Layhill Nursing And Rehabilitation Center
Inspection history, citations, penalties and survey trends for this long-term care facility in Silver Spring, Maryland.
- Location
- 3227 Bel Pre Road, Silver Spring, Maryland 20906
- CMS Provider Number
- 215168
- Inspections on file
- 21
- Latest survey
- February 18, 2026
- Citations (last 12 mo.)
- 42
Citation history
Health deficiencies cited at Layhill Nursing And Rehabilitation Center during CMS and state inspections, most recent first.
The facility failed to maintain food service sanitation standards when a cook and a dietary aide were observed without beard nets and wet nesting was observed with stacked pans and cups. A commercial dishwasher was also observed with rinse temperatures below the required high-temp setting, and the DDM reported the unit had been converted to chemical mode.
Resident personal funds were not fully accessible for all 54 residents with Resident Fund Accounts. One resident reported funds were not always available during the week and were never available on weekends or holidays. The BOM said funds were kept at the front desk, but only $50.00 was provided for the entire weekend or holiday period, while the DON stated residents could access funds during front desk hours.
Failure to Obtain Orders for Bed Positioning Used as a Physical Restraint: Four residents were observed with beds positioned directly against the wall, and their care plans did not show they requested this placement. The DON later reported that most beds were moved away from the wall, but 47 residents remained care planned for refusing to have their beds moved, and their records did not contain physician orders for the physical restraint.
Lack of Comfortable Chairs in Resident Rooms: Surveyors observed that five residents did not have a chair in their rooms, and each resident confirmed the absence of a chair during interview. The DON later stated that each resident should have a chair in the room.
A resident identified for transfer due to a bed lock was referred by the Social Service Director to two other SNFs without prior discussion of the proposed transfer with the resident’s known medical decision maker. The Business Office Manager stated the resident was chosen because they were easygoing and reported that referrals were made in the context of opening rehab beds, while assuming Social Services had notified the representative. The resident’s representative only learned of the transfer when contacted by an outside facility, and later reported confusion and upset that another family member was called instead. The DON stated that the expectation is to discuss proposed transfers with residents or their representatives before sending referrals, and the Ombudsman reported not being notified of the bed lock or the residents referred out.
The facility failed to arrange an ordered head CT for a resident after a neurosurgery visit, with no documentation that the scan was ever scheduled or completed after the initial call to the imaging provider was not followed up. The facility also failed to maintain dignity when an LPN entered a resident's room without permission or announcing herself, despite acknowledging that she should wait for permission and identify herself.
Homelike Environment Deficiencies in Resident Rooms: Surveyors observed multiple resident rooms with peeling paint, mismatched paint patches, paint drips, and damaged furniture. A resident reported the wall condition and missing dresser handle had been present since moving in, and the MDS later agreed the affected walls and dresser needed repair.
Failure to Develop Care Plans for Identified Needs: Two residents had identified needs that were not reflected in their care plans. One resident screened positive for trauma after reporting childhood trauma, but no trauma care plan was present. Another resident had a palliative care consult order and was confirmed by the DON to be on palliative care, but no palliative care care plan was found.
Care plans were not revised for two residents to match current orders and care needs. One resident’s plan still listed left hand and elbow splints even though the splint order had been discontinued and staff confirmed the resident no longer had or used splints. Another resident’s plan still listed a midline venous access site after the midline had been discontinued. The DON confirmed the care plans should have been updated when those changes occurred.
A resident with ongoing diarrhea reported that the facility was not doing anything about it. A stool test for C. diff was ordered, but the record showed it was signed off as completed even though no lab result was found and the specimen was not picked up; the binder noted “no stool.” An LPN said the resident had no BM during her shift and the need for the specimen was passed to the next shift, while the ADON confirmed the order should not have been marked complete without a specimen and should have been extended when stool was not obtained.
A resident’s pharmacy MRR recommendations were not reviewed by the physician in a timely manner. One recommendation to reduce Pantoprazole from 40 mg to 20 mg was not signed until weeks later, and another MRR note about Sertraline HCl with Eliquis was not signed for months. The DON acknowledged the delay in provider review of the pharmacy recommendations.
Medication error rate exceeded the 5% threshold when an LPN crushed medications for a resident with dysphagia without a physician order. The LPN crushed Carbidopa/Levodopa and an enteric-coated Aspirin tablet, then mixed them with applesauce for administration, and acknowledged that the enteric-coated tablet should not have been crushed. Record review showed both medications were listed on the facility’s not-to-be-crushed list, and the medication administration policy required pharmacist review before crushing medications.
Incomplete medical record documentation was identified for two residents. One resident’s PASRR was not in the chart at admission even though it had been approved, and a later review showed it had not been uploaded until after the deficiency was found. For another resident, a C. diff stool test order was marked complete on the TAR even though no specimen was obtained, no lab result was present, and the order was labeled as no stool.
Infection Control Failure During Bed Bath: A GNA exited one resident’s room, entered another resident’s room, and brought a bottle of body wash back to continue a bed bath for a resident after the assigned GNA ran out of supplies. The GNA and the DON confirmed that personal hygiene products should not be taken from one resident’s room for use with another resident, and the DON identified the action as an infection control issue.
Resident Smoke Detector Not Working: A surveyor heard a chirping sound coming from a resident's room and traced it to the ceiling smoke detector. The resident said it had been chirping for an extended period, and an LPN who had been at the doorway said she did not hear it and did not report it to maintenance. The DON later confirmed the detector batteries needed replacement.
A resident with a history of organ transplant did not receive prescribed anti-rejection medications, Sirolimus and Tacrolimus, after admission due to failures in the admission process and medication reconciliation. The omission was discovered when the resident's cardiologist noted low drug levels and found the medications were not ordered or administered, resulting from multiple missed opportunities by nursing and pharmacy staff.
A resident with a history of organ transplant did not receive prescribed anti-rejection medications after admission because the facility failed to reconcile and order all medications listed on the hospital discharge summary. Confusion between the CRNP and admitting nurse regarding responsibility for medication reconciliation contributed to the omission, which was identified after the resident's drug levels were found to be low.
A resident who required anti-rejection medications after an organ transplant was re-admitted from the hospital, but the pharmacy failed to identify and include two essential immunosuppressant drugs listed on the hospital discharge summary during the admission medication review. The DON confirmed that the pharmacy overlooked these medications when reconciling the resident's medication regimen.
The facility did not inform representatives for two residents when there were significant changes in condition or treatment. One resident's G-tube feeding method was changed by the dietitian without notifying the representative, and another resident's worsening Stage 4 pressure ulcer was not communicated to their representative. Both the LPN and DON confirmed that required notifications were not made.
A resident was overcharged for Beauty Shop/Barber services due to accounting errors in the management of their personal fund account. Review of billing records and service logs revealed a discrepancy between the amount charged and the actual services received, which was confirmed by the Business Office Management.
Two residents experienced incidents involving suspected abuse or injury, but the facility did not report these allegations to the State Survey Agency within the required 24-hour period. In one case, a resident with dementia and other conditions sustained significant skin tears from an unqualified staff member, and in another, a resident's abuse allegation was delayed in being reported due to staff inaction.
A resident was discharged with an abdominal drain and on TPN, but the discharge summary provided was incomplete, missing essential nursing instructions on TPN management, drain care, patient education, and a full medication list. Staff interviews and record reviews confirmed that the nursing sections of the discharge summary were not fully completed as required by facility policy.
A resident with dementia and muscle weakness experienced a fall, after which a nurse recommended keeping the bed in a low position to prevent further incidents. However, the care plan was not updated to include this intervention, despite confirmation from the unit manager and DON that it should have been added. This deficiency was identified through record review and staff interviews.
Surveyors found that two residents' wound dressings were not labeled or initialed to indicate when dressing changes occurred, despite physician orders specifying scheduled changes. The wound nurse confirmed that standard practice required labeling, but was unable to identify who performed the changes or when they were done.
A resident admitted without pressure ulcers and assessed as mild risk developed an unstageable sacral pressure ulcer during their stay. No change in condition assessment was completed, and the family was not notified of the new ulcer, contrary to facility expectations as confirmed by the DON.
A resident with dementia and other medical conditions sustained significant skin tears on both forearms after being assisted out of a chair by a Hospitality Aide who was not qualified to provide direct care. The incident was identified by an LPN, and the resident reported the circumstances through an interpreter. Facility records and staff interviews confirmed that the aide's actions were outside their permitted duties, resulting in the resident's injuries.
The facility failed to maintain an effective system for identifying decision-makers and ensuring residents' wishes regarding CPR were documented. This led to confusion with multiple residents having conflicting MOLST forms, resulting in uncertainty about their code status. For example, a resident had two active MOLST forms with contradictory orders, and another resident's MOLST was based on a surrogate's input despite the resident being capable of making their own decisions.
The facility failed to conduct and document interdisciplinary care plan meetings effectively, resulting in outdated and incomplete care plans for several residents. Residents experienced a lack of updated care plans reflecting their current needs and conditions, with some care plans missing input from various departments. This deficiency affected the quality of care provided to the residents.
The facility did not post complete nursing staffing information, as required, during a survey. The posted lists at the reception desk included nursing staff by unit and shift but lacked the resident census and total actual nursing hours worked. The Staffing Coordinator and Nursing Home Administrator confirmed the deficiency, with no further information provided by the survey's end.
The facility failed to manage Maryland MOLST forms, crucial for documenting residents' life-sustaining treatment wishes, due to the absence of a system to void outdated forms. The Medical Director was aware but did not communicate the issue to the QUAPI program, leading to non-compliance and potential impact on all residents.
The facility did not have a medical director present at the quality assurance committee meetings for three consecutive months, which equates to one quarterly meeting. The absence was confirmed by the NHA, and no substitute medical director attended these meetings, leading to a deficiency in the facility's compliance with regulatory requirements.
The facility failed to provide communication training for nine staff members, including the NHA, DON, ADON, two social workers, the Director of Rehabilitation, two Unit Managers, and two LPN supervisors. This deficiency was identified during an extended survey triggered by an Immediate Jeopardy situation involving conflicting MOLST and resuscitation code status documents in resident records. The NHA acknowledged the lack of training during an interview.
A facility failed to create a comprehensive, resident-centered care plan for a resident on psychotropic medication for depression. The care plan lacked specific details about the resident's behaviors and did not include measurable goals or non-pharmaceutical interventions. The DON was informed but did not comment.
A facility failed to honor a resident's right to self-determination by not confirming their code status directly with them, despite the resident having the capacity to make decisions. Instead, the facility confirmed the code status through a family member, without specifying which family member was contacted. This oversight was discovered during an Immediate Jeopardy investigation into conflicting resuscitation instructions.
