified as Staff #22, was seen pointing at a resident in bed and repeatedly calling the resident 'crazy.' The GNA also blamed the resident for causing her to fall behind in her work and refused to identify herself when asked by the surveyor. The GNA was not wearing a name tag at the time of the incident. The surveyor documented that the GNA continued to verbally abuse the resident even after the surveyor identified herself. The facility's internal investigation included a review of Staff #22's statement, in which she did not acknowledge calling the resident 'crazy.' The Administrator confirmed the occurrence of abuse and noted that the Maryland Board of Nursing was notified. The incident involved an agency staff member who became upset during questioning and left the interview prematurely. The report does not provide additional details about the resident's medical history or condition at the time of the incident.
Failure to Timely Report Alleged Abuse
Penalty
Summary
Facility staff failed to report an allegation of abuse involving a resident who was found with a red mark on their forehead. A family member discovered the mark and brought it to the attention of staff, but was told it was not reportable. Photographic evidence confirmed the presence of the mark. Multiple staff members, including a unit manager and an LPN, were aware of the mark and discussed it internally, with the LPN asking the resident abuse-related questions and the GNA reporting the concern to the DON. Despite these actions, the incident was not reported to the appropriate authorities as required. The DON assumed the mark was caused by a TV remote, although no one witnessed this. The administrator later acknowledged that the family member had alleged someone hit the resident and confirmed the incident was reportable, but it had not been reported until after surveyor intervention. The failure to report the suspected abuse in a timely manner constituted a deficiency in the facility's abuse reporting procedures.
Failure to Investigate and Report Alleged Abuse
Penalty
Summary
Facility staff failed to thoroughly investigate an allegation of abuse involving a resident who was found with a red mark on their forehead. A family member discovered the mark and reported it to staff, who informed them it was not reportable. The incident was not initially documented or reported as required. Multiple staff members, including a unit manager and an LPN, observed or were informed about the mark but did not provide written statements or initiate a formal investigation at that time. The DON assumed the mark was caused by a TV remote, although no one witnessed this, and there was no evidence to support this explanation. Interviews revealed that neither the unit manager nor the LPN were asked to provide written statements regarding the incident. The administrator later acknowledged that the family member had alleged someone hit the resident, confirming the event was reportable. However, the allegation was not reported to the appropriate authorities or investigated until after surveyor intervention. The lack of timely reporting and investigation constituted a failure to respond appropriately to an alleged violation.
Failure to Provide Necessary Oral Care Due to Staff Role Confusion and Missed Documentation
Penalty
Summary
A deficiency was identified when a resident did not receive necessary oral care as required. The issue was first brought to attention by the resident's family member, who expressed concern about the resident's oral hygiene. Upon observation, the surveyor noted that the resident's tongue appeared yellow, dry, and crusty, and the front upper teeth had a thick, creamy film. This condition was confirmed during a joint observation with the unit manager, who stated that the respiratory therapist was responsible for oral care, performed one or two times per shift as recommended by respiratory therapy. Further interviews revealed confusion among staff regarding responsibility for oral care. Respiratory therapists reported that their duties were limited to suctioning and that nurses were responsible for oral care. A nurse confirmed that nurses were responsible for oral care and that it should be documented on the MAR/TAR, with an active medical order for oral care every shift. However, review of the treatment administration records showed missing documentation for oral care on several shifts, indicating that the required care was not consistently provided.
Failure to Follow Therapy Orders and Psychotropic Medication Monitoring
Penalty
Summary
The facility failed to provide appropriate treatment and care according to physician orders and resident needs for two residents. For one resident, surveyors observed multiple instances where the resident was lying in bed with their feet in a plantarflexed position, without the required support devices such as boots or splints, despite active medical orders for continuous offloading of heels and regular turning and repositioning every two hours. Therapy staff confirmed that the resident was not seen at the prescribed frequency of five times per week for physical therapy, and there was no documented reason for the missed sessions. Documentation for turning, repositioning, and floating heels was also found to be inconsistent, with several missed entries in the point of care records for the month reviewed. For another resident, the facility failed to ensure proper monitoring for side effects of psychotropic medications. The resident had active orders for two psychotropic medications and a specific order requiring every-shift documentation of whether the resident was free from side effects, with instructions to document any side effects in the progress notes. Review of the medication administration record revealed that this monitoring was not documented for 38 out of 40 shifts over a two-week period, and there were no progress notes indicating side effects or their absence. The DON confirmed that the required documentation was missing and acknowledged that nurses may have misinterpreted the order. These deficiencies were identified through direct observation, interviews with staff, and review of medical records and documentation. The failures included not following therapy recommendations and medical orders for positioning and support devices, as well as not completing required monitoring and documentation for psychotropic medication side effects.
Unsecured Chemical Storage in Resident Area
Penalty
Summary
A deficiency was identified when a surveyor, accompanied by the facility's Director of Maintenance and Regional Director of Nursing, observed that a closet on the A wing between two resident rooms was unlocked and contained a container of carpet cleaning chemical. The surveyor was able to freely access and open the closet door, directly observing the unsecured chemical. Both the Director of Maintenance and Regional Director of Nursing acknowledged and confirmed the surveyor's concern regarding the unsecured chemical. Further, when the Director of Maintenance attempted to lock the closet, it was found that the door could still be pulled open, indicating the locking mechanism was ineffective. The chemical was subsequently removed, but the deficiency was based on the initial unsecured storage.
Lack of Documented Abuse Training for Nursing Staff
Penalty
Summary
The facility failed to provide evidence that all nursing staff had completed required abuse training, as demonstrated by the absence of documentation for one Geriatric Nursing Assistant (GNA) among five employee records reviewed during a recertification and complaint survey. The surveyor thoroughly reviewed the complete employee file for the GNA, including health, training/education, and general employee documents, and found no record of abuse training completion. The Assistant Director of Nursing (ADON) confirmed that such training is required prior to staff starting on the unit and is part of orientation, with annual training on safety and dementia also required. The facility uses HealthStream as its training platform, and the Director of Nursing (DON) stated that transcripts of completed training are printed and placed in employee files. Despite these procedures, a review of the GNA's HealthStream transcript revealed completion of 33 training courses, but none related to abuse training. The ADON and DON indicated that previous training records from a prior platform, Vita Learn, had been migrated to HealthStream, but no evidence of abuse training was found in either system or in the employee's file. The ADON/IP confirmed the absence of abuse training documentation after further review, substantiating the deficiency.
