Fox Chase Healthcare
Inspection history, citations, penalties and survey trends for this long-term care facility in Silver Spring, Maryland.
- Location
- 2015 East-west Highway, Silver Spring, Maryland 20910
- CMS Provider Number
- 215197
- Inspections on file
- 20
- Latest survey
- April 24, 2026
- Citations (last 12 mo.)
- 5
Citation history
Health deficiencies cited at Fox Chase Healthcare during CMS and state inspections, most recent first.
A resident with quadriplegia and intact cognition reported via email to the Administrator that $85.00 was taken from their wallet while they were out of the facility in the hospital. The facility’s abuse, neglect, and exploitation policy required all alleged violations to be reported to the state agency and other authorities within specified timeframes, but the allegation was not reported to the state survey agency until about a month later. The Administrator acknowledged being aware of the resident’s email at the time and admitted that the allegation of misappropriation of resident property was not reported as required.
A resident with quadriplegia and intact cognition reported via email to the Administrator that $85.00 was taken from their wallet while they were out of the facility in the hospital. The facility’s abuse, neglect, and exploitation policy required an immediate investigation of any allegation or suspicion of exploitation. The resident later stated they had reported the missing money immediately and had not received any response. The allegation was not reported to the state agency until a month after the resident’s email, and the Administrator acknowledged being aware of the allegation and not conducting an investigation, contrary to facility policy.
A resident with osteoarthritis, reduced mobility, difficulty walking, a history of falls, and moderate cognitive impairment experienced a fall when they leaned to the side, tipped their wheelchair, and fell to the floor. Staff implemented an immediate intervention by placing a gel cushion in the resident’s wheelchair to help prevent further falls, and the cushion was observed in use. However, the resident’s fall-risk care plan, which addressed falls related to poor safety awareness and cognitive impairment, was never revised to include the gel cushion intervention, despite facility expectations that nurses and supervisors update care plans with new post-fall interventions.
A resident with macular degeneration and moderate cognitive impairment had a care plan directing staff to arrange eye care consultations and a written consult order to schedule an appointment with a cataract surgeon. The resident’s family reported missed eye appointments due to lack of facility follow-up. The Medical Records Director admitted he had not scheduled the surgery because he was backed up with other work, while the Administrator was unaware of the order and the Medical Director stated he expected Social Services to arrange the appointment and transportation. As a result, the facility did not coordinate the ordered vision services in accordance with its own policy.
Multiple residents experienced prolonged periods of cold temperatures in their rooms and common areas due to ongoing heating system failures. Residents reported discomfort, needing extra blankets and clothing, and avoiding activities because of the cold. Staff interviews and documentation confirmed that heating repairs were delayed by incorrect parts and incomplete fixes, resulting in inadequate heating throughout the facility.
Surveyors found that the facility did not provide an ongoing activities program to meet residents' physical, mental, and psychological needs. Residents were observed without engagement or supervision in common areas, and the Activities Director position was vacant for several months. Part-time activities staff were not present every day, resulting in no activities for residents, including those needing 1:1 interaction. The Administrator confirmed the lack of formal activities and staffing shortages.
A deficiency was identified when a test tray revealed that hot food items were served below the required 135°F and a cold dessert was above the 41°F standard. The CDM confirmed the temperature discrepancies, and staff interviews indicated that nursing staff were expected to distribute trays promptly after meal carts arrived.
A surveyor found an opened carton of lactose free milk in the kitchen refrigerator that was not labeled with the date it was opened or a discard date, as required by facility policy. The CDM confirmed the labeling was incomplete, as only the received date was marked, not the opening date.
The facility did not document whether several residents had advance directives or had been offered the opportunity to create one. Interviews confirmed that the responsible staff member had not asked most of the affected residents about their wishes regarding advance directives, and the required documentation was missing from their records.
The facility did not consistently revise care plans, hold required care plan meetings, or reassess care plan effectiveness for multiple residents, including those with complex medical needs such as AV fistula shunts and those requiring total care. Some residents were not involved in care plan meetings, and care plans contained outdated or inaccurate information, with staff confirming that meetings and updates were not current.
Surveyors found that medications on two medication carts were not properly stored or labeled, including expired drugs, unrefrigerated and undated insulin, and controlled substances that were not disposed of as required. Interviews with the DON and policy reviews confirmed that nursing staff are responsible for medication storage and that expired or discontinued medications should be removed promptly.
Surveyors found that the facility failed to maintain proper infection control practices, including inadequate surveillance for infections, improper storage of personal items in the laundry area, and inconsistent implementation of Enhanced Barrier Precautions (EBP) for residents with indwelling catheters and wounds. Staff did not consistently use required PPE or post EBP signage, and there was confusion among staff about EBP protocols, leading to lapses in infection prevention measures.
Surveyors found that the facility did not maintain a safe, clean, and comfortable environment, with resident rooms and common areas at uncomfortably low temperatures and multiple items in disrepair, including cracked furniture, loose fixtures, and a mouse trap found in a resident room. The laundry area also had missing tiles, a missing ceiling panel, and other maintenance issues, as confirmed by interviews with the DON, Environmental Services Director, and Maintenance Director.
A resident's family requested a meeting with the social service department to discuss grievances about inadequate care, but the facility did not provide the requested meeting. Review of the medical record showed no evidence of the meeting, and the DON confirmed it did not occur.
Facility staff did not conduct a thorough investigation into an alleged incident of resident-to-resident abuse, as they failed to interview other residents and staff before concluding the allegation was unsubstantiated. The DON confirmed the investigation was incomplete.
Surveyors identified that two residents had inaccurate MDS assessments: one resident's continuous oxygen use was not reflected in the MDS despite medical documentation and observation, and another resident's discharge status was inconsistently coded, with two separate MDS assessments indicating both discharge to home/community and discharge to hospital for the same event.
The facility did not provide or document the delivery of baseline care plan summaries to two residents within 48 hours of admission. Record reviews and staff interviews confirmed that required care plan meetings and signatures were missing, and there was no evidence that the residents or their representatives received the necessary information.
Surveyors identified that the facility did not develop or update care plans to address the specific needs of two residents: one with a history of smoking and noncompliance with smoking policies, and another with cognitive deficits and prescribed antipsychotic medication. The care plans lacked required details regarding smoking interventions, functional abilities, and antipsychotic use, as confirmed by staff and record review.
Three residents who required staff assistance with ADLs did not receive regular showers or proper nail care. One resident received only two showers in four months despite needing maximal help, while two others were observed with long, dirty fingernails and were dependent on staff for grooming. Staff confirmed there was no set schedule for nail care, resulting in unmet hygiene needs.
The facility failed to document daily wound care for a resident with a physician order for sacral wound treatment, and did not implement wound care team recommendations for two residents with pressure ulcers. Despite recommendations for an air mattress and Prevalon boots, these interventions were not provided, and there was no documentation of required wound care in the treatment records.
A resident with severe right hand pain and contractures due to arthritis was not provided with a physician-ordered right-hand splint. The order was not transcribed onto the MAR/TAR, and staff were unaware of it, resulting in the splint never being applied and the resident not receiving the prescribed treatment for limited mobility.
A resident receiving a six-week course of IV antibiotics did not receive a recommended MRI prior to the completion of therapy, as advised by a consulting provider. The DON confirmed that the MRI, which was necessary to determine if IV antibiotics should be prolonged, was not performed, resulting in inadequate management of the resident's IV antibiotic schedule.
A resident receiving oxygen therapy was found with undated and unlabeled oxygen tubing and humidifier bottle, contrary to facility policy and physician orders requiring weekly changes and proper labeling. Both the nurse and DON confirmed the expectation for dating and labeling, and acknowledged the omission when it was brought to their attention.
The facility did not complete required annual performance evaluations and skills competency assessments for two GNAs, as confirmed by a review of employee files and the Administrator. Documentation for these evaluations and assessments was missing and could not be located.
