Green Acres Nursing And Rehab
Inspection history, citations, penalties and survey trends for this long-term care facility in La Plata, Maryland.
- Location
- 10200 La Plata Road, La Plata, Maryland 20646
- CMS Provider Number
- 215106
- Inspections on file
- 16
- Latest survey
- January 20, 2026
- Citations (last 12 mo.)
- 15
Citation history
Health deficiencies cited at Green Acres Nursing And Rehab during CMS and state inspections, most recent first.
Food items in the kitchen were found without expiration dates, including dessert, chicken tenders, spices, juice containers, cut vegetables, and mayonnaise, and staff confirmed the items were not labeled as required. The facility also had a high-temp dishwasher showing a low wash temp warning at 128.4F, and staff acknowledged the issue.
Surveyors found multiple resident rooms with missing caulking, brown discoloration at toilet bases, chipped and scraped paint, incomplete wall repairs with dry spackle, open wall holes, and stained bathroom flooring. The issues were observed in 13 of 24 rooms, and staff stated room repair concerns are reported through the maintenance system.
Missing Dementia Baseline Care Plan: A resident with unspecified dementia, severe cognitive impairment, and no behaviors was observed in bed being fed breakfast and appeared pleasantly confused. Record review showed the baseline care plan did not include a patient-centered comprehensive care plan for dementia care, and the DON and NHA agreed no dementia care plan was present.
Missing Dementia Care Plan: A resident with unspecified dementia, psychotic disturbance, mood disturbance, and anxiety had severe cognitive impairment on MDS review and was observed in bed being fed breakfast by a GNA while pleasantly confused. Record review showed the current care plan did not include a patient-centered comprehensive dementia care plan, and the DON and NHA agreed no dementia care plan was present.
Incomplete Care Plan Participation and Non-Individualized Dementia Interventions: The facility failed to ensure that the IDT fully participated in updating care plans for two residents, as the physician and responsible aide were not involved in the meetings or documented as providing input. The facility also failed to keep one resident’s care plan current on a quarterly basis and did not include specific, individualized interventions for two residents with dementia related to cognition, safety, or behavior management.
A licensed nurse failed to follow professional standards during a medication pass for a resident by crushing divalproex sodium DR and giving Humalog insulin by injection into the deltoid region instead of by subcutaneous administration. The DON and NHA were notified of the findings.
Failure to Document Informed Consent for Bedrail Use: Surveyors observed 1/4 bedrails in use for multiple residents, but EMR review did not show consent forms for several residents at the time of review. The DOR stated the rails were attached when the beds arrived, and the DON reported verbal or email approval from resident reps, but no signed consents were in the charts when surveyed. For three residents, consent forms were later produced with dates after the bedrails were already in use.
Expired and discharged resident medications were found in medication storage rooms. A vancomycin solution for one resident remained in the refrigerator after the resident had been discharged, and another medication for a different resident was found expired in the refrigerator. The DON was notified and acknowledged the concerns.
Medication administration was not performed according to accepted standards, with an observed error rate of 11.54% during a medication pass. An RN/LPN crushed a delayed-release divalproex tablet for one resident, gave Humalog insulin in the deltoid region instead of the recommended subcutaneous site, and then prepared medication for another resident without performing hand hygiene between residents.
A resident’s care plan did not accurately reflect the resident’s current diagnosis. The record listed psychotropic medication use for mood/behavior related to schizophrenia even though the resident did not have an active schizophrenia diagnosis. The resident was observed in bed eating breakfast, being fed by a GNA, and was pleasantly confused but able to respond to the surveyor. The DON reviewed the care plan and agreed the schizophrenia diagnosis was not active.
Infection control was deficient when surveyors found multiple resident rooms with sanitation issues, including empty hand sanitizer and soap dispensers, discarded gloves on bathroom floors, a soiled washcloth on the floor, and open paper towels placed on a grab bar instead of the dispenser. During a med pass, an LPN attempted to give medication to one resident immediately after giving an insulin injection to another resident without hand hygiene between residents; the surveyor stopped the administration before the medication was given.
Failure to Post Nurse Staffing Ratio Information: Surveyors observed that nurse staffing ratio information was not posted on the staffing boards on Units 100, 200, and 300, and Unit 200 had no visible staffing board in the secured area. The DON stated the ratio was on a separate paper on Unit 100, but the document was not filled out, and the secured area board was only visible through a small window and difficult for residents to read.
The facility failed to protect residents from abuse and neglect, with incidents including a resident left unchanged for 23 hours, a GNA neglecting proper wheelchair use, and resident-to-resident altercations. These events highlight significant lapses in care and supervision, as well as misunderstandings about abuse definitions.
The facility failed to ensure that several residents had an Advance Directive or were offered the opportunity to create one. A resident's record lacked an Advance Directive despite a request, and there was no follow-up. Additionally, Advance Directives were not located for three other residents, and there was no documentation of them being offered. The facility acknowledged the issue and was working on the process.