Failure to Provide Required Number of Weekly Showers
Penalty
Summary
Facility staff failed to ensure that residents received showers twice a week, as required. Three residents were identified during interviews and clinical record reviews as not having received the expected number of showers over a specified period. One resident reported receiving only one shower per week, with records confirming 17 showers out of a possible 20. Another resident also stated not receiving two showers weekly, with the same number of showers documented. A third resident's spouse reported only one shower per week, and records showed 12 showers out of a possible 20. The DON confirmed that the shower logs accurately reflected the number of showers provided.
Failure to Provide Advance Directive Information to Resident Representative
Penalty
Summary
A deficiency was identified when a resident's medical record was reviewed and it was found that, although a surrogate had been selected on the Maryland Orders for Life Sustaining Treatment (MOLST) form and two certifications of incapacity were present, there was no documentation that the resident's representative had been provided with written information or offered the opportunity to formulate an advance directive upon admission. The review of the hard chart and medical record did not reveal any evidence that information regarding advance directives was given or discussed with the resident's representative at the time of admission, nor was there documentation of any existing advance directive. The deficiency was confirmed through interviews and record reviews, including a discussion with the DON, who was unable to locate any documentation that the advance directive process had been followed for this resident. The lack of documentation indicated that the facility failed to ensure the resident representative was informed and given the opportunity to create or provide an advance directive as required.
Failure to Provide Written Bed Hold Policy Notification Upon Hospital Transfer
Penalty
Summary
The facility failed to provide written notification of its bed hold policy to a resident or the resident’s representative when the resident was transferred to an acute care hospital. Medical record review for the resident, who was receiving long-term care and was transferred to the hospital due to a change in condition, did not contain documentation that the bed hold policy was offered or provided at the time of transfer. The facility’s policy requires staff involved in the transfer, such as nursing, admissions, or social services, to provide the bed hold notice and authorization form to the resident and/or representative. Staff interviews revealed inconsistent practices regarding the provision of the bed hold policy. An LPN stated that the policy may not always be offered when residents are sent to the hospital, especially in urgent situations. An RN reported that the policy is typically communicated and distributed, with copies sent to the hospital, business office, and the resident’s family. However, when asked to produce documentation for this specific transfer, the RN was unable to locate any evidence in the medical record or elsewhere that the bed hold policy had been provided to the resident or their representative.
Failure to Complete and Distribute Baseline Care Plans Within Required Timeframe
Penalty
Summary
The facility failed to ensure that residents and/or their representatives were provided with summaries of their baseline care plans (BLCP), including a list of medications, and did not complete the BLCP within the required 48-hour timeframe following admission. Specifically, for two residents reviewed, there was no evidence in the medical records that a BLCP summary or medication list was provided within the mandated period. In one case, the section of the medical record designated for documenting that a copy was given to the resident or representative was left unchecked, and the assessment was completed after the 48-hour window. In the other case, the BLCP was completed after the required timeframe, and the responsible staff member confirmed the delay without providing a reason. Interviews with facility staff, including the DON and the Regional Director of Social Services, revealed inconsistencies in the process and responsibility for completing and distributing the BLCP. The staff acknowledged that the process was not followed as required, and there was a lack of documentation to support that residents or their representatives received the necessary information in a timely manner. These findings were based on a review of medical records and staff interviews during the recertification/complaint survey.
Failure to Complete Quarterly Care Plan Reviews
Penalty
Summary
The facility failed to revise care plans for residents on a quarterly basis as required. During a review of medical records and staff interviews, it was found that one resident had only a single care plan documented, which was created at the time of admission. There was no evidence in the medical record that the care plan had been reviewed or revised by the interdisciplinary team (IDT) after the initial development, despite the resident having been admitted for a period that would require at least one quarterly review. The Regional Director of Social Services confirmed during an interview that care plans are supposed to be reviewed every 90 days and acknowledged that the resident in question should have had at least one care plan revision since admission. The facility's process involves using an electronic medical record system to track care plan review tasks, but in this case, the system did not indicate that a review was due, and no subsequent care plan reviews were documented for the resident.
Failure to Complete Discharge Summary for Resident Leaving AMA
Penalty
Summary
A deficiency was identified when a resident left the facility against medical advice (AMA), and the facility failed to complete a required discharge summary. The medical record review showed that the resident expressed a desire to leave AMA, and this was documented by a nurse practitioner, who notified the primary care provider via voicemail and informed the Director of Nursing (DON) about the situation. Nursing progress notes indicated that the resident left the facility accompanied by paramedical transport, with no pain or distress noted, and that the nurse practitioner was made aware of the departure. Despite these actions, the medical record did not contain a discharge summary from the physician. Specifically, there was no documentation providing a recapitulation of the resident's stay, a final summary of the resident's status, reconciliation of pre-discharge and post-discharge medications, or a post-discharge plan of care. The DON confirmed during interviews that a discharge summary should have been completed for any resident leaving the facility, regardless of the circumstances, and acknowledged that this documentation was missing.
Missing Staff Training and Competency Documentation
Penalty
Summary
Facility staff failed to ensure that all nurses and nurse aides received the appropriate training and competencies necessary to care for residents, as evidenced by a review of five employee files. Three staff members were found to be missing documentation of required training in key areas such as behavioral health, tracheotomy care, ventilator care, resident rights, communication, and abuse prevention. Interviews with facility leadership confirmed that these training records could not be located despite searching through employee files. The deficiency was identified during a recertification and complaint survey, based on direct review of staff files and staff interviews.
