Lions Rehab Center
Inspection history, citations, penalties and survey trends for this long-term care facility in Cumberland, Maryland.
- Location
- 901 Seton Drive, Cumberland, Maryland 21502
- CMS Provider Number
- 215073
- Inspections on file
- 22
- Latest survey
- March 27, 2026
- Citations (last 12 mo.)
- 8
Citation history
Health deficiencies cited at Lions Rehab Center during CMS and state inspections, most recent first.
A resident with an ADL self-care deficit and a care plan requiring assistance to the toilet/commode with maximum assistance of one staff was placed in a room where the bathroom was out of order due to renovation. During an incident involving alleged abuse/neglect, a GNA reported attempting to assist the resident to the bathroom, discovering it was under construction, and instead providing a bedpan. The DON later confirmed that the bathroom was nonfunctional at admission because the floor was setting and acknowledged that a commode should have been available, indicating the resident’s toileting needs and preferences for toilet/commode use were not reasonably accommodated.
A resident who had been determined unable to make medical treatment decisions and had a designated healthcare power of attorney developed a new genital wound that was evaluated by a wound provider and documented by an RN as a change in condition. The RN recorded that the resident, described as alert and oriented, refused to allow family notification, and no notification of the responsible party occurred. In an interview, the DON acknowledged that the responsible party should have been notified of the new skin condition and required treatment.
A resident urgently requested assistance to use the toilet, stating they had been asking for help for a long time and feared wetting themselves, but the assigned GNA told the resident to go ahead and wet the bed because they were serving breakfast trays and would clean the resident later, then left without providing the requested care. When another GNA later returned to collect breakfast trays, the resident again reported needing to use the bathroom and believed they had started to wet themselves. Other residents reported that the same GNA frequently delayed or failed to return to provide promised baths and incontinence care, stated they did not have time to change residents, expressed hating their job when asked for help, and made residents feel afraid to request assistance, including during painful bathing. The coworker GNA confirmed their account, and the facility’s investigation verified the allegation of verbal abuse and neglect.
Surveyors found that the facility failed to timely revise care plans after changes in condition for two residents. One resident had new physician orders for PRN and then continuous O2 via nasal cannula, was observed on O2, yet had no care plan addressing oxygen use; the DON acknowledged the care plan should have been updated. Another resident, admitted earlier in the month, sustained a fall from bed, with an RN note indicating fall protocol was initiated; although a fall-risk care plan existed and was revised to add monitoring for medication side effects, it did not capture the actual fall or fully reflect existing risk factors. Only after a second fall was a more detailed fall-risk care plan created, documenting history of falls and multiple contributing conditions that were already present after the first fall, which the DON agreed were not captured in the earlier revision.
A resident’s coccyx wound care was not consistently ordered or documented after a change in treatment orders. An initial order directed application of skin guard ointment to both the genital area and coccyx each day and evening, but when the order was changed, it specified only the genital area and omitted the coccyx. No coccyx wound treatment was ordered or documented for several days until a new order was written to cleanse the wound, apply medi-honey, and cover with a border foam dressing. During an interview, the DON acknowledged the concern and was unable to provide additional documentation of coccyx wound care for the gap period.
A resident with increased behaviors had lorazepam changed from PRN to scheduled BID and was also started on Depakote BID for behaviors and agitation. Over several days, lorazepam doses were left blank on the MAR, indicating they were not given, while Depakote was documented as administered after an initial "not available" entry. Progress notes alternately stated that lorazepam was not given due to pharmacy and unsigned-provider-order issues and, on other entries, that it was given as ordered, yet these administrations were not reflected on the MAR. In an interview, the DON stated that the pharmacy would not release medication without a signed order and acknowledged that the medication should have been administered as ordered and properly documented.
A resident on comfort care for pain management did not receive the correct dose of morphine as ordered, with nursing staff administering only 0.25 ml instead of the prescribed 5 ml per dose over multiple administrations. Additionally, an agency LPN failed to document five administrations of the medication, as confirmed by the DON after review of records.
A resident on comfort care received incorrect doses of morphine for pain management after nursing staff administered a discontinued morphine solution multiple times, rather than the newly ordered concentration. The DON confirmed that the wrong medication was used and that the error was not prevented.
A resident's physician was not notified when doses of metoprolol were withheld due to low blood pressure or heart rate, as documented in the MAR. Review by the DON and Regional Nurse confirmed the absence of physician notification for these missed doses.
The facility did not complete a thorough investigation into an allegation of verbal abuse involving a resident. Interview statements from residents lacked interviewer names and dates, staff interviews were incomplete, and there was no list of staff present during the incident or evidence of abuse education provided to staff. The DON confirmed the investigation's deficiencies.
A resident who suffered an unwitnessed fall and fractured their left wrist had conflicting medical records filed, with duplicate documents indicating both the right and left wrist as affected. The DON and orthopedic PA could not confirm who altered the documentation, and the facility accepted the amended record without proper verification, resulting in a deficiency for failing to maintain accurate medical records.
Surveyors found that several residents did not receive prescribed medications and treatments, including pain management, diabetes care, thyroid medication, and port monitoring. The DON confirmed that these omissions occurred and that there was no documentation to show the care was provided.
A resident with a Foley catheter was found with their urine collection bag resting on the floor, contrary to the care plan instructions to keep the bag above the floor and below bladder level. The assigned GNA confirmed the situation during surveyor observation and acknowledged the bag's improper placement.
Staff failed to document complete pain assessments—including pain location, description, and use of non-pharmacological interventions—when administering PRN pain medications to two residents. Pain intensity was sometimes recorded, but other required assessment elements and interventions were missing, as confirmed by the DON.
A resident continued to receive both a 40 mg and a 20 mg daily dose of an antiulcer medication after a provider ordered a reduction to 20 mg daily, resulting in a medication error confirmed by the DON.
Staff failed to implement Enhanced Barrier Precautions (EBP) for two residents with pressure ulcers, as required by infection prevention protocols. During wound care, staff did not wear protective gowns, and there was no documentation, care plan indication, or physician order for EBP. The DON confirmed EBP should have been used for these residents.
The facility failed to monitor and document temperatures for the dishwasher and certain food items, compromising sanitation and food safety. During a GI outbreak, the dish machine log was not updated for several days, and food temperature logs lacked documentation for pureed and mechanical soft diets on three occasions.
The facility failed to ensure accurate MDS assessments for several residents, leading to discrepancies in documentation. One resident was incorrectly recorded as having natural teeth, while another's insulin use was inaccurately documented. Additionally, a resident's pressure ulcer documentation was inconsistent with available records. The DON confirmed these inaccuracies during interviews.
The facility failed to update a resident's care plan to reflect a decline in functional abilities and did not include another resident in their care plan meeting despite being off isolation. The RN responsible for care plan meetings was not informed of changes in the resident's condition, and the resident capable of making decisions was not followed up with after the meeting.
The facility failed to provide adequate assistance to residents during meals and incontinence care, as evidenced by missing documentation and interviews with the DON. Several residents requiring extensive assistance with eating had missing documentation for meal assistance on multiple days. Additionally, residents needing incontinence care were found in soiled briefs or reported being left soiled, with documentation confirming a lack of care on specific days. These deficiencies were confirmed through interviews and documentation reviews.
The facility failed to document and manage pain effectively for residents, including a resident with chronic pain and another with a crushing injury. PRN pain medications were administered without proper documentation of pain assessments or non-pharmacological interventions (NPIs) as required by the facility's policy. The DON acknowledged the lack of documentation and confirmed that NPIs should precede medication.
The facility failed to ensure the dignity of two residents with urinary catheters by not using privacy bags for their urine collection bags. Observations showed the bags were visible from the hallway, and staff acknowledged the issue.
A facility failed to provide a resident with quarterly statements of their personal funds account, despite the resident being capable of making their own decisions. The BOM admitted to only providing copies upon request, leading to the deficiency as the resident had not received a written statement for a year.
A facility failed to inform a resident of their right to formulate an advance directive. The resident, capable of making decisions, had no documentation of being informed about this right. The nurse manager, acting as the social services designee, only asked if residents had existing directives and did not discuss creating one if they did not. This occurred after the facility lost their social worker, and the nurse manager assumed additional duties.
A facility failed to notify a physician when a resident's Metoprolol was held multiple times due to low systolic blood pressure (SBP) and heart rate, as per the medication order for cardiomyopathy. Despite the order to hold the medication if the pulse was below 60 or SBP was below 100, the physician was not informed of these instances, as confirmed by the primary care physician. The deficiency was identified during a surveyor's review of the April 2024 MAR and discussed with the DON.
A facility failed to include catheter care in a resident's comprehensive care plan, despite physician orders and completed care documented in the Treatment Administration Record. The DON acknowledged the omission after reviewing the care plan.
A facility failed to adhere to a physician's orders for a resident with CHF, who required daily weights to manage fluid volume imbalance. The resident refused daily weights, and the physician agreed to change the order to weekly weights. However, the facility did not document this change, and the medical record incorrectly showed an order for monthly weights. The ADON confirmed the lack of documentation, and the physician later stated the order should have been for weekly weights.
A resident identified as a fall risk was repeatedly observed without the fall mat properly placed as per their care plan. Despite being at risk for falls, the fall mat was found folded and not in use on multiple occasions. A GNA acknowledged the oversight and corrected the placement after being prompted. The DON was informed of the issue.
Two residents in the facility were found to have inadequate catheter care. One resident's urine collection bag was observed on the floor, and their medical record lacked complete documentation of catheter size and balloon fluid amount. Another resident's Foley bag was repeatedly observed on the floor, despite staff acknowledging it should not be there. The DON was informed of these issues, which could lead to infection risks.