Facility staff failed to ensure an accurate MDS assessment for a resident's vision. Initially, the MDS noted impaired vision without eyeglasses, despite a nursing note indicating the resident used eyeglasses. A later MDS corrected this, noting both impaired vision and eyeglass use. This discrepancy was reported to the Administrator and DON.
Facility staff failed to ensure a resident wore their eyeglasses, as identified in a complaint investigation. The resident's family expressed concern about the absence of eyeglasses, and clinical records showed discrepancies in the resident's vision care. MDS assessments noted impaired vision, with one indicating no eyeglasses and another indicating their use. There was no evidence of eyeglass use during the first four months of admission.
A facility failed to provide or obtain routine dental care for a resident. Despite a dental consult recommending x-rays and possible extractions over a year ago, no follow-up appointments or exams were documented. Interviews with staff confirmed the absence of further documentation regarding the resident's dental care.
A resident's dignity was compromised when their meal tray was removed before they finished eating. The resident was left with a breakfast casserole on the tray table, and an LPN confirmed the resident had not completed the meal. The Nursing Home Administrator was informed, and an investigation was initiated.
The facility failed to notify the local Ombudsman of resident transfers to the hospital, as required. Two residents were transferred without proper notification, and staff interviews revealed a lapse in the notification process after a change in responsibility. The facility could not provide evidence of notification during the survey.
A resident was transferred to the hospital, and the facility staff failed to provide the required bed hold policy. Despite having a transfer form, there was no evidence that the policy was communicated to the resident or their responsible party. The DON and Administrator acknowledged the oversight during a surveyor interview.
The facility failed to conduct proper care plan meetings for two residents. One resident reported not having a meeting since admission, with no evidence of meetings in their records. Another resident's meeting was attended only by Activities and Social Service staff, lacking a full team of health professionals. The facility's administration acknowledged the absence of documentation.
A resident reported right arm pain to an LPN, leading to a physician's order for an X-ray and Tylenol administration. However, the X-ray order was delayed for three days, resulting in a late diagnosis of a right proximal humerus fracture. The resident was subsequently sent to the emergency department.
A resident was not consistently wearing an ordered brace due to staff inaction, despite instructions to apply it after morning care. The resident expressed frustration over the inconsistency, and the issue was acknowledged by the facility's administration.
Two residents experienced deficiencies in G-tube care. One resident's G-tube was discolored due to medication, but the agency nurse failed to notify the physician. Another resident's G-tube was flushed with less water than ordered, as the LPN did not verify the correct amount. The Unit Manager expected staff to follow medical orders precisely.
The facility failed to maintain oxygen therapy equipment according to policy and physician orders for two residents. Observations revealed unlabeled and undated oxygen tubing and humidifier bottles, with one resident's equipment found on the floor. The DON and Unit Manager confirmed the issues, noting that the equipment should be changed and labeled weekly.
A resident received insulin despite physician's orders to hold it if blood sugar was below 150. The MAR showed insulin was administered six times when blood sugar was under the threshold, indicating a failure to follow medical directives.
A facility failed to provide dental services and assessments for a resident, who had missing teeth and plaque buildup. The resident's family mentioned the need for a dental consult, but it was unclear if this was communicated to the facility. A review of the resident's medical records showed no dental consult, and the DON confirmed the lack of a dental service provider since a change in ownership.
A resident's meal preferences were not met, as their meal included bread, which they disliked, and lacked the requested coffee. A staff member confirmed the resident's preferences and acknowledged the oversight.
Facility staff failed to maintain food items in the kitchen safely. Salami deli meat was found partially wrapped with an expired use-by date, and an opened bag of mozzarella cheese was not in a sealed container. Two bags of bologna lacked date labels. The Food Service Manager confirmed the incorrect date labeling, and the Administrator acknowledged the findings.
Facility staff failed to honor resident shower preferences, as two residents reported not receiving scheduled showers. One resident stated showers only occur with sufficient staff, and records showed a significant gap since the last documented shower. Another resident reported only receiving bed baths and had a noticeable odor, with records confirming only two showers in a month. The Administrator and DON acknowledged the issue and planned to review records.
A facility failed to notify a resident's POA about a stage 2 sacrum pressure ulcer. The ulcer was documented in a wound evaluation, but there was no record of notification to the POA. An LPN claimed to have informed the POA in person but did not document it, contrary to the facility's policy requiring such notifications to be recorded.
The facility failed to report allegations of neglect and missing money to the Maryland Department of Health - Office of Healthcare Quality (OHCQ) within the required time frame. A resident was left in the same clothes for 23 hours, and the final report was delayed. Another resident reported missing money twice, with the first incident reported late and the second not reported at all. The facility did not adhere to the required reporting timelines.