A resident with dementia and agitation was prescribed Quetiapine, but staff failed to monitor behaviors or initiate a care plan as required for psychotropic medication use. Facility policy mandates such monitoring and care planning, but this was not completed, as confirmed by staff review and interviews.
A resident who was cognitively intact and prescribed multiple psychotropic medications for depression, anxiety, and suicidal ideation did not receive required behavior monitoring. Staff interviews confirmed that no tools or processes were in place for monitoring, and the DON verified that no behavior monitoring was documented, despite facility policy requiring it.
Two residents did not receive timely dental care as required, despite documented requests and physician orders. One resident's need for dental services was discussed in care plan meetings but not followed up with an appointment, and another resident with an order for an annual dental exam was not seen by a dentist, with staff confirming the lapse in the process.
Surveyors identified that the facility did not have a required written transfer agreement with local hospitals for dialysis services. Review of administrative documents and interviews with the Administrator confirmed the absence of a Dialysis Agreement for residents receiving ESRD care.
Surveyors found that the facility did not have a current transfer agreement with a local hospital, as required. During document review, no agreement was found, and the Administrator confirmed its absence and ongoing efforts to obtain one.
The facility did not maintain an effective QAPI program, as evidenced by missing documentation and lack of a designated leader for the QAPI committee. Despite conducting audits, the facility was unable to provide evidence that corrective actions were implemented for multiple previously cited deficiencies, resulting in continued noncompliance with 10 federal regulations.
The facility did not have documented participation of an Infection Preventionist (IP) in its QAA committee meetings for nine months. Although the DON stated she served as the IP and attended the meetings, the facility could not provide evidence of her IP credentials.
Surveyors found that several residents did not have up-to-date documentation or evidence of being offered the pneumococcal vaccine. Medical records lacked informed consent forms for one resident, while two others had forms indicating they could not sign due to confusion. The DON and Infection Preventionist confirmed the absence or incompleteness of required documentation.
A resident was not provided facility-arranged transportation to attend scheduled medical appointments for wound care and infectious disease follow-up due to an expired Medicaid coverage. Staff were aware of the transportation issue, but the facility did not arrange alternative transportation, resulting in the resident's family having to call 911 for hospital transport.
A resident with paraplegia and moderate fall risk experienced multiple falls that were not documented in the medical record, and required fall assessments and care plan updates were not completed. Staff confirmed that expected protocols for post-fall assessment and documentation were not followed, resulting in a deficiency related to accident prevention and supervision.
A resident who alleged inappropriate touching by an unidentified male did not receive a trauma informed care assessment or care plan following the incident. The DON confirmed that such assessments are required at admission and after changes in condition, but none was completed after the resident's report.
A nurse practitioner documented several new care interventions for a resident in the admission progress note, including medication continuation, live vest monitoring, specialty consults, and therapy evaluations, but these were not transcribed as formal medical orders. Staff confirmed the NP was no longer at the facility and the orders were never entered, with the medical director stating the NP was responsible for writing the orders.
Staff failed to maintain accurate and complete medical records, including missing documentation of a resident's shower schedule, unrecorded administration of injectable insulin for a resident with diabetes, and outdated physician orders for medication administration routes for a resident who no longer had a gastrostomy tube. The DON confirmed these documentation lapses and inconsistencies.
Failure to Timely Report Allegation of Misappropriation of Resident Property
Penalty
Summary
The facility failed to timely report an allegation of misappropriation of resident property to the state survey agency as required by its abuse, neglect, and exploitation policy. The written policy, reviewed on 10/12/2025, required all alleged violations to be reported to the Administrator, state agency, adult protective services, and other required agencies within specified timeframes: immediately but not later than 2 hours if the allegation involved abuse or resulted in serious bodily injury, or not later than 24 hours if the events did not involve abuse and did not result in serious bodily injury. Resident #1, who had a diagnosis of quadriplegia and an intact cognition as evidenced by a BIMS score of 15 on a quarterly MDS with an ARD of 02/26/2026, was admitted on 04/25/2025. On 03/09/2026, Resident #1 sent an email to the Administrator stating that $85.00 had been taken from their wallet while they were out of the facility in the hospital. During an interview, the resident reported they immediately informed the Administrator about the missing money and had not received any response regarding the issue. Email confirmation from the Maryland Department of Health - Office of Health Care Quality showed the facility did not report this allegation until 04/09/2026 at 8:55 PM, well beyond the policy’s required reporting timeframe. In a subsequent interview, the Administrator acknowledged awareness of the resident’s 03/09/2026 email and admitted that she did not report the allegation of misappropriation of resident property, stating that she should have done so.
Failure to Investigate Allegation of Misappropriation of Resident Funds
Penalty
Summary
The facility failed to investigate an allegation of misappropriation of resident property after a cognitively intact resident with quadriplegia reported missing money. Facility policy on Abuse, Neglect and Exploitation, last reviewed on 10/12/2025, required an immediate investigation whenever there was suspicion or a report of abuse, neglect, or exploitation. Resident #1 was admitted on 04/25/2025 and had a BIMS score of 15 on a quarterly MDS with an ARD of 02/26/2026, indicating intact cognition. On 03/09/2026, the resident emailed the Administrator stating that $85.00 had been taken from their wallet while they were out of the facility in the hospital. During an interview on 04/09/2026, the resident stated they had immediately reported the missing money to the Administrator and had not received any response. Email confirmation from the Maryland Department of Health – Office of Health Care Quality showed the facility did not report the allegation until 04/09/2026 at 8:55 PM. In an interview on 04/23/2026, the Administrator acknowledged being aware of the resident’s 03/09/2026 email about the missing $85.00 and admitted she did not investigate the allegation, despite the policy requirement for an immediate investigation.
Failure to Update Care Plan With Post-Fall Wheelchair Cushion Intervention
Penalty
Summary
The deficiency involves the facility’s failure to revise a resident’s care plan to include a new fall-prevention intervention implemented after a fall. The resident, admitted with diagnoses including osteoarthritis of the knee, reduced mobility, difficulty walking, and a history of falling, had a quarterly MDS showing moderate cognitive impairment (BIMS score of 11) and one fall since admission or re-entry. A progress note documented that the resident, while in the activity room, leaned to the left, tipped their wheelchair over, and fell to the floor. The immediate intervention documented in the progress note was placement of a gel cushion in the resident’s wheelchair to prevent further falls. The resident’s care plan, initiated for risk of falls related to poor safety awareness and cognitive impairment, did not contain any intervention directing staff to place or maintain a gel cushion in the wheelchair, despite this intervention being implemented after the fall. Surveyors confirmed during observation that the resident was seated in a wheelchair with a gel cushion in place, but the Care Plan Report showed no evidence that this intervention had been added. Interviews with nursing staff and the Director of Nursing confirmed that nurses were expected to place interventions at the time of a fall and that supervisors were responsible for updating the care plan, yet the gel cushion intervention was not incorporated into the written care plan for this resident.
Failure to Coordinate Ordered Cataract Surgery for a Visually Impaired Resident
Penalty
Summary
The facility failed to coordinate and arrange ordered vision services for one resident with known visual impairment. The resident, admitted in 2022, had a medical history of macular degeneration and a care plan focus area for impaired visual function, with interventions directing staff to arrange consultation with an eye care practitioner as required. A quarterly MDS assessment showed the resident had moderate cognitive impairment (BIMS score of 11) and documented vision as adequate without corrective lenses, while the care plan still identified impaired vision related to macular degeneration. A consult form dated 03/10/2025 instructed staff to schedule an appointment with a cataract surgeon for this resident. Despite this written directive, the appointment and surgery were not scheduled. The resident’s family member reported that the resident’s eye appointments had been missed because no one at the facility followed up on them. The Medical Records Director acknowledged he had not recently called to schedule the surgery, stating he was backed up with other work. The Administrator reported she was unaware of the order to schedule cataract surgery for the resident. The Medical Director stated that if there was a request for a surgical appointment for cataract removal, he expected the Social Services Director to arrange the appointment and transportation. These interviews and records showed that the facility did not ensure the resident received the ordered vision services in accordance with its own Vision Services Policy.
