Forestville Rehabilitation And Wellness Center
Inspection history, citations, penalties and survey trends for this long-term care facility in Forestville, Maryland.
- Location
- 7420 Marlboro Pike, Forestville, Maryland 20747
- CMS Provider Number
- 215020
- Inspections on file
- 20
- Latest survey
- January 12, 2026
- Citations (last 12 mo.)
- 44
Citation history
Health deficiencies cited at Forestville Rehabilitation And Wellness Center during CMS and state inspections, most recent first.
No full-time qualified social worker was employed in a 162-bed facility. Surveyors found that the SSD was not licensed and did not have a college degree, the prior licensed social worker had resigned, and the facility could only report that a regional social worker came monthly without providing evidence of those visits. The DON, NHA, and HRD confirmed the staffing gap during interviews.
Resident Council grievances were not adequately addressed, with repeated concerns documented over several months and no evidence of resident-specific follow-up, resolution, or notification. Concerns included delayed laundry returns, slow call light response, poor staff attitude, medication delays, smoking outings not occurring on time, staff turning off call lights without helping, excessive noise during shift change, and staff using phones or Bluetooth devices. An Activity Director said grievance forms were kept in a missing binder, while the Administrator said concerns should be resolved and communicated back to the complainant.
Food was found improperly labeled and stored during a kitchen tour. Surveyors observed fruit past its use-by date, vegetable soup and fish with no dates, French toast with an unclear date, sliced cheese and cantaloupe with prep and use-by dates that had already passed, and a bin of starch with an expired use-by date. The dietary manager confirmed food should be dated and discarded on the expiration date.
Failure to Ensure Communication Training for Direct Care Staff: An LPN and three GNAs had no evidence of mandatory communication training in their files. Interviews showed the HRD did not complete trainings, the IP/SE relied on Relias modules and in-services, and the facility’s binder and attendance sheets documented multiple care-related trainings but no communication training for the reviewed staff. The IP/SE confirmed the GNA Relias modules did not include communication training and that staff completion tracking was inconsistent.
Surveyors found that the facility did not report two mandatory reportable events to the State Survey Agency. One resident filed a concern that a GNA was roughly handling them, and another resident’s complainant reported a missing wallet/purse and wigs, indicating possible misappropriation. In both cases, the facility documented internal follow-up, but the Administrator and DON acknowledged that these allegations of abuse and misappropriation, which should have been reported to the Office of Health Care Quality, were not reported.
Two residents did not receive timely, ordered diagnostic and specialty services due to failures in the facility’s appointment scheduling process. For one resident, physician orders for a GI consult to evaluate G-tube removal and for an MBSS were not acted upon because the Unit Secretary reported never receiving the appointment request forms from nursing staff, and she only became aware of the needed appointments much later. For another resident with a documented neck mass, a CT neck ordered by the provider was not scheduled before the resident’s transfer to the hospital, where the CT was ultimately completed and an ENT evaluation with possible biopsy was recommended. After discharge, the provider ordered an ENT consult and biopsy, but the appointment was set more than two months later; the appointment scheduler stated this was the earliest date and informed the Unit Manager, who documented only that the family was notified of the date, while the family later reported they were merely told they could try to find an earlier appointment. The resident was subsequently rehospitalized, where a biopsy confirmed oropharyngeal cancer.
Two residents were affected by incomplete and inaccurate medical record documentation. For one resident, two physician certification forms regarding medical condition, decision-making, and treatment limitations were signed and dated but left blank in the section certifying decision-making capacity, and one form had an illegible date, contrary to facility expectations that a physician indicate whether the resident had or lacked capacity. For another resident with vascular dementia and a finger laceration, documentation conflicted on the injury site and pain status: a PA note described pain and active bleeding with bone exposure, while an RN marked on a pain observation tool that the resident did not verbalize or exhibit non-verbal pain. The same tool also incorrectly indicated the resident received scheduled pain medication and no PRN medication, despite the MAR showing only a PRN acetaminophen order and no scheduled pain medication, and other records confirming the injury was to the right pinky rather than the left side as documented in the PA note.
A resident’s chart lacked an advance directive and lacked documentation that the resident was offered information to formulate one. The record contained an Advance Directives section with MOLST forms, but no advance directive documentation, and social services notes did not show that the resident was given the opportunity to complete one. The SSD said the document should have been uploaded, while the DON stated the resident was alert and oriented, had a MOLST, and did not need an advance directive.
A resident received Risperdal with inconsistent documentation supporting schizophrenia or psychosis, and the chart showed frequent changes in dose and indication without proper assessment or timely documentation. MDS coding, psych notes, and provider entries conflicted over whether schizophrenia was present, while the DON validated the lack of proper documentation for the antipsychotic regimen.
Failure to Thoroughly Investigate Abuse and Misappropriation Allegations: The facility did not thoroughly investigate an allegation of suspected abuse involving a resident who reported rough handling and missed dinner assistance, or an allegation of misappropriation involving another resident’s missing wallet/purse and wigs. Documentation was limited, and the DON confirmed that a thorough investigation did not occur for either allegation.
A resident was discharged to home, but the facility could not provide written evidence that the State Ombudsman’s Office was notified of the discharge. The DON said the SW was responsible for ombudsman notification by email, while the SW designee could not verify that the prior SW had sent the notice and was unable to confirm it by phone.
MDS coding was inaccurate for two residents. One resident had documented significant weight loss, but the MDS coded weight loss as no even though the RD confirmed the loss was significant. Another resident had anxiety and unspecified psychosis, was receiving Risperdal for schizophrenia without a verified schizophrenia diagnosis, and the MDS showed inconsistent coding of schizophrenia versus psychotic disorder based on changing documentation and staff direction.
Failure to provide and document baseline care plans for two residents. The facility stated BLCPs were completed within 24 to 48 hours of admission and should be resident-specific, include key care areas such as pain, falls, skin, and ADLs, and be given to the resident or family with a signed receipt in the chart. However, review of the paper chart and EMR for two residents found no BLCPs or signature pages, and MR staff could not locate the records. LPN interviews also showed uncertainty about whether the BLCP was provided or documented.
A resident with paraplegia and a chronic Foley catheter had repeated catheter dislodgements over a short period, with nursing staff reinserting catheters of different sizes and no TAR documentation of the reinsertions. The DON confirmed there was no provider documentation addressing the recurrent issues and no planned urology follow-up, and the DON validated concern that catheter sizes were changed without a specific order.
Failure to Timely Address Significant Weight Loss: The facility did not consistently respond to significant resident weight changes. Records showed one resident with major weight loss over several months, another with severe loss in 30 days, and a third with a 13% weight change in one month. The RD and DON confirmed that weight loss should trigger re-weighing, assessment, documentation, and provider notification, but the survey found delayed assessments, missing documentation, and no evidence that the provider was timely notified for the affected residents.
A resident receiving tube feeding had multiple diet order changes, including transitions between puree/nectar-thickened liquids, NPO, and a pleasure diet, but the record lacked provider assessment and documentation for the changes. The RD noted that pleasure feeding had been discontinued and family agreed, yet no documentation was found for the later return to pleasure feeding, and intake was not monitored because the EMR blocked the intake columns. The DON confirmed that diet order changes should be documented.
A facility failed to ensure required physician face-to-face visits occurred at least every 60 days after the initial 90-day admission period. During a record review, two residents had only an initial physician assessment documented, and one had a single follow-up visit with no further notes for the rest of the year. The DON confirmed the missing 60-day physician documentation.
The facility failed to timely respond to pharmacist MRR recommendations for 3 residents. One resident had an active PRN acetaminophen order that the pharmacist recommended discontinuing, another had repeated recommendations to review risperidone because the diagnosis did not support its use, and a third had a PRN senna order with no provider signature or documented response. The DON confirmed the facility’s process was to print the recommendations, send them to the provider, and file the completed forms, but the survey found the recommendations were not consistently addressed in the medical record.
Medication administration errors exceeded the allowed rate when an LPN failed to instruct a resident to rinse after using an inhaler and an RN used an insulin aspart pen labeled for another resident to prepare insulin for a different resident. The resident’s order was for Fiasp, but the RN withdrew insulin from the wrong single-patient-use pen after noting the resident’s own pen was unavailable.
Delayed Dental Consultation: A resident was observed pointing to his/her mouth and saying it hurt, and had two dental consult orders for teeth complications and difficulty chewing. The dental visit was not documented until months after the first order and nearly a month after the second. The Unit Manager described a monthly Health Drive process, and the DON stated she expected dental consults to be scheduled immediately for discomfort or difficulty chewing.
An infection control deficiency occurred when a wound nurse entered a resident's Contact Precautions room without the required PPE, despite the resident having necrotizing fasciitis, an open foot wound, and MSSA. The room lacked accessible gloves outside the door, the hand sanitizer in the room was not working, and a unit manager described entering the room with a needle and sanitizing only after disposing of it on the med cart. In a separate event, an LPN used the same portable blood pressure machine on multiple residents before med pass without cleaning it between uses.
Missing Mandatory QAPI Training Documentation: The facility failed to ensure staff received required QAPI training. The HRD stated she did not complete trainings, and the IP/SE said staff training was mainly through Relias and in-services documented by attendance sheets. Review of the training binder, manila folders, and employee files showed no QAPI training documentation for a GNA and a HH/FT, and the IP/SE confirmed the sampled employees had no evidence of QAPI training.
The facility failed to ensure staff received compliance and ethics training. Interviews showed the HRD did not complete trainings and the IP/SE relied on Relias modules and in-services, but the binder and attendance folders contained many topics without any compliance and ethics training. Employee files for two staff members also lacked documentation of this required training, and the IP/SE confirmed the onboarding Relias training did not include it.
Failure to Post Required Nursing Staffing Data: Surveyors found that the unit dry erase board displayed the date, census, day-shift GNA/nurse ratios, and assignments, but it did not include the facility name, the total number and actual hours worked by RNs, LPNs/LVNs, and CNAs per shift, or information for other shifts. The DON confirmed the missing information and stated that some staffing details were kept on a schedule in the nurse's station that was not visible to residents or visitors.
A resident with a known history of inappropriate sexual behaviors was able to repeatedly enter female residents' rooms and inappropriately touch others without adequate supervision or intervention, despite a care plan outlining the need for monitoring and redirection. Staff interviews and medical records confirmed ongoing behavioral issues and insufficient preventive actions prior to the implementation of 1:1 supervision.
A resident did not receive multiple scheduled medications and treatments, including high-risk drugs such as insulin, antibiotics, and antihypertensives, within the required timeframes. Audit findings showed repeated late administration over two days, with staff citing short staffing and competing clinical priorities as reasons. Facility policy required timely administration, especially for high-risk medications, but confusion over scheduling and documentation contributed to the deficiency.
Surveyors observed improper storage of ice scoops and disposable cups, with items placed in open containers and partially enclosed in plastic bags close to the floor in the nutrition room. Facility staff, including the DON, acknowledged these concerns during the survey.
Staff failed to perform hand hygiene during medication administration and resident care, as observed when an LPN administered medication and assisted a resident without sanitizing hands, and a GNA handled a resident's overbed table and straw without hand hygiene. Both staff members only acknowledged the issue after it was pointed out by the surveyor.
A resident experienced severe pain after a transfer by a physical therapist, who ignored the resident's request for assistance. Despite being on a pain management regimen, the resident's increasing pain was not adequately addressed or documented by staff. The resident's complaints were dismissed, and there was a lack of communication and documentation regarding the pain, leading to harm.
The facility failed to provide a safe and homelike environment, with surveyors observing water damage, structural issues, and inadequate maintenance responses in residents' rooms and bathrooms. Staff painted over stained ceiling tiles instead of replacing them, and additional deficiencies included non-functional heating/air conditioning units, missing knobs, and unsecured doors. The Director of Maintenance acknowledged these issues during a tour.