A resident's care was not properly overseen, as necessary A1C and TSH blood work were not completed in 2024 despite the attending provider's notes indicating the need for these tests. The facility lacked documentation of these tests being ordered or completed, and interviews revealed a lack of awareness and oversight regarding the resident's blood work orders.
The facility failed to ensure complete, accurate, and timely physician documentation for two residents. One resident's attending provider's notes were not part of the medical record and inaccurately reported stable blood sugar levels without testing. Another resident's medical record lacked documentation from the primary care provider for 2024, with no goal range for PT/INR results noted. Both cases involved late signing of notes, highlighting deficiencies in maintaining accurate medical records.
The facility failed to ensure nursing staff competency, as two RNs lacked competency evaluations. RN #19, hired in August 2024, and RN #3, an agency staff member since May 2023, had no records of evaluations. This was identified during a recertification survey, and the DON acknowledged the deficiency.
The facility was found deficient for not having a full-time Director of Nursing (DON) during a survey. The DON was also serving as the only Infection Preventionist (IP) nurse, which prevented her from fulfilling the full-time DON role. This dual role was acknowledged by the facility's administration as a concern, potentially impacting all residents, staff, and visitors.
A facility failed to ensure timely review and action on a pharmacist's medication regimen recommendation for a resident. The pharmacist suggested changing an antifungal cream to a barrier cream in May, but the attending physician did not sign off until September, and the change was not implemented until December. The facility's policy lacked a clear timeframe for addressing such recommendations.
Two residents received medications outside of prescribed parameters. One resident was given Morphine without documented pain levels, and another received Metoprolol and Spironolactone despite low blood pressure readings. The DON confirmed these findings.
The facility failed to properly document narcotic reconciliation, store medications according to standards, and ensure medications were not left unattended. A narcotic record book was incorrectly signed, expired medications were found in two medication carts, and an inhaler was not dated when opened. Additionally, a resident's medications were left at the bedside without a process to ensure they were taken. The DON acknowledged these issues.
The facility was found deficient in employing a qualified dietary staff, as the Director of Food Services is not yet certified and is currently enrolled in school to obtain the necessary credentials. The Clinical Dietitian, working remotely, confirmed her role does not include managing or supervising the kitchen.
The facility failed to employ a qualified social worker, monitor employee health status, provide the required bedside care hours, and ensure the Quality Assurance committee had the necessary members. The absence of a licensed social worker led to unqualified staff performing social work duties. Employee health records were incomplete, lacking necessary immunizations and TB tests. The facility also did not meet the required bedside care hours for 27 out of 60 days, and the Quality Assurance committee lacked attendance from key members.
The facility failed to maintain accurate and legible medical records for three residents. Medications were documented as administered without confirming ingestion, a change in condition note lacked physician response, and handwritten notes were illegible. These issues highlight deficiencies in record-keeping practices.
A facility failed to properly disinfect a glucometer between resident uses, risking the spread of infections. A nurse used the device on a resident without cleaning it and attempted to use it on another without disinfection. The DON, also the infection preventionist, was unsure of the correct disinfectant, which should have been Super Sani-Germicidal or Bleach Germicidal wipes, not alcohol wipes. Additionally, the facility's IPCP policies for Pneumonia, Influenza, and COVID-19 were outdated, not reviewed annually as required.
The facility failed to provide the 2024-2025 COVID-19 vaccine to five residents and four staff members. Despite requests from some residents, there was no documentation of the vaccine being administered or refused. The DON confirmed the lack of vaccination and was unable to provide necessary records, indicating a lapse in the facility's vaccination protocol.
A resident, dependent on staff for mobility and toileting, had their call device repeatedly placed out of reach, despite a care plan emphasizing its accessibility. The DON was aware of the issue and had conducted staff education, but the problem persisted, as observed by both an RN and a GNA who found the device on the roommate's nightstand or floor, confirming the deficiency.
A resident reported stolen items and suspected a staff member, but the facility failed to log the grievance or report the allegation to the state agency as required by their abuse policy. The NHA investigated but did not follow through with mandatory reporting, and the DON acknowledged the oversight.
A facility failed to report an alleged misappropriation of a resident's property to the Office of Health Care Quality. A resident reported stolen items and suspected a staff member, but the Nursing Home Administrator did not report the incident as required by facility policy. The Director of Nursing confirmed the failure to report to the state agency responsible for monitoring care quality.
A resident with diabetes was admitted to the facility with hospital discharge orders for insulin administration, which were not followed. The resident's blood glucose was significantly elevated, and the facility failed to administer Insulin Lispro as prescribed. The DON acknowledged the oversight and confirmed that the insulin order was not entered into the system correctly.
A resident admitted with a sacral ulcer did not receive adequate care as the facility failed to follow treatment recommendations. The resident's protein supplement was administered less frequently than ordered, and a heel wound was not documented upon admission. The sacral wound worsened due to insufficient dressing changes, highlighting a lack of adherence to prescribed wound care protocols.
Failure to Provide Commode When Bathroom Was Out of Order
Penalty
Summary
Failure to reasonably accommodate a resident’s toileting needs occurred when a resident with an ADL self-care deficit and a care plan intervention requiring assistance to the toilet/commode with maximum assistance of one staff was admitted to a room whose bathroom was out of order due to recent floor renovation. During review of a facility-reported incident alleging abuse/neglect, a GNA documented that while attempting to assist this resident to the bathroom, it was discovered that the resident’s bathroom was under construction, and a bedpan was provided instead. The care plan, initiated two days after admission, specified assistance to the toilet/commode, but no commode had been made available in the resident’s room while the bathroom was nonfunctional. In an interview, the DON stated that at the time of the resident’s admission the bathroom was out of order because the floor needed time to set after renovation, and acknowledged that a commode should have been available for the resident’s use while the bathroom was out of commission. These findings, based on record review and staff interview, show that the resident’s identified need for assisted toileting to a toilet/commode was not reasonably accommodated when only a bedpan was provided in the absence of an accessible bathroom or commode.
Failure to Notify Responsible Party of Change in Condition
Penalty
Summary
The facility failed to notify a resident’s Responsible Party (RP) of a change in condition when a new wound was identified. Record review showed that the attending physician had determined on 12/5/25 that Resident #96 was unable to comprehend and make medical treatment decisions, and the resident had an advance directive naming a healthcare power of attorney. On 12/10/25, a wound provider documented a new wound on the resident’s genitalia, and RN #34 also entered a change of condition note for this new wound. In the section of the note addressing notification of the resident representative, RN #34 documented that the resident, described as alert and oriented, refused to have family notified, stating that it was their genitalia and they did not want to tell them. During an interview, the DON confirmed that the RP should have been notified when the new skin condition was found and treatment was needed. These findings, based on record review of the complaint and facility-reported incident and interviews, showed that the facility did not ensure the RP was informed of the resident’s new wound and related treatment needs, despite the resident’s documented inability to make medical treatment decisions and the presence of a designated healthcare power of attorney.
Failure to Protect Residents From Verbal Abuse and Neglect by a GNA
Penalty
Summary
The deficiency involves the facility’s failure to protect a resident from verbal abuse and neglect by a Geriatric Nursing Assistant (GNA). According to the facility’s own investigation, an allegation that a GNA verbally abused and refused to provide care to a resident was substantiated. On the morning in question, a GNA asked a coworker to assist in repositioning the resident. As they entered the room, the resident stated that they had been asking for help to use the toilet for a long time and urgently needed to urinate to avoid wetting themselves and the bed. The assigned GNA responded that they were serving breakfast trays and told the resident to go ahead and urinate in the bed, stating they would clean the resident up later. The coworker then left to return to their own assignment and, upon returning later to pick up breakfast trays, the resident again reported needing help to use the bathroom, stating they badly needed to urinate and believed they had started to wet themselves. Additional statements in the investigation file from other residents described broader concerns with how the same GNA provided care and spoke to them. One resident reported that when they asked this GNA for anything and the GNA was in a bad mood, the GNA would become upset, say they hated their job, and the resident felt scared to ask for help. Another resident stated that the GNA would offer a bath, say they would return, and then not come back until the afternoon, and also told the resident they did not have time to change them and would do it later, causing the resident to be afraid to ask for things because they would be told no. A third resident reported that the GNA would say they would be right back in the morning but would not return until after lunch even though the resident was wet and dependent on staff for help, and also reported hearing another resident yell in pain during a bath while the GNA told that resident they did not have to bathe them and could be taken off the assignment. The coworker GNA confirmed the accuracy of their statement during an interview, and the facility’s investigation concluded that the allegation of verbal abuse and neglect was verified.
Failure to Timely Revise Care Plans After Changes in Condition and Falls
Penalty
Summary
The deficiency involves the facility’s failure to review, update, and revise residents’ care plans after changes in condition. For one resident, surveyors observed the resident in bed using oxygen and later confirmed through record review that the resident had a physician’s order for PRN oxygen at 2 L/min via nasal cannula and a subsequent order for continuous oxygen every shift. Despite these orders, oxygen use was not reflected anywhere in the resident’s care plan. In an interview, the DON acknowledged that the resident was new to oxygen use and agreed that the care plan should have been updated to address oxygen usage. For another resident, the deficiency centered on incomplete and delayed care plan revisions following falls. The resident was admitted in early February and experienced a fall from bed on 2/9, documented by an RN note stating that fall protocol was initiated. A fall-risk care plan had been initiated earlier in the month, and after the 2/9 fall, an intervention was added to monitor side effects of medication; however, the actual fall event and existing risk factors were not fully captured in that revision. A later care plan, initiated after a second fall, documented that the resident was at risk for falls related to history of falls, gait and transfer dysfunctions, fatigue or weakness, new environment, impaired safety awareness/cognition loss, and unsteady gait—conditions that were already present after the first fall. In an interview, the DON confirmed that the fall care plan revised on 2/10 did not capture the actual fall and that care plans are expected to be updated as needed after such events.
