Hebrew Home Of Greater Washington
Inspection history, citations, penalties and survey trends for this long-term care facility in Rockville, Maryland.
- Location
- 6121 Montrose Road, Rockville, Maryland 20852
- CMS Provider Number
- 215071
- Inspections on file
- 20
- Latest survey
- April 23, 2026
- Citations (last 12 mo.)
- 5
Citation history
Health deficiencies cited at Hebrew Home Of Greater Washington during CMS and state inspections, most recent first.
Facility staff failed to promptly notify a family member after a hospice-enrolled resident’s death, resulting in a delay of several hours between the documented time the resident was found with no vital signs and the time the family/resident representative was contacted. Review of the Facility Reported Incident and the Resident Change Evaluation (END OF LIFE) showed that the resident was documented as having no pulse, respirations, blood pressure, or temperature in the evening, but the family notification was not recorded until much later that night. The family subsequently reported concern about the late notification, and the DON confirmed the timing discrepancy identified by the surveyor.
Surveyors identified multiple failures to maintain a safe, clean, and homelike environment, including damaged and warped flooring, a wall vent held in place with peeling tape, and stained carpet with food debris in several rooms. On another unit, a resident reported seeing a mouse in their room, where a full trash can, debris on the floor, and chipping along the wall baseboard were observed. In a separate room, a large pile of laundry was found stacked on the floor without an appropriate container for storage.
A resident reported to a surveyor that the call system in their room was not working after pressing the call button and receiving no response. The surveyor observed that pressing the call button did not activate the call light above the door or the call station at the nurses’ station. An LPN confirmed that the system should provide visual hallway lights, an audible alert, and display the room number at the call station when used, but testing showed the call system in that room was not functioning properly.
The facility failed to report allegations of abuse, neglect, and injuries of unknown origin to the Office of Health Care Quality (OHCQ) within the required 2-hour timeframe. This deficiency affected 18 residents and involved various allegations, including rape, physical abuse, and injuries of unknown origin. Delays were often due to internal discussions or misunderstandings of reporting requirements, with staff acknowledging the reporting failures.
The facility failed to thoroughly investigate allegations of abuse for nine residents, as investigations often lacked interviews with other residents or staff. In one case, a resident alleged rape, but no other residents from the unit were interviewed. Another resident reported being punched, yet no other residents were interviewed to assess safety concerns. Investigations were further compromised by missing documentation and incomplete interviews, undermining the reliability of the facility's response to these serious allegations.
A facility failed to maintain accurate medical records and document narcotic medication administration for several residents. Errors included incorrect uploading of a hospital transfer summary, missing documentation of narcotic administration, and incomplete medication orders lacking indications for use. These issues were confirmed by the DON and other staff during the survey.
The facility failed to maintain an effective pest control program, as evidenced by numerous reports of mice sightings and droppings in one of the two buildings reviewed. Pest activity logs and resident interviews confirmed persistent pest issues, despite regular visits from a pest control company. The deficiency was discussed with the facility's administration.
The facility failed to ensure proper labeling and dating of food items, maintain a sanitary environment in the nourishment refrigerator, and meet required temperatures for dishwashing machines. Observations revealed unlabeled food, unsanitary conditions, and malfunctioning dishwashers, leading to concerns about food safety and sanitation.
The facility staff failed to timely notify physicians and responsible parties of changes in two residents' conditions. One resident's pressure ulcer assessments and treatment changes were not communicated to the primary physician or responsible party. Another resident's physician was notified an hour after a fall with injury. These communication lapses were confirmed by the DON.
The facility failed to involve a resident with full mental capacity in their care plan meetings and did not document reasons for their absence. Additionally, the care plan for another resident was not updated after a stage 2 sacral pressure ulcer was discovered, despite the requirement to revise care plans following a change in condition.
A facility failed to provide a resident with scheduled showers twice per week, as required by their care plan. The resident, admitted for rehabilitation and strengthening, needed physical help with bathing. The shower log indicated scheduled showers on Mondays and Thursdays, but the GNA Documentation Report for January showed no documentation for these days. The DON confirmed the lack of documentation and stated that GNAs should have recorded if the resident refused or received showers.
A facility failed to provide adequate care for a resident after falls, missing required neuro checks. Another resident experienced delays in assessment and treatment for a fracture, with an X-ray and orthopedic consult delayed. A third resident did not receive a scheduled antibiotic dose due to pharmacy delays. These deficiencies highlight lapses in protocol adherence and timely medical intervention.
