King David Nursing And Rehabilitation Center
Inspection history, citations, penalties and survey trends for this long-term care facility in Baltimore, Maryland.
- Location
- 4204 Old Milford Mill Road, Baltimore, Maryland 21208
- CMS Provider Number
- 215022
- Inspections on file
- 17
- Latest survey
- April 27, 2026
- Citations (last 12 mo.)
- 22
Citation history
Health deficiencies cited at King David Nursing And Rehabilitation Center during CMS and state inspections, most recent first.
Nursing staff did not follow a physician’s hold parameters for a cardiac medication. A resident with a history of stroke, left eye blindness, and Alzheimer’s type dementia had an order for Nifedipine 60 mg ER at bedtime, with instructions to hold the dose if SBP was below 110 or HR was below 60 bpm. Review of the MAR showed that staff administered the scheduled Nifedipine dose despite a documented HR of 59 bpm, contrary to the physician’s order, as identified during a complaint survey and discussed with facility leadership.
A resident with intact cognition was found with three Hydralazine tablets left in a medication cup on the bedside table after reporting they had refused the morning dose based on their recorded BP of 110/66 and pulse of 68. The physician’s order required Hydralazine 25 mg, three tablets q8h PO for HTN, to be held if SBP was less than 110 mmHg or pulse less than 60, and facility policy required reporting and documenting medication refusals. However, an LPN had documented administration of the dose on the MAR, and the pills remained at the bedside, demonstrating that staff did not adequately supervise the medication pass to ensure ingestion or remove and document the refused medication.
Staff failed to maintain sanitary food storage and kitchen conditions, including undated and outdated food items in a unit nourishment room, spilled and unclean refrigerator and freezer surfaces, and incomplete refrigerator temperature logs. In the main kitchen, surveyors found broken tiles, standing water, dusty ventilation and AC units, food and supply boxes stored directly on the floor in refrigerated, frozen, and dry storage areas, and multiple undated prepared food containers and opened juices. Dietary staff were observed preparing food without required hair and beard restraints, and the dietary manager acknowledged awareness of cleanliness and staff compliance issues but had not acted on them.
Facility staff did not properly manage outdoor waste containers, resulting in four large dumpsters being observed with open lids or doors, exposed trash bags, and waste on the ground near one container. From a dining room window, a surveyor saw multiple containers with open tops or side doors, bags of rubbish protruding or hanging over the sides, and scattered waste on the ground. The Maintenance Director reported that EVS is responsible for overseeing the dumpsters and keeping the surrounding areas clean, while the EVS Director stated that porters are responsible for recognizing when dumpsters are full and ensuring they are closed after use, even though all departments dispose of trash in them.
Staff failed to maintain multiple interior and exterior areas in a safe, clean, and homelike condition. Surveyors observed damaged drywall, a broken cabinet hinge, and water-damaged cabinetry in a nourishment room; uncapped electrical wires hanging from a box in a shower room; supplies and plumbing tools stored on a blanket under a sink in a supply room; and a broken soap dispenser in another shower room. Dining room windows had large gaps that allowed cold air to enter. Interviews with an LPN, the DON, and the Maintenance Director showed that maintenance concerns were not consistently documented in unit maintenance books, nourishment and supply rooms were not part of routine preventive checks, and there was no checklist to confirm repairs. Outside, the parking lot, tree line, and building entrance areas were littered with masks, gloves, bottles, plastic bags, and other debris, despite EVS leadership stating that housekeeping was assigned and monitored to clean these areas.
Staff failed to protect a cognitively intact resident from verbal abuse when a GNA, while assisting with care and responding to complaints about the facility, told the resident to "calm down and shut up." The incident was not reported at the time it occurred, and the GNA did not notify a nurse or supervisor about the resident’s concerns or the exchange. In subsequent interviews, the resident confirmed the statement and described another GNA in the room who witnessed it, while the involved GNA acknowledged making the remark and having prior abuse training, and the DON later characterized the situation as a cultural misunderstanding despite incomplete documentation of all witnesses in the investigation.
The facility failed to follow its abuse, neglect, and exploitation policy when a resident reported that a GNA rolled them in bed, causing their head to hit a bedrail. The policy required that any such report be treated as an abuse allegation, trigger an immediate investigation, prompt protective measures such as staffing changes, and be reported to the Administrator and state agency within 2 hours. Instead, the RN who received the report did not immediately notify the DON or Administrator, the state agency was notified well beyond the 2-hour window, and the GNA continued working the remainder of the shift with vulnerable residents.
Staff failed to follow required timeframes for reporting abuse allegations and investigation results. In one case, a resident told an RN that a GNA rolled the resident in bed and struck the resident’s head on a bedrail, but the RN waited many hours before notifying the DON, delaying the report to the state agency beyond the policy’s 2‑hour requirement. In another case, the facility submitted a 5‑day follow‑up investigation report on an abuse allegation to the state agency one working day late, despite the DON’s understanding that such reports must be submitted within 5 days.
Staff failed to thoroughly investigate multiple abuse allegations and did not consistently remove alleged abusers from resident care. In one case, a resident’s verbal abuse allegation was investigated without obtaining a written statement from a second GNA who was present, and the DON did not directly ask an LPN whether they used the specific derogatory term alleged by a resident during medication administration. In another case, a resident reported that a GNA rolled them in bed and caused their head to hit the bedrail, yet the GNA continued working for several hours after the report and returned the next morning before being suspended, contrary to the facility’s abuse policy requiring immediate investigation and protective staffing changes.
A resident with Influenza A and bacteremia did not receive ordered Tamiflu or the adjusted dose of IV Vancomycin as prescribed, and there was no documentation that the pharmacy or prescribers were notified when these medications were not available or not administered. In addition, an IV NaCl order initially lacked a specified volume, and a subsequent IV fluid order that required documentation of total volume infused each shift was not properly documented on the MAR. Interviews with an LPN, the DON, a physician, and an NP confirmed lack of awareness of missed doses and incomplete documentation, as well as failure to clarify incomplete IV fluid orders.
A resident requested to receive a turkey or tuna sandwich every day while on a regular diet for rehabilitation, but this preference was not honored. The resident’s written food preferences specified chicken salad sandwiches on certain days and turkey sandwiches on others, with no entry for tuna. The Certified Dietary Manager explained that kitchen staff could only provide turkey on meat days and tuna on dairy or meat days, and therefore could not offer the requested sandwich every day under the facility’s Jewish milk day dietary schedule.
A resident’s electronic health record showed multiple missing entries for ADL care over a two-month period, including undocumented personal hygiene, turning and repositioning, bathing, and bladder/bowel incontinence care across various shifts. An LPN unit manager confirmed that staff are expected to document ADL and incontinence care by the end of each shift and that clinical staff are responsible for ensuring completion of this documentation, but these expectations were not met for this resident.
