Frederick Villa Healthcare
Inspection history, citations, penalties and survey trends for this long-term care facility in Catonsville, Maryland.
- Location
- 711 Academy Road, Catonsville, Maryland 21228
- CMS Provider Number
- 215178
- Inspections on file
- 18
- Latest survey
- March 23, 2026
- Citations (last 12 mo.)
- 57
Citation history
Health deficiencies cited at Frederick Villa Healthcare during CMS and state inspections, most recent first.
A resident admitted with STEMI, CHF, atrial fibrillation, chronic embolism and thrombosis of deep veins, and hypertensive heart disease with heart failure had anticoagulant therapy changed from Eliquis to Xarelto per the hospital discharge summary, and Xarelto was ordered by the physician on admission. However, the baseline care plan created within 48 hours did not list the anticoagulant among current medications and did not include a care plan for anticoagulant therapy. The DON confirmed the resident was receiving Xarelto at admission and that it should have been included in the baseline care plan.
Facility staff failed to develop a comprehensive, person-centered care plan for a resident admitted with paraplegia, severe malnutrition, and multiple Stage IV pressure ulcers. The existing care plan included only general goals and basic interventions such as repositioning and nonspecific wound/dressing care, without specifying dressing types or frequencies. It omitted key interventions to prevent worsening heel ulcers (e.g., heel elevation or heel boots), did not address the ordered wound vac or required monitoring for seal integrity, infection, bleeding, or fluid leakage, and did not specify the type of mattress needed. During review, the DON acknowledged that the care plan was not comprehensive for the resident’s pressure wounds.
A resident admitted after a cerebral infarction with hemiplegia and hemiparesis had been diagnosed with a UTI in the hospital and started on Amoxicillin 500 mg TID, with instructions on the discharge summary to continue the antibiotic for five additional days. On review, the MAR contained no documentation that the Amoxicillin was administered after admission. During interviews, the DON reported having reviewed the discharge summary but believed the antibiotic had been completed in the hospital, and another staff member explained that the facility’s second-day chart check process for new admissions likely failed to identify and implement the ongoing antibiotic order.
A resident with a history of STEMI, CHF, A-fib, chronic embolism/DVT, and hypertensive heart disease was discharged from the hospital with instructions to switch from Eliquis to Xarelto, including a loading dose followed by a maintenance dose. Although Xarelto was ordered on admission, multiple erroneous Eliquis orders were entered by the pharmacy and verified by an LPN supervisor, then repeatedly discontinued by an RN Unit Manager who recognized that only Xarelto was intended. Despite these actions, Eliquis continued to appear on the MAR, and an LPN ultimately administered Eliquis 5 mg together with Xarelto 15 mg during a morning med pass, resulting in both anticoagulants being given concurrently and increasing the resident’s risk for bleeding.
Surveyors found that the facility failed to maintain complete and accurate medical records for two residents. One resident with paraplegia, multiple stage 4 pressure ulcers, a colostomy, and severe malnutrition had missing weekly wound care notes after an EMR system change, incomplete documentation of ordered colostomy output monitoring, and no nursing notes of nausea or vomiting despite staff recollections and a PRN ondansetron order. The same resident’s change-in-condition documentation omitted reported respiratory issues that were later reflected in hospital records and by the RN who sent the resident out. For both this resident and another recently admitted resident, there were care plan invitation letters but no corresponding documentation in the EMR that required care plan meetings after admission actually occurred, as confirmed by the regional social worker.
A deficiency was identified when ongoing pest infestations, including roaches, mice, ants, spiders, and other insects, were repeatedly documented in multiple care areas and common spaces. Despite the use of a pest management company, the NHA confirmed the continued presence of pests, and a complaint was filed regarding the issue. Surveyor review of logs and staff interviews confirmed that the facility's pest control program was not effective.
The facility did not ensure timely reporting of multiple allegations of abuse, neglect, and theft to the appropriate authorities. Several residents reported rough treatment, derogatory comments, delayed care, and missing property, but these incidents were not consistently documented or reported as required. Leadership interviews confirmed lapses in recognizing and reporting these events, resulting in noncompliance with regulatory standards.
Multiple residents reported staff being rough, making inappropriate comments, or providing aggressive care, but the facility did not conduct timely or thorough investigations or document required assessments. In several cases, allegations were not immediately reported, investigated, or followed up with resident assessments, and staff interviews and protective measures were lacking.
Surveyors found that two residents experienced persistent pest infestations, including flies and gnats, in their rooms, with complaints also referencing ants and mice. Maintenance staff did not routinely check rooms unless issues were reported, and pest control measures were insufficient to resolve the problem. Additionally, another resident's room was observed to have longstanding maintenance issues, such as unpainted walls, a corroded faucet, loose plaster, a displaced ceiling tile, and a non-functioning light, all of which contributed to an environment that was not safe, clean, or homelike.
A staff member used a resident's bank card and account information to withdraw funds for personal use, with multiple unauthorized transactions identified through a police investigation. The administrator was unaware of the extent of the staff member's actions and could not confirm if the resident received the withdrawn funds, despite facility policy prohibiting such conduct.
A resident's discharge paperwork was found to be incomplete, with missing information in several sections of the discharge planning tool, including responsible party details, physician information, required signatures, and the medication list. Staff interviews confirmed that all sections should have been completed prior to discharge, but this was not done, and the DON acknowledged the concern.
Surveyors identified that two residents did not have baseline care plans, including medication lists, properly provided or documented within 48 hours of admission. In both cases, required signatures and evidence of delivery to the resident or their representative were missing, and documentation was not present in the EHR as expected. Staff interviews confirmed the deficiencies in the care plan process.
