Keswick Multi-care Center
Inspection history, citations, penalties and survey trends for this long-term care facility in Baltimore, Maryland.
- Location
- 700 West 40th Street, Baltimore, Maryland 21211
- CMS Provider Number
- 215037
- Inspections on file
- 18
- Latest survey
- March 3, 2026
- Citations (last 12 mo.)
- 23
Citation history
Health deficiencies cited at Keswick Multi-care Center during CMS and state inspections, most recent first.
Unclean and damaged food service equipment, sinks, drains, and storage areas were observed during the kitchen tour. Surveyors found soiled gaskets, cracked and pitted parts, leaking graywater lines, mold-like substances on caulking, missing backflow prevention devices, unclean ice and dish equipment, a live cockroach in the ware washing area, and multiple rusted, chipped, or broken surfaces. The kitchen GM and Maintenance Director were interviewed about the deficient conditions.
Missing Bathroom Call Light Pull Cords: Surveyors observed wall-mounted call light devices in 5 resident bathrooms without accessible pull cords on the [NAME] Ground unit. The LNHA and VP of Facility Services/Maintenance were informed, and the VP stated there were issues with the durability of the pull cords.
Pest Control Program Not Maintained: Surveyors observed fruit flies under the coffee/tea sink drainpipe, fruit flies near the dish machine hand sink, and live cockroaches in the manual ware washing area, laundry room, and on the dish machine leg. A kitchen janitor's closet light cover also contained a significant number of dead insects, and the kitchen GM stated that a pest control contractor was scheduled to treat the premises weekly.
The facility failed to ensure accurate completion of MDS assessments for two residents. One resident with atrial fibrillation had an active order and care plan for the anticoagulant Xarelto, but the admission and 5-day Medicare MDS (Section N – Medications) did not code the use of an anticoagulant. Another resident’s progress notes documented a discharge to the hospital, while the Discharge – return not anticipated MDS incorrectly coded a discharge home under home health services. These discrepancies show that MDS coding did not accurately reflect the residents’ actual medication regimen and discharge status.
Failure to Document Advance Directive Offerings: The facility failed to document that advance directives were offered and discussed for three residents. Record review showed MOLST review and, in some cases, no advance directives on file, but the chart lacked documentation that the residents were offered education to complete an advance directive. The SW acknowledged missing documentation for two residents, and later notes for each resident documented that advance directives were offered and declined.
A resident's room was observed with a grey bed pan under the sink in the bathroom and a used blue surgical mask on the floor in the corner. The UM/RN acknowledged the items on the floor were an issue and called housekeeping to remove them.
The facility failed to provide and document written bed hold policy notification when two residents were transferred to the hospital. One resident, who received dialysis and was sent out for bleeding from an AV fistula after treatment, had no record of notification to the resident or RP. Another resident was transferred after low BP during an avascular appointment, and staff could not produce written proof that the RP received the bed hold policy.
The facility failed to transmit a completed MDS assessment for a resident after discharge. The MDS was completed but not submitted to CMS, and an MDS consultant confirmed the omission during interview.
Care plans were not reviewed and revised after changes in condition for two residents. One resident had repeated falls and reported increased discomfort and difficulty moving a foot, but the fall care plan was not updated after the events. Another resident’s care plan remained active for PO antibiotic therapy for bronchitis even after the antibiotic course had ended, and the DON confirmed the record issue.
The facility failed to complete an ordered MBS for a resident who reported food getting stuck in the throat, and failed to properly assess and implement physician-recommended treatment plans for skin impairments in two other residents. One resident had a left great toe infection/paronychia with delayed follow-up and conflicting wound treatment orders, while another resident with sacral MASD and other skin issues continued to receive a prior topical treatment instead of the ordered zinc paste.
Inadequate monitoring and documentation of a Stage IV sacral pressure injury. A resident with immobility and comorbidities had an ongoing sacral wound treated with hypochlorous acid solution, but wound documentation did not show evaluation of treatment effectiveness or complete wound characteristics. The record also showed a 14-day gap without a documented wound assessment, even though the wound had been described as worsening on a prior observation tool.
Safe respiratory care was not provided when an unsecured O2 tank was observed at the nursing station and two residents with active O2 orders had emergency O2 tanks in their rooms without the required door signage. One resident’s tank was stored in a wheelchair pocket in the bathroom, and another resident’s tank was secured in an O2 stand, but neither room had signage indicating the presence of an emergency O2 tank.
A resident’s MRR recommendations to adjust Allopurinol and Tiotropium were not addressed in a timely manner. The DON described the facility’s MRR follow-up process, but the resident’s review was not signed and the order update was not documented until two months later. The LNHA confirmed no additional documentation showed the recommendations were addressed earlier.
A facility failed to ensure resident drug regimens were free from unnecessary meds and did not follow physician orders or psychotropic monitoring requirements. A resident received metoprolol despite BP hold parameters, two residents on psychotropics lacked documented side effect monitoring, and another resident’s PRN hydroxyzine lacked physician rationale for continued use as well as documentation of side effect monitoring and non-pharmacological interventions before administration.
A resident reported needing dental cleaning and waiting months for the facility to make an appointment. The record showed a physician ordered a referral for dental care, but follow-up remained pending and the resident was still unaware of any appointment. The DON stated the resident had previously refused dental services, but did not explain why the later order was not addressed.
Unclean Exterior Trash Compactor Area: The facility failed to maintain the exterior trash compactor area to prevent pest harborage. Surveyors observed waste leaks and debris on the cement surfaces around and beneath the compactor, with wooden pallets propped against the side wall. The compactor was located near the kitchen rear doors and a storage room holding emergency water supplies, and the Maintenance Director acknowledged the area would be cleaned.
Surveyors observed a clean linen cart on a nursing unit that was stocked with wash clothes and linen but left uncovered while two staff members obtained linen from it. An RN later covered the cart and stated that the clean linen cart should have been covered. Facility management was notified of the infection control concern at the exit conference.
Kitchen equipment was not maintained in proper operating condition during survey. Surveyors observed a cookline steam table being used as a prep table with paper products stored in the steam wells, a Chef Base 4-drawer refrigerator with cooking equipment placed on top, and a solid interceptor beneath the pre-rinse station leaking greywater onto the floor.