Staff failed to follow infection prevention and control practices when linen carts were left uncovered and used as storage for personal items, and when used washcloths and a towel were left on surfaces and the floor in a shower room. An LPN unit manager acknowledged that linen carts should be covered and free of items on top, and reported that GNAs were responsible for cleaning the shower room after use while Environmental Services cleaned it daily. These observations show lapses in maintaining clean linen handling and shower room hygiene.
Surveyors found that the facility’s admission agreement and related forms did not disclose the facility’s kosher diet practices and improperly required residents to waive certain rights and facility liability. The admission packet lacked written information about kosher dietary restrictions, and the Hospital Liaison reported that potential residents and families were not routinely informed in writing about the kosher diet, only possibly mentioned verbally without explanation. A Risk Acknowledgement form stated the facility was not responsible for stolen, lost, or damaged personal property and not responsible for the development of pressure sores, despite regulatory requirements against such waivers and requirements to provide care to prevent pressure sores. The NHA could not provide evidence that the admission agreement had been approved at the time of a change in ownership and confirmed that residents were not consistently informed in writing about the kosher diet.
A resident's family, acting as surrogate decision makers due to the resident's lack of mental capacity, raised concerns about the resident's declining condition and requested an ambulance from an LPN, who refused and failed to check on the resident. The family submitted a formal complaint via email, but facility management did not initiate the grievance process or communicate with the family, and the incident was not documented in the grievance log.
A resident's family reported that an LPN refused to call 911 when the resident's condition worsened, argued with the family, and did not check on the resident after their request. The family called 911 themselves and submitted a formal complaint to facility management, but the allegation of neglect was not reported to the State Survey Agency as required. The DON and Administrator confirmed the incident was not reported, viewing it as a customer service issue.
A resident experienced two separate incidents where staff changed their clothing without consent, despite the resident's verbal objections and distress. Staff interviews confirmed that care was provided against the resident's wishes, and although notes were added to the care plan, no changes were made to prevent future occurrences. This resulted in repeated allegations of abuse without effective intervention.
A resident admitted with obstructive sleep apnea and acute respiratory failure did not receive timely physician orders for CPAP therapy at night or a structured plan to wean off supplemental oxygen, as specified in the hospital discharge plan. Initial orders only included oxygen via nasal cannula, and there was a significant delay before appropriate orders for CPAP and oxygen weaning were written.
A resident with OSA and acute respiratory failure did not have a comprehensive, individualized care plan addressing all respiratory needs, including oxygen weaning and CPAP use. The care plan lacked specific interventions, protocols, and staff assignments for both oxygen therapy and CPAP management, despite physician orders and facility policy requirements.
A resident with multiple chronic conditions and behavioral health concerns did not have an individualized care plan addressing their specific needs, including medication refusals, noncompliance, and behavioral issues. The care plans contained only generic interventions and lacked guidance for staff on how to provide patient-centered care, despite documented evidence of the resident's ongoing challenges and preferences. The DON was unable to provide evidence of actual care plan updates or individualized interventions.
Facility staff did not follow hospital discharge plans for a resident with respiratory conditions, failing to initiate and document both oxygen weaning and CPAP use as ordered. Nursing staff continued to provide and sign off on oxygen therapy without evidence of a coordinated weaning process or clear documentation, while rehab staff conducted isolated weaning trials during therapy sessions. The facility lacked a defined protocol for oxygen weaning and did not ensure interdisciplinary communication or documentation of the resident's response to respiratory interventions.
A resident's bed rails were found to be loose and not securely attached to the bed frame, creating a significant gap between the mattress and the rail. Multiple observations confirmed the issue over several days, and the facility was unable to provide up-to-date inspection logs, only offering an audit from the previous year. The problem was not addressed until brought to the attention of the surveyor, despite prior awareness by maintenance staff.
A resident was moved to different bed assignments on three occasions without written notice, including the reason for the room changes, being provided to the resident's representative. The NHA confirmed that while verbal notification occurred, there was no documentation of written notice for any of the bed reassignments.
A resident was not adequately protected from sexual abuse by a roommate who repeatedly engaged in sexually inappropriate behavior, including exposing themselves and inviting participation. Despite a care plan and interventions by staff, the inappropriate conduct continued, leading the affected resident to request a room change after feeling uncomfortable.
Staff did not report or investigate allegations of sexual abuse after an LPN documented that a resident exposed and touched their private parts and invited a roommate to participate. The Nursing Home Administrator was unaware of the incidents, and no report was made to regulatory agencies.
The facility did not prevent potential abuse after a resident was observed engaging in sexually inappropriate behavior toward a roommate, and failed to remove either resident from the shared room. Additionally, the facility did not complete or maintain thorough investigation records for allegations of misappropriation of funds and verbal abuse, as required, with missing resident statements and insufficient documentation.
Nursing staff did not document ADL care for a resident who was present in the facility, incorrectly noting the resident was unavailable, and a required social history assessment for another resident was missing from the medical record despite being completed by the social worker.
A resident repeatedly reported a non-working clock in their room and requested assistance from staff, but the issue was not resolved over several days. The clock remained non-functional during multiple surveyor observations, despite the NHA, DON, and Maintenance Director being informed.
Surveyors observed that staff did not provide adequate housekeeping and maintenance services, resulting in rooms with crumbs, debris, mouse droppings, makeshift repairs, accumulated dust in bathroom vents, and an uncovered thermostat with exposed wires. These deficiencies were found across two units and affected multiple residents.
The facility did not notify the Ombudsman prior to the hospital transfers of three residents following changes in condition. Record reviews and staff interviews with the NHA and DON confirmed that required notifications were not made or documented.
A resident with two Stage 4 pressure ulcers did not receive updated wound care as recommended by the wound consult physician. Instead, outdated treatment orders were followed, and the physician's instructions for specific wound cleansing and dressings were not implemented. The DON confirmed that the process for updating orders after wound consultations was not followed, resulting in the resident not receiving the intended care to promote healing.
A physician did not document a note addressing a resident's significant weight loss, despite the dietitian identifying and reporting the issue to the care team. The facility's policy requires providers to document clinical conditions contributing to weight loss, but the available provider note did not address the matter, and both the DON and Medical Director confirmed the lack of appropriate documentation.
A resident did not receive prescribed doses of metformin on several occasions because the facility ran out of the medication and was waiting for pharmacy delivery. Documentation on the MAR indicated missed doses, and in some cases, there was no explanation for the omissions. The DON confirmed the medication was not administered as ordered, and the facility's policy to ensure a sufficient medication supply was not followed.