The facility failed to conduct thorough investigations for two residents' allegations. One involved a sexual assault claim with insufficient interviews and no skin assessments, while the other concerned missing money with no documented interviews. The NHA provided incomplete investigation files and did not address the lack of comprehensive investigation procedures.
The facility failed to maintain the most recent survey results in an accessible location for residents and visitors, with no visible signage initially indicating the binder's location. The survey binder was eventually found but lacked documentation of Life Safety Inspections or local fire department inspections. The Nursing Home Administrator was unaware of these inspections, and the Maintenance Director was responsible for such records.
Food Storage and Dishwasher Temperature Deficiencies
Penalty
Summary
Food was not stored in accordance with professional food safety standards, as multiple items in the kitchen were found without expiration dates during an initial tour. The items observed missing expiration dates included one 36 oz lemon meringue pie, one large bag of chicken tenders, several spice containers, several 4 oz orange juice containers, one platter of sliced tomatoes and cucumbers, and two 1-gallon containers of heavy-duty mayonnaise. Staff confirmed that these items did not have expiration dates and stated that food items are supposed to be labeled with an expiration date, while another staff member stated that all food items are to be labeled with delivery and/or expiration dates when received. The facility also failed to ensure that the high-temperature dishwasher provided safe heat sanitization when the monitor displayed a warning that the wash temperature was low and read 128.4F, and staff acknowledged the reading and stated they would call to have it fixed.
Unsafe and Unfinished Resident Room Conditions
Penalty
Summary
The facility failed to ensure a safe, clean, comfortable, homelike environment for 13 of 24 resident rooms observed during the annual survey. Surveyors observed multiple room and bathroom conditions, including missing caulking with brown discoloration at the base of toilets, scrapes and chipped paint on bathroom walls, incomplete wall repairs with dry spackle present, open holes in a bathroom wall, multiple paint colors on a wall, chipped and lifting paint between beds, and heavily stained bathroom floor tiles. In several rooms, the observed repairs appeared unfinished and there were no signs indicating "work in progress." The observations were made in rooms 102, 103, 104, 107, 111, 112, 115, 116, 117, 118, 119, 120, and 122. During interview, the LPN Manager stated that everyone is responsible for speaking about room repair concerns and that orders are placed in the maintenance system called TELS. During interview, the NHA stated the rooms would be reviewed for repairs.
Missing Dementia Baseline Care Plan
Penalty
Summary
Failure to develop and implement a baseline care plan for a resident requiring patient-centered dementia care was identified during the annual survey. Resident #4 had diagnoses of unspecified dementia, unspecified severity, without behavioral disturbance, psychotic disturbance, mood disturbance, and anxiety. The resident’s annual MDS dated 12/11/25 showed a BIMS score of 0, indicating severe cognitive impairment and no behaviors, and the quarterly assessment dated 9/11/25 also documented impaired cognitive status and no behaviors. During observation on 01/14/2026, the resident was in bed eating breakfast and was being fed by a GNA, appeared relaxed and smiling, and was able to respond to the surveyor but was pleasantly confused and unable to answer detailed questions. Record review on 01/15/2026 showed the baseline care plan initiated on 12/4/24 did not include a patient-centered comprehensive care plan for dementia care. In interview, the DON and NHA agreed that no care plan was present for dementia care and concern.
Missing Dementia Care Plan
Penalty
Summary
The facility failed to develop and initiate a comprehensive person-centered care plan for resident #4, who had diagnoses of unspecified dementia, psychotic disturbance, mood disturbance, and anxiety. During observation, the resident was in bed eating breakfast and being fed by a GNA, was relaxed and smiling, and was able to respond to the surveyor but denied discomfort and concerns while appearing pleasantly confused. Record review showed an annual MDS dated 12/11/25 with a BIMS score of 0, indicating severe cognitive impairment and no behaviors, and a quarterly assessment dated 9/11/25 also documented impaired cognitive status and no behaviors. Review of the resident’s care plan reports, including the baseline plan and later revisions, showed that the current plan initiated 8/22/25 did not include a patient-centered comprehensive care plan for dementia care, which was identified as four missed opportunities to provide dementia patient-centered care. During interview, the DON and NHA agreed that no care plan was present for dementia care and concern.
