Lorien Health Systems - Columbia
Inspection history, citations, penalties and survey trends for this long-term care facility in Columbia, Maryland.
- Location
- 6334 Cedar Lane, Columbia, Maryland 21044
- CMS Provider Number
- 215112
- Inspections on file
- 19
- Latest survey
- January 14, 2026
- Citations (last 12 mo.)
- 37
Citation history
Health deficiencies cited at Lorien Health Systems - Columbia during CMS and state inspections, most recent first.
Food labeling, temperature monitoring, and tray accuracy failures were identified in the kitchen, pantries, and on a resident meal tray. Surveyors found unlabeled and undated food items, missing refrigerator/freezer and tray line temp logs, heavy frost buildup in the ice cream freezer, expired food in a pantry, and a resident tray that did not match the meal ticket. The DM and NHA acknowledged the omissions and inaccuracies.
Medication security was not maintained when a narcotic storage box holding two residents’ lorazepam was found unsecured and removable from the med refrigerator, a hospice resident had an open box of morphine left on the bedside table, and an LPN’s med cart keys were observed sitting on top of a cart in the hallway with no nursing staff immediately nearby.
Infection Control: Improper Mask Use and Hand Hygiene During Flu Outbreak. During a facility flu outbreak and community respiratory virus increase, staff were observed wearing masks below the nose or mouth, leaving resident rooms with masks improperly positioned, and failing to perform hand hygiene between resident contacts. An LPN, a GNA, a nurse, and an NP were all observed with incorrect source control use, and one LPN did not wash hands when entering or leaving two residents' rooms.
A resident experienced severe left hip pain and was sent to a hospital, where a left hip fracture of unknown origin was diagnosed. Facility records and staff interviews showed that a charge nurse and a unit manager became aware of the severe injury the following day, and the charge nurse learned of the fracture when speaking with the resident’s family. Despite this knowledge, the facility did not submit the required Facility Reported Incident to the State Agency within the mandated two-hour timeframe after learning of the injury’s severity, instead reporting it the next day.
A resident experienced severe left hip pain and was sent to a hospital, where a left hip fracture was diagnosed. The facility’s incident file contained only one on-duty staff statement and two staff email statements, with no further documented investigative steps. A charge nurse learned of the severe fracture from the family but delayed notifying the Administrator and did not initiate additional staff or resident interviews. The Administrator later reported that a unit manager withheld information about the severe injury and confirmed that no comprehensive investigation, including interviews with staff on the involved shift and residents on the same floor, was completed.
Failure to maintain resident dignity affected two residents. One resident with stroke, dysphagia, paraplegia, vascular dementia, and depression had a feeder sign posted on the wall and left there during care. Another resident who said it was very important to choose clothing was repeatedly observed in a hospital gown without shoes, despite the guardian reporting that loungewear and Velcro shoes had been provided to staff, and the resident's clothing could not be located.
Inaccurate MOLST and Missing Advance Directive Documentation: A resident with dementia and a BIMS of 10 had conflicting life-sustaining treatment documentation, including a MOLST that was not properly completed on both sides and no Advance Directive on file to verify the designated Health Care Agent or surrogate. The chart also contained inconsistent notes about the family member’s role, and the resident’s recorded wishes were contradicted by a later MOLST showing Full CPR and all life-sustaining treatments.
Bathroom Wall Repairs Not Maintained: Surveyors observed unsealed areas and a jagged hole around sink drain pipes in four resident bathroom walls. The Maintenance Director confirmed the trim ring was missing after recent plumbing work and stated the trim had not been put back on.
The facility failed to provide required written bed hold and transfer notices when residents were sent to the hospital. For three residents reviewed, records and staff interviews showed the notices were either not sent or could not be documented as sent to the resident or responsible representative, including missing email support and no copy in the chart.
A resident with severe cognitive impairment, HF, vascular dementia, DM, and ESRD received tube feedings and had a quarterly MDS with an ARD that triggered a required care plan review. The record did not show an interdisciplinary care plan meeting was scheduled or held within the required timeframe, even though SW noted a meeting would be scheduled with the guardian. The resident’s status had changed to comfort care with MOLST orders limiting treatment, but the care plan did not reflect the full comfort care status or all related orders.