A resident with intact cognition and a history of depression, who was dependent on staff for toileting, was subjected to verbal abuse by a GNA during incontinence care. The GNA used inappropriate and expletive language, causing the resident to become embarrassed and cry. The incident was confirmed through interviews and documentation, revealing a failure to protect the resident from verbal abuse.
A resident with severe cognitive impairment and multiple comorbidities was found to have a left shoulder fracture of unknown origin. After x-ray results confirmed the injury, the facility did not report the incident to state authorities within the required two-hour window, as mandated by policy. The delay occurred because the supervisor did not complete the initial report after being notified of the injury.
Surveyors identified deficiencies in the facility's kitchen, including a dietary aide not wearing a hair restraint, uncovered and unlabeled food items, and a dishwasher operating below the recommended temperature. The CDM confirmed these issues and acknowledged the concerns raised by the surveyors.
The facility failed to report allegations of abuse within the required timeframes, as identified in incidents MD#00188565, MD#00200867, and MD#00181354. The Administrator misunderstood the reporting requirements, believing that allegations not involving serious bodily injury could be reported within 24 hours. This misunderstanding was reflected in the facility's policies, which did not ensure timely reporting to the appropriate authorities.
The facility failed to report a resident's missing funds to law enforcement and delayed reporting abuse allegations to the Office of Health Care Quality (OHCQ) within the required 2-hour timeframe. A resident's missing money was not reported to the police, and abuse allegations involving two residents were reported late to OHCQ due to a misunderstanding of reporting requirements by the Nursing Home Administrator.
A resident reported abuse involving a male perpetrator over two nights. Despite the facility being informed, no immediate protective measures were taken. Two male staff members continued working during the investigation without being removed from assignment. The facility's ADON confirmed no staff were placed on leave during the investigation.
The facility failed to develop comprehensive care plans for three residents, including one with prostheses, another with denture issues, and a third with ESRD requiring dialysis. The care plans lacked specific interventions and goals, as confirmed by nursing staff and management.
A resident experienced repeated removal of a g-tube, requiring multiple replacements over five months. The care plan was revised but lacked effective interventions. Staff acknowledged the issue, and the DON was informed.
A facility failed to provide scheduled showers for a resident who was dependent on staff for ADL care. Despite a physician's order for showers twice a week, the resident only received bed baths due to scheduling conflicts with dialysis days. Staff interviews confirmed the oversight, and the ADON acknowledged the issue.
A resident experienced a fall and reported severe pain, but the facility delayed administering pain medication for over two hours. A STAT X-ray was ordered but not conducted until the next day, and despite a physician's order, the resident was not promptly sent to the hospital. Staff interviews confirmed these delays and previous issues with the X-ray company's response times.
A facility failed to provide appropriate care for a resident with a urostomy, as there were no specific orders for stoma care, site assessment, or urine output documentation. The resident experienced issues with a leaking urine bag and prolonged periods without emptying. The DON confirmed the absence of necessary orders, indicating a deficiency in the facility's management process.
A resident's call device was found inaccessible during a survey, as it was attached to a bed rail in the down position and resting on the floor, obstructed by a bedside table. An LPN confirmed the device should be within reach, aligning with the resident's care plan, which was not followed.
The facility failed to transmit MDS assessments within the required 14 days for two residents and did not complete a discharge assessment for another. An MDS nurse confirmed the oversight, stating assessments were transmitted weekly but without specific days. The DON and ADON were informed of these deficiencies.
A facility failed to accurately document a resident's oral assessment, leading to incorrect MDS coding. The resident, who had no natural teeth and used dentures, was inaccurately recorded as having natural teeth in both the admission assessment and baseline care plan. Interviews with staff revealed that the MDS assessment did not capture the resident's edentulous status correctly, indicating a lapse in documentation and assessment processes.
A resident received medications improperly when an LPN punctured soft gel capsules, contrary to facility policy, and administered Docusate Sodium in capsule form instead of the prescribed tablet. The DON and ADON acknowledged the errors during a follow-up discussion.
A resident with chronic pain and prostate cancer experienced inconsistent pain management due to the facility's failure to adhere to professional standards. PRN pain medication orders lacked parameters for pain scores, leading to inappropriate administration of Oxycodone and Acetaminophen. Interviews with staff confirmed the absence of pain score parameters and acknowledged the inconsistency in medication administration.
A resident was administered Docusate Sodium in a soft gel capsule form instead of the ordered tablet form. An LPN prepared and administered the medication by cutting the capsules and mixing the contents with applesauce. The error was confirmed upon review of the resident's medical records, and the DON and ADON were notified.
A resident with COVID-19 was unnecessarily administered Azithromycin, an antibiotic, despite it not being a standard treatment for the virus. The order was created by an RN and later signed by a physician, although both the Infection Preventionist and the physician expressed confusion over the necessity of the antibiotic. The facility's antibiotic stewardship program flagged the order, but no documented communication with the physician was found.
The facility failed to post Enhanced Barrier Precaution (EBP) signs in front of residents' rooms, which are necessary to prevent infection transmission. During a survey, it was found that two residents' rooms lacked the required EBP signs, and another resident had an incorrect sign posted. This deficiency affected residents with specific medical needs, such as tube feeding, highlighting a lapse in the facility's infection control measures.
The facility failed to document the vaccination status of influenza and pneumococcal vaccines for three residents. A resident admitted in September 2024 had no documented flu vaccination status, another admitted in June 2024 lacked pneumococcal vaccine documentation, and a third resident did not have their annual flu vaccine status documented for 2022. The unit manager was responsible for assessing vaccination status, but the required documentation was missing from the electronic medical records. The DON acknowledged these findings.
A facility failed to document COVID-19 vaccine education for a resident who refused the vaccine upon admission. Despite the facility's routine of providing education at admission, no evidence was found in the resident's records. The deficiency was acknowledged by the DON during a survey.