Failure to Maintain Continuous Ordered Treatment for Coccyx Wound
Penalty
Summary
The facility failed to provide treatment according to a resident’s wound care orders and plan of care for a coccyx wound. Record review showed that on 12/10/25 an order was written to apply skin guard ointment to the genital area and coccyx every day and evening shift for skin healing, and this was documented as completed on the evening of 12/10/25 and the morning and afternoon of 12/11/25 before being discontinued on 12/11/25. A new order effective 12/12/25 directed staff to apply skin guard to the genital area every day and evening shift for wound healing, but this order did not include treatment to the coccyx. No other coccyx wound treatment was ordered or documented from 12/12/25 through 12/16/25. A new coccyx wound order was not written until 12/17/25, directing staff to cleanse with wound cleaner, apply medi-honey to the wound bed, and cover with a border foam dressing as needed. During an interview on 3/24/26, the DON was informed of the gap in coccyx wound care orders and documentation between 12/12/25 and 12/17/25 and stated she would look for wound care documentation; no additional documentation was provided by the time of survey exit. The deficiency involved one resident reviewed for wound care whose coccyx wound lacked ordered and documented treatment for several days following a change in the treatment orders.
Failure to Administer and Document Psychotropic Medication as Ordered
Penalty
Summary
The deficiency involves the facility’s failure to ensure medications were administered as ordered for one resident. Record review showed that this resident had a lorazepam order changed on 3/14/25 from every hour as needed to a scheduled twice-daily dose due to an increase in behaviors. On the same day, Depakote was ordered twice daily for behaviors and agitation. Review of the March 2026 MAR revealed that lorazepam doses were left blank, indicating they were not given, from the afternoon dose on 3/14/26 through the morning dose on 3/19/26, when the medication was discontinued in the afternoon. In contrast, Depakote was marked as not available only for the afternoon dose on 3/14/26 and then documented as administered as ordered on subsequent days. Progress notes documented multiple reasons for lorazepam not being given, including waiting for medication delivery on 3/16/26 and the prescription not being signed by the provider on 3/17/26 and 3/19/26. Additional progress notes on 3/17/26 at 11:36 AM and on 3/18/26 at 11:53 AM and 7:40 PM stated that lorazepam was given as ordered, but these administrations were not recorded on the MAR. During an interview, the DON explained that if a provider had not signed the medication order, the pharmacy would not release the medication, and acknowledged that the medication should have been given as ordered and that staff should have obtained the provider’s signature. No additional documentation was provided to reconcile the discrepancies between the progress notes and the MAR entries.
Failure to Accurately Dispense and Document Pain Medication Administration
Penalty
Summary
The facility failed to ensure accurate dispensing and administration of medications for a resident receiving comfort care for pain management. A physician's verbal order was given to administer 5 ml of Morphine every 3 hours and to discontinue all other medications. However, review of the narcotic count sheet revealed that nursing staff were administering only 0.25 ml per dose from the morphine solution, rather than the ordered 5 ml. This incorrect dosing occurred 22 times over a period of several days, involving multiple nurses. Additionally, documentation discrepancies were identified, as there was no evidence in the electronic medication administration record (eMAR) that the medication was administered on 5 out of the 22 occasions when it was pulled from the stock solution. All five undocumented administrations were recorded by an agency LPN. The Director of Nursing confirmed the lack of documentation for these administrations after reviewing the records and acknowledged the concern regarding the facility's failure to ensure accurate medication dispensing and administration.
Failure to Prevent Significant Medication Error in Pain Management
Penalty
Summary
The facility failed to ensure that a resident was free from significant medication errors related to pain management. The resident, who was on comfort care, was prescribed morphine for pain relief. Initially, a verbal order was given for morphine 10mg/5ml, to be administered 5ml by mouth every 3 hours. This order was later discontinued the same day, and a new order for morphine 100mg/ml, to be administered at 0.25ml every 3 hours as needed, was entered. Despite the change, both morphine solutions were delivered to the facility, and nursing staff continued to use the discontinued 10mg/5ml solution, administering 0.25ml doses from it over a period of several days. A review of narcotic count sheets confirmed that the discontinued morphine solution was used 22 times by different nurses, instead of the newly ordered concentration. The Director of Nursing acknowledged that the discontinued medication should not have been delivered and that the nursing staff should have used the correct morphine solution as per the updated order. As a result, the resident received incorrect doses of morphine for pain management, and the facility did not prevent a significant medication error.
Failure to Notify Physician When Medication Held
Penalty
Summary
The facility failed to notify a resident's physician when doses of metoprolol, a blood pressure-lowering medication, were held due to low systolic blood pressure or low heart rate. Record review showed that the medication was withheld on multiple occasions in May 2025, as documented in the Medication Administration Record (MAR), but there was no evidence that the physician was informed of these occurrences. Both the Director of Nursing and the Regional Nurse confirmed, upon review of the MAR and nursing documentation, that there was no documentation of physician notification for the held doses.
Failure to Conduct Thorough Abuse Investigation
Penalty
Summary
The facility failed to conduct a thorough investigation into an allegation of verbal abuse involving a resident. The investigation file included several resident interview statements, but none of these statements identified the interviewer or the date the interviews were conducted. Staff interview statements were also incomplete; one Geriatric Nursing Assistant (GNA) stated she was not assigned to the resident at the time, while the other did not clarify if she worked with the resident during the incident. Additionally, the investigation file did not include a list of staff who were working on the resident's unit on the day of the alleged incident, nor was there any documentation showing that abuse education was provided to staff following the event. The Director of Nursing confirmed that the investigation was not thorough.
Failure to Maintain Accurate Medical Records Following Resident Fall
Penalty
Summary
The facility failed to maintain medical records in accordance with professional standards of quality for one of seven facility-reported incidents reviewed during a complaint survey. Specifically, after a resident experienced an unwitnessed fall resulting in a left wrist fracture, the facility's investigation file contained two duplicate handwritten documents from the consultant orthopedic Physician Assistant. One document indicated the right wrist was affected, while the other indicated the left wrist, with both otherwise being identical. The presence of these conflicting documents created confusion regarding the accurate medical record for the resident's injury. Interviews with the DON and the Physician Assistant revealed uncertainty about who altered the documentation to correct the affected wrist from right to left. The DON acknowledged that the facility accepted and filed the document with the correction, despite not knowing who made the change. The Physician Assistant stated he did not amend the document or write an addendum in this case. The DON confirmed that the document was incorrectly amended and that this constituted a deficiency in maintaining accurate medical records.
Failure to Administer Ordered Medications and Treatments
Penalty
Summary
Surveyors identified that the facility failed to administer physician-ordered medications and treatments to three residents, as evidenced by a review of Medication Administration Records (MAR) and Treatment Administration Records (TAR). Specific missed medications included acetaminophen for chronic pain, levothyroxine for hypothyroidism, megestrol acetate for benign endometrial hyperplasia, and multiple scheduled doses of insulin and blood sugar checks for diabetes management. Additionally, a physician's order to maintain and monitor a chest port for signs of infection every shift was not followed for one resident. These omissions were confirmed by the Director of Nursing (DON) after a review of the records, with no documentation found to indicate the medications or treatments had been provided. The missed administrations occurred on multiple dates and shifts, affecting residents with chronic pain, diabetes, hypothyroidism, and a need for port maintenance. The surveyor discussed the findings with the DON, who acknowledged the lapses, and later with the Regional Director and Consultant RN, who were also made aware of the deficiencies. The report documents that the required medications and treatments were not given as ordered, and the necessary monitoring was not performed, as confirmed by facility leadership.
Urine Collection Bag Not Secured Off Floor for Catheterized Resident
Penalty
Summary
A deficiency was identified when a resident with a Foley catheter was observed with their urine collection bag resting on the floor while sleeping in bed. The observation was made by surveyors, and the assigned Geriatric Nursing Assistant (GNA) confirmed the resident's identity and later acknowledged that the urine collection bag was on the floor. The GNA stated she was preparing to clean the resident at the time of the observation. A review of the resident's care plan indicated specific interventions for catheter care, including maintaining the catheter tubing and bag above the floor and below the level of the bladder, ensuring the tubing was free of kinks or occlusions, and securing the catheter with a leg strap if needed. Despite these documented interventions, the urine collection bag was not properly secured, resulting in noncompliance with the care plan and facility policy.
Failure to Document Comprehensive Pain Assessments and Non-Pharmacological Interventions
Penalty
Summary
The facility failed to provide safe and appropriate pain management for residents requiring such services. Specifically, staff did not document the reasons for administering as-needed (PRN) pain medications, nor did they record comprehensive pain assessments that included the intensity, location, and description of pain. Additionally, non-pharmacological interventions (NPI) were not implemented or documented prior to administering pain medications, as required by facility policy and physician orders. For two residents reviewed, one received acetaminophen on multiple occasions with only the pain intensity recorded, lacking documentation of pain location, description, and use of NPI. Another resident was administered oxycodone and acetaminophen regularly, but the records did not consistently include pain assessments or documentation of pain characteristics and NPI. The DON confirmed that pain management should include assessment of location, intensity, description, and effectiveness, as well as the use of NPI, and acknowledged the documentation deficiencies upon review.
Failure to Discontinue Medication as Ordered
Penalty
Summary
A deficiency occurred when a resident continued to receive an antiulcer medication at a total daily dosage of 60 mg, despite the attending provider's order to reduce the dose to 20 mg daily. The pharmacist had recommended a dose reduction after reviewing the resident's medication regimen, and the provider issued a new order to decrease the medication. However, review of the Medication Administration Record (MAR) showed that the resident was administered both the original 40 mg dose and the new 20 mg dose daily, rather than discontinuing the higher dose as ordered. The DON confirmed during interview that the staff failed to discontinue the 40 mg dose, resulting in a medication error.