Incomplete narcotic reconciliation documentation was found for two narcotic books when the on-coming LPN’s signature was missing from the controlled medication count. The required end-of-shift count by both the on-coming and out-going licensed nurses was not documented per standard practice, and the unit manager acknowledged the deficiency.
Failure to provide outdoor activity opportunities for a resident whose assessment and preferences showed that going outside was very important. The resident preferred individual activities and time outside, and although the resident later no longer needed ventilator assistance or suctioning and had no respiratory impediments to going outside, the activity record did not show any opportunity to go outside during the stay. The administrator confirmed the resident was not given that opportunity after the medical condition improved.
A resident with Type 2 DM had orders for pre-meal and bedtime blood glucose checks and Novolog with meals, but the MAR showed no documentation of a scheduled blood sugar check or insulin dose. The ADON confirmed the blank MAR entries meant the care was not signed off as completed, and there was no nursing note explaining why the ordered monitoring and insulin were not documented, even though the resident had an off-site neurology appointment that day.
Wound care for a resident with a sacral pressure ulcer did not match the physician's documented orders. An RN used Plurogel and a collagen dressing during the dressing change, while the EHR/TAR listed different wound products and no order was found for Plurogel. The wound physician later confirmed the current order should have been Col-Active Plus Ag with Betadine to the periwound, and the report noted similar documentation-versus-treatment discrepancies had been cited in a prior complaint survey.
Failure to provide ordered double portions: An underweight resident with declining wt was supposed to receive a regular diet with double portions of entree and vegetables, but surveyors found the lunch tray missing the protein and the 2 chicken salad sandwiches listed on the meal ticket. The resident confirmed the sandwiches were not received, and the dietary mgr later confirmed the resident should have gotten them.
A resident with diabetes, CHF, ESRD, and post-stroke memory deficits developed new right knee/lower extremity pain that was not documented or reported to the PCP. An RN applied Biofreeze ordered for the resident’s left arm to the knee without an order, and PRN acetaminophen was given even though the MAR showed a pain score of 0 and there was no documented rationale. The resident was later found to have an acute right tibia/fibula fracture.
Pharmacy recommendations were not effectively routed to the provider for review for a resident's admission med review. The pharmacist's review was not uploaded to the chart, the provider signature was undated, and an EKG order was not present until after surveyor intervention. The ADON stated the review had not been sent to the provider before that time and that the facility's process relied on the nurse manager to communicate pharmacy recommendations to the provider.
Incomplete Electronic Medical Record: A resident’s chart was missing the MOLST form and death certificate from the electronic record, and no hard copy record was available during the closed record review. Staff stated that all pages should be in the EHR, and the Administrator later learned the MOLST had been shredded by the floor clerk.
A resident’s arbitration agreement was signed by a family member instead of the resident, despite records showing the resident was able to understand and sign admission documents and communicate decisions. Staff described the agreement as voluntary and not binding, but the document stated in bold all-caps that signing waived the right to have claims decided in court before a judge and jury. The resident later said they did not know what an arbitration agreement was and was unaware the family member had signed it.
Three residents with significant medical conditions did not receive proper pressure ulcer care due to failures in following physician orders, incorrect documentation in the electronic medical record, and inconsistent implementation of wound care protocols. In one case, daily wound treatments were missed for nearly two weeks; in another, wound care was performed more frequently than ordered due to an eMAR error; and in a third, prescribed treatments were not initiated or matched to physician instructions, as confirmed by the DON.
Outside providers performed a debridement on a resident with dementia and a right heel DTI without obtaining consent from the resident's representative. The resident's representative was informed only of a wound assessment, not a procedure, and facility staff did not ensure consent was secured before the debridement took place.
A resident reported being roughly handled by a GNA during ADL care, and several other residents voiced similar concerns about the same staff member's behavior. The facility's investigation was incomplete, lacking interviews with residents and staff regarding the care provided by another implicated staff member, resulting in a failure to thoroughly investigate the abuse allegations.
A resident with complex medical needs, including ventilator dependence and multiple wounds, did not have their care plan updated to reflect specific interventions for heel injuries. Although weekly assessments documented deep tissue injuries and a pressure ulcer, the care plan only included general skin integrity measures and omitted details such as heel elevation, heel boots, or air mattress use. The DON acknowledged the care plan should have been revised to include these interventions.