The facility failed to provide timely treatment and care, as evidenced by a resident who experienced severe leg pain and a fracture after being transferred without assistance, and another resident who was not consistently wearing a physician-ordered helmet for safety. Staff did not adequately address the pain or ensure the helmet was in place, leading to deficiencies in care.
The facility staff failed to properly store food, maintain sanitary conditions, and monitor freezer temperatures. A surveyor found unlabeled and undated food items in the refrigerator, frost-covered items in the freezer, and a missing thermometer. The Food Service Manager confirmed these issues, and the Dietary Aide was unable to check the freezer temperature. The Maintenance Director was informed about a faulty freezer door handle.
A facility failed to include a discharge summary in a resident's medical record after their planned discharge following successful rehabilitation. During a survey, the absence of a physician discharge summary was noted, and the DON confirmed the missing document upon review.
A resident's dignity was compromised when a housekeeping staff member opened a shower room door without knocking, exposing the resident to others in the hallway. There were no signs indicating the room was occupied, and only staff had access codes to the entry key. An LPN confirmed the resident was independent and did not need assistance.
A resident's preference for showers over bed baths was not honored, as they reported not receiving a shower since a specific date despite requests. Observations noted inadequate personal care, including malodorous breath and dingy bed linens. The resident's records showed they required two-person assistance for bathing and had only received a shower once per week, contrary to their requests and physician orders.
A resident with a history of amputation and neuropathy reported pain after a transfer by a PT, but the facility failed to notify the physician. Despite the resident's complaints and increased requests for Tylenol, the LPN did not contact the doctor, acknowledging the oversight.
A resident's cell phone was wrongfully taken by a GNA while the resident attempted to call 911 for their unwell roommate, whose call light was not answered. The phone was handed to a Nursing Supervisor and later returned after a complaint. The incident was confirmed by interviews with the involved residents and the DON.
A facility failed to conduct quarterly and as-needed care plan meetings for a resident, as required. The resident reported not being invited to participate in such meetings this year or the previous year. The DON stated that the SSD was responsible for organizing these meetings, with oversight from the CSW, who had only recently joined the company and had not been onsite. This lack of oversight and organization resulted in the deficiency.
Two residents did not receive showers as per their care plans, with inconsistent documentation in their EMRs. One resident reported irregular showers, while another's records lacked documentation of scheduled showers, despite receiving bed baths due to wounds. Staff acknowledged the need for proper documentation, but records did not consistently reflect care provided.
A facility failed to provide a resident-centered activities program for a resident, who was often observed lying in bed without engagement. Despite a care plan requiring staff-dependent activities due to cognitive deficits, no 1:1 activities were documented over 30 days, and only two group activities were recorded. Staff interviews confirmed the lack of regular 1:1 activities, and the Administrator could not provide evidence of such activities during the survey period.
A resident was unsafely transferred using a malfunctioning Hoyer lift, with GNAs attempting a manual adjustment while the shower chair's brakes were unlocked. The lift had a damaged remote cord, and maintenance staff were unaware of the damage and uncertain about weight limitations. Inspections focused mainly on battery checks, with the last documented inspection on 5/1/24.
A resident with a neurogenic bladder and an indwelling Foley catheter reported multiple UTIs over two years, indicating insufficient catheter care. Despite a physician's order for regular Foley care, the resident could not recall receiving it since returning from the hospital. An LPN claimed to have provided care but demonstrated a lack of knowledge about the correct cleaning procedure, cleaning only two centimeters instead of the required six inches as per facility policy.
A facility failed to administer oxygen to a resident as prescribed by physician orders. The resident was observed receiving 1 liter of oxygen instead of the ordered 3 liters. A staff member confirmed the error and corrected it after surveyor intervention. The resident's medical record showed a physician order for 3 liters of oxygen every shift for shortness of breath.
A facility failed to maintain a medication error rate of 5% or less, resulting in a 7.41% error rate. Two incidents were observed: one where an RN did not administer Xanax due to it being unavailable and failing to notify the pharmacy promptly, and another where the RN incorrectly prepared a Vitamin D supplement. These errors highlight deficiencies in the medication administration process.
The facility failed to ensure medications were date-labeled upon opening and that medication and treatment carts were securely locked. Nurses were unsure of the correct procedures for labeling insulin bottles, and several carts were found unlocked during the survey, contrary to facility policy.
Facility staff failed to deliver meals at appropriate temperatures. Breakfast trays were prepared and delivered with significant delays, resulting in food temperatures below acceptable levels. A resident dependent on staff for feeding received their meal 28 minutes after preparation. The Food Service Manager acknowledged that thermo-plates should have been used to maintain food temperatures.
A facility failed to accurately document the dates on a resident's PASARR form. During a survey, it was found that the PASARR was missing from the resident's records. The social worker later provided the document, which was incorrectly dated by a social services designee, with both the form and the date of admission recorded as 1964 instead of the correct year, 2024, as per the resident's medical record.
The facility failed to maintain infection control precautions, with issues observed in the kitchen, utility rooms, and laundry areas. Exposed undergarments, improper storage of items, and outdated infection control policies were noted, highlighting lapses in maintaining cleanliness and updated procedures.
The facility failed to provide accessible call bells for residents, as observed during a survey. A resident's call bell was disconnected, another resident had no call bell, and a third resident's call bell was out of reach. Staff confirmed these issues, and the deficiency was reported to the Administrator.
Facility staff failed to maintain a safe and sanitary environment, with issues such as standing water and leaking pipes in the dishwashing area, and chemical buildup and structural damage in the laundry room. The Food Service Manager noted incorrect pipe sizes were used during previous maintenance, and the Maintenance Director was unaware of some issues.
No Full-Time Qualified Social Worker
Penalty
Summary
A facility licensed for 162 beds and operating with a census of 147 did not have a qualified full-time social worker or qualified social services designee employed on a full-time basis. During the recertification/complaint survey, staff interviews and a review of the facility staff roster showed that the facility’s Social Services Director was not licensed and did not have a college degree. The previous licensed social worker had resigned, and the facility reported that a regional social worker came to the building monthly, but no evidence was provided to show when those visits occurred. On interview, the DON identified staff #1 as the Social Services Director but stated that this person was not licensed. The NHA confirmed that the prior social worker had worked at the facility for 4.5 months and that the regional social worker visited monthly. The HR Director confirmed that the Social Services Director did not have a college degree, and the Social Services Director stated that he or she did not have a bachelor’s degree and was working toward SSD certification. The DON and NHA were informed that the lack of a full-time qualified social worker resulted in an extended survey, and they acknowledged the concern.
Resident Council Grievances Not Adequately Addressed
Penalty
Summary
The facility failed to give adequate responses to grievances presented by the Resident Council, as shown by a review of 6 months of Resident Council meeting minutes and interviews with residents and staff. During an interview, Resident #155 stated the facility does not respond to concerns raised in Resident Council meetings, so the same concerns continue to recur. The reviewed minutes lacked resident-specific information, evidence that individual concerns were addressed, and documentation showing any resolution or action taken, including notification of the resident about the outcome. The Resident Council minutes documented repeated concerns across multiple months, including missing or delayed laundry returns, slow call light response, lack of access to an eye doctor, poor staff attitude, inadequate training for new GNAs, delayed medication ordering, residents not being taken out on time for smoking, staff turning off call lights without addressing needs, staff speaking a different language, excessive noise during the 11 PM to 7 AM shift change, staff using Bluetooth devices, staff being on phones, and inability to watch football during the season. Staff interviews indicated the Activity Director kept grievance forms in a binder that was missing, while the Administrator stated concerns were supposed to be assigned to departments, resolved on the form, communicated to the complainant, and returned to him.
Food Items Stored With Missing or Expired Dates
Penalty
Summary
Food was not stored and maintained in accordance with professional standards during the initial kitchen tour. In the large walk-in refrigerator, surveyors found three clear medium-sized containers of fruit with a use-by date of 01/04/2026, one large container of vegetable soup with no date, and French toast in a steel container dated 12/29, with Staff #9 unable to determine whether that date was an open date or a use-by date. A continued observation found a small steel container of fish with no date, a large container of sliced cheese with a prep date of 10/23/2025 and a use-by date of 12/23/2025, and a clear container of cantaloupe with a prep date of 12/23/2025 and a use-by date of 12/30/2025. A further observation found a large bin labeled Starch under the food tray line with a use-by date of 12/28/2025. Staff #9 later confirmed that food should be labeled with a date and discarded on the expiration date.
Failure to Ensure Mandatory Communication Training for Direct Care Staff
Penalty
Summary
The facility failed to ensure that direct care staff received mandatory communication training. During the extended survey portion of the recertification survey, 4 of 6 direct care staff employees reviewed did not have evidence of communication training in their employee files: an LPN and three GNAs. The report states that direct care staff are those who provide care and services through interpersonal contact with residents or resident care management, and that effective communication is a mandatory part of staff training. Interviews with the HRD and the IP/SE showed that the HRD did not personally complete staff trainings and only handled background checks and orientation paperwork. The IP/SE stated that staff completed Relias training scheduled from corporate and that she personally provided some in-services such as handwashing, PPE, and falls. She also stated that staff completed onboarding paperwork on the first day, then Relias, PPD, and flu-related items on the second day, followed by floor orientation. When asked how training participation was tracked, she described attendance sheets kept in a binder in her office, but during review of the binder and manila folders, no staff roster check-off was found to verify that all staff had received the offered education, training, or in-services. Review of the employee files for the LPN and three GNAs showed no communication training documentation. Review of the facility’s training records, including the white 3-ring binder labeled 2025 In Service and the five manila folders, showed multiple in-services on topics such as hand hygiene, PPE, abuse, perineal care, med pass, falls, HIPAA, and other resident care topics, but no communication training attendance sheets were found in those folders. The IP/SE confirmed that the binder and folders contained all training, in-services, and education outside of Relias, and later acknowledged that the Relias training for GNAs did not include communication training. When the surveyor compared the Relias transcripts and attendance sheets, the IP/SE confirmed there was no evidence of communication training for the LPN or the three GNAs and stated there was inconsistency in module scheduling and completion.
Failure to Report Allegations of Abuse and Misappropriation to State Agency
Penalty
Summary
The deficiency involves the facility’s failure to timely report allegations of abuse and misappropriation to the State Survey Agency, the Office of Health Care Quality (OHCQ), as required. Review of facility concern forms for October 2025 showed that one resident submitted a concern form on 10/30/2025 alleging that an assigned geriatric nursing assistant was roughly handling the resident. The facility documented that the geriatric nursing assistant was removed from the assignment and that the Director of Nursing was made aware, but there was no report of this allegation of suspected abuse/neglect to OHCQ. This omission was identified during the recertification/complaint survey through document review. A second concern form from October 2025 documented an allegation from another resident’s complainant that a wallet/purse and wigs were missing from the resident’s belongings, constituting an allegation of misappropriation. The facility’s documented response was to search the room and for the Unit Manager RN to request a receipt from the complainant, but the allegation was not reported to OHCQ. During interviews, the Administrator, who serves as the Grievance Officer, described the grievance process and acknowledged that these specific allegations of abuse, neglect, and misappropriation were not reported to OHCQ. The DON also confirmed that rough handling of a resident is considered physical abuse and that a missing purse or wallet is considered misappropriation, and both are mandatory reportable events that were not reported.