A resident lost the ability to perform activities of daily living (ADLs) without a documented medical reason, as the facility did not ensure that such declines only occurred when medically necessary.
Three residents did not receive appropriate pain management, including lack of pain monitoring, failure to schedule pain management appointments, and improper administration of PRN pain medications without following pain scale parameters or attempting non-pharmacological interventions. Pain medications were sometimes given when pain was not present, and documentation was incomplete or missing.
Two residents did not have complete or accurate documentation in their medical records. One received a one-time dose of Narcan that was not recorded on the MAR, and another had a therapeutic boot recommended by an orthopedist, but its use was not documented on the Treatment Administration Record. These actions resulted in incomplete medical records, contrary to professional standards.
A GNA began caring for residents before completing mandatory training in abuse prevention, dementia care, and infection control, with required education not finished until nearly two months after hire. The NHA confirmed that essential training should have been completed during orientation, but the staff member worked with residents prior to receiving this education.
Baseline Care Plan Omitted Resident’s Anticoagulant Therapy
Penalty
Summary
The facility failed to ensure that a resident’s baseline care plan reflected the resident’s current medications at the time of admission. The resident was admitted with diagnoses including ST elevation myocardial infarction (STEMI), congestive heart failure, atrial fibrillation, chronic embolism and thrombosis of deep veins, and hypertensive heart disease with heart failure. The hospital discharge summary documented that the resident’s anticoagulant therapy had been changed from Eliquis to Xarelto, with a loading dose of Xarelto 15 mg twice daily starting on 12/7/2025 and a planned transition to Xarelto 20 mg daily on 12/29/2025. Upon admission, the physician orders at the facility included Xarelto as an anticoagulant medication. Record review showed that the resident’s baseline care plan, dated 12/10/2025, did not list anticoagulant medication among the resident’s current medications and did not include any care plan addressing anticoagulant therapy. During an interview, the DON confirmed that the resident was taking Xarelto at the time of admission and acknowledged that the anticoagulant medication should have been included in the baseline care plan. This omission occurred despite the requirement that the baseline care plan, provided within 48 hours of admission, detail the components of care the facility intends to provide, including current medications.
Failure to Develop Comprehensive Care Plan for Resident With Stage IV Pressure Ulcers
Penalty
Summary
Facility staff failed to develop a comprehensive, person-centered care plan for a resident admitted with extensive Stage IV pressure ulcers. The resident was admitted with paraplegia due to a motor vehicle accident, Stage IV pressure ulcers to the left buttock, sacral region, and left ankle, a local infection of the skin and subcutaneous tissue, and unspecified severe protein-calorie malnutrition. A pressure ulcer care plan was created and initiated with a goal that the resident would be free from signs of infection and that the ulcers would improve by the next review date. The listed interventions included carefully drying between toes without applying lotion between them, positioning the resident off affected areas, changing position every two hours and as needed, and a general directive for wound/dressing care "as order" with instructions to observe and change dressings and record observations at a frequency to be specified. The care plan was not comprehensive or resident-centered for the type and severity of the resident’s pressure ulcers. It did not specify the types of wound dressings or the frequency of dressing changes and observations. The plan omitted interventions to prevent further worsening of heel ulcers, such as elevating the heels or using heel boots. It also failed to include any information about the ordered wound vac, including monitoring for an intact seal, assessing for infection, bleeding, or fluid leakage. Additionally, the care plan did not address the type of mattress the resident should use. During review of the pressure ulcer care plan with the DON, the DON acknowledged that the care plan was not comprehensive for the resident’s pressure wounds present on admission.
Failure to Continue Prescribed Post-Hospital Antibiotic Therapy
Penalty
Summary
Facility staff failed to provide ordered treatment and care by not administering a prescribed antibiotic following a resident’s hospital discharge. The resident was admitted with hemiplegia and hemiparesis after a cerebral infarction affecting the left dominant side and had been diagnosed with a urinary tract infection in the hospital, for which Amoxicillin 500 mg three times daily was initiated. The hospital discharge summary specified that this Amoxicillin regimen was to be continued for an additional five days after discharge. Review of the resident’s January 2026 MAR showed no evidence that the Amoxicillin was administered upon admission. During interviews, the DON acknowledged reviewing the discharge summary and initially believing the antibiotic had been given in the hospital, and another staff member stated that the facility’s process includes a second-day chart check for new admissions and believed the antibiotic order was missed.
Concurrent Administration of Eliquis and Xarelto Due to Medication Order Errors
Penalty
Summary
The facility failed to ensure a resident remained free from significant medication errors when both Eliquis and Xarelto were ordered and administered contrary to the hospital discharge instructions. The resident was admitted with diagnoses including STEMI, congestive heart failure, atrial fibrillation, chronic embolism and thrombosis of deep veins, and hypertensive heart disease with heart failure. The hospital discharge summary documented that Eliquis had been changed to Xarelto, with a loading dose of Xarelto 15 mg twice daily starting on 12/7/2025 and a planned transition to Xarelto 20 mg daily on 12/29/2025. Upon admission, Xarelto was ordered as directed; however, multiple Eliquis orders were subsequently entered and then discontinued on 12/10/2025, 12/11/2025, and 12/15/2025. The DON stated that the Eliquis order was stopped and restarted to change the indication from DVT to atrial fibrillation. The LPN supervisor reported that the Eliquis orders were created by the pharmacy and verified with the provider, but he could not explain why they were created. The Unit Manager RN acknowledged that the resident was supposed to be on Xarelto per the hospital discharge orders and identified the Eliquis orders as errors on multiple dates, contacting the provider to verify the correct Xarelto order and discontinuing Eliquis each time. Despite these discontinuations, Eliquis continued to appear on the MAR. Review of the December 2025 MAR showed that on 12/16/2025 at the 9:00 AM medication pass, the resident received Eliquis 5 mg along with Xarelto 15 mg, resulting in the administration of both anticoagulants. LPN #18 confirmed administering both medications as documented. The DON later confirmed, upon review of the MAR, that the resident received both Xarelto and Eliquis during that medication administration, and that the resident should have remained on Xarelto per the hospital discharge orders. The administration of both anticoagulant medications increased the resident's risk for bleeding.