Failure to Maintain Comfortable Room Temperatures
Penalty
Summary
The facility failed to maintain comfortable room temperatures for multiple residents, as evidenced by observations and interviews. Temperatures in several resident rooms and common areas were recorded as significantly below standard comfort levels, with some rooms as low as 37.7 to 66 degrees Fahrenheit. Residents reported that the facility had been cold for an extended period, with some stating the issue had persisted since Thanksgiving and even over the past three years. Residents described needing to use extra blankets, wear hoodies, and avoid activities due to the cold conditions in their rooms and common areas. Interviews with residents confirmed ongoing discomfort, with several stating that the cold was unbearable and that they had to rely on family members to bring additional blankets or space heaters. The Resident Council president noted that activities were not being held because the activity room was too cold, and residents had to sleep in thick clothing and multiple blankets. Observations corroborated these statements, with residents seen bundled in blankets and expressing dissatisfaction with the facility's temperature. Staff interviews and documentation revealed that the facility's heating system had been malfunctioning, with one boiler out of service and issues with newly installed rooftop units. Delays in obtaining and installing the correct parts, as well as incomplete repairs, contributed to the prolonged period of inadequate heating. Temporary measures, such as rental heaters and providing hot beverages, were implemented, but these did not fully resolve the issue, as residents continued to report discomfort and low temperatures persisted in various areas of the facility.
Failure to Provide Ongoing 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 psychological well-being of each resident. Surveyors observed residents sitting in hallways, dining rooms, and common areas without supervision or engagement, and noted the absence of any activities or engagement in these areas. The position of Activities Director had been vacant since November 2024, and the facility relied on part-time activities assistants who were not present every day. On days when no activities staff were present, no activities were provided for residents, including those who required one-on-one interaction. Interviews with staff confirmed that there was no formal activities program in place during the absence of a full-time Activities Director, and that activities were not documented or tracked. Vulnerable residents who remained in their rooms did not receive individualized activities or engagement. The Administrator acknowledged the staffing shortages and confirmed that no formal activities were provided on days when activities staff were not present, and that efforts to secure an interim Activities Director were unsuccessful.
Failure to Serve Food at Safe and Palatable Temperatures
Penalty
Summary
The facility failed to ensure that food was delivered to residents at an appropriate and palatable temperature, as observed during a lunch tray line inspection. Six dietary aides prepared four meal carts, with the last cart completed at 12:34 PM and the final tray distributed at 12:55 PM. A test tray from the last cart was checked by the Certified Dietary Manager (CDM) using a food thermometer, revealing that hot food items such as potatoes, carrots, and chopped steak were served below the facility's expected standard of 135°F, with recorded temperatures of 134.6°F, 134.7°F, and 136°F respectively. The cold dessert pudding was served at 48.5°F, above the expected maximum of 41°F. The CDM confirmed these temperatures did not meet facility standards. Staff interviews indicated that nursing staff were expected to distribute meal trays promptly upon arrival to the unit.
Failure to Properly Label and Store Opened Dairy Product
Penalty
Summary
During an initial kitchen tour, a surveyor observed an opened carton of lactose free milk in the refrigerator that was marked only with the letter 'R' and a date, but lacked any indication of when it was opened or when it should be discarded. The Certified Dietary Manager (CDM) confirmed that facility policy requires dairy items to be discarded seven days after opening, but acknowledged that the carton was not labeled with the opening date. The CDM verified that the 'R' indicated the date the milk was received, not opened, and confirmed the absence of the required labeling.
Failure to Document and Offer Advance Directives
Penalty
Summary
The facility failed to provide documentation regarding whether four residents had an advance directive or wished to formulate one. During record reviews, it was found that the medical records, including social services progress notes and assessments, did not contain information to determine if these residents had advance directives or had been offered the opportunity to create one. The surveyor specifically reviewed the records of four residents and found this documentation lacking for all of them. Interviews with the DON and the Social Services Director (SSD) confirmed that the responsibility for documenting advance directives lay with the SSD. The SSD acknowledged that three of the residents did not have advance directives and had not been asked if they wished to formulate one, while one resident was in the process of being provided with information. The SSD also stated she was new to the facility but was aware of the documentation expectations. No additional information or documentation was provided by the facility at the time of the survey exit.
Failure to Revise Care Plans and Hold Required Interdisciplinary Meetings
Penalty
Summary
The facility failed to revise and update comprehensive care plans, hold required care plan meetings, reassess the effectiveness of care plan approaches, and conduct quarterly care plan meetings with the Interdisciplinary Team for several residents. For one resident with an arteriovenous (AV) fistula shunt, the care plan continued to list issues related to surgical staples and the AV fistula site months after the initial event, with no evidence of timely revision or removal of resolved problems. The Director of Nursing acknowledged that the care plan had not been appropriately updated. Another resident, who was cognitively intact, reported not being involved in any care plan meetings, and a review of the medical record confirmed there was no documentation of such meetings. The Social Worker and DON both confirmed the absence of records indicating that care plan meetings had occurred for this resident. Additionally, a resident's care plan inaccurately listed the use of an antidepressant medication that the resident was not actually receiving, and this discrepancy had not been corrected in the care plan. Further review revealed that two residents requiring total care had not had recent care plan meetings, with the last documented meetings occurring several months prior. The Social Worker confirmed that care plan meetings were not up to date for these residents. These findings demonstrate a pattern of failure to maintain, review, and revise care plans as required, and to involve residents and their representatives in the care planning process.
Failure to Properly Store and Label Medications
Penalty
Summary
Surveyors observed that the facility failed to ensure medications were properly stored and labeled on two medication carts. On one cart, expired medications were found, including Oxycodone tablets and two boxes of Albuterol Sulfate Inhalation Solution vials. On the second cart, there were expired, unrefrigerated, and undated open medications, including an unopened and unrefrigerated Insulin Lispro vial, an opened Lantus Solostar pen with no opening date, and an unopened, unrefrigerated Basaglar Injection pen that required refrigeration. Additionally, expired Percocet tablets were found on the cart. Interviews with the DON confirmed that the expectation is for nurses to remove expired medications or those belonging to discharged residents, and that insulin should be refrigerated and dated when removed. Policy reviews indicated that nursing staff are responsible for medication storage, and that discontinued, outdated, or deteriorated drugs should be returned to the pharmacy or destroyed, with controlled substances to be disposed of within three days of discontinuation.
Infection Control and Enhanced Barrier Precautions Deficiencies
Penalty
Summary
The facility failed to implement appropriate infection prevention and control practices in several key areas. During a tour of the laundry department, surveyors observed staff personal items, such as coats and beverages, in the clean laundry area, as well as cardboard boxes and bags of personal clothing placed directly on the floor. These items were found in both clean and adjacent areas, and the Environmental Services Director acknowledged the concerns when brought to their attention. Additionally, the facility's infection prevention and control program and surveillance policies were outdated, and there was no system in place for ongoing surveillance of infections. The Director of Nursing and Infection Preventionist were unable to provide documentation of infection surveillance data, data collection, or infection rates for the current or previous year, and the available records were incomplete. Surveyors also identified deficiencies in the maintenance and monitoring of indwelling urinary catheters and the implementation of Enhanced Barrier Precautions (EBP) for residents at increased risk of multidrug-resistant organism (MDRO) transmission. For one resident, a catheter drainage bag was observed on the floor, and although an EBP sign was posted, there was no PPE cart available. Another resident with an indwelling catheter had neither an EBP sign nor a PPE cart outside their room, and staff confirmed that the required precautions were not consistently followed. Interviews with staff revealed inconsistent understanding and application of EBP protocols, with some staff only using gloves and masks, and not gowns, during high-contact care activities. A third resident with a stage 3 pressure ulcer and a surgical wound also lacked an EBP sign and PPE cart outside their room until after the surveyor's observation. Review of medical records confirmed the presence of wounds and ongoing treatment, but no EBP orders were documented. Staff interviews further indicated confusion regarding when to implement full EBP measures, with some staff associating gown use only with contact isolation rather than EBP. The facility's own policy required gloves and gowns for high-contact care of residents with wounds or indwelling devices, but these procedures were not consistently followed or documented.