Failure to Implement Enhanced Barrier Precautions for Residents with Pressure Ulcers
Penalty
Summary
The facility failed to implement Enhanced Barrier Precautions (EBP) as part of its infection prevention and control program for residents with pressure ulcers. Specifically, during a wound care observation for a resident with an active wound and a history of pressure ulcers, staff did not adhere to EBP requirements by failing to wear protective gowns in addition to gloves. The medical record review for this resident did not show any physician order for EBP, nor was there documentation or care plan indication that EBP was being used or considered. Another resident requiring wound care also did not have documentation of EBP implementation or assessment in their record, and there was no signage at the resident's doorway indicating the need for EBP. The Director of Nursing confirmed that EBP should be implemented for residents with pressure ulcers and was made aware of the staff's failure to wear gowns during wound care and the lack of physician orders for EBP for both residents.
Failure to Monitor Dishwasher and Food Temperatures
Penalty
Summary
The facility failed to adequately monitor and document temperatures for both the dishwasher machine and certain food items, leading to deficiencies in sanitation and food safety. During a gastrointestinal outbreak, it was observed that the dish machine log had not been updated since January 3, 2025, indicating a lack of temperature checks for several days. This was confirmed during a kitchen tour on January 8, 2025, and discussed with the Nursing Home Administrator and the Director of Nursing. A follow-up on January 14, 2025, confirmed that the dishwasher eventually reached the required temperature of 180 degrees after several runs. Additionally, a review of food temperature logs for January 2024 revealed missing documentation for the temperatures of pureed and mechanical soft diets during dinner meals on three specific days. This was confirmed by the Regional Manager, highlighting a failure to ensure food safety standards were consistently met.
Inaccurate MDS Assessments and Documentation Errors
Penalty
Summary
The facility failed to ensure that Minimum Data Set (MDS) assessments were accurately documented and reflected the residents' status. This was evident in four residents out of 35 reviewed during the survey. For Resident #60, the MDS assessment inaccurately recorded the resident as having natural teeth, despite observations and dental assessments indicating the resident was edentulous and wore dentures. Similarly, Resident #24's MDS assessment incorrectly documented the presence of natural teeth, contrary to the resident's statement and dental records showing edentulism. Resident #64's MDS assessments inaccurately recorded insulin use, while the resident was actually receiving Ozempic injections for diabetes, which is not insulin. The Director of Nursing (DON) confirmed these inaccuracies during interviews. Additionally, the facility failed to accurately document the presence of pressure ulcers for Resident #75. The Admission MDS assessment indicated two unstageable pressure ulcers were present upon admission, based on a wound specialist's note dated four days after admission. However, there was no documentation in the hospital discharge summary, facility nursing documentation, or primary care physician notes to support the presence of a heel wound upon admission. The MDS nurse acknowledged the discrepancy during a phone interview, but no additional documentation was provided to confirm the heel ulcer was present at the time of admission.
Deficiencies in Care Planning and Resident Participation
Penalty
Summary
The facility failed to ensure that a resident participated in the care plan process and failed to revise a resident's care plan. For one resident, the comprehensive assessment indicated a decline in functional abilities, including eating, mobility, and transfers, which was not reflected in the care plan. The resident required more assistance than previously documented, but the care plan was not updated to reflect these changes. The RN responsible for scheduling care plan meetings was not informed of the changes in the resident's condition, and the care plan meeting did not address the decline in the resident's abilities. Another resident did not participate in their care plan meeting due to a gastrointestinal outbreak in the facility. Although the resident's symptoms had resolved, and they were off contact isolation, they were not included in the meeting. The nurse manager confirmed that the resident and their representative were not part of the meeting, and the resident was not followed up with afterward, despite being capable of making their own decisions. The Director of Nursing acknowledged that the resident should have been part of the meeting once they were off isolation. The facility's process for updating care plans and involving residents in their care planning was inadequate, leading to deficiencies in the care planning process for these residents.
Deficiencies in Meal Assistance and Incontinence Care
Penalty
Summary
The facility failed to provide adequate assistance to residents during meals and incontinence care, as evidenced by the lack of documentation and interviews with the Director of Nursing (DON). Resident #469, who required extensive assistance with eating, had missing documentation for meal percentages and fluid consumption for several days in May 2023. Similarly, Resident #74, who also needed extensive assistance with eating, had missing documentation for meal assistance on multiple days. Resident #270, with moderately impaired cognition, also lacked documentation for meal assistance on several days. The DON confirmed that the absence of documentation indicated a lack of care provided on those days. In addition to meal assistance deficiencies, the facility failed to provide incontinence care to residents who required it. Resident #60 was found in a soiled brief upon transfer to the emergency room, with documentation showing a lack of toileting hygiene care on specific days before the transfer. The DON confirmed that Resident #60 did not receive care the night and morning prior to the transfer. Resident #22 also reported being left soiled on certain days, and a review of complaints and documentation revealed multiple instances where toilet care was not provided. The deficiencies in providing assistance with activities of daily living (ADLs) were confirmed through interviews with the DON and reviews of documentation. The lack of documentation for meal assistance and incontinence care indicated that the necessary care was not provided to the residents, leading to the deficiencies identified during the recertification survey.
Deficiencies in Pain Management Documentation and Practices
Penalty
Summary
The facility failed to adequately document and manage pain for several residents, leading to deficiencies in pain management practices. Resident #24, who has been residing in the facility since 2015 with chronic pain conditions such as arthritis and neuropathy, received PRN pain medications without proper documentation of the reasons for administration, pain assessment details, or implementation of non-pharmacological interventions (NPIs) prior to medication. The resident's care plan required NPIs before administering PRN pain medication, but this was not followed, and the staff only provided NPIs if explicitly ordered by the attending provider. Resident #59, admitted in early 2024, was identified as having constant pain. Despite having routine and PRN orders for pain medications, there was no documentation of NPIs being attempted before administering PRN medications. The facility's policy required evaluation and documentation of NPIs before administering pain medication, but this step was not followed. The Director of Nursing acknowledged the lack of documentation and confirmed that NPIs should be the first step in pain management. Similarly, Resident #64, who suffered a crushing injury with paralysis, received PRN pain medication without documentation of NPIs being attempted beforehand. The facility's policy was again not adhered to, as the required steps for evaluating and documenting NPIs were not followed. The Director of Nursing confirmed the absence of documentation for NPIs and recognized the concern, indicating that a non-medicated approach should always precede medication administration.
Failure to Maintain Privacy for Residents with Urinary Catheters
Penalty
Summary
The facility failed to maintain the dignity of residents with urinary catheters by not ensuring that urine collection bags were kept in privacy bags. This deficiency was observed in two residents. For Resident #419, multiple observations were made over several days where the foley bag was seen without a privacy cover, either on the floor or attached to the bed rail, visible from the hallway. Staff, including a Licensed Practical Nurse (LPN) and the Director of Nursing (DON), acknowledged the absence of a privacy cover during these observations. Similarly, Resident #64's urine collection bag was observed without a privacy cover during an initial tour of the facility, visible from the hallway. The Registered Nurse (RN) assigned to the unit confirmed the observation and subsequently applied a privacy bag. A review of Resident #64's medical record indicated a care plan for catheter care, which included positioning the catheter bag and tubing below the bladder level and away from the entrance room door. The Director of Nursing acknowledged the concern regarding the visibility of the urine collection bag from the hallway.
Failure to Provide Quarterly Financial Statements to Resident
Penalty
Summary
The facility failed to provide residents with quarterly statements in writing of their personal funds account managed by the facility. This deficiency was identified during a survey when a resident confirmed that they had not received a written quarterly statement of their account for a year, despite keeping money in the facility. The resident's medical record indicated that they were capable of making their own decisions, which should have ensured they received these statements. The Business Office Manager (BOM) admitted to hand-delivering quarterly statements to residents who could make their own decisions and discussing the statements with them. However, the BOM only made copies for residents who specifically requested them. During the survey, the BOM presented a quarterly statement for the resident, which was signed but did not confirm that a copy was provided to the resident. This oversight led to the deficiency, as the facility did not ensure that residents received their quarterly financial statements in writing as required.
Failure to Inform Resident of Advance Directive Rights
Penalty
Summary
The facility failed to inform a resident of their right to formulate an advance directive, as evidenced during a survey. The medical record review for a resident admitted in December 2024 showed that the resident was capable of making their own decisions. However, there was no documentation indicating that the resident had been informed of their right to create an advance directive or that they had one in place. The nurse manager, who was also acting as the social services designee, admitted during an interview that she only inquired if residents already had advance directives and did not discuss the option to create one if they did not. This oversight occurred after the facility lost their social worker, and the nurse manager took on additional responsibilities. The nursing home administrator expected staff to assist residents in establishing advance directives if needed, but this expectation was not met in this instance.
Failure to Notify Physician of Medication Holds
Penalty
Summary
The facility failed to notify the physician when a medication was held several times for low systolic blood pressure (SBP) in the case of Resident #44, who was being treated for cardiomyopathy with Metoprolol. The medication order specified that Metoprolol 50 mg should be administered twice daily unless the resident's pulse was less than 60 or the SBP was less than 100. Despite these parameters, the medication was held on multiple occasions in April 2024 due to low SBP or heart rate, but there was no documentation indicating that the physician was informed of these instances. The surveyor's review of the April 2024 Medication Administration Record (MAR) revealed several dates when the medication was withheld due to low SBP or heart rate, including instances on April 3, 6, 9, 10, 12, 13, 14, 16, 17, and 18. During an interview, the primary care physician confirmed that she expected to be notified via fax or phone call if medications were held due to vital signs outside of the prescribed parameters. The lack of communication with the physician regarding these medication holds was discussed with the Director of Nursing (DON) and highlighted as a deficiency in the facility's processes.
