Future Care Northpoint
Inspection history, citations, penalties and survey trends for this long-term care facility in Baltimore, Maryland.
- Location
- 1046 Old North Point Road, Baltimore, Maryland 21224
- CMS Provider Number
- 215147
- Inspections on file
- 18
- Latest survey
- October 27, 2025
- Citations (last 12 mo.)
- 10
Citation history
Health deficiencies cited at Future Care Northpoint during CMS and state inspections, most recent first.
A resident's nephrostomy drainage bag was observed resting on a towel on the floor mat and, on another occasion, hanging from the bedrail with the cap touching the floor. An LPN explained the bag was placed on the towel to prevent leaks onto the floor and did not correct its position during the survey. Unit managers confirmed that urinary drainage bags should not touch the floor, and the infection control nurse acknowledged the non-compliance with infection control protocols.
A resident's right to a clean and comfortable environment was not honored when a heavily soiled privacy curtain, marked with brown stains, remained in place despite the resident's requests for it to be changed. Both an LPN and the DON confirmed the curtain's condition and acknowledged it was inappropriate for a resident's room.
Facility staff did not report an allegation of abuse by a GNA within the required 2-hour window and failed to submit the investigation results to the State Survey Agency within 5 working days. A resident reported rough care and an inappropriate comment by a night shift aide to the night nurse, but the incident was not reported to authorities as required, and facility leadership confirmed the omission.
A resident was transferred to an acute care facility for a change in medical condition, but there was no written evidence that the required bed hold policy notification was provided to the resident or their representative at the time of transfer. Documentation and staff interviews confirmed the absence of this notification.
A resident receiving medications via gastrostomy tube did not receive their prescribed medications at the scheduled time due to staff scheduling issues, and the nurse administering the medications failed to change gloves or wash hands after touching potentially contaminated surfaces before administration.
A resident with documented impaired vision and a need for corrective lenses was observed struggling to eat without glasses and confirmed difficulty seeing. Medical records showed a missed follow-up eye exam, and the DON could not verify if the resident received the required care, with an appointment only scheduled after surveyor intervention.
Two residents experienced inconsistent pain management, with PRN pain medications administered outside of physician-ordered parameters and without documentation of non-pharmacological interventions. Both the DON and an LPN confirmed that pain medications should be given according to orders and pain scales, but staff did not consistently follow these practices or document required interventions.
A required annual performance review for a GNA was not completed or documented, as confirmed by both the HRD and DON after a review of employee files and interviews. The missing evaluation was not found in any office files or binders, resulting in a deficiency related to staff performance monitoring.
A facility did not timely implement a consulting pharmacist's recommendation to document the rationale and duration for a resident's PRN lorazepam order, despite the prescriber agreeing with the recommendation. The PRN order remained active without a specified duration or rationale in the medical record, contrary to regulatory requirements.
A resident with impaired dentition did not receive timely periodic and annual dental exams by a dentist, despite multiple notes from the dental hygienist and a care plan indicating the need for dental follow-up. The exams were not scheduled or completed as required until after surveyor intervention, and facility staff confirmed the delay in providing these routine dental services.
Surveyors found excessive ice accumulation in both the main kitchen walk-in freezer and the second-floor nourishment room refrigerator/freezer, with dietary staff unaware of the preventive maintenance schedule. Residents' snacks and outside food were stored in these affected units.
Staff did not consistently discuss or document advance directives with several residents, and current copies of these legal documents were missing from medical records. Interviews confirmed that some residents were not offered the opportunity to complete advance directives upon admission, and required documentation of these discussions was not present until after surveyor intervention.
A resident who was fully dependent on staff for bathing, due to medical conditions including seizures and muscle weakness, did not receive any showers or baths for an entire month as scheduled. There was no documentation of care provided or of any refusal by the resident, and this was confirmed by facility nursing leadership.
Staff failed to maintain accurate and complete medical records for two residents. In one case, a physician's incapacity certification for one resident was incorrectly filed in another's record. In another instance, a resident received a dose of Dilaudid that was not documented in the medical record, as confirmed by the nurse who administered it.
Failure to Maintain Proper Positioning of Nephrostomy Drainage Bag
Penalty
Summary
Clinical staff failed to follow infection control protocols regarding the proper positioning of a nephrostomy drainage bag for a resident with urinary drainage needs. During a survey, it was observed that the resident's nephrostomy bag was placed on a towel on top of a floor mat next to the bed, rather than being hung off the floor as required. An LPN explained that the bag was placed on the towel to prevent urine from leaking onto the floor, and indicated that the bag had been properly hung at the end of her previous shift, suggesting the night shift may have moved it. The LPN did not correct the positioning of the bag during the observation. Further observations revealed that, on a subsequent day, the nephrostomy bag was hanging from the bedrail but the cap of the bag was touching the floor. Unit managers confirmed that urinary drainage bags should not be in contact with the floor. The infection control nurse was later notified of the issue and acknowledged the non-compliance with infection control policies regarding the proper hanging of nephrostomy drainage bags.