Incomplete and Inaccurate Medical Record Documentation for Two Residents
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 with paraplegia, multiple stage 4 pressure ulcers, local skin infection, and severe protein-calorie malnutrition, the medical record initially contained only a few wound notes despite weekly wound care visits. The wound care NP reported that the facility changed electronic systems and that prior wound notes had not transferred into the EMR; the DON later produced printed wound notes that had not been in the record. For the same resident, a change-in-condition note documented hypotension and critical labs with normal respiratory rate and oxygen saturation and no mention of breathing problems, while hospital records from the same day documented shortness of breath and use of a non-rebreather mask at 15 L/min. The RN who sent the resident out stated the resident was having respiratory issues and acknowledged he failed to document this. Additional documentation gaps for this resident included incomplete GNA task records for colostomy output, despite an order to monitor bowel movements every shift. Several shifts in December, January, and February lacked documentation of bowel movements, and the DON stated that if tasks were not signed off, they were not done. A complaint alleged the resident could not keep food down; although there was a PRN order for ondansetron for nausea and vomiting and staff and the physician both recalled an episode of vomiting, there was no nursing documentation of nausea or vomiting in the medical record. Another complaint alleged the facility failed to hold mandated care plan meetings; while there was a letter inviting the family to a care plan meeting on a specific date, there was no documentation in the medical record that the meeting occurred, and the regional social worker confirmed there were no social work notes and that the meeting should have been documented in the assessment section. For a second resident admitted in October 2025, the medical record did not contain documentation that a care plan meeting was held after admission. The EMR’s miscellaneous section contained only a care plan invitation letter for a meeting scheduled in January 2026, with nothing documented for the months immediately following admission. The regional social worker confirmed there was no documentation related to a post-admission care plan meeting for this resident and that only the January meeting notes could be found. These omissions collectively demonstrate that the facility did not maintain complete, accurate, and properly filed medical record documentation for assessments, treatments, changes in condition, and care plan meetings for the residents reviewed.
Failure to Maintain Effective Pest Control Program
Penalty
Summary
The facility failed to maintain an effective pest control program, as evidenced by multiple documented sightings of roaches, mice, ants, spiders, water bugs, flies, and gnats in various patient care areas, medication rooms, break rooms, laundry, conference rooms, and shower rooms. The pest problem logs reviewed by the surveyor showed repeated entries of pest infestations over several months, including in resident rooms and critical care areas. These logs indicated that the issue was ongoing and widespread throughout the facility. During interviews, the Nursing Home Administrator acknowledged the presence of roaches and rodents in the facility, attributing the problem to the building's age and its location near woods and water. Despite the facility having a pest management company, the logs and staff interviews confirmed that pest sightings continued to occur, and a complaint had been filed regarding the infestation. The surveyor verified and confirmed the presence of pests during the investigation, establishing that the facility's pest control measures were not effective in preventing or addressing infestations.
Failure to Timely Report Alleged Abuse, Neglect, and Theft
Penalty
Summary
The facility failed to ensure timely reporting of alleged abuse, neglect, exploitation, or mistreatment of residents to the appropriate authorities, as required. Multiple residents reported incidents of staff being rough, making hurtful statements, refusing care, and other forms of mistreatment. In several cases, residents reported these concerns to staff or surveyors, but there was no documented evidence that the facility initiated timely investigations or reported the allegations to the Office of Health Care Quality (OHCQ) within the required timeframes. For example, two residents alleged that a nurse was rough and had a poor attitude, but the concerns were not reported to OHCQ, and there was no documentation of a timely investigation. Another resident reported that a GNA made derogatory comments about their weight and delayed providing care, but these incidents were not reported as abuse or neglect to OHCQ, and the actions taken were only documented as customer service issues. Additionally, the facility failed to report an incident of alleged theft in a timely manner. A resident's cellphone went missing, and although staff were notified on the day of the incident, the report to OHCQ was not made within the required 24-hour period. In another case, a resident alleged being pushed into bed by a GNA, but the initial self-report to OHCQ was not made within the mandated 2-hour window. Furthermore, a resident reported ongoing issues with a roommate to a GNA, but the allegation was not reported to the state agency, and the facility only addressed the issue internally by arranging a room change. Interviews with facility leadership, including the DON and NHA, revealed a lack of consistent understanding and execution of reporting requirements. In several instances, staff acknowledged that incidents were not reported as abuse or neglect, and documentation was either lacking or delayed. The facility's failure to recognize, document, and report these allegations in a timely manner resulted in noncompliance with regulatory requirements for reporting suspected abuse, neglect, or theft.