Failure to Timely Arrange Ordered GI, Diagnostic, and ENT Services
Penalty
Summary
The deficiency involves the facility’s failure to follow physician orders and arrange necessary gastrointestinal and diagnostic services for two residents. For one resident, the medical record showed a physician order dated 11/12/25 to schedule a gastrointestinal (GI) appointment for evaluation for gastrostomy tube (G-tube) removal, and a separate order dated 08/13/25 for a modified barium swallow study (MBSS). Interviews with the DON, a Unit Manager LPN, and the Unit Secretary established that the facility’s process required a nurse to relay appointment requests to the Unit Secretary, who would then schedule the appointment and return the details to the nurse for order updating and family notification. The Unit Secretary stated she never received any request for this resident’s MBSS or GI consult and was unaware these appointments needed to be scheduled until 01/07/26, at which point she began making calls to schedule them. The deficiency also includes the facility’s failure to timely arrange a critical diagnostic test and specialty consultation for another resident with a neck mass. The resident’s provider assessed the resident on 10/30/25 and ordered a neck ultrasound, which was performed the same day and showed a left neck solid mass measuring 3 x 2 x 2 cm with a recommendation for a CT of the neck and chest. A CT neck order was placed on 10/30/25 at 11:11 PM, but the CT was not scheduled by the facility before the resident was transferred to the hospital on a later date at 6:30 AM per family request for neck pain management. During that hospital stay from 11/10/25 to 11/11/25, the resident received a CT scan of the neck, which revealed enlarged, partially necrotic, and enhancing left-sided lymph nodes suspicious for metastatic lymphadenopathy, and an ENT evaluation with possible biopsy was recommended. The hospital discharge summary instructed that an appointment with the ENT doctor be made or verified within one week. Following the hospital discharge, the facility provider wrote an order on 11/12/25 for an ENT appointment and possible biopsy, but the ENT appointment was scheduled for 1/22/26. The appointment scheduler stated that this was the earliest available date and that, when a specific time window is required, she informs the doctor’s office so they can adjust the schedule; she confirmed she communicated the details of this case to the Unit Manager. The Unit Manager reported informing the resident’s family member of the earliest ENT appointment and stated the family member said they would look for an earlier appointment themselves, leading the Unit Manager to take no further action to adjust the schedule. However, a progress note documented only that the family was updated about the 1/22/26 appointment as the earliest available, and the family member later stated they were told they could seek an earlier appointment but did not indicate they would handle scheduling entirely on their own. The resident was later transferred back to the hospital for neck pain management, where a biopsy was performed and oropharyngeal cancer was diagnosed. The DON acknowledged that the CT scan and ENT consultation were not arranged in a timely manner.
Incomplete Capacity Certifications and Inaccurate Pain and Injury Documentation
Penalty
Summary
The deficiency involves the facility’s failure to maintain complete and accurate medical records in accordance with accepted professional standards for two residents. For one resident, review of the medical record showed two “Physician’s Certifications Related to Medical Condition, Decision Making, and Treatment Limitations” forms. Although both forms were signed and dated, the section titled “Certification Regarding Decision Making Capacity” was left blank on each form. The provider did not check either box to indicate whether the resident had adequate decision-making capacity or lacked adequate decision-making capacity, including for life-sustaining treatments. During an interview and dual review of the forms, the Regional Director of Clinical Services confirmed that the forms were not completed and acknowledged that it was the facility’s expectation that the physician check one of the boxes. The date on one form, completed by the Medical Director, was also illegible and not easy to decipher. For the second resident, the deficiency centers on inaccurate and inconsistent documentation related to an injury and pain assessment. A facility-reported incident described a GNA calling the assigned nurse to the resident’s room for a laceration to the right pinky finger with bright red blood and swelling. However, a progress note by a physician assistant from a video visit documented the resident as presenting with a laceration to the left leg with bone exposure and active bleeding, and further described the left fifth digit with bone exposure at the base. The resident had a history of vascular dementia and was a poor historian due to cognitive impairment. Review of a Pain Observation Tool for the same date showed that an RN documented “No” to the question asking whether the resident verbalized and/or exhibited non-verbal symptoms of pain, despite the physician assistant’s note stating the resident was experiencing pain and the wound was actively bleeding. Additional review of the Pain Observation Tool revealed further inaccuracies in medication documentation. In the section on pain relief, the RN documented that the resident received scheduled pain medication (“Yes”) and did not receive PRN pain medication (“No”). A dual review of the December medication administration record showed the resident did not have an order for scheduled pain medication but did have an order for PRN acetaminophen 325 mg, two tablets by mouth every six hours as needed for pain or fever, with a maximum daily dose specified. The DON confirmed that this documentation was not accurate. The DON also stated that the resident only had a laceration to the right pinky finger, and a hospital discharge summary verified that the resident was seen for a laceration to the right pinky, further demonstrating discrepancies between the medical record entries and the resident’s actual condition.
Failure to Document and Provide Advance Directive Information
Penalty
Summary
The facility failed to provide a resident with information to formulate an advance directive and failed to ensure that a current copy of the resident’s advance directive was in the medical record. Review of the record for one resident showed no advance directive and no documented evidence that the resident was given an opportunity to formulate one. The record did contain a bolded “Advance Directives” heading in the electronic chart, but there was no advance directive documentation under that section; instead, two MOLST forms were present. During interview, the Social Services Designee stated that residents are asked on admission whether they have an advance directive, that a copy is uploaded if provided, and that if a resident does not have one, one is completed if the resident is alert and oriented. She also stated that if a resident is not alert and oriented, a health care surrogate form is completed. When asked for the resident’s advance directive, she said she would need to check the prior social worker’s desk and acknowledged that it should have been scanned and uploaded during the resident’s nearly one-year stay. The record review also showed five social services notes, but none documented that the resident was offered the opportunity to formulate an advance directive. The DON stated she did not think the resident had an advance directive, explaining that the resident was alert and oriented times three, had a MOLST, and had not been deemed incapable, so she believed an advance directive was not needed. Facility policy stated that on admission the facility will determine whether the resident has executed an advance directive, determine whether the resident would like to formulate one if not, and provide the resident or resident representative with information on how to formulate an advance directive.
Unnecessary Psychotropic Medication and Inconsistent Diagnosis Documentation
Penalty
Summary
The facility failed to ensure that one resident’s medication regimen was free from unnecessary psychotropic medication and chemical restraint concerns. Resident #17 had diagnoses including anxiety and unspecified psychosis not due to a substance or known physiological condition, but was prescribed Risperdal 1 mL by mouth twice daily for schizophrenia even though the record did not support a clinical diagnosis of schizophrenia. The resident’s MDS assessments were inconsistent, with schizophrenia coded on 12/03/24, not coded on several later assessments, and psychotic disorder coded on 12/13/25. The MDS Coordinator stated that corporate directed the facility to inactivate schizophrenia diagnoses for residents because of a CMS memo and that a new schizophrenia evaluation had not yet been completed. Psychiatric documentation also showed inconsistent diagnosis and medication indication entries over time. Notes from January 2025 through January 2026 alternated between documenting schizophrenia, no schizophrenia, psychosis, or no diagnosis while continuing Risperdal use, and one note stated that the presentation did not meet full criteria for schizophrenia and assigned unspecified psychosis instead. The record also showed frequent changes in Risperdal dose and indication between 11/09/23 and 1/09/26, including periods of 0.5 mg BID and 1 mg BID, with no documentation around the 10/12/25 increase from 0.5 mg BID to 1 mg BID. The DON was informed of the lack of proper, timely assessment and documentation and validated the findings.
Failure to Thoroughly Investigate Abuse and Misappropriation Allegations
Penalty
Summary
The facility failed to thoroughly investigate an allegation of suspected resident abuse involving Resident #164 and an allegation of misappropriation involving Resident #163. For Resident #164, a concern form dated 10/30/2025 stated that an assigned geriatric nursing assistant was roughly handling the resident and was not assisting with dinner. The facility’s documented resolution was that the assigned geriatric nursing assistant was removed from the assignment and the DON was made aware, but the only accompanying documentation was a statement from the alleged perpetrator that addressed only not receiving assistance with the dinner meal. For Resident #163, a concern form dated 10/15/2025 documented a complaint about a missing wallet/purse and wigs. The facility’s resolution was to search the room and have Staff #21 request a receipt from the complainant, but the only attached documentation was a Personal Effects Inventory sheet dated 08/18/2025 showing the resident had a pocketbook and wig. During interview, the DON described the facility’s investigation process for abuse and misappropriation and confirmed that a thorough investigation did not occur for either Resident #163’s misappropriation allegation or Resident #164’s abuse allegation.
Failure to Document Ombudsman Notification for Resident Discharge
Penalty
Summary
The facility failed to provide documented evidence that it notified a representative of the Office of the State Long-Term Care Ombudsman when Resident #162 was discharged to home. A review of the resident’s medical record on 01/09/2026 showed the discharge, but there was no written documentation that the State Ombudsman’s Office had been notified. During interviews, the DON stated that the social worker was responsible for ombudsman notification and that it was done by email. The social work designee stated that the previous social work designee was responsible for notifying the ombudsman of the resident’s transfer and discharge for November 2025, but she was not copied on the email and could not verify that the notification was sent. She also stated that she tried to call the ombudsman to verify, but the ombudsman was not available.
Inaccurate MDS Coding for Weight Loss and Psychiatric Diagnosis
Penalty
Summary
The facility failed to ensure that Minimum Data Set (MDS) assessments were accurately coded for resident status for 2 of 32 residents reviewed. For one resident, the medical record showed a weight of 214.0 lbs on 12/9/24 and 181.6 lbs on 6/8/25, reflecting a 32.4 lb, 15.14% weight loss over 6 months. However, the 8/17/25 MDS coded Section K0300, Weight Loss, as no despite the documented significant loss. During interview, the MDS Coordinator stated she did not look at alerts on her dashboard and said the dietician completed that section, while the Registered Dietician confirmed the weight loss was significant and stated the MDS should have been coded as yes. For another resident, the record showed diagnoses of anxiety and unspecified psychosis, and the resident was prescribed Risperdal specifically for schizophrenia even though the clinical record did not verify a schizophrenia diagnosis to support that indication. Review of MDS assessments showed schizophrenia was coded on 12/03/24, then not coded on 05/25/25, 08/21/25, 09/09/25, and 12/13/25, with psychotic disorder captured on the last assessment. The MDS Coordinator stated the resident had been admitted with schizophrenia and explained that corporate office directed staff to inactivate schizophrenia diagnoses due to a CMS memo until new evaluations were completed. Psychiatric notes from January 2025 through November 2025 showed inconsistent documentation of schizophrenia and psychosis. An initial psychiatric assessment documented schizophrenia, later follow-up notes excluded schizophrenia from ICD codes while continuing to reference Risperdal for schizophrenia, and later notes changed the indication for Risperdal from schizophrenia to unspecified psychosis. The DON was informed that the resident's active diagnoses were not accurately coded on the MDS and validated the findings.
Failure to Provide and Document Baseline Care Plans
Penalty
Summary
The facility failed to ensure that a baseline care plan, including a current medication list, was provided to the resident and/or resident representative and documented in the medical record for 2 of 52 residents reviewed. The report states that a baseline care plan was to be completed within 48 hours of admission and include initial goals based on admission orders, physician orders, dietary orders, therapy services, and social services, with a summary and current medication list given to the resident and/or representative and documented in the record. For Resident #1, review of the medical record showed admission to the facility, but no baseline care plan and no evidence that a copy was given to the resident and/or representative. The same was found for Resident #8, whose record also did not reveal a baseline care plan or evidence that it had been provided. During interviews, the DON stated that new admissions received a baseline care plan triggered from the initial assessment and that it was completed within 24 to 48 hours, with four major care plans for pain, falls, skin, and ADLs, plus any other triggered areas. She stated the care plan was resident-specific before being printed and given to the resident and family, and that a signature sheet showing receipt should be in the paper chart. She also stated Unit Managers or the ADON were responsible for providing the copy and obtaining the signature. However, review of the paper chart and EMR for both residents failed to reveal a signature page from around the time of admission, and the medical records staff could not locate records for either resident in the paper files or on the computer. LPN interviews also showed uncertainty about whether the baseline care plan was provided and documented, with one LPN stating she was not sure and did not document that the BLCP was given, and another stating she had not been trained to document receipt or obtain a signature.