Failure to Maintain Clean and Homelike Resident Environment Due to Soiled Privacy Curtain
Penalty
Summary
The facility failed to provide a clean, comfortable, and homelike environment for a resident, as evidenced by a heavily soiled privacy curtain in the resident's room. The resident reported that the curtain was dirty and had requested it be changed, noting that in a previous room, a similarly soiled curtain was not changed for months despite staff being aware of its condition. During an interview and observation, both the Regional Mobile Director of Nursing and an LPN confirmed the curtain was dirty and soiled with brown marks, and the LPN acknowledged that this was not appropriate for a resident's environment. These findings were based on direct resident interviews and staff observations, with staff verifying the presence of the soiled curtain and acknowledging its unsuitability for the resident's living space.
Failure to Timely Report Alleged Abuse and Investigation Results
Penalty
Summary
Facility staff failed to report an allegation of abuse involving a resident within the required 2-hour timeframe and did not submit the results of the investigation to the State Survey Agency within 5 working days, as mandated by regulation. The incident began when a resident reported to a surveyor that a night shift Geriatric Nursing Assistant (GNA) was rough while providing care and made an inappropriate comment. The resident stated that this concern was reported to the night nurse. However, the Unit Manager (UM) was not aware of the allegation until informed by the surveyor and subsequently indicated she would follow up. Further interviews revealed that neither the initial self-report nor the final investigation report was submitted to the Office of Health Care Quality (OHCQ) as required. The DON confirmed that the facility did not report the allegation within the specified timeframes, citing the resident's later statement that the GNA's actions were not intentional. A review of facility records corroborated that the required reports were not made to the appropriate agencies, and no additional information was provided by facility leadership to validate that reporting occurred.
Failure to Provide Written Bed Hold Policy Notification Upon Hospital Transfer
Penalty
Summary
The facility failed to provide written notification of the bed hold policy to a resident and/or the resident's representative when the resident was transferred to an acute care facility due to a change in medical condition. Medical record review showed that the resident was admitted to the facility and later sent to an acute care hospital, but there was no written evidence in the medical record that the bed hold policy was given at the time of transfer. Documentation reviewed, including the change in condition transfer form, nurse's progress notes, and the eINTERACT SBAR Summary, did not indicate that the required notification was provided. Staff interviews confirmed that while the bed hold policy is typically signed and sent with the resident, no documentation could be produced to verify that this occurred for the resident in question.
Failure to Administer G-Tube Medications as Ordered and Lapse in Hand Hygiene
Penalty
Summary
A deficiency was identified when a registered nurse failed to administer medications to a resident with a gastrostomy tube according to the physician's orders and scheduled times. The resident, who was receiving long-term care and required multiple medications via G-tube, did not receive their medications at the scheduled 9 AM time. The delay in administration was attributed to the absence of a Certified Medicine Aide, which resulted in the nurse administering the medications later than ordered. Additionally, the nurse did not follow proper infection control procedures during medication administration. The nurse was observed touching the bathroom faucet and the resident's bed control without changing gloves or washing hands before administering the medications. The nurse acknowledged these lapses in both medication timing and hand hygiene during an interview with the surveyor.
Failure to Ensure Timely Vision Services for Resident
Penalty
Summary
A deficiency was identified when a resident was observed eating breakfast with their eyes closed, not wearing glasses, and using their hands to locate food items. During an interview, the resident confirmed difficulty seeing and was noted to have impaired vision on their most recent MDS assessment, with corrective lenses indicated as being used. The medical record showed an order for ophthalmology evaluation and treatment as needed, and a prior eye exam recommended a comprehensive follow-up in March 2024. Despite these documented needs and recommendations, there was no evidence that the required follow-up eye exam was provided as scheduled. The DON was unable to confirm whether the resident had received the necessary follow-up care, relying instead on a service provider's list of upcoming appointments. It was only after surveyor intervention that the resident was scheduled for an eye appointment, indicating a lapse in ensuring timely access to vision services as required by the resident's care plan and medical orders.