A resident's room was found to have crumbs, debris, and mouse droppings, despite a history of reported pest issues and prior treatment. Review of pest control records showed inconsistent intervals between treatments, which were described as weekly but varied from 4 to 18 days, leading to a failure in maintaining an effective pest control program.
The facility did not complete required significant change assessments for two residents who experienced notable weight loss and declines in functional ability. Despite documentation of these changes and notification of the care team, the MDS was not updated to reflect the residents' altered conditions, as confirmed by staff interviews and record review.
A resident's room contained accident hazards due to the use of a power strip and extension cord for bed and charging needs after an outlet became inoperable, while another resident with a history of inappropriate sexual behaviors was not adequately monitored or documented by staff, despite care plan requirements and psychiatric evaluations indicating ongoing incidents.
Failure to Follow Hold Parameters for Cardiac Medication
Penalty
Summary
Facility nursing staff failed to follow a physician’s order specifying blood pressure and pulse parameters prior to administering a cardiac medication. A resident admitted with stroke, left eye blindness, and Alzheimer’s type dementia, and deemed incapable of making all medical decisions by two attending physicians in December 2025, had a physician’s order dated 12/17/2025 for Nifedipine 60 mg extended release to be given orally every 24 hours at bedtime, with instructions to hold the medication if the systolic blood pressure was less than 110 or the heart rate was lower than 60 beats per minute. Review of the December 2025 MAR showed that on 12/20/2025 at the 9 pm dose, nursing staff administered Nifedipine despite a documented pulse of 59 beats per minute, contrary to the hold parameters ordered by the physician. These findings were identified through review of the closed clinical record and administrative records for this resident during a complaint survey and were discussed with the DON and the Administrator at the exit conference.
Failure to Supervise Medication Administration and Handle Refusal Appropriately
Penalty
Summary
The deficiency involves the facility’s failure to provide adequate supervision during medication administration and to properly handle a medication refusal. During an evening tour, surveyors observed three small round orange pills in a medication cup on a resident’s bedside table. The resident, seated in a wheelchair next to the bed and behind the bedside table, stated the pills were their blood pressure medication from the morning that they had refused to take. The resident reported that they record every blood pressure obtained by nursing staff before medication administration and that their blood pressure that morning was 110/66 with a pulse of 68. The resident stated they interpreted this reading as too low and had been instructed not to take their blood pressure medication if the reading was low. A nurse was then made aware and observed the three pills still in front of the resident before removing them. Record review showed a physician’s order for Hydralazine 25 mg, three tablets by mouth every 8 hours for hypertension, with instructions to withhold the medication for a systolic blood pressure less than 110 mmHg or a pulse less than 60. The April MAR indicated that an LPN administered Hydralazine at 6 a.m. and documented a blood pressure of 110/66 and heart rate of 68 at that time. The resident had a recent BIMS score of 15/15, indicating intact cognition. Facility policy for Medication Administration directed staff to report and document any adverse side effects or medication refusals, but the presence of the pills at the bedside and the resident’s report of refusal showed that the medication was not removed when refused and that supervision during the medication pass was insufficient to ensure the medication was taken or properly handled in accordance with the order and policy.
Unsanitary Food Storage and Poor Kitchen Hygiene Practices
Penalty
Summary
Staff failed to maintain safe and sanitary dietary services in both a unit nourishment room and the main kitchen. In the Sudbrook unit nourishment room, surveyors observed an opened container of Amish Style Potato Salad and an opened container of honey uncured ham, both dated 01/26/26, still present weeks later. Vanilla ice cream was spilled in the freezer, there were multiple spills in the refrigerator, and two small containers of applesauce were unlabeled and undated. Review of the refrigerator temperature logs for Sudbrook showed multiple days in December 2025 and February 2026 when temperatures were not recorded. An LPN unit manager stated that environmental services (EVS) was responsible for cleaning the refrigerator but that all staff should monitor its contents, and indicated the temperature log was kept in a binder on the crash cart. The EVS director reported that EVS checked the refrigerator weekly, discarded outdated or undated items, and checked temperatures once a week for reporting to the administrator. In the main kitchen, surveyors observed multiple sanitation and food storage issues. There was a plastic container with water under a sink drain, broken floor tiles, a dusty exhaust fan, and a dusty, leaning window air conditioning unit. Bread crates with loaves of bread were stacked directly on the floor, and the dishwashing area had standing water on the floor. Inside the refrigerator, several containers of applesauce, fruit, Jell-O, egg salad, potato salad, chicken salad, and opened juice containers were undated, and boxes of food were stored on the floor. In the freezer, boxes were stored on the floor and fans had condensation and ice buildup on the ceiling. In the dry storage area, a bag of sugar and bags of portion cups were stored on the floor, there were lids and debris on the floor, and boxes were piled on air conditioning tubing. Dietary staff were observed preparing meals and portion cups without required hair and beard restraints. The dietary manager acknowledged responsibility for kitchen cleanliness and staff use of hair and beard nets, stated awareness of cleanliness issues and staff noncompliance with restraints, but reported he had not addressed these issues.
Improper Management of Outdoor Waste Containers
Penalty
Summary
Facility staff failed to ensure that outdoor waste refuse containers were properly closed and not overflowing with waste. During an observation from the dining room window on Mount [NAME], a surveyor observed four large waste containers, all with open lids or doors and exposed trash. Waste container #8320 had its top lid open with large bags of rubbish exposed at the top and a clear white bag hanging off the left side. Waste container #8319 had its left sliding door open with a clear waste bag hanging out of the side. Waste container #8213 had its top lid open with brown boxes and waste bags exposed. Waste container #8148 had its lid open with clear waste bags exposed and hanging over the front, and there was waste on the ground on both sides of this container. In an interview, the Maintenance Director stated that the Environmental Services (EVS) Department oversees the dumpsters, which are emptied on Monday, Wednesday, and Friday, and that EVS is responsible for keeping the areas around the dumpsters clean. In a separate interview, the EVS Director stated that porters are supposed to know when the dumpsters are full and to close them after placing trash inside, and that while all departments use the dumpsters, the porters are responsible for ensuring the dumpsters are closed.