Failure to Include Catheter Care in Resident's Care Plan
Penalty
Summary
The facility failed to provide a person-centered comprehensive care plan for a resident with an indwelling Foley catheter. The deficiency was identified during a survey when it was found that the resident's comprehensive care plan did not include catheter care, despite physician orders indicating the need for maintaining a 16 French indwelling Foley catheter and providing catheter care every shift. The Treatment Administration Record showed that catheter care was being completed, but this was not reflected in the care plan. The Director of Nursing acknowledged the omission upon review of the care plan, confirming that it did not address the resident's catheter care needs.
Failure to Follow Physician's Orders for Resident Weights
Penalty
Summary
The facility failed to follow the physician's orders for monitoring the weight of a resident diagnosed with congestive heart failure (CHF). The care plan for the resident included an intervention of daily weights to manage potential fluid volume imbalance related to CHF. However, the resident refused daily weights, and the facility communicated with the physician, who agreed to change the order to weekly weights. Despite this agreement, there was no documentation in the medical record to indicate that the order was officially changed to weekly weights. Instead, the medical record showed an order for monthly weights, which was not consistent with the physician's response. The Assistant Director of Nursing confirmed the lack of documentation for the change to weekly weights, and the primary care physician later reiterated that the order should have been for weekly weights.
Failure to Properly Place Fall Mat for Resident at Risk of Falls
Penalty
Summary
The facility failed to ensure that fall mats were properly placed for a resident identified as a fall risk. Resident #10, who has been residing in the facility since 2018, was observed multiple times with the fall mat folded and not in the designated position on the left side of the bed as per the care plan. On several occasions, the resident was found in bed without the fall mat in place, despite being identified as a fall risk in the most recent evaluation dated 12/30/24. During an observation, the resident was noted to be in a precarious position with their head hanging over the side of the bed, and the fall mat was still not in place. A Geriatric Nursing Assistant (GNA #4) acknowledged the oversight and repositioned the fall mat after being prompted. The Director of Nursing was informed of the repeated failure to utilize the fall mat correctly, and they acknowledged the concern.
Inadequate Catheter Care and Documentation
Penalty
Summary
The facility failed to provide appropriate treatment and services for residents with indwelling catheters, as evidenced by observations and interviews. Resident #64 was observed with a urine collection bag lying directly on the floor, which was confirmed by RN #3. The resident's medical record lacked complete documentation regarding the catheter size and balloon fluid amount, which was only corrected after the surveyor's inquiry. LPN #5 confirmed the incomplete order and attempted to rectify it, but there was no documentation to verify the catheter size. The Assistant Director of Nursing confirmed the absence of documentation, and a statement was provided indicating an attempt to clarify the catheter size with Urology. Resident #419 was repeatedly observed with a Foley bag on the floor, despite being in bed or using a bedside table. The bag was observed on the floor multiple times over several days, and staff confirmed that it should not be on the floor. The Director of Nursing was informed of the frequent observations of the Foley bag on the floor, acknowledging that it could be a source of infection. These observations indicate a failure to maintain proper catheter care and documentation, potentially compromising resident safety.
Failure to Oversee Resident's Medical Care
Penalty
Summary
The facility failed to ensure that a resident's care was properly overseen by a physician, specifically in the management of their antidiabetic and thyroid medications. The resident, who had been living in the facility since 2015, did not have necessary A1C and TSH blood work completed in 2024, despite the attending provider's notes indicating the need for these tests. The provider's notes from June, July, and August 2024 mentioned the requirement for A1C blood work, but there was no documentation of these tests being ordered or completed. Interviews with the Director of Nursing and the medical director revealed a lack of awareness and oversight regarding the resident's blood work orders. The attending provider admitted to missing the orders for the resident's blood work and acknowledged the oversight in managing the resident's care. This deficiency was evident in the lack of documentation and follow-through on necessary medical tests for the resident, which were crucial for monitoring their health condition.
Incomplete and Inaccurate Physician Documentation for Two Residents
Penalty
Summary
The facility failed to ensure that physician's notes were complete, accurate, signed, and dated at each visit for two residents. For Resident #24, the attending provider's visit notes from January to December 2024 were not part of the medical record at the time of the survey. Although the resident received regular visits from the attending provider, the progress notes were not signed at each visit and were only completed on January 12, 2025. Additionally, the notes inaccurately stated that the resident's blood sugar levels were stable, despite no orders or tests being conducted to verify this information. The attending provider admitted to documenting based on staff reports without reviewing the resident's blood sugar logs. For Resident #44, the medical record lacked documentation from the primary care provider for the entire year of 2024. The resident, who had a diagnosis of atrial fibrillation and was on Coumadin, required regular PT/INR tests, but there was no documentation of the goal range for these results in the provider's notes. The primary care physician's notes, faxed to the facility on January 14, 2025, contained lab values from before 2024 and were signed off on January 13, 2025, indicating a lack of timely and accurate documentation in the resident's medical record.
Lack of Competency Evaluations for Nursing Staff
Penalty
Summary
The facility failed to ensure that nursing staff were competent in their skill set, as evidenced by the lack of competency evaluations for two registered nurses. RN #19, who was hired in August 2024, and RN #3, an agency staff member hired in May 2023, both had no records of competency evaluations. This deficiency was identified during a recertification survey when the Director of Nursing (DON) was asked to provide competency evaluations for two randomly selected nurses. Upon review of staff documents, it was confirmed that there were no competency evaluations for these two RNs. The DON acknowledged the absence of these evaluations as a deficiency.
Deficiency in Full-Time Director of Nursing
Penalty
Summary
The facility was found to be deficient in having a Director of Nursing (DON) who worked on a full-time basis during a recertification survey. The deficiency was identified through interviews and record reviews. The DON confirmed that she was also serving as the only Infection Preventionist (IP) nurse, which resulted in her not being able to fulfill the role of a full-time DON. The dual role of the DON was acknowledged by the facility's administration as a concern, indicating awareness of the deficiency. This situation had the potential to impact all residents, staff, and visitors at the facility.
Delayed Response to Pharmacist's Medication Review
Penalty
Summary
The facility failed to ensure that irregularities identified by the pharmacist during the monthly Medication Regimen Review (MRR) were reviewed and acted upon in a timely manner by the attending physician. This deficiency was observed in the case of a resident who had been residing in the facility since 2015 and was receiving multiple medications, including an antifungal cream for moisture-associated skin damage. The pharmacist recommended on 5/21/2024 that the antifungal cream be reviewed for possible change to a barrier cream, in line with the antibiotic stewardship program. However, the attending physician did not sign off on this recommendation until 9/25/2024, and the change in medication was not implemented until 12/11/2024. The facility's policy and procedure for MRR were found to be inadequate as they did not specify a timeframe for the attending physician to address the MRR recommendations. Although the Director of Nursing (DON) reported that the regional office advised that MRRs should be addressed within 30 days, the delay in addressing the pharmacist's recommendation for the resident's medication change exceeded this timeframe. The DON confirmed that the facility did not receive the signed report from the attending provider's office until 12/11/2024, which contributed to the delay in implementing the new order.
Failure to Adhere to Medication Administration Parameters
Penalty
Summary
The facility failed to ensure that residents' drug regimens were free from unnecessary medications, as evidenced by the administration of medications outside of prescribed parameters. Resident #59, who had been residing in the facility since early 2024, was observed to be in discomfort and declined an interview due to not feeling well. The resident had orders for Morphine Sulfate to be administered as needed for severe pain, with specific instructions for administration prior to dressing changes. However, the resident received Morphine on several occasions without documentation of the pain level, including an instance where it was administered for a pain level of 3, which was outside the prescribed parameters. The Director of Nursing (DON) confirmed these findings upon review. Additionally, Resident #44 had an order for Metoprolol to be held if the pulse was less than 60 or systolic blood pressure was less than 100. Despite this, the medication was administered when the resident's blood pressure was below the specified threshold on two occasions. Furthermore, Spironolactone was also administered when the resident's blood pressure was below the ordered parameter. The surveyor discussed these concerns with the DON, who was unable to provide additional documentation or information before the survey exit.
Medication Management Deficiencies
Penalty
Summary
The facility failed to accurately document the reconciliation of controlled medications and store medications according to professional standards. During an observation, a narcotic record book was found on a medication cart with a nurse's signature in the space designated for a later shift, indicating an incorrect documentation of the narcotic count. The Director of Nursing confirmed that the signature was incorrect as it was placed before the actual transfer of narcotics to another nurse. The facility's policy requires that both the oncoming and outgoing nurses count the narcotics together and document the count, which was not adhered to in this instance. Additionally, expired medications were found in two medication carts during inspections. The medications included Allergy Relief, [NAME]-Tussin DM, Oyster shell, Fish oil, Mucus relief, Vitamin C, Dulcolax, and Aspirin, all of which were past their expiration dates. Furthermore, an inhaler for a resident was not dated when opened, contrary to the instructions that require it to be discarded six weeks after opening or when the counter reads zero. The LPNs responsible for the carts confirmed the presence of expired medications and the lack of proper documentation for the inhaler. Another issue was observed with a resident's medications being left unattended at the bedside. A plastic medicine cup with pills was found on the resident's bedside table, and the medications were documented as given in the Medication Administration Record. The LPN stated that the resident takes the medications at their discretion, and the facility lacked a process to ensure the resident takes their medications. The Director of Nursing acknowledged the need for procedures to secure the resident's medications until they are ready to take them.