The facility failed to maintain a safe and clean environment, with stained carpets, missing floor planks, and damaged walls observed. Housekeeping issues included holes in bed linens and inadequate cleaning, while maintenance deficiencies involved missing emergency call light cords and cracked wheelchair padding. Despite staff acknowledgment, no corrective actions were documented.
The facility failed to provide adequate activities for residents, as evidenced by observations and lack of documentation for four residents. A resident with severe cognitive impairment was found alone without activities, and another resident's care plan was outdated and did not reflect their preferences. Two other residents had no documented participation in activities, and the Activity Director failed to gather necessary information from family members.
The facility failed to provide adequate pain management for three residents, leading to deficiencies in care. A resident did not receive their prescribed oxycodone consistently due to pharmacy and insurance issues. Another resident with a sacral ulcer had no active pain medication orders, and their pain was improperly documented by a CMA. A third resident's pain medication was administered late, and non-pharmacological interventions were not attempted as required by policy.
The facility failed to follow proper procedures for bed rail use for four residents, including not assessing risks, obtaining informed consent, or developing care plans. Observations showed bed rails were used without physician orders or documentation, and a loose bed rail was found without prior awareness by staff.
The facility failed to adhere to medication administration parameters, resulting in unnecessary drug use. A resident received Oxycontin without proper blood pressure monitoring or pain assessment, and Midodrine was given without checking blood pressure. Another resident's pain management lacked guidance on medication order, and a diuretic was administered despite low blood pressure. Additionally, a Lidocaine patch was applied without a specified removal time, leading to incomplete documentation.
The facility failed to serve residents the correct meal portions and items as indicated on their meal tickets. A resident reported not receiving a high protein diet consistently, and an observation revealed incorrect portioning practices, such as using tongs instead of a scoop for beef pepper steak. A test tray showed discrepancies, including incorrect portion sizes and missing items, which were confirmed by the Food Service Director.
The facility failed to conduct regular inspections of bed frames, mattresses, and bed rails, affecting three residents and potentially all residents. The Maintenance Director confirmed that only one audit had been conducted, limited to the first floor, and relied on reports from nursing or housekeeping to address issues. New beds did not come with rails, and there was no proactive inspection process, posing a risk of entrapment.
A facility failed to notify a resident's HCPOA of changes in treatment, including the start of a new medication and a change in the attending physician. The resident, who had significant functional limitations and was dependent on staff, was not understood well and required various therapies. The lack of documentation regarding the notification of these changes was confirmed by the DON.
A facility failed to prevent further potential abuse during an investigation due to an inaccurate assessment of a resident. The DON's pain assessment incorrectly reported no pain in the last five days, despite the resident receiving as-needed pain medication with significant pain scores. Additionally, the assessment inaccurately stated the resident had not received rehab services, which was contradicted by the Director of Rehab. The DON and NHA acknowledged these documentation errors.
A facility failed to document a resident's communication needs during a hospital transfer. The resident, who was deaf, required an ASL interpreter device, but this was not noted on the transfer form completed by an LPN. The omission was confirmed during a recertification survey, and the DON could not provide evidence that the hospital staff were informed of the resident's needs.
A deaf resident in an LTC facility was unable to communicate effectively due to the absence of a functioning video interpreter device in their room. Despite signs indicating the availability of an interpreter service, the device was not present, and no alternative communication methods were provided. The resident's care plan lacked strategies for communication, and staff interviews revealed that the device had been unavailable for an extended period, with no disruptions reported by the software company.
A facility failed to administer g-tube feedings as ordered for a resident with dysphagia, leading to significant weight loss. The resident was admitted with orders for Jevity 1.5 bolus feedings, but discrepancies in orders and documentation resulted in confusion about the nutrition provided. The resident experienced weight loss due to insufficient caloric intake, which was not addressed in a timely manner. Additionally, a new feeding order was not accurately reflected in the dietitian's assessment, leading to further confusion about the number of bolus feeds administered.
A resident with severe cognitive impairment and psychiatric diagnoses did not receive adequate behavioral health monitoring, leading to a deficiency in care. The facility failed to document a planned gradual dose reduction of Zoloft, and behavior monitoring was inaccurately recorded, despite aggressive incidents. Additionally, psychiatric medication adjustments were made without proper documentation, contributing to the deficiency.
The facility failed to ensure residents were informed and involved in code status decisions when new MOLST forms were created. A resident was not consulted about their DNR status despite being cognitively intact, another had their code status changed without contacting their Health Care Agent, and a third resident's MOLST was completed without consulting their Medical POA despite incapacity certifications.
A resident reported that staff sometimes entered his room without knocking, which was confirmed when a CNA entered without knocking to deliver a lunch tray. The CNA admitted to not knowing the requirement to knock before entering. The issue was discussed with the Administrator and DON, but no further information was provided.
The facility failed to provide information on advance directives to three residents, despite their capacity to make decisions. One resident's record lacked documentation of advance directives, another's family confirmed an existing directive not discussed with the resident, and a third resident's record showed no evidence of an advance directive despite being cognitively intact. The Director of Social Services and DON acknowledged these deficiencies.
Food Service Sanitation and Dishwasher Temperature Deficiency
Penalty
Summary
The facility failed to ensure food and equipment were prepared in a manner that maintained professional standards of food service safety and sanitation. During the initial kitchen tour, the surveyor observed Cook #1 and Dietary Aide #2 without beard nets. The surveyor also observed wet nesting between silver metal pans stacked on a metal rack in the kitchen and plastic cups stacked on a tray by the steam table. During a follow-up kitchen tour, Dietary Aide #2 ran the commercial dishwasher in the dish room and the rinse temperature read 160 degrees Fahrenheit on two separate runs. The District Dietary Manager also ran the dishwasher twice and obtained the same rinse temperature of 160 degrees Fahrenheit, while reporting that the machine was a high-temperature dishwasher requiring a 180 degrees Fahrenheit rinse cycle. The District Dietary Manager reported that the dishwasher had been converted to chemical instead of high temp, and the surveyor later observed the dishwasher running on a chemical cycle with wash and rinse temperatures maintained at 140 degrees Fahrenheit.
Resident Personal Funds Not Fully Accessible
Penalty
Summary
The facility failed to ensure resident personal funds were fully accessible for 54 out of 54 residents who had Resident Fund Accounts. During an interview, one resident reported that money from the Resident Fund Account was not always available during the week and was never available on weekends or holidays, although the resident could not identify a specific date or time when access was denied. The Business Office Manager reported that resident funds were kept at the front desk during weekday hours and that only $50.00 was provided for the entire weekend or holiday period, while stating that residents were generally given their money on Fridays so they would not need funds on weekends. The Director of Nursing reported that the front desk receptionist was available from 7:00 AM to 10:00 PM seven days a week, including holidays, and stated that residents could access their funds during those hours. The surveyor noted concern that $50.00 was available for the entire weekend and holidays for 54 residents with Resident Fund Accounts, and that residents who were not able to receive money on Friday would receive limited funds on weekends and/or holidays.
Failure to Obtain Orders for Bed Positioning Used as a Physical Restraint
Penalty
Summary
The facility failed to ensure residents were free from physical restraints and failed to obtain physician orders for the use of physical restraints. During an initial tour of the second-floor nursing unit, four residents were observed with their beds positioned directly against the wall. A review of their care plans did not show that these residents had requested to have their beds placed against the wall. During an interview, the DON stated she would conduct a facility sweep to ensure beds were not positioned against the wall and that any beds against the wall would be immediately removed. A later interview with the DON indicated that staff completed a facility sweep and moved resident beds 18 inches from the wall, except for residents who refused to have their beds moved. The DON provided a list of 47 residents who were care planned for refusing to have their beds moved from against the wall. Review of the medical records for those residents showed they did not have a physician's order for a physical restraint.
Lack of Comfortable Chairs in Resident Rooms
Penalty
Summary
The facility failed to ensure that residents had a comfortable chair in their rooms. During random observations on 02/08/2026, the surveyor was unable to locate a chair in the rooms of Resident #40, #41, #12, #108, and #11, and each of these residents confirmed during interviews that they did not have a chair in their room. During a later interview on 02/18/2026, the DON was provided the room numbers of the residents without chairs and stated that each resident should have a chair in their room.
Failure to Notify Resident Representative and Ombudsman of Proposed Transfer
Penalty
Summary
The facility failed to ensure that a resident’s representative and the Ombudsman were notified of a proposed transfer to another SNF. A complaint was submitted to the Office of Health Care Quality alleging that the facility attempted to transfer the resident for LTC without notifying the designated medical decision maker. The Business Office Manager (BOM) stated that the resident was identified for transfer because the facility was bed locked and needed to open beds for rehab, and also described a practice she called “Quid Pro Quo,” in which facilities with low census contacted them to obtain residents. The BOM believed Social Services had notified the representative but could not confirm this. The resident’s representative, identified as the medical decision maker known to the facility, reported learning of the proposed transfer only after another facility, Kensington Rehab, contacted a family member about accepting the resident. The Social Service Director (SSD) reported receiving a list of residents to be referred out due to the bed lock and stated that her usual process was to send referrals and then contact families. She acknowledged that she did not contact this resident’s representative about the proposed transfer, explaining that she was busy and that Kensington had reached out to the representative quickly. Record review showed that the SSD sent a referral to [NAME] Grove on 01/27/26 and another referral to Kensington Rehab on 02/04/26 before any documented communication with the resident’s representative about the transfer. The DON stated that other facilities do not contact them to obtain residents and denied any “Quid Pro Quo,” and also stated that the facility’s expectation is to discuss a proposed transfer with the resident or representative before sending referrals. The Ombudsman reported not being notified of the bed lock or of residents referred out for transfer.
Failure to Arrange Ordered CT and Respect Resident Privacy
Penalty
Summary
The facility failed to provide access to services outside the facility for a resident who had been seen by a neurosurgeon and had a follow-up order for a CT scan of the head without contrast. The medical record showed a progress note and order on 5/22/2025 directing that the head CT be scheduled and that the results be faxed to the neurosurgeon, but there was no documentation that the CT was ever scheduled or completed. During interview, the Unit Manager stated the appointment should have been scheduled but was not completed, and the Unit Clerk stated she made an initial call to schedule the CT, was told the system was down, and did not make a second call to complete the scheduling. The facility also failed to ensure a resident was provided a dignified existence when an LPN entered the resident's room without gaining permission and without announcing herself. During observation, the LPN knocked and then entered the room while holding a clipboard and blood pressure cuff. When interviewed immediately afterward, the LPN stated the expectation was to knock and enter, but also acknowledged that she should wait for permission and announce herself. She said she entered the room to see who was inside.