Recurrent Foley Catheter Dislodgement Without Provider Orders or Documentation
Penalty
Summary
The Treatment Administration Records contained no documentation of the Foley catheter reinsertions, and there was no documentation from medical providers addressing the repeated dislodgements. An LPN stated that a physician order is required to reinsert a Foley catheter unless a PRN order is already in place. The DON stated nurses are expected to notify providers, assess and document the resident's condition, and follow provider orders regarding catheter size, and confirmed that no urology follow-up was planned for the recurrent catheter issues. The surveyor also raised concern that the catheter size was changed from 16 Fr to 18 Fr and then back to 16 Fr without a specific provider order, and the DON validated that concern.
Failure to Timely Address Significant Weight Loss
Penalty
Summary
The facility failed to timely address and notify the provider for residents with significant weight changes. During the survey, records and staff interviews showed that weight loss concerns were identified through the facility’s dashboard and morning clinical meetings, but the expected follow-through was not consistently documented or completed for several residents reviewed for nutrition. For one resident, the medical record showed a weight of 214.0 lbs on 12/9/24, 173.2 lbs on 3/7/25, and 181.6 lbs on 6/8/25, reflecting a 40.8 lb loss in 3 months and a 32.4 lb loss in 6 months. The RD confirmed that these changes represented significant weight loss and stated that the resident was not on a prescribed weight loss regimen. However, the RD could not provide evidence of interventions put in place after the significant weight loss was noted, and the DON confirmed that the provider should have been notified within 24 hours and evaluated the resident within 24 to 48 hours. The DON also confirmed there was no evidence the provider had been notified on the dates the significant weight loss was identified. For another resident, the record showed a weight of 116 lbs on 12/6/24 and 82 lbs on 1/7/25, a loss of 34 lbs or 29% in 30 days. A dietary progress note was not written until 10 days after the severe weight loss was first noted, and no additional nutritional assessment was found until 3/7/25. The resident’s care plan for altered nutrition status was not initiated until 4/25/25. The RD stated that when the electronic record flags weight loss, the resident should be assessed, progress notes documented, staff and providers notified, and the case discussed in clinical meetings, but the assessment for this resident was not documented when the weight loss was first identified. A third resident had a weight of 212 lbs on 9/5/25 and 183 lbs on 10/7/25, a 29 lb or 13% change in one month. The resident also had multiple hospitalizations during that period. The RD stated that the resident’s weight should have been re-checked and, if confirmed, interventions would then be implemented. The DON confirmed that a resident’s weight should be re-checked within 24 hours of a significant change, and the surveyor found that the severe weight loss was not addressed in a timely manner.
Failure to Monitor and Document Tube-Feeding Diet Changes
Penalty
Summary
The facility failed to monitor, assess, and document a resident’s tube-feeding program. Resident #78 had been receiving tube feeding since May 2025 for adequate nutrition. The resident’s diet orders changed over time, including a puree/nectar-thickened liquid diet, then NPO status, and later a return to a regular diet with puree texture and nectar-thickened liquids. The care plan included tube feeding and pleasure meals, but the record did not contain provider documentation or assessment for the change from pleasure feeding to NPO, and there was no further assessment or documentation for the later change from NPO back to a pleasure diet. A nutrition assessment completed by the clinical dietitian noted that pleasure feeding had been discontinued and that family members were informed and agreed, but no documentation was found for the later diet order change. During interview, the dietitian stated that all diet order changes should be assessed and documented and confirmed she did not have the documentation for Resident #78. She also stated that because it was pleasure feeding, the electronic medical record blocked the intake columns, so it was not monitored. The DON confirmed that staff should document diet order changes and validated the surveyor’s concerns regarding the resident’s diet changes.
Missing Required Physician Face-to-Face Visits
Penalty
Summary
The facility failed to ensure that attending physicians visited residents at the required frequency of at least once every 60 days after the initial 90-day admission period. During a random audit of physician service records for three residents on 1/12/26, the surveyor found that Resident #38, who was admitted on [DATE], had an initial physician assessment on 5/22/25 and a follow-up visit on 6/16/25, but no documentation of any additional physician visits for the remainder of the year. The review also found that Resident #94, who was admitted on [DATE], had an initial physician assessment on 3/31/25 with no further follow-up documentation in the medical record to show subsequent visits. When interviewed on 1/12/26, the DON stated that the facility uses two regular physicians to assess residents and confirmed that physicians are required to document assessments every 60 days following the first 90 days of admission; after reviewing the records with the surveyor, the DON validated that the required 60-day physician notes were missing.
Delayed Response to Pharmacist Medication Review Recommendations
Penalty
Summary
The facility failed to respond in a timely manner to consulting pharmacist recommendations made during monthly medication regimen reviews for 3 residents reviewed for unnecessary medications. The Director of Nursing stated that monthly pharmacy MRRs were received by the Unit Managers, DON, and ADON, printed, given to physicians, and kept in a folder in the DON’s office. The survey found that the pharmacist’s recommendations were not consistently addressed, signed, or documented in the medical record as required by the facility’s stated process. For one resident, a pharmacist recommended discontinuing an active PRN acetaminophen order because it had not been used in the prior 30 to 60 days, but the order remained active in the medical record and the DON could not explain why the recommendation had not been addressed. For another resident, the pharmacist twice recommended review of risperidone because the resident lacked an allowable diagnosis to support its use; the physician responses were incomplete, and the psychiatric nurse practitioner confirmed she had signed the recommendations but had not changed the medication while awaiting a psychiatrist evaluation. For a third resident, the pharmacist recommended review and possible discontinuation of a PRN senna order that had not been used in the prior 30 to 60 days, but the MRR form had no provider signature or documented response, and the DON confirmed no response had been documented or updated.
Medication Administration Errors Exceeded Allowed Rate
Penalty
Summary
The facility failed to keep the medication error rate below 5 percent during a recertification survey, with 2 of 11 residents observed and 2 of 5 nurses observed involved in medication administration errors across 30 opportunities, resulting in a 6.67% error rate. One event involved a nurse administering scheduled morning medications to a resident and giving Duelera 20 mcg/5 mcg inhaler, 2 puffs twice daily, without educating the resident to rinse the mouth after use, and the resident did not rinse independently. A second event involved an RN preparing insulin for a resident with diabetes and using an insulin aspart pen labeled for single-patient use and tagged with another resident’s name. The resident’s order was for Fiasp FlexTouch 100 UNIT/ML, 8 units subcutaneously with meals, but the nurse withdrew 8 units from the incorrect insulin aspart pen for the resident’s blood sugar of 218. The nurse stated the resident’s own insulin pen was unavailable and that he was using a facility, non-resident-specific insulin pen to provide coverage, while the DON later stated that nurses must follow the 5 Rights of Medication Administration and that one resident’s medication may not be used for another resident.
Delayed Dental Consultation
Penalty
Summary
The facility failed to provide timely dental services for Resident #19. On 01/05/2026, the resident was observed pointing to his/her mouth and stating that it hurt. A review of physician orders on 01/06/2026 showed two separate dental consultation orders: one dated 10/3/2025 for teeth complications and another dated 12/9/2025 for difficulty chewing. The resident’s dental visit was documented on 01/06/2026, which occurred three months after the initial dental consult order and nearly 30 days after the second order was placed. During interview, the Unit Manager described the facility’s dental consultation process as completing a Health Drive form and submitting it for a monthly provider visit, with the list of residents to be seen sent two to three days before the visit. The surveyor requested the current dental consult list during the interview. The DON stated that for resident dental concerns such as teeth complications or difficulty chewing, the nurse should complete an oral and pain assessment, notify the physician, and implement a care plan, and she stated her expectation that a dental consult must be scheduled immediately for any discomfort or difficulty chewing.
Infection Control Failures During Contact Precautions and Medication Administration
Penalty
Summary
The facility failed to maintain an effective infection control program when a wound nurse entered a resident's room that was posted for Contact Precautions without wearing the required PPE. The resident's room had a Contact Precautions sign outside the door, and the wound nurse entered the room without donning a gown or gloves. During interview, the nurse acknowledged she had entered and exited the room, stated she only had her mask on, and confirmed that Contact Precautions required a mask, gown, and gloves, but she did not have those items on in the room. The resident involved was admitted with diagnoses including necrotizing fasciitis, an unspecified open wound of the right foot, and MSSA. The surveyor also found that the supply container outside the resident's room contained gowns but no gloves, and the nurse stated she usually got gloves from another room. The hand sanitizer in the resident's room was not working, and there was no hand sanitizer outside the room. A unit manager stated she had entered the room and sanitized after disposing of a needle on the medication cart, and confirmed staff were expected to perform hand hygiene before exiting a Contact Precautions room and to dispose of sharps in the room's sharps container before exiting. The facility also failed to follow infection prevention practices during medication administration. A LPN obtained blood pressure readings on multiple residents using the same portable machine before medication administration and did not clean the machine between each resident use. The surveyor observed the machine used on three residents in sequence, and when the concern was addressed, the LPN acknowledged that the machine had not been cleaned between patient usage.
Missing Mandatory QAPI Training Documentation
Penalty
Summary
The facility failed to ensure staff received mandatory Quality Assurance and Performance Improvement (QAPI) training. During interviews, the Human Resources Director stated that she handled background checks and orientation paperwork but did not complete trainings, and the Infection Preventionist/Staff Educator confirmed that staff training was primarily completed through Relias and a few in-services she provided. She also stated that staff completed onboarding paperwork on the first day, then Relias, PPD, and flu-related items on the second day, followed by floor orientation, and that the facility tracked in-services with attendance sheets kept in a binder in her office. When the surveyor requested documentation for staff training, education, and in-services for 2024 and 2025, the Infection Preventionist/Staff Educator provided a white 3-ring binder labeled 2025 In Service and five manila folders containing attendance sheets. She stated there was no further documentation to provide and indicated that competency documentation for GNAs was in Relias and that nurse competency documentation was in a folder for med pass completion. However, when asked how she verified that all nurses or GNAs completed required trainings, she said she used a staff roster and checked it off, but no roster check-off documentation was produced, and a dual observation confirmed there was no staff roster verification in the materials reviewed. Review of employee files showed that GNA #47, hired on 6/5/24, did not have documentation of communication training, QAPI training, 8 hours of cognitive impairment/mental illness training within 90 days of hire, or 2 hours of annual cognitive impairment/mental illness training for 2025. Heavy Housekeeper/Floor Tech #50, hired on 12/21/23, did not have documentation of QAPI, compliance and ethics, or 1 hour of annual cognitive impairment/mental illness training for 2024 and 2025. Review of the binder and folders showed multiple in-services on topics such as hand hygiene, PPE, abuse, perineal care, fall prevention, and other care-related subjects, but no QAPI training was found in the 2025 binder or the attendance sheets reviewed. The Infection Preventionist/Staff Educator confirmed that the Relias onboarding trainings did not include QAPI training and acknowledged that she did not see any documentation related to QAPI for the sampled employees.