Two residents in the facility experienced inadequate pressure ulcer care. One resident did not receive weekly skin assessments for a sacral pressure ulcer, while another resident's worsening pressure ulcers were not properly documented or treated. The facility failed to update wound care orders and conduct necessary evaluations, leading to discrepancies in the residents' medical records.
A resident experienced significant weight loss, dropping from 210 to 192.6 pounds, without timely intervention or documentation of nutritional status. The facility's protocol required action for weight changes over 5%, but the resident's weight loss was not addressed until it reached 8%. The resident was discharged before any confirmation or intervention could be made.
A facility failed to accurately reflect a resident's oral/dental status in the MDS assessments. Despite documentation of a lower denture in the nursing admission assessment and a physician order, the MDS assessments did not indicate any oral or dental concerns. The resident reported broken dentures, which was confirmed by observation. The issue was discussed with the facility's administration.
A facility failed to implement a comprehensive care plan for a resident, leading to delayed incontinence care. The care plan did not address all medical, nursing, and psychosocial needs, and staff interviews revealed that the plan was not updated to reflect the resident's needs. The Director of Nursing acknowledged the oversight, indicating a missed review by the unit manager.
The facility failed to conduct the annual performance review for a GNA, as required. A review of employee records showed no signed evidence of the GNA's performance review and in-service education for 2023 and 2024. The DON confirmed that the 2023 review was missed, and the 2024 review was not signed due to the GNA's PRN schedule. Additionally, no competency assessment was conducted in 2024.
A facility failed to monitor side effects for a resident on Escitalopram Oxalate for depression. The oversight occurred because the order for side effect monitoring was inadvertently dropped from the MAR. Staff interviews confirmed the usual process involves a separate order on the MAR to alert nurses for side effect assessments, which was missing in this case. The DON acknowledged the oversight.
A facility failed to provide adequate dental care for a resident, as evidenced by the lack of follow-up on dental consultations and inaccurate monitoring of the resident's dental status. The resident, who had broken upper and lower dentures and missing teeth, did not receive necessary dental services despite documented orders and referrals. Staff interviews revealed a lack of awareness about the resident's denture status, and the DON acknowledged the absence of follow-up on dental referrals.
Delayed Family Notification Following Resident Death
Penalty
Summary
Facility staff failed to ensure timely notification of a resident’s death to the resident’s family, resulting in a documented delay of approximately two and a half hours between confirmation of death and family notification. A Facility Reported Incident (FRI #2685784) showed that a hospice-enrolled resident was found with no pulse, no respirations, no blood pressure, and no temperature at 7:35 PM on 11/9/2025, as documented on a Resident Change Evaluation (END OF LIFE) form. However, the same document recorded that the family/resident representative was not notified until 10:00 PM that evening. The family member later expressed concern that the resident had passed away around 7:00 PM and that the facility did not notify them until nearly 10:00 PM. During an interview, the DON confirmed the surveyor’s findings regarding the timing documented in the resident’s end-of-life evaluation and the delayed notification to the family.
Failure to Maintain Safe, Clean, and Homelike Resident Rooms
Penalty
Summary
The facility failed to maintain a safe, clean, comfortable, and homelike environment in multiple resident rooms as observed during the annual recertification survey. On 2 East [NAME]-Kogod Unit, one room had structural damage to several boards of the center flooring, including soft spots, gaps between planks, edge chipping, warping, and lifting at the seams. In another room on the same unit, a wall vent near the doorway appeared to be held in place by peeling white duct tape-like adhesive. A separate room on this unit had various pink, cream, and brown dry patches of residue bonded with the fibers of the green carpet, along with food particles on the carpet near the bedside table. On the 4 [NAME] Unit, an observation screening identified additional environmental concerns. One resident reported seeing a mouse in their room earlier that morning; upon dual observation with the Clinical Team Manager, the surveyor noted the resident’s trash can was full and had not been emptied, black specs were present on the floor in the corner, and chipping was observed along the wall baseboard area. In another resident’s room, a large pile of clothes was observed on the floor extending approximately midway up the wall, which the resident identified as their laundry, and there was no appropriate container in the room for storing these clothes.