Staff failed to provide prescribed treatments for two residents, including a resident with dermatitis who did not receive Clotrimazole as ordered for a period of time, and another resident with a diabetic foot wound who missed several days of wound care per physician orders. The DON confirmed these lapses in treatment.
Surveyors found that nursing staff failed to follow physician-ordered parameters when administering blood pressure and diabetic medications for three residents with complex medical conditions. Medications were given or withheld outside of prescribed blood pressure and heart rate thresholds, and there was no documentation of physician notification or new orders. The DON confirmed these findings and acknowledged a pattern of noncompliance on the unit.
A resident with known exit-seeking behaviors eloped from the facility after removing their wanderguard, which they had a history of doing. The resident exited through the main entrance by following a visitor and was later returned by a good Samaritan. Staff interviews revealed the resident used a makeshift cutter, possibly a plastic knife, to remove the wanderguard. The facility's failure to supervise and address the resident's behavior led to the incident being classified as Immediate Jeopardy.
The facility did not complete annual performance evaluations for five GNAs, as required. A review of personnel records showed missing evaluations, and interviews with the NHA and HR Director confirmed this deficiency.
The facility failed to prevent bare hand contact with food, maintain proper hair coverings, and ensure accurate food storage and tray line accuracy. Observations included improper food labeling, unsanitary kitchen conditions, and inadequate monitoring of dishwashing temperatures, affecting all residents.
The facility failed to provide effective communication training for its staff, as revealed during a survey. Interviews with the HR Director, DON, and CEO, along with a review of training records for several GNAs, confirmed the absence of such training in the annual plan and recent materials. Additional records provided by the President of Clinical Services also lacked evidence of effective communication training.
The facility was found to lack a Behavioral Health Training Program during a recertification survey. The Human Resources Director and other staff provided training records and materials, none of which included behavioral health training. The President of Clinical Services confirmed the absence of such a program, noting the end of a previous contract with a behavioral health company.
The facility failed to provide written notification to residents and their representatives regarding hospital transfers, affecting multiple residents. Staff interviews and medical record reviews revealed a consistent practice of verbal notification without written documentation, contrary to regulatory requirements.
The facility failed to provide written notification of the bed-hold policy to residents or their representatives upon transfer to a hospital. Staff confirmed that the policy was included in the transfer packet sent to the hospital but was not given in writing to the residents or their representatives. This deficiency was identified for four residents during a survey.
The facility failed to develop comprehensive care plans for residents, leading to deficiencies in care. A resident on dialysis had a care plan lacking critical details such as dialysis access monitoring. Another resident on psychotropic medications lacked monitoring for side effects. A resident with hand contractures had no care plan addressing the issue, and a hospice resident had no hospice care plan developed. These deficiencies were confirmed by facility staff.
The facility failed to report a resident's injury of unknown origin and an alleged abuse incident within the required timeframe. In the first case, a resident's arm fracture was not reported promptly due to a delay in recognizing the incident. In the second case, an alleged abuse incident between two residents was reported more than two days late, despite the facility's investigation finding no abuse or injury.
A facility failed to thoroughly investigate an injury of unknown origin and an elopement incident involving two residents. One resident was found with a fractured arm, but the facility did not interview other residents for additional information. Another resident eloped after cutting off a wander guard, and the facility did not document how the resident returned or address the frequent cutting of the device.
A resident with a history of elopement behaviors frequently removed their Wanderguard bracelet, leading to an elopement incident. The facility's care plans and records did not include effective interventions or behavior monitoring to address the resident's actions. Staff interviews indicated the resident used plastic knives to cut the Wanderguard, but no measures were taken to prevent this.
A resident was left undressed and without assistance for an extended period, compromising their dignity and privacy. Despite expressing a preference to be dressed, the resident was observed undressed on multiple occasions. The resident's medical records indicated dependency on staff for dressing, and the DON acknowledged the need for staff to ensure privacy and dignity during care activities.
A facility failed to maintain a safe and clean environment in a resident's bathroom, where two ceiling tiles above the shower were falling, and one was heavily discolored. The Maintenance Director suggested a possible water leak from the floor above, and the DON was unaware of the issue until informed during the survey.