Failure to Ensure Safe and Consistent Pain Management
Penalty
Summary
Facility staff failed to provide safe and appropriate pain management for two residents, as evidenced by inconsistent administration of pain medications and lack of adherence to physician orders. One resident, who had a history of surgical amputation, diabetes, bacteremia, and atrial fibrillation, reported severe pain rated at 10/10 and stated that pain medications were not given regularly and were delayed. Review of clinical records showed that PRN Oxycodone was administered without clear parameters or pain scale, and was sometimes given for a pain score of 0, contrary to the intended use for moderate to severe pain. Additionally, there was no documentation of non-pharmacological interventions being attempted prior to administering PRN pain medications. A second resident, with diagnoses including urinary tract infection, aseptic necrosis of the femur, low back pain, atrial fibrillation, muscle weakness, and legal blindness, also reported chronic, severe pain that was not well managed. Clinical record review revealed that PRN pain medications, including Oxycodone and Acetaminophen, were administered without consistent use of pain scales or parameters, and were sometimes given for pain scores outside the ordered range, including for a pain score of 0. Again, there was no documentation of non-pharmacological interventions prior to medication administration. Interviews with the DON confirmed that PRN pain medications should be administered according to physician orders and that non-pharmacological interventions are expected to be attempted and documented prior to PRN medication use. However, the DON acknowledged that staff did not consistently document these interventions. An LPN also stated that pain medications should be given based on ordered parameters and pain scores, but records showed this was not consistently followed.
Failure to Complete Annual Performance Review for GNA
Penalty
Summary
The facility failed to conduct annual performance reviews for Geriatric Nursing Assistants (GNAs) as required. During a recertification survey, a review of two randomly selected GNA employee files revealed that one GNA, hired in April 2022, did not have a documented performance evaluation for the 2023 calendar year. The absence of this required evaluation was confirmed through examination of employee files and interviews with the Human Resources Director (HRD) and the Director of Nursing (DON). Both the HRD and DON were unable to locate the 2023 performance review for the GNA in question, despite searching through office files and binders. The HRD acknowledged that some performance reviews had not been filed and were possibly misplaced, but after a thorough search, neither the 2022, 2023, nor 2024 performance reviews for the GNA could be found. The DON also confirmed that she did not have copies of the missing performance reviews and only had access to a binder from the previous DON containing 2022 reviews. The lack of a documented performance review for the specified period was acknowledged by both the HRD and DON during the survey process.
Failure to Implement Pharmacist's PRN Psychotropic Medication Recommendations
Penalty
Summary
The facility failed to respond in a timely manner to recommendations made by the consulting pharmacist and agreed upon by the medical director regarding a resident's PRN lorazepam order. The pharmacist's monthly medication regimen review identified that the PRN lorazepam order lacked a specified duration, as required by CMS regulations, and recommended that the prescriber document both the rationale for continued use and the duration of the PRN order in the medical record. The prescriber agreed with the pharmacist's recommendation and signed the form, but did not document the required rationale or specify the duration in the resident's medical record. Subsequent review of the resident's medical orders showed that the PRN lorazepam order remained active with an indefinite end date and no documented rationale or duration in the medical record. Interviews with the DON and Regional Director of Operations confirmed that, prior to surveyor intervention, there was no documentation in the medical record addressing the pharmacist's recommendation. The deficiency was identified for one resident reviewed for unnecessary medications during the facility's recertification survey.
Failure to Provide Timely Routine Dental Services
Penalty
Summary
Facility staff failed to ensure that a resident received routine dental services in a timely manner. The resident, who reported having bad teeth and a need to see the dentist, had multiple notes from the facility's dental hygienist indicating that periodic and annual dental exams were due. However, there was no documentation that the resident had been seen by a dentist for these required exams. The medical record showed only an initial dental exam by the dentist, with subsequent recommendations for periodic and annual exams, but no evidence that these were completed as scheduled. Interviews with facility staff, including the DON and the medical scheduler, confirmed that annual and periodic dental exams are to be performed by a dentist, not a hygienist. Despite this, the resident was not scheduled for these exams until after surveyor intervention. The resident's care plan also identified impaired dentition and included an approach to consult with a dentist and follow up with recommendations, but this was not carried out in a timely manner. The deficiency was confirmed when the DON acknowledged that the resident was not seen for the required exams until prompted by the surveyor.
Ice Buildup in Kitchen and Nourishment Room Cold Storage
Penalty
Summary
Surveyors observed significant ice buildup in two cold storage areas within the facility's kitchen. In the main kitchen's walk-in freezer, ice was found on the floor and covering approximately 75% of the ceiling. Dietary staff present during the observation was unaware of the preventive maintenance schedule for the freezer room. Additionally, in the second-floor nourishment room, the refrigerator/freezer used to store residents' outside food had more than an inch of ice accumulation around the freezer. Residents' snacks were also stored in this refrigerator. These findings were based on direct observations and staff interviews during the survey period. No information about the medical history or condition of residents was provided in relation to the deficiency.