Failure to Document Behavioral Symptom Monitoring for Depression
Penalty
Summary
Facility staff failed to document the monitoring of behavioral symptoms for one resident who had an order for depression symptom monitoring during the month of April. Clinical record review showed that the required behavior monitoring documentation was missing. During an interview, the DON and surveyor reviewed the electronic health record and found that the responsibility for monitoring had been incorrectly assigned to ancillary staff instead of nursing, resulting in the monitoring task not appearing on the Medication Administration Record for nursing staff to document.
Failure to Address Pharmacist's Medication Recommendation
Penalty
Summary
The facility failed to respond in a timely manner to a recommendation made by the consulting pharmacist regarding a resident's medication regimen. Specifically, the pharmacist identified a discrepancy in the resident's orders, noting that the discharge summary listed a Lidocaine 4% patch, while the active order in the system was for Lidocaine 4% gel. The pharmacist's recommendation, dated 2/18/25, requested verification and correction to ensure the correct item was active for the resident. Despite this recommendation, the Director of Nursing confirmed that the issue was not addressed by the physician, and a subsequent review of the resident's orders showed that the Lidocaine 4% gel order remained active. The resident's name was also missing from the facility's list of residents reviewed with no recommendations for February 2025, indicating a lapse in the medication regimen review process for this individual.
Failure to Administer Medications According to Ordered Parameters and Unnecessary Drug Use
Penalty
Summary
Facility staff failed to ensure that residents received medications according to physician-ordered parameters, resulting in the administration of unnecessary drugs. For one resident, Atenolol was administered on multiple occasions despite the resident's systolic blood pressure being below the ordered threshold of 110, and Humalog insulin was given even when the resident's blood sugar was below the ordered hold parameter of 100. These actions were confirmed through clinical record review and acknowledged by the Director of Nursing, who stated that administering insulin outside of parameters was an ongoing issue among nursing staff. Additionally, another resident was prescribed oxycodone to be administered as needed for moderate pain, defined as a pain score of 4-7. However, staff administered oxycodone when the resident's documented pain scores were below the ordered threshold, with pain assessments recorded as 2 or 3 at the time of administration. The Director of Nursing confirmed that the pain medication was not administered according to the physician's parameters, as evidenced by the medication administration records and pain assessments.
Psychotropic Medication Administered Without Documented Diagnosis
Penalty
Summary
Surveyors identified that a resident was receiving trazodone HCL 50 mg via gastrostomy tube at bedtime for insomnia. Upon review of the resident's medical record, there was no documented diagnosis of insomnia to support the use of this psychotropic medication. The order for trazodone specified its use for insomnia, but the required corresponding diagnosis was absent from the resident's medical documentation. Interviews with the Director of Nursing (DON) confirmed that all medications should have an indication and a matching diagnosis in the medical record. The DON verified that there was no evidence of an insomnia diagnosis for the resident in question and acknowledged the lack of documentation supporting the medication order. This failure to ensure that psychotropic medications were only used to treat a specific, diagnosed, and documented condition constituted the deficiency.
Failure to Hold Required QAA Meetings with Proper Attendance
Penalty
Summary
Facility staff failed to demonstrate compliance with requirements for the Quality Assessment and Assurance (QAA) committee, as evidenced by administrative record review and staff interviews. Over the past 12 months, QAA meetings did not occur on a quarterly basis, with a required meeting in October 2024 not held. Additionally, the minimum required committee members were not present at the quarterly meetings in April, July, and October 2024. The Nursing Home Administrator, who has been in charge of QA meetings since September 2024, confirmed these findings during an interview.
Failure to Maintain Preventative Pest Control Program
Penalty
Summary
The facility failed to maintain a preventative pest control program, as evidenced by the presence of mouse droppings and roaches within the building. During the recertification survey and investigation of a specific complaint, it was found that the facility did not have ongoing pest control services. The Director of Maintenance reported that, upon returning to their position in January 2025, they noticed the absence of pest control visits and could not locate any pest control logs. The Director also acknowledged having observed roaches in the facility in the past and stated that pest issues were only addressed after they were observed, rather than through a preventative program. Documentation provided to the surveyor confirmed that the last pest control service occurred in November 2024, and there was a lapse in services due to a payment issue, which resulted in the suspension of the pest control contractor's account. No pest control logs or current contracts were initially available for review, confirming the lack of an active preventative pest control program at the time of the survey.
Failure to Maintain Accurate and Timely Nurse Staffing Postings
Penalty
Summary
Facility staff failed to ensure that nurse staffing information was accurately posted and kept up to date on the staffing whiteboards for both nursing units. During multiple facility tours, surveyors observed that the whiteboards displayed outdated staffing information from previous days, lacked required staffing ratios, and in one instance, did not include the names of Geriatric Nursing Assistants on duty. Additionally, staffing information was not posted at the facility entrance as required. These deficiencies were confirmed through staff interviews, including with the Director of Nursing, who acknowledged the missing and outdated postings.
Facility Fails to Maintain Sanitary and Safe Environment
Penalty
Summary
The facility staff failed to maintain a sanitary, orderly, and comfortable environment, as evidenced by multiple deficiencies observed across several nursing units. During an environmental tour, it was noted that there was water dripping through the ceiling light in the shower of room Dogwood Vent D2-B 3 Bed, with towels on the floor and a musty odor present. The Rehab gym had a spackled ceiling with residual brown stains on the light, and room D1, which was unoccupied, had a toilet filled with feces, dead bugs, and debris on the floor. Ceiling tiles in the hallway and various rooms were stained, missing chunks, or improperly fitted, contributing to the unsanitary conditions. Additional observations included missing vinyl floor tiles, peeling plaster, and damaged furniture in several rooms. In room D8, there were brown circles on ceiling tiles, and the closet door handle was broken. The medical supply room had a ceiling tile covered with a brown stain, and room B12 had an opened enema on the windowsill, ripped pillows, and a ceiling with silver tape holding brown paper. The hallway carpets were stained, and several bathrooms had black mold/mildew, chipped porcelain, and non-functional bathtubs, which were not draining properly. Interviews with staff revealed a lack of awareness and action regarding the maintenance issues. The Maintenance Director had recently resigned, and the Regional Director of Maintenance was unaware of current projects to address the needed repairs. The Director of Housekeeping acknowledged that soiled laundry should not be stored in resident rooms and that many bathtubs were not draining, leading to unclean appearances. The Nursing Home Administrator was aware of the building's need for repairs, but the deficiencies persisted, impacting the residents' right to a safe, clean, and comfortable environment.