Nonfunctioning Call System in Resident Room
Penalty
Summary
A deficiency occurred when the facility failed to ensure that a resident’s call system in a specific room bathroom and bathing area was functioning properly. During an initial tour of the 2 East [NAME]-Kogod unit, a resident in the identified room reported to the Surveyor that the call system in his/her room did not work because he/she had pressed the call button and no one came to assist. The Surveyor then observed the resident press the call button, and the call light above the resident’s door did not illuminate, and the call station at the nurses’ station did not activate a call from that room. During an interview with an LPN, the Surveyor was informed that when a resident presses the call button, the system should trigger a visual light outside the resident’s room and another in the hallway by the nurses’ station, an audible alert, and activation of the resident room number at the call station to alert staff that assistance is needed. Upon testing the system, the LPN verified that the call system for this resident’s room was not functioning properly. These observations and interviews demonstrated that the facility did not have a working call system available for this resident’s room as required.
Failure to Timely Report Allegations of Abuse and Neglect
Penalty
Summary
The facility failed to report allegations of abuse, neglect, and injuries of unknown origin to the Office of Health Care Quality (OHCQ) within the required 2-hour timeframe. This deficiency was identified during an annual and complaint survey, affecting 18 residents out of 60 facility-reported incidents reviewed. The incidents involved various allegations, including rape, physical abuse, and injuries of unknown origin, which were not reported promptly to the regulatory agency as required by regulations. In several cases, the facility staff delayed reporting incidents due to internal discussions or misunderstandings of the reporting requirements. For instance, in one case, a resident alleged rape, and the facility was informed by the resident's daughter, but the report to OHCQ was delayed beyond the 2-hour window. Similarly, other incidents involved residents reporting physical abuse or injuries, but the facility's initial reports to OHCQ were not submitted within the required timeframe, often due to staff waiting to discuss the incidents internally before reporting. The Director of Nursing (DON) and other staff members were interviewed and acknowledged the delays in reporting. In some instances, staff were unaware of the requirement to report within 2 hours if there were no visible injuries, leading to further delays. The facility's failure to adhere to the mandated reporting timeframe for allegations of abuse and neglect highlights a significant deficiency in their reporting processes.
Incomplete Investigations into Abuse Allegations
Penalty
Summary
The facility failed to provide thorough documentation of investigations into allegations of abuse for nine residents during a recertification/complaint survey. In several cases, the investigations lacked interviews with other residents or staff members who could provide additional context or corroborate the allegations. For instance, in the case of a resident who alleged rape, the investigation included interviews with 36 staff members but did not include interviews with other residents from the same unit. Similarly, another resident alleged being punched, but the investigation did not include interviews with other residents on the unit to assess their safety or concerns. In other instances, the investigations were incomplete due to missing interviews with relevant staff or residents. For example, a resident alleged rough treatment during incontinence care, but the investigation only included an interview with the accused GNA and lacked interviews with other residents or staff from the same assignment. Another case involved a resident who reported being slapped by staff, yet the investigation did not include interviews with other residents on the unit who might have witnessed or experienced similar incidents. The facility's investigations were further compromised by missing documentation and incomplete interviews. In one case, a resident alleged sexual assault, but the investigation did not include interviews with other residents on the unit. Additionally, a resident reported a GNA violating their rights, but the investigation lacked interviews with other staff members. These deficiencies highlight a pattern of incomplete investigations, where critical interviews and documentation were missing, undermining the thoroughness and reliability of the facility's response to serious allegations of abuse.
Deficiencies in Medical Record Accuracy and Medication Documentation
Penalty
Summary
The facility failed to maintain complete and accurate medical records in accordance with accepted professional standards, as evidenced by several deficiencies identified during a recertification/complaint survey. One significant issue involved the incorrect uploading of a hospital transfer summary for one resident into another resident's medical record. This error was confirmed by the Director of Nursing (DON) after an interview with the unit secretary responsible for the upload. Another deficiency was the failure to document the administration of narcotic medications on the Medication Administration Records (MARs) for multiple residents. The review revealed that a staff member signed out narcotic medications for several residents, but these administrations were not documented in the MARs. Interviews with the DON confirmed that the staff member failed to accurately document the administration of these medications, and some residents could not recall the number of doses received. Additionally, the survey identified incomplete medical orders for a resident, where the orders for Seroquel and Amlodipine did not include an indication for use. Despite prior recommendations from a pharmacist to include diagnoses or indications for use in medical orders, these were not reflected in the orders. The Clinical Team Manager and the DON confirmed the absence of indications in the orders, acknowledging the oversight in ensuring that the indication for use was displayed in the medical orders.