Unclean and Damaged Kitchen Equipment and Plumbing Conditions
Penalty
Summary
The facility failed to maintain food service equipment and kitchen surfaces in a sanitary condition during the initial kitchen tour of the recertification survey. Surveyors observed soiled gaskets on the Victory #145 one-door reach-in unit, torn, cracked, and pitted green plastic guards in the Victory #144 unit, uneven grouting where the refrigerators were sealed to the tiled floor, and multiple areas where equipment, walls, floors, and storage surfaces were unclean, rusted, cracked, chipped, or otherwise damaged. The kitchen GM was present during the tour, and the surveyors documented these conditions as part of the deficiency findings. Surveyors also observed multiple plumbing and drainage problems in the kitchen and related work areas. These included a dump sink faucet and a cookline preparation sink faucet that were not securely fastened, mold-like substances on caulking, broken drain stoppers, leaking drain lines that discharged graywater directly onto the kitchen floor, an unclean floor sink and drain cover, and fruit flies around the drain line. The report also noted missing backflow prevention devices on the coffee and tea machine water lines, a hand sink not properly sealed to the wall, and a locked door adjacent to the eye-washing station that limited access during the survey. Additional observations included improper storage and cleanliness issues throughout the kitchen, dish room, ware washing area, walk-ins, and dry storage room. Surveyors found clean dish and utensil shelving less than 18 inches off the floor, a clean equipment rack placed on top of the grease trap interceptor, unclean knife holders, unclean ice machine surfaces, cracked ice machine bin doors, unclean racks and cutting boards, a live cockroach on the wall at the ware washing area, damaged floor tiles, open kitchen doors with light gaps, unclean compressor fan covers, condensate dripping over food products, and steam and vapors escaping from the dish machine. At 11:30 AM, the kitchen GM and Maintenance Director were interviewed to review the deficient practices identified.
Missing Bathroom Call Light Pull Cords
Penalty
Summary
A working call system was not available in the bathrooms of 5 resident rooms on the [NAME] Ground Nursing Unit because the wall-mounted call light devices had no accessible pull cords attached. During a tour at 8:45 AM on 2/24/2026, the surveyor observed this condition in the bathrooms of Resident #113, #115, #132, #161, and #172, out of 34 resident bathrooms observed on the unit. The report states that these call light devices were located on the wall next to the toilet, but no cord was attached to them. During an interview at 11:30 AM on 2/27/2026, the LNHA and the [NAME] President of Facility Services/Maintenance were informed of the missing pull cords. The LNHA and the VP observed the call light device in Resident #161's bathroom and confirmed that there was no pull cord attached to the wall-mounted device next to the toilet. The VP stated that there were issues with the durability of the call light device pull cords.
Pest Control Program Not Maintained
Penalty
Summary
The facility failed to maintain a pest-free environment for residents, as evidenced by multiple pest sightings during the recertification survey in 6 of 6 areas reviewed. Surveyors observed fruit flies beneath the drainpipe of the coffee/tea preparation sink at 7:50 AM, a live cockroach crawling on the wall at the manual ware washing area at 8:10 AM, and fruit flies near the dish machine hand sink in front of the chemical storage room at 9:00 AM. At 10:08 AM, a live cockroach was seen crawling on the floor of the laundry room, and the Maintenance Director acknowledged the cockroach near the laundry machine. At 10:30 AM, the kitchen janitor's closet light cover was found to have a significant number of dead insects, which the Maintenance Director confirmed would be cleaned. Later, at 2:40 PM, a live roach was observed crawling on the leg of the dish machine during a revisit with the Administrator, and the kitchen General Manager stated that a pest control contractor was scheduled to treat the premises weekly every Wednesday.
Inaccurate MDS Coding for Medications and Discharge Status
Penalty
Summary
The deficiency involves the facility’s failure to accurately complete Minimum Data Set (MDS) assessments for two residents, despite having clear clinical documentation to support correct coding. For one resident with atrial fibrillation, the medical record showed an active physician order for the anticoagulant Xarelto and a current care plan problem for anticoagulant therapy. However, the admission and Medicare 5-Day MDS assessments, specifically Section N – Medications, did not reflect that the resident was taking an anticoagulant. This discrepancy was identified during surveyor review of the resident’s medical record and comparison of the MDS with the physician orders and care plan. For another resident, review of a closed medical record showed that progress notes documented a discharge to the hospital on a specific date. In contrast, the Discharge – return not anticipated MDS assessment coded that the resident was discharged home under the care of an organized home health service organization. During an interview, the LNHA confirmed that the resident had in fact been discharged to the hospital, not home with home health services. These inconsistencies between the MDS assessments and the residents’ actual medication regimen and discharge destination demonstrate that the facility did not ensure accurate completion of MDS assessments for the residents reviewed.
Failure to Document Advance Directive Offerings
Penalty
Summary
The facility failed to document that advance directives were offered and discussed with residents. During record review, Resident #144 had a social services progress note documenting review of MOLST with the resident and responsible party, but there was no documentation that an advance directive was discussed. The Social Services Coordinator stated that the expectation was to document whether advance directives were on file and, if none were on file, to offer education to formulate one. A later note for this resident documented that MOLST was reviewed, no advance directives were on file, and the resident was offered the opportunity to complete advance directives and declined. Resident #172 also had a social services progress note documenting review of MOLST and that no advance directives were on file, but there was no documentation that the resident was offered education to complete an advance directive. The Social Services Coordinator acknowledged missing documentation for this resident. Resident #173 had no documentation that the resident did or did not have an advance directive and no documentation that education on formulation of an advance directive was offered. A later note for this resident documented that no advance directive was on file and that the resident was offered the opportunity to complete one and declined.
Unsanitary Items Left on Resident Room Floor
Penalty
Summary
The facility failed to ensure that Resident #14's environment was kept clean, comfortable, and sanitary. During the annual recertification survey, surveyors observed two items on the floor in the resident's room: a grey bed pan in the bathroom under the sink and a blue surgical mask in the corner of the room that appeared to have been worn. When the Unit Manager/RN was shown the items, the RN acknowledged that the items being on the floor was an issue and called housekeeping to remove them.
Failure to Document Bed Hold Policy Notification During Hospital Transfers
Penalty
Summary
The facility failed to notify residents or their resident representatives in writing of the bed hold policy and failed to document that notification when residents were transferred to the hospital. This deficiency was identified in 2 of 5 residents reviewed for the discharge process, including Resident #172 and Resident #9. Resident #172 received dialysis at the facility and was transferred to University of Maryland Midtown hospital after bleeding from the AV fistula site following a dialysis session. The medical record contained no documentation that the resident or responsible party was notified of the bed hold policy at the time of the hospital transfer. In interview, the ADON stated the expectation was for nursing staff to document bed hold notification in the progress notes, but no progress note was present for the transfer. Resident #9 was sent to the hospital after low blood pressure during an avascular appointment, and staff were unable to provide written documentation that the resident's responsible party was given the bed hold policy upon transfer.