Resident's Right to Wear Personal Clothing Not Honored
Penalty
Summary
The facility failed to ensure that a resident's right to a dignified existence and self-determination was honored, as evidenced by the inability of a resident to wear their own clothing. The resident, who was dependent on staff for activities of daily living due to conditions including hemiplegia and heart disease, was observed on multiple occasions wearing a hospital gown instead of their personal clothing. The resident expressed a preference for wearing their own clothes but believed they did not have any available at the facility. Observations revealed that the resident's clothing was present in the room but was balled up and wrinkled, and it was unclear whether the clothing was clean or dirty. Interviews with facility staff, including GNAs and the DON, indicated a lack of awareness and responsibility regarding the resident's clothing. The GNAs were unsure if the resident had personal clothing, and the DON was unaware of the condition of the clothing found in the resident's room. The facility's policy required GNAs to bag and label soiled clothing and place it in the soiled linen closet, with the expectation that laundry staff would clean and return the clothing the same day. However, this process was not followed, resulting in the resident's clothing being neglected and the resident being unable to exercise their right to wear their own clothes.
Failure to Notify Physician of Medication Error
Penalty
Summary
The facility failed to notify the physician when a resident experienced a significant medication error. This deficiency was identified during a complaint survey for a resident who was administered the wrong dose of the anti-seizure medication, Trileptal (Oxcarbazepine), over a period of several days. The resident, who had a history of epilepsy and was admitted to the facility following an acute hospitalization, was supposed to receive 900 mg of Oxcarbazepine twice daily. However, due to a transcription error in the Medication Administration Record (MAR), the resident received incorrect doses on ten occasions between November 17 and November 23, 2023. The MAR contained two separate orders for Oxcarbazepine, leading to the administration of incorrect doses. Despite this error, there was no evidence in the medical record that the physician was informed of the medication error. During an interview, the Medical Director confirmed that the physician should have been notified of the error, especially since it occurred over multiple days. The Director of Nurses was made aware of these concerns and acknowledged them during the survey.
Failure to Conduct Thorough Investigations of Alleged Abuse and Neglect
Penalty
Summary
The facility failed to conduct thorough investigations into several incidents of alleged abuse, neglect, and misappropriation of property involving multiple residents. In one case, a resident reported inadequate care, including long response times to call bells, but the facility's investigation was incomplete as it only interviewed a small fraction of the staff who actually cared for the resident during the relevant period. Additionally, the investigation did not follow up on the resident's claims, leaving the issue unresolved. Another incident involved a resident who was found outside the facility unattended. The Director of Nursing (DON) was unable to locate the investigation documentation, and although some related documents were reproduced, there was no evidence of a thorough investigation being conducted. This lack of documentation and follow-up indicates a failure to properly address the incident of elopement. In a separate case, a resident alleged assault by a staff member, but the facility could not provide any investigation records, including interviews with the involved parties. Similarly, another resident reported mistreatment, but the facility failed to obtain a direct statement from the resident, despite having interviewed other staff and residents. These deficiencies highlight the facility's failure to adhere to its own policies and procedures for investigating allegations of abuse and neglect.
Failure to Assist Residents with ADLs
Penalty
Summary
The facility failed to provide adequate assistance with activities of daily living (ADLs) for two residents, R9 and R58, who were dependent on staff for such care. R9, who was cognitively intact and dependent on staff for toileting, was left in a soiled brief with feces from approximately 3:30 AM until after breakfast, which was served at 7:15 AM. Despite turning on the call light and requesting assistance, R9 was not helped until much later, and staff served breakfast while R9 was still in a soiled state. Observations confirmed a strong odor of urine and feces in R9's room, and staff interviews revealed a lack of timely assistance with incontinent care, which was against the facility's policy of checking residents every two hours. R58, who had a BIMS score indicating cognitive impairment and was dependent on staff for personal hygiene, was observed with excessively long nails and dark brown substances under the nail bed. Despite expectations for staff to trim the nails, this care was not provided, and the resident's representative was under the impression that nail care was the family's responsibility due to previous unfulfilled requests for staff assistance. This lack of personal hygiene care was contrary to the facility's policy, which mandates necessary ADL assistance to maintain good personal hygiene.
Failure to Prevent Resident Elopement
Penalty
Summary
The facility failed to provide adequate supervision to prevent a vulnerable resident, identified as an elopement risk, from leaving the facility unattended. The resident, who had Alzheimer's Dementia with behavioral disturbance, was admitted with a history of wandering and attempted elopement. Despite wearing a functioning wanderguard, the resident was able to exit the facility unnoticed and was found outside by a dining service staff member. The incident report did not document how the resident managed to leave the facility undetected. The resident's medical records indicated a history of wandering and attempts to elope, with a care plan in place addressing the risk of elopement due to cognitive loss and dementia. On a specific occasion, the resident was observed walking towards the main road and was redirected back inside. The CRNP noted that the resident had exited through a side door that was left open, which was an uncommon event, but consistent with the resident's history of wandering due to Alzheimer's disease and dementia. The Director of Nurses (DON) was unable to locate the investigation report for the incident and confirmed that the facility did not complete a thorough investigation when the resident eloped. The DON reported that the administrative personnel had changed since the incident, and some staff familiar with the case were unavailable for interviews. The facility was unable to provide evidence of a comprehensive investigation, although some documents related to elopement drills and evaluations were reproduced.