Failure to Maintain Safe, Clean, and Well-Maintained Interior and Exterior Areas
Penalty
Summary
Facility staff failed to maintain a safe, clean, and comfortable physical environment in multiple interior areas. During complaint survey observations, damaged drywall was noted on two walls in the nourishment room, along with a cabinet door that flung open due to a broken bottom hinge and a sink cabinet with water damage and a hole in its base. In a shower room on Sudbrook, an electrical box contained two red and two black uncapped wires hanging out. In the Sudbrook supply room, a package of clear cups, a blue basket, and plumbing tools and parts were stored on a blanket under the sink. A broken soap dispenser was observed in another shower room, with the front cover placed on a shower bed inside the stall. Staff interviews revealed that although there were maintenance binders on each unit and a process to report issues during morning meetings, the identified concerns had not been documented in the binder, and no one had inspected the cabinet prior to the surveyor. The DON and LPN unit manager described reliance on unit maintenance books and verbal reporting, while the Maintenance Director reported that nourishment and supply rooms were not part of regular preventive checks, the maintenance book was not always checked daily, and there was no checklist to verify completion of repairs. Additionally, three dining room windows on Mount [NAME] had large gaps at the upper and lower sections, allowing cold air to enter the room until the surveyor demonstrated the issue to the Maintenance Director. The exterior environment was also not maintained in a clean and orderly condition. On two consecutive mornings, surveyors observed discarded face masks, gloves, water bottles, plastic cups, straws, plastic bags, paper, and other debris scattered throughout the parking lot, along the curb, in a tree line, and near the front of the building. Debris was noted in trees and bushes, lined against the building, and around the porch area at the entry door, where a trash can had debris nearby and a broken orange snow shovel and black plastic piece were present, with additional plastic bags and paper in the adjacent grass. During interviews, the EVS Director stated that housekeeping was responsible for cleaning the parking lot and that a porter was assigned daily to this task, and also stated that she personally monitored whether it was done, but acknowledged she had not checked the area since a recent snow event.
Failure to Protect Resident From Verbal Abuse by GNA
Penalty
Summary
Facility staff failed to ensure a resident was free from verbal abuse when a GNA told Resident #1 to "shut up." The incident occurred during the 3:00 pm–11:00 pm shift on 10/02/25, but was not reported until 10/05/25 during the 7:00 am–7:00 pm shift, when Resident #1 informed an LPN Unit Manager. At the time of the incident, the GNA was working but assigned to a different unit than where the resident was located, and the alleged perpetrator was allowed to complete the shift. Resident #1, who had a BIMS score of 15/15 as of 09/30/25, later provided a statement to the Administrator confirming that a GNA told them to shut up, adding that the GNA apologized and that the resident did not think it was meant in a harmful way, though they were surprised. During the survey, review of the GNA’s employee record showed she had completed abuse and dementia training and had an active GNA certificate with a clear background check. In an interview, the GNA confirmed she told the resident to "calm down and shut up" while the resident was complaining about the facility, acknowledging that, based on the resident’s reaction, it was verbal abuse. She stated she did not intend it in a bad way and attributed her wording partly to her culture, explaining she was encouraging the resident to calm down and look inward. She did not report the resident’s concerns or the incident to a nurse or supervisor. The DON later stated they learned of the allegation via a supervisor’s phone call and described the situation as a cultural misunderstanding, but the investigation documentation did not include mention or a statement from another GNA who, according to both the DON and the resident, was present in the room during the incident and observed the exchange.
Failure to Implement Abuse Policy for Timely Reporting and Resident Protection
Penalty
Summary
The deficiency involves the facility’s failure to implement its abuse, neglect, and exploitation policy as written, specifically regarding timely identification, reporting, and protection of residents following an abuse allegation. The facility’s policy, last reviewed/revised in 11/2023, stated that any report by a resident, staff, or family was to be considered an abuse allegation, that an immediate investigation was warranted when there was suspicion of abuse, that room or staffing changes were to be made if necessary to protect residents from an alleged perpetrator, and that all alleged violations were to be reported to the Administrator, state agency, adult protective services, and other required agencies immediately, but no later than 2 hours after the allegation was made. Record review of a facility-reported incident showed that a resident reported to an RN that a GNA rolled the resident over in bed, causing the resident’s head to hit the bedrail. This allegation was made at 8:30 PM, but the Administrator was not informed until approximately 11 hours later, at 7:30 AM the following day, and the DON was not informed until about 7:00 AM. The report to the state agency was submitted at 9:25 AM, exceeding the policy’s 2-hour reporting requirement. During interview, the DON stated that the RN reported she was unsure whether this was an abuse allegation and did not call immediately, despite staff being aware they could contact the DON at any time. Additionally, the alleged perpetrator GNA continued to work the remainder of the shift until 11:00 PM with vulnerable residents, contrary to the policy’s requirement to make staffing changes as necessary to protect residents from the alleged perpetrator.
Failure to Timely Report Abuse Allegations and Investigation Results
Penalty
Summary
Facility staff failed to report allegations of abuse within the required timeframes as outlined in the facility’s Abuse, Neglect, and Exploitation policy and federal requirements. The policy, last revised in 11/2023, required that all alleged violations reported by a resident, staff, or family be reported to the Administrator, state agency, adult protective services, and other required agencies immediately, but no later than 2 hours after the allegation is made. For one incident, a resident reported to an RN that a GNA rolled the resident over in bed and hit the resident’s head on the bedrail. The RN did not report this allegation of abuse to the DON until approximately 11 hours later, and the DON then reported the allegation to the State Agency after she became aware of it. The DON stated that the nurse was unsure it was an allegation of abuse and confirmed that her expectation was that staff report allegations as soon as possible. In a separate incident involving another resident, the facility submitted an initial allegation of abuse to the State Agency and was required to submit the final investigation results within 5 working days. The final 5‑day report was submitted one working day late, beyond the required 5‑day timeframe. During an interview, the DON acknowledged that the timeframe for submitting follow‑up investigation results to the State Agency is 5 days. These failures to report the initial allegation within 2 hours and to submit the final investigation report within 5 working days constituted noncompliance with the facility’s own policy and reporting requirements.
Failure to Thoroughly Investigate Abuse Allegations and Remove Alleged Abusers from Resident Care
Penalty
Summary
Facility staff failed to conduct thorough investigations into multiple resident abuse allegations and did not consistently remove alleged perpetrators from resident care during investigations. In one incident, a resident reported verbal abuse that allegedly occurred during a prior shift; the DON stated that staff and residents were interviewed and that another GNA had been present in the room during the alleged verbal abuse. However, the investigation file contained no written statement from that GNA, despite the DON acknowledging having spoken with the aide. In another case involving an allegation that an LPN called a resident a derogatory name during medication administration, the DON reported using open-ended questions with the nurse but did not directly ask whether the LPN had used the specific expletive alleged by the resident. The LPN later denied the allegation when directly questioned by the surveyor, and also stated they had not been aware of any problem with that resident. The facility’s abuse, neglect, and exploitation policy defined any report by a resident, staff, or family as an abuse allegation requiring immediate investigation and indicated that room or staffing changes should be made as needed to protect residents from alleged perpetrators. In a separate incident, a resident reported to an RN that a GNA rolled them in bed and caused their head to hit the bedrail. The GNA’s timesheet showed that the aide continued working for approximately 2.5 hours after the allegation and returned to work the next morning before being suspended. The DON later stated that the RN had failed to notify her of the allegation immediately, which resulted in the GNA continuing to work with residents after the abuse allegation was made.