Homelike Environment Deficiencies in Resident Rooms
Penalty
Summary
The facility failed to provide a homelike environment for 4 of 27 resident rooms observed. In Resident #53’s room, surveyors observed a large white area where paint had peeled or been scraped off behind the bed, and a small dresser with a bottom drawer that was lopsided, did not close completely, and was missing a handle. The resident stated the wall condition had been present since moving into the room and that the dresser had been supplied by the facility and had been missing the handle since transfer into the room. In the room shared by Residents #22 and #62, surveyors observed a large area above and to the right of the doorway painted white in a way that did not match the room’s coloration, along with several black streaks along the lower wall and additional patches of white paint and paint drips on the mid and upper wall. In Resident #119’s room, the bed was against a wall with large areas of peeling paint, and the resident stated the wall had been like that for some time. The Maintenance Director later agreed the walls in these rooms needed to be painted and acknowledged he had been unaware of the peeling paint in Resident #119’s room.
Failure to Develop Care Plans for Identified Needs
Penalty
Summary
The facility failed to ensure care plans were developed for two residents whose records showed identified needs that were not reflected in their care plans. One resident reported experiencing childhood trauma and stated that the trauma has messed my head up. A trauma screening completed for that resident was positive for trauma, but review of the care plan did not show a trauma care plan. During interview, the DON stated that the SSD should have triggered a care plan for trauma and confirmed that the resident was not care planned for trauma. For another resident, the medical record showed an order for a palliative care consultation, and review of the care plan did not show a palliative care plan. During interview, the DON confirmed that the resident was on palliative care but did not have a care plan. The deficiency was identified during record review and staff interviews during the recertification and complaint survey.
Care plans were not updated to reflect current resident care needs
Penalty
Summary
The facility failed to revise care plans to match residents’ current needs for 2 of 2 residents reviewed for care plan revisions. For Resident #15, the care plan still included a focus added on 1/14/2024 stating the resident wore a left hand splint and left elbow splint, with a goal to maintain range of motion and an intervention of periodic review by a licensed nurse. However, during observation on 2/11/2026 the resident was not wearing a splint on the left hand or elbow, and a GNA later confirmed the resident did not have a splint to wear. Record review showed a prior splint order for left hand and left elbow splints for 5 hours during the day had been discontinued on 6/11/2024, and the Unit Manager and DON confirmed the resident no longer used splints and the care plan should have been updated to remove that information. For Resident #13, the care plan still included a focus added on 4/15/2025 stating the resident had a midline venous access site, but record review showed the midline had been discontinued on 4/23/2025. The DON confirmed the care plan should have been updated to discontinue the midline as part of the resident’s care. The facility’s policy stated care plans are to be updated on an ongoing basis as changes occur and reviewed quarterly with the quarterly assessment.
Failure to Obtain and Track Ordered C. diff Stool Specimen
Penalty
Summary
The facility failed to ensure nursing standards of practice were met for a resident who reported having diarrhea every day for the prior two weeks and stated he or she did not feel the facility was doing anything about it. A stool test for C. diff was ordered, and the treatment record showed it as completed, but the medical record contained no lab result for the test. The Laboratory Orders and Results binder showed the order was marked as “no stool” rather than as a collected specimen, and the lab did not pick up a specimen for that order. An LPN who worked the shift confirmed the resident did not have a bowel movement during that shift and said the oncoming shift was notified that the specimen was still needed. However, the record review showed bowel movements were documented on multiple shifts after the order was placed, including day, evening, and night shifts over several consecutive days. The ADON confirmed that if no stool was obtained, the order should not have been signed off as completed and should have been documented as not done because the resident did not have a bowel movement; she also stated the order should have been extended since the specimen was not obtained. A new order for stool testing for C. diff was later placed.
Delayed Review of Pharmacy Medication Regimen Recommendations
Penalty
Summary
The facility failed to ensure that Pharmacy Medication Regimen Review recommendations were reviewed in a timely manner for Resident #4. On 09/20/2025, the pharmacy recommended decreasing Pantoprazole from 40 mg to 20 mg, but the physician did not review, agree, and sign the recommendation until 11/15/2025. The Medication Administration Record showed the dose was decreased to 20 mg on 11/21/2025, well after the pharmacy recommendation was made. A later Medication Regimen Review for Resident #4 dated 11/23/2025 included a pharmacy recommendation noting that antidepressants with antiplatelet effects, such as Sertraline HCl 50 mg, may enhance the anticoagulant effect of direct oral anticoagulants, such as Eliquis 5 mg. The physician selected that no change was needed because the benefit outweighed the risk, but did not sign the recommendation until 02/13/2026. During interview, the DON acknowledged the delay in physician review and response to the pharmacy recommendations.
Medication Error Rate Exceeded During Crushing of Medications
Penalty
Summary
The facility failed to keep its medication error rate below 5% during a medication administration observation, with 3 errors identified out of 29 medications administered. During the observation, an LPN began administering medications to a resident with dysphagia and stated that she routinely crushes medications for residents with this condition. When asked, she confirmed there was no physician’s order authorizing medications to be crushed, but said she used her nursing judgment to decide whether to crush them. The LPN crushed two Carbidopa/Levodopa tablets, one enteric-coated Aspirin tablet, and one Losartan potassium tablet and mixed them with applesauce for administration. During interview, she acknowledged that enteric-coated medications should not be crushed and stated that crushing the enteric-coated Aspirin was a mistake. Record review showed that Aspirin (enteric-coated) and Carbidopa/Levodopa were listed on the facility’s Medications Not to Be Crushed list, and the facility’s medication administration policy stated that long-acting or enteric-coated dosage forms should not be crushed and that the pharmacist should be contacted before crushing medications.
Incomplete Medical Record Documentation
Penalty
Summary
The facility failed to ensure medical records were complete and accurate for two residents reviewed during the recertification survey. For one resident, a completed PASRR was not documented in the medical record at the time of review even though the resident had been admitted and the PASRR had been approved on the Qualitrac website. The Social Work Director stated the PASRR should have been uploaded into the record and explained that it had not been added initially because the facility identification had not been entered for access to the document. A later review showed the PASRR was added to the resident’s chart on 2/10/2026, and the facility policy required PASRRs to be scanned and uploaded no later than five days after admission. For the second resident, an order was placed for stool testing for C. diff and was signed off as completed on the TAR, but the medical record contained no lab results for the order. The laboratory order record showed the C. diff order was not signed off as picked up by the lab and was labeled as no stool. An LPN confirmed the resident did not have a bowel movement during her shift, so the specimen was not obtained, and she had notified the oncoming shift that the specimen was still needed. The ADON stated that if no stool was obtained, the order should not have been signed off as completed and should have been documented as not done because the resident did not have a bowel movement.
Infection Control Failure During Bed Bath
Penalty
Summary
The facility failed to ensure staff practiced infection control when GNA #17 exited the room of Resident #13, entered the room of Resident #22, and returned holding a plastic bottle that he took back into Resident #13’s room. During interview, GNA #17 stated that GNA #18 was giving Resident #13 a bed bath and had run out of body wash, so he obtained body wash from Resident #22’s room to allow the bath to continue. GNA #18 confirmed she was bathing Resident #13, had run out of body wash, and asked GNA #17 to get more; she also stated that each resident gets their own body wash and that it was not common practice for staff to take supplies from one resident’s room for use with another resident. The DON later stated that personal hygiene products should not be taken from one resident’s room to another and that GNA #17 should have gone to storage to get a new bottle of body wash for Resident #13, identifying the action as an infection control issue.
Resident Smoke Detector Not Working
Penalty
Summary
The facility failed to ensure that a resident's smoke detector was in working condition. During a random observation on 02/08/2026 at 10:28 AM, the surveyor heard a chirping sound from the 2nd floor nurse's station and followed it to Resident #44's room, where the sound was determined to be coming from the ceiling smoke detector. During an interview at 10:30 AM, Resident #44 reported that the smoke detector had been chirping for an extended period. At the same time, the surveyor observed an LPN at the entry door of the room. During an interview at 10:33 AM, the LPN reported that although she had been in front of the room, she did not hear the chirping and therefore had not reported it to maintenance. At 10:35 AM, the surveyor reported the issue to the DON, who entered the room, confirmed that the smoke detector batteries needed to be replaced, and contacted the Maintenance Director to request batteries.
Failure to Administer Prescribed Anti-Rejection Medications After Admission
Penalty
Summary
A deficiency occurred when a resident with a history of organ transplant did not receive prescribed anti-rejection medications, specifically Sirolimus and Tacrolimus, following admission from a hospital. The resident's hospital discharge summary included these medications, but a review of the facility's physician orders and Medication Administration Record (MAR) for the relevant period showed no orders or administration of these drugs. The omission was discovered after the resident's cardiologist, during a routine appointment, noted low therapeutic drug levels and requested a review of the resident's active medication list, revealing the absence of the necessary anti-rejection medications. Interviews and record reviews indicated that the failure to administer these medications resulted from multiple system failures during the admission process. The admitting nurse did not enter orders for the anti-rejection medications as listed on the discharge summary, and the pharmacy's medication regimen review also failed to identify the omission. Additionally, when the cardiologist requested lab troughs for the medications, staff did not question the absence of active orders for these drugs. These oversights led to the resident not receiving essential immunosuppressive therapy for an extended period.
Failure to Reconcile and Administer Discharge Medications for Transplant Patient
Penalty
Summary
The facility failed to ensure that all medications listed on a hospital discharge summary were ordered and administered for a resident with a history of organ transplant. Upon review of facility-reported incidents and the resident's medical records, it was found that two essential anti-rejection medications, Sirolimus and Tacrolimus, were not ordered or given as prescribed following the resident's admission from the hospital. The omission was discovered after a discussion with the resident's cardiologist, who identified low therapeutic drug levels, indicating the resident had not received the necessary anti-rejection medications. Interviews with facility staff revealed confusion and lack of clarity regarding responsibility for medication reconciliation. The Certified Registered Nurse Practitioner (CRNP) stated that she reviews hospital discharge summaries but does not change or stop medications, and believed that the admitting nurse was responsible for reconciling medications. The Director of Nursing confirmed that while the admitting nurse enters medication orders, the provider is expected to reconcile the medication list. This lack of clear accountability led to the failure to order and administer critical medications as required.