The facility failed to provide baseline care plans to two residents or their representatives within 48 hours of admission, as required. Documentation was missing in the residents' records, and interviews with the DON confirmed the absence of evidence that the care plans were communicated. This deficiency was identified during an annual survey and a recertification survey.
The facility failed to update care plans for two residents after significant incidents. One resident experienced a fall requiring hospitalization, but their care plan was not revised upon return. Another resident attempted to elope, yet their care plan remained unchanged since a prior update. Staff interviews confirmed that care plans should be updated after such events, but this was not done.
A facility failed to follow medical orders for a resident with pressure injuries, including not elevating heels and not changing wound dressings daily. The resident's call bell was out of reach, and staff inconsistently used PPE despite enhanced barrier precautions. There was confusion about responsibilities for dressing changes and documentation.
The facility failed to follow physician's orders and care plans for oxygen administration, and did not maintain proper labeling and timely changing of respiratory equipment for three residents. One resident received oxygen at an incorrect rate, another had unlabeled tubing and lacked required humidification, and a third had no active medical order for humidification with an incorrect oxygen setting. Staff were unaware of the prescribed settings and failed to document and monitor the respiratory care properly.
A facility agency provider failed to timely place visit notes into a resident's medical record. A pharmacist recommended a gradual dose reduction (GDR) of Seroquel, and an agency psychiatric NP was contracted to assess the resident for safety. The NP did not assess the resident due to not finding Seroquel in the medical orders, and the visit notes were entered eight days late. The DON acknowledged this delay was not timely.
The facility failed to securely store medications, properly label multidose medications with opening dates, and consistently monitor refrigerator temperatures for medication storage. An unattended and unlocked medication cart was observed, and multiple medications lacked opening dates, confirmed by staff. Additionally, the refrigerator temperature logbook had missing entries, indicating inadequate monitoring.
The facility failed to maintain accurate medical records for two residents, leading to discrepancies in dialysis access documentation, fluid intake monitoring, and enteral feeding protocols. Staff inaccurately documented a discontinued dialysis catheter and failed to record fluid intake for a resident on fluid restriction. Another resident's records lacked specific orders for water flushes during medication administration, as outlined in an outdated enteral protocol. Staff confirmed the inaccuracies, attributing them to outdated information and lack of updates in records.
The facility failed to ensure proper use of PPE for enhanced barrier precautions and timely implementation of medical orders for a resident with pressure injuries. Staff inconsistently used PPE, and the resident and their roommate were concerned about the lack of communication. Additionally, a urine collection bag for another resident was found on the floor, violating infection control practices. These issues were identified during a recertification survey.
Facility staff failed to document that a resident or their Responsible Party received education on the Influenza vaccine before refusing it. The Infection Control Preventionist confirmed that verbal education was provided but not documented, which was acknowledged by the NHA and DON.
A resident admitted with a stage two sacral pressure wound experienced worsening to a stage 4 wound over eight weeks due to inadequate pressure ulcer management. The facility failed to provide necessary wound care treatments, and specialized care was only ordered after the wound had significantly deteriorated. The DON acknowledged the deficiency in managing the resident's condition.
The facility failed to ensure proper monitoring of psychotropic medication use for residents, leading to unnecessary medication administration. A resident was prescribed psychotropic medications without comprehensive monitoring, and another resident had active orders for such medications without side effect or behavior monitoring. Additionally, a delay in implementing a recommended gradual dose reduction for a resident's medication was noted due to an oversight by an agency psychiatric NP.
The facility failed to provide timely dental services for two residents. One resident had a dental consult order that was discontinued without follow-up, and the resident expressed a desire for missing teeth replacement. Another resident's family requested a dental appointment for a cracked tooth, but no action was taken. The deficiencies were due to poor communication and inadequate processes for scheduling dental services.