Failure to Clarify and Follow Medication and IV Fluid Orders
Penalty
Summary
Facility staff failed to ensure that physician orders were clarified, followed, and that ordered medications and treatments were administered to a resident diagnosed with Influenza A and bacteremia. The resident was diagnosed with Influenza A and had an order entered for Tamiflu 30 mg PO BID for 5 days, which was discontinued the same day and re-entered later that night; however, the medication was never administered according to the MAR. Documentation showed the physician was notified late in the evening on the day of the order that the medication was not received, but there was no documentation that the pharmacy was contacted or that the physician was notified when the medication was still not received the following day. During interviews, the LPN Unit Manager stated that medications are typically received within 24 hours or within a 4-hour window for STAT orders, and the physician and NP later reported they were not aware that the Tamiflu had not been administered. The same resident had a critical blood culture result positive for gram-positive cocci, and was ordered Vancomycin 750 mg IV BID for 14 days for bacteremia. The resident received three doses, and a Vancomycin trough level was reported as high, leading to a dose reduction to Vancomycin 500 mg IV BID for 14 days. The resident did not receive any doses of the reduced Vancomycin prior to being sent to the emergency room, and there was no documentation that the physician or pharmacy were notified that the lower dose was not administered. Additionally, the resident had an order for 0.9% NaCl IV q shift that did not specify the volume in milliliters to be infused each shift, and this incomplete order was not clarified. A later order for 1 liter NaCl IV on specific evenings at 100 ml/hr directed nurses to document the total amount of IV fluid given each shift, but the MAR showed that nurses were not documenting the volume administered. The DON acknowledged that the amount of fluids given should be written in the notes, and the LPN Unit Manager stated that if a medication is not available on site, they would obtain an equivalent and call the pharmacy for a STAT dose.
Failure to Honor Resident’s Daily Sandwich Preference Due to Jewish Dietary Schedule
Penalty
Summary
Facility staff failed to honor a resident’s stated food preference for a daily turkey or tuna sandwich due to restrictions related to Jewish dietary observance. A complaint review on 02/19/26 showed the resident, who was on a regular diet and in the facility for rehabilitation, requested to receive a turkey or tuna sandwich every day, but this request was not honored during the stay. Review of the resident’s food preference record on 02/26/26 showed scheduled sandwiches at lunch: chicken salad sandwiches on Sunday, Tuesday, Thursday, and Saturday, and turkey sandwiches on Monday, Wednesday, and Friday, with no documented preference for a tuna sandwich. In an interview on 02/26/26, the Certified Dietary Manager stated that if a resident requested a turkey or tuna sandwich daily, the kitchen could provide turkey during a meat meal and tuna during a dairy or meat meal, but not every day, indicating the resident’s daily preference could not be accommodated within the facility’s Jewish milk day meal structure.
Failure to Document ADL and Incontinence Care for a Resident
Penalty
Summary
Facility staff failed to document activities of daily living (ADL) assistance for one resident in accordance with accepted professional standards. Review of the electronic health record on 02/25/26 at 8:39 am for Resident #6’s ADL tasks for December 2025 and January 2026 showed multiple GNA tasks not completed in the record. On 12/24 and 12/25 during the 11 pm–7 am shift, 12/26 during the 7 am–3 pm shift, and 12/31 during the 11 pm–7 am shift, there was no documentation to verify whether the resident received personal hygiene care. On those same dates and shifts (12/24, 12/25, 12/26, and 12/31), there was also no documentation to verify that the resident was turned and repositioned. Further review of January 2026 documentation revealed additional gaps. On 01/03 during the 3 pm–11 pm shift, there was no documentation to verify that the resident was turned and repositioned. On 01/03, 01/11, and 01/18 during the 11 pm–7 am shift, there was no documentation to verify that the resident was bathed. On those same dates during the 3 pm–11 pm shift, there was no documentation to verify whether the resident had episodes of bladder or bowel incontinence or whether personal hygiene was provided. During an interview on 02/25/26 at 9:42 am, the LPN Unit Manager stated that staff were expected to document ADL care each shift, either at the time the task was completed or by the end of the shift, and that incontinence episodes should be documented. The LPN Unit Manager also stated that clinical staff are responsible for ensuring completion of documentation and that chart reviews are done the day after care is provided.
Failure to Maintain Infection Control for Linen Carts and Shower Room
Penalty
Summary
Facility staff failed to maintain infection prevention and control practices related to linen handling and shower room cleanliness. During observation rounds, a surveyor observed a linen cart outside a resident room with personal items, including a tube of cream, shower gel, a fan, and a bag of washcloths, placed on top of the cart. On another occasion, an uncovered linen cart was observed outside a resident room. When these issues were brought to the attention of an LPN unit manager, the manager acknowledged that the linen cart should have been covered and that items should not have been placed on top of it. In a separate observation in the Sudbrook shower room with the same LPN unit manager, the surveyor observed a used washcloth on the grab bar in a shower stall and two used washcloths and a towel on the floor in front of the first shower stall. The LPN unit manager stated that GNAs were supposed to clean up after using the shower room and that, to their knowledge, Environmental Services cleaned the shower room daily. These observations demonstrate failures in staff actions to follow established infection control practices for maintaining clean linen carts and properly cleaning and maintaining the shower room environment.
Noncompliant Admission Agreement and Failure to Disclose Kosher Diet Requirements
Penalty
Summary
The deficiency involves the facility’s admission agreement and related documents failing to disclose special service limitations related to the facility’s kosher diet and improperly requiring residents to waive certain rights and facility liability. Record review of the admission packet showed that the Admission Agreement did not contain information about the facility’s kosher dietary practices, despite the facility following a kosher diet. A separate welcome packet included an “Always Available Menu” listing items such as tuna salad, egg salad, turkey, bologna, and pastrami sandwiches, with a note that any alternate chosen must reflect a kosher-appropriate option (dairy for dairy meal, meat for meat meal), but there was no other mention of special dietary considerations. The Hospital Liaison, who speaks with potential residents in the hospital, stated that residents and families are not informed in writing prior to admission that the facility follows a kosher diet, and that she may only casually mention it without explaining what it means unless specifically asked. Further review of the admission documents revealed that the Admission Agreement required the resident and sponsor to agree not to hold the facility responsible for injury or harm that could have been avoided if they had hired a private duty nurse. A separate Risk Acknowledgement form stated that the facility was not responsible for stolen, lost, or damaged personal property and was not responsible for the development of pressure sores, despite regulatory requirements prohibiting waiver of potential facility liability for personal property losses and requiring the facility to provide quality care, including treatment and services to prevent pressure sores. When requested, the NHA was unable to provide proof that the admission agreement had been approved at the time of the change in ownership in 2017 and confirmed that residents were not informed in writing prior to admission that the facility followed a kosher diet. The NHA could not verify that any brochure describing the kosher diet was consistently provided to residents and offered no rationale for the noncompliant admission agreement and risk acknowledgement language.