Failure to Timely Investigate and Document Abuse Allegations
Penalty
Summary
The facility failed to thoroughly investigate and document allegations of abuse in a timely manner for multiple residents. In several instances, residents reported that staff were rough, mean, or made inappropriate comments during care. For example, two residents reported that a nurse was rough and had a poor attitude, but there was no evidence that the facility conducted a timely or thorough investigation after these concerns were reported to a unit manager and later to the Director of Nursing (DON). The only documentation provided was a single statement form, with no further evidence of interviews, assessments, or protective measures taken while the investigation was pending. Another resident reported that a Geriatric Nursing Aide (GNA) made hurtful comments about the resident's weight and was rude during care. Although the incident was documented as a concern, there was no evidence that the facility conducted a thorough investigation, assessed the resident, or interviewed staff and residents in a timely manner. The Nursing Home Administrator (NHA) acknowledged that the incident was not treated as abuse and that the GNA was only verbally instructed not to return to the resident's room. Additional incidents included a resident calling 911 to report being aggressively grabbed by a nurse, with a significant delay in conducting required assessments after the NHA was notified. In another case, a family member reported aggressive care by a GNA, but the resident's assessment was not completed until the following day. The DON confirmed that immediate assessments and investigations were not performed as required in these cases.
Failure to Maintain Safe, Clean, and Homelike Environment
Penalty
Summary
Surveyor observations and resident interviews revealed that the facility failed to maintain a safe, clean, comfortable, and homelike environment for its residents. In two separate rooms, residents reported persistent issues with flies and gnats, which were also directly observed by the surveyor at multiple times during the facility tour. A complaint had previously documented problems with pest control, including ants, fruit flies, gnats, and mice. The Maintenance Director confirmed that routine checks of resident rooms were not performed unless an issue was reported, and that fly traps and spraying were not permitted in resident rooms. The Administrator acknowledged the ongoing pest issue and indicated that pest control services were in place, but could not specify the frequency of visits or provide immediate evidence of effective pest management. Despite some pest control measures, the presence of flies and gnats persisted in resident rooms at the time of the survey. In a separate incident, a complaint and subsequent observation of another resident's room revealed that the room had not been painted in years, with visible old paint where items had been removed from the walls. The bathroom faucet was corroded, plaster on the walls was loose and flaky, a ceiling tile was ajar, and the light above one bed was not functioning due to a missing bulb and pull cord. The resident confirmed the light had not worked for some time. The Nursing Home Administrator agreed that these conditions did not constitute a comfortable, homelike environment.
Staff Misappropriation of Resident Funds
Penalty
Summary
Facility staff failed to protect a resident from misappropriation of property when a Geriatric Nursing Assistant (GNA) used the resident's bank card and account information to access funds for personal benefit. The GNA admitted to withdrawing $100 at the resident's request, but denied making other withdrawals. However, a police investigation revealed 28 transactions over several months, with the GNA's name associated with withdrawals via a cash app. Bank records showed two significant withdrawals to the GNA's cash app prior to his termination. The resident confirmed that the staff member used their bank card and stated there had been no further incidents since the last event. The facility administrator was unaware of the GNA's actions until after the staff member's termination and could not confirm whether the withdrawn funds were given to the resident. The administrator also did not know the reason for the GNA's termination and was unable to provide a clear policy regarding staff obtaining money for residents. Facility policy prohibits misuse or abuse of nursing home funds, dishonesty, theft, and misrepresentation, but the events indicate that these policies were not effectively enforced in this case.
Incomplete Discharge Documentation for Resident
Penalty
Summary
The facility failed to ensure that discharge documentation for a resident was fully completed. Upon review of the resident's closed medical record, it was found that several sections of the Engage Discharge Planning Tool were left blank, including responsible parties' information, primary physician information, staff and resident or responsible party signatures, and the medication list. Additionally, the section regarding whether a pharmacy printout of the medication regimen was attached was not completed, and no medication list or indication of its status was present in the record. Interviews with facility staff revealed that the discharge paperwork is typically initiated by the social worker and completed by various disciplines, including the physician, nurse, rehab, activities, and dietician. The unit manager stated that medication lists are not routinely printed out, and new prescriptions are provided to residents on paper. The social worker confirmed that all sections of the discharge planning tool should be completed before the resident or responsible party receives the paperwork. The Director of Nursing acknowledged the concern when informed of the incomplete documentation, and no additional documentation related to the resident's discharge was provided.
Failure to Provide and Document Baseline Care Plans Upon Admission
Penalty
Summary
The facility failed to ensure that a baseline care plan (BLCP), including a current list of medications, was provided to residents and/or their representatives and documented in the medical record within 48 hours of admission. For two residents reviewed, there was no evidence in the electronic health record (EHR) that the BLCP was present under the designated section, nor was there documentation that the BLCP had been provided to the resident or their representative. In one case, a resident with severely impaired cognition, as indicated by a BIMS score of 0, had a BLCP signed by the resident instead of the representative, contrary to facility expectations. The Director of Nursing (DON) confirmed that the required documentation and signatures were missing and that the BLCP was not properly scanned into the EHR. In another instance, a resident with dementia and a BIMS score of 2 had a BLCP with missing signatures from both the staff and the resident or representative, and there was no evidence that the BLCP or medication list had been provided. The DON and Regional Director of Clinical Operations (RDCO) verified that the required fields were incomplete and that the documentation process had not been followed as expected. These findings were based on medical record reviews and staff interviews conducted during the recertification survey.
Failure to Prevent Unjustified Decline in ADL Abilities
Penalty
Summary
Residents experienced a decline in their ability to perform activities of daily living (ADLs) without a documented medical reason to justify the loss. The facility failed to ensure that residents maintained their ADL abilities unless a medical condition necessitated the decline, as required by regulations.