Failure to Maintain Safe, Comfortable, and Homelike Environment
Penalty
Summary
Surveyors observed that the facility failed to maintain a safe, clean, comfortable, and homelike environment for residents. During a facility tour, the temperature in resident rooms and common areas was noted to be cool to cold, with residents using multiple blankets for warmth. Temperature logs showed that several rooms were recorded at 70 degrees, which did not meet federal and state regulations for minimum design air temperature. Additionally, complaints were reviewed that confirmed residents' rooms were not at a comfortable temperature level. Further observations revealed multiple items in disrepair, including cracked and chipped dressers, a loose bathroom sink faucet, marred doors and dressers, and a wooden mouse trap with a metal spring found on the floor in a resident room. In the laundry department, chipped and missing floor tiles, a missing ceiling panel, a chipped and loose doorframe, a loose baseboard, and a missing cabinet door were also noted. These findings were confirmed through interviews with the Director of Nursing, Environmental Services Director, and Maintenance Director, who acknowledged the disrepair and the presence of the mouse trap.
Failure to Provide Family Meeting for Grievance Resolution
Penalty
Summary
The facility failed to provide a family meeting to address grievances regarding the care of a resident, as requested by the resident's family. A complaint was filed by the family, indicating that they had asked the social service department for a meeting to discuss concerns about inadequate care. Upon review of the resident's medical record, there was no documentation that such a meeting was provided. The Director of Nursing confirmed during an interview that the requested meeting did not occur.
Failure to Thoroughly Investigate Resident-to-Resident Abuse Allegation
Penalty
Summary
Facility staff failed to thoroughly investigate an alleged incident of resident-to-resident abuse involving one resident who reported being inappropriately touched by another resident. The facility's investigation documents indicated that the allegation was deemed unsubstantiated; however, the investigation was incomplete as staff did not interview other residents or staff members who may have had relevant information about the incident. The Director of Nursing confirmed that the investigation was not comprehensive before reaching a conclusion.
Inaccurate MDS Coding for Oxygen Use and Discharge Status
Penalty
Summary
The facility failed to accurately code the Minimum Data Set (MDS) assessments for two residents, resulting in deficiencies related to oxygen usage and discharge status. For one resident, continuous oxygen use was observed and documented in the medical record and physician orders, yet the MDS assessment did not indicate oxygen use on admission or within the previous 14 days. The Director of Nursing confirmed the resident's oxygen use and acknowledged the discrepancy between the MDS and the medical record. For another resident, a review of the medical record and SBAR summary indicated a transfer to the hospital, but the MDS Discharge Return Not Anticipated assessment was coded as discharge to home/community. Further investigation revealed two separate MDS discharge assessments with the same assessment reference date, each coded differently—one as discharge to home/community and the other as discharge to hospital. The MDS nurse confirmed the discrepancy and that two nurses had completed separate discharge assessments for the same event.
Failure to Provide and Document Baseline Care Plan Summaries
Penalty
Summary
The facility failed to ensure that residents were provided with summaries of their baseline care plans within 48 hours of admission, as required. For two residents reviewed, there was no documentation that a baseline care plan meeting occurred or that a summary was provided to the resident or their representative. One resident, who was cognitively intact as indicated by a BIMS score of 14, reported not being involved in any care plan meetings, and a review of the medical record confirmed the absence of documentation regarding care plan meetings or provision of the care plan summary. The Social Worker and DON both verified that there was no supporting documentation or signature sheet for the baseline care plan meeting for this resident. For another resident, the 48-hour baseline care plan lacked a documented signature from the resident or their representative, and the Administrator was unable to locate a signed copy or confirm that the care plan summary was provided. These findings were based on record reviews and staff interviews, which consistently indicated that the required documentation and communication regarding the baseline care plan were not completed for these residents.
Failure to Develop and Update Comprehensive Care Plans for Resident Needs
Penalty
Summary
The facility failed to develop, implement, and update comprehensive care plans addressing specific resident needs, as evidenced by deficiencies found during a recertification survey. For one resident with coronary artery disease and a history of smoking, the care plan did not specify interventions related to smoking, nor was it updated to reflect the resident's noncompliance with the facility's smoking policy. Despite documentation of the resident's ongoing smoking behavior and refusal of cessation support, the care plan lacked necessary details and revisions to address these issues. Another resident, admitted with vascular dementia, agitation, and cognitive communication deficits, had a care plan that did not specify the resident's level of independence or dependence in meeting emotional, intellectual, physical, and social needs. Additionally, although this resident was prescribed an antipsychotic medication for agitation and anxiety, there was no evidence that a care plan was initiated to address the use of this medication. These omissions were confirmed by staff interviews and record reviews.
Failure to Provide Adequate ADL Assistance: Bathing and Grooming Deficiencies
Penalty
Summary
The facility failed to provide adequate assistance with Activities of Daily Living (ADLs) for residents who required such support, specifically in the areas of bathing and personal grooming. One resident, who required maximal assistance with showers according to their MDS assessment, only received two documented showers over a four-month period since admission. Documentation provided by the Director of Nursing confirmed only two shower dates within that timeframe, despite the resident's care needs. Additionally, two other residents were observed with long, dirty fingernails, with one resident's nails being jagged and broken. Both residents were dependent on staff for ADLs, as indicated in their care plans and MDS assessments. The care plan for one resident specifically included an intervention to check and trim nails on bath days and as necessary. Staff interviews revealed there was no established schedule for nail care, and responsibility for this task was assigned to Geriatric Nursing Assistants. The lack of regular nail care and inadequate bathing support led to the observed deficiencies.
Failure to Document and Implement Pressure Ulcer Care and Interventions
Penalty
Summary
The facility failed to document the delivery of daily wound care for a resident with a physician order for sacral wound treatment. Despite the presence of a pressure ulcer and an order for daily care, there was no documentation on the treatment administration records for two consecutive months indicating that the wound care was provided. The Director of Nursing confirmed that the order for wound care was not reflected in the records, resulting in a lack of evidence that the required treatment was administered. Additionally, the facility did not implement wound care team recommendations for another resident with multiple pressure ulcers, including a deep tissue injury and two Stage 3 pressure ulcers. The wound care provider had recommended the use of an air mattress and Prevalon boots to relieve pressure, but these interventions were not in place. Staff interviews and observations confirmed that the resident did not have the recommended equipment, and there were no orders for these items in the resident's chart, despite ongoing weekly wound care provider visits and documented recommendations.
Failure to Provide Prescribed Splint for Resident with Limited Mobility
Penalty
Summary
A deficiency was identified when a resident with a history of scleroderma and severe right hand pain, as well as arthritis-related contractures in both hands, was observed without the prescribed right-hand splint. The resident was seen sitting in a wheelchair with contracted fingers bent towards the palms, and fingernails that were long and visibly dirty. The resident confirmed that the contractures were due to arthritis. Despite an active physician's order for a right-hand splint, there was no evidence in the Medication Administration Record or Treatment Administration Record that the splint had ever been applied. Further review revealed that the physician's order for the right-hand splint, dated several weeks prior, lacked specific directions and had not been transcribed onto the MAR/TAR. Staff interviewed were unaware of the order, and the Director of Nursing was notified of these findings. The failure to provide the prescribed splint and to clarify or implement the physician's order resulted in the resident not receiving appropriate care to maintain or improve range of motion and mobility.
Failure to Provide Recommended MRI Prior to Completion of IV Antibiotic Therapy
Penalty
Summary
A review of the medical record for Resident #324 revealed that the resident was prescribed intravenous (IV) antibiotics once daily for six weeks to prevent infection. During this course of treatment, a consulting provider, Maximed Associates Inc, recommended that the resident receive an MRI one week prior to completing the IV antibiotics to determine if the treatment should be extended. However, there was no evidence in the medical record that the MRI was performed before the completion of the IV antibiotic therapy. The Director of Nursing confirmed that the MRI was not provided as recommended, resulting in a failure to adequately manage the resident's IV antibiotic schedule.