Failure to Transmit Completed MDS Assessment
Penalty
Summary
The facility failed to transmit a Minimum Data Set (MDS) assessment to CMS within 14 days of completion for one resident reviewed for assessment transmission. Resident #133 was discharged on 11/11/2025, and the MDS Assessment Discharge Return, Not Anticipated with ADR of 11/11/2025, was completed on 11/17/2025. During record review, it was found that the completed assessment had not been transmitted to CMS. In a telephone interview, the MDS Consultant confirmed that the assessment was completed but not submitted to CMS and stated, "I am going to submit it now."
Care plans not revised after falls and completion of antibiotic therapy
Penalty
Summary
The facility failed to ensure interdisciplinary care plans were reviewed and revised after changes in condition related to resident falls and resident treatment. Resident #143 reported a recent fall while self-transporting to the bathroom in a wheelchair, stating the call cord was too far away to reach and that he/she lay on the floor for a period of time calling out for help. The resident also reported increased discomfort and difficulty moving the left foot, with a need for more assistance with transport to the bathroom. Medical record review showed two documented falls, including one where the resident was heard yelling for help and found on the bathroom floor during rounds, and another where the resident was observed on the floor between the wheelchair and toilet with legs toward the door. Resident #143 had an existing fall care plan addressing actual falls without injury and poor balance, with interventions such as keeping the bed low, placing the call bell and personal items within reach, using a wheelchair seat, encouraging use of a reacher, and ensuring appropriate footwear. However, there was no evidence the fall care plan was revised after the two February falls. Resident #92’s record showed antibiotic therapy for bronchitis from 01/08/2026 through 01/12/2026, but the care plan remained active and continued to state the resident was on PO antibiotic therapy related to bronchitis and elevated WBC of 11.8 after the antibiotic course had ended. The DON reviewed the record and confirmed the finding.
Failure to Complete Ordered Swallow Study and Implement Wound Treatment Orders
Penalty
Summary
The facility failed to ensure an ordered modified barium swallow study was completed for a resident who reported that food sometimes got stuck in the throat. The resident had a physician order dated 12/05/2025 to obtain the study to evaluate swallowing, but the medical record did not show that the test was scheduled. The Director of Nursing described the process for outside appointments, including daily review of orders and updating physician orders with appointment details once scheduled, but no evidence of scheduling was found in the record. The facility also failed to properly assess, evaluate, and implement physician recommendations for treatment of skin impairments for two residents. One resident had a left great toe infection/paronychia with purulent drainage and erythema, and a wound physician recommended a podiatry consult; however, there was no further assessment of the toe for 21 days, and later consult recommendations differed from the existing treatment orders in the record. Another resident had skin integrity issues including a surgical site and pressure injury, and a wound physician later documented sacral MASD with measurements and ordered zinc paste every shift and as needed, but the treatment administration record showed the sacral wound continued to be treated with Greer's Go instead of the ordered zinc paste.
Inadequate Monitoring and Documentation of a Stage IV Sacral Pressure Injury
Penalty
Summary
The facility failed to ensure that a resident with a Stage IV sacral pressure ulcer received treatment and care in accordance with professional standards of practice. Resident #109 had a care plan focused on the Stage IV sacral pressure ulcer related to immobility and comorbidities, with interventions to administer ordered treatments and monitor and document changes in skin status, wound size, stage, appearance, color, healing, and signs and symptoms of infection. A physician order from 10/16/2024 directed daily sacrum wound treatment with hypochlorous acid solution, moist-to-dry gauze soaked in the solution, and a bordered gauze dressing. Review of the wound documentation showed that a wound physician note on 2/3/2026 measured the sacral Stage IV pressure injury at 5.9 cm x 1.6 cm x 0.8 cm with no necrotic tissue. A wound observation tool on 2/10/2026 documented the wound as worsening, described the tissue as moist, and measured it at 6 cm x 2 cm x 1.2 cm, but the record did not show evaluation of the effectiveness of the hypochlorous treatment or include the wound's appearance characteristics. A later wound physician note on 2/24/2026 measured the wound at 4.3 cm x 2.0 cm x 1.6 cm with no necrotic tissue, and the record showed no documented assessment of the sacral wound from 2/10/2026 until 2/24/2026, leaving a 14-day gap without monitoring. During interview, the ADON stated that weekly wound rounds are conducted, wound descriptions are required, and treatment changes are expected if a wound is not improving or is deteriorating.
Improper Oxygen Storage and Missing Room Signage
Penalty
Summary
Safe and appropriate respiratory care was not provided when oxygen equipment was observed improperly stored and identified in resident rooms without the required signage. On the Ground Nursing Unit nursing station, an emergency oxygen tank was observed standing upright and not secured in a stand or bracket. When asked about the storage expectation, an RN stated, "who put that there" and removed the tank to the oxygen storage room. Two residents were observed with active oxygen therapy orders and oxygen tubing in their nostrils. In one resident room, an emergency oxygen tank was secured in the back pocket of a wheelchair in the bathroom, and there was no oxygen signage on the room door to indicate that an emergency tank was present. In another resident room, an emergency oxygen tank was secured in an oxygen stand, but there was also no oxygen signage on the room door. The facility's Oxygen Tank Storage Policy dated 5/2023 stated that when an oxygen tank is in a resident room, it should be placed in its holder stand at all times.
Delayed Response to Pharmacist Medication Review Recommendations
Penalty
Summary
The facility failed to respond to consulting pharmacist recommendations in a timely manner for Resident #13. The resident’s medication regimen review dated 6/28/2025 identified recommendations to increase Allopurinol and decrease Tiotropium, but the recommendations were not addressed until 8/28/2025. The DON stated that monthly MRRs are emailed by the pharmacist, printed, and followed up on by the nursing team or physician, with new orders updated in PCC and the recommendation uploaded to PCC. However, the resident’s MRR was signed by a Registered Nurse and Unit Manager on 8/28/2025, and the order update was documented the same day. The LNHA was asked to provide additional documentation showing the MRR had been addressed earlier, but confirmed that no other documentation was available.