Food Labeling, Temperature Monitoring, and Tray Accuracy Failures
Penalty
Summary
The facility failed to ensure proper kitchen and dining practices, including labeling and dating food items, monitoring refrigerator and freezer temperatures, recording safe food temperatures, discarding expired food, maintaining the ice cream freezer, and serving residents the foods listed on their meal tickets. During the kitchen tour, surveyors found multiple refrigerators and the walk-in freezer without documented temperatures for a prior day, and observed numerous food items stored without labels or dates, including produce, cottage cheese, prunes, desserts, beverages, sliced watermelon, salads, pickles, sandwiches, cheese, dressing, and food items wrapped for freezer storage. The ice cream freezer also had heavy frost buildup inside it. Surveyors later found that tray line temperature logs were incomplete and disorganized, with multiple missing dates, missing breakfast, lunch, or dinner temperatures, and some illegible entries. The Dietary Manager confirmed the omissions and stated that Korean breakfast temperature records were missing on several days because residents received the American breakfast instead. A meal tray audit also showed that a resident’s tray did not match the meal ticket: the ticket called for double portions of tomato soup, Italian blend vegetables, fruit ambrosia salad, lemonade, and 2% milk, but the tray did not contain the ordered double portions, included spinach instead of Italian blend vegetables, and also contained beef, a vegetable, and rice that were not listed on the ticket. In resident food pantries, surveyors found additional labeling and dating problems. In one pantry, items in the refrigerator included a brown bag with the resident’s name but no date, blueberries with no date or resident name, and sauerkraut with the resident’s name but no date or room number. In another pantry, surveyors found bags and containers without required identifying information and fruit dated far beyond the posted discard timeframe. The Dietary Director acknowledged that food labeling should identify the item and date, and the Nursing Home Administrator acknowledged the gaps in the tray line logs, the incorrect sandwich labeling, and the freezer defrost documentation that did not match the surveyor’s observations.
Medication Security Lapses
Penalty
Summary
The facility failed to ensure medications were kept secure. On one unit, the medication refrigerator contained a designated narcotic storage compartment holding two residents’ lorazepam, a Schedule IV controlled medication. The compartment was a clear plastic box with an intact lock, but it was not affixed and could be removed from the refrigerator and the medication room. The unit manager acknowledged that the compartment was unaffixed and could be removed. On another occasion, Resident #47, who had been admitted to hospice care with terminal senile degeneration of the brain, dysphagia, failure to thrive, and weight loss, was observed agitated in the room with an open box of Morphine Sulfate 100 mg/5 ml sitting on the bedside table. The surveyor remained in the room and later the psychiatric nurse practitioner assessed the resident. In a separate observation, a set of keys was found sitting on top of a medication cart in the hallway with no nursing staff immediately present nearby; a nurse later confirmed the keys belonged to him and were his medication cart keys.
Infection Control: Improper Mask Use and Hand Hygiene During Flu Outbreak
Penalty
Summary
The facility failed to ensure staff appropriately wore source control face masks during a period of increased influenza in the community and a current flu outbreak on the [NAME] 1 unit. On 12/31/25, the Maryland Department of Health issued recommendations for healthcare facilities to implement facility-wide source control measures in patient care areas and other patient-facing settings, including requiring all individuals to wear masks in patient-facing areas. On 1/5/26, surveyors observed a sign at the facility entrance notifying the public of the mask requirement. On 1/6/26 and 1/7/26, the Infection Preventionist confirmed there was an active flu outbreak on [NAME] 1 unit, that a line listing had been started, and that the local health department had been notified. She also stated that staff entering resident rooms on that unit were expected to wear a mask and a face shield. During multiple observations on 1/8/26 and 1/12/26, staff were seen with masks worn incorrectly or not maintained over the nose and mouth. Nurse #9 was observed at the nursing station with his mask below his mouth while interacting with a pharmacy delivery person, then later leaving resident rooms with the mask below his mouth on three separate occasions. GNA #32 was observed repositioning a dependent resident in bed with the mask below the nose. LPN #31 was observed administering medications with the mask below the nose and did not wash hands upon entering or leaving two residents' rooms. NP #22 was observed walking in the hall with a procedure mask pulled down on her chin while talking on the phone and then continuing a conversation with another employee before repositioning the mask after being questioned. The Nursing Home Administrator acknowledged concern about NP #22's failure to wear a mask correctly during the outbreak.