Failure to Provide Safe and Appropriate Pain Management
Penalty
Summary
The facility failed to provide safe and appropriate pain management for three residents, as evidenced by lack of pain monitoring, failure to schedule necessary pain management appointments, and improper administration of pain medications. One resident, following hospital discharge, was recommended to follow up with a pain management clinic and spine specialist. Although physician orders and a pain care plan were in place, there was no evidence that pain was monitored or recorded every shift, and the resident did not have a scheduled appointment with the pain specialist until after surveyor intervention. The resident continued to experience pain and was unaware of any scheduled follow-up, indicating a breakdown in communication and care coordination. Another resident was administered PRN pain medication even when their pain level was documented as zero, and there was no evidence that non-pharmacological interventions were attempted prior to medication administration. The physician's order did not include non-pharmacological interventions, and the Medication Administration Record did not reflect their use. The DON confirmed that pain medication should not be given when pain is absent and that non-pharmacological interventions should be implemented, but these standards were not followed. A third resident with chronic pain and opioid dependence had PRN orders for both acetaminophen and oxycodone without specific pain scale parameters. Review of records showed inconsistent pain management, with medications given for pain scores that did not align with best practices (e.g., oxycodone for a pain score of 1). There was also no documentation of non-pharmacological interventions prior to medication administration. Staff interviews confirmed that pain medications should be administered according to pain severity and that non-pharmacological interventions should be attempted and documented, but these practices were not consistently followed.
Incomplete and Inaccurate Medical Record Documentation for Two Residents
Penalty
Summary
The facility failed to maintain complete and accurate medical records for two residents, as required by professional standards. In the first instance, a resident who had returned from a leave of absence was administered a one-time dose of Narcan after exhibiting unresponsiveness and excessive drowsiness. Although the administration of Narcan was documented in the nursing progress notes, the Medication Administration Record (MAR) for the month did not include documentation of the Narcan administration. Additionally, there was no documented evidence that the resident’s behavior was being routinely monitored following the event. In the second instance, another resident was admitted with a therapeutic boot and had an orthopedist consultation recommending continued use of the boot for weight bearing as tolerated. However, there was no evidence in the clinical record that nursing staff documented the use of the boot on the Treatment Administration Record, despite the expectation that such recommendations would be followed. These omissions resulted in incomplete and inaccurate medical records for both residents.
Failure to Provide Timely Abuse Education to Newly Hired GNA
Penalty
Summary
The facility failed to provide required abuse education to a geriatric nursing assistant (GNA) upon hire, as evidenced by a review of staff training records and administrative interviews. One GNA, who was later falsely accused of sexual abuse by a resident, was hired and began caring for residents before completing mandatory training in infection control, dementia care, and abuse prevention. The training was not completed until nearly two months after the hire date, despite facility policy requiring such education during orientation. The Nursing Home Administrator confirmed that the staff member worked with residents prior to completing the required training.
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Facility staff did not ensure that 2nd floor residents who could not use stairs were able to receive visitors when the only elevator was out of service for an extended period. Complaints indicated that some family members, who were themselves unable to ambulate stairs, could not visit their relatives on the 2nd floor during this time. The emergency plan directed non-ambulatory 2nd floor residents to remain on that floor unless there was an emergency and did not address how visitation would be maintained when the elevator was inoperable. The Administrator reported that visitors could use the stairs and that an emergency chair system could be used to move residents, but also stated that the chair system was not used for visitation and was unaware of any complaints, despite two having been filed.
Facility staff did not complete required quarterly smoking safety assessments for several residents identified as smokers, including some who had not been reassessed for many months and one who had never been assessed during their stay. This issue was discovered during a complaint survey after the facility’s only elevator was out of service for an extended period, affecting a group of residents on an upper floor who needed to reach a designated smoking area on a lower floor. Review of records and staff interviews, including with the DON and a unit manager, confirmed that the facility’s own practice of quarterly smoking safety assessments for smokers was not followed for half of the affected residents.
Facility staff failed to accurately code multiple MDS assessments for several residents, leading to discrepancies between MDS entries and MARs for pain management, falls, and high-risk drug classes. In several cases, scheduled pain management was coded as provided when MARs did not show daily pain medications, often because an LPN counted low-dose Aspirin ordered for cardiovascular prophylaxis or heart failure as pain medication, contrary to RAI guidance. One resident’s falls were underreported on the MDS despite two documented falls, and daily use of a topical analgesic and an antiplatelet (Aspirin) was not correctly captured. Other residents had MDS entries indicating use of hypnotic or antianxiety medications when MARs showed none, while actual antidepressant and hypoglycemic medications administered daily were omitted from Section N0415. These errors were confirmed by the involved LPNs during surveyor interviews.
Staff failed to conduct complete investigations into two residents’ abuse allegations. In one case, a resident reported that an employee poked their face and made an obscene gesture, but the investigation lacked a statement from the corporate representative who was first notified of the allegation. In another case, a resident reported that someone in blue clothing put a hand by their face and over their mouth, with a specific GNA identified as the alleged perpetrator; however, the investigation did not include statements from two GNAs who were on duty on the unit at the time of the alleged incident, despite leadership having the opportunity to ensure all relevant documents were present.
Staff failed to create person-centered care plans for two residents, one with mobility limitations and one receiving peritoneal dialysis. For the resident with mobility issues, the care plan did not address the resident’s refusal to use a Hoyer lift and preference for pivot transfers, despite therapy prohibiting pivot transfers and staff awareness of the resident’s resistance. For the resident on peritoneal dialysis, the care plan did not specify that the treatment was peritoneal dialysis, nor did it include the treatment schedule or cycle time frames; an LPN Unit Manager acknowledged using a generalized renal care plan without incorporating the specific dialysis prescription.
A resident’s medical record lacked documentation confirming that scheduled showers or bed baths were provided on multiple dates, and there was also no record of any refusals of care on those days. The DON and an LPN unit manager reported that showers were scheduled on specific shifts and that completed showers and refusals should be documented on shower/skin sheets and in the care plan, but the surveyor found gaps where no such entries existed. This resulted in incomplete ADL documentation and failure to maintain medical records according to accepted professional standards.