Failure to Accurately Review and Reconcile Hospital Discharge Medications
Penalty
Summary
The facility failed to ensure an accurate pharmacy medication regimen review for a resident who was re-admitted following a hospital stay. Upon review of the resident's medical records, it was found that the hospital discharge summary included two essential anti-rejection medications, Sirolimus and Tacrolimus, which were not identified during the pharmacy's new admission medication review. The omission was discovered during a review of the resident's records and confirmed by the Director of Nursing, who stated that the pharmacy is responsible for reconciling the hospital discharge medication list upon admission. The deficiency was specifically related to the pharmacy's failure to recognize and include the two anti-rejection medications listed on the hospital discharge summary in the resident's medication regimen review. This oversight was evident in the documentation and was acknowledged by facility leadership during interviews. The resident's medical history included the need for immunosuppressant therapy following an organ transplant, making the accurate review and reconciliation of these medications critical at the time of re-admission.
Failure to Notify Representatives of Changes in Condition and Treatment
Penalty
Summary
The facility failed to notify residents' representatives of significant changes in condition or treatment for two residents. In the first case, a resident with a gastrostomy tube had their feeding method changed from infusion via pump to bolus administration by the dietitian to accommodate the resident's preference for being out of their room. The clinical record did not contain documentation that the resident's representative was informed of this change. Both the LPN Unit Manager and the DON confirmed that the representative should have been notified at the time of the order change, but this did not occur. In the second case, a resident with a Stage 4 pressure ulcer on the coccyx experienced a worsening of the wound, as evidenced by increased measurements in length and width. Despite this change in condition, there was no documentation in the medical record that the resident's representative was notified of the deterioration. The DON confirmed that notification was not completed for this change in the resident's condition.
Resident Overcharged Due to Inaccurate Fund Account Management
Penalty
Summary
The facility failed to accurately manage a resident's personal fund account, as evidenced by a review of billing records and interviews. The resident was charged $571 for Beauty Shop/Barber services, but a review of the Senior Salon log sheets showed that the actual charges totaled only $515. The Business Office Management (BOM) confirmed that the previous BOM had not paid for the resident's Beauty Shop/Barber services for one year, resulting in an inaccurate charge. The BOM acknowledged that accounting errors led to the resident being overcharged for these services. This deficiency was identified during a complaint survey and was based on direct record review and staff interviews, which confirmed the overcharge and the failure to properly manage the resident's fund account.
Failure to Timely Report Allegations of Abuse to State Agency
Penalty
Summary
The facility failed to report allegations of abuse to the State Survey Agency, the Office of Health Care Quality (OHCQ), within the required 24-hour timeframe for two residents. In the first instance, a resident with diagnoses including shortness of breath, dementia, and osteoarthritis of the right shoulder sustained two large skin tears on both forearms while being assisted out of a chair by a Hospitality Aide who was not qualified to provide resident care. The incident was documented in a complaint and confirmed by the aide, but a review of the clinical record and investigative notes revealed that the incident was not reported to OHCQ as required. In the second instance, another resident reported an allegation of abuse to a Unit Manager, but the Unit Manager did not inform the administration. The allegation was not reported to OHCQ until three days later, after the resident brought the matter to the attention of the DON and Administrator. These failures to report suspected abuse in a timely manner were confirmed through staff interviews and review of facility documentation.
Incomplete Discharge Summary Provided at Resident Discharge
Penalty
Summary
A deficiency was identified when a resident was discharged to a group home with an abdominal drain and receiving total parenteral nutrition (TPN). Upon review of the resident's closed medical record and discharge summary, it was found that the nursing instructions section was incomplete. Specifically, the discharge instructions lacked documentation regarding TPN management, abdominal drain care, patient education provided, and a complete list of medications. The facility's policy required that a licensed nurse complete all applicable nursing sections of the discharge instructions prior to discharge. Interviews with facility staff, including the social worker and the Director of Nursing (DON), confirmed that each discipline is responsible for their respective sections of the discharge summary, with nursing staff responsible for medication and treatment areas. The DON acknowledged that the nursing sections of the discharge summary were incomplete and did not accurately reflect the resident's status at the time of discharge, despite the resident being sent home with TPN supplies, an abdominal drain, and prescribed medications.
Failure to Update Care Plan with Fall Prevention Intervention
Penalty
Summary
The facility failed to review and revise the interdisciplinary care plan to accurately reflect interventions for a resident with diagnoses including dementia, generalized muscle weakness, and cognitive communication deficit. The resident experienced a fall in their room while attempting to retrieve an item from a drawer. Following the fall, a licensed nurse assessed the resident, performed neuro checks, and documented that there were no injuries. The nurse's post-fall documentation included a recommendation for the bed to be kept in a low position as an intervention to prevent further falls. Upon review, it was found that the resident's care plan for falls, which had been initiated and revised prior to and after the fall, did not include the intervention of keeping the bed in a low position, despite this being documented in the nurse's note. Both the unit manager and the DON confirmed that the care plan should have been updated to include this intervention, as it is a standard measure for fall prevention. The deficiency was identified through record review and staff interviews, which confirmed that the care plan did not accurately reflect the interventions in place for the resident.
Failure to Label Wound Dressings with Change Date and Shift
Penalty
Summary
Surveyors determined that the facility failed to ensure wound dressings were properly labeled to indicate when dressing changes occurred, as required by facility protocol. During observations, two residents receiving wound care for a skin tear and a knee wound, respectively, were found to have dressings that were not initialed, dated, or labeled to show when the last dressing change took place or on which shift it was performed. Review of clinical records confirmed that physician orders specified scheduled dressing changes, but the actual dressings lacked the required labeling. Interviews with the wound nurse confirmed that the standard practice was for licensed nurses to initial, date, and label dressings after each change. However, the nurse was unable to identify who performed the most recent dressing changes or on which shift they occurred. The deficiency was acknowledged by both the wound nurse and the nurse educator during the survey process.
Failure to Provide Timely Pressure Ulcer Assessment and Notification
Penalty
Summary
A deficiency was identified when a resident, admitted without pressure ulcers and assessed as having a mild risk for pressure sore development using the Braden Scale, developed an unstageable pressure ulcer to the sacral area while residing in the facility. The medical record review showed that the resident was admitted with diagnoses of morbid obesity and type 2 diabetes mellitus, and had no pressure ulcers at admission. Despite the resident's risk factors and the development of a new pressure ulcer, there was no documentation of a change in condition assessment being completed at the time the ulcer was identified. Further review revealed that the family representative was not notified of the change in the resident's condition, as confirmed by the DON. The wound continued to progress in size over time, as documented in subsequent wound assessments. The DON acknowledged that the facility's expectation is for nurses to complete a change in condition assessment and notify residents or their representatives of any change, but this was not done in this case.
Resident Injured by Unqualified Staff Member During Transfer
Penalty
Summary
A deficiency occurred when a resident with diagnoses including shortness of breath, dementia, and osteoarthritis of the right shoulder sustained two large skin tears on both forearms while being assisted out of a chair to go to the bathroom. The assistance was provided by a Hospitality Aide who was not qualified or permitted to provide direct care to residents. The incident was discovered when an LPN was called to the resident's room and observed the injuries. The resident, who was non-English speaking, communicated through an interpreter that the injuries occurred during the transfer. The LPN documented the incident but did not measure the skin tears at the time. Further investigation revealed that the Hospitality Aide admitted to assisting the resident, which was outside the scope of their job responsibilities as outlined in the facility's job description. The Director of Nursing confirmed that Hospitality Aides are not allowed to provide direct care or assist residents physically. The facility's documentation and staff interviews confirmed that the resident was injured due to the actions of an unqualified staff member, and there was inconsistency in the facility's communication with the resident's representative regarding the incident.
Failure to Maintain Accurate MOLST Documentation
Penalty
Summary
The facility failed to maintain an effective system for identifying the appropriate decision-maker regarding healthcare decisions and ensuring that residents' wishes regarding CPR were clearly documented in their medical records. This deficiency was evident in four residents who had conflicting MOLST forms, leading to confusion about their code status. For instance, one resident had two active MOLST forms with contradictory orders, one indicating a DNR status and the other a full code status. The staff was unsure which order to follow, and the resident's wishes were not accurately reflected in the medical records. Another resident's MOLST form was completed based on information from a surrogate, despite the resident being cognitively intact and capable of making their own healthcare decisions. The medical director confirmed the resident's capacity, yet the MOLST form did not reflect the resident's actual wishes, which were to receive CPR. This discrepancy highlights the facility's failure to ensure that residents' current wishes were accurately documented and followed. Additionally, a resident with severe cognitive impairment had multiple active MOLST forms with conflicting orders, and there was no documentation of attempts to consult the resident's healthcare agent. The physician completed a new MOLST form without verifying the resident's decision-making capacity or consulting the healthcare agent, resulting in a full code order that contradicted the resident's previous DNR status. These failures put residents at risk of not receiving the correct orders for life-sustaining treatments.
Deficiencies in Care Plan Meetings and Documentation
Penalty
Summary
The facility failed to ensure that interdisciplinary care plan meetings were conducted and documented effectively for several residents. For Resident #30, the medical record showed a lack of care plan meetings since October 2023, despite the resident's complex medical conditions, including severe cognitive impairment. The Multidisciplinary Care Conference note was incomplete, lacking input from various departments, and there was no evidence of a scheduled care plan meeting as indicated in a previous note. Resident #23's care plan was not updated to reflect the resident's progress in therapy, and there was no documentation of interdisciplinary team involvement in care plan meetings. The care plan still included outdated interventions, such as the use of a hoyer lift, despite the resident's improved mobility. Similarly, Resident #95's care plan did not reflect the resident's preferences for activities, and there was no evidence of care plan meetings since December 2023. Other residents, such as Resident #78, #55, #84, #10, and #100, also experienced deficiencies in care plan meetings and updates. These residents either did not have care plan meetings after assessments or had care plans that were not revised to reflect their current needs and conditions. The facility's failure to conduct regular and comprehensive care plan meetings led to outdated and incomplete care plans, impacting the quality of care provided to the residents.
Incomplete Nursing Staffing Information Posting
Penalty
Summary
The facility failed to post complete nursing staffing information, as required, during the recertification survey. On the morning of the survey, the survey team observed a staffing list at the reception desk, which included nursing staff by unit and shift. However, upon further review and interviews with the Staffing Coordinator and the Nursing Home Administrator, it was confirmed that the posted documents did not include the resident census or the total actual nursing hours worked. The Staffing Coordinator explained that the lists were signed by staff upon arrival and included orientee staff names, but acknowledged the absence of the required information. The Nursing Home Administrator also confirmed the deficiency and indicated an intention to seek more information, but no additional details were provided by the end of the survey.