Unnecessary Medication Use and Inadequate Psychotropic Monitoring
Penalty
Summary
The facility failed to ensure that resident drug regimens were free from unnecessary medications and failed to follow physician orders and monitoring requirements for several residents. During the annual recertification survey, surveyors identified deficiencies involving 4 of 5 residents reviewed for unnecessary medications, including failure to hold a prescribed beta blocker when blood pressure parameters were not met, inadequate monitoring of psychotropic medication side effects, and lack of documentation supporting continued use of an as-needed psychotropic medication. For Resident #26, the record showed an order for Metoprolol ER 100 mg daily for hypertension with instructions to hold the medication if systolic blood pressure was below 100. The MAR showed the medication was administered on three occasions when the documented systolic blood pressure was 98, 98, and 97. The DON and ADON reviewed the MAR with the surveyor and acknowledged that the medication had been given despite the hold parameter. For Resident #33 and Resident #92, the clinical records showed ongoing psychotropic medication use, including Seroquel, Trazodone, Mirtazapine, and Sertraline, but the records did not show a process for monitoring side effects, including the frequency or tools used. For Resident #7, the record showed an order for hydroxyzine HCl 25 mg every 6 hours as needed for anxiety, but there was no physician documentation supporting continued use, and the record lacked documentation of side effect monitoring and non-pharmacological interventions before administration. The DON stated that psychotropic side effect monitoring and non-pharmacological interventions for as-needed psychotropics were documented in progress notes, and the concern was discussed during the survey.
Failure to Arrange Ordered Dental Follow-Up
Penalty
Summary
The facility failed to assist a resident in obtaining routine dental care after a physician ordered a referral to a dental school for dental cleaning at the resident’s request. The resident stated that his/her teeth needed cleaning and that he/she had been waiting for 6 months for the facility to make an appointment. The clinical record showed a physician note indicating the resident requested follow-up with a dentist, a physician’s order for referral to the dental school, and later notes stating the resident was still pending dental follow-up and was not aware of any appointment. A psychotherapist note also documented the resident’s frustration about waiting for the dental appointment. During interview, the DON stated the resident had been offered dental services earlier and had refused, but did not explain why the later physician’s order was not addressed.
Unclean Exterior Trash Compactor Area
Penalty
Summary
The facility failed to ensure appropriate maintenance of the exterior trash compactor to prevent the harborage and infestation of pests. During observation with the Maintenance Director, the trash compactor was found at the far end of the open loading dock, about 24 feet from the rear kitchen doors and about 6 feet from the central storage room doors where emergency water supplies were stored. The cemented surfaces around and beneath the trash compactor were unclean and had waste leaks and debris, and several wooden pallets were propped against the side wall. The Maintenance Director acknowledged the area would be cleaned, and stated there were no alternative locations available for relocating the trash compactor.
Uncovered Clean Linen Cart Observed in Hallway
Penalty
Summary
Provide and implement an infection prevention and control program was cited after surveyors observed that the facility failed to maintain infection prevention and control practices related to linen availability, usage, and storage. On 2/24/2026 at 12:07 PM, the surveyor observed a clean linen cart on the [NAME] Ground Nursing Unit in the hall next to Resident room [ROOM NUMBER]. The cart was sufficiently stocked with wash clothes and linen, but it was left uncovered while two staff members were observed obtaining linen from it. During an interview at 12:12 PM, RN employee #14 was asked about the expectation for the clean linen cart, observed the cart, covered it with the tan-colored plastic cover attached to it, and stated that the clean linen cart should have been covered. Facility management was notified of the concern at the survey exit conference.
Kitchen Equipment Not Maintained in Safe Operating Condition
Penalty
Summary
Essential kitchen equipment was not maintained in proper operating condition during the recertification survey, as evidenced by 3 of 3 pieces of equipment reviewed being nonfunctional according to the manufacturer's specifications. On 02/24/2026 at 8:30 AM, surveyors observed the steam table on the cookline being used as a prep table with steam wells used to store paper products, the Chef Base 4-drawer refrigerator on the cookline with cooking equipment placed on top of it, and the solid interceptor beneath the pre-rinse station in the dish machine area leaking greywater directly onto the floor. The Administrator and the kitchen General Manager later confirmed that the solid interceptor had been repaired, and the surveyor visually verified its functionality.
Failure to Protect Resident from Verbal Abuse During Incontinence Care
Penalty
Summary
A resident with a history of cerebrovascular disease, depression, dementia, and chronic kidney disease, who was dependent on staff for toileting hygiene and was always incontinent of bowel and bladder, was subjected to verbal abuse by a Geriatric Nursing Assistant (GNA) during incontinence care. The resident had intact cognition, as indicated by a BIMS score of 13, and was known to experience feelings of depression and low energy. The care plan documented the resident's dependence on staff for incontinence care and noted behavioral concerns related to depression and anxiety. The incident occurred when the resident's family member, while on the phone with the resident, overheard the GNA use inappropriate and expletive language directed at the resident during incontinence care. The GNA questioned the resident in a derogatory manner about their incontinence, which caused the resident to become embarrassed, upset, and cry. The resident later confirmed to the social worker that the GNA used inappropriate language and expletives during care, and this was corroborated by behavioral health notes documenting the resident's distress over the interaction. The GNA denied using inappropriate language but admitted to making comments about the resident's actions during care. Facility documentation, including interviews with the resident, family member, and staff, as well as behavioral health progress notes, confirmed that the resident experienced verbal abuse during care. The incident was substantiated by the facility, and the resident reported feeling embarrassed and upset as a result of the GNA's comments. The facility's policy stated zero tolerance for abuse, but the actions of the GNA failed to protect the resident from verbal abuse during a vulnerable moment.