Failure to Identify Medication Irregularities in Drug Regimen Review
Penalty
Summary
The facility staff failed to ensure that medication irregularities were identified during monthly drug regimen reviews for a resident. The resident, who was admitted in mid-November 2023 with diagnoses including cerebral palsy and seizures, was administered an incorrect dose of the anti-seizure medication Trileptal (oxcarbazepine) from November 19, 2023, to November 23, 2023. The hospital discharge summary indicated that the resident should continue with oxcarbazepine 900 mg twice a day, but the Medication Administration Record (MAR) showed two separate orders for oxcarbazepine, leading to the resident receiving an extra dose on multiple occasions. On November 21, 2023, a Drug Regimen Review (DDR) was conducted by the consulting pharmacist, who documented that no irregularities were found. However, the pharmacist failed to identify the irregularity of multiple oxcarbazepine orders and did not refer this issue to the physician. This oversight was later acknowledged by the Director of Nurses, who expressed that the pharmacist should have identified the discrepancy in the resident's medication orders.
Significant Medication Error Due to Incorrect Dosing of Anti-Seizure Medication
Penalty
Summary
The facility failed to ensure that residents were free from significant medication errors, as evidenced by the case of a resident who was administered the wrong dose of Trileptal (Oxcarbazepine), an anti-seizure medication. The resident, who had a history of epilepsy and cerebral palsy, was admitted to the facility following an acute hospitalization. The hospital discharge summary specified that the resident should continue Oxcarbazepine 900 mg twice daily. However, the Medication Administration Record (MAR) showed that the resident received an extra dose of Oxcarbazepine on multiple occasions between November 17 and November 23, 2023, due to two conflicting medication orders. The medical record review revealed that there was no evidence of physician notification or investigation into the medication error. During interviews, the Medical Director and the Director of Nurses (DON) acknowledged that the physician should have been notified of the error, and an incident report should have been completed. Despite these acknowledgments, no additional information or interventions to prevent recurrence were provided by the time of the survey exit.
Unattended and Unlocked Medication Carts
Penalty
Summary
The facility staff failed to ensure that treatment carts were locked and secured when unattended, as observed on one of the three nursing hallways. On December 3, 2024, at 1:41 PM, two medication carts were parked side by side in the C wing hallway, with a nurse preparing medication in front of the first cart. By 1:50 PM, the carts were observed to be unlocked and unattended, accessible to residents and not within direct observation of authorized staff. The surveyor stood near the carts for five minutes before a Licensed Practical Nurse (LPN) approached and confirmed the carts were unlocked without providing an explanation. The Regulatory Compliance Advisor was informed of the situation and acknowledged the concerns without further comment.
Inaccurate Documentation of Resident Assessment on MDS
Penalty
Summary
The facility failed to accurately document a resident's assessment on the Minimum Data Set (MDS). Specifically, the Admission MDS for a resident indicated that the resident did not use a wander/elopement alarm, despite clinical physician orders and nursing documentation showing that the resident had a wander guard/wander elopement device in use since 11/4/23. This discrepancy was identified during a review of the resident's medical record by the surveyor on 5/9/24. Further review of the medical record revealed that the Treatment Administration Records (TAR) for November 2023 documented the use of the wander guard/wander elopement device for the resident. Additionally, an elopement evaluation completed on 11/14/23 indicated that the resident had a history of elopement, wandering, and a desire to go home. The Director of Nursing (DON) was informed of the inaccurate coding in the MDS assessment, which did not align with the physician's orders and the TAR documentation.
Inaccurate Documentation of Wanderguard Placement and Functionality
Penalty
Summary
The facility failed to ensure accurate medical records in accordance with accepted professional standards of practice. Specifically, staff inaccurately documented a resident's wanderguard placement and functionality. A review of Resident #1's progress note indicated that the wanderguard order was discontinued on 04/11/2024, but the physician orders did not reflect this discontinuation until 04/23/2024. Despite the removal of the wanderguard on 04/11/2024, multiple LPNs documented that the wanderguard was functional and in place from 04/12/2024 to 04/22/2024. This discrepancy was confirmed during an interview with the Director of Nursing, who acknowledged the error in documentation and the failure to update the resident's medical record accurately. The deficiency was identified during a review of Resident #1's Treatment Administration Record (TAR) and progress notes. The TAR contained orders to check the functionality and placement of the wanderguard every shift, yet the documentation inaccurately reflected that the wanderguard was still in use after it had been discontinued. The Director of Nursing confirmed that the order to discontinue the wanderguard was not entered into the resident's medical record, leading to the inaccurate documentation by multiple LPNs. This failure to maintain accurate medical records compromised the facility's adherence to professional standards of practice.
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Facility staff did not ensure that 2nd floor residents who could not use stairs were able to receive visitors when the only elevator was out of service for an extended period. Complaints indicated that some family members, who were themselves unable to ambulate stairs, could not visit their relatives on the 2nd floor during this time. The emergency plan directed non-ambulatory 2nd floor residents to remain on that floor unless there was an emergency and did not address how visitation would be maintained when the elevator was inoperable. The Administrator reported that visitors could use the stairs and that an emergency chair system could be used to move residents, but also stated that the chair system was not used for visitation and was unaware of any complaints, despite two having been filed.
Facility staff did not complete required quarterly smoking safety assessments for several residents identified as smokers, including some who had not been reassessed for many months and one who had never been assessed during their stay. This issue was discovered during a complaint survey after the facility’s only elevator was out of service for an extended period, affecting a group of residents on an upper floor who needed to reach a designated smoking area on a lower floor. Review of records and staff interviews, including with the DON and a unit manager, confirmed that the facility’s own practice of quarterly smoking safety assessments for smokers was not followed for half of the affected residents.
Facility staff failed to accurately code multiple MDS assessments for several residents, leading to discrepancies between MDS entries and MARs for pain management, falls, and high-risk drug classes. In several cases, scheduled pain management was coded as provided when MARs did not show daily pain medications, often because an LPN counted low-dose Aspirin ordered for cardiovascular prophylaxis or heart failure as pain medication, contrary to RAI guidance. One resident’s falls were underreported on the MDS despite two documented falls, and daily use of a topical analgesic and an antiplatelet (Aspirin) was not correctly captured. Other residents had MDS entries indicating use of hypnotic or antianxiety medications when MARs showed none, while actual antidepressant and hypoglycemic medications administered daily were omitted from Section N0415. These errors were confirmed by the involved LPNs during surveyor interviews.