Failure to Ensure Advance Directives Are Discussed and Documented
Penalty
Summary
Facility staff failed to ensure that advance directives were discussed with residents or their responsible representatives and did not maintain current copies of residents' advance directives in the medical records. This deficiency was identified for six residents out of forty-seven reviewed during the recertification survey. Surveyor review of the medical records for these residents did not reveal any advance directives on file. Interviews with the Unit Manager confirmed that not all residents had advance directives and that, if available, they should be located in both the paper chart and the electronic medical record (PCC). Further interviews with the Social Services Director (SSD) revealed that, while the process requires offering advance directives at admission and quarterly for LTC residents, there was no documentation of these discussions for several residents. The SSD acknowledged that for some residents, there was no record of advance directive discussions or copies in the medical record. Additionally, it was confirmed that some residents were not offered the opportunity to formulate an advance directive upon admission, and documentation of these discussions was lacking until prompted by the surveyor.
Failure to Provide Bathing Assistance for Dependent Resident
Penalty
Summary
A deficiency was identified when a resident, who was dependent on staff for bathing due to a history of seizures, muscle weakness, and osteoarthritis, did not receive the required assistance with activities of daily living (ADL). The resident's admission Minimum Data Set (MDS) assessment documented total dependence on staff for bathing, and the geriatric nursing assistant (GNA) Kardex indicated that the resident was scheduled to receive showers twice weekly. However, a review of the resident's ADL documentation revealed that no showers were provided throughout the entire month of January, and there was no record of a bed bath or any documentation indicating that the resident had refused bathing or showering during this period. This deficiency was further substantiated by staff interview, where the Corporate Director of Nurses confirmed that the resident did not receive a shower or bath in January and that there was no documentation of refusal. The lack of both care provision and documentation demonstrated a failure to meet the resident's individualized care needs as identified in the assessment and care plan.
Failure to Maintain Accurate and Complete Medical Records
Penalty
Summary
Facility staff failed to maintain complete and accurate medical records in accordance with accepted professional standards for two residents. In one instance, a review of a closed medical record revealed that a physician certification of incapacity for one resident was incorrectly filed in another resident's record. The certification, which documented incapacity due to dementia, was signed and dated by the physician, but a second certificate in the same record pertained to a different resident entirely. The facility administrator was unaware of this error until it was identified by the surveyor. In another case, a complaint alleged improper administration of pain medication to a resident who had been admitted following lower extremity surgery. Physician orders directed nursing staff to administer pain medication as needed. Medication administration records showed three documented doses of Dilaudid on a specific date, but a printout from the interim medication dispensing machine indicated an additional dose was administered that was not documented in the resident's medical record. The nurse involved confirmed that the medication was given but admitted to forgetting to document the administration.
Latest citations in Maryland
Facility staff did not ensure that 2nd floor residents who could not use stairs were able to receive visitors when the only elevator was out of service for an extended period. Complaints indicated that some family members, who were themselves unable to ambulate stairs, could not visit their relatives on the 2nd floor during this time. The emergency plan directed non-ambulatory 2nd floor residents to remain on that floor unless there was an emergency and did not address how visitation would be maintained when the elevator was inoperable. The Administrator reported that visitors could use the stairs and that an emergency chair system could be used to move residents, but also stated that the chair system was not used for visitation and was unaware of any complaints, despite two having been filed.
Facility staff did not complete required quarterly smoking safety assessments for several residents identified as smokers, including some who had not been reassessed for many months and one who had never been assessed during their stay. This issue was discovered during a complaint survey after the facility’s only elevator was out of service for an extended period, affecting a group of residents on an upper floor who needed to reach a designated smoking area on a lower floor. Review of records and staff interviews, including with the DON and a unit manager, confirmed that the facility’s own practice of quarterly smoking safety assessments for smokers was not followed for half of the affected residents.
Facility staff failed to accurately code multiple MDS assessments for several residents, leading to discrepancies between MDS entries and MARs for pain management, falls, and high-risk drug classes. In several cases, scheduled pain management was coded as provided when MARs did not show daily pain medications, often because an LPN counted low-dose Aspirin ordered for cardiovascular prophylaxis or heart failure as pain medication, contrary to RAI guidance. One resident’s falls were underreported on the MDS despite two documented falls, and daily use of a topical analgesic and an antiplatelet (Aspirin) was not correctly captured. Other residents had MDS entries indicating use of hypnotic or antianxiety medications when MARs showed none, while actual antidepressant and hypoglycemic medications administered daily were omitted from Section N0415. These errors were confirmed by the involved LPNs during surveyor interviews.