Failure to Manage MOLST Forms
Penalty
Summary
The facility failed to address issues with the Maryland MOLST forms, which are crucial for documenting residents' wishes regarding life-sustaining treatments, including CPR. The annual survey identified non-compliance due to the absence of a system to properly void outdated MOLST forms, ensuring only one active form per resident in their electronic health record. The Medical Director was aware of these concerns but did not communicate them effectively to the facility's quality assurance and performance improvement (QUAPI) program. Consequently, the issue was not discussed or addressed in QUAPI meetings, which focused on other concerns such as pressure ulcer reduction and re-hospitalization. Further investigation revealed that the Medical Director did not attend three consecutive QUAPI meetings, and no substitute was present to address the MOLST concerns. Despite being informed of the issue, the Facility Administrator and Director of Nursing were unaware of the MOLST-related deficiencies until the survey. This lack of communication and oversight contributed to the facility's failure to ensure that residents' resuscitative wishes were accurately recorded and managed, potentially affecting all residents in the facility.
Absence of Medical Director in QA Meetings
Penalty
Summary
The facility failed to establish a quality assurance committee that included a medical director at every quarterly meeting. Upon review of the attendance sheets from September 2023 through August 2024, it was found that the medical director did not attend the quality assurance committee meetings in May, June, and July 2024. This absence was confirmed by the Facility Administrator (NHA) during an interview, who also reported that there was no substitute medical director present at these meetings. This resulted in the facility not meeting the requirement of having a medical director present at each quarterly meeting.
Lack of Communication Training for Staff
Penalty
Summary
The facility failed to ensure that staff received training in interpersonal communication, as evidenced by a review of training records during an extended survey. This deficiency was identified for nine out of ten staff members whose records were reviewed, including the Nursing Home Administrator, Director of Nursing, Assistant Director of Nursing, two Social Workers, the Director of Rehabilitation, two Unit Managers, and two LPN nursing supervisors. The lack of communication training was discovered during an extended survey triggered by an Immediate Jeopardy situation related to conflicting Medical Orders for Life Sustaining Treatment (MOLST) and resuscitation code status documents in resident records. The Director of Human Resources was unable to provide evidence of communication training for these staff members, and the Nursing Home Administrator acknowledged the finding during an interview.
Failure to Develop Comprehensive Care Plan for Resident on Psychotropic Medication
Penalty
Summary
The facility staff failed to develop and implement a comprehensive, resident-centered care plan for a resident receiving psychotropic medications. The resident, who was admitted at the end of June 2024, had a diagnosis of depression and was prescribed Escitalopram Oxalate (Lexapro), an antidepressant, to be taken once daily. The medication was administered consistently from the beginning of September 2024 until mid-September 2024. However, the care plan for this resident, initiated in mid-August 2024, was not comprehensive and did not include specific details about the resident's behaviors for which the psychotropic medication was prescribed. The care plan lacked measurable goals and interventions, including non-pharmaceutical interventions, to assist the resident with their behaviors. The existing care plan only included general interventions such as administering medications as ordered, physician review of medications as needed, and removing the resident from the environment. The Director of Nurses was informed of these concerns but did not provide any comments at the time.
Failure to Honor Resident's Right to Self-Determination in Code Status Confirmation
Penalty
Summary
The facility failed to honor a resident's right to self-determination, specifically regarding the Medical Orders for Life Sustaining Treatments (MOLST) documentation. During an Immediate Jeopardy investigation, it was found that there were conflicting resuscitation instructions for a resident, prompting an audit of all residents' code status choices. The audit revealed that a resident, who was determined by the Medical Director to have the capacity to make decisions, had their code status confirmed through a family member rather than directly with the resident. The documentation showed that the Regional Social Work Director contacted the resident's family to confirm the code status, but did not specify which family member was contacted, despite the resident having two listed family members. The Medical Director confirmed that the resident should have been asked directly about their code status choice, and there was no evidence that this was done. This oversight in confirming the resident's code status choice directly with the resident, despite their capacity to make decisions, led to the deficiency.
Deficiencies in Facility Maintenance and Housekeeping
Penalty
Summary
The facility failed to maintain a safe, clean, comfortable, and homelike environment, as evidenced by multiple deficiencies observed by surveyors. On both floors of the nursing facility, the carpet in the hallways was stained, and several rooms had missing or loose floor planks, particularly around HVAC units. Despite the Maintenance Director's acknowledgment of the flooring issues and a plan to address them, no documentation was provided to indicate that new carpets or flooring had been ordered by the time of the survey exit. Additionally, the facility's housekeeping practices were found lacking. Surveyors observed holes in bed linens and a lack of appropriately sized sheets for bariatric beds, with the Housekeeping Supervisor confirming issues with laundry processes. Resident complaints about room cleaning delays and observations of unclean conditions, such as brown smudges on walls and damaged furniture, further highlighted the inadequacies in maintaining a clean environment. The Housekeeping Supervisor acknowledged these issues but indicated that some maintenance concerns had not been reported to her. The facility also exhibited maintenance deficiencies, including damaged walls, missing emergency call light cords, and cracked wheelchair padding. Observations of ceiling tiles with brown stains and damaged shower room flooring were noted, with the Maintenance Director attributing some issues to condensation from the air conditioner. Despite staff acknowledging these problems, there was a lack of evidence that corrective actions had been initiated or completed by the survey's conclusion.
Failure to Provide Adequate Resident Activities
Penalty
Summary
The facility failed to provide adequate activities to meet the needs of its residents, as evidenced by the cases of four residents during the survey. Resident #30, who has severe cognitive impairment and a history of major depressive disorder and dementia, was observed alone in a wheelchair without any music or activity. The resident's care plan indicated a preference for group activities and 1:1 activities, but there was no documentation of participation in these activities or any interdisciplinary care plan meetings since October 2023. The Activity Director was unable to provide documentation of activity participation, except for a single 1:1 visit documented in April 2024. Resident #95, diagnosed with dementia and lung disease, was observed sitting alone in a wheelchair in the hallway on multiple occasions. The resident's care plan, which had not been updated since August 2023, failed to reflect the resident's preference for listening to music and participating in religious activities. The Activity Director could not provide documentation of the resident's participation in activities or 1:1 visits, and the resident's responsible party confirmed the lack of recent care plan meetings. Resident #13, with diagnoses including dementia, heart disease, and diabetes, was not documented to have participated in any activities, despite a care plan indicating a preference for group activities and religious services. The Activity Director could not locate documentation of 1:1 activities for this resident. Similarly, Resident #109, a long-term resident, reported a lack of interaction with staff and had no documented 1:1 activities since admission. The Activity Director admitted to not interviewing the resident's family to obtain information about activity preferences, despite their frequent visits.
Deficiencies in Pain Management for Residents
Penalty
Summary
The facility failed to provide adequate pain management for three residents, leading to deficiencies in care. Resident #31 did not receive their prescribed oxycodone medication consistently due to issues with pharmacy delivery and insurance coverage. The medication was administered only 42 out of 62 scheduled times, with no documentation explaining the missed doses. Both the LPN and the DON acknowledged the problem, citing insurance issues as the reason for the delay in medication delivery. Resident #57, who had a sacral ulcer, did not have any active pain medication orders despite experiencing pain. The resident's pain was documented by a Certified Medicine Aide, which is against the facility's protocol as pain assessment should be conducted by a licensed nurse. The DON confirmed that the CMA should not have documented pain monitoring, and the Medical Director was unaware of the lack of pain medication orders for the resident. Resident #50 expressed the importance of timely pain medication administration to manage their pain effectively. However, the facility failed to implement non-pharmacological interventions before administering pain medication, as required by their policy. Additionally, the resident's narcotic pain medication was administered late on multiple occasions, with discrepancies in documentation noted by the LPN responsible. The DON acknowledged these concerns, highlighting a lack of adherence to the facility's pain management policy.
Deficiencies in Bed Rail Use and Documentation
Penalty
Summary
The facility failed to ensure proper procedures were followed before the installation and use of bed rails for four residents. Observations and medical record reviews revealed that the facility did not identify and use appropriate alternatives to bed rails, assess the residents' risk of injury or entrapment, or discuss the risks and benefits of bed rails with the residents or their representatives. Additionally, informed consent was not obtained, and there was no documentation of monitoring and supervision during the use of bed rails. Care plans with measurable objectives and specific interventions for the use of bed rails were also not developed for these residents. For Resident #78, the medical record indicated that bed rails were not needed as a mobility enabler, yet they were installed without a physician's order or documentation of risk assessment and informed consent. Similarly, Resident #380's records showed no need for bed rails as a mobility enabler, but they were used without proper documentation or consent. Resident #13, who had severe cognitive impairment, had a bed rail installed based on preference, but there was no documentation of a risk-benefit discussion or a care plan. The facility also failed to assess the risk of entrapment for this resident. Resident #57 was observed with a loose bed rail, which was acknowledged by an LPN and the Maintenance Director, who was unaware of the issue despite regular checks. The Director of Nursing was also unaware of the loose bed rail and could not provide additional evidence to address the observation. These deficiencies highlight a lack of adherence to protocols for bed rail use, posing potential safety risks to residents.
Failure to Adhere to Medication Administration Parameters
Penalty
Summary
The facility failed to maintain a resident's drug regimen free from unnecessary drugs by not adhering to physician-ordered blood pressure parameters for medication administration. For Resident #78, the facility did not document blood pressure monitoring before administering Oxycontin, nor did it assess the resident's pain level or the medication's effectiveness. Additionally, Midodrine was administered without documenting blood pressure checks to ensure it was within the prescribed parameters. These issues were discussed with the Director of Nurses, who did not provide a response. For Resident #380, the facility did not provide adequate parameters for administering as-needed pain medications. The orders for Acetaminophen and Percocet lacked guidance on which medication to administer first for pain management. This concern was acknowledged by the Director of Nurses without further comments. Similarly, Resident #24 received a diuretic despite having a systolic blood pressure below the threshold specified in the physician's order, and Resident #50 was given a narcotic pain medication despite having a pain score of zero. Furthermore, the facility did not ensure that the attending provider's orders for Resident #78's topical anesthetic medication included a time for removal. The Lidocaine patch was applied daily without documentation of its removal, as the order did not specify a removal time. This oversight was confirmed by the Director of Nursing, who acknowledged the lack of documentation for the patch's removal.