Deficiency in Qualified Dietary Staff
Penalty
Summary
The facility failed to employ a qualified dietary staff, specifically in the position of Director of Food Services. During an interview, the Director of Food Services revealed that she was currently enrolled in school to obtain the necessary certification for her role, indicating that she did not yet possess the required credentials. Additionally, the Clinical Dietitian, who began working remotely with the facility, confirmed that while she interacts with the kitchen staff regarding snacks, supplements, and menus for residents, she does not manage or supervise the kitchen. The Regional Manager of Food Services acknowledged the deficiency, noting that the Director of Food Services is expected to complete her certification by July.
Deficiencies in Staffing and Health Monitoring
Penalty
Summary
The facility was found to be non-compliant with state regulations due to the absence of a qualified social worker. Since November 2024, the facility has not employed a licensed social worker, and the duties have been performed by the Administrative Nurse and the Director of Nursing (DON). Interviews with staff confirmed that there was no social worker employed or contracted to provide oversight, which is a requirement under the State of Maryland Code of Regulations. The facility also failed to monitor the relevant health status of its employees as required by state regulations. During the survey, it was discovered that several employees lacked documentation of necessary immunizations and tuberculosis (TB) tests. Specifically, a registered nurse lacked evidence of varicella immunization, another nurse lacked evidence of TB tests, and a dietary aide lacked both TB tests and Hepatitis B immunization documentation. The DON confirmed the absence of these records, indicating a failure in monitoring employee health status. Additionally, the facility did not meet the required minimum of 3 hours of bedside care per occupied bed per day for 27 out of 60 days. The DON acknowledged this deficiency and confirmed that the facility was aware of the shortfall. Furthermore, the Quality Assurance committee did not have the required members attending meetings, with the social worker, dietician, and geriatric nursing assistant missing several meetings throughout the year. This lack of attendance was acknowledged by the Chief Operating Officer and the DON, failing to meet state requirements for the committee's composition.
Deficiencies in Medical Record Accuracy and Legibility
Penalty
Summary
The facility failed to maintain complete, accurate, and legible medical records for three residents. For one resident, medications were left at the bedside, and the LPN documented them as administered when they were brought into the room, without confirming ingestion. The DON acknowledged the lack of a process to verify when the resident took the medications, and the MAR inaccurately reflected the administration time. This discrepancy was against the facility's Medication Administration Policy, which requires medications to be administered within a specific timeframe and documented post-ingestion. Another resident's medical record showed a change in condition note that lacked the physician's response and notification to the responsible party. The note was closed by the DON without this critical information. Additionally, the paper chart for a third resident contained illegible handwritten notes by the primary care physician, which even the nursing staff could not decipher. These deficiencies highlight the facility's failure to ensure medical records are complete, accurate, and legible, as required by professional standards.
Inadequate Disinfection of Glucometer and Outdated IPCP Policies
Penalty
Summary
The facility failed to ensure proper disinfection of a glucometer between uses on different residents, which is crucial to minimize the risk of spreading blood-borne pathogens. During a recertification/complaint survey, a nurse was observed using a glucometer on a resident and then placing it back in the medication cart without disinfecting it. The nurse later attempted to use the same glucometer on another resident without cleaning it first. When questioned by the surveyor, the nurse used alcohol wipes to clean the device, although the facility's policy and manufacturer guidelines specified the use of Super Sani-Germicidal Disposable wipes or Bleach Germicidal wipes for effective disinfection. The Director of Nursing (DON), who also served as the facility's infection preventionist, was initially unsure about the appropriate disinfectant and had to verify the correct procedure. Additionally, the facility did not review and update its Infection Prevention Control Program (IPCP) policies and procedures annually, as required. During the survey, the DON provided outdated policies for Pneumonia, Influenza, and COVID-19, which had not been revised since 2022 and 2021, respectively. Despite being asked to provide evidence of annual updates, the DON confirmed that the facility had not updated these policies annually, indicating a lapse in maintaining current infection control standards.
Failure to Administer COVID-19 Vaccine to Residents and Staff
Penalty
Summary
The facility failed to provide the 2024-2025 COVID-19 immunization to both residents and staff, as evidenced by the survey findings. Five residents, including Resident #3, Resident #22, Resident #63, Resident #64, and Resident #269, did not receive or refuse the COVID-19 vaccine, despite some having requested it. Interviews with residents and reviews of their health records confirmed the absence of documentation regarding the administration or refusal of the vaccine. The Director of Nursing (DON) acknowledged the lack of vaccination for these residents and was unable to provide immunization records or declination forms. Similarly, the facility did not provide the COVID-19 vaccine to four staff members, identified as Staff #3, Staff #24, Staff #25, and Staff #26. A review of their immunization records showed no evidence of the vaccine being administered or refused. The DON confirmed that these staff members neither refused nor received the vaccine, and no further immunization evidence was available. This deficiency was identified during the recertification survey, highlighting a failure in the facility's vaccination protocol for both residents and staff.
Failure to Ensure Call Device Accessibility for Resident
Penalty
Summary
The facility failed to ensure that call devices were kept within reach of a resident, specifically Resident #40, who had been residing in the facility since 2022. The resident was coded as dependent on staff for transfers and mobility and required substantial assistance for toileting hygiene, as per the Minimum Data Set (MDS) assessment. Despite having a care plan in place that emphasized the importance of keeping the call light within reach and encouraging its use for assistance, the call device was repeatedly found out of reach. On multiple occasions, the call device was observed on the roommate's nightstand or on the floor, making it inaccessible to the resident. The Director of Nursing (DON) was aware of the issue since October 2024 and had conducted staff education and random inspections to address the problem. However, the interventions were ineffective, as evidenced by the continued observations of the call device being out of reach. The Registered Nurse (RN #3) and a Geriatric Nursing Assistant (GNA #15) both confirmed the improper placement of the call device during their respective observations and took immediate action to secure it within the resident's reach. Despite these efforts, the deficiency persisted, indicating a failure in maintaining the resident's safety and ability to request assistance when needed.
Failure to Implement Abuse Policy for Misappropriation Allegation
Penalty
Summary
The facility failed to implement its abuse policy regarding the misappropriation of property for a resident who alleged theft. The resident reported that their items were stolen in December 2024 and suspected a staff member. Despite the resident filing a grievance, the facility's grievance log for December 2024 did not reflect this allegation. The Director of Nursing (DON) confirmed that the Nursing Home Administrator (NHA) investigated the allegation, but the facility's policy requiring the reporting of such allegations to the state agency was not followed. The NHA provided documents related to the investigation, including a hand-written statement from the resident and a typed witness statement. However, the NHA admitted to not reporting the misappropriation allegation to the state agency, as required by the facility's abuse policy. The DON acknowledged the facility's failure to implement their policy on abuse, neglect, mistreatment, and misappropriation of resident property, highlighting a significant oversight in handling the resident's grievance appropriately.
Failure to Report Misappropriation of Resident Property
Penalty
Summary
The facility failed to report an incident of alleged misappropriation of a resident's property to the Office of Health Care Quality (OHCQ). This deficiency was identified during interviews and record reviews, revealing that a resident reported stolen items in December 2024 and suspected a staff member. The resident had filed a grievance with the facility. Despite the facility's policy requiring either the Nursing Home Administrator (NHA) or the Director of Nursing (DON) to report such allegations to the state agency, the NHA admitted to not reporting the incident. The DON confirmed the failure to report the misappropriation to OHCQ, which is responsible for monitoring the quality of care in Maryland's healthcare facilities.
Failure to Administer Insulin on Admission
Penalty
Summary
The facility failed to ensure essential care upon admission for a resident with diabetes, as evidenced by the lack of administration of prescribed insulin. Upon review, it was found that the resident's blood glucose level was significantly elevated at 361.0 mg/dL on the evening of their admission. The hospital discharge orders included specific instructions for insulin administration, which were not followed by the facility. The Medication Administration Record (MAR) lacked documentation of the administration of Insulin Lispro on the day of admission, despite the resident having received Insulin Glargine earlier that morning before transfer. Interviews with the Director of Nursing (DON) revealed that the facility did not correctly enter the insulin orders into their system, resulting in the omission of necessary medication. The DON acknowledged the oversight and stated that the expectation was for the nurse to contact the doctor if the blood glucose level exceeded 300 mg/dL. However, this protocol was not followed, leading to a failure in providing the required diabetic management for the resident upon admission.
Failure to Provide Adequate Pressure Ulcer Care
Penalty
Summary
The facility failed to provide necessary treatment and services to promote the healing of pressure ulcers for a resident who was admitted with a sacral decubitus ulcer. Upon admission, the resident required assistance with movement and was incontinent of bowel, which increased the risk of skin breakdown. Despite the presence of a sacral ulcer noted in the hospital transfer summary, there was no documentation of a treatment or dressing change order for the sacral ulcer until four days after admission when the resident was seen by a wound specialist. The resident was prescribed a protein supplement, ProSource, to aid in wound healing, but there was conflicting documentation regarding the frequency of administration. The supplement was ordered to be given twice daily, but the Medication Administration Record showed it was only administered once daily for over a week. Additionally, the wound specialist identified a right heel wound that was not documented upon admission, and the treatment recommendations for this wound were not followed as prescribed, with dressing changes occurring less frequently than advised. The sacral wound was documented as worsening, and the treatment recommendations for both the sacral and heel wounds were not fully implemented according to the wound specialist's instructions. The sacral wound required twice-daily dressing changes, but the Treatment Administration Record indicated it was only changed once daily. These discrepancies in care and documentation contributed to the facility's failure to provide adequate pressure ulcer care and prevent further deterioration of the resident's condition.
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Facility staff did not ensure that 2nd floor residents who could not use stairs were able to receive visitors when the only elevator was out of service for an extended period. Complaints indicated that some family members, who were themselves unable to ambulate stairs, could not visit their relatives on the 2nd floor during this time. The emergency plan directed non-ambulatory 2nd floor residents to remain on that floor unless there was an emergency and did not address how visitation would be maintained when the elevator was inoperable. The Administrator reported that visitors could use the stairs and that an emergency chair system could be used to move residents, but also stated that the chair system was not used for visitation and was unaware of any complaints, despite two having been filed.