A resident with multiple fractures and chronic pain was receiving an opioid-based pain regimen, including PRN hydromorphone. The resident was later found unresponsive and "out of it" by an LPN, who located an order for Narcan and administered it, with the resident responding to the medication. A physician note documented an opioid overdose treated with Narcan. Review of the medical record showed no documentation that the resident’s representative was notified of this significant change in condition and emergency intervention, and staff interviews confirmed that notification likely did not occur, despite the DON’s expectation that the responsible party should have been informed.
Staff failed to follow updated wound care orders and to document an opioid overdose event and Narcan use for two residents. One resident with venous and arterial lower extremity wounds did not receive the prescribed change from oil emulsion to daily skin prep on one foot wound, and did not receive ordered skin prep on a new plantar wound for several days after the wound physician revised the treatment plan. Another resident with multiple fractures and chronic pain, receiving multiple opioid and adjunct analgesics, reportedly experienced an opioid overdose; an LPN found the resident unresponsive, located an existing Narcan order, administered Narcan, and observed the resident return to baseline, but did not complete or document a change-in-condition assessment, vital signs, or the Narcan administration in the medical record.
Surveyors substantiated a deficiency when disinfectant wipes, labeled for storage in areas inaccessible to children and not for personal cleansing, were observed sitting openly on a wire shelf in the dining room of a locked dementia unit while cognitively impaired residents waited for breakfast. A GNA and an LPN present on the unit stated that staff used the wipes to clean tables and that residents were never left alone in the dining room and had not been seen using the wipes. The ICP reported being unaware that the wipes’ placement in the dining room was a concern, and the NHA and DON stated they had not previously been informed about the issue, though the DON acknowledged understanding the concern.
A resident’s medical record showed multiple instances where Hydromorphone, a controlled narcotic, was documented as signed out and given on the Controlled Drug Administration Record but was not documented on the MAR on the same dates and times. An LPN reported signing only the narcotic sheet and not the MAR, while the DON acknowledged awareness that nurses were signing the narcotic sheet without completing the MAR, and a unit manager stated they were unaware this was occurring and that both records should be completed. The NHA and DON agreed with the surveyor’s findings after the issue was identified.
Failure to Ensure Visitation Rights During Elevator Outage
Penalty
Summary
Facility staff failed to ensure that residents residing on the 2nd floor who could not safely ambulate using stairs were able to exercise their right to have visitors when the facility’s only elevator malfunctioned. Complaint reviews showed that family members were unable to visit their relatives on the 2nd floor when the elevator was inoperative, and these family members themselves were unable to use the stairs. An incident report documented that the facility’s only elevator was malfunctioning for an extended period, from 3/28/26 to 4/23/26. During this time, residents who could not use the stairs remained on the 2nd floor, and some of their family members could not access them due to the lack of elevator service. Review of the facility’s emergency plan revealed that it instructed that 2nd floor residents who could not safely use the stairs should remain on the 2nd floor unless there was an emergency, and it did not include any provisions for maintaining visitation when the elevator was inoperable. In an interview, the Administrator stated that visitors could use the stairs to visit 2nd floor residents and that residents could be transported using an emergency chair system to meet visitors who could not use the stairs. However, the Administrator acknowledged that the emergency chair system was not used for visitation purposes during the elevator outage and reported being unaware of any complaints about the inoperative elevator, despite two complaints having been received by OHCQ. No additional documentation was provided to show a plan to support visitation for 2nd floor residents during the elevator malfunction.
Failure to Complete Required Quarterly Smoking Safety Assessments
Penalty
Summary
Facility staff failed to update smoking safety assessments at least once every three months for multiple residents identified as smokers. During a complaint survey focused on smoking safety, surveyors reviewed an incident involving the facility’s only elevator being inoperative for nearly a month, which affected residents who lived on the 2nd floor and needed to access the 1st-floor smoking area. The facility’s investigation identified a group of 10 residents on the 2nd floor who smoked and required additional accommodations to safely ambulate to the designated smoking area. Review of these residents’ medical records showed that 5 of the 10 did not receive quarterly smoking safety assessments as required by the facility’s practice. Specifically, four residents had not received a smoking assessment since May 2025, and one resident had no documented smoking assessment at any time during their stay. During interviews, the Unit Manager stated that residents identified as smokers are to be assessed quarterly for smoking safety. When the surveyor pointed out the missing assessments, the DON reviewed the records and confirmed that these residents had not received the required quarterly smoking assessments. This lack of timely reassessment occurred in the context of an extended elevator outage that necessitated special consideration for safe smoking access for residents residing on the 2nd floor.