Missing Compliance and Ethics Training Documentation
Penalty
Summary
The facility failed to ensure staff received compliance and ethics training. During interviews, the Human Resources Director stated she only handled background checks and orientation paperwork and did not personally complete trainings. The Infection Preventionist/Staff Educator stated staff completed Relias training assigned by corporate and that she provided some in-services such as handwashing, PPE, and fall education, but she also stated that there was no training on the first day of onboarding and that the second day consisted of Relias, PPD, and flu-related items, followed by floor orientation. When asked how required trainings were tracked, the Infection Preventionist/Staff Educator stated staff signed attendance sheets for in-services and that she kept them in a binder in her office. However, when the surveyor reviewed the white 3-ring binder titled 2025 In Service and the four manila folders, the documentation showed multiple in-services on topics such as effective communication, abuse, hand hygiene, PPE, perineal care, med pass, fall prevention, HIPAA, and other clinical and operational topics, but no compliance and ethics training was found in the binder or folders. The Infection Preventionist/Staff Educator also confirmed there was no staff roster check-off available to verify that all staff had completed the offered education. Review of employee files showed that GNA #48, hired on 6/5/24, did not have compliance and ethics training documented, and HH/FT #50, hired on 12/21/23, also lacked compliance and ethics training documentation. The Infection Preventionist/Staff Educator further confirmed that the Relias onboarding training provided to staff did not include compliance and ethics training, and she acknowledged that there was inconsistency in module completion and that she could not verify that all assigned modules were completed timely.
Failure to Post Required Nursing Staffing Data
Penalty
Summary
The facility failed to post the required nursing staffing data on the nursing units. On 1/5/26, surveyors observed a dry erase board on a nursing unit that displayed the date, unit census, the ratio of GNAs and nurses to residents for the day shift, and the day shift assignments for GNAs and nurses. The board was clear, readable, and in a prominent place accessible to residents and visitors, but it did not display the facility name, the total number and actual hours worked by licensed and unlicensed nursing staff per shift, did not differentiate RNs from LPNs, and did not include information for other shifts. A second observation on 1/9/26 found the same information still posted. During an interview on 1/9/26, the DON stated the facility posted assignments on the board and on the wall, and described the information as staff assignments, special compliance items, group assignments, the patient ratio for GNAs and nurses, the date, and the shift. When the surveyor asked to see where the required staffing information was posted, the DON showed the dry erase board and then the schedule in the back of the nurse's station. The DON confirmed that the facility name was not on the board and that the total number and actual hours worked by RNs, LPNs/LVNs, and CNAs were not included. She also confirmed that the schedule in the back of the nurse's station was not visible to visitors or residents and that the whiteboard also did not include the required facility name or staffing totals.
Failure to Prevent and Investigate Resident-to-Resident Abuse
Penalty
Summary
The facility failed to investigate and take appropriate action to prevent further abuse involving a resident with a documented history of inappropriate sexual behaviors. Medical record review showed that the resident had a care plan in place due to repeated attempts to touch female staff and residents, as well as entering female residents' rooms without permission. Despite these known behaviors, the interventions outlined in the care plan, such as monitoring and redirection, were not effectively implemented, as evidenced by continued incidents of inappropriate touching and unsupervised entry into other residents' rooms. On a specific occasion, the resident was witnessed inappropriately touching another resident, which led to the implementation of 1:1 supervision and a room change. Interviews with staff confirmed that prior to this incident, the resident had been able to access other residents' rooms and engage in inappropriate behaviors without adequate supervision. Social worker progress notes over an extended period also documented ongoing behavioral issues, indicating a pattern of insufficient preventive measures and lack of thorough investigation into the resident's actions.
Failure to Administer Medications and Treatments Timely According to Orders and Standards
Penalty
Summary
The facility failed to ensure timely administration of medications, adherence to medical care orders, and compliance with professional standards of quality for one resident reviewed during a complaint survey. Multiple medications, including high-risk drugs such as antihypertensives, insulin, antibiotics, and wound care treatments, were not administered within the prescribed timeframes. The facility's policy outlined specific requirements for medication administration, including the need for certain medications to be given at exact times and for high-risk medications to be administered within one hour of the scheduled time. Despite these policies, audit reports showed that numerous medications were given several hours late over two consecutive days, and wound care orders were also not completed within the required shift times. Interviews with facility staff revealed that the delays in medication administration were attributed to staffing shortages and competing clinical priorities, such as a nurse attending to another patient in critical condition. Staff members, including an LPN and the Director of Clinical Operations, confirmed that medications like antibiotics, blood pressure medications, and insulin are expected to be administered within a strict one-hour window and should not be liberalized. However, the audit showed that these medications were not given within the required timeframes, and there was confusion regarding the scheduling and documentation of liberalized versus non-liberalized medications. Further, the Medical Director did not express concern about the timeliness of medication administration and deferred to facility staff and regulations for guidance. Documentation reviewed by the surveyor included a resident's complaint about not receiving short-acting insulin as ordered. Additional interviews with nursing leadership indicated that staff were performing multiple roles due to staffing shortages, which contributed to the failure to administer medications and treatments as ordered.
Improper Storage of Ice Scoops and Cups in Nutrition Room
Penalty
Summary
The facility failed to adhere to professional standards for food service safety as observed during a survey related to a complaint about ice storage and handling for resident ice water. During the survey, an ice scoop was found stored on top of and partially within a plastic bag inside an ice scoop holder in the second floor nutrition room. Additionally, an ice scoop for an ice cooler was observed on the bottom rack of an open metal cart, approximately three inches from the hallway floor, stored in an open plastic container and partially enclosed in a plastic bag. A container of disposable plastic drinking cups was also stored on the bottom rack of the cart, similarly close to the floor. These storage practices were observed and confirmed by facility staff, including the Medical Record Coordinator and the Director of Nursing. No information about specific residents, their medical history, or their condition at the time of the deficiency was provided in the report.
Failure to Ensure Staff Hand Hygiene During Resident Care and Medication Administration
Penalty
Summary
The facility failed to ensure staff performed proper hand hygiene during medication administration and resident care, as observed by the surveyor during two separate incidents. In the first instance, a Licensed Practical Nurse (LPN) was observed administering medication to a resident without performing hand hygiene before or after the process. The LPN assisted the resident with taking pills and using a straw, then exited the room still holding the used medication cup and straw, again without performing hand hygiene. The LPN only performed hand hygiene after the surveyor intervened and pointed out the concern. In the second instance, a Geriatric Nursing Assistant (GNA) entered a resident's room, moved the overbed table, and handled a straw for the resident's ice water without performing hand hygiene before or after the interaction. The GNA exited the room without sanitizing their hands, and only acknowledged the concern when it was brought up by the surveyor. Both incidents were confirmed and acknowledged by the facility's Director of Nursing during the survey.
Inadequate Pain Management Leads to Resident Harm
Penalty
Summary
The facility failed to provide adequate pain management for a resident who complained of severe pain, resulting in harm. The resident, who was receiving multiple medications for pain management, reported a popping sound and severe pain in the right leg during a transfer by a physical therapist. Despite the resident's complaints and the presence of two geriatric nursing assistants, the physical therapist insisted on performing the transfer alone and did not respond to the resident's pain complaints. The resident later called 911 due to the pain, but the facility dismissed the call, citing the resident's dementia. The resident's medical records indicated that they were on a regimen of pain medications, including Tramadol, Gabapentin, Lidocaine Patch, Cymbalta, and PRN Acetaminophen. However, the records showed that the resident had not requested Tylenol since September until after the incident. The Medical Administration Record documented the administration of Tylenol for a pain level of 2/10 on several occasions, but there was no evidence of further assessment or escalation of care despite the resident's increasing pain levels reported during therapy sessions. Interviews with staff revealed a lack of communication and documentation regarding the resident's pain. The physical therapist claimed to have notified the charge nurse of the resident's pain, but there was no documentation to support this. The LPN responsible for administering PRN Tylenol did not contact the physician despite the resident's ongoing pain complaints. The facility's failure to adequately assess, document, and address the resident's pain resulted in a delay in appropriate treatment and management of the resident's condition.
Facility Fails to Maintain Safe and Homelike Environment
Penalty
Summary
The facility failed to maintain a safe, clean, and homelike environment for its residents, as evidenced by multiple observations of water damage and inadequate maintenance responses. During an initial tour, a surveyor observed significant water damage in the room and bathroom of two residents, including brown stains on ceiling tiles, a pool of water with black debris on the bathroom floor, and structural damage such as bubbled and cracked walls. The toilet paper dispenser was detached, and gnats were present in the bathroom. Staff responses to these issues were inadequate, with the Environmental Services Manager only noting the need for a deep scrub of the floor and the Maintenance Associate painting over stained ceiling tiles instead of replacing them, due to a lack of available tiles. Further observations during a tour with the Director of Maintenance revealed additional deficiencies, including a non-functional heating/air conditioning unit, missing knobs, chipping paint, and trim issues in various rooms. A crawling bug was found in a bathtub, and blinds in several rooms needed replacement. The shower room door on the first floor did not lock, compromising security. These issues were acknowledged by the Director of Maintenance, who stated an intention to conduct a walkthrough and make necessary repairs. The administration team was informed of these concerns at the time of the survey exit.
Failure to Provide Timely Treatment and Ensure Safety Measures
Penalty
Summary
The facility failed to provide timely treatment and care according to orders and resident preferences, as evidenced by two specific incidents involving residents. In the first case, a resident complained of pain and a possible fracture after being transferred by a physical therapist without assistance, despite the resident's request for help. The resident reported severe pain in the right leg, which was not adequately addressed by the staff. The resident's pain was documented multiple times, but there was no evidence of appropriate follow-up or communication with the nursing staff or physician until an x-ray was ordered weeks later, revealing an acute fracture. In the second incident, the facility did not ensure that a resident's helmet was in place as ordered by the physician. The resident was observed multiple times without the helmet, which was supposed to be worn at all times for safety. Staff interviews revealed a lack of adherence to the physician's orders, with the helmet being removed or not placed on the resident as required. The staff's misunderstanding of the helmet's necessity and the physician's orders contributed to the deficiency. These deficiencies highlight a failure in communication and adherence to care plans and physician orders, resulting in inadequate care for the residents involved. The incidents demonstrate a lack of timely response to resident complaints and a failure to ensure safety measures were consistently applied, as evidenced by the observations and staff interviews conducted during the survey.
Deficiencies in Food Storage and Sanitation Practices
Penalty
Summary
The facility staff failed to properly store food, maintain sanitary conditions, and consistently monitor freezer temperatures, as observed during a survey. During an initial inspection of the kitchen, a surveyor found a white powdery substance on a communal coffee dispenser, brown spots on a food tray rack, and a sticky substance on the kitchen floor. Additionally, the refrigerator contained several unlabeled and undated food items, including a black plastic bag of fruit, a clear bag of bagels, a container of Aquafina water, a bag with beets, and a container with a sandwich. The Food Service Manager confirmed these findings and acknowledged that the items should have been discarded, following the first-in, first-out principle. Further inspection revealed additional issues, such as frost covering items in the freezer, a missing thermometer, and an incomplete freezer temperature log. The freezer contained multiple containers of juice on the floor and an unlabeled container of cooked chicken strips without a date. The Food Service Manager stated that the freezer door might have been left open over the weekend, and the Dietary Aide responsible for logging temperatures was unable to check the freezer temperature due to the missing thermometer. The Maintenance Director was informed about the faulty freezer door handle, which was in the process of being addressed.
Missing Discharge Summary in Resident's Medical Record
Penalty
Summary
The facility failed to include a discharge summary in a resident's medical record following their planned discharge. This deficiency was identified during a survey when a review of the medical record for a resident revealed the absence of a physician discharge summary after the resident was discharged from the facility. The resident had been discharged after successful rehabilitation. An interview with the Director of Nursing confirmed the lack of a discharge summary in the medical record, as the DON was unable to locate it upon review.