Failure to Timely Report Injury of Unknown Source
Penalty
Summary
The facility failed to report an injury of unknown source within two hours of being informed that a resident sustained a serious bodily injury, as required by their abuse and neglect policy. The policy mandates that allegations of abuse, neglect, exploitation, or injury of unknown origin resulting in serious bodily injury must be reported to state agencies within two hours. In this case, a resident with severe cognitive impairment, dementia, and a history of osteoarthritis and osteoporosis was found to have a minimally angulated fracture of the proximal neck of the left humerus. The injury was identified after the resident exhibited swelling and pain in the left shoulder, prompting an x-ray ordered by the physician. The x-ray results, which indicated a fracture, were received and sent to the physician between 6:30 PM and 7:00 PM, with the physician responding around 9:30 PM. Despite the facility becoming aware of the injury upon receipt of the x-ray results, the initial two-hour report to the state agency was not completed within the required timeframe. The Executive Director confirmed that the supervisor did not complete the initial two-hour report after being notified of the injury. The facility ultimately notified the state survey agency at 10:45 PM, which was outside the two-hour window from when the x-ray results were received and the injury was identified. This delay constituted a failure to comply with regulatory reporting guidelines for suspected abuse or injury of unknown source.
Kitchen Deficiencies in Food Safety and Equipment Maintenance
Penalty
Summary
The facility was found to have several deficiencies in its kitchen operations. During an initial tour, a dietary aide was observed plating food without a hair restraint, which was against the facility's expectations. The Certified Dietary Manager (CDM) confirmed that staff were expected to wear hair restraints and acknowledged the concern. Additionally, surveyors observed uncovered and unlabeled food items in the produce walk-in refrigerator, including cups of mandarin oranges and diced pears, as well as salads without labeling. The CDM acknowledged that these items should have been dated and labeled, confirming the surveyor's concerns. The facility's dishwasher was also found to be operating below the manufacturer's recommended minimum wash temperature of 160°F. Observations showed the dishwasher's temperature at 148°F, and previous logs indicated temperatures of 154°F on two separate occasions. The CDM was unaware of the correct minimum temperature and had not documented any corrective actions or managerial reviews for the dishwasher's temperature logs. The CDM acknowledged the issue after being shown the manufacturer's placard and confirmed understanding of the surveyor's concerns.
Deficiency in Abuse Reporting Timeframes
Penalty
Summary
The facility failed to accurately address reporting timeframes for allegations of abuse in their policies, as identified during a surveyor's review of a facility-reported incident, MD#00188565. The incident involved an allegation of abuse that was not reported to the Office of Health Care Quality (OHCQ) within the required timeframe. The facility's Administrator believed that allegations not involving serious bodily injury could be reported within 24 hours, contrary to the requirement for immediate reporting or within two hours if serious bodily injury is involved. This misunderstanding was evident in additional facility-reported incidents, MD#00200867 and MD#00181354, which also involved delayed reporting of abuse allegations. The surveyor reviewed two facility policies related to abuse reporting, which outlined different reporting timeframes based on the seriousness of bodily injury. However, the policies did not ensure timely reporting to the appropriate authorities as required. During interviews, the Administrator acknowledged the misunderstanding and confirmed that the policies were reviewed annually and updated as needed. Despite this, the surveyor noted that no changes had been made to the abuse policies in response to the current understanding of reporting timeframes, highlighting a deficiency in the facility's compliance with abuse reporting requirements.
Failure to Timely Report Abuse and Misappropriation
Penalty
Summary
The facility staff failed to report the misappropriation of a resident's funds to local law enforcement. Resident #75 reported missing $200 from his wallet after returning from a hospital visit. Although the facility conducted an investigation and reported the incident to the Office of Health Care Quality (OHCQ), they did not notify the police, which was acknowledged as a lapse by the Director of Nursing (DON). The facility also failed to report allegations of abuse within the required 2-hour timeframe to the regulatory agency, OHCQ. Resident #310 reported an abuse allegation to dialysis staff, which was communicated to the facility's DON and other officials. However, the initial self-report to OHCQ was made more than 27 hours later. Similarly, Resident #69's allegation of being pushed by a staff member was reported to the police but not to OHCQ within the required timeframe. The Nursing Home Administrator (NHA) misunderstood the reporting requirements, believing that incidents not involving serious bodily injury could be reported within 24 hours. Another incident involved Resident #93, who expressed discomfort with a Geriatric Nursing Assistant (GNA) being rough. This was reported to the House Supervisor, but the initial self-report to OHCQ was delayed beyond the 2-hour requirement. The NHA again cited a misunderstanding of the reporting timeframe for incidents not involving serious bodily injury, leading to a failure to meet the regulatory requirements.
Failure to Protect Resident During Abuse Investigation
Penalty
Summary
The facility failed to take appropriate measures to protect a resident during an abuse investigation. A resident reported an allegation of abuse to dialysis staff, who then informed the facility's Director of Nursing, Assistant Director of Nursing, and the President of Clinical Services. The facility was aware of the allegation shortly after it was reported. The resident expressed fear for their safety, and the alleged abuse involved a male perpetrator over two consecutive nights. Despite this, the facility did not take immediate action to protect the resident from potential harm by male staff members during the investigation. The investigation file revealed that two male staff members, who were working during the alleged timeframe, continued to work their shifts without being removed from assignment or placed on administrative leave. The facility's Assistant Director of Nursing confirmed that no staff had been removed from assignment during the investigation. The surveyor noted that the psych consult for the resident occurred the day after the allegation was reported. The facility's failure to take precautionary measures during the investigation was acknowledged by the Assistant Director of Nursing during an interview with the surveyor.
Deficiencies in Comprehensive Care Planning for Residents
Penalty
Summary
The facility failed to develop and implement comprehensive and person-centered care plans for three residents during a recertification/complaint survey. For Resident #50, the care plan did not include the use of lower extremity prostheses, despite the resident having medical diagnoses of acquired absence of both legs below the knee and using prostheses daily. The absence of a medical order or care plan for the prostheses was confirmed by both a registered nurse and a unit manager, who acknowledged the oversight. Resident #12's care plan lacked pertinent goals and interventions related to denture use, despite the resident having no upper or lower teeth and experiencing issues with ill-fitting lower dentures. The resident's admission assessment incorrectly documented natural teeth, and no orders were placed for denture care and storage. The unit manager was unaware of the missing denture care plan until informed by the surveyor. For Resident #312, the facility did not develop a care plan addressing the resident's End Stage Renal Disease (ESRD) and dependence on hemodialysis. Although the resident's medical records and physician orders indicated the need for dialysis and monitoring of an AV fistula, the care plan failed to include specific interventions and approaches for these needs. The Director of Nursing and Assistant Director of Nursing confirmed the deficiency upon review.