Failure to Date and Label Oxygen Tubing and Humidifier Bottle for Resident on Oxygen Therapy
Penalty
Summary
A deficiency was identified when a resident receiving oxygen therapy was observed with an oxygen cannula in use, connected to an oxygen concentrator with both the tubing and humidifier bottle lacking required date labels. The observation occurred during a tour of the nursing unit, and the nurse assigned to the resident confirmed that the tubing and humidifier bottle were not dated as per facility protocol, which requires labeling and dating by the night shift. The nurse acknowledged the omission upon review. Further review of the resident's medical record showed active physician orders for oxygen therapy, including instructions to change the oxygen tubing every seven days and to follow a care plan for oxygen therapy related to respiratory illness. The facility's policy also mandates weekly changes and labeling of oxygen tubing/cannula and changing humidifier bottles every seventy-two hours or when empty. The DON confirmed the expectation for dating and labeling these items, and acknowledged the deficiency when informed that the required labeling was not present for the resident in question.
Failure to Complete Annual Evaluations and Skills Assessments for GNAs
Penalty
Summary
The facility failed to complete required annual performance evaluations and skills competency assessments for its Geriatric Nurse Assistants (GNAs). Specifically, a review of employee files revealed that one GNA did not have an annual performance evaluation documented, and another GNA lacked a completed skills competency assessment. These omissions were confirmed by the Administrator, who acknowledged that the records were missing and should have been present based on the employees' hire dates. No documentation was found to support that these evaluations or assessments had been conducted.
Failure to Monitor Behaviors and Care Plan for Resident on Antipsychotic Medication
Penalty
Summary
A deficiency was identified when a resident with vascular dementia, mild with agitation, and cognitive communication deficit was prescribed the antipsychotic medication Quetiapine (Seroquel) for anxiety and agitation. Upon review of the resident's clinical record, it was found that there was no evidence of behavior monitoring related to the use of this psychotropic medication. Additionally, there was neither a physician order nor a care plan in place to address the resident's behaviors associated with the medication use. Interviews with facility staff confirmed that the required monitoring and care planning for residents on antipsychotic medications had not been completed for this resident. The facility's own policy mandates monitoring and review of psychotropic medication use, but this was not followed in the case of the resident receiving Quetiapine. The deficiency was brought to the attention of the Director of Nursing after these findings were confirmed.
Failure to Monitor Behaviors for Resident on Psychotropic Medications
Penalty
Summary
The facility failed to provide adequate behavior monitoring for a resident who was prescribed multiple psychotropic medications. Record review showed that the resident, who was cognitively intact as indicated by a BIMS score of 15/15, was on several psychotropic drugs including aripiprazole, clonazepam, duloxetine, escitalopram, lisdexamfetamine, and trazodone for conditions such as depression, anxiety, and suicidal ideation. Despite the facility's policy requiring monitoring and review of psychotropic medication use, there was no evidence in the resident's medical record that behavior monitoring was conducted. Interviews with facility staff confirmed the deficiency. An LPN stated that there were no tools or processes in place for behavior monitoring of residents on psychotropic medications. The DON initially indicated that a behavior monitoring tool was available in the Treatment Administration Record, but upon review of the electronic medical record, she confirmed that no behavior monitoring had been provided for the resident. The lack of documented behavior monitoring was identified during the recertification survey.
Failure to Provide Timely Dental Services to Residents
Penalty
Summary
The facility failed to ensure that residents requiring dental services received them in a timely manner, as evidenced by two residents who did not receive routine or requested dental care. For one resident, the need for a dental appointment was discussed and documented during two separate care plan meetings, with the resident's representative specifically requesting dental services due to chewing issues. Despite the facility's process involving nurses notifying physicians and entering consults into a shared system for dental providers, there was no record of a dental consult or appointment being made for this resident over several months. Another resident expressed a desire for dentures and had an active physician order for an annual dental exam, but the clinical record did not show that the resident had been seen by a dentist as required. The only documentation found was an appointment where the resident was not seen, and no subsequent dental visits were recorded. Interviews with staff confirmed that the process for arranging dental care was not followed, resulting in the resident not receiving the necessary dental services in accordance with physician orders.
Failure to Obtain Required Dialysis Transfer Agreement
Penalty
Summary
The facility failed to obtain a written transfer agreement with local hospitals for dialysis services, as required when providing care for residents needing End Stage Renal Dialysis (ESRD). During a review of administrative documents, surveyors found that there was no Dialysis Agreement present in the facility's records. The Administrator confirmed during interviews that she was unable to locate the agreement and had not received one from the current dialysis service provider. The absence of this agreement was identified during the review of the facility's documentation and confirmed through interviews with the Administrator.
Failure to Maintain Hospital Transfer Agreement
Penalty
Summary
The facility failed to obtain and maintain a transfer agreement with at least one local hospital certified by Medicare or Medicaid, as required. During a review of administrative documents, surveyors were unable to locate a current transfer agreement with any local hospitals. The Administrator confirmed during an interview that she could not find the agreement and was searching for it. Further, in a follow-up phone interview, the Administrator stated that she had reached out to local hospitals to obtain a transfer agreement but had not yet received a response. This deficiency was identified during an extended survey and was evident in the review of the facility's transfer agreement documentation.
Failure to Maintain Effective QAPI Program and Document Corrective Actions
Penalty
Summary
The facility failed to maintain an effective Quality Assurance and Performance Improvement (QAPI) program that addressed previously identified deficient practices. During a revisit recertification survey, it was found that the facility's Plan of Correction and supporting evidence for multiple deficiencies were incomplete, with missing documentation to demonstrate compliance for several federal regulations, including F578, F623, F695, F699, F711, F744, F812, F842, F880, and F883. Despite the existence of a QAPI committee, there was no designated individual in charge of the program, and the committee was unable to provide documentation reflecting the implementation of corrective actions for the cited deficiencies. Interviews with the DON and NHA revealed that while audits were conducted, there was insufficient evidence to show that the facility had achieved compliance with the plan of correction for the deficiencies identified in the previous annual survey. As a result, 10 federal regulations were recited as noncompliant due to the facility's ongoing failure to provide adequate documentation and evidence of corrective actions through its QAPI program.
Infection Preventionist Not Documented in QAA Committee Meetings
Penalty
Summary
The facility failed to ensure that an Infection Preventionist (IP) participated in the Quality Assessment and Assurance (QAA) committee meetings, as required. Review of the QAA sign-in sheets from January 2024 through September 2024 showed no evidence of an IP attending these meetings for nine months. When questioned, the Administrator believed that one of the committee members was an IP, and the Director of Nursing (DON) stated she served as the IP from April 2024 to September 2024 and attended the meetings. However, the Administrator was unable to provide documentation of the DON's IP credentials at the time of the survey exit.
Failure to Document and Offer Pneumococcal Vaccination
Penalty
Summary
The facility failed to provide documentation that residents were offered the pneumococcal vaccine, as evidenced by record reviews and staff interviews. Specifically, three residents lacked up-to-date documentation of pneumococcal immunization in their medical records. Recent MDS assessments for these residents indicated that the pneumococcal vaccine was not up to date, not received, and not offered. The medical records did not contain informed consent forms for one resident, and for two other residents, the forms indicated they could not sign due to confusion. During interviews, the DON stated that documentation of pneumococcal vaccination should be present in the residents' medical records. However, upon review with the Infection Preventionist, it was confirmed that the necessary informed consent forms and immunization records were incomplete or missing. No additional information regarding pneumococcal immunization was provided by the facility at the time of survey exit.