Staff failed to conduct complete investigations into two residents’ abuse allegations. In one case, a resident reported that an employee poked their face and made an obscene gesture, but the investigation lacked a statement from the corporate representative who was first notified of the allegation. In another case, a resident reported that someone in blue clothing put a hand by their face and over their mouth, with a specific GNA identified as the alleged perpetrator; however, the investigation did not include statements from two GNAs who were on duty on the unit at the time of the alleged incident, despite leadership having the opportunity to ensure all relevant documents were present.
Staff failed to create person-centered care plans for two residents, one with mobility limitations and one receiving peritoneal dialysis. For the resident with mobility issues, the care plan did not address the resident’s refusal to use a Hoyer lift and preference for pivot transfers, despite therapy prohibiting pivot transfers and staff awareness of the resident’s resistance. For the resident on peritoneal dialysis, the care plan did not specify that the treatment was peritoneal dialysis, nor did it include the treatment schedule or cycle time frames; an LPN Unit Manager acknowledged using a generalized renal care plan without incorporating the specific dialysis prescription.
A resident’s medical record lacked documentation confirming that scheduled showers or bed baths were provided on multiple dates, and there was also no record of any refusals of care on those days. The DON and an LPN unit manager reported that showers were scheduled on specific shifts and that completed showers and refusals should be documented on shower/skin sheets and in the care plan, but the surveyor found gaps where no such entries existed. This resulted in incomplete ADL documentation and failure to maintain medical records according to accepted professional standards.
A resident with multiple fractures and chronic pain was receiving an opioid-based pain regimen, including PRN hydromorphone. The resident was later found unresponsive and "out of it" by an LPN, who located an order for Narcan and administered it, with the resident responding to the medication. A physician note documented an opioid overdose treated with Narcan. Review of the medical record showed no documentation that the resident’s representative was notified of this significant change in condition and emergency intervention, and staff interviews confirmed that notification likely did not occur, despite the DON’s expectation that the responsible party should have been informed.
Staff failed to follow updated wound care orders and to document an opioid overdose event and Narcan use for two residents. One resident with venous and arterial lower extremity wounds did not receive the prescribed change from oil emulsion to daily skin prep on one foot wound, and did not receive ordered skin prep on a new plantar wound for several days after the wound physician revised the treatment plan. Another resident with multiple fractures and chronic pain, receiving multiple opioid and adjunct analgesics, reportedly experienced an opioid overdose; an LPN found the resident unresponsive, located an existing Narcan order, administered Narcan, and observed the resident return to baseline, but did not complete or document a change-in-condition assessment, vital signs, or the Narcan administration in the medical record.
Surveyors substantiated a deficiency when disinfectant wipes, labeled for storage in areas inaccessible to children and not for personal cleansing, were observed sitting openly on a wire shelf in the dining room of a locked dementia unit while cognitively impaired residents waited for breakfast. A GNA and an LPN present on the unit stated that staff used the wipes to clean tables and that residents were never left alone in the dining room and had not been seen using the wipes. The ICP reported being unaware that the wipes’ placement in the dining room was a concern, and the NHA and DON stated they had not previously been informed about the issue, though the DON acknowledged understanding the concern.
A resident’s medical record showed multiple instances where Hydromorphone, a controlled narcotic, was documented as signed out and given on the Controlled Drug Administration Record but was not documented on the MAR on the same dates and times. An LPN reported signing only the narcotic sheet and not the MAR, while the DON acknowledged awareness that nurses were signing the narcotic sheet without completing the MAR, and a unit manager stated they were unaware this was occurring and that both records should be completed. The NHA and DON agreed with the surveyor’s findings after the issue was identified.
Failure to Ensure Visitation Rights During Elevator Outage
Penalty
Summary
Facility staff failed to ensure that residents residing on the 2nd floor who could not safely ambulate using stairs were able to exercise their right to have visitors when the facility’s only elevator malfunctioned. Complaint reviews showed that family members were unable to visit their relatives on the 2nd floor when the elevator was inoperative, and these family members themselves were unable to use the stairs. An incident report documented that the facility’s only elevator was malfunctioning for an extended period, from 3/28/26 to 4/23/26. During this time, residents who could not use the stairs remained on the 2nd floor, and some of their family members could not access them due to the lack of elevator service. Review of the facility’s emergency plan revealed that it instructed that 2nd floor residents who could not safely use the stairs should remain on the 2nd floor unless there was an emergency, and it did not include any provisions for maintaining visitation when the elevator was inoperable. In an interview, the Administrator stated that visitors could use the stairs to visit 2nd floor residents and that residents could be transported using an emergency chair system to meet visitors who could not use the stairs. However, the Administrator acknowledged that the emergency chair system was not used for visitation purposes during the elevator outage and reported being unaware of any complaints about the inoperative elevator, despite two complaints having been received by OHCQ. No additional documentation was provided to show a plan to support visitation for 2nd floor residents during the elevator malfunction.
Failure to Complete Required Quarterly Smoking Safety Assessments
Penalty
Summary
Facility staff failed to update smoking safety assessments at least once every three months for multiple residents identified as smokers. During a complaint survey focused on smoking safety, surveyors reviewed an incident involving the facility’s only elevator being inoperative for nearly a month, which affected residents who lived on the 2nd floor and needed to access the 1st-floor smoking area. The facility’s investigation identified a group of 10 residents on the 2nd floor who smoked and required additional accommodations to safely ambulate to the designated smoking area. Review of these residents’ medical records showed that 5 of the 10 did not receive quarterly smoking safety assessments as required by the facility’s practice. Specifically, four residents had not received a smoking assessment since May 2025, and one resident had no documented smoking assessment at any time during their stay. During interviews, the Unit Manager stated that residents identified as smokers are to be assessed quarterly for smoking safety. When the surveyor pointed out the missing assessments, the DON reviewed the records and confirmed that these residents had not received the required quarterly smoking assessments. This lack of timely reassessment occurred in the context of an extended elevator outage that necessitated special consideration for safe smoking access for residents residing on the 2nd floor.