Staff failed to conduct complete investigations into two residents’ abuse allegations. In one case, a resident reported that an employee poked their face and made an obscene gesture, but the investigation lacked a statement from the corporate representative who was first notified of the allegation. In another case, a resident reported that someone in blue clothing put a hand by their face and over their mouth, with a specific GNA identified as the alleged perpetrator; however, the investigation did not include statements from two GNAs who were on duty on the unit at the time of the alleged incident, despite leadership having the opportunity to ensure all relevant documents were present.
Staff failed to create person-centered care plans for two residents, one with mobility limitations and one receiving peritoneal dialysis. For the resident with mobility issues, the care plan did not address the resident’s refusal to use a Hoyer lift and preference for pivot transfers, despite therapy prohibiting pivot transfers and staff awareness of the resident’s resistance. For the resident on peritoneal dialysis, the care plan did not specify that the treatment was peritoneal dialysis, nor did it include the treatment schedule or cycle time frames; an LPN Unit Manager acknowledged using a generalized renal care plan without incorporating the specific dialysis prescription.
A resident’s medical record lacked documentation confirming that scheduled showers or bed baths were provided on multiple dates, and there was also no record of any refusals of care on those days. The DON and an LPN unit manager reported that showers were scheduled on specific shifts and that completed showers and refusals should be documented on shower/skin sheets and in the care plan, but the surveyor found gaps where no such entries existed. This resulted in incomplete ADL documentation and failure to maintain medical records according to accepted professional standards.
A resident with multiple fractures and chronic pain was receiving an opioid-based pain regimen, including PRN hydromorphone. The resident was later found unresponsive and "out of it" by an LPN, who located an order for Narcan and administered it, with the resident responding to the medication. A physician note documented an opioid overdose treated with Narcan. Review of the medical record showed no documentation that the resident’s representative was notified of this significant change in condition and emergency intervention, and staff interviews confirmed that notification likely did not occur, despite the DON’s expectation that the responsible party should have been informed.
Staff failed to follow updated wound care orders and to document an opioid overdose event and Narcan use for two residents. One resident with venous and arterial lower extremity wounds did not receive the prescribed change from oil emulsion to daily skin prep on one foot wound, and did not receive ordered skin prep on a new plantar wound for several days after the wound physician revised the treatment plan. Another resident with multiple fractures and chronic pain, receiving multiple opioid and adjunct analgesics, reportedly experienced an opioid overdose; an LPN found the resident unresponsive, located an existing Narcan order, administered Narcan, and observed the resident return to baseline, but did not complete or document a change-in-condition assessment, vital signs, or the Narcan administration in the medical record.
Surveyors substantiated a deficiency when disinfectant wipes, labeled for storage in areas inaccessible to children and not for personal cleansing, were observed sitting openly on a wire shelf in the dining room of a locked dementia unit while cognitively impaired residents waited for breakfast. A GNA and an LPN present on the unit stated that staff used the wipes to clean tables and that residents were never left alone in the dining room and had not been seen using the wipes. The ICP reported being unaware that the wipes’ placement in the dining room was a concern, and the NHA and DON stated they had not previously been informed about the issue, though the DON acknowledged understanding the concern.
A resident’s medical record showed multiple instances where Hydromorphone, a controlled narcotic, was documented as signed out and given on the Controlled Drug Administration Record but was not documented on the MAR on the same dates and times. An LPN reported signing only the narcotic sheet and not the MAR, while the DON acknowledged awareness that nurses were signing the narcotic sheet without completing the MAR, and a unit manager stated they were unaware this was occurring and that both records should be completed. The NHA and DON agreed with the surveyor’s findings after the issue was identified.
Failure to Ensure Visitation Rights During Elevator Outage
Penalty
Summary
Facility staff failed to ensure that residents residing on the 2nd floor who could not safely ambulate using stairs were able to exercise their right to have visitors when the facility’s only elevator malfunctioned. Complaint reviews showed that family members were unable to visit their relatives on the 2nd floor when the elevator was inoperative, and these family members themselves were unable to use the stairs. An incident report documented that the facility’s only elevator was malfunctioning for an extended period, from 3/28/26 to 4/23/26. During this time, residents who could not use the stairs remained on the 2nd floor, and some of their family members could not access them due to the lack of elevator service. Review of the facility’s emergency plan revealed that it instructed that 2nd floor residents who could not safely use the stairs should remain on the 2nd floor unless there was an emergency, and it did not include any provisions for maintaining visitation when the elevator was inoperable. In an interview, the Administrator stated that visitors could use the stairs to visit 2nd floor residents and that residents could be transported using an emergency chair system to meet visitors who could not use the stairs. However, the Administrator acknowledged that the emergency chair system was not used for visitation purposes during the elevator outage and reported being unaware of any complaints about the inoperative elevator, despite two complaints having been received by OHCQ. No additional documentation was provided to show a plan to support visitation for 2nd floor residents during the elevator malfunction.