Facility staff did not complete required quarterly smoking safety assessments for several residents identified as smokers, including some who had not been reassessed for many months and one who had never been assessed during their stay. This issue was discovered during a complaint survey after the facility’s only elevator was out of service for an extended period, affecting a group of residents on an upper floor who needed to reach a designated smoking area on a lower floor. Review of records and staff interviews, including with the DON and a unit manager, confirmed that the facility’s own practice of quarterly smoking safety assessments for smokers was not followed for half of the affected residents.
Facility staff failed to accurately code multiple MDS assessments for several residents, leading to discrepancies between MDS entries and MARs for pain management, falls, and high-risk drug classes. In several cases, scheduled pain management was coded as provided when MARs did not show daily pain medications, often because an LPN counted low-dose Aspirin ordered for cardiovascular prophylaxis or heart failure as pain medication, contrary to RAI guidance. One resident’s falls were underreported on the MDS despite two documented falls, and daily use of a topical analgesic and an antiplatelet (Aspirin) was not correctly captured. Other residents had MDS entries indicating use of hypnotic or antianxiety medications when MARs showed none, while actual antidepressant and hypoglycemic medications administered daily were omitted from Section N0415. These errors were confirmed by the involved LPNs during surveyor interviews.
Staff failed to conduct complete investigations into two residents’ abuse allegations. In one case, a resident reported that an employee poked their face and made an obscene gesture, but the investigation lacked a statement from the corporate representative who was first notified of the allegation. In another case, a resident reported that someone in blue clothing put a hand by their face and over their mouth, with a specific GNA identified as the alleged perpetrator; however, the investigation did not include statements from two GNAs who were on duty on the unit at the time of the alleged incident, despite leadership having the opportunity to ensure all relevant documents were present.
Staff failed to create person-centered care plans for two residents, one with mobility limitations and one receiving peritoneal dialysis. For the resident with mobility issues, the care plan did not address the resident’s refusal to use a Hoyer lift and preference for pivot transfers, despite therapy prohibiting pivot transfers and staff awareness of the resident’s resistance. For the resident on peritoneal dialysis, the care plan did not specify that the treatment was peritoneal dialysis, nor did it include the treatment schedule or cycle time frames; an LPN Unit Manager acknowledged using a generalized renal care plan without incorporating the specific dialysis prescription.
A resident’s medical record lacked documentation confirming that scheduled showers or bed baths were provided on multiple dates, and there was also no record of any refusals of care on those days. The DON and an LPN unit manager reported that showers were scheduled on specific shifts and that completed showers and refusals should be documented on shower/skin sheets and in the care plan, but the surveyor found gaps where no such entries existed. This resulted in incomplete ADL documentation and failure to maintain medical records according to accepted professional standards.
A resident with multiple fractures and chronic pain was receiving an opioid-based pain regimen, including PRN hydromorphone. The resident was later found unresponsive and "out of it" by an LPN, who located an order for Narcan and administered it, with the resident responding to the medication. A physician note documented an opioid overdose treated with Narcan. Review of the medical record showed no documentation that the resident’s representative was notified of this significant change in condition and emergency intervention, and staff interviews confirmed that notification likely did not occur, despite the DON’s expectation that the responsible party should have been informed.
Staff failed to follow updated wound care orders and to document an opioid overdose event and Narcan use for two residents. One resident with venous and arterial lower extremity wounds did not receive the prescribed change from oil emulsion to daily skin prep on one foot wound, and did not receive ordered skin prep on a new plantar wound for several days after the wound physician revised the treatment plan. Another resident with multiple fractures and chronic pain, receiving multiple opioid and adjunct analgesics, reportedly experienced an opioid overdose; an LPN found the resident unresponsive, located an existing Narcan order, administered Narcan, and observed the resident return to baseline, but did not complete or document a change-in-condition assessment, vital signs, or the Narcan administration in the medical record.
Surveyors substantiated a deficiency when disinfectant wipes, labeled for storage in areas inaccessible to children and not for personal cleansing, were observed sitting openly on a wire shelf in the dining room of a locked dementia unit while cognitively impaired residents waited for breakfast. A GNA and an LPN present on the unit stated that staff used the wipes to clean tables and that residents were never left alone in the dining room and had not been seen using the wipes. The ICP reported being unaware that the wipes’ placement in the dining room was a concern, and the NHA and DON stated they had not previously been informed about the issue, though the DON acknowledged understanding the concern.
A resident’s medical record showed multiple instances where Hydromorphone, a controlled narcotic, was documented as signed out and given on the Controlled Drug Administration Record but was not documented on the MAR on the same dates and times. An LPN reported signing only the narcotic sheet and not the MAR, while the DON acknowledged awareness that nurses were signing the narcotic sheet without completing the MAR, and a unit manager stated they were unaware this was occurring and that both records should be completed. The NHA and DON agreed with the surveyor’s findings after the issue was identified.
Failure to Ensure Visitation Rights During Elevator Outage
Penalty
Summary
Facility staff failed to ensure that residents residing on the 2nd floor who could not safely ambulate using stairs were able to exercise their right to have visitors when the facility’s only elevator malfunctioned. Complaint reviews showed that family members were unable to visit their relatives on the 2nd floor when the elevator was inoperative, and these family members themselves were unable to use the stairs. An incident report documented that the facility’s only elevator was malfunctioning for an extended period, from 3/28/26 to 4/23/26. During this time, residents who could not use the stairs remained on the 2nd floor, and some of their family members could not access them due to the lack of elevator service. Review of the facility’s emergency plan revealed that it instructed that 2nd floor residents who could not safely use the stairs should remain on the 2nd floor unless there was an emergency, and it did not include any provisions for maintaining visitation when the elevator was inoperable. In an interview, the Administrator stated that visitors could use the stairs to visit 2nd floor residents and that residents could be transported using an emergency chair system to meet visitors who could not use the stairs. However, the Administrator acknowledged that the emergency chair system was not used for visitation purposes during the elevator outage and reported being unaware of any complaints about the inoperative elevator, despite two complaints having been received by OHCQ. No additional documentation was provided to show a plan to support visitation for 2nd floor residents during the elevator malfunction.
Failure to Complete Required Quarterly Smoking Safety Assessments
Penalty
Summary
Facility staff failed to update smoking safety assessments at least once every three months for multiple residents identified as smokers. During a complaint survey focused on smoking safety, surveyors reviewed an incident involving the facility’s only elevator being inoperative for nearly a month, which affected residents who lived on the 2nd floor and needed to access the 1st-floor smoking area. The facility’s investigation identified a group of 10 residents on the 2nd floor who smoked and required additional accommodations to safely ambulate to the designated smoking area. Review of these residents’ medical records showed that 5 of the 10 did not receive quarterly smoking safety assessments as required by the facility’s practice. Specifically, four residents had not received a smoking assessment since May 2025, and one resident had no documented smoking assessment at any time during their stay. During interviews, the Unit Manager stated that residents identified as smokers are to be assessed quarterly for smoking safety. When the surveyor pointed out the missing assessments, the DON reviewed the records and confirmed that these residents had not received the required quarterly smoking assessments. This lack of timely reassessment occurred in the context of an extended elevator outage that necessitated special consideration for safe smoking access for residents residing on the 2nd floor.
Inaccurate MDS Coding for Pain Management, Falls, and High-Risk Drug Classes
Penalty
Summary
Facility staff failed to ensure that Minimum Data Set (MDS) assessments were accurately coded for multiple residents, based on medical record review and staff interviews. For one resident with cerebrovascular disease, an MDS with an Assessment Reference Date (ARD) of 3/2/26 coded Section J0100A (scheduled pain management) as "yes," but the March Medication Administration Record (MAR) did not show daily pain medication administration. An LPN stated she coded it that way because the resident received Aspirin 81 mg daily, although the physician’s order showed the Aspirin was prescribed as prophylaxis for cardiovascular events, and the RAI Manual specifies that medications not primarily intended for pain relief should not be coded as pain management. Another resident with cerebral infarction, congestive heart failure, and vascular dementia had two documented falls in progress notes between the prior assessment and the ARD of 2/4/26, but Section J1900 (number of falls since admission or prior assessment) captured only one fall. The same MDS coded Section J0100A (scheduled pain management) as "no" despite the February MAR documenting daily use of Diclofenac topical gel for pain. The MAR also showed daily Aspirin 81 mg for coronary artery disease, but Section N0415 (high-risk drug classes) did not capture the use of an antiplatelet medication. The responsible LPN confirmed missing the second fall and the Aspirin coding error. Additional residents had similar discrepancies: one resident’s MDS repeatedly coded use of hypnotic medications in Section N0415 when MARs showed no hypnotics administered, and failed to capture an antidepressant (Sertraline) that was given; the LPN reported coding Clonazepam as a hypnotic based on dual use, though reference guidelines did not classify it as such. Further inaccuracies were identified for other residents in pain management and high-risk drug class coding. One resident’s MDS with an ARD of 1/8/26 coded receipt of PRN pain medication in Section J0100A, but the January MAR showed no PRN pain medications given; a later MDS for the same resident coded use of an antianxiety medication in Section N0415, while the April MAR showed no such medication administered. Another resident with traumatic subarachnoid hemorrhage, type 2 diabetes with neuropathy, atrial fibrillation, and atherosclerotic heart disease had an MDS with an ARD of 2/3/26 that coded scheduled pain medication as "yes" and PRN pain medication as "no," although the MAR showed intermittent PRN Tylenol for pain and no daily pain medication, and also documented daily Aspirin 81 mg for heart failure and daily Rybelus for diabetes; the MDS failed to capture PRN pain use, incorrectly coded daily pain medication, and did not code hypoglycemic medication in Section N0415. Another resident with a history of stroke and right-sided hemiplegia/hemiparesis had two MDS assessments in February coded as receiving scheduled pain medication, but the February MAR did not show daily pain medication; the LPN reported coding based on daily prophylactic Aspirin 81 mg, which was not ordered for pain.