Failure to Prevent Repeated G-Tube Removal
Penalty
Summary
The facility failed to implement an effective interdisciplinary care plan to prevent the repeated removal of a gastronomy tube (g-tube) for a resident. The resident experienced five incidents of g-tube removal over approximately five months, requiring multiple replacements. Despite the care plan being revised in August 2024, no additional effective interventions were added to address the issue. The care plan initially stated that the resident would have fewer episodes of g-tube removal, but this goal was not achieved. Interviews with staff revealed that an abdominal binder was ordered to prevent the resident from removing the g-tube, but no further measures were considered. The unit manager acknowledged the care plan's ineffectiveness and the need for updates. The Director of Nursing was informed of these findings and acknowledged the deficiency.
Failure to Provide Scheduled Showers for Resident
Penalty
Summary
The facility failed to provide adequate Activities of Daily Living (ADL) care for a dependent resident, as identified during a recertification and complaint survey. The deficiency was noted for a resident who had been in the facility for over 45 days without receiving a full shower or bath, as reported by the resident's family. The physician's order specified that the resident was to have skin assessments and baths on Monday and Thursday evenings, but a review of the GNA task sheet from July to October 2024 showed that the resident only received bed baths and not showers on the assigned days. Interviews with staff revealed that the resident's shower days coincided with their dialysis days, and the night shift staff, responsible for preparing the resident for dialysis, did not provide showers. The GNA confirmed that the resident never received showers since admission, and the Assistant Director of Nursing acknowledged the oversight. This failure to adhere to the prescribed bathing schedule resulted in the resident not receiving the necessary ADL care as ordered by the physician.
Delayed Pain Management and Hospital Transfer After Resident Fall
Penalty
Summary
The facility failed to provide timely treatment and care to a resident who sustained a fall, resulting in severe pain. The resident fell on 09/03/23 around 8 PM and reported a pain level of 9/10. Despite the resident's escalating pain, which reached a level of 10/10, the facility staff delayed administering pain medication until 10:30 PM, over two hours after the fall. This delay in pain management was a significant oversight in providing care according to professional standards. Additionally, a STAT X-ray was ordered for the resident's left hip following the fall, but the X-ray was not conducted until the next day at 10:30 AM. Furthermore, despite a physician's order to send the resident to the hospital at 8:59 PM on the day of the fall, the facility staff delayed this action. Interviews with facility staff, including a Registered Nurse and the Director of Nursing, confirmed these delays and highlighted previous issues with the X-ray company's response times, which contributed to the delay in sending the resident to the hospital for evaluation.
Failure to Provide Urostomy Care and Management
Penalty
Summary
The facility failed to provide appropriate care and management for a resident with a urostomy, as evidenced by the lack of specific orders for urostomy care. The resident, who was admitted with a urostomy, experienced issues with her urine bag leaking near the surgical wound and being left full of waste for extended periods. This situation was reported during a complaint investigation, where it was found that the resident's records did not include necessary orders for stoma care, site assessment, or documentation of urine output. During an interview, the Director of Nursing (DON) explained that residents with urostomies should have specific orders in the electronic record system, POINT CLICK CARE, to guide nursing staff in assessing and monitoring the urostomy site. However, it was confirmed that no such orders were present for the resident in question, leading to inadequate care and management of the urostomy. The DON acknowledged the absence of these orders as a concern, highlighting a deficiency in the facility's process for managing residents with urostomies.
Resident's Call Device Inaccessibility
Penalty
Summary
During a recertification survey, it was observed that a resident's call device was not accessible, leading to a deficiency in accommodating the resident's needs. The resident was found sitting on the side of their bed with the call device attached to the bed's side rail, which was in the down position, causing the device to rest on the floor underneath the bed. The bedside table was positioned between the resident and the call device, making it unreachable for the resident. A Licensed Practical Nurse (LPN) confirmed the issue and acknowledged that the call device should be within the resident's reach when staff leave the room. The resident's care plan included an intervention to ensure the call light was within reach and to encourage its use for assistance, highlighting the facility's failure to adhere to this plan.
Failure to Transmit MDS Assessments Timely
Penalty
Summary
The facility failed to transmit Minimum Data Set (MDS) assessments within the required 14 days of completion and did not create a discharge assessment for three residents. Specifically, Resident #64's MDS assessment was completed on 6/5/24 but was not transmitted to CMS' IQIES for over 120 days. Similarly, Resident #146's MDS assessment was completed on 6/6/24 and also not transmitted for over 120 days. Additionally, a discharge assessment for Resident #148 was never completed as required. During an interview, MDS nurse #5 stated that assessments were transmitted weekly to CMS but without specific days, and confirmed that all assessments are required to be transmitted regardless of the payer source. The nurse acknowledged the oversight in transmitting the assessments. The Director of Nursing (DON) and the Assistant Director of Nursing (ADON) were informed of the deficiencies, which included two resident MDS assessments not being transmitted and one resident assessment not being completed and transmitted for over 120 days.
Inaccurate Oral Assessment Documentation and MDS Coding
Penalty
Summary
The facility failed to accurately document the oral assessment of a resident, leading to an inaccurate coding of the resident's oral status on the Minimum Data Set (MDS) assessment. During the recertification/complaint survey, it was observed that a resident had no upper or lower teeth and used dentures, which was not accurately reflected in their medical records. The resident's admission assessment incorrectly indicated that they had their own teeth, and the baseline care plan also inaccurately noted natural teeth. This discrepancy was evident despite multiple dental consultations confirming the presence of dentures. Interviews with facility staff revealed that the oral assessments were completed by nurses upon admission and documented in the admission packet. However, the Unit Manager and MDS nurse acknowledged the inaccuracies in the documentation and coding. The MDS nurse confirmed that the MDS assessment did not capture the resident's edentulous status accurately, as it was coded incorrectly. The Director of Nursing and Assistant Director of Nursing were informed of these inaccuracies, highlighting a failure in the facility's documentation and assessment processes.