Failure to Serve Correct Meal Portions and Items
Penalty
Summary
The facility failed to provide residents with the correct portions and items as indicated on their meal tickets, which was evident during a survey. On a specific date, a resident reported not consistently receiving a high protein diet as advised by their physician. During an observation of the tray line, it was noted that a 1/2 cup scoop was used for portions, except for the beef pepper steak, which was served using tongs by a staff member who claimed the portion was three ounces. This practice was not in line with the expected use of a scoop for portion control. A test tray was randomly selected from the food cart, and discrepancies were found between the meal ticket and the actual items on the tray. The meal ticket for a resident indicated specific items, including a grilled cheese sandwich, sugar snap peas, mashed potatoes, a dinner roll, margarine, tossed salad with dressing, chocolate pudding parfait, and hot tea. However, the test tray had only half a cup of sugar snap peas, no dinner roll, and a chocolate cream pie instead of the chocolate pudding parfait. The Food Service Director confirmed these discrepancies and acknowledged the use of incorrect portion sizes and items.
Failure to Conduct Regular Bed Safety Inspections
Penalty
Summary
The facility failed to conduct regular inspections of bed frames, mattresses, and bed rails, which is a part of their regular maintenance program. This deficiency was identified during observations and interviews with staff. Specifically, three residents were observed with bed rails attached to their beds, but the facility did not have a routine audit process in place to ensure the safety and proper maintenance of these items. The Maintenance Director, who had been in the position for about a year, confirmed that only one audit had been conducted, and it only included beds on the first floor. The second floor beds had not been audited, and maintenance relied on reports from nursing or housekeeping to address any issues with beds, mattresses, or side rails. The Maintenance Director also indicated that new beds purchased for the facility did not come with rails, and rails could not be added to these beds. If a bed rail broke, the facility might have a spare to replace it, but there was no proactive inspection process in place. The Director of Nurses was informed of these concerns, acknowledging the issues without further comment. The lack of regular inspections and maintenance of bed frames, mattresses, and bed rails had the potential to affect all residents, posing a risk of entrapment.
Failure to Notify HCPOA of Treatment Changes
Penalty
Summary
The facility failed to notify a resident's Health Care Power of Attorney (HCPOA) of changes in the resident's treatment, which was identified during a survey. The resident, who was admitted in June 2024 after a hospitalization, was rarely or never understood, had functional limitations in range of motion in both upper extremities, and impairment in one lower extremity. The resident was dependent on staff for activities of daily living and was receiving occupational, speech, and physical therapy. The medical record review revealed that a new medication, Metoprolol, was started on June 26, 2024, for high blood pressure, but there was no documentation indicating that the HCPOA was informed of this change. Additionally, the attending physician for the resident changed on July 1, 2024, as noted in a Medical Discharge Summary progress note. However, there was no documentation to show that the HCPOA was notified of this change in the primary care provider. The Director of Nursing reported that the healthcare organization should contact the other provider when there is a change in the primary care provider, and the prior primary care provider should inform the family of the change. The lack of documentation regarding the notification of the HCPOA about the medication and physician changes was confirmed during discussions with the Director of Nursing.
Inaccurate Assessment During Abuse Investigation
Penalty
Summary
The facility failed to prevent further potential abuse while an investigation was in progress due to an inaccurate immediate assessment of an alleged victim. The deficiency was identified in a resident who had been in the facility for 20 days and was involved in a facility-reported incident of alleged abuse. The Director of Nursing (DON) conducted a pain assessment, which inaccurately indicated that the resident had no pain in the last five days, despite the resident receiving as-needed pain medication with pain scores ranging from 4/10 to 10/10 during that period. Additionally, the assessment inaccurately documented that the resident had not received rehabilitation services in the past five days, although the Director of Rehab confirmed that the resident was on their caseload for four weeks. The DON and the Nursing Home Administrator acknowledged the inaccuracies in the documentation, which included the failure to specify that the assessment focused solely on the resident's shoulder. These inaccuracies in the immediate assessment of the alleged victim contributed to the facility's failure to prevent further potential abuse.
Failure to Document Communication Needs During Resident Transfer
Penalty
Summary
The facility failed to provide essential information to emergency department staff when a resident was transferred to the hospital. Specifically, the transfer form for a resident who was experiencing abdominal pain and required an emergency room transfer did not include critical information about the resident's communication needs. The resident, who was deaf, had a device for ASL interpretation, but this was not documented on the transfer form completed by an LPN. This omission was discovered during a review of the resident's medical records and confirmed through interviews with the LPN and the Director of Nursing. The deficiency was identified during a recertification survey, where it was noted that the section of the transfer form regarding the resident's communication needs was left blank. Despite the presence of a sign above the resident's bed indicating the need for an ASL interpreter device, this information was not conveyed to the hospital staff. The Director of Nursing was unable to provide any additional evidence that the hospital staff were informed of the resident's communication needs, highlighting a lapse in the facility's protocol for ensuring comprehensive communication during resident transfers.
Failure to Meet Communication Needs of Deaf Resident
Penalty
Summary
The facility failed to ensure that the communication needs of a deaf resident were met, as observed during a recertification survey. The resident was unable to communicate effectively with staff due to the absence of a functioning video interpreter device in their room. Although signs were posted indicating the availability of an interpreter service via a tablet, the device was not present, and the resident had no alternative means of communication, such as pen and paper, readily available. The resident's care plan did not include any strategies for communication, such as using a live video interpreter, a whiteboard, or written notes. Interviews with staff revealed that the video interpreter device had been removed from the resident's room due to technical issues, and no alternative communication methods were provided. The Director of Nursing acknowledged the resident's non-compliance with the video interpreter device but did not address why communication strategies were absent from the care plan. The Admissions Director and Assistant Admissions Director confirmed that the device had been unavailable for an extended period, contradicting their initial claim of a shorter duration. A follow-up with the software company revealed no disruptions in service, indicating a lack of proper communication support for the resident.
Failure to Administer G-Tube Feedings as Ordered and Address Weight Loss
Penalty
Summary
The facility failed to ensure that feedings via a g-tube were administered as ordered and did not establish a plan to restore oral eating for a resident with dysphagia. The resident was admitted with a g-tube for nutrition and had orders for bolus feedings of Jevity 1.5 four times a day. However, there were discrepancies in the orders and documentation, with two different enteral feed orders in effect simultaneously, leading to confusion about the actual amount of nutrition being provided. The medical record lacked documentation of the actual amount of Jevity administered during each bolus feed, and there was a significant weight loss noted for the resident, which was not addressed in a timely manner. The resident experienced a significant weight loss from 132 lbs to 125 lbs over a month, which was unfavorable and unplanned. The dietitian noted that the tube feeding was providing insufficient calories, leading to the weight loss. Despite the resident's estimated caloric needs being between 1710-2000 calories per day, the tube feeding regimen was only providing 1600 calories per day. A recommendation was made to change the tube feeding regimen to provide 2130 calories per day, but there was no documentation indicating that the weight loss was addressed by the dietitian before the recommendation was made. Further issues arose when a new g-tube order was put in place, and the resident was supposed to receive six bolus feeds per day. However, there was an order to hold the 10 AM feeding to promote oral intake, which was not reflected in the dietitian's assessment. The resident was only receiving five bolus feeds per day, contrary to the dietitian's note. The nursing staff confirmed that the 10 AM feeding was held, and the resident was receiving lunch only and bolus feeds for all other meals. The discrepancy in the number of bolus feeds being administered was not addressed in the dietitian's assessment, leading to further confusion and potential nutritional inadequacy for the resident.
Inadequate Behavioral Health Monitoring and Medication Management
Penalty
Summary
The facility failed to provide adequate behavioral health monitoring for a resident, leading to a deficiency in ensuring the resident's highest practicable mental and psychosocial well-being. The resident, who had severe cognitive impairment and diagnoses including major depressive disorder and dementia, was receiving psychiatric medications such as Seroquel and Zoloft. However, there was a lack of documentation regarding the gradual dose reduction (GDR) of Zoloft, which was discontinued without clear documentation of a planned GDR. This oversight was evident when the resident exhibited aggressive behavior, resulting in the administration of IM Haldol and Benadryl. Further investigation revealed that the facility's behavior monitoring documentation was inadequate. The Medication Administration Record (MAR) showed only check marks for each shift, indicating no behaviors of concern, despite the resident's aggressive incidents. Interviews with nursing staff confirmed that the check marks were meant to indicate the absence of behaviors, but this was not an accurate assessment of the resident's condition. The lack of proper documentation and monitoring contributed to the failure to address the resident's behavioral health needs effectively. Additionally, there were inconsistencies in the management of the resident's psychiatric medications. The resident's Seroquel dosage was increased following aggressive behavior, but this change occurred after a significant delay and without adequate documentation of the need for the increase. Similarly, the dose of Risperdal was doubled without documented justification. These actions, combined with the inadequate behavior monitoring, highlight the facility's failure to provide necessary behavioral health care and services to the resident.
Failure to Ensure Resident Involvement in Code Status Decisions
Penalty
Summary
The facility failed to ensure that residents were fully informed and involved in discussions regarding their code status when new Medical Orders for Life-Sustaining Treatment (MOLST) forms were created. This deficiency was identified in three residents during the survey. For Resident #97, the MOLST form indicated a Do Not Resuscitate (DNR) order, but the resident, who was cognitively intact, was not consulted about their wishes. Instead, the physician communicated only with the resident's representative. It was later discovered that the resident's wishes differed from those of the representative, as the resident wanted resuscitative treatment. Resident #30, who had severe cognitive impairment, had a MOLST form completed upon readmission to the facility that indicated a full code status. However, there was no documentation that the resident's Health Care Agent was contacted to discuss this change from the previous DNR status. The physician responsible for completing the MOLST did not recall the resident and indicated that a new MOLST was required for each readmission, defaulting to full code if the resident could not make decisions and no Power of Attorney was available. For Resident #23, who was rarely understood and dependent on staff for daily activities, the MOLST was completed without consulting the resident's Medical Power of Attorney, despite certifications of the resident's incapacity. The physician did not document any assessment or examination of the resident in the months leading up to the MOLST completion. The facility's Director of Nursing confirmed that the MOLST from the hospital should remain in place until updated by a practitioner, who must review it with the family if the resident is incapable of making decisions.
Failure to Ensure Resident Dignity
Penalty
Summary
The facility failed to ensure that a resident received services with dignity, as evidenced by the actions of a certified nursing assistant (CNA). During an interview with Resident #42, the resident reported that facility staff sometimes entered his room without knocking. This was confirmed during an observation when Staff #10, a CNA, entered the resident's room to deliver a lunch tray without knocking. Staff #10 later admitted during an interview that she did not knock before entering and was unaware of the requirement to do so. The issue was discussed with the Administrator and Director of Nursing, but no additional information was provided.