Failure to Provide Transportation for Medical Appointments
Penalty
Summary
The facility failed to provide necessary transportation services for a resident to attend medical appointments, specifically for wound care and infectious disease follow-up. The resident reported that due to the lack of facility-arranged transportation, family members had to call 911 on two occasions to transport the resident to the hospital for wound treatment. Record review confirmed that the resident had an acquired wound and had multiple appointments scheduled for infectious disease and gastrointestinal care, but transportation was not arranged due to the expiration of the resident's Medicaid coverage. Notes indicated that staff were aware of the transportation issue and attempted to address the insurance lapse, but were unable to secure external transportation in time for the scheduled appointments. Interviews with facility staff revealed that the responsibility for arranging transportation typically fell to the Medical Records department, but in the absence of that position, nurses were expected to handle scheduling. The Business Office Manager confirmed the resident's insurance had expired, and the Administrator stated that the facility was expected to pay for transportation if insurance was not in place. Despite this expectation, the resident was not provided transportation by the facility, resulting in missed or delayed medical appointments.
Failure to Document and Update Fall Prevention Interventions
Penalty
Summary
The facility failed to document incidents of falls and did not implement or update interventions to prevent further falls for a resident identified as a fall risk. The resident, who was cognitively intact and had paraplegia with limited physical mobility, reported experiencing three falls during their stay, but could not recall the specific dates. A review of the care plan showed interventions for fall prevention were in place, such as keeping the bed in the lowest position and ensuring the call light was within reach. However, there was no evidence in the medical record that any fall incidents were documented since admission, nor were there records of fall assessments or investigations being completed following these events. Interviews with facility staff, including the DON and Unit Manager, confirmed that falls had occurred but were not properly documented in the progress notes or through formal fall reports and assessments as required. Staff described the expected protocol for post-fall assessment and documentation, but acknowledged that these steps were not followed or recorded for this resident. The lack of documentation and failure to update the care plan after each fall constituted a deficiency in ensuring the area was free from accident hazards and that adequate supervision and interventions were provided to prevent accidents.
Failure to Provide Trauma Informed Care Assessment After Resident Allegation
Penalty
Summary
The facility failed to develop and implement a process to ensure that residents with a history of trauma received appropriate trauma informed care. Specifically, after a resident alleged being inappropriately touched by an unidentified male, a review of the resident's medical record showed no evidence that a trauma informed assessment or care plan was completed following the incident. The Director of Nursing confirmed that trauma informed assessments are required at admission and after a change in condition, but acknowledged that no such assessment was conducted after the resident's allegation.
Failure to Transcribe NP Care Plan Interventions as Medical Orders
Penalty
Summary
A deficiency was identified when a nurse practitioner (NP) documented several new care interventions in the admission history and physical progress note for a resident, including continuing all medications as prescribed, attaching a live vest and monitoring every shift, neurology consults as needed, PT/OT evaluation and treatment as required, pain evaluation as required, and a cardiology consult. However, these interventions were not transcribed as formal medical orders in the resident's record. Medical record review confirmed the absence of these orders, and staff interviews revealed that the NP no longer worked at the facility and the orders were never entered. The medical director confirmed that the NP was responsible for writing the orders independently.
Incomplete and Inaccurate Medical Record Documentation
Penalty
Summary
Facility staff failed to maintain complete and accurate medical records for multiple residents, as evidenced by missing documentation and discrepancies in medication administration records. For one resident, the Director of Nursing (DON) was unable to locate the shower schedule documentation, despite stating that such records should be present in the medical record. Additionally, a review of another resident's medication administration record revealed that the administration of injectable insulin was not recorded on a specific date, a fact confirmed by the DON. Further deficiencies were identified in the documentation and physician orders for a resident who previously had a gastrostomy tube. Although the feeding tube had been removed, the resident's medical record and physician orders still included instructions for administering certain medications via the gastrostomy tube, while others were to be given by mouth. The DON confirmed that the tube had been removed months prior and acknowledged the inconsistency in the current orders, which did not accurately reflect the resident's current status and medication administration route.
Latest citations in Maryland
Facility staff did not ensure that 2nd floor residents who could not use stairs were able to receive visitors when the only elevator was out of service for an extended period. Complaints indicated that some family members, who were themselves unable to ambulate stairs, could not visit their relatives on the 2nd floor during this time. The emergency plan directed non-ambulatory 2nd floor residents to remain on that floor unless there was an emergency and did not address how visitation would be maintained when the elevator was inoperable. The Administrator reported that visitors could use the stairs and that an emergency chair system could be used to move residents, but also stated that the chair system was not used for visitation and was unaware of any complaints, despite two having been filed.
Facility staff did not complete required quarterly smoking safety assessments for several residents identified as smokers, including some who had not been reassessed for many months and one who had never been assessed during their stay. This issue was discovered during a complaint survey after the facility’s only elevator was out of service for an extended period, affecting a group of residents on an upper floor who needed to reach a designated smoking area on a lower floor. Review of records and staff interviews, including with the DON and a unit manager, confirmed that the facility’s own practice of quarterly smoking safety assessments for smokers was not followed for half of the affected residents.
Facility staff failed to accurately code multiple MDS assessments for several residents, leading to discrepancies between MDS entries and MARs for pain management, falls, and high-risk drug classes. In several cases, scheduled pain management was coded as provided when MARs did not show daily pain medications, often because an LPN counted low-dose Aspirin ordered for cardiovascular prophylaxis or heart failure as pain medication, contrary to RAI guidance. One resident’s falls were underreported on the MDS despite two documented falls, and daily use of a topical analgesic and an antiplatelet (Aspirin) was not correctly captured. Other residents had MDS entries indicating use of hypnotic or antianxiety medications when MARs showed none, while actual antidepressant and hypoglycemic medications administered daily were omitted from Section N0415. These errors were confirmed by the involved LPNs during surveyor interviews.
Staff failed to conduct complete investigations into two residents’ abuse allegations. In one case, a resident reported that an employee poked their face and made an obscene gesture, but the investigation lacked a statement from the corporate representative who was first notified of the allegation. In another case, a resident reported that someone in blue clothing put a hand by their face and over their mouth, with a specific GNA identified as the alleged perpetrator; however, the investigation did not include statements from two GNAs who were on duty on the unit at the time of the alleged incident, despite leadership having the opportunity to ensure all relevant documents were present.
Staff failed to create person-centered care plans for two residents, one with mobility limitations and one receiving peritoneal dialysis. For the resident with mobility issues, the care plan did not address the resident’s refusal to use a Hoyer lift and preference for pivot transfers, despite therapy prohibiting pivot transfers and staff awareness of the resident’s resistance. For the resident on peritoneal dialysis, the care plan did not specify that the treatment was peritoneal dialysis, nor did it include the treatment schedule or cycle time frames; an LPN Unit Manager acknowledged using a generalized renal care plan without incorporating the specific dialysis prescription.
A resident’s medical record lacked documentation confirming that scheduled showers or bed baths were provided on multiple dates, and there was also no record of any refusals of care on those days. The DON and an LPN unit manager reported that showers were scheduled on specific shifts and that completed showers and refusals should be documented on shower/skin sheets and in the care plan, but the surveyor found gaps where no such entries existed. This resulted in incomplete ADL documentation and failure to maintain medical records according to accepted professional standards.
A resident with multiple fractures and chronic pain was receiving an opioid-based pain regimen, including PRN hydromorphone. The resident was later found unresponsive and "out of it" by an LPN, who located an order for Narcan and administered it, with the resident responding to the medication. A physician note documented an opioid overdose treated with Narcan. Review of the medical record showed no documentation that the resident’s representative was notified of this significant change in condition and emergency intervention, and staff interviews confirmed that notification likely did not occur, despite the DON’s expectation that the responsible party should have been informed.
Staff failed to follow updated wound care orders and to document an opioid overdose event and Narcan use for two residents. One resident with venous and arterial lower extremity wounds did not receive the prescribed change from oil emulsion to daily skin prep on one foot wound, and did not receive ordered skin prep on a new plantar wound for several days after the wound physician revised the treatment plan. Another resident with multiple fractures and chronic pain, receiving multiple opioid and adjunct analgesics, reportedly experienced an opioid overdose; an LPN found the resident unresponsive, located an existing Narcan order, administered Narcan, and observed the resident return to baseline, but did not complete or document a change-in-condition assessment, vital signs, or the Narcan administration in the medical record.