Facility Fails to Maintain Effective Pest Control Program
Penalty
Summary
The facility failed to maintain an effective pest control program, as evidenced by numerous reports of mice sightings and droppings in one of the two buildings reviewed during the recertification/complaint survey. The pest activity logs from September 2024 to February 2025 revealed frequent entries of mouse sightings and droppings in various patient care areas, including resident rooms, dining rooms, and common areas. Despite the facility's pest control company visiting three times a week, the logs indicated persistent pest activity, with multiple entries each month documenting the presence of mice. Interviews conducted with residents and staff corroborated the findings in the pest activity logs. Several residents reported seeing mice in their rooms and common areas, with some residents experiencing daily sightings. A geriatric nursing assistant also confirmed seeing a mouse in the resident hallway and reported it to the housekeeping staff. These interviews highlighted the ongoing issue of mice presence within the facility, affecting the residents' living conditions. The findings were discussed with the facility's Vice President of Building Services and the Administrator, who acknowledged the pest control logs and resident reports. The surveyor's investigation and interviews confirmed the facility's failure to effectively address the pest control issue, leading to a deficiency in maintaining a safe and sanitary environment for the residents.
Deficiencies in Food Safety and Dishwashing Practices
Penalty
Summary
The facility failed to ensure proper labeling, dating, and expiration of nourishment items in one of its kitchens. During an initial tour, a surveyor observed a reach-in refrigerator containing various food items such as orange slices, cold salad sandwiches, and containers of fruit and cottage cheese without any labeling or dates to indicate preparation or expiration. A tray of cheese sandwiches was also found with an expired label, leading to its disposal by the Certified Dietary Manager (CDM). The CDM acknowledged the issue but was unable to confirm when the foods had been prepared or were to expire. Additionally, the facility did not maintain a sanitary environment in the nourishment refrigerator. The surveyor found a cardboard box with condiment packets and tea bags showing visible spots of black, brown, and green matter. A container of soymilk was also found with an expired label. The Project Manager, overseeing the kitchen temporarily, confirmed the unsanitary conditions and disposed of the items. The Senior Dining Director and CDM were made aware of these concerns and acknowledged the issues. The facility's dishwashing machines also failed to meet the required manufacturer temperatures for sanitization. Observations revealed that the dishwashing machines in both the main and additional kitchens were not reaching the necessary temperatures for wash and final rinse cycles. Maintenance staff identified issues with the machines, such as a malfunctioning sensor and blown fuses, which prevented the machines from sustaining the required temperatures. Despite attempts to address these issues, the machines continued to operate below the recommended temperatures, leading to concerns about their effectiveness in sanitizing dishware.
Failure to Timely Notify Physicians and Responsible Parties
Penalty
Summary
The facility staff failed to notify a resident's physician and responsible party for changes in the resident's condition in a timely manner. For Resident #630, the staff did not inform the primary physician about the assessments of a sacral pressure ulcer when the wound care doctor was unavailable. Additionally, there was no documentation indicating that the resident's responsible party was notified of changes in wound care orders, despite multiple changes occurring over several months. This lack of communication was confirmed by the Director of Nursing during an interview. In another instance, the facility staff delayed notifying Resident #643's physician after the resident experienced a fall with injury. The fall occurred at 5:45 PM, but the physician was not informed until an hour later. The resident sustained an injury to the right elbow and hit their head, necessitating a hospital transfer for further assessment and treatment. The Director of Nursing confirmed the delay in notification during an interview.
Failure to Involve Resident in Care Plan Meetings and Update Care Plan for Pressure Ulcer
Penalty
Summary
The facility failed to involve a resident with the capacity to attend their own care plan meetings and did not document the reasons for their absence. Resident #96, who had a perfect BIMS score indicating full mental capacity, reported never being informed about care plan meetings. The Director of Social Work claimed the resident often declined to attend due to personal issues, but there was no documentation to support this claim. Upon review, it was confirmed that there was no record of the resident being invited or the reasons for their non-attendance. Additionally, the facility did not update the care plan for Resident #963 after a significant change in condition. Initially, the resident's skin was noted as normal upon admission, but a stage 2 sacral pressure ulcer was discovered five days later. Despite this change, the care plan was not revised to address the new condition. The Director of Nursing confirmed that the care plan had not been updated following the discovery of the pressure ulcer, which was a requirement when there is a change in a resident's condition.