Inaccurate MDS Coding for Pain Management, Falls, and High-Risk Drug Classes
Penalty
Summary
Facility staff failed to ensure that Minimum Data Set (MDS) assessments were accurately coded for multiple residents, based on medical record review and staff interviews. For one resident with cerebrovascular disease, an MDS with an Assessment Reference Date (ARD) of 3/2/26 coded Section J0100A (scheduled pain management) as "yes," but the March Medication Administration Record (MAR) did not show daily pain medication administration. An LPN stated she coded it that way because the resident received Aspirin 81 mg daily, although the physician’s order showed the Aspirin was prescribed as prophylaxis for cardiovascular events, and the RAI Manual specifies that medications not primarily intended for pain relief should not be coded as pain management. Another resident with cerebral infarction, congestive heart failure, and vascular dementia had two documented falls in progress notes between the prior assessment and the ARD of 2/4/26, but Section J1900 (number of falls since admission or prior assessment) captured only one fall. The same MDS coded Section J0100A (scheduled pain management) as "no" despite the February MAR documenting daily use of Diclofenac topical gel for pain. The MAR also showed daily Aspirin 81 mg for coronary artery disease, but Section N0415 (high-risk drug classes) did not capture the use of an antiplatelet medication. The responsible LPN confirmed missing the second fall and the Aspirin coding error. Additional residents had similar discrepancies: one resident’s MDS repeatedly coded use of hypnotic medications in Section N0415 when MARs showed no hypnotics administered, and failed to capture an antidepressant (Sertraline) that was given; the LPN reported coding Clonazepam as a hypnotic based on dual use, though reference guidelines did not classify it as such. Further inaccuracies were identified for other residents in pain management and high-risk drug class coding. One resident’s MDS with an ARD of 1/8/26 coded receipt of PRN pain medication in Section J0100A, but the January MAR showed no PRN pain medications given; a later MDS for the same resident coded use of an antianxiety medication in Section N0415, while the April MAR showed no such medication administered. Another resident with traumatic subarachnoid hemorrhage, type 2 diabetes with neuropathy, atrial fibrillation, and atherosclerotic heart disease had an MDS with an ARD of 2/3/26 that coded scheduled pain medication as "yes" and PRN pain medication as "no," although the MAR showed intermittent PRN Tylenol for pain and no daily pain medication, and also documented daily Aspirin 81 mg for heart failure and daily Rybelus for diabetes; the MDS failed to capture PRN pain use, incorrectly coded daily pain medication, and did not code hypoglycemic medication in Section N0415. Another resident with a history of stroke and right-sided hemiplegia/hemiparesis had two MDS assessments in February coded as receiving scheduled pain medication, but the February MAR did not show daily pain medication; the LPN reported coding based on daily prophylactic Aspirin 81 mg, which was not ordered for pain.
Incomplete Investigations of Resident Abuse Allegations
Penalty
Summary
Facility staff failed to complete thorough investigations of two separate resident allegations that were reported to the state agency. For the first incident, a resident alleged that on a specific date and time an employee poked two fingers into their face and showed them their middle finger. The five-day follow-up documented the allegation, but the investigation file did not clearly identify who was the first point of contact for the report. During interview, the Administrator stated that a corporate representative was initially made aware of the alleged incident, but there was no statement from this corporate representative included in the investigation file. The Administrator described their usual investigation process as interviewing involved parties, identifying and interviewing witnesses, reviewing staffing for the date of the alleged incident, and interviewing the resident’s roommate and other nearby residents if there were no direct witnesses. In the second incident, a resident reported that during a specific shift someone wearing blue put a hand by their face and over their mouth, and a particular GNA was identified as the alleged perpetrator. Review of the staffing sheet for the time of the alleged incident showed that two GNAs were working on the unit where the incident was reported to have occurred. However, the investigation file contained no statements or interviews from these two GNAs. Prior to the surveyor’s review of the investigation, the DON and a regional nurse were given the opportunity to review the investigation to ensure all necessary documents were available, yet the statements from the two GNAs remained absent. These omissions demonstrated that the facility did not conduct complete investigations into the reported allegations.
Failure to Develop Person-Centered Care Plans for Mobility and Peritoneal Dialysis Needs
Penalty
Summary
Facility staff failed to develop and implement person-centered care plans that addressed all identified needs for two residents, one with mobility limitations and one receiving peritoneal dialysis. For the resident with mobility limitations, the care plan included interventions for resistance to care and adjustment issues, but did not address the resident’s specific resistance to use of a Hoyer lift and the resident’s insistence on pivot transfers from bed to wheelchair. The Unit Manager confirmed that the resident was resistant to care, did not like the Hoyer lift, and preferred pivot transfers, but also stated that physical therapy had prohibited pivot transfers. Despite this known conflict between the resident’s preferences and therapy restrictions, the care plan lacked individualized interventions related to the resident’s resistance to the Hoyer lift and continued request for pivot transfers. For the resident receiving peritoneal dialysis, review of the electronic health record showed an order for peritoneal dialysis, but the resident’s care plans did not include a person-centered care plan specific to this treatment. The existing dialysis care plan did not specify the type of dialysis treatment being provided, did not document when the resident was scheduled to receive the treatment, and did not include time frames for the dialysis cycles. During an interview, the LPN Unit Manager stated that they do not place the dialysis prescription details into the care plan and instead use a generalized renal care plan by selecting standard items, confirming that the care plan was not individualized to the resident’s ordered peritoneal dialysis regimen.
Failure to Document Resident Showers and Refusals
Penalty
Summary
Facility staff failed to maintain complete and accurate documentation of bathing care for a resident, specifically regarding showers and refusals of showers. During a complaint survey, the surveyor requested verification that Resident #5 was receiving scheduled showers. The DON stated that the resident was scheduled for showers on the 3 pm–11 pm shift on Tuesdays and Fridays, and provided shower sheets for several dates in October and early November. However, there was no documentation to verify that the resident received a shower or bed bath on 10/17/25, 10/21/25, and 10/24/25. The DON explained that when a resident receives a shower it is documented on a skin sheet, and that refusals of showers should be documented both in the plan of care and on the shower sheet. Despite this, the surveyor did not receive any documentation indicating that the resident either received bathing care or refused showers on the missing dates. This lack of documentation showed that the facility did not safeguard resident-identifiable information and maintain medical records in accordance with accepted professional standards, as there was no record confirming whether the resident’s scheduled showers or refusals occurred on the identified dates.