Failure to Promptly Address and Resolve Resident Grievance
Penalty
Summary
Facility staff failed to make prompt efforts to resolve a grievance and did not keep the resident's representative informed of progress toward resolution. A resident, who had been determined by two physicians to lack mental capacity, had their children acting as surrogate decision makers. On the evening in question, one of the resident's children expressed concern about the resident's deteriorating condition and requested that an LPN call an ambulance. The LPN refused, instructed the family to call themselves, argued with the family, and did not check on the resident after the request. The family sent an email complaint to facility management and the Social Work Director that night, but received no response. Review of the facility's grievance logs showed no record of this complaint, and the Administrator initially denied knowledge of any grievance related to the resident. Upon further inquiry, it was revealed that the Social Work Director had forwarded the family's email to the Administrator, who confirmed receipt but did not initiate the grievance process or follow up with the resident's representative. The Administrator stated that no action was taken because the resident had been discharged, despite being the designated Grievance Officer for the facility.
Failure to Report Allegation of Neglect to State Survey Agency
Penalty
Summary
Facility staff failed to report an allegation of neglect to the State Survey Agency after a resident's family expressed concerns about the resident's deteriorating condition. On the evening in question, the family requested that an LPN call an ambulance for the resident, but the LPN refused, instructed the family to call 911 themselves, argued with them, and did not check on the resident after the request. The family subsequently called 911 and sent an email to facility management and the Social Work Director, formally complaining about the LPN's refusal to assist and lack of concern for the resident's well-being. The email complaint was forwarded to the facility Administrator, but the allegation was not reported to the State Survey Agency as required. The Director of Nursing and Administrator confirmed during interviews that they did not report the incident, considering it a customer service issue rather than a reportable allegation of neglect. Medical record review confirmed that the family, not the nurse, called 911 following the change in the resident's condition. The failure to report the allegation of neglect constituted a deficiency in the facility's compliance with reporting requirements.
Failure to Prevent Recurrence of Abuse Allegations
Penalty
Summary
The facility failed to implement interventions to prevent the recurrence of abuse and neglect allegations for a resident who reported two separate incidents within a two-week period. The first incident involved the resident alleging that staff changed and dressed them without permission, despite the resident verbally refusing and expressing distress. The resident reported being held down by the wrists and forced to change their shirt, which they described as a violation of their rights. The second incident occurred under similar circumstances, with another staff member changing the resident's shirt without consent, even after the resident became combative and verbally objected. Interviews with staff confirmed that care was provided despite the resident's refusal, and the staff continued with the task after the resident expressed their wishes. The Director of Nursing acknowledged that while notes were added to the resident's care plan regarding these events, there were no actual adjustments made to the plan of care to address the resident's needs or to prevent future occurrences. This lack of intervention contributed to repeated allegations of abuse by the same resident.
Failure to Implement Hospital Discharge Plan for Respiratory Care
Penalty
Summary
Upon admission of a resident with diagnoses including obstructive sleep apnea and acute respiratory failure with hypercapnia, the attending physician did not address the hospital discharge plan that specified the need for CPAP therapy at night and a plan to wean the resident off supplemental oxygen. The initial physician orders only included oxygen inhalation via nasal cannula at 2 liters per minute, with no mention of CPAP use or a structured oxygen weaning protocol as directed by the hospital discharge summary. Subsequent physician documentation referenced the resident's history of obstructive sleep apnea and the need to continue CPAP, but no formal order for CPAP was written at that time, nor was there documentation addressing the plan to wean off oxygen or a rationale for not following the discharge plan. It was not until several days after admission that an order to wean off oxygen was written, and this order did not specify a target oxygen saturation level. An order for nighttime CPAP use was not written until approximately one month after admission. Interviews with the DON revealed uncertainty regarding the reconciliation of hospital discharge plans at admission, and no further clarification was provided to the surveyor before the survey exit. These actions and omissions resulted in a failure to implement the hospital's post-discharge respiratory care plan for the resident.
Failure to Develop and Implement Comprehensive Respiratory Care Plan
Penalty
Summary
The facility failed to develop and implement a comprehensive, person-centered care plan to address all of a resident's respiratory needs. The resident, who had diagnoses including obstructive sleep apnea (OSA) and acute respiratory failure with hypercapnia, was admitted from the hospital with discharge instructions to continue weaning off supplemental oxygen and to use CPAP at night. Although a care plan was created shortly after admission, it did not initially address the resident's altered respiratory status or difficulty breathing related to COPD until several weeks later. The care plan also lacked individualized interventions for the resident's use of supplemental oxygen and did not include a protocol or designate staff responsible for oxygen weaning, despite a physician's order for oxygen weaning being present. Additionally, the care plan was not updated to include specific, resident-centered interventions for the use of the CPAP machine, such as mask type, humidification, cleaning schedules, supply provision, or staff responsibilities. Facility policies reviewed did not provide a protocol for oxygen weaning, and the DON was unable to explain the omissions in the care plan or provide further information before the survey concluded. These deficiencies were identified through record review and staff interviews, and the administrator was made aware of the concerns.
Failure to Individualize and Revise Care Plan for Resident with Complex Needs
Penalty
Summary
The facility failed to revise and individualize the care plan for a resident with multiple comorbidities, including chronic pain, mood and adjustment disorder, cancer, and a history of respiratory failure. The resident had recent allegations of abuse related to ADL care, and the care plans reviewed did not contain interventions tailored to the resident's specific mental health, behavioral, or ADL needs. Instead, the care plans included generic interventions such as administering medications, referring to psychiatric services, and monitoring mood, without addressing the resident's established patterns of medication refusal, noncompliance, or specific behavioral concerns. The care plans also lacked descriptions of the resident's confabulatory statements or hallucinations, and did not provide staff with individualized strategies to address these behaviors. Despite documentation in the medical record of the resident's refusals and noncompliance, the interventions remained non-specific and did not guide staff on how to provide patient-centered care. During interviews, the DON stated that care plans were updated, but only care plan progress notes and evaluations were provided, not actual updates to the care plan itself. The DON also asserted that no interventions could be put in place for this resident, and there was no care plan addressing the resident's verbalized preferences or specific needs related to ADL care. This lack of individualized care planning was evident despite ongoing concerns and repeated refusals by the resident.