Failure to Complete Required Quarterly Smoking Safety Assessments
Penalty
Summary
Facility staff failed to update smoking safety assessments at least once every three months for multiple residents identified as smokers. During a complaint survey focused on smoking safety, surveyors reviewed an incident involving the facility’s only elevator being inoperative for nearly a month, which affected residents who lived on the 2nd floor and needed to access the 1st-floor smoking area. The facility’s investigation identified a group of 10 residents on the 2nd floor who smoked and required additional accommodations to safely ambulate to the designated smoking area. Review of these residents’ medical records showed that 5 of the 10 did not receive quarterly smoking safety assessments as required by the facility’s practice. Specifically, four residents had not received a smoking assessment since May 2025, and one resident had no documented smoking assessment at any time during their stay. During interviews, the Unit Manager stated that residents identified as smokers are to be assessed quarterly for smoking safety. When the surveyor pointed out the missing assessments, the DON reviewed the records and confirmed that these residents had not received the required quarterly smoking assessments. This lack of timely reassessment occurred in the context of an extended elevator outage that necessitated special consideration for safe smoking access for residents residing on the 2nd floor.
Inaccurate MDS Coding for Pain Management, Falls, and High-Risk Drug Classes
Penalty
Summary
Facility staff failed to ensure that Minimum Data Set (MDS) assessments were accurately coded for multiple residents, based on medical record review and staff interviews. For one resident with cerebrovascular disease, an MDS with an Assessment Reference Date (ARD) of 3/2/26 coded Section J0100A (scheduled pain management) as "yes," but the March Medication Administration Record (MAR) did not show daily pain medication administration. An LPN stated she coded it that way because the resident received Aspirin 81 mg daily, although the physician’s order showed the Aspirin was prescribed as prophylaxis for cardiovascular events, and the RAI Manual specifies that medications not primarily intended for pain relief should not be coded as pain management. Another resident with cerebral infarction, congestive heart failure, and vascular dementia had two documented falls in progress notes between the prior assessment and the ARD of 2/4/26, but Section J1900 (number of falls since admission or prior assessment) captured only one fall. The same MDS coded Section J0100A (scheduled pain management) as "no" despite the February MAR documenting daily use of Diclofenac topical gel for pain. The MAR also showed daily Aspirin 81 mg for coronary artery disease, but Section N0415 (high-risk drug classes) did not capture the use of an antiplatelet medication. The responsible LPN confirmed missing the second fall and the Aspirin coding error. Additional residents had similar discrepancies: one resident’s MDS repeatedly coded use of hypnotic medications in Section N0415 when MARs showed no hypnotics administered, and failed to capture an antidepressant (Sertraline) that was given; the LPN reported coding Clonazepam as a hypnotic based on dual use, though reference guidelines did not classify it as such. Further inaccuracies were identified for other residents in pain management and high-risk drug class coding. One resident’s MDS with an ARD of 1/8/26 coded receipt of PRN pain medication in Section J0100A, but the January MAR showed no PRN pain medications given; a later MDS for the same resident coded use of an antianxiety medication in Section N0415, while the April MAR showed no such medication administered. Another resident with traumatic subarachnoid hemorrhage, type 2 diabetes with neuropathy, atrial fibrillation, and atherosclerotic heart disease had an MDS with an ARD of 2/3/26 that coded scheduled pain medication as "yes" and PRN pain medication as "no," although the MAR showed intermittent PRN Tylenol for pain and no daily pain medication, and also documented daily Aspirin 81 mg for heart failure and daily Rybelus for diabetes; the MDS failed to capture PRN pain use, incorrectly coded daily pain medication, and did not code hypoglycemic medication in Section N0415. Another resident with a history of stroke and right-sided hemiplegia/hemiparesis had two MDS assessments in February coded as receiving scheduled pain medication, but the February MAR did not show daily pain medication; the LPN reported coding based on daily prophylactic Aspirin 81 mg, which was not ordered for pain.