Incomplete Care Plan Participation and Non-Individualized Dementia Interventions
Penalty
Summary
The facility failed to ensure that each member of the interdisciplinary team participated in updating residents’ care plans. For Resident #16, a care plan meeting attendance sheet dated 11/26/25 showed attendance by nursing, dietician, activities, social services, the resident’s wife by telephone, and the resident, but did not show participation by the physician or the nursing aide responsible for the resident. When the surveyor asked for progress notes documenting input from those staff members, the Nursing Home Administrator and DON said they would check the record, but no documentation was provided by the end of the exit conference. For Resident #65, a care plan meeting attendance sheet dated 12/09/2025 also did not include the resident’s physician or the nursing aide responsible for the resident, and the NHA and another staff member verified that the care plan meeting did not occur with those staff members present. The facility also failed to develop and implement person-centered care plans with specific, individualized interventions for residents with diagnosed conditions. Resident #109’s most recent care plan was dated 8/22/25 and had not been reviewed and updated on a quarterly basis, remaining overdue for approximately five months. In addition, Resident #10 and Resident #109 both had diagnoses of dementia, but their care plans did not include specific interventions addressing cognitive impairment, safety needs, or dementia-related behaviors. The surveyor asked the DON to review the care plans for individualized, measurable interventions such as supervision, redirection, communication approaches, or safety precautions, but no additional information, documentation, or clarification was provided for either resident.
Medication Preparation and Insulin Administration Errors
Penalty
Summary
Nursing services were not provided in accordance with professional standards of practice during a medication pass for Resident #122. A licensed nurse was observed crushing and preparing divalproex sodium 125 mg delayed-release for administration, even though delayed-release medication should not be crushed because it alters the medication's delivery mechanism. During the same medication pass, the nurse administered Humalog insulin by injection into the deltoid region rather than by subcutaneous administration at an appropriate site. The report states that these actions were observed during record review, observation, and interview, and that the Director of Nursing and Nursing Home Administrator were notified of the findings.
Failure to Document Informed Consent for Bedrail Use
Penalty
Summary
The facility failed to document that informed consent was obtained and retained before bedrails were used for 6 of 6 residents observed during the survey, including Residents #83, #103, #118, #10, #13, and #14. Surveyors observed 1/4 length bedrails in place on both sides of the beds for Residents #83 and #118 in one room, and observed 1/4 length bedrails in place on Resident #103’s bed during a separate observation. Review of the electronic medical records for these residents did not reveal consent forms for bedrail installation at the time of review. During a unit tour, surveyors observed three additional residents with 1/4 siderails in place. The Director of Maintenance stated that the bedrails were attached when the beds arrived at the facility and that he did not complete a formal form for each bedrail assessment. The DON later stated that resident representatives had been contacted by telephone and that approval of the 1/4 siderails was obtained verbally or by email, but also stated that there were no signed consents currently in any of the residents’ charts. For Residents #10, #13, and #14, the facility later provided informed consent forms dated after the bedrails were already in use.
Expired and Discharged Resident Medications Found in Storage
Penalty
Summary
The facility failed to ensure medications were properly removed and disposed of when no longer appropriate for use, including after resident discharge and upon expiration, affecting 2 of 3 medication rooms reviewed. In the Unit 400 medication room, a vancomycin solution labeled for Resident #166 was found stored in the refrigerator door even though the electronic medical record showed the resident had been discharged from the facility on 12/13/2025. In the Unit 100 medication storage room, a medication labeled for Resident #97 was found in the refrigerator with an expiration date of 04/2025 and a fill date of 09/27/2023. The DON was notified of the findings and acknowledged the concerns about expired medications and medications for discharged residents kept in the storage rooms.
Medication Administration Errors During Observed Pass
Penalty
Summary
Medication administration was not performed in accordance with professional standards of practice, resulting in an overall medication error rate of 11.54% during observation of 26 medication administrations. During the medication pass, Staff #21 was observed crushing divalproex sodium 125 mg delayed-release for Resident #122, even though delayed-release medication is not to be crushed. Staff #21 also administered Humalog insulin to Resident #122 by injection into the deltoid region rather than the recommended subcutaneous injection site on the back of the arm. In addition, Staff #21 prepared and attempted to administer medication to Resident #152 immediately after administering medication to Resident #122 without performing hand hygiene between residents.
Inaccurate Diagnosis Listed in Care Plan
Penalty
Summary
The facility failed to maintain medical records in accordance with accepted professional standards because resident #4’s care plan did not accurately reflect the resident’s current medical diagnosis. During observation, resident #4 was seen in bed eating breakfast and being fed by GNA #24 while seated. The resident was relaxed, smiling, able to respond to the surveyor, denied discomfort or concerns, and was described as pleasantly confused and unable to answer detailed questions. Record review showed resident #4 had multiple active diagnoses, including paroxysmal atrial fibrillation, chronic diastolic CHF, hypertension, vitamin D deficiency, depression, neuralgia and neuritis, hyperlipidemia, essential tremor, constipation, a stage 4 sacral pressure ulcer, unspecified dementia, antiphospholipid syndrome, presence of a cardiac pacemaker, chronic embolism and thrombosis of an unspecified vein, and anemia. However, the care plan contained a focus entry stating the resident was prescribed a psychotropic medication for alteration in mood/behavior related to schizophrenia, even though the resident did not have an active diagnosis of schizophrenia. The DON reviewed the care plan and agreed that schizophrenia was not an active diagnosis for the resident.