Failure to Implement and Document Oxygen Weaning and CPAP Orders
Penalty
Summary
Facility staff failed to implement hospital discharge treatment plans for a resident requiring supplemental oxygen weaning and CPAP use upon admission. The resident, who had diagnoses including obstructive sleep apnea and acute respiratory failure with hypercapnia, was admitted with specific hospital instructions to continue weaning off oxygen and to use CPAP at night. However, the admission physician orders only included oxygen therapy at 2 liters per minute via nasal cannula, with no orders for oxygen weaning or CPAP use as directed by the hospital discharge plan. The baseline care plan documented oxygen therapy but did not address oxygen weaning or CPAP use. Although a physician order to wean off oxygen was written later, it did not specify a target SpO2 level, and there was no clear documentation of how or if the weaning was being carried out. The comprehensive care plan was updated to include altered respiratory status and CPAP use, but still lacked details on oxygen therapy, weaning protocols, goals, or responsible staff. Nursing staff continued to sign off on oxygen therapy and weaning orders every shift, but there was no evidence they were involved in or aware of the weaning process, and documentation of the resident's response to weaning was absent. Rehab staff reported conducting oxygen weaning trials during therapy sessions and documenting these in the rehab record, but these efforts were not coordinated with nursing staff, who were responsible for ongoing care outside of therapy hours. The facility's policy for oxygen administration did not include a protocol for oxygen weaning or designate responsible staff. Interviews with the DON and other staff revealed a lack of clarity and communication regarding the implementation and documentation of the oxygen weaning process, and the DON was unable to provide further information before the survey concluded.
Failure to Secure Bed Rails and Maintain Inspection Documentation
Penalty
Summary
The facility failed to ensure that bed rails were securely affixed to the bed frame, resulting in loose rails that created a gap of approximately 4-5 inches between the mattress and the rail for one resident. During observations on multiple dates, the bed rails were found to be unstable and easily tilted away from the mattress. The facility was unable to provide current bed rail inspection logs when requested, only producing a single audit from the previous year and indicating that audits were conducted annually. Despite being informed of the issue, the loose bed rails were not addressed for several days until surveyor intervention. The Maintenance Director confirmed the rails were loose during a joint observation with the surveyor, acknowledging that he had previously attempted to tighten them, but the problem persisted.
Failure to Provide Written Notice for Room Changes
Penalty
Summary
The facility failed to provide written notice, including the reason for room changes, to the resident's representative for three separate bed reassignments involving Resident #23. Record review showed that the resident was relocated to different bed assignments on three occasions. When the surveyor requested documentation of written notice for these changes, the Nursing Home Administrator confirmed that, although the resident or their representative was verbally informed, there was no documentation to validate that written notice with the reason for the room changes was provided for any of the bed reassignments.
Failure to Protect Resident from Sexual Abuse by Roommate
Penalty
Summary
A deficiency was identified when the facility failed to protect a resident from sexual abuse by another resident. The incident involved a resident who was observed by an LPN exposing and touching their private parts and inviting their roommate to participate in the inappropriate behavior. Progress notes indicated that this behavior was ongoing, with the resident continuing to grab and expose their private area to anyone entering the room. A care plan was initiated addressing the resident's sexually inappropriate behavior, with interventions to protect others, but the inappropriate conduct persisted. The roommate of the resident confirmed during an interview that they experienced an incident where the resident explicitly exposed themselves, causing discomfort. The roommate subsequently requested a room change. The facility's failure to effectively intervene and prevent further exposure to the inappropriate behavior resulted in the resident not being adequately protected from abuse.
Failure to Report and Investigate Alleged Sexual Abuse
Penalty
Summary
Facility staff failed to report an allegation of abuse to regulatory agencies and the Office of Health Care Quality (OHCQ) after a complaint was made regarding a resident sexually harassing a roommate. Medical record review revealed that an LPN documented multiple incidents where the resident exposed and touched their private parts, inviting the roommate to participate, and continued to display this behavior to anyone entering the room. Despite these documented observations, no investigation was initiated, and the Nursing Home Administrator confirmed he was unaware of the incidents and that no report or investigation had been conducted.
Failure to Prevent Abuse and Incomplete Investigations
Penalty
Summary
The facility failed to prevent potential abuse and did not complete thorough investigations or maintain proper records following documented incidents. In one case, a resident was observed by staff engaging in sexually inappropriate behavior toward a roommate, including exposing and touching private parts and inviting the roommate to participate. Despite staff awareness of these behaviors, neither the resident exhibiting the behavior nor the roommate was removed from the shared room, and no immediate protective measures were documented. Additionally, the facility did not conduct or document comprehensive investigations into allegations of misappropriation of funds and verbal abuse involving another resident. Investigation files lacked statements from the affected resident and did not include documentation or notations demonstrating that the facility reviewed relevant evidence, such as bank account transactions. When questioned, the Nursing Home Administrator was unable to provide complete investigation records or resident statements, and only a minimal, one-sentence statement was later produced. No evidence was provided to show that a statement was taken regarding the verbal abuse allegation.
Failure to Maintain Accurate and Complete Medical Records
Penalty
Summary
The facility failed to maintain accurate and complete medical records in accordance with accepted professional standards for two residents. For one resident, nursing staff did not document Activities of Daily Living (ADL) care after 7:00 AM on a specific date, instead recording that the resident was not available for care, despite evidence that the resident was present in the facility all day. For another resident, the required social history assessment was missing from the medical record, even though the responsible social worker stated that the assessment had been completed. These deficiencies were identified through medical record review and staff interviews during a complaint survey.
Failure to Accommodate Resident's Request for Clock Repair
Penalty
Summary
The facility failed to provide reasonable accommodation for a resident's need regarding a non-functioning clock in the resident's room. Over the course of several days, the resident reported to staff that the clock was not working and requested assistance to have it fixed. Despite these requests, the clock remained non-functional during three separate observations by the surveyor. Both the Nursing Home Administrator and the Director of Nursing were made aware of the issue, and the Maintenance Director acknowledged the need for repair, but the deficiency persisted as the clock was not fixed during the survey period.