Failure to Provide Scheduled Showers
Penalty
Summary
The facility failed to ensure that a resident who required assistance received showers twice per week, as was the established care plan. This deficiency was identified during a recertification/complaint survey for a resident admitted in December 2022 from an acute care hospital for rehabilitation and strengthening. The resident's medical record indicated a need for physical help with bathing, and the shower log specified that showers were to be provided on Mondays and Thursdays. However, the GNA Documentation Report for January 2023 showed blank spaces for all scheduled shower days, indicating that the showers were not documented as given. During an interview, the Director of Nursing confirmed the lack of documentation and stated that GNAs should have recorded whether the resident refused or received showers.
Deficiencies in Resident Care and Treatment
Penalty
Summary
The facility failed to provide adequate care for Resident #614 following two falls on the same day. After the first fall, the staff did not complete the required neuro checks according to the facility's 72-hour assessment protocol, missing checks at 4:15 PM and 5:15 PM. After the second fall, the staff failed to restart the neuro check protocol, missing several checks that were supposed to occur every 15 minutes and hourly thereafter. This lack of adherence to protocol was confirmed by the Director of Nursing. Resident #131 experienced a delay in receiving appropriate medical assessment and treatment for a left arm fracture. Despite the resident's daughter requesting an assessment for soreness, the initial assessment was not thorough, focusing only on the hand. An X-ray was not ordered until several days later, after the resident exhibited significant pain. The Occupational Therapy evaluation was also delayed, occurring five days after the order was given, and the resident did not receive an orthopedic consult until being sent to the ER, where the fracture was confirmed. Resident #913 did not receive a scheduled dose of Daptomycin for endocarditis due to a delay in medication delivery from the pharmacy. The resident was admitted to the facility with orders to continue antibiotic therapy, but the medication was not administered until two days later. Despite multiple calls to the pharmacy, the medication was not delivered on time, resulting in a delay in treatment. The Director of Nursing and Clinical Team Manager acknowledged the delay in administering the medication.
Failure to Provide Adequate Pressure Ulcer Care
Penalty
Summary
The facility staff failed to provide adequate treatment and services to prevent and heal pressure ulcers for two residents. Resident #630 was assessed to have a Stage II sacral pressure ulcer, but the facility staff did not conduct weekly skin assessments, including measurements, on several occasions. Specifically, there were no assessments from 6/26/23 to 7/13/23, a gap of 17 days. The Director of Nursing confirmed the failure to perform these assessments during an interview. Resident #660 was admitted with a Stage II pressure ulcer on the right buttock, and the condition of the resident's wounds worsened over time. The facility's documentation showed discrepancies in the wound's status, and there were no additional orders or evaluations despite the worsening condition. The wound consultant's notes were not updated weekly, and there was a lack of follow-up assessments and order changes when the resident's wounds deteriorated. The Director of Nursing confirmed the absence of additional documentation to support evaluations during the worsening of the resident's condition.
Failure to Address Significant Weight Loss in Resident
Penalty
Summary
The facility failed to address appropriate care for a resident experiencing significant weight loss. The deficiency was identified during a recertification survey, where it was found that a resident had lost a substantial amount of weight over a short period. The resident's initial weight was recorded at 210 pounds, and over the course of several weeks, the weight decreased to 192.6 pounds, marking an 8% loss from the initial weight. Despite this significant weight loss, there was no documentation of any follow-up nutrition assessment or intervention after the initial assessment upon admission. Interviews with facility staff revealed a lack of timely response to the resident's weight changes. The clinical nutrition manager stated that weight changes were only addressed if they exceeded a 5% difference, and the resident's weight loss was not acted upon until it reached 8%. The Director of Nursing confirmed that nursing staff were expected to re-check weights with more than a 5-pound difference and notify providers, but this protocol was not followed. The resident was discharged before any confirmation or intervention could be made regarding the weight loss, and there was no documentation of the resident's nutritional status or any actions taken to address the weight loss trend.