Incomplete Investigations of Resident Abuse Allegations
Penalty
Summary
Facility staff failed to complete thorough investigations of two separate resident allegations that were reported to the state agency. For the first incident, a resident alleged that on a specific date and time an employee poked two fingers into their face and showed them their middle finger. The five-day follow-up documented the allegation, but the investigation file did not clearly identify who was the first point of contact for the report. During interview, the Administrator stated that a corporate representative was initially made aware of the alleged incident, but there was no statement from this corporate representative included in the investigation file. The Administrator described their usual investigation process as interviewing involved parties, identifying and interviewing witnesses, reviewing staffing for the date of the alleged incident, and interviewing the resident’s roommate and other nearby residents if there were no direct witnesses. In the second incident, a resident reported that during a specific shift someone wearing blue put a hand by their face and over their mouth, and a particular GNA was identified as the alleged perpetrator. Review of the staffing sheet for the time of the alleged incident showed that two GNAs were working on the unit where the incident was reported to have occurred. However, the investigation file contained no statements or interviews from these two GNAs. Prior to the surveyor’s review of the investigation, the DON and a regional nurse were given the opportunity to review the investigation to ensure all necessary documents were available, yet the statements from the two GNAs remained absent. These omissions demonstrated that the facility did not conduct complete investigations into the reported allegations.
Failure to Develop Person-Centered Care Plans for Mobility and Peritoneal Dialysis Needs
Penalty
Summary
Facility staff failed to develop and implement person-centered care plans that addressed all identified needs for two residents, one with mobility limitations and one receiving peritoneal dialysis. For the resident with mobility limitations, the care plan included interventions for resistance to care and adjustment issues, but did not address the resident’s specific resistance to use of a Hoyer lift and the resident’s insistence on pivot transfers from bed to wheelchair. The Unit Manager confirmed that the resident was resistant to care, did not like the Hoyer lift, and preferred pivot transfers, but also stated that physical therapy had prohibited pivot transfers. Despite this known conflict between the resident’s preferences and therapy restrictions, the care plan lacked individualized interventions related to the resident’s resistance to the Hoyer lift and continued request for pivot transfers. For the resident receiving peritoneal dialysis, review of the electronic health record showed an order for peritoneal dialysis, but the resident’s care plans did not include a person-centered care plan specific to this treatment. The existing dialysis care plan did not specify the type of dialysis treatment being provided, did not document when the resident was scheduled to receive the treatment, and did not include time frames for the dialysis cycles. During an interview, the LPN Unit Manager stated that they do not place the dialysis prescription details into the care plan and instead use a generalized renal care plan by selecting standard items, confirming that the care plan was not individualized to the resident’s ordered peritoneal dialysis regimen.
Failure to Document Resident Showers and Refusals
Penalty
Summary
Facility staff failed to maintain complete and accurate documentation of bathing care for a resident, specifically regarding showers and refusals of showers. During a complaint survey, the surveyor requested verification that Resident #5 was receiving scheduled showers. The DON stated that the resident was scheduled for showers on the 3 pm–11 pm shift on Tuesdays and Fridays, and provided shower sheets for several dates in October and early November. However, there was no documentation to verify that the resident received a shower or bed bath on 10/17/25, 10/21/25, and 10/24/25. The DON explained that when a resident receives a shower it is documented on a skin sheet, and that refusals of showers should be documented both in the plan of care and on the shower sheet. Despite this, the surveyor did not receive any documentation indicating that the resident either received bathing care or refused showers on the missing dates. This lack of documentation showed that the facility did not safeguard resident-identifiable information and maintain medical records in accordance with accepted professional standards, as there was no record confirming whether the resident’s scheduled showers or refusals occurred on the identified dates.
Failure to Notify Responsible Party After Narcan Administration for Suspected Opioid Overdose
Penalty
Summary
The deficiency involves the facility’s failure to notify a resident’s responsible party when there was a significant change in the resident’s medical status requiring emergency medication. A complaint alleged that there was no communication with the responsible party when Narcan (naloxone) was administered to a resident for an alleged opioid overdose. Medical record review showed the resident was admitted in March 2026 with multiple fractures, including a nondisplaced zone 1 sacral fracture, a nondisplaced fracture of the posterior column of the right acetabulum, a fracture of the right pubis, and other chronic pain. The resident’s pain regimen included multiple opioids and other pain medications, including Hydromorphone 6 mg every 4 hours PRN, Hydromorphone 4 mg every 4 hours PRN, Tylenol, Lidocaine cream, Methocarbamol, Celebrex, and Gabapentin. A physician’s note dated 4/8/26 documented that the resident reportedly had an opioid overdose earlier that morning and responded well to Narcan administration by nursing, with the note listing chronic pain and opioid overdose status post Narcan. Further review of the resident’s medical record did not show any documentation that the resident’s representative was notified of this overdose event and Narcan administration. During interviews, an agency LPN stated that the resident was “out of it and not responding” during rounds, prompting the LPN to check for and then administer Narcan, after which the resident responded. Another LPN reported that Narcan was given because the resident appeared to be having an overdose and that the physician saw the resident afterward, but stated, “I don’t think anyone was notified, but should have been.” The DON also stated that she would have expected the responsible party to be notified. These findings confirmed that the facility failed to notify the resident’s responsible party of a significant change in condition and emergency treatment.