Infection Control Lapses in Resident Rooms and Medication Pass
Penalty
Summary
Provide and implement an infection prevention and control program was deficient because the facility did not maintain infection prevention and control in resident care areas and did not ensure appropriate hand hygiene during medication administration. Surveyors observed 6 of 24 resident rooms with sanitation concerns, including an empty hand sanitizer dispenser near the door in one room, discarded clear gloves on the bathroom floor in two rooms, a soiled yellow-stained washcloth on the bathroom floor in one room, open paper towels placed on a safety grab bar despite an intact wall-mounted paper towel holder in one room, and an empty soap dispenser in one room. During interview, the LPN manager stated that discarding items on the floor and failing to maintain a clean environment was not the expectation. During a medication administration observation, staff prepared and attempted to administer medication to one resident immediately after giving an insulin injection to another resident without performing hand hygiene between residents. The surveyor intervened before the medication was given, the prepared medication was disposed of, and the staff member then performed hand hygiene before continuing the medication pass. The DON and NHA were informed of the infection control concern, and the DON stated that in-service training would be performed in response to the observation.
Failure to Post Nurse Staffing Ratio Information
Penalty
Summary
The facility failed to post required nurse staffing ratio information in a visible and accessible location on resident units. During the recertification survey, observation on Unit 200 showed that nurse staffing ratio information was not posted on the unit, and on the secured side of Unit 200 there was no visible staffing board for residents to view. Observation of Unit 100 also showed that the nurse staffing ratio was not posted on the unit's staffing board. On the following day, surveyors again observed that no nurse staffing ratio was posted on the staffing boards on Units 200, 300, and 100. When the DON and NHA accompanied the surveyor, the DON stated that the nurse staffing ratio was on a separate paper posted on a bulletin board further down the hallway on Unit 100, but the document was not filled out. It was also observed that Unit 200 did not have a staffing ratio sheet posted at all, and residents in the secured area of Unit 200 could not view the staffing board because it was only visible through a small window in the door and was difficult to read.
Failure to Protect Residents from Abuse and Neglect
Penalty
Summary
The facility failed to protect residents from abuse and neglect, as evidenced by several incidents involving multiple residents. In one case, a resident was left in the same clothes for 23 hours, with a full catheter bag and a urine-soaked brief, after being placed in bed by a responsible party. The Geriatric Nursing Assistant (GNA) on duty assumed the previous shift had changed the resident, leading to neglect. The Unit Manager was not informed of the incident until after the responsible party reported it to the Administrator and Director of Nursing (DON). Another incident involved a GNA who was witnessed by a maintenance worker pushing a resident in a wheelchair without foot pedals and allegedly kicking the resident's foot. The facility's investigation found evidence of neglect due to the failure to provide appropriate services, such as footrests. The resident, who had a BIMS score indicating moderate cognitive impairment, recalled the incident but could not provide details. Additionally, a resident was found soiled in urine and feces due to GNAs switching assignments, resulting in missed care. Further incidents included a resident being pulled from a wheelchair and kicked by another resident, and an unprovoked attack where one resident slapped another. Both incidents were captured on video, and the facility initially questioned whether these constituted abuse due to the mental incompetence of the perpetrators. However, the surveyor clarified that any willful act is considered abuse, regardless of mental status, emphasizing the residents' right to be free from abuse.
Failure to Ensure Advance Directives for Residents
Penalty
Summary
The facility staff failed to ensure that several residents had an Advance Directive or were offered the opportunity to create one. This deficiency was identified for five residents out of a sample of 52 during a survey. For Resident #21, a review of the clinical record revealed the absence of an Advance Directive, despite a progress note indicating that the resident's Power of Attorney was in progress. There was no evidence of follow-up to this request. Similarly, Resident #98's record lacked an Advance Directive, although a progress note stated that the resident requested one at admission, but the facility did not follow up. Additionally, during a record review, the surveyor could not locate Advance Directives for Residents #286, #287, and #296. The facility was unable to provide documentation that Advance Directives were offered to these residents. An interview with Social Worker #6 confirmed that there was no documentation of Advance Directives being offered to these residents, and the process of following up with family members was not documented. The Director of Nursing acknowledged that the facility was working on the Advance Directives process.
Inaccurate MDS Assessment for Resident's Vision
Penalty
Summary
The facility staff failed to ensure an accurate assessment for a resident, as identified during a survey. The Minimum Data Set (MDS), a federally mandated assessment tool, was inaccurately completed for a resident. A nursing note from March 2021 indicated that the resident's sister had called about the resident's eyeglasses, which the staff had not seen. Despite this, the MDS completed in May 2021 noted the resident had impaired vision but did not use eyeglasses. However, a subsequent MDS in August 2021 correctly noted the resident's impaired vision and use of eyeglasses. This discrepancy in the MDS assessments was highlighted to the Administrator and Director of Nursing during the Exit Conference.