Surveyors substantiated a deficiency when disinfectant wipes, labeled for storage in areas inaccessible to children and not for personal cleansing, were observed sitting openly on a wire shelf in the dining room of a locked dementia unit while cognitively impaired residents waited for breakfast. A GNA and an LPN present on the unit stated that staff used the wipes to clean tables and that residents were never left alone in the dining room and had not been seen using the wipes. The ICP reported being unaware that the wipes’ placement in the dining room was a concern, and the NHA and DON stated they had not previously been informed about the issue, though the DON acknowledged understanding the concern.
A resident’s medical record showed multiple instances where Hydromorphone, a controlled narcotic, was documented as signed out and given on the Controlled Drug Administration Record but was not documented on the MAR on the same dates and times. An LPN reported signing only the narcotic sheet and not the MAR, while the DON acknowledged awareness that nurses were signing the narcotic sheet without completing the MAR, and a unit manager stated they were unaware this was occurring and that both records should be completed. The NHA and DON agreed with the surveyor’s findings after the issue was identified.
Failure to Ensure Visitation Rights During Elevator Outage
Penalty
Summary
Facility staff failed to ensure that residents residing on the 2nd floor who could not safely ambulate using stairs were able to exercise their right to have visitors when the facility’s only elevator malfunctioned. Complaint reviews showed that family members were unable to visit their relatives on the 2nd floor when the elevator was inoperative, and these family members themselves were unable to use the stairs. An incident report documented that the facility’s only elevator was malfunctioning for an extended period, from 3/28/26 to 4/23/26. During this time, residents who could not use the stairs remained on the 2nd floor, and some of their family members could not access them due to the lack of elevator service. Review of the facility’s emergency plan revealed that it instructed that 2nd floor residents who could not safely use the stairs should remain on the 2nd floor unless there was an emergency, and it did not include any provisions for maintaining visitation when the elevator was inoperable. In an interview, the Administrator stated that visitors could use the stairs to visit 2nd floor residents and that residents could be transported using an emergency chair system to meet visitors who could not use the stairs. However, the Administrator acknowledged that the emergency chair system was not used for visitation purposes during the elevator outage and reported being unaware of any complaints about the inoperative elevator, despite two complaints having been received by OHCQ. No additional documentation was provided to show a plan to support visitation for 2nd floor residents during the elevator malfunction.
Failure to Complete Required Quarterly Smoking Safety Assessments
Penalty
Summary
Facility staff failed to update smoking safety assessments at least once every three months for multiple residents identified as smokers. During a complaint survey focused on smoking safety, surveyors reviewed an incident involving the facility’s only elevator being inoperative for nearly a month, which affected residents who lived on the 2nd floor and needed to access the 1st-floor smoking area. The facility’s investigation identified a group of 10 residents on the 2nd floor who smoked and required additional accommodations to safely ambulate to the designated smoking area. Review of these residents’ medical records showed that 5 of the 10 did not receive quarterly smoking safety assessments as required by the facility’s practice. Specifically, four residents had not received a smoking assessment since May 2025, and one resident had no documented smoking assessment at any time during their stay. During interviews, the Unit Manager stated that residents identified as smokers are to be assessed quarterly for smoking safety. When the surveyor pointed out the missing assessments, the DON reviewed the records and confirmed that these residents had not received the required quarterly smoking assessments. This lack of timely reassessment occurred in the context of an extended elevator outage that necessitated special consideration for safe smoking access for residents residing on the 2nd floor.
Inaccurate MDS Coding for Pain Management, Falls, and High-Risk Drug Classes
Penalty
Summary
Facility staff failed to ensure that Minimum Data Set (MDS) assessments were accurately coded for multiple residents, based on medical record review and staff interviews. For one resident with cerebrovascular disease, an MDS with an Assessment Reference Date (ARD) of 3/2/26 coded Section J0100A (scheduled pain management) as "yes," but the March Medication Administration Record (MAR) did not show daily pain medication administration. An LPN stated she coded it that way because the resident received Aspirin 81 mg daily, although the physician’s order showed the Aspirin was prescribed as prophylaxis for cardiovascular events, and the RAI Manual specifies that medications not primarily intended for pain relief should not be coded as pain management. Another resident with cerebral infarction, congestive heart failure, and vascular dementia had two documented falls in progress notes between the prior assessment and the ARD of 2/4/26, but Section J1900 (number of falls since admission or prior assessment) captured only one fall. The same MDS coded Section J0100A (scheduled pain management) as "no" despite the February MAR documenting daily use of Diclofenac topical gel for pain. The MAR also showed daily Aspirin 81 mg for coronary artery disease, but Section N0415 (high-risk drug classes) did not capture the use of an antiplatelet medication. The responsible LPN confirmed missing the second fall and the Aspirin coding error. Additional residents had similar discrepancies: one resident’s MDS repeatedly coded use of hypnotic medications in Section N0415 when MARs showed no hypnotics administered, and failed to capture an antidepressant (Sertraline) that was given; the LPN reported coding Clonazepam as a hypnotic based on dual use, though reference guidelines did not classify it as such. Further inaccuracies were identified for other residents in pain management and high-risk drug class coding. One resident’s MDS with an ARD of 1/8/26 coded receipt of PRN pain medication in Section J0100A, but the January MAR showed no PRN pain medications given; a later MDS for the same resident coded use of an antianxiety medication in Section N0415, while the April MAR showed no such medication administered. Another resident with traumatic subarachnoid hemorrhage, type 2 diabetes with neuropathy, atrial fibrillation, and atherosclerotic heart disease had an MDS with an ARD of 2/3/26 that coded scheduled pain medication as "yes" and PRN pain medication as "no," although the MAR showed intermittent PRN Tylenol for pain and no daily pain medication, and also documented daily Aspirin 81 mg for heart failure and daily Rybelus for diabetes; the MDS failed to capture PRN pain use, incorrectly coded daily pain medication, and did not code hypoglycemic medication in Section N0415. Another resident with a history of stroke and right-sided hemiplegia/hemiparesis had two MDS assessments in February coded as receiving scheduled pain medication, but the February MAR did not show daily pain medication; the LPN reported coding based on daily prophylactic Aspirin 81 mg, which was not ordered for pain.
Incomplete Investigations of Resident Abuse Allegations
Penalty
Summary
Facility staff failed to complete thorough investigations of two separate resident allegations that were reported to the state agency. For the first incident, a resident alleged that on a specific date and time an employee poked two fingers into their face and showed them their middle finger. The five-day follow-up documented the allegation, but the investigation file did not clearly identify who was the first point of contact for the report. During interview, the Administrator stated that a corporate representative was initially made aware of the alleged incident, but there was no statement from this corporate representative included in the investigation file. The Administrator described their usual investigation process as interviewing involved parties, identifying and interviewing witnesses, reviewing staffing for the date of the alleged incident, and interviewing the resident’s roommate and other nearby residents if there were no direct witnesses. In the second incident, a resident reported that during a specific shift someone wearing blue put a hand by their face and over their mouth, and a particular GNA was identified as the alleged perpetrator. Review of the staffing sheet for the time of the alleged incident showed that two GNAs were working on the unit where the incident was reported to have occurred. However, the investigation file contained no statements or interviews from these two GNAs. Prior to the surveyor’s review of the investigation, the DON and a regional nurse were given the opportunity to review the investigation to ensure all necessary documents were available, yet the statements from the two GNAs remained absent. These omissions demonstrated that the facility did not conduct complete investigations into the reported allegations.