Failure to Follow Wound Care Orders and Document Narcan Administration
Penalty
Summary
Facility staff failed to provide treatment and care in accordance with professional standards and physician orders for two residents. For one resident admitted after hospitalization with acute systolic heart failure and peripheral edema, a wound physician initially ordered daily oil emulsion dressings for venous wounds on the right shin, left medial foot, and left second toe. At a follow-up assessment, the wound physician changed the treatment for the left medial foot from oil emulsion to daily skin prep and ordered daily skin prep for a newly identified arterial wound on the left plantar foot. Review of the March 2026 medication and treatment administration records showed staff did not discontinue the oil emulsion or initiate the ordered skin prep to the left medial foot, and did not administer skin prep to the left plantar foot wound from the date of the new orders until the resident was sent to the hospital. The DON confirmed that treatments were not administered per the updated wound care orders during this period. For another resident admitted with multiple pelvic and sacral fractures and chronic pain, the record showed extensive opioid and adjunct pain medication orders, and a physician note documented that the resident reportedly experienced an opioid overdose and responded well to Narcan administration by nursing. However, the medical record contained no nursing assessment of the resident at the time of the event, no documentation of the resident’s condition or vital signs, and no record of Narcan administration or the resident’s response afterward. An agency LPN reported finding the resident unresponsive or "out of it" during rounds, knowing the resident was on significant pain medications, and, after checking for an existing order, administering Narcan, after which the resident returned to baseline. The LPN acknowledged not completing or documenting a change-in-condition assessment, and both the DON and unit manager stated they would have expected an assessment and vital signs to be documented in this situation.
Disinfectant Wipes Left Accessible in Dementia Unit Dining Room
Penalty
Summary
The deficiency involves the facility’s failure to keep the environment free from accident hazards on one locked dementia unit. During a complaint survey regarding unsecured cleaning supplies and the potential for residents to use cleaning wipes for personal use, a surveyor observed disinfectant wipes stored openly on a wire shelf in the dining room of the Seagull Unit, a locked dementia unit. The product labeling on the container directed that it be stored in areas inaccessible to children and specifically stated it was not to be used as a diaper wipe or for personal cleansing and that it was not a baby wipe. At the time of the observation, residents with cognitive impairment were present in the dining room awaiting breakfast. A GNA was in the dining room with the residents during the observation, and the unit manager, an LPN, accompanied the surveyor. The surveyor expressed concern about the wipes being accessible in a public area where cognitively impaired residents were present. The LPN reported she had never seen residents use or attempt to use the wipes and stated staff used them to wipe down tables before and after meals. The GNA stated she was always present when residents were in the dining room, that residents were never left alone there, and that she had never seen a resident use a wipe. The Infection Control Nurse stated she was not aware the disinfectant wipes in the dining room were a concern because no residents had gone near them and confirmed they were intended for staff use to clean tables. The NHA and DON reported they had not been made aware of the concern with the wipes, though the DON stated she understood the concern.
Incomplete Documentation of Narcotic Administration on MAR
Penalty
Summary
The deficiency involves the facility’s failure to maintain complete and accurate medical records in accordance with accepted professional standards for one resident. Review of the resident’s April 2026 Medication Administration Record (MAR) and the Controlled Drug Administration Record showed multiple discrepancies for Hydromorphone, a narcotic medication. On several specific dates in April, the Controlled Drug Administration Record documented that Hydromorphone doses were signed out and given by licensed nursing staff at various times, but the corresponding MAR entries for those same dates and times were left blank, indicating no documentation of administration on the MAR. During interviews, an LPN stated that they sign out the medication on the narcotic sheet but do not document it on the MAR. The DON acknowledged awareness that nurses were signing off on the narcotic sheet but not on the MAR, and a unit manager reported not being aware that nurses were failing to sign the MAR when also signing the narcotic sheet, stating that documentation should occur on both records. The NHA and DON later stated they were not aware of the concern until it was identified by the surveyor and agreed with the findings. These observations and interviews demonstrate that the facility did not ensure that all medication administrations were consistently and accurately documented on the MAR for this resident.
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