Failure to Notify Responsible Party After Narcan Administration for Suspected Opioid Overdose
Penalty
Summary
The deficiency involves the facility’s failure to notify a resident’s responsible party when there was a significant change in the resident’s medical status requiring emergency medication. A complaint alleged that there was no communication with the responsible party when Narcan (naloxone) was administered to a resident for an alleged opioid overdose. Medical record review showed the resident was admitted in March 2026 with multiple fractures, including a nondisplaced zone 1 sacral fracture, a nondisplaced fracture of the posterior column of the right acetabulum, a fracture of the right pubis, and other chronic pain. The resident’s pain regimen included multiple opioids and other pain medications, including Hydromorphone 6 mg every 4 hours PRN, Hydromorphone 4 mg every 4 hours PRN, Tylenol, Lidocaine cream, Methocarbamol, Celebrex, and Gabapentin. A physician’s note dated 4/8/26 documented that the resident reportedly had an opioid overdose earlier that morning and responded well to Narcan administration by nursing, with the note listing chronic pain and opioid overdose status post Narcan. Further review of the resident’s medical record did not show any documentation that the resident’s representative was notified of this overdose event and Narcan administration. During interviews, an agency LPN stated that the resident was “out of it and not responding” during rounds, prompting the LPN to check for and then administer Narcan, after which the resident responded. Another LPN reported that Narcan was given because the resident appeared to be having an overdose and that the physician saw the resident afterward, but stated, “I don’t think anyone was notified, but should have been.” The DON also stated that she would have expected the responsible party to be notified. These findings confirmed that the facility failed to notify the resident’s responsible party of a significant change in condition and emergency treatment.
Failure to Follow Wound Care Orders and Document Narcan Administration
Penalty
Summary
Facility staff failed to provide treatment and care in accordance with professional standards and physician orders for two residents. For one resident admitted after hospitalization with acute systolic heart failure and peripheral edema, a wound physician initially ordered daily oil emulsion dressings for venous wounds on the right shin, left medial foot, and left second toe. At a follow-up assessment, the wound physician changed the treatment for the left medial foot from oil emulsion to daily skin prep and ordered daily skin prep for a newly identified arterial wound on the left plantar foot. Review of the March 2026 medication and treatment administration records showed staff did not discontinue the oil emulsion or initiate the ordered skin prep to the left medial foot, and did not administer skin prep to the left plantar foot wound from the date of the new orders until the resident was sent to the hospital. The DON confirmed that treatments were not administered per the updated wound care orders during this period. For another resident admitted with multiple pelvic and sacral fractures and chronic pain, the record showed extensive opioid and adjunct pain medication orders, and a physician note documented that the resident reportedly experienced an opioid overdose and responded well to Narcan administration by nursing. However, the medical record contained no nursing assessment of the resident at the time of the event, no documentation of the resident’s condition or vital signs, and no record of Narcan administration or the resident’s response afterward. An agency LPN reported finding the resident unresponsive or "out of it" during rounds, knowing the resident was on significant pain medications, and, after checking for an existing order, administering Narcan, after which the resident returned to baseline. The LPN acknowledged not completing or documenting a change-in-condition assessment, and both the DON and unit manager stated they would have expected an assessment and vital signs to be documented in this situation.
Disinfectant Wipes Left Accessible in Dementia Unit Dining Room
Penalty
Summary
The deficiency involves the facility’s failure to keep the environment free from accident hazards on one locked dementia unit. During a complaint survey regarding unsecured cleaning supplies and the potential for residents to use cleaning wipes for personal use, a surveyor observed disinfectant wipes stored openly on a wire shelf in the dining room of the Seagull Unit, a locked dementia unit. The product labeling on the container directed that it be stored in areas inaccessible to children and specifically stated it was not to be used as a diaper wipe or for personal cleansing and that it was not a baby wipe. At the time of the observation, residents with cognitive impairment were present in the dining room awaiting breakfast. A GNA was in the dining room with the residents during the observation, and the unit manager, an LPN, accompanied the surveyor. The surveyor expressed concern about the wipes being accessible in a public area where cognitively impaired residents were present. The LPN reported she had never seen residents use or attempt to use the wipes and stated staff used them to wipe down tables before and after meals. The GNA stated she was always present when residents were in the dining room, that residents were never left alone there, and that she had never seen a resident use a wipe. The Infection Control Nurse stated she was not aware the disinfectant wipes in the dining room were a concern because no residents had gone near them and confirmed they were intended for staff use to clean tables. The NHA and DON reported they had not been made aware of the concern with the wipes, though the DON stated she understood the concern.
Incomplete Documentation of Narcotic Administration on MAR
Penalty
Summary
The deficiency involves the facility’s failure to maintain complete and accurate medical records in accordance with accepted professional standards for one resident. Review of the resident’s April 2026 Medication Administration Record (MAR) and the Controlled Drug Administration Record showed multiple discrepancies for Hydromorphone, a narcotic medication. On several specific dates in April, the Controlled Drug Administration Record documented that Hydromorphone doses were signed out and given by licensed nursing staff at various times, but the corresponding MAR entries for those same dates and times were left blank, indicating no documentation of administration on the MAR. During interviews, an LPN stated that they sign out the medication on the narcotic sheet but do not document it on the MAR. The DON acknowledged awareness that nurses were signing off on the narcotic sheet but not on the MAR, and a unit manager reported not being aware that nurses were failing to sign the MAR when also signing the narcotic sheet, stating that documentation should occur on both records. The NHA and DON later stated they were not aware of the concern until it was identified by the surveyor and agreed with the findings. These observations and interviews demonstrate that the facility did not ensure that all medication administrations were consistently and accurately documented on the MAR for this resident.
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