Resident Dignity Compromised Due to Inadequate Privacy Measures
Penalty
Summary
The facility failed to treat a resident with dignity by exposing them in a public area. During observation rounds on the 1st floor, a surveyor witnessed a housekeeping staff member opening the shower room door wide open without knocking or checking if it was occupied. This action exposed a resident who was showering to others in the hallway, including residents, staff, and surveyors. There were no signs or notices outside the door indicating that the shower room was in use or that knocking was required before entry. The door had an entry key on the outside, and only staff had codes to access it. The Licensed Practical Nurse confirmed that the resident was independent and did not require assistance while showering, and there was no other system in place to indicate the room's occupancy.
Failure to Honor Resident's Bathing Preferences
Penalty
Summary
The facility failed to honor a resident's choice to receive showers twice a week, as evidenced by observations and interviews conducted by the surveyor. The resident expressed a preference for showers over bed baths and reported not receiving a shower since a specific date, despite having requested them. Observations noted the resident in a hospital gown with malodorous breath and yellow-stained teeth, indicating a lack of proper oral hygiene assistance. The resident's bed linens were also observed to be dingy, further suggesting inadequate personal care. The surveyor reviewed the resident's electronic medical records, which documented that the resident required two-person assistance for bathing and had only received a shower once per week over a four-week period, contrary to the resident's requests and physician orders. The facility's failure to provide showers as per the resident's choice and physician's directive was confirmed through documentation and staff interviews, highlighting a deficiency in promoting and facilitating resident self-determination and choice in personal care routines.
Failure to Notify Physician of Resident's Change in Condition
Penalty
Summary
The facility failed to notify the physician of a change in condition for a resident, which was identified during a survey. The resident, who had a below-the-knee amputation, diabetic neuropathy, and rheumatoid arthritis, reported hearing a popping sound and experiencing pain during a transfer by a physical therapist. Despite the resident's complaints of pain and the presence of two GNAs in the room, the physical therapist instructed them not to assist, and neither the therapist nor the nurse responded to the resident's report of pain. The resident later called 911 due to the pain, but the facility dismissed the call, citing the resident's dementia. The resident's medical records showed they were on multiple pain medications, including Tramadol, Gabapentin, and Tylenol, with the latter being administered as needed. The MAR indicated that the resident began requesting Tylenol for pain on November 22, 2023, and continued to do so frequently, which was a change from their previous pattern. An LPN confirmed administering the Tylenol but did not contact the physician about the increased pain medication requests, acknowledging that perhaps they should have done so.
Misappropriation of Resident's Property
Penalty
Summary
The facility failed to protect a resident from the wrongful use of their belongings, specifically a cell phone, which constitutes misappropriation of property. The incident involved a Geriatric Nursing Assistant (GNA) who took a resident's cell phone while the resident was attempting to call 911 for their roommate, who was not feeling well and whose call light was not being answered by the staff. The GNA removed the phone from the room and handed it over to the Nursing Supervisor, who instructed the GNA to return it to the resident. Interviews with the involved residents confirmed the sequence of events. The resident who attempted to call 911 stated that the GNA took their phone and only returned it after they complained to the nursing supervisor. The roommate corroborated this account, stating that they had asked their roommate to call 911 due to feeling unwell and the staff's failure to respond to the call light. The Director of Nursing validated that the phone was taken without permission, confirming the misappropriation of the resident's property.
Failure to Conduct Timely Care Plan Meetings
Penalty
Summary
The facility failed to ensure that care plan meetings were provided to a resident quarterly and as needed, as required by regulations. This deficiency was identified during a survey when a resident reported not being invited to participate in care plan meetings. The resident stated that they had not had a care plan meeting this year and did not recall having one the previous year. Upon request, the facility could only provide three invitations for care plan meetings, with the most recent being scheduled for a future date, and the others dating back to 2022. The Director of Nursing (DON) explained that care plan meetings should occur quarterly, as needed, and when there is a significant change in the resident's status. The responsibility for organizing these meetings and ensuring residents receive invitations was assigned to the Social Services Designee (SSD), who is not licensed and is currently in school. Oversight was supposed to be provided by the Corporate Social Worker (CSW), who had only been with the company for 30 days and had not been onsite. This lack of oversight and organization led to the failure to conduct timely care plan meetings for the resident in question.
Failure to Document and Provide Scheduled Showers
Penalty
Summary
The facility staff failed to ensure that residents' plans of care were followed and updated according to professional nursing standards, specifically regarding the provision of showers. Resident #134 reported not receiving regular showers since their arrival at the facility, with documented showers only on specific dates. The electronic medical records (EMR) lacked consistent documentation of bathing, and there was a discrepancy between the resident's account and the staff's claims. The Unit Manager confirmed the resident's scheduled shower days but was unable to provide the necessary documentation to verify compliance with the care plan. Similarly, Resident #126's EMR showed a lack of documentation for scheduled showers, with only a few recorded instances of showering. The Unit Manager acknowledged that the resident typically received bed baths due to their wounds, but staff failed to document these occurrences. The Director of Nursing emphasized the importance of documenting care provided and any refusals by residents, yet the records did not reflect consistent adherence to this protocol. These deficiencies highlight a failure in maintaining accurate records and ensuring that residents receive the care outlined in their plans.
Failure to Implement Resident-Centered Activities Program
Penalty
Summary
The facility failed to implement an ongoing resident-centered activities program designed to meet the interests and support the physical, mental, and psychosocial well-being of each resident, specifically for one resident. Observations and interviews revealed that the resident was often found lying in bed without any activities or engagement, such as TV or music, in their room. The resident's care plan indicated a need for staff-dependent activities, cognitive stimulation, and social interaction due to cognitive deficits, with goals for participation in 1:1 visits and movie matinees. However, there was no documentation of any 1:1 activities over the past 30 days, and only two group activities were recorded. Interviews with facility staff, including an LPN and the Activities Lead, confirmed that the resident did not regularly participate in activities and that 1:1 activities were not being conducted as planned. The Activities Lead admitted to not performing regular 1:1 activities with the resident, although they expressed an intention to start. The Administrator was unable to provide evidence of 1:1 room visits for the resident during the specified period. Throughout the survey, the resident was not observed participating in any activities, either group or individual, nor being transported to or from group activities.
Unsafe Transfer and Equipment Maintenance Deficiency
Penalty
Summary
The facility failed to ensure the safety of a resident during a transfer using a Hoyer lift. The incident involved two Geriatric Nursing Assistants (GNAs) attempting to transfer a resident from the lift to a reclining shower chair. The lift malfunctioned, preventing the resident from being raised to the necessary height for a safe transfer. The GNAs were observed attempting to manually adjust the resident while the shower chair's brakes were unlocked, posing a risk to the resident's safety. The surveyor intervened and communicated the safety concerns to the staff, who then locked the chair and completed the transfer. Further investigation revealed that the Hoyer lift used in the transfer had a damaged remote cord, with tape wrapped around it and exposed wiring. The Director of Maintenance was unaware of the damage and expressed uncertainty about the lift's weight limitations. Maintenance staff reported that their inspections primarily involved checking the battery, and the last documented inspection was on 5/1/24. The damaged lift was observed being moved to another hallway for use, indicating a lack of proper equipment maintenance and safety checks.
Deficiency in Foley Catheter Care
Penalty
Summary
The facility staff failed to provide appropriate and sufficient care for a resident with an indwelling urinary catheter, leading to a deficiency. The resident, who has a neurogenic bladder, reported having 4-5 urinary tract infections (UTIs) over the two years they have had the Foley catheter. The medical record indicated a physician's order for continuous drainage with specific instructions for Foley catheter care every shift and as needed, including cleaning with soap and water, securing straps, and documenting output. However, the resident could not recall receiving Foley care since returning from the hospital, indicating a lapse in the care routine. During an interview, an LPN claimed to have provided Foley care earlier in the day, but the resident contradicted this, suggesting a possible oversight or miscommunication. The LPN demonstrated a lack of knowledge regarding the proper cleaning procedure, as she was unsure of the correct length of the catheter tubing to clean. The facility's Catheter Care Policy and Procedures specify cleaning approximately six inches of the catheter from the meatus downward, but the LPN only cleaned about two centimeters. This discrepancy highlights a failure to adhere to established care protocols, contributing to the resident's recurrent UTIs.
Failure to Administer Prescribed Oxygen Levels
Penalty
Summary
The facility failed to administer oxygen to a resident as prescribed by physician orders. During observation rounds, it was noted that the resident was receiving 1 liter of oxygen with humidification via aerosol collar, contrary to the physician's order for 3 liters. A staff member confirmed the discrepancy and adjusted the oxygen level after surveyor intervention. The resident's medical record indicated a physician order dated several months prior, specifying the need for 3 liters of oxygen every shift for shortness of breath.
Medication Administration Errors Lead to Elevated Error Rate
Penalty
Summary
The facility failed to maintain a medication error rate of 5% or less, resulting in a 7.41% error rate during a survey. This deficiency was observed in two separate incidents involving medication administration by RN #6. In the first incident, RN #6 did not administer Xanax to a resident as prescribed due to the medication not being available in the medication cart. Despite the facility's protocol requiring immediate notification to the pharmacy and the Unit Manager when a controlled medication is missing, RN #6 did not follow this procedure, delaying the process by over three hours. In the second incident, RN #6 incorrectly prepared a Vitamin D supplement for another resident. The nurse intended to dispense Vitamin D3 125 mcg but instead retrieved Vitamin D 25 mcg. This error was identified by the surveyor, who intervened and prompted RN #6 to verify the medication and dosage. Both incidents highlight a failure in the medication administration process, contributing to the facility's elevated medication error rate.
Medication Labeling and Cart Security Deficiencies
Penalty
Summary
The facility failed to ensure that medications were properly date-labeled upon opening, as observed during a survey. On the second floor, a registered nurse's medication cart contained bottles of Lantus, Lispro, and Glargine for two residents, all of which had open seals but lacked date labels. The nurse explained that facility policy requires medications to be dated when opened, and insulin expires 28 days after opening. However, she was unsure why the bottles were not labeled by the person who opened them and incorrectly dated a bottle she did not open. On the first floor, another nurse's cart contained an open bottle of Lantus without a date label, and the nurse was unsure of the correct date to use. The Director of Nursing confirmed that the nurse who opens an insulin bottle is responsible for dating it immediately. Additionally, the survey revealed issues with medication and treatment cart security. On one occasion, a medication cart outside a resident's room was found unlocked, and the drawers could be opened without difficulty. A unit manager locked the cart upon noticing the surveyor's presence. The Director of Nursing stated that carts should be locked when not in use. Another incident involved an unlocked treatment cart on Unit 2 South Hall, which was also easily opened. An LPN locked the cart after observing the surveyor and mentioned that it was likely left unlocked by a nurse performing treatments.
Failure to Serve Meals at Appropriate Temperatures
Penalty
Summary
Facility staff failed to ensure that food was delivered to residents at an appropriate and palatable temperature. On the morning of May 30, 2024, the kitchen staff began preparing breakfast trays at 7:05 am. The surveyor observed the preparation of breakfast trays starting at 7:58 am, and by 8:43 am, the last resident tray was prepared. A test tray was requested by the surveyor, and at 8:53 am, the food cart, along with the surveyor and Regional Healthcare Service #11, departed the kitchen to Unit 2. The last food cart arrived on the unit at 8:55 am, but the last breakfast tray was delivered to a resident at 9:08 am, who was dependent on staff for feeding. The resident's food was warmed by GNA #60, and the resident was fed breakfast at 9:11 am, 28 minutes after the tray was prepared. The temperatures of the food on the test tray were checked at 9:11 am by Regional Healthcare Service #11 using a thermometer. The recorded temperatures were: Orange Juice 72.8 F, Oatmeal 113.7 F, Ground Sausage 114.4 F, Eggs 106.4 F, and Turkey Bacon 94.6 F. During an interview later that morning, the Food Service Manager was informed of the test tray temperatures and stated that all meal trays should be served using a thermo-plate to maintain appropriate food temperatures, but was unsure why the dietary staff did not use them.