Inaccurate MDS Coding for Pain Management, Falls, and High-Risk Drug Classes
Penalty
Summary
Facility staff failed to ensure that Minimum Data Set (MDS) assessments were accurately coded for multiple residents, based on medical record review and staff interviews. For one resident with cerebrovascular disease, an MDS with an Assessment Reference Date (ARD) of 3/2/26 coded Section J0100A (scheduled pain management) as "yes," but the March Medication Administration Record (MAR) did not show daily pain medication administration. An LPN stated she coded it that way because the resident received Aspirin 81 mg daily, although the physician’s order showed the Aspirin was prescribed as prophylaxis for cardiovascular events, and the RAI Manual specifies that medications not primarily intended for pain relief should not be coded as pain management. Another resident with cerebral infarction, congestive heart failure, and vascular dementia had two documented falls in progress notes between the prior assessment and the ARD of 2/4/26, but Section J1900 (number of falls since admission or prior assessment) captured only one fall. The same MDS coded Section J0100A (scheduled pain management) as "no" despite the February MAR documenting daily use of Diclofenac topical gel for pain. The MAR also showed daily Aspirin 81 mg for coronary artery disease, but Section N0415 (high-risk drug classes) did not capture the use of an antiplatelet medication. The responsible LPN confirmed missing the second fall and the Aspirin coding error. Additional residents had similar discrepancies: one resident’s MDS repeatedly coded use of hypnotic medications in Section N0415 when MARs showed no hypnotics administered, and failed to capture an antidepressant (Sertraline) that was given; the LPN reported coding Clonazepam as a hypnotic based on dual use, though reference guidelines did not classify it as such. Further inaccuracies were identified for other residents in pain management and high-risk drug class coding. One resident’s MDS with an ARD of 1/8/26 coded receipt of PRN pain medication in Section J0100A, but the January MAR showed no PRN pain medications given; a later MDS for the same resident coded use of an antianxiety medication in Section N0415, while the April MAR showed no such medication administered. Another resident with traumatic subarachnoid hemorrhage, type 2 diabetes with neuropathy, atrial fibrillation, and atherosclerotic heart disease had an MDS with an ARD of 2/3/26 that coded scheduled pain medication as "yes" and PRN pain medication as "no," although the MAR showed intermittent PRN Tylenol for pain and no daily pain medication, and also documented daily Aspirin 81 mg for heart failure and daily Rybelus for diabetes; the MDS failed to capture PRN pain use, incorrectly coded daily pain medication, and did not code hypoglycemic medication in Section N0415. Another resident with a history of stroke and right-sided hemiplegia/hemiparesis had two MDS assessments in February coded as receiving scheduled pain medication, but the February MAR did not show daily pain medication; the LPN reported coding based on daily prophylactic Aspirin 81 mg, which was not ordered for pain.
Incomplete Investigations of Resident Abuse Allegations
Penalty
Summary
Facility staff failed to complete thorough investigations of two separate resident allegations that were reported to the state agency. For the first incident, a resident alleged that on a specific date and time an employee poked two fingers into their face and showed them their middle finger. The five-day follow-up documented the allegation, but the investigation file did not clearly identify who was the first point of contact for the report. During interview, the Administrator stated that a corporate representative was initially made aware of the alleged incident, but there was no statement from this corporate representative included in the investigation file. The Administrator described their usual investigation process as interviewing involved parties, identifying and interviewing witnesses, reviewing staffing for the date of the alleged incident, and interviewing the resident’s roommate and other nearby residents if there were no direct witnesses. In the second incident, a resident reported that during a specific shift someone wearing blue put a hand by their face and over their mouth, and a particular GNA was identified as the alleged perpetrator. Review of the staffing sheet for the time of the alleged incident showed that two GNAs were working on the unit where the incident was reported to have occurred. However, the investigation file contained no statements or interviews from these two GNAs. Prior to the surveyor’s review of the investigation, the DON and a regional nurse were given the opportunity to review the investigation to ensure all necessary documents were available, yet the statements from the two GNAs remained absent. These omissions demonstrated that the facility did not conduct complete investigations into the reported allegations.
Failure to Develop Person-Centered Care Plans for Mobility and Peritoneal Dialysis Needs
Penalty
Summary
Facility staff failed to develop and implement person-centered care plans that addressed all identified needs for two residents, one with mobility limitations and one receiving peritoneal dialysis. For the resident with mobility limitations, the care plan included interventions for resistance to care and adjustment issues, but did not address the resident’s specific resistance to use of a Hoyer lift and the resident’s insistence on pivot transfers from bed to wheelchair. The Unit Manager confirmed that the resident was resistant to care, did not like the Hoyer lift, and preferred pivot transfers, but also stated that physical therapy had prohibited pivot transfers. Despite this known conflict between the resident’s preferences and therapy restrictions, the care plan lacked individualized interventions related to the resident’s resistance to the Hoyer lift and continued request for pivot transfers. For the resident receiving peritoneal dialysis, review of the electronic health record showed an order for peritoneal dialysis, but the resident’s care plans did not include a person-centered care plan specific to this treatment. The existing dialysis care plan did not specify the type of dialysis treatment being provided, did not document when the resident was scheduled to receive the treatment, and did not include time frames for the dialysis cycles. During an interview, the LPN Unit Manager stated that they do not place the dialysis prescription details into the care plan and instead use a generalized renal care plan by selecting standard items, confirming that the care plan was not individualized to the resident’s ordered peritoneal dialysis regimen.
Failure to Document Resident Showers and Refusals
Penalty
Summary
Facility staff failed to maintain complete and accurate documentation of bathing care for a resident, specifically regarding showers and refusals of showers. During a complaint survey, the surveyor requested verification that Resident #5 was receiving scheduled showers. The DON stated that the resident was scheduled for showers on the 3 pm–11 pm shift on Tuesdays and Fridays, and provided shower sheets for several dates in October and early November. However, there was no documentation to verify that the resident received a shower or bed bath on 10/17/25, 10/21/25, and 10/24/25. The DON explained that when a resident receives a shower it is documented on a skin sheet, and that refusals of showers should be documented both in the plan of care and on the shower sheet. Despite this, the surveyor did not receive any documentation indicating that the resident either received bathing care or refused showers on the missing dates. This lack of documentation showed that the facility did not safeguard resident-identifiable information and maintain medical records in accordance with accepted professional standards, as there was no record confirming whether the resident’s scheduled showers or refusals occurred on the identified dates.