Failure to Maintain Safe and Clean Resident Environment
Penalty
Summary
Facility staff failed to maintain a safe, clean, and homelike environment as evidenced by multiple observations across two of four units during the annual survey. In one resident's room, crumbs, debris, and mouse droppings were found along the back corner wall, and these remained present on a follow-up visit the next day. In another unit, a room was observed to have a makeshift cardboard plank covering cracked drywall and a wooden board above the air conditioning unit. Additionally, a gap at the top of an air conditioner allowed outside light to enter, and a rough notch was protruding from the metal edging of the unit. Bathroom vents in two rooms were found to have accumulated dust, indicating a lack of regular cleaning. Further deficiencies included an uncovered thermostat with exposed wires and coils in a resident room. The Maintenance Director confirmed that these thermostats were non-functional and should not have been present in resident rooms. The presence of these issues demonstrates a failure to provide necessary housekeeping and maintenance services to ensure a safe, clean, and comfortable environment for residents.
Failure to Notify Ombudsman of Resident Transfers
Penalty
Summary
The facility failed to notify the Ombudsman prior to the transfer of three residents who were sent to the hospital following changes in their conditions. Record reviews and staff interviews confirmed that, for each of these residents, there was no documentation or evidence that the Ombudsman had been informed of their transfers. The Nursing Home Administrator and the Director of Nursing both acknowledged during interviews that they were unable to provide proof of such notifications for the relevant hospitalizations. This deficiency was identified through the review of medical records and direct questioning of facility leadership regarding the required notifications.
Failure to Update and Implement Physician-Recommended Wound Care Orders
Penalty
Summary
A deficiency was identified when a resident with two Stage 4 pressure ulcers, one on the right hip and one in the sacral area, did not receive updated wound care treatment as recommended by the in-house wound consult physician. The physician's recommendations, made after a debridement procedure, included specific instructions for cleansing and dressing both wounds using Dakin solution, santyl with calcium alginate, and appropriate dressings. However, these recommendations were not incorporated into the resident's treatment orders. Instead, the resident continued to receive wound care based on outdated orders from several weeks prior, which did not reflect the physician's updated recommendations. Documentation showed that the older orders were followed for an extended period, and the Director of Nursing confirmed that the process for updating orders after wound consultations was not followed in this instance. The failure to update and implement the recommended wound care regimen resulted in the resident not receiving treatment intended to promote healing of the pressure ulcers.
Physician Failed to Document Significant Weight Loss
Penalty
Summary
A physician failed to document a note addressing a significant weight loss in a resident, as identified during a review of medical records and staff interviews. The resident experienced a weight decrease from 135.8 lbs to 109 lbs over a six-month period, amounting to a 19.73% loss. The dietitian recognized the weight loss as significant and documented that the interdisciplinary team, Medical Director, and resident representative were informed. However, a review of the physician's notes revealed no documentation addressing the weight loss following the notification. The facility's weight monitoring policy states that providers should document diagnoses or clinical conditions contributing to significant weight loss. Despite this, the only provider note available after the weight loss did not address the issue. Interviews with the DON and Medical Director confirmed that the physician did not document an updated plan of care or address the significant weight loss in the resident's medical record, even though the expectation was for such documentation to occur.
Failure to Administer Prescribed Medication Due to Unavailable Supply
Penalty
Summary
The facility failed to ensure that medications were administered to a resident as ordered, specifically regarding the administration of metformin, a medication used to treat type 2 diabetes. Record reviews and interviews revealed that the resident did not receive prescribed doses of metformin on multiple occasions over a two-month period. On certain dates, the medication was not available due to the facility waiting for pharmacy delivery, despite the medication not being new. Documentation on the Medication Administration Records (MAR) indicated missed doses, with some entries referencing progress notes for further explanation. Interviews with the resident confirmed that there were several occasions when the prescribed metformin was not provided because the facility had run out. The Director of Nursing (DON) verified that on specific dates, the medication was not administered due to delays in pharmacy delivery, and in some instances, there was no documentation explaining the missed doses. The facility's policy required established procedures to ensure a sufficient supply of medications for residents, but these procedures were not followed, resulting in the resident missing prescribed doses.
Failure to Maintain Effective Pest Control Program
Penalty
Summary
The facility failed to maintain an effective pest control program, as evidenced by the presence of crumbs, debris, and mouse droppings observed in a resident's room on the [NAME] View Unit. The issue was first identified by a surveyor and subsequently confirmed by the Nursing Home Administrator (NHA) during a follow-up visit. Review of the pest problem log book indicated that the same room had previously been reported for mice concerns in September 2024 and was treated at that time. Examination of pest management treatment invoices for 2025 revealed that although the facility described its pest control services as weekly, the actual intervals between treatments were inconsistent, ranging from 4 to 18 days. The recurrence of mouse droppings in a room with a known history of pest issues, combined with irregular pest control service intervals, contributed to the deficiency.
Failure to Complete Significant Change Assessments for Residents with Weight Loss and Functional Decline
Penalty
Summary
The facility failed to comprehensively assess two residents who experienced significant changes in condition, specifically regarding weight loss and functional ability, using the CMS-specified Resident Assessment Instrument (RAI) process. For one resident, medical record review revealed significant weight loss and a decline in feeding ability from independent to dependent, but the Minimum Data Set (MDS) was not updated to reflect these changes at any point during the resident's stay. Interviews with the MDS Coordinator and Administrator confirmed that the MDS record was not updated as required. Another resident experienced a weight loss of 19.73% over six months, which was documented as significant by the dietitian, and the interdisciplinary team, Medical Director, and Resident Representative were notified. However, review of the MDS showed that while changes in self-care ability were coded in subsequent assessments, there was no significant change of status assessment conducted in the MDS to reflect the weight loss and changes in activities of daily living. The MDS Coordinator acknowledged that the significant change of status assessment was missed after reviewing the resident's chart.
Failure to Prevent Accident Hazards and Inadequate Behavioral Monitoring
Penalty
Summary
The facility failed to ensure that a resident's room was free from accident hazards and did not provide adequate supervision to prevent accidents. Specifically, one resident's bed was plugged into an outlet across the room using a power strip and an extension cord, both of which were resting on the floor. The resident reported that the outlet on their side of the room had not worked for approximately four months, necessitating the use of the extension cord and power strip for charging needs. The power strip, which had previously been secured to the wall, was found on the floor during the surveyor's observation. The situation persisted until the time of the survey, with the resident relying on this setup due to the inoperable outlet. Additionally, the facility did not adequately monitor and document the behaviors of a resident with known inappropriate sexual behaviors. The care plan for this resident included monitoring and documenting behavior episodes, but a review of the treatment administration record and progress notes revealed inconsistent or absent documentation of the resident's sexual behaviors, despite psychiatric evaluations noting ongoing incidents. The lack of detailed documentation and monitoring was confirmed during interviews with facility staff, who acknowledged that the expected behavioral documentation was not present in the resident's records.
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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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