Inaccurate MDS Assessment of Oral/Dental Status
Penalty
Summary
The facility failed to ensure that the Comprehensive Minimum Data Set (MDS) assessments accurately reflected a resident's oral and dental status. This deficiency was identified during a recertification/complaint survey for one of the four residents reviewed. The resident in question was initially admitted to the facility after abdominal surgery and was readmitted following a hospitalization for high ostomy output. Despite the presence of a lower denture being documented in the nursing admission assessment and a physician order, the MDS assessments conducted on two separate occasions did not reflect any oral or dental concerns. The MDS manager, responsible for conducting the assessments, acknowledged the oversight. She confirmed that the assessments included a record review, resident interview, and physical assessment, yet failed to code any oral or dental issues in the relevant section of the MDS. The resident, during an interview, reported having broken upper and lower dentures, which was corroborated by a surveyor's observation. The discrepancy between the documented presence of dentures and the MDS coding was discussed with the facility's Administrator and Director of Nursing during the exit conference.
Failure to Implement Comprehensive Care Plan
Penalty
Summary
The facility failed to develop and implement a comprehensive person-centered care plan for a resident, as identified during a recertification/complaint survey. The deficiency was evident for one resident whose care plan did not address all medical, nursing, and psychosocial needs identified in the admission comprehensive assessment. Specifically, the resident experienced an episode of incontinence, and the care was delayed for several hours despite staff being notified. The Geriatric Nursing Assistant (GNA) task list showed incontinence care was documented only once on the day of the incident. Interviews with staff revealed that the care plan was not updated to reflect the resident's needs. RN #55 confirmed that the care plan needed updating and that all nurses could update it as needed. The unit manager, RN #70, stated that care plans should be updated initially within 30 days, as needed with any change, and every 90 days with the admission assessment. However, the care plan for the resident did not reflect personal care needs or active diagnoses and interventions. The Director of Nursing acknowledged the oversight, indicating that the unit manager was responsible for the care plan review, which was missed.
Failure to Conduct Annual Performance Review for GNA
Penalty
Summary
The facility failed to conduct the required annual performance review for a Geriatric Nursing Assistant (GNA), identified as GNA #71, during the recertification/complaint survey process. The surveyor's review of three GNA employee records revealed that there was no signed documented evidence of GNA #71's performance review and in-service education for the years 2023 and 2024. During a telephone interview, the Director of Nursing (DON) acknowledged that the performance review and competency assessment for GNA #71 were missed in 2023. Although the 2024 performance review was documented, it was not signed due to GNA #71's PRN (as needed) work schedule. Furthermore, the DON confirmed that no competency assessment was conducted in 2024, as it is typically done alongside the performance review.
Failure to Monitor Side Effects of Psychotropic Medication
Penalty
Summary
The facility failed to ensure proper monitoring for side effects of a psychotropic medication for a resident, which was identified during a recertification/complaint survey. The resident was receiving Escitalopram Oxalate for depression, starting from early January. However, the medical record review revealed that side effect monitoring was not instituted for this medication, which is a necessary step in managing psychotropic medications. Interviews with facility staff, including an LPN and the Clinical Team Manager, confirmed that the usual process for monitoring side effects involves a separate order on the medication administration record (MAR). This order alerts nurses to complete and document assessments for side effects. It was discovered that the order for side effect monitoring was inadvertently dropped from the MAR in late December, leading to the oversight. The Director of Nursing acknowledged the oversight, confirming that the medications had been reviewed but the monitoring order was missed.
Failure to Provide Adequate Dental Care
Penalty
Summary
The facility failed to provide appropriate dental care for Resident #269, as evidenced by the lack of accurate monitoring of the resident's dental status and failure to follow up on dental services. The resident was admitted to the facility in February 2024 and readmitted in mid-April 2024 after hospitalization. The nursing admission assessment documented the presence of partial lower dentures, but subsequent oral health assessments indicated significant dental issues, including decayed or broken teeth. Despite a physician's order for assistance with the resident's partial lower denture, there was no follow-up documentation for dental consultations requested in August and October 2024. Interviews and medical record reviews revealed that the resident's dental needs were not adequately addressed. The resident reported having broken upper and lower dentures and missing teeth, which was confirmed by the surveyor. Staff interviews indicated a lack of awareness regarding the resident's denture status, and the social worker confirmed that the resident's insurance did not cover new dentures. The Director of Nursing acknowledged the absence of follow-up on the dental referral, highlighting a deficiency in the facility's dental care provision.
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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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