Failure to Notify Responsible Party After Narcan Administration for Suspected Opioid Overdose
Penalty
Summary
The deficiency involves the facility’s failure to notify a resident’s responsible party when there was a significant change in the resident’s medical status requiring emergency medication. A complaint alleged that there was no communication with the responsible party when Narcan (naloxone) was administered to a resident for an alleged opioid overdose. Medical record review showed the resident was admitted in March 2026 with multiple fractures, including a nondisplaced zone 1 sacral fracture, a nondisplaced fracture of the posterior column of the right acetabulum, a fracture of the right pubis, and other chronic pain. The resident’s pain regimen included multiple opioids and other pain medications, including Hydromorphone 6 mg every 4 hours PRN, Hydromorphone 4 mg every 4 hours PRN, Tylenol, Lidocaine cream, Methocarbamol, Celebrex, and Gabapentin. A physician’s note dated 4/8/26 documented that the resident reportedly had an opioid overdose earlier that morning and responded well to Narcan administration by nursing, with the note listing chronic pain and opioid overdose status post Narcan. Further review of the resident’s medical record did not show any documentation that the resident’s representative was notified of this overdose event and Narcan administration. During interviews, an agency LPN stated that the resident was “out of it and not responding” during rounds, prompting the LPN to check for and then administer Narcan, after which the resident responded. Another LPN reported that Narcan was given because the resident appeared to be having an overdose and that the physician saw the resident afterward, but stated, “I don’t think anyone was notified, but should have been.” The DON also stated that she would have expected the responsible party to be notified. These findings confirmed that the facility failed to notify the resident’s responsible party of a significant change in condition and emergency treatment.
Failure to Follow Wound Care Orders and Document Narcan Administration
Penalty
Summary
Facility staff failed to provide treatment and care in accordance with professional standards and physician orders for two residents. For one resident admitted after hospitalization with acute systolic heart failure and peripheral edema, a wound physician initially ordered daily oil emulsion dressings for venous wounds on the right shin, left medial foot, and left second toe. At a follow-up assessment, the wound physician changed the treatment for the left medial foot from oil emulsion to daily skin prep and ordered daily skin prep for a newly identified arterial wound on the left plantar foot. Review of the March 2026 medication and treatment administration records showed staff did not discontinue the oil emulsion or initiate the ordered skin prep to the left medial foot, and did not administer skin prep to the left plantar foot wound from the date of the new orders until the resident was sent to the hospital. The DON confirmed that treatments were not administered per the updated wound care orders during this period. For another resident admitted with multiple pelvic and sacral fractures and chronic pain, the record showed extensive opioid and adjunct pain medication orders, and a physician note documented that the resident reportedly experienced an opioid overdose and responded well to Narcan administration by nursing. However, the medical record contained no nursing assessment of the resident at the time of the event, no documentation of the resident’s condition or vital signs, and no record of Narcan administration or the resident’s response afterward. An agency LPN reported finding the resident unresponsive or "out of it" during rounds, knowing the resident was on significant pain medications, and, after checking for an existing order, administering Narcan, after which the resident returned to baseline. The LPN acknowledged not completing or documenting a change-in-condition assessment, and both the DON and unit manager stated they would have expected an assessment and vital signs to be documented in this situation.
Disinfectant Wipes Left Accessible in Dementia Unit Dining Room
Penalty
Summary
The deficiency involves the facility’s failure to keep the environment free from accident hazards on one locked dementia unit. During a complaint survey regarding unsecured cleaning supplies and the potential for residents to use cleaning wipes for personal use, a surveyor observed disinfectant wipes stored openly on a wire shelf in the dining room of the Seagull Unit, a locked dementia unit. The product labeling on the container directed that it be stored in areas inaccessible to children and specifically stated it was not to be used as a diaper wipe or for personal cleansing and that it was not a baby wipe. At the time of the observation, residents with cognitive impairment were present in the dining room awaiting breakfast. A GNA was in the dining room with the residents during the observation, and the unit manager, an LPN, accompanied the surveyor. The surveyor expressed concern about the wipes being accessible in a public area where cognitively impaired residents were present. The LPN reported she had never seen residents use or attempt to use the wipes and stated staff used them to wipe down tables before and after meals. The GNA stated she was always present when residents were in the dining room, that residents were never left alone there, and that she had never seen a resident use a wipe. The Infection Control Nurse stated she was not aware the disinfectant wipes in the dining room were a concern because no residents had gone near them and confirmed they were intended for staff use to clean tables. The NHA and DON reported they had not been made aware of the concern with the wipes, though the DON stated she understood the concern.
Incomplete Documentation of Narcotic Administration on MAR
Penalty
Summary
The deficiency involves the facility’s failure to maintain complete and accurate medical records in accordance with accepted professional standards for one resident. Review of the resident’s April 2026 Medication Administration Record (MAR) and the Controlled Drug Administration Record showed multiple discrepancies for Hydromorphone, a narcotic medication. On several specific dates in April, the Controlled Drug Administration Record documented that Hydromorphone doses were signed out and given by licensed nursing staff at various times, but the corresponding MAR entries for those same dates and times were left blank, indicating no documentation of administration on the MAR. During interviews, an LPN stated that they sign out the medication on the narcotic sheet but do not document it on the MAR. The DON acknowledged awareness that nurses were signing off on the narcotic sheet but not on the MAR, and a unit manager reported not being aware that nurses were failing to sign the MAR when also signing the narcotic sheet, stating that documentation should occur on both records. The NHA and DON later stated they were not aware of the concern until it was identified by the surveyor and agreed with the findings. These observations and interviews demonstrate that the facility did not ensure that all medication administrations were consistently and accurately documented on the MAR for this resident.
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