Failure to Timely Report Severe Injury of Unknown Origin to State Agency
Penalty
Summary
The deficiency involves the facility’s failure to timely report a severe injury of unknown origin to the State Agency, the Office of Health Care Quality (OHCQ), within the required two-hour timeframe after becoming aware of the injury’s severity. On 12/06/2025 at approximately 4:00 PM, a resident was reported to be screaming in severe pain in the left hip and was transported to a nearby hospital. The facility’s investigation file for this incident contained one on-duty staff incident statement and two staff email statements regarding the unknown origin injury. On 12/07/2025, records show that the Charge Nurse (Staff #41) and the Unit Manager (Staff #42) were informed that the hospital had diagnosed the resident with a left hip fracture. During an interview on 01/14/2026, the Charge Nurse reported that on 12/07/2025 she encountered the resident’s family picking up personal belongings and at that time learned that the resident had sustained a severe left hip fracture. In a separate interview on the same day, the Administrator confirmed that facility staff became aware of the resident’s severe injury of unknown origin on 12/07/2025. Despite this, the initial Facility Reported Incident (FRI) was not submitted to OHCQ until 12/08/2025 at 9:54 AM, which was one day after staff became aware of the severity of the injury. This delay did not comply with FRI reporting requirements that mandate immediate notification, and no later than two hours after the facility becomes aware of a severe injury.
Failure to Thoroughly Investigate Severe Injury of Unknown Origin
Penalty
Summary
The deficiency involves the facility’s failure to thoroughly investigate a severe injury of unknown origin sustained by Resident #208. According to the Facility Reported Incident file, an initial report was submitted to the State Agency on 12/08/2025 regarding an incident that occurred on 12/06/2025 at approximately 4:00 PM, when the resident was reported to be screaming in severe left hip pain and was transported to a nearby hospital. Hospital records from 12/07/2025 indicated that the resident had a left hip fracture. The facility’s investigation file contained only one on-duty staff incident statement and two staff email statements related to the event, with no further documented investigative steps. On 12/07/2025, Charge Nurse Staff #41 learned from the resident’s family, who were picking up personal belongings, that the resident had sustained a severe left hip fracture, but she did not notify the Administrator until 12/08/2025 and did not initiate further staff or resident interviews. During an interview, the Administrator reported that Unit Manager Staff #42 withheld information about the severe injury of unknown origin and acknowledged that, despite the severity of the injury, no thorough investigation was conducted. The Administrator confirmed that interviews with staff working the relevant shift and residents on the same floor were not completed, resulting in an incomplete investigation into the cause of the resident’s severe injury.
Failure to Maintain Resident Dignity
Penalty
Summary
The facility failed to maintain resident dignity by not honoring clothing preferences and by allowing a dignified environment to be compromised for two residents. Resident #150, who had diagnoses including Cerebral Infarction (stroke), Dysphagia, Paraplegia, Vascular Dementia, and Depression, had a sign posted on the wall stating that the resident was a feeder. The sign was observed on multiple occasions while the resident was in the room and receiving breakfast assistance, and facility staff acknowledged that the sign had been posted on the wall after the resident was transferred from another room. Resident #4, a long-term care resident, stated a preference for wearing shoes and clothing rather than a hospital gown, and the admission MDS documented that choosing what clothes to wear was very important to the resident. Despite this, the resident was repeatedly observed in bed wearing a hospital gown and without footwear on several survey observations. The resident's legal guardian reported having purchased loungewear and Velcro shoes and giving them to the nurse unit manager, but staff later reported the clothing could not be located and that the resident had only been seen wearing a hospital gown since returning from the hospital.
Inaccurate MOLST and Missing Advance Directive Documentation
Penalty
Summary
The facility failed to ensure the accuracy of Resident #67’s life-sustaining treatment wishes and failed to maintain an Advance Directive/designated point person on file. Record review found a MOLST indicating No CPR and Do Not Intubate based on a discussion with the resident, but the Other Treatment section on the back of the MOLST was dated and not properly checked off or signed by the facility’s medical provider. During interview, the resident was in bed watching TV, had difficulty answering questions, could not identify the current location or year, and could not successfully repeat words as requested. The resident’s history included hypertension, falls, lower back pain, muscle wasting and atrophy, unspecified dementia, and a BIMS score of 10. Further review found no documentation or Advance Directive to support that the family member contacted by social work was actually the resident’s Health Care Agent. After surveyor intervention, the NP voided the prior MOLST and initiated a new one, but the progress note stated the new form was intended for no aggressive medical workup or life-sustaining interventions while the actual MOLST indicated Full CPR Status and yes to all life-sustaining treatments. The record also contained conflicting references to the family member as either Health Care Agent or healthcare surrogate, and the Director of Social Work agreed the facility had failed to ensure accurate life-sustaining treatment documentation and lacked the necessary Advance Directive documentation.