Improper Medication Administration and Form Discrepancy
Penalty
Summary
The facility failed to adhere to professional standards of nursing practice during medication administration for Resident #318. On the morning of October 16, 2024, an LPN was observed preparing medications for the resident, who required medications to be crushed. The LPN improperly handled soft gel capsules by cutting them open and mixing the contents with applesauce, despite the known risks of altering drug absorption when capsules are punctured. This practice was contrary to the facility's policy, which prohibits the crushing or puncturing of non-crushable medications, such as soft gel capsules. Additionally, there was a discrepancy in the form of medication administered to Resident #318. The resident was prescribed Docusate Sodium in tablet form, but the LPN administered it in a soft gel capsule form instead. This error was confirmed by the LPN and acknowledged by the Director of Nursing (DON) and Assistant Director of Nursing (ADON) during a follow-up discussion. The facility's policy and in-service education documents were provided to the surveyor, highlighting the expectation that nurses should contact a physician to change medication forms when necessary.
Inconsistent Pain Management for Resident
Penalty
Summary
The facility staff failed to provide appropriate pain management for a resident, as evidenced by inconsistent administration of pain medication and lack of adherence to professional standards of practice. The resident, who was readmitted to the facility with chronic pain syndrome, unspecified abdominal pain, and prostate cancer, reported being in constant pain and experiencing delays in receiving pain medication. A review of the resident's clinical records revealed that PRN pain medication orders lacked parameters corresponding to pain scores, leading to inconsistent administration. For instance, Oxycodone was administered for a pain score of 0, and Acetaminophen was given for a pain score of 0, indicating a lack of adherence to appropriate pain management protocols. Interviews with facility staff, including an LPN and the DON, confirmed the absence of pain score parameters for PRN medications and acknowledged the inconsistency in medication administration. The DON noted that Oxycodone should not have been given for a pain score of 0 and recognized that the resident's pain was never truly at zero. Additionally, a review of the resident's September MAR showed that Oxycodone was administered outside the ordered parameters, further highlighting the deficiency in pain management practices. The facility staff acknowledged these discrepancies and the need for proper adherence to pain management protocols.
Medication Administration Error: Incorrect Form Given
Penalty
Summary
The facility failed to administer the correct form of medication to a resident, as observed during a recertification/complaint survey. A Licensed Practical Nurse (LPN) was seen preparing medications for a resident who required medications to be crushed. The LPN used a PAXIT system to obtain an Omega 3 capsule and a house stock bottle for Docusate Sodium, both of which were in soft gel capsule form. The LPN cut the tips of these capsules, squeezed the contents into a medication cup, and mixed them with applesauce before administering them to the resident. Upon reviewing the resident's medical records, it was found that the order specified Docusate Sodium in tablet form, not as a soft gel capsule. The LPN confirmed the error, acknowledging that the medication administered was not in the ordered form. The Director of Nursing (DON) and the Assistant Director of Nursing (ADON) were informed of this discrepancy, highlighting a failure in adhering to the prescribed medication form for the resident.
Unnecessary Antibiotic Use for COVID-19
Penalty
Summary
The facility failed to ensure that a resident was free from unnecessary antibiotic use, specifically Azithromycin, which was administered to a resident diagnosed with COVID-19. The resident had reported sinus pressure, and the attending physician noted mild upper respiratory infection and ordered COVID-19 and flu tests. Despite the positive COVID-19 test result, a registered nurse created an order for Azithromycin to treat postnasal drip and COVID-19, which was later signed by the attending physician. The medication was administered over several days, although antibiotics are not typically used to treat COVID-19. The facility's antibiotic stewardship program flagged the Azithromycin order with a question mark, indicating a concern. The Infection Preventionist RN acknowledged the issue, stating that antibiotics were not used to treat COVID-19 and was unsure why the order was placed. The attending physician also expressed confusion over the order, stating that she did not place it and that it did not make sense to treat COVID-19 with antibiotics. The Director of Nursing was informed of these findings, acknowledging the issues discussed.
Failure to Post Enhanced Barrier Precaution Signs
Penalty
Summary
The facility failed to implement an effective infection prevention and control program by not posting Enhanced Barrier Precaution (EBP) signs in front of residents' rooms, which are necessary to prevent the transmission of infections. This deficiency was identified during a recertification/complaint survey, where it was observed that two residents' rooms did not have the required EBP signs, despite having orders for such precautions. Additionally, another resident had a contact isolation sign posted instead of the required EBP sign. The deficiency was evident for three residents who were reviewed for infection precaution signs. One resident had tube feeding equipment at the bedside, indicating a need for EBP, yet no sign was posted. The facility's infection preventionist acknowledged the issue, and the Director of Nursing was informed of the findings. The lack of proper signage failed to communicate the necessary precautions to individuals entering and exiting the rooms, which is crucial for infection control.
Deficiency in Documenting Vaccination Status
Penalty
Summary
The facility failed to document the vaccination status of influenza and pneumococcal vaccines for three residents during a recertification/complaint survey. Resident #127, admitted in September 2024, had no documented evidence of flu vaccination status upon admission, despite a previous vaccination in October 2019. Resident #152, admitted in June 2024, lacked documentation of pneumococcal vaccine status. Additionally, Resident #16, admitted in July 2019, did not have documentation of their annual flu vaccine status for the year 2022. The surveyor's review of the residents' records and interviews with the Infection Preventionist RN revealed that the facility's unit manager was responsible for assessing vaccination status and providing education at admission. However, the required documentation was missing from the electronic medical records. The Director of Nursing acknowledged these findings when informed by the surveyor, and no additional documentation was provided to support that the facility completed the necessary vaccination assessments.
Deficiency in Documenting COVID-19 Vaccine Education
Penalty
Summary
The facility failed to document that COVID-19 vaccine education was provided to a resident, leading to a deficiency identified during a recertification/complaint survey. Specifically, for one resident, upon admission in March 2023, the resident refused the COVID-19 vaccine. However, the electronic medical record indicated that no vaccination education was documented as provided to the resident or their representative. This lack of documentation was noted during a review of the resident's vaccination records. Interviews with the Infection Preventionist Nurse revealed that the facility's routine included offering vaccination and providing education at the time of admission assessment. Despite this, the facility could not provide documented evidence to support that COVID-19 vaccine education was given to the resident or their representative. The Director of Nursing acknowledged these findings during the surveyor's review.
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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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