Failure to Develop Person-Centered Care Plans for Mobility and Peritoneal Dialysis Needs
Penalty
Summary
Facility staff failed to develop and implement person-centered care plans that addressed all identified needs for two residents, one with mobility limitations and one receiving peritoneal dialysis. For the resident with mobility limitations, the care plan included interventions for resistance to care and adjustment issues, but did not address the resident’s specific resistance to use of a Hoyer lift and the resident’s insistence on pivot transfers from bed to wheelchair. The Unit Manager confirmed that the resident was resistant to care, did not like the Hoyer lift, and preferred pivot transfers, but also stated that physical therapy had prohibited pivot transfers. Despite this known conflict between the resident’s preferences and therapy restrictions, the care plan lacked individualized interventions related to the resident’s resistance to the Hoyer lift and continued request for pivot transfers. For the resident receiving peritoneal dialysis, review of the electronic health record showed an order for peritoneal dialysis, but the resident’s care plans did not include a person-centered care plan specific to this treatment. The existing dialysis care plan did not specify the type of dialysis treatment being provided, did not document when the resident was scheduled to receive the treatment, and did not include time frames for the dialysis cycles. During an interview, the LPN Unit Manager stated that they do not place the dialysis prescription details into the care plan and instead use a generalized renal care plan by selecting standard items, confirming that the care plan was not individualized to the resident’s ordered peritoneal dialysis regimen.
Failure to Document Resident Showers and Refusals
Penalty
Summary
Facility staff failed to maintain complete and accurate documentation of bathing care for a resident, specifically regarding showers and refusals of showers. During a complaint survey, the surveyor requested verification that Resident #5 was receiving scheduled showers. The DON stated that the resident was scheduled for showers on the 3 pm–11 pm shift on Tuesdays and Fridays, and provided shower sheets for several dates in October and early November. However, there was no documentation to verify that the resident received a shower or bed bath on 10/17/25, 10/21/25, and 10/24/25. The DON explained that when a resident receives a shower it is documented on a skin sheet, and that refusals of showers should be documented both in the plan of care and on the shower sheet. Despite this, the surveyor did not receive any documentation indicating that the resident either received bathing care or refused showers on the missing dates. This lack of documentation showed that the facility did not safeguard resident-identifiable information and maintain medical records in accordance with accepted professional standards, as there was no record confirming whether the resident’s scheduled showers or refusals occurred on the identified dates.
Failure to Notify Responsible Party After Narcan Administration for Suspected Opioid Overdose
Penalty
Summary
The deficiency involves the facility’s failure to notify a resident’s responsible party when there was a significant change in the resident’s medical status requiring emergency medication. A complaint alleged that there was no communication with the responsible party when Narcan (naloxone) was administered to a resident for an alleged opioid overdose. Medical record review showed the resident was admitted in March 2026 with multiple fractures, including a nondisplaced zone 1 sacral fracture, a nondisplaced fracture of the posterior column of the right acetabulum, a fracture of the right pubis, and other chronic pain. The resident’s pain regimen included multiple opioids and other pain medications, including Hydromorphone 6 mg every 4 hours PRN, Hydromorphone 4 mg every 4 hours PRN, Tylenol, Lidocaine cream, Methocarbamol, Celebrex, and Gabapentin. A physician’s note dated 4/8/26 documented that the resident reportedly had an opioid overdose earlier that morning and responded well to Narcan administration by nursing, with the note listing chronic pain and opioid overdose status post Narcan. Further review of the resident’s medical record did not show any documentation that the resident’s representative was notified of this overdose event and Narcan administration. During interviews, an agency LPN stated that the resident was “out of it and not responding” during rounds, prompting the LPN to check for and then administer Narcan, after which the resident responded. Another LPN reported that Narcan was given because the resident appeared to be having an overdose and that the physician saw the resident afterward, but stated, “I don’t think anyone was notified, but should have been.” The DON also stated that she would have expected the responsible party to be notified. These findings confirmed that the facility failed to notify the resident’s responsible party of a significant change in condition and emergency treatment.
Failure to Follow Wound Care Orders and Document Narcan Administration
Penalty
Summary
Facility staff failed to provide treatment and care in accordance with professional standards and physician orders for two residents. For one resident admitted after hospitalization with acute systolic heart failure and peripheral edema, a wound physician initially ordered daily oil emulsion dressings for venous wounds on the right shin, left medial foot, and left second toe. At a follow-up assessment, the wound physician changed the treatment for the left medial foot from oil emulsion to daily skin prep and ordered daily skin prep for a newly identified arterial wound on the left plantar foot. Review of the March 2026 medication and treatment administration records showed staff did not discontinue the oil emulsion or initiate the ordered skin prep to the left medial foot, and did not administer skin prep to the left plantar foot wound from the date of the new orders until the resident was sent to the hospital. The DON confirmed that treatments were not administered per the updated wound care orders during this period. For another resident admitted with multiple pelvic and sacral fractures and chronic pain, the record showed extensive opioid and adjunct pain medication orders, and a physician note documented that the resident reportedly experienced an opioid overdose and responded well to Narcan administration by nursing. However, the medical record contained no nursing assessment of the resident at the time of the event, no documentation of the resident’s condition or vital signs, and no record of Narcan administration or the resident’s response afterward. An agency LPN reported finding the resident unresponsive or "out of it" during rounds, knowing the resident was on significant pain medications, and, after checking for an existing order, administering Narcan, after which the resident returned to baseline. The LPN acknowledged not completing or documenting a change-in-condition assessment, and both the DON and unit manager stated they would have expected an assessment and vital signs to be documented in this situation.
Disinfectant Wipes Left Accessible in Dementia Unit Dining Room
Penalty
Summary
The deficiency involves the facility’s failure to keep the environment free from accident hazards on one locked dementia unit. During a complaint survey regarding unsecured cleaning supplies and the potential for residents to use cleaning wipes for personal use, a surveyor observed disinfectant wipes stored openly on a wire shelf in the dining room of the Seagull Unit, a locked dementia unit. The product labeling on the container directed that it be stored in areas inaccessible to children and specifically stated it was not to be used as a diaper wipe or for personal cleansing and that it was not a baby wipe. At the time of the observation, residents with cognitive impairment were present in the dining room awaiting breakfast. A GNA was in the dining room with the residents during the observation, and the unit manager, an LPN, accompanied the surveyor. The surveyor expressed concern about the wipes being accessible in a public area where cognitively impaired residents were present. The LPN reported she had never seen residents use or attempt to use the wipes and stated staff used them to wipe down tables before and after meals. The GNA stated she was always present when residents were in the dining room, that residents were never left alone there, and that she had never seen a resident use a wipe. The Infection Control Nurse stated she was not aware the disinfectant wipes in the dining room were a concern because no residents had gone near them and confirmed they were intended for staff use to clean tables. The NHA and DON reported they had not been made aware of the concern with the wipes, though the DON stated she understood the concern.
Incomplete Documentation of Narcotic Administration on MAR
Penalty
Summary
The deficiency involves the facility’s failure to maintain complete and accurate medical records in accordance with accepted professional standards for one resident. Review of the resident’s April 2026 Medication Administration Record (MAR) and the Controlled Drug Administration Record showed multiple discrepancies for Hydromorphone, a narcotic medication. On several specific dates in April, the Controlled Drug Administration Record documented that Hydromorphone doses were signed out and given by licensed nursing staff at various times, but the corresponding MAR entries for those same dates and times were left blank, indicating no documentation of administration on the MAR. During interviews, an LPN stated that they sign out the medication on the narcotic sheet but do not document it on the MAR. The DON acknowledged awareness that nurses were signing off on the narcotic sheet but not on the MAR, and a unit manager reported not being aware that nurses were failing to sign the MAR when also signing the narcotic sheet, stating that documentation should occur on both records. The NHA and DON later stated they were not aware of the concern until it was identified by the surveyor and agreed with the findings. These observations and interviews demonstrate that the facility did not ensure that all medication administrations were consistently and accurately documented on the MAR for this resident.
Trusted data from CMS and state health departments
Every citation, penalty and Plan of Correction is sourced from public CMS records (latest release June 24, 2026) and official state health department websites — never guesswork.
Trusted by long-term care providers and associations.