Failure to Ensure Resident Wore Eyeglasses
Penalty
Summary
The facility staff failed to ensure that a resident wore their eyeglasses, which was identified during an investigation of a complaint (Intake MD00166696). The complaint was initiated by the resident's family, who expressed concern that the resident was not wearing their eyeglasses. A review of the clinical record showed that on March 24, 2021, a nurse documented a phone call from the resident's sister requesting the resident's glasses, noting that the glasses had never been seen on the resident or in their room. The Minimum Data Set (MDS) assessments, which are federally mandated to guide care planning, indicated discrepancies in the resident's vision care. The MDS completed on May 21, 2021, noted impaired vision without eyeglasses, while the MDS on August 10, 2021, noted the resident used eyeglasses. There was no evidence that the resident used their eyeglasses during the first four months of their admission.
Failure to Provide Routine Dental Care
Penalty
Summary
The facility staff failed to promptly provide or obtain routine dental care or treatment for a resident, as identified during an annual survey. The deficiency was evident for one resident who was reviewed for dental services. A record review revealed that the resident's daughter reported the facility did not provide dental care. A dental consult completed over a year prior recommended x-rays and possible extractions, but no follow-up appointments or exams were documented. Interviews with the 300 Unit Manager and the Director of Nursing confirmed the lack of additional documentation regarding the resident's dental care.
Resident's Meal Tray Removed Prematurely
Penalty
Summary
The facility failed to respect a resident's dignity by removing a meal tray before the resident had finished eating. During an observation, a surveyor noted that a resident was left with a breakfast casserole directly on the tray table after the meal tray was taken away. The resident confirmed that the plate was removed, leaving them with the casserole. This incident was observed during a breakfast service, and the resident was in bed at the time. An LPN later interacted with the resident and confirmed that the resident had not finished the breakfast casserole before it was removed. The LPN acknowledged the situation and indicated they would identify the GNA responsible for removing the meal tray. The Nursing Home Administrator was informed of the incident and initiated an investigation. A grievance form later revealed that the GNA claimed the resident was holding the casserole and feeding themselves when the tray was removed, but the resident had not completed their meal.
Failure to Notify Ombudsman of Resident Transfers
Penalty
Summary
The facility staff failed to notify the local Ombudsman of facility-initiated resident discharges or transfers, as required by regulations. This deficiency was identified during an annual survey, where it was found that two residents, #19 and #108, were transferred to the hospital for further medical evaluation and treatment without the Ombudsman being notified. Resident #19 was transferred on January 15, 2024, and Resident #108 on June 7, 2024. In both cases, there was no documentation in the clinical records indicating that the Ombudsman had been informed of these transfers. Interviews with facility staff revealed that the responsibility for notifying the Ombudsman had shifted from the previous Director of Nursing (DON) to the Social Work Director in February 2024. The Social Work Director admitted that some transfer notices might have been missed since she took over this responsibility. The Nursing Home Administrator confirmed the absence of evidence showing that the Ombudsman was notified for the transfers in question. At the time of the survey exit conference, the facility was unable to provide any documentation to prove that the required notifications had been made.
Failure to Provide Bed Hold Policy
Penalty
Summary
The facility staff failed to provide a bed hold policy to a resident upon their hospitalization. This deficiency was identified during a review of the clinical record of a resident who was transferred to the hospital. Although a transfer form was present, there was no evidence that the bed hold policy was communicated to the resident or their responsible party. The Director of Nursing and the Administrator acknowledged the oversight during an interview with the surveyor.
Deficiency in Care Plan Meetings for Residents
Penalty
Summary
The facility staff failed to ensure that care plan meetings were held for two residents, as required. Resident #4 reported not having a care plan meeting since admission, and a review of their clinical record suggested a meeting might have been held on February 14, 2024, but there was no evidence, such as a sign-in sheet, to confirm the resident's invitation or attendance. A subsequent meeting, due in May, also lacked documentation. Interviews with the Administrator and Director of Nursing confirmed the absence of evidence for these meetings. Resident #21 also experienced a deficiency in care plan meetings. Although a meeting was recorded on January 31, 2024, it was attended only by staff from the Activities and Social Service Departments, lacking a comprehensive team of health professionals. A meeting noted for May 1, 2024, was marked as 'in progress,' with no clear indication that it occurred. The Administrator and Director of Nursing acknowledged the issue and intended to search the electronic health records for evidence of these meetings.
Delayed X-ray Order Leads to Fracture Diagnosis
Penalty
Summary
The facility failed to ensure timely care for a resident who reported pain in their right arm. The resident informed an LPN about the pain, and the physician was notified, resulting in a new order for an X-ray and administration of Tylenol. However, the staff delayed placing the order for the X-ray for three days. Consequently, the resident only received the X-ray three days later, which revealed a fracture of the right proximal humerus. Following the X-ray results, the resident was sent to the emergency department as per physician orders. The Unit Manager confirmed that the facility's expectation is for the nurse who obtains an order to follow through and place it. The Unit Manager recalled the incident and mentioned that staff were educated on following physician orders.