Inaccurate Documentation of PASARR Dates
Penalty
Summary
The facility failed to accurately document the dates on a resident's Preadmission's Screening and Resident Review (PASARR) form. This deficiency was identified during a surveyor's review of a resident's record, where it was found that there was no PASARR in the resident's paper or electronic chart. Upon inquiry, the social worker indicated that all PASARRs are kept in social services and promised to provide the document. When the PASARR was eventually provided, it was discovered that the form was incorrectly dated by a social services designee, with both the form and the date of admission recorded as 4/8/1964, instead of the correct date of 4/8/2024 as documented in the resident's medical record.
Infection Control Deficiencies in Facility
Penalty
Summary
The facility staff failed to maintain infection control precautions and ensure that the policies and procedures related to infection control were updated. During a survey, several deficiencies were observed. In the kitchen, a dietary aide was seen with exposed undergarments despite previous verbal counseling, and another staff member placed cheese on a cutting board with food particles. On Unit 2 East wing, items such as hand sanitizer and shampoo were improperly stored on a linen cart, contrary to the facility's usual practice of retrieving linen from the Clean Utility Room. Further observations revealed a dirty, uncovered trash can with used gloves in a clean utility room, along with an uncovered IV pole and a dirty walking cane. In the laundry facility, clean linens were left uncovered in the hallway, and personal items were found in the clean laundry folding area. Structural issues such as holes in the wall and a dirty filter on a washing machine were noted. Additionally, the facility's Antibiotic Stewardship Plan had not been reviewed or updated since February 2022, indicating a lapse in maintaining current infection control policies.
Deficiency in Resident Call Bell Accessibility
Penalty
Summary
The facility failed to ensure that residents had access to functioning call bells, as observed during the surveyor's initial tour. For Resident #3, the call bell was found pulled out from the wall, rendering it unusable until reconnected. Resident #66 was observed without a call bell in their room, and upon inquiry, the staff confirmed the absence of a call bell. Resident #66 expressed willingness to use a call bell if provided, and Resident #3 reported that they had been assisting Resident #66 by communicating their needs. Additionally, Resident #49's call bell was found gathered and hung out of reach behind their bed. The resident indicated the location of the call bell when asked, and a staff member confirmed the resident's capability to use it. After the surveyor's intervention, the call bell was retrieved and given to the resident. These observations were shared with the facility Administrator, highlighting the deficiency in providing residents with accessible call systems.
Deficient Environmental Conditions in Facility
Penalty
Summary
Facility staff failed to maintain a safe, sanitary, and comfortable environment, as observed in multiple areas. In the dishwashing area, there were multiple areas of standing water and a leaking pipe under the sink, with a hole around a pipe and corrosion on several pipes under the stainless-steel tables. The Food Service Manager reported that plumbers had serviced the pipes the previous summer but used the wrong size pipes, leading to leaks. In the clean laundry room, two holes were observed in the wall above the door near a vent, and there was a buildup of green and white washing chemicals on the wall near the washing machines. A taped hose was leaking, and in the dryer room, plaster was falling from the ceiling and missing from the wall below the window. The Maintenance Director was unaware of the leaking hose and chemical buildup, attributing the plaster peeling to heat from the dryers.
Latest citations in Maryland
Facility staff did not ensure that 2nd floor residents who could not use stairs were able to receive visitors when the only elevator was out of service for an extended period. Complaints indicated that some family members, who were themselves unable to ambulate stairs, could not visit their relatives on the 2nd floor during this time. The emergency plan directed non-ambulatory 2nd floor residents to remain on that floor unless there was an emergency and did not address how visitation would be maintained when the elevator was inoperable. The Administrator reported that visitors could use the stairs and that an emergency chair system could be used to move residents, but also stated that the chair system was not used for visitation and was unaware of any complaints, despite two having been filed.
Facility staff did not complete required quarterly smoking safety assessments for several residents identified as smokers, including some who had not been reassessed for many months and one who had never been assessed during their stay. This issue was discovered during a complaint survey after the facility’s only elevator was out of service for an extended period, affecting a group of residents on an upper floor who needed to reach a designated smoking area on a lower floor. Review of records and staff interviews, including with the DON and a unit manager, confirmed that the facility’s own practice of quarterly smoking safety assessments for smokers was not followed for half of the affected residents.
Facility staff failed to accurately code multiple MDS assessments for several residents, leading to discrepancies between MDS entries and MARs for pain management, falls, and high-risk drug classes. In several cases, scheduled pain management was coded as provided when MARs did not show daily pain medications, often because an LPN counted low-dose Aspirin ordered for cardiovascular prophylaxis or heart failure as pain medication, contrary to RAI guidance. One resident’s falls were underreported on the MDS despite two documented falls, and daily use of a topical analgesic and an antiplatelet (Aspirin) was not correctly captured. Other residents had MDS entries indicating use of hypnotic or antianxiety medications when MARs showed none, while actual antidepressant and hypoglycemic medications administered daily were omitted from Section N0415. These errors were confirmed by the involved LPNs during surveyor interviews.
Staff failed to conduct complete investigations into two residents’ abuse allegations. In one case, a resident reported that an employee poked their face and made an obscene gesture, but the investigation lacked a statement from the corporate representative who was first notified of the allegation. In another case, a resident reported that someone in blue clothing put a hand by their face and over their mouth, with a specific GNA identified as the alleged perpetrator; however, the investigation did not include statements from two GNAs who were on duty on the unit at the time of the alleged incident, despite leadership having the opportunity to ensure all relevant documents were present.
Staff failed to create person-centered care plans for two residents, one with mobility limitations and one receiving peritoneal dialysis. For the resident with mobility issues, the care plan did not address the resident’s refusal to use a Hoyer lift and preference for pivot transfers, despite therapy prohibiting pivot transfers and staff awareness of the resident’s resistance. For the resident on peritoneal dialysis, the care plan did not specify that the treatment was peritoneal dialysis, nor did it include the treatment schedule or cycle time frames; an LPN Unit Manager acknowledged using a generalized renal care plan without incorporating the specific dialysis prescription.
A resident’s medical record lacked documentation confirming that scheduled showers or bed baths were provided on multiple dates, and there was also no record of any refusals of care on those days. The DON and an LPN unit manager reported that showers were scheduled on specific shifts and that completed showers and refusals should be documented on shower/skin sheets and in the care plan, but the surveyor found gaps where no such entries existed. This resulted in incomplete ADL documentation and failure to maintain medical records according to accepted professional standards.
A resident with multiple fractures and chronic pain was receiving an opioid-based pain regimen, including PRN hydromorphone. The resident was later found unresponsive and "out of it" by an LPN, who located an order for Narcan and administered it, with the resident responding to the medication. A physician note documented an opioid overdose treated with Narcan. Review of the medical record showed no documentation that the resident’s representative was notified of this significant change in condition and emergency intervention, and staff interviews confirmed that notification likely did not occur, despite the DON’s expectation that the responsible party should have been informed.
Staff failed to follow updated wound care orders and to document an opioid overdose event and Narcan use for two residents. One resident with venous and arterial lower extremity wounds did not receive the prescribed change from oil emulsion to daily skin prep on one foot wound, and did not receive ordered skin prep on a new plantar wound for several days after the wound physician revised the treatment plan. Another resident with multiple fractures and chronic pain, receiving multiple opioid and adjunct analgesics, reportedly experienced an opioid overdose; an LPN found the resident unresponsive, located an existing Narcan order, administered Narcan, and observed the resident return to baseline, but did not complete or document a change-in-condition assessment, vital signs, or the Narcan administration in the medical record.
Surveyors substantiated a deficiency when disinfectant wipes, labeled for storage in areas inaccessible to children and not for personal cleansing, were observed sitting openly on a wire shelf in the dining room of a locked dementia unit while cognitively impaired residents waited for breakfast. A GNA and an LPN present on the unit stated that staff used the wipes to clean tables and that residents were never left alone in the dining room and had not been seen using the wipes. The ICP reported being unaware that the wipes’ placement in the dining room was a concern, and the NHA and DON stated they had not previously been informed about the issue, though the DON acknowledged understanding the concern.
A resident’s medical record showed multiple instances where Hydromorphone, a controlled narcotic, was documented as signed out and given on the Controlled Drug Administration Record but was not documented on the MAR on the same dates and times. An LPN reported signing only the narcotic sheet and not the MAR, while the DON acknowledged awareness that nurses were signing the narcotic sheet without completing the MAR, and a unit manager stated they were unaware this was occurring and that both records should be completed. The NHA and DON agreed with the surveyor’s findings after the issue was identified.
Failure to Ensure Visitation Rights During Elevator Outage
Penalty
Summary
Facility staff failed to ensure that residents residing on the 2nd floor who could not safely ambulate using stairs were able to exercise their right to have visitors when the facility’s only elevator malfunctioned. Complaint reviews showed that family members were unable to visit their relatives on the 2nd floor when the elevator was inoperative, and these family members themselves were unable to use the stairs. An incident report documented that the facility’s only elevator was malfunctioning for an extended period, from 3/28/26 to 4/23/26. During this time, residents who could not use the stairs remained on the 2nd floor, and some of their family members could not access them due to the lack of elevator service. Review of the facility’s emergency plan revealed that it instructed that 2nd floor residents who could not safely use the stairs should remain on the 2nd floor unless there was an emergency, and it did not include any provisions for maintaining visitation when the elevator was inoperable. In an interview, the Administrator stated that visitors could use the stairs to visit 2nd floor residents and that residents could be transported using an emergency chair system to meet visitors who could not use the stairs. However, the Administrator acknowledged that the emergency chair system was not used for visitation purposes during the elevator outage and reported being unaware of any complaints about the inoperative elevator, despite two complaints having been received by OHCQ. No additional documentation was provided to show a plan to support visitation for 2nd floor residents during the elevator malfunction.
Failure to Complete Required Quarterly Smoking Safety Assessments
Penalty
Summary
Facility staff failed to update smoking safety assessments at least once every three months for multiple residents identified as smokers. During a complaint survey focused on smoking safety, surveyors reviewed an incident involving the facility’s only elevator being inoperative for nearly a month, which affected residents who lived on the 2nd floor and needed to access the 1st-floor smoking area. The facility’s investigation identified a group of 10 residents on the 2nd floor who smoked and required additional accommodations to safely ambulate to the designated smoking area. Review of these residents’ medical records showed that 5 of the 10 did not receive quarterly smoking safety assessments as required by the facility’s practice. Specifically, four residents had not received a smoking assessment since May 2025, and one resident had no documented smoking assessment at any time during their stay. During interviews, the Unit Manager stated that residents identified as smokers are to be assessed quarterly for smoking safety. When the surveyor pointed out the missing assessments, the DON reviewed the records and confirmed that these residents had not received the required quarterly smoking assessments. This lack of timely reassessment occurred in the context of an extended elevator outage that necessitated special consideration for safe smoking access for residents residing on the 2nd floor.