Failure to Provide Advance Directive Information
Penalty
Summary
The facility failed to provide residents with information to formulate an advance directive, as evidenced by the cases of three residents. Resident #37's clinical record lacked documentation related to advance directives, despite a care plan meeting discussing the resident's code status. The Director of Social Work confirmed that advance directive information was typically offered at admission but not during care plan meetings, and there was no evidence of discussions with the resident or their family regarding advance directives. Resident #24's medical records did not reveal an advance directive, although the resident was certified as having decision-making capacity. The Social Services Coordinator indicated that the Director of Social Services, who was on vacation, usually handled advance directives. A Discharge Planning Psychosocial Assessment was overdue, and the resident's family later confirmed the existence of an advance directive, but it had not been discussed with the resident prior to the surveyor's inquiry. Resident #55's electronic medical record showed no evidence of an advance directive, despite the resident being cognitively intact and having resided in the facility since 2020. The Director of Social Services confirmed the lack of documentation and discussion regarding the resident's right to formulate an advance directive. The Director of Nursing acknowledged the concerns for all three residents.
Latest citations in Maryland
Facility staff did not ensure that 2nd floor residents who could not use stairs were able to receive visitors when the only elevator was out of service for an extended period. Complaints indicated that some family members, who were themselves unable to ambulate stairs, could not visit their relatives on the 2nd floor during this time. The emergency plan directed non-ambulatory 2nd floor residents to remain on that floor unless there was an emergency and did not address how visitation would be maintained when the elevator was inoperable. The Administrator reported that visitors could use the stairs and that an emergency chair system could be used to move residents, but also stated that the chair system was not used for visitation and was unaware of any complaints, despite two having been filed.
Facility staff did not complete required quarterly smoking safety assessments for several residents identified as smokers, including some who had not been reassessed for many months and one who had never been assessed during their stay. This issue was discovered during a complaint survey after the facility’s only elevator was out of service for an extended period, affecting a group of residents on an upper floor who needed to reach a designated smoking area on a lower floor. Review of records and staff interviews, including with the DON and a unit manager, confirmed that the facility’s own practice of quarterly smoking safety assessments for smokers was not followed for half of the affected residents.
Facility staff failed to accurately code multiple MDS assessments for several residents, leading to discrepancies between MDS entries and MARs for pain management, falls, and high-risk drug classes. In several cases, scheduled pain management was coded as provided when MARs did not show daily pain medications, often because an LPN counted low-dose Aspirin ordered for cardiovascular prophylaxis or heart failure as pain medication, contrary to RAI guidance. One resident’s falls were underreported on the MDS despite two documented falls, and daily use of a topical analgesic and an antiplatelet (Aspirin) was not correctly captured. Other residents had MDS entries indicating use of hypnotic or antianxiety medications when MARs showed none, while actual antidepressant and hypoglycemic medications administered daily were omitted from Section N0415. These errors were confirmed by the involved LPNs during surveyor interviews.
Staff failed to conduct complete investigations into two residents’ abuse allegations. In one case, a resident reported that an employee poked their face and made an obscene gesture, but the investigation lacked a statement from the corporate representative who was first notified of the allegation. In another case, a resident reported that someone in blue clothing put a hand by their face and over their mouth, with a specific GNA identified as the alleged perpetrator; however, the investigation did not include statements from two GNAs who were on duty on the unit at the time of the alleged incident, despite leadership having the opportunity to ensure all relevant documents were present.
Staff failed to create person-centered care plans for two residents, one with mobility limitations and one receiving peritoneal dialysis. For the resident with mobility issues, the care plan did not address the resident’s refusal to use a Hoyer lift and preference for pivot transfers, despite therapy prohibiting pivot transfers and staff awareness of the resident’s resistance. For the resident on peritoneal dialysis, the care plan did not specify that the treatment was peritoneal dialysis, nor did it include the treatment schedule or cycle time frames; an LPN Unit Manager acknowledged using a generalized renal care plan without incorporating the specific dialysis prescription.
A resident’s medical record lacked documentation confirming that scheduled showers or bed baths were provided on multiple dates, and there was also no record of any refusals of care on those days. The DON and an LPN unit manager reported that showers were scheduled on specific shifts and that completed showers and refusals should be documented on shower/skin sheets and in the care plan, but the surveyor found gaps where no such entries existed. This resulted in incomplete ADL documentation and failure to maintain medical records according to accepted professional standards.
A resident with multiple fractures and chronic pain was receiving an opioid-based pain regimen, including PRN hydromorphone. The resident was later found unresponsive and "out of it" by an LPN, who located an order for Narcan and administered it, with the resident responding to the medication. A physician note documented an opioid overdose treated with Narcan. Review of the medical record showed no documentation that the resident’s representative was notified of this significant change in condition and emergency intervention, and staff interviews confirmed that notification likely did not occur, despite the DON’s expectation that the responsible party should have been informed.
Staff failed to follow updated wound care orders and to document an opioid overdose event and Narcan use for two residents. One resident with venous and arterial lower extremity wounds did not receive the prescribed change from oil emulsion to daily skin prep on one foot wound, and did not receive ordered skin prep on a new plantar wound for several days after the wound physician revised the treatment plan. Another resident with multiple fractures and chronic pain, receiving multiple opioid and adjunct analgesics, reportedly experienced an opioid overdose; an LPN found the resident unresponsive, located an existing Narcan order, administered Narcan, and observed the resident return to baseline, but did not complete or document a change-in-condition assessment, vital signs, or the Narcan administration in the medical record.
Surveyors substantiated a deficiency when disinfectant wipes, labeled for storage in areas inaccessible to children and not for personal cleansing, were observed sitting openly on a wire shelf in the dining room of a locked dementia unit while cognitively impaired residents waited for breakfast. A GNA and an LPN present on the unit stated that staff used the wipes to clean tables and that residents were never left alone in the dining room and had not been seen using the wipes. The ICP reported being unaware that the wipes’ placement in the dining room was a concern, and the NHA and DON stated they had not previously been informed about the issue, though the DON acknowledged understanding the concern.
A resident’s medical record showed multiple instances where Hydromorphone, a controlled narcotic, was documented as signed out and given on the Controlled Drug Administration Record but was not documented on the MAR on the same dates and times. An LPN reported signing only the narcotic sheet and not the MAR, while the DON acknowledged awareness that nurses were signing the narcotic sheet without completing the MAR, and a unit manager stated they were unaware this was occurring and that both records should be completed. The NHA and DON agreed with the surveyor’s findings after the issue was identified.
Failure to Ensure Visitation Rights During Elevator Outage
Penalty
Summary
Facility staff failed to ensure that residents residing on the 2nd floor who could not safely ambulate using stairs were able to exercise their right to have visitors when the facility’s only elevator malfunctioned. Complaint reviews showed that family members were unable to visit their relatives on the 2nd floor when the elevator was inoperative, and these family members themselves were unable to use the stairs. An incident report documented that the facility’s only elevator was malfunctioning for an extended period, from 3/28/26 to 4/23/26. During this time, residents who could not use the stairs remained on the 2nd floor, and some of their family members could not access them due to the lack of elevator service. Review of the facility’s emergency plan revealed that it instructed that 2nd floor residents who could not safely use the stairs should remain on the 2nd floor unless there was an emergency, and it did not include any provisions for maintaining visitation when the elevator was inoperable. In an interview, the Administrator stated that visitors could use the stairs to visit 2nd floor residents and that residents could be transported using an emergency chair system to meet visitors who could not use the stairs. However, the Administrator acknowledged that the emergency chair system was not used for visitation purposes during the elevator outage and reported being unaware of any complaints about the inoperative elevator, despite two complaints having been received by OHCQ. No additional documentation was provided to show a plan to support visitation for 2nd floor residents during the elevator malfunction.
Failure to Complete Required Quarterly Smoking Safety Assessments
Penalty
Summary
Facility staff failed to update smoking safety assessments at least once every three months for multiple residents identified as smokers. During a complaint survey focused on smoking safety, surveyors reviewed an incident involving the facility’s only elevator being inoperative for nearly a month, which affected residents who lived on the 2nd floor and needed to access the 1st-floor smoking area. The facility’s investigation identified a group of 10 residents on the 2nd floor who smoked and required additional accommodations to safely ambulate to the designated smoking area. Review of these residents’ medical records showed that 5 of the 10 did not receive quarterly smoking safety assessments as required by the facility’s practice. Specifically, four residents had not received a smoking assessment since May 2025, and one resident had no documented smoking assessment at any time during their stay. During interviews, the Unit Manager stated that residents identified as smokers are to be assessed quarterly for smoking safety. When the surveyor pointed out the missing assessments, the DON reviewed the records and confirmed that these residents had not received the required quarterly smoking assessments. This lack of timely reassessment occurred in the context of an extended elevator outage that necessitated special consideration for safe smoking access for residents residing on the 2nd floor.
Inaccurate MDS Coding for Pain Management, Falls, and High-Risk Drug Classes
Penalty
Summary
Facility staff failed to ensure that Minimum Data Set (MDS) assessments were accurately coded for multiple residents, based on medical record review and staff interviews. For one resident with cerebrovascular disease, an MDS with an Assessment Reference Date (ARD) of 3/2/26 coded Section J0100A (scheduled pain management) as "yes," but the March Medication Administration Record (MAR) did not show daily pain medication administration. An LPN stated she coded it that way because the resident received Aspirin 81 mg daily, although the physician’s order showed the Aspirin was prescribed as prophylaxis for cardiovascular events, and the RAI Manual specifies that medications not primarily intended for pain relief should not be coded as pain management. Another resident with cerebral infarction, congestive heart failure, and vascular dementia had two documented falls in progress notes between the prior assessment and the ARD of 2/4/26, but Section J1900 (number of falls since admission or prior assessment) captured only one fall. The same MDS coded Section J0100A (scheduled pain management) as "no" despite the February MAR documenting daily use of Diclofenac topical gel for pain. The MAR also showed daily Aspirin 81 mg for coronary artery disease, but Section N0415 (high-risk drug classes) did not capture the use of an antiplatelet medication. The responsible LPN confirmed missing the second fall and the Aspirin coding error. Additional residents had similar discrepancies: one resident’s MDS repeatedly coded use of hypnotic medications in Section N0415 when MARs showed no hypnotics administered, and failed to capture an antidepressant (Sertraline) that was given; the LPN reported coding Clonazepam as a hypnotic based on dual use, though reference guidelines did not classify it as such. Further inaccuracies were identified for other residents in pain management and high-risk drug class coding. One resident’s MDS with an ARD of 1/8/26 coded receipt of PRN pain medication in Section J0100A, but the January MAR showed no PRN pain medications given; a later MDS for the same resident coded use of an antianxiety medication in Section N0415, while the April MAR showed no such medication administered. Another resident with traumatic subarachnoid hemorrhage, type 2 diabetes with neuropathy, atrial fibrillation, and atherosclerotic heart disease had an MDS with an ARD of 2/3/26 that coded scheduled pain medication as "yes" and PRN pain medication as "no," although the MAR showed intermittent PRN Tylenol for pain and no daily pain medication, and also documented daily Aspirin 81 mg for heart failure and daily Rybelus for diabetes; the MDS failed to capture PRN pain use, incorrectly coded daily pain medication, and did not code hypoglycemic medication in Section N0415. Another resident with a history of stroke and right-sided hemiplegia/hemiparesis had two MDS assessments in February coded as receiving scheduled pain medication, but the February MAR did not show daily pain medication; the LPN reported coding based on daily prophylactic Aspirin 81 mg, which was not ordered for pain.