Bathroom Wall Repairs Not Maintained
Penalty
Summary
The facility failed to ensure bathroom walls were kept in good repair in four resident bathrooms. During observations, the area where the sink drain pipe met the wall was not sealed in one bathroom, another bathroom had a jagged hole in the wall approximately 3 inches in diameter where the sink drain pipe was located, and a third bathroom also had an unsealed area where the sink drain pipe met the wall. During a later observation with the Maintenance Director, the same conditions were confirmed in the four resident bathrooms, including the bathroom in room [ROOM NUMBER] and the bathrooms in rooms 167, 178, and 197. The Maintenance Director stated that the hole in the wall was not supposed to be there, that a trim ring should have been present, and that the pipes had recently been replaced but the trim ring had been forgotten. He also provided documentation showing plumbing repairs had been completed in June 2025 for some rooms and in July 2025 for another room, and stated that the trim had not been put back on.
Missing Bed Hold and Transfer Notices
Penalty
Summary
The facility failed to provide the required written bed hold notice and transfer notification to the resident and/or responsible representative when residents were transferred to the hospital. During the annual survey, this was identified for 3 of 4 residents reviewed for hospitalization: Resident #201, Resident #9, and Resident #166. For Resident #201, a progress note documented transfer to the hospital, but review of the paper chart and electronic health record found no evidence that the resident or representative received the required written hospital bed hold notice. Staff interviews confirmed the bed hold notice was part of the transfer documents, but the Unit Manager could not find a copy or confirm it had been received, and the Social Service Director acknowledged the notice was not sent and had been missed. For Resident #9, the medical record showed transfer to the hospital, and the facility produced a Notice of Emergency Transfer and Bedhold Policy, but no documentation supported that it was emailed or given to the resident's responsible representative. The Admission Director was unable to locate supporting email documentation when asked. For Resident #166, the record showed transfer to the hospital and noted the responsible representative would meet the resident at the hospital, but the facility again provided a Notice of Emergency Transfer and Bedhold Policy without documentation showing it was sent to the responsible representative. The Admission Staff member was unable to find supporting email documentation when requested, and the Nursing Home Administrator was informed of the missing transfer and bed hold notice documentation.
Failure to Hold Care Plan Meeting and Update Care Plan for Comfort Care Status
Penalty
Summary
The facility failed to ensure an interdisciplinary care plan meeting was held and the resident’s care plan was updated after a quarterly MDS assessment for Resident #9. The resident had been admitted to the facility more than 6 months earlier and had severe cognitive impairment, with a BIMS score of 3 out of 15. Diagnoses included heart failure, vascular dementia, diabetes, and end stage renal disease, and the resident received nutrition via a gastric feeding tube. The most recent MDS had an ARD of 12/4/25, but review of the record on 1/12/26 did not reveal documentation that a care plan meeting had been scheduled within 7 calendar days of completing the assessment. A social work note from 12/4/25 stated that SW would schedule a care plan meeting with the patient’s guardian, but no documentation was found showing that the meeting was scheduled or held at that time. The record also showed that the resident’s status changed to comfort care around the time of the MDS, but the care plan did not reflect that change. Handwritten orders dated 12/4/25 included a MOLST, PRN morphine and lorazepam, discontinuation of weights, labs, and vital signs, a dietitian consult to decrease tube feedings, and discontinuation of nine medications. On 1/12/26, the Assistant Unit Nurse Manager stated the resident was currently comfort care and that the changes appeared to have been made on 12/4/25. Review of the care plan showed two new plans added on 12/16/25 by the Nursing Home Administrator, including one for code status, but it did not address all MOLST orders such as no blood products, no diagnostic or treatment tests, no hospital transfer, and no antibiotics. No documentation was found showing the resident was receiving palliative/comfort care in the care plan, and no updates were found in the other care plans to reflect the change.