Inaccurate MDS Coding for Pain Management, Falls, and High-Risk Drug Classes
Penalty
Summary
Facility staff failed to ensure that Minimum Data Set (MDS) assessments were accurately coded for multiple residents, based on medical record review and staff interviews. For one resident with cerebrovascular disease, an MDS with an Assessment Reference Date (ARD) of 3/2/26 coded Section J0100A (scheduled pain management) as "yes," but the March Medication Administration Record (MAR) did not show daily pain medication administration. An LPN stated she coded it that way because the resident received Aspirin 81 mg daily, although the physician’s order showed the Aspirin was prescribed as prophylaxis for cardiovascular events, and the RAI Manual specifies that medications not primarily intended for pain relief should not be coded as pain management. Another resident with cerebral infarction, congestive heart failure, and vascular dementia had two documented falls in progress notes between the prior assessment and the ARD of 2/4/26, but Section J1900 (number of falls since admission or prior assessment) captured only one fall. The same MDS coded Section J0100A (scheduled pain management) as "no" despite the February MAR documenting daily use of Diclofenac topical gel for pain. The MAR also showed daily Aspirin 81 mg for coronary artery disease, but Section N0415 (high-risk drug classes) did not capture the use of an antiplatelet medication. The responsible LPN confirmed missing the second fall and the Aspirin coding error. Additional residents had similar discrepancies: one resident’s MDS repeatedly coded use of hypnotic medications in Section N0415 when MARs showed no hypnotics administered, and failed to capture an antidepressant (Sertraline) that was given; the LPN reported coding Clonazepam as a hypnotic based on dual use, though reference guidelines did not classify it as such. Further inaccuracies were identified for other residents in pain management and high-risk drug class coding. One resident’s MDS with an ARD of 1/8/26 coded receipt of PRN pain medication in Section J0100A, but the January MAR showed no PRN pain medications given; a later MDS for the same resident coded use of an antianxiety medication in Section N0415, while the April MAR showed no such medication administered. Another resident with traumatic subarachnoid hemorrhage, type 2 diabetes with neuropathy, atrial fibrillation, and atherosclerotic heart disease had an MDS with an ARD of 2/3/26 that coded scheduled pain medication as "yes" and PRN pain medication as "no," although the MAR showed intermittent PRN Tylenol for pain and no daily pain medication, and also documented daily Aspirin 81 mg for heart failure and daily Rybelus for diabetes; the MDS failed to capture PRN pain use, incorrectly coded daily pain medication, and did not code hypoglycemic medication in Section N0415. Another resident with a history of stroke and right-sided hemiplegia/hemiparesis had two MDS assessments in February coded as receiving scheduled pain medication, but the February MAR did not show daily pain medication; the LPN reported coding based on daily prophylactic Aspirin 81 mg, which was not ordered for pain.
Incomplete Investigations of Resident Abuse Allegations
Penalty
Summary
Facility staff failed to complete thorough investigations of two separate resident allegations that were reported to the state agency. For the first incident, a resident alleged that on a specific date and time an employee poked two fingers into their face and showed them their middle finger. The five-day follow-up documented the allegation, but the investigation file did not clearly identify who was the first point of contact for the report. During interview, the Administrator stated that a corporate representative was initially made aware of the alleged incident, but there was no statement from this corporate representative included in the investigation file. The Administrator described their usual investigation process as interviewing involved parties, identifying and interviewing witnesses, reviewing staffing for the date of the alleged incident, and interviewing the resident’s roommate and other nearby residents if there were no direct witnesses. In the second incident, a resident reported that during a specific shift someone wearing blue put a hand by their face and over their mouth, and a particular GNA was identified as the alleged perpetrator. Review of the staffing sheet for the time of the alleged incident showed that two GNAs were working on the unit where the incident was reported to have occurred. However, the investigation file contained no statements or interviews from these two GNAs. Prior to the surveyor’s review of the investigation, the DON and a regional nurse were given the opportunity to review the investigation to ensure all necessary documents were available, yet the statements from the two GNAs remained absent. These omissions demonstrated that the facility did not conduct complete investigations into the reported allegations.
Failure to Develop Person-Centered Care Plans for Mobility and Peritoneal Dialysis Needs
Penalty
Summary
Facility staff failed to develop and implement person-centered care plans that addressed all identified needs for two residents, one with mobility limitations and one receiving peritoneal dialysis. For the resident with mobility limitations, the care plan included interventions for resistance to care and adjustment issues, but did not address the resident’s specific resistance to use of a Hoyer lift and the resident’s insistence on pivot transfers from bed to wheelchair. The Unit Manager confirmed that the resident was resistant to care, did not like the Hoyer lift, and preferred pivot transfers, but also stated that physical therapy had prohibited pivot transfers. Despite this known conflict between the resident’s preferences and therapy restrictions, the care plan lacked individualized interventions related to the resident’s resistance to the Hoyer lift and continued request for pivot transfers. For the resident receiving peritoneal dialysis, review of the electronic health record showed an order for peritoneal dialysis, but the resident’s care plans did not include a person-centered care plan specific to this treatment. The existing dialysis care plan did not specify the type of dialysis treatment being provided, did not document when the resident was scheduled to receive the treatment, and did not include time frames for the dialysis cycles. During an interview, the LPN Unit Manager stated that they do not place the dialysis prescription details into the care plan and instead use a generalized renal care plan by selecting standard items, confirming that the care plan was not individualized to the resident’s ordered peritoneal dialysis regimen.
Failure to Document Resident Showers and Refusals
Penalty
Summary
Facility staff failed to maintain complete and accurate documentation of bathing care for a resident, specifically regarding showers and refusals of showers. During a complaint survey, the surveyor requested verification that Resident #5 was receiving scheduled showers. The DON stated that the resident was scheduled for showers on the 3 pm–11 pm shift on Tuesdays and Fridays, and provided shower sheets for several dates in October and early November. However, there was no documentation to verify that the resident received a shower or bed bath on 10/17/25, 10/21/25, and 10/24/25. The DON explained that when a resident receives a shower it is documented on a skin sheet, and that refusals of showers should be documented both in the plan of care and on the shower sheet. Despite this, the surveyor did not receive any documentation indicating that the resident either received bathing care or refused showers on the missing dates. This lack of documentation showed that the facility did not safeguard resident-identifiable information and maintain medical records in accordance with accepted professional standards, as there was no record confirming whether the resident’s scheduled showers or refusals occurred on the identified dates.
Failure to Notify Responsible Party After Narcan Administration for Suspected Opioid Overdose
Penalty
Summary
The deficiency involves the facility’s failure to notify a resident’s responsible party when there was a significant change in the resident’s medical status requiring emergency medication. A complaint alleged that there was no communication with the responsible party when Narcan (naloxone) was administered to a resident for an alleged opioid overdose. Medical record review showed the resident was admitted in March 2026 with multiple fractures, including a nondisplaced zone 1 sacral fracture, a nondisplaced fracture of the posterior column of the right acetabulum, a fracture of the right pubis, and other chronic pain. The resident’s pain regimen included multiple opioids and other pain medications, including Hydromorphone 6 mg every 4 hours PRN, Hydromorphone 4 mg every 4 hours PRN, Tylenol, Lidocaine cream, Methocarbamol, Celebrex, and Gabapentin. A physician’s note dated 4/8/26 documented that the resident reportedly had an opioid overdose earlier that morning and responded well to Narcan administration by nursing, with the note listing chronic pain and opioid overdose status post Narcan. Further review of the resident’s medical record did not show any documentation that the resident’s representative was notified of this overdose event and Narcan administration. During interviews, an agency LPN stated that the resident was “out of it and not responding” during rounds, prompting the LPN to check for and then administer Narcan, after which the resident responded. Another LPN reported that Narcan was given because the resident appeared to be having an overdose and that the physician saw the resident afterward, but stated, “I don’t think anyone was notified, but should have been.” The DON also stated that she would have expected the responsible party to be notified. These findings confirmed that the facility failed to notify the resident’s responsible party of a significant change in condition and emergency treatment.
Failure to Follow Wound Care Orders and Document Narcan Administration
Penalty
Summary
Facility staff failed to provide treatment and care in accordance with professional standards and physician orders for two residents. For one resident admitted after hospitalization with acute systolic heart failure and peripheral edema, a wound physician initially ordered daily oil emulsion dressings for venous wounds on the right shin, left medial foot, and left second toe. At a follow-up assessment, the wound physician changed the treatment for the left medial foot from oil emulsion to daily skin prep and ordered daily skin prep for a newly identified arterial wound on the left plantar foot. Review of the March 2026 medication and treatment administration records showed staff did not discontinue the oil emulsion or initiate the ordered skin prep to the left medial foot, and did not administer skin prep to the left plantar foot wound from the date of the new orders until the resident was sent to the hospital. The DON confirmed that treatments were not administered per the updated wound care orders during this period. For another resident admitted with multiple pelvic and sacral fractures and chronic pain, the record showed extensive opioid and adjunct pain medication orders, and a physician note documented that the resident reportedly experienced an opioid overdose and responded well to Narcan administration by nursing. However, the medical record contained no nursing assessment of the resident at the time of the event, no documentation of the resident’s condition or vital signs, and no record of Narcan administration or the resident’s response afterward. An agency LPN reported finding the resident unresponsive or "out of it" during rounds, knowing the resident was on significant pain medications, and, after checking for an existing order, administering Narcan, after which the resident returned to baseline. The LPN acknowledged not completing or documenting a change-in-condition assessment, and both the DON and unit manager stated they would have expected an assessment and vital signs to be documented in this situation.
Disinfectant Wipes Left Accessible in Dementia Unit Dining Room
Penalty
Summary
The deficiency involves the facility’s failure to keep the environment free from accident hazards on one locked dementia unit. During a complaint survey regarding unsecured cleaning supplies and the potential for residents to use cleaning wipes for personal use, a surveyor observed disinfectant wipes stored openly on a wire shelf in the dining room of the Seagull Unit, a locked dementia unit. The product labeling on the container directed that it be stored in areas inaccessible to children and specifically stated it was not to be used as a diaper wipe or for personal cleansing and that it was not a baby wipe. At the time of the observation, residents with cognitive impairment were present in the dining room awaiting breakfast. A GNA was in the dining room with the residents during the observation, and the unit manager, an LPN, accompanied the surveyor. The surveyor expressed concern about the wipes being accessible in a public area where cognitively impaired residents were present. The LPN reported she had never seen residents use or attempt to use the wipes and stated staff used them to wipe down tables before and after meals. The GNA stated she was always present when residents were in the dining room, that residents were never left alone there, and that she had never seen a resident use a wipe. The Infection Control Nurse stated she was not aware the disinfectant wipes in the dining room were a concern because no residents had gone near them and confirmed they were intended for staff use to clean tables. The NHA and DON reported they had not been made aware of the concern with the wipes, though the DON stated she understood the concern.
Incomplete Documentation of Narcotic Administration on MAR
Penalty
Summary
The deficiency involves the facility’s failure to maintain complete and accurate medical records in accordance with accepted professional standards for one resident. Review of the resident’s April 2026 Medication Administration Record (MAR) and the Controlled Drug Administration Record showed multiple discrepancies for Hydromorphone, a narcotic medication. On several specific dates in April, the Controlled Drug Administration Record documented that Hydromorphone doses were signed out and given by licensed nursing staff at various times, but the corresponding MAR entries for those same dates and times were left blank, indicating no documentation of administration on the MAR. During interviews, an LPN stated that they sign out the medication on the narcotic sheet but do not document it on the MAR. The DON acknowledged awareness that nurses were signing off on the narcotic sheet but not on the MAR, and a unit manager reported not being aware that nurses were failing to sign the MAR when also signing the narcotic sheet, stating that documentation should occur on both records. The NHA and DON later stated they were not aware of the concern until it was identified by the surveyor and agreed with the findings. These observations and interviews demonstrate that the facility did not ensure that all medication administrations were consistently and accurately documented on the MAR for this resident.
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