Failure to Ensure Consistent Use of Ordered Brace
Penalty
Summary
The facility staff failed to ensure that a resident consistently wore an ordered brace, which was necessary to maintain or improve the resident's range of motion. During an interview, the resident indicated that not all staff members applied the brace as required, despite a sign above the bed instructing that the brace should be put on after morning care. On multiple occasions, the resident was observed without the brace, including during meals, and expressed frustration that some staff did not apply it, leading to the resident's resignation to the situation. The facility's Administrator and Director of Nursing were informed of these observations and interviews, acknowledging the issue but not detailing any immediate corrective actions.
Failure to Follow G-Tube Orders and Notify Physician
Penalty
Summary
The facility staff failed to administer additional water flushes via gastrostomy tube (G-tube) according to the prescriber's orders and did not notify the physician of a change in the color of the tubing for two residents. For Resident #73, a nursing note indicated that the G-tube was black in color, raising concerns about a potential infection. However, the Unit Manager confirmed that the tube was not being used for feeding, only for administering medications like Ferrous Sulfate, which caused the discoloration. The agency nurse who noted the change did not inform anyone or contact the doctor, delaying necessary medical consultation. For Resident #78, the treatment administration record specified that the G-tube should be flushed with 250 ml of water every 4 hours. However, an agency LPN flushed the tube with only 120 ml of water without verifying the correct order. The LPN admitted to not reviewing the physician's orders before administering the flush. The Unit Manager expressed that it was expected for staff to follow medical orders precisely, highlighting a lapse in adherence to protocol.
Failure to Maintain Oxygen Therapy Equipment
Penalty
Summary
The facility failed to maintain oxygen therapy equipment according to its policy and physician orders for two residents during the annual survey. For one resident, the surveyor observed that the oxygen tubing and humidifier bottle were not labeled or dated, and the oxygen was found lying on the floor. The Unit Manager confirmed the lack of labeling and stated that the tubing is supposed to be changed, labeled, and dated every Sunday. The Director of Nursing (DON) acknowledged the issue, explaining that the resident had just been admitted and the tubing had not yet been labeled. For another resident, the oxygen tubing was not labeled, and the humidification bottle was dated several days prior, with a low water level observed. The clinical record review showed physician orders for weekly changes of the humidification bottle and oxygen tubing, which were not followed. The facility's Oxygen Administration Policy did not provide guidelines on changing or dating the equipment. The Unit Manager confirmed the discrepancy and noted that the equipment should have been changed according to the physician's orders.
Failure to Administer Medications According to Physician's Orders
Penalty
Summary
The facility staff failed to administer medications according to physician's orders for a resident. The resident's primary physician had ordered Novolog pen 100 unit/ml, 16 units before meals, with instructions to hold the insulin if the resident's blood sugar was less than 150. However, a review of the resident's Medication Administration Record (MAR) revealed that the insulin was administered on six occasions when the resident's blood sugar was below 150. Specifically, the blood sugar levels were recorded as 143, 145, 117, 140, 143, and 142 on different days, yet the insulin was still given. This deficiency was identified during a clinical record review and staff interview, which included discussions with the Administrator and Director of Nursing. The facility acknowledged the findings and indicated they would review the MARs.
Failure to Provide Dental Services
Penalty
Summary
The facility failed to provide necessary dental services and assessments for a resident, as evidenced by the case of a resident who was reviewed for dental care. During a phone interview, the resident's family mentioned that the resident had missing teeth and required a dental consult, although it was unclear if this concern had been communicated to the facility. An observation of the resident revealed missing teeth and apparent plaque buildup on the bottom front teeth. A review of the resident's medical records showed no evidence of a dental consult. The Director of Nursing acknowledged that the facility had not secured a dental service provider since a change in ownership earlier in the year.
Failure to Meet Resident Meal Preferences
Penalty
Summary
The facility staff failed to ensure that a resident's meals matched their preferences, as observed during a survey. The deficiency was identified for one resident out of a sample of 52. During an observation in the dining room, the resident showed the surveyor a plate of food that included bread, which was listed as a dislike on the meal slip. Additionally, the resident had requested coffee with every meal, but it was not provided on the tray. A staff member confirmed the resident's preferences and acknowledged that the incorrect meal upset the resident.
Improper Food Storage and Labeling in Kitchen
Penalty
Summary
The facility staff failed to maintain food items in the kitchen in a safe and appropriate manner. During a kitchen tour, several slices of salami deli meat were found partially wrapped in plastic wrap with a label indicating it was opened on 7/26/24 and had a use-by date of 8/2/24, which had already passed. Additionally, an opened bag of shredded mozzarella cheese was not stored in a sealed container, and two bags of bologna lacked date labels. The Food Service Manager confirmed that lunchmeat is considered good for 7 days and acknowledged that the wrong date was written on the label. The Administrator was informed of these findings and acknowledged them.