Incomplete Narcotic Reconciliation Documentation
Penalty
Summary
The facility failed to ensure acceptable standards of practice for controlled medication reconciliation. During review of the narcotic books for cart 1 and cart 2, surveyors found that 2 of 2 morning narcotic reconciliation counts were not documented according to standard practice because the on-coming licensed nurse’s signature was missing. Standard practice described in the report required the end-of-shift controlled medication count to be completed by two licensed personnel, with both the on-coming and out-going nurses counting the controlled medications and documenting their initials in the narcotic book. On 1/7/26 at 9:20 AM, the on-coming LPN confirmed that he had not signed the narcotic reconciliation that day, and at 9:23 AM the unit manager acknowledged the lack of narcotic reconciliation per acceptable standards of practice.
Failure to Provide Outdoor Activity Opportunities
Penalty
Summary
The facility failed to provide an activity program according to a resident’s comprehensive assessment and personal choice. Resident #4, who required ventilator assistance to aid respirations, stated during interview that he or she wanted a wheelchair to go outside. Admission information dated 2/24/25 showed that the resident said going outside to get fresh air when the weather was good was very important. The resident’s activity progress notes also documented a preference for individual activities and spending time outside. Review of the resident’s activity records did not show that the resident was provided an opportunity to go outside during the stay at the facility. The Activities Director stated that attendance was recorded for group and one-on-one activities and that refusals to participate in one-on-one activities were documented. The Respiratory Therapist reported that from the end of May through September, the resident did not require ventilator assistance or suctioning and had no respiratory impediments to going outside during that time. Facility census records showed the resident was transferred on 5/27/25 from the ventilator unit to a regular care room and remained there until 10/1/25, yet the administrator confirmed the resident was not provided the opportunity to go outside after the medical condition improved and the resident had the ability to go outside.
Failure to Follow Diabetes Monitoring and Insulin Orders
Penalty
Summary
The facility failed to ensure physician orders were followed for a resident with Type 2 Diabetes Mellitus. The resident had orders for Novolog FlexPen 3 units subcutaneously with meals, to be held if blood sugar was below 100, and for blood glucose monitoring before meals and at bedtime with instructions to call the MD if blood sugar was less than 60 or greater than 300. Review of the MAR showed no documentation of a blood sugar reading at 2:30 PM and no documentation of Novolog administration at 3:00 PM on 1/9/26, both of which were scheduled under the physician orders. During interview, the ADON stated that a blank space on the MAR meant the medication or treatment was not signed off as completed and confirmed that neither the blood sugar check nor the Novolog administration was documented. The ADON also reviewed the nursing notes and could not find documentation explaining why the ordered care was not completed, and there was no documentation indicating the resident had been out of the facility. Later review showed the resident had a neurology appointment that day, and the ADON acknowledged that blood sugar checks were expected upon return and that the record should have reflected the resident being out of the facility and the required assessments and medications being completed upon return.
Wound care orders did not match documented treatment
Penalty
Summary
The facility failed to ensure wound treatment was completed as ordered and that the documented wound orders matched the treatments being provided for one resident with a sacral pressure ulcer. The resident was admitted in spring 2025 with a stage 2 sacral pressure ulcer, and weekly wound physician notes later documented the wound as stage 3 starting on 7/18/25. On 9/5/25, the wound physician note documented Collagen and Bordered dressing once daily with Betadine to the periwound area. However, on 1/8/26, the surveyor observed an RN clean the wound with normal saline, apply Betadine to the periwound area, apply a gel to a white collagen dressing sheet, and cover it with a Cosmopor adhesive dressing. The surveyor confirmed the products used were Plurogel and PLUS collagen dressing. Review of the EHR after the observation showed the active order listed Puracol Dressing with collagen sheet, Betadine to the periwound, and bordered dressing daily, and the TAR listed the wound care order twice, including a separate entry for Betadine. Review of wound physician notes from 12/26/25 and 1/2/26 showed the current dressing was Col-active (collagen) plus Ag dressing once daily and as needed, bordered dressing once daily, and Betadine to the periwound area. The unit nurse manager confirmed PLUS and Puracol were collagen dressings, but no order was found for Plurogel. The RN stated she used the regular PLUS dressing and reported there was an order for Plurogel, identifying the Puracol order as the gel. The wound physician later confirmed the current dressing order should have been Col-Active Plus Ag with Betadine around the periwound and stated Plurogel was not supposed to be used for the resident's