Incomplete Investigations of Resident Abuse Allegations
Penalty
Summary
Facility staff failed to complete thorough investigations of two separate resident allegations that were reported to the state agency. For the first incident, a resident alleged that on a specific date and time an employee poked two fingers into their face and showed them their middle finger. The five-day follow-up documented the allegation, but the investigation file did not clearly identify who was the first point of contact for the report. During interview, the Administrator stated that a corporate representative was initially made aware of the alleged incident, but there was no statement from this corporate representative included in the investigation file. The Administrator described their usual investigation process as interviewing involved parties, identifying and interviewing witnesses, reviewing staffing for the date of the alleged incident, and interviewing the resident’s roommate and other nearby residents if there were no direct witnesses. In the second incident, a resident reported that during a specific shift someone wearing blue put a hand by their face and over their mouth, and a particular GNA was identified as the alleged perpetrator. Review of the staffing sheet for the time of the alleged incident showed that two GNAs were working on the unit where the incident was reported to have occurred. However, the investigation file contained no statements or interviews from these two GNAs. Prior to the surveyor’s review of the investigation, the DON and a regional nurse were given the opportunity to review the investigation to ensure all necessary documents were available, yet the statements from the two GNAs remained absent. These omissions demonstrated that the facility did not conduct complete investigations into the reported allegations.
Failure to Develop Person-Centered Care Plans for Mobility and Peritoneal Dialysis Needs
Penalty
Summary
Facility staff failed to develop and implement person-centered care plans that addressed all identified needs for two residents, one with mobility limitations and one receiving peritoneal dialysis. For the resident with mobility limitations, the care plan included interventions for resistance to care and adjustment issues, but did not address the resident’s specific resistance to use of a Hoyer lift and the resident’s insistence on pivot transfers from bed to wheelchair. The Unit Manager confirmed that the resident was resistant to care, did not like the Hoyer lift, and preferred pivot transfers, but also stated that physical therapy had prohibited pivot transfers. Despite this known conflict between the resident’s preferences and therapy restrictions, the care plan lacked individualized interventions related to the resident’s resistance to the Hoyer lift and continued request for pivot transfers. For the resident receiving peritoneal dialysis, review of the electronic health record showed an order for peritoneal dialysis, but the resident’s care plans did not include a person-centered care plan specific to this treatment. The existing dialysis care plan did not specify the type of dialysis treatment being provided, did not document when the resident was scheduled to receive the treatment, and did not include time frames for the dialysis cycles. During an interview, the LPN Unit Manager stated that they do not place the dialysis prescription details into the care plan and instead use a generalized renal care plan by selecting standard items, confirming that the care plan was not individualized to the resident’s ordered peritoneal dialysis regimen.
Failure to Document Resident Showers and Refusals
Penalty
Summary
Facility staff failed to maintain complete and accurate documentation of bathing care for a resident, specifically regarding showers and refusals of showers. During a complaint survey, the surveyor requested verification that Resident #5 was receiving scheduled showers. The DON stated that the resident was scheduled for showers on the 3 pm–11 pm shift on Tuesdays and Fridays, and provided shower sheets for several dates in October and early November. However, there was no documentation to verify that the resident received a shower or bed bath on 10/17/25, 10/21/25, and 10/24/25. The DON explained that when a resident receives a shower it is documented on a skin sheet, and that refusals of showers should be documented both in the plan of care and on the shower sheet. Despite this, the surveyor did not receive any documentation indicating that the resident either received bathing care or refused showers on the missing dates. This lack of documentation showed that the facility did not safeguard resident-identifiable information and maintain medical records in accordance with accepted professional standards, as there was no record confirming whether the resident’s scheduled showers or refusals occurred on the identified dates.
Failure to Notify Responsible Party After Narcan Administration for Suspected Opioid Overdose
Penalty
Summary
The deficiency involves the facility’s failure to notify a resident’s responsible party when there was a significant change in the resident’s medical status requiring emergency medication. A complaint alleged that there was no communication with the responsible party when Narcan (naloxone) was administered to a resident for an alleged opioid overdose. Medical record review showed the resident was admitted in March 2026 with multiple fractures, including a nondisplaced zone 1 sacral fracture, a nondisplaced fracture of the posterior column of the right acetabulum, a fracture of the right pubis, and other chronic pain. The resident’s pain regimen included multiple opioids and other pain medications, including Hydromorphone 6 mg every 4 hours PRN, Hydromorphone 4 mg every 4 hours PRN, Tylenol, Lidocaine cream, Methocarbamol, Celebrex, and Gabapentin. A physician’s note dated 4/8/26 documented that the resident reportedly had an opioid overdose earlier that morning and responded well to Narcan administration by nursing, with the note listing chronic pain and opioid overdose status post Narcan. Further review of the resident’s medical record did not show any documentation that the resident’s representative was notified of this overdose event and Narcan administration. During interviews, an agency LPN stated that the resident was “out of it and not responding” during rounds, prompting the LPN to check for and then administer Narcan, after which the resident responded. Another LPN reported that Narcan was given because the resident appeared to be having an overdose and that the physician saw the resident afterward, but stated, “I don’t think anyone was notified, but should have been.” The DON also stated that she would have expected the responsible party to be notified. These findings confirmed that the facility failed to notify the resident’s responsible party of a significant change in condition and emergency treatment.
Failure to Follow Wound Care Orders and Document Narcan Administration
Penalty
Summary
Facility staff failed to provide treatment and care in accordance with professional standards and physician orders for two residents. For one resident admitted after hospitalization with acute systolic heart failure and peripheral edema, a wound physician initially ordered daily oil emulsion dressings for venous wounds on the right shin, left medial foot, and left second toe. At a follow-up assessment, the wound physician changed the treatment for the left medial foot from oil emulsion to daily skin prep and ordered daily skin prep for a newly identified arterial wound on the left plantar foot. Review of the March 2026 medication and treatment administration records showed staff did not discontinue the oil emulsion or initiate the ordered skin prep to the left medial foot, and did not administer skin prep to the left plantar foot wound from the date of the new orders until the resident was sent to the hospital. The DON confirmed that treatments were not administered per the updated wound care orders during this period. For another resident admitted with multiple pelvic and sacral fractures and chronic pain, the record showed extensive opioid and adjunct pain medication orders, and a physician note documented that the resident reportedly experienced an opioid overdose and responded well to Narcan administration by nursing. However, the medical record contained no nursing assessment of the resident at the time of the event, no documentation of the resident’s condition or vital signs, and no record of Narcan administration or the resident’s response afterward. An agency LPN reported finding the resident unresponsive or "out of it" during rounds, knowing the resident was on significant pain medications, and, after checking for an existing order, administering Narcan, after which the resident returned to baseline. The LPN acknowledged not completing or documenting a change-in-condition assessment, and both the DON and unit manager stated they would have expected an assessment and vital signs to be documented in this situation.
Disinfectant Wipes Left Accessible in Dementia Unit Dining Room
Penalty
Summary
The deficiency involves the facility’s failure to keep the environment free from accident hazards on one locked dementia unit. During a complaint survey regarding unsecured cleaning supplies and the potential for residents to use cleaning wipes for personal use, a surveyor observed disinfectant wipes stored openly on a wire shelf in the dining room of the Seagull Unit, a locked dementia unit. The product labeling on the container directed that it be stored in areas inaccessible to children and specifically stated it was not to be used as a diaper wipe or for personal cleansing and that it was not a baby wipe. At the time of the observation, residents with cognitive impairment were present in the dining room awaiting breakfast. A GNA was in the dining room with the residents during the observation, and the unit manager, an LPN, accompanied the surveyor. The surveyor expressed concern about the wipes being accessible in a public area where cognitively impaired residents were present. The LPN reported she had never seen residents use or attempt to use the wipes and stated staff used them to wipe down tables before and after meals. The GNA stated she was always present when residents were in the dining room, that residents were never left alone there, and that she had never seen a resident use a wipe. The Infection Control Nurse stated she was not aware the disinfectant wipes in the dining room were a concern because no residents had gone near them and confirmed they were intended for staff use to clean tables. The NHA and DON reported they had not been made aware of the concern with the wipes, though the DON stated she understood the concern.
Incomplete Documentation of Narcotic Administration on MAR
Penalty
Summary
The deficiency involves the facility’s failure to maintain complete and accurate medical records in accordance with accepted professional standards for one resident. Review of the resident’s April 2026 Medication Administration Record (MAR) and the Controlled Drug Administration Record showed multiple discrepancies for Hydromorphone, a narcotic medication. On several specific dates in April, the Controlled Drug Administration Record documented that Hydromorphone doses were signed out and given by licensed nursing staff at various times, but the corresponding MAR entries for those same dates and times were left blank, indicating no documentation of administration on the MAR. During interviews, an LPN stated that they sign out the medication on the narcotic sheet but do not document it on the MAR. The DON acknowledged awareness that nurses were signing off on the narcotic sheet but not on the MAR, and a unit manager reported not being aware that nurses were failing to sign the MAR when also signing the narcotic sheet, stating that documentation should occur on both records. The NHA and DON later stated they were not aware of the concern until it was identified by the surveyor and agreed with the findings. These observations and interviews demonstrate that the facility did not ensure that all medication administrations were consistently and accurately documented on the MAR for this resident.
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