Incomplete Investigations of Resident Abuse Allegations
Penalty
Summary
Facility staff failed to complete thorough investigations of two separate resident allegations that were reported to the state agency. For the first incident, a resident alleged that on a specific date and time an employee poked two fingers into their face and showed them their middle finger. The five-day follow-up documented the allegation, but the investigation file did not clearly identify who was the first point of contact for the report. During interview, the Administrator stated that a corporate representative was initially made aware of the alleged incident, but there was no statement from this corporate representative included in the investigation file. The Administrator described their usual investigation process as interviewing involved parties, identifying and interviewing witnesses, reviewing staffing for the date of the alleged incident, and interviewing the resident’s roommate and other nearby residents if there were no direct witnesses. In the second incident, a resident reported that during a specific shift someone wearing blue put a hand by their face and over their mouth, and a particular GNA was identified as the alleged perpetrator. Review of the staffing sheet for the time of the alleged incident showed that two GNAs were working on the unit where the incident was reported to have occurred. However, the investigation file contained no statements or interviews from these two GNAs. Prior to the surveyor’s review of the investigation, the DON and a regional nurse were given the opportunity to review the investigation to ensure all necessary documents were available, yet the statements from the two GNAs remained absent. These omissions demonstrated that the facility did not conduct complete investigations into the reported allegations.
Failure to Develop Person-Centered Care Plans for Mobility and Peritoneal Dialysis Needs
Penalty
Summary
Facility staff failed to develop and implement person-centered care plans that addressed all identified needs for two residents, one with mobility limitations and one receiving peritoneal dialysis. For the resident with mobility limitations, the care plan included interventions for resistance to care and adjustment issues, but did not address the resident’s specific resistance to use of a Hoyer lift and the resident’s insistence on pivot transfers from bed to wheelchair. The Unit Manager confirmed that the resident was resistant to care, did not like the Hoyer lift, and preferred pivot transfers, but also stated that physical therapy had prohibited pivot transfers. Despite this known conflict between the resident’s preferences and therapy restrictions, the care plan lacked individualized interventions related to the resident’s resistance to the Hoyer lift and continued request for pivot transfers. For the resident receiving peritoneal dialysis, review of the electronic health record showed an order for peritoneal dialysis, but the resident’s care plans did not include a person-centered care plan specific to this treatment. The existing dialysis care plan did not specify the type of dialysis treatment being provided, did not document when the resident was scheduled to receive the treatment, and did not include time frames for the dialysis cycles. During an interview, the LPN Unit Manager stated that they do not place the dialysis prescription details into the care plan and instead use a generalized renal care plan by selecting standard items, confirming that the care plan was not individualized to the resident’s ordered peritoneal dialysis regimen.
Failure to Document Resident Showers and Refusals
Penalty
Summary
Facility staff failed to maintain complete and accurate documentation of bathing care for a resident, specifically regarding showers and refusals of showers. During a complaint survey, the surveyor requested verification that Resident #5 was receiving scheduled showers. The DON stated that the resident was scheduled for showers on the 3 pm–11 pm shift on Tuesdays and Fridays, and provided shower sheets for several dates in October and early November. However, there was no documentation to verify that the resident received a shower or bed bath on 10/17/25, 10/21/25, and 10/24/25. The DON explained that when a resident receives a shower it is documented on a skin sheet, and that refusals of showers should be documented both in the plan of care and on the shower sheet. Despite this, the surveyor did not receive any documentation indicating that the resident either received bathing care or refused showers on the missing dates. This lack of documentation showed that the facility did not safeguard resident-identifiable information and maintain medical records in accordance with accepted professional standards, as there was no record confirming whether the resident’s scheduled showers or refusals occurred on the identified dates.
Failure to Notify Responsible Party After Narcan Administration for Suspected Opioid Overdose
Penalty
Summary
The deficiency involves the facility’s failure to notify a resident’s responsible party when there was a significant change in the resident’s medical status requiring emergency medication. A complaint alleged that there was no communication with the responsible party when Narcan (naloxone) was administered to a resident for an alleged opioid overdose. Medical record review showed the resident was admitted in March 2026 with multiple fractures, including a nondisplaced zone 1 sacral fracture, a nondisplaced fracture of the posterior column of the right acetabulum, a fracture of the right pubis, and other chronic pain. The resident’s pain regimen included multiple opioids and other pain medications, including Hydromorphone 6 mg every 4 hours PRN, Hydromorphone 4 mg every 4 hours PRN, Tylenol, Lidocaine cream, Methocarbamol, Celebrex, and Gabapentin. A physician’s note dated 4/8/26 documented that the resident reportedly had an opioid overdose earlier that morning and responded well to Narcan administration by nursing, with the note listing chronic pain and opioid overdose status post Narcan. Further review of the resident’s medical record did not show any documentation that the resident’s representative was notified of this overdose event and Narcan administration. During interviews, an agency LPN stated that the resident was “out of it and not responding” during rounds, prompting the LPN to check for and then administer Narcan, after which the resident responded. Another LPN reported that Narcan was given because the resident appeared to be having an overdose and that the physician saw the resident afterward, but stated, “I don’t think anyone was notified, but should have been.” The DON also stated that she would have expected the responsible party to be notified. These findings confirmed that the facility failed to notify the resident’s responsible party of a significant change in condition and emergency treatment.
Failure to Follow Wound Care Orders and Document Narcan Administration
Penalty
Summary
Facility staff failed to provide treatment and care in accordance with professional standards and physician orders for two residents. For one resident admitted after hospitalization with acute systolic heart failure and peripheral edema, a wound physician initially ordered daily oil emulsion dressings for venous wounds on the right shin, left medial foot, and left second toe. At a follow-up assessment, the wound physician changed the treatment for the left medial foot from oil emulsion to daily skin prep and ordered daily skin prep for a newly identified arterial wound on the left plantar foot. Review of the March 2026 medication and treatment administration records showed staff did not discontinue the oil emulsion or initiate the ordered skin prep to the left medial foot, and did not administer skin prep to the left plantar foot wound from the date of the new orders until the resident was sent to the hospital. The DON confirmed that treatments were not administered per the updated wound care orders during this period. For another resident admitted with multiple pelvic and sacral fractures and chronic pain, the record showed extensive opioid and adjunct pain medication orders, and a physician note documented that the resident reportedly experienced an opioid overdose and responded well to Narcan administration by nursing. However, the medical record contained no nursing assessment of the resident at the time of the event, no documentation of the resident’s condition or vital signs, and no record of Narcan administration or the resident’s response afterward. An agency LPN reported finding the resident unresponsive or "out of it" during rounds, knowing the resident was on significant pain medications, and, after checking for an existing order, administering Narcan, after which the resident returned to baseline. The LPN acknowledged not completing or documenting a change-in-condition assessment, and both the DON and unit manager stated they would have expected an assessment and vital signs to be documented in this situation.
Disinfectant Wipes Left Accessible in Dementia Unit Dining Room
Penalty
Summary
The deficiency involves the facility’s failure to keep the environment free from accident hazards on one locked dementia unit. During a complaint survey regarding unsecured cleaning supplies and the potential for residents to use cleaning wipes for personal use, a surveyor observed disinfectant wipes stored openly on a wire shelf in the dining room of the Seagull Unit, a locked dementia unit. The product labeling on the container directed that it be stored in areas inaccessible to children and specifically stated it was not to be used as a diaper wipe or for personal cleansing and that it was not a baby wipe. At the time of the observation, residents with cognitive impairment were present in the dining room awaiting breakfast. A GNA was in the dining room with the residents during the observation, and the unit manager, an LPN, accompanied the surveyor. The surveyor expressed concern about the wipes being accessible in a public area where cognitively impaired residents were present. The LPN reported she had never seen residents use or attempt to use the wipes and stated staff used them to wipe down tables before and after meals. The GNA stated she was always present when residents were in the dining room, that residents were never left alone there, and that she had never seen a resident use a wipe. The Infection Control Nurse stated she was not aware the disinfectant wipes in the dining room were a concern because no residents had gone near them and confirmed they were intended for staff use to clean tables. The NHA and DON reported they had not been made aware of the concern with the wipes, though the DON stated she understood the concern.
Incomplete Documentation of Narcotic Administration on MAR
Penalty
Summary
The deficiency involves the facility’s failure to maintain complete and accurate medical records in accordance with accepted professional standards for one resident. Review of the resident’s April 2026 Medication Administration Record (MAR) and the Controlled Drug Administration Record showed multiple discrepancies for Hydromorphone, a narcotic medication. On several specific dates in April, the Controlled Drug Administration Record documented that Hydromorphone doses were signed out and given by licensed nursing staff at various times, but the corresponding MAR entries for those same dates and times were left blank, indicating no documentation of administration on the MAR. During interviews, an LPN stated that they sign out the medication on the narcotic sheet but do not document it on the MAR. The DON acknowledged awareness that nurses were signing off on the narcotic sheet but not on the MAR, and a unit manager reported not being aware that nurses were failing to sign the MAR when also signing the narcotic sheet, stating that documentation should occur on both records. The NHA and DON later stated they were not aware of the concern until it was identified by the surveyor and agreed with the findings. These observations and interviews demonstrate that the facility did not ensure that all medication administrations were consistently and accurately documented on the MAR for this resident.
Trusted data from CMS and state health departments
Every citation, penalty and Plan of Correction is sourced from public CMS records (latest release June 24, 2026) and official state health department websites — never guesswork.
Trusted by long-term care providers and associations.