Failure to Honor Resident Shower Preferences
Penalty
Summary
The facility staff failed to honor resident choices regarding showering, as evidenced by interviews and clinical record reviews for two residents. One resident reported not receiving the scheduled two showers per week, stating that showers only occur if there are four or more geriatric nursing aides on duty. A review of the electronic health record showed the last documented shower was nearly a year ago. Another resident reported only receiving bed baths and exhibited a distinct odor, indicating a lack of proper bathing. Clinical records confirmed that this resident only received two showers in a 30-day period, with no refusals documented. The Administrator and Director of Nursing acknowledged the findings and indicated they would review the records and shower sheets.
Failure to Notify POA of Pressure Ulcer
Penalty
Summary
The facility failed to notify the Power of Attorney (POA) of a resident's medical condition, specifically a stage 2 sacrum pressure ulcer. This deficiency was identified during a survey where it was found that the POA of Resident #29 was not informed about the pressure ulcer, which was acquired prior to the resident's re-admission to the facility. The pressure ulcer was documented in a wound evaluation, but there was no record of notification to the POA. During interviews, the POA confirmed not being notified about the pressure ulcer, while an LPN claimed to have informed the POA in person but admitted that this notification was not documented in the resident's medical record. The facility's policy requires that any change in a resident's condition be communicated to the Resident Representative and documented in the medical record, which was not adhered to in this case.
Failure to Timely Report Allegations of Neglect and Missing Money
Penalty
Summary
The facility failed to report allegations of neglect and missing money to the Maryland Department of Health - Office of Healthcare Quality (OHCQ) within the required time frame. In the first incident, a responsible party (RP) reported that a resident was left in the same clothes for 23 hours, with a full catheter bag and a urine-soaked brief. The initial report was submitted to OHCQ on the day the RP reported it, but the final report was delayed and not sent until 22 days later, exceeding the 5-day requirement. Interviews with the Unit Manager, Director of Nursing (DON), and Administrator revealed a lack of communication and awareness among staff regarding the incident. In the second incident, a resident reported missing money on two separate occasions. The facility initially reported the first allegation of missing money in August 2023 to OHCQ, but the final report was submitted late, beyond the required timeframe. Furthermore, the second allegation of missing money in November 2023 was not reported to OHCQ at all. The Nursing Home Administrator (NHA) confirmed the oversight during interviews with the surveyor and acknowledged the absence of a complaint form for the November incident. The facility is required to submit initial self-reports for abuse, neglect, injury of unknown origin, and misappropriation of resident property within 2 hours if serious bodily harm resulted, or within 24 hours for all other cases, and to forward investigation results within 5 business days. The failure to adhere to these reporting timelines for both incidents indicates a deficiency in the facility's reporting procedures.
Inadequate Investigation of Alleged Violations
Penalty
Summary
The facility failed to conduct thorough investigations for alleged violations involving two residents. For one resident, an allegation of sexual assault was reported, and the facility's investigation included only three resident interviews and three employee interviews, with no documentation of skin assessments for other residents. The Nursing Home Administrator (NHA) initially provided an incomplete investigation file, which lacked a fourth employee interview statement and an investigation summary report. The NHA later acknowledged the limited number of staff interviews due to the number of staff on the unit but did not address the lack of additional resident interviews or skin assessments. In another case, a resident reported missing money, initially $100, later changed to $160. The facility's investigation file for this incident lacked any documentation of resident or employee interviews. The NHA confirmed the file was complete but did not provide any additional documentation when questioned by the surveyor. These deficiencies highlight the facility's failure to ensure comprehensive investigations into reported incidents, as required by regulatory standards.
Inaccessible and Incomplete Survey Binder
Penalty
Summary
The facility staff failed to have the most recent survey results readily accessible to residents, family members, and legal representatives, which has the potential to affect all residents and visitors. Initially, the survey team could not locate the survey binder in the lobby, and there was no visible signage indicating its location. The receptionist was unaware of its whereabouts, and the Director of Nursing (DON) had to search for it. Eventually, the binder was found and provided to the surveyors, but it was not in the lobby as claimed by the DON. A new sign was posted indicating the binder's availability from the receptionist, but the receptionist was not on duty during the surveyor's visit, limiting access to the binder. Additionally, the survey binder lacked documentation of Life Safety Inspections or local fire department inspections. When questioned, the Nursing Home Administrator (NHA) stated that no such inspections had occurred since her tenure and that the Maintenance Director was responsible for these records. This lack of documentation further contributed to the deficiency, as the facility could not provide evidence of compliance with safety inspections. The surveyor later observed a new survey binder in the lobby, but the initial failure to maintain accessible and complete survey records was a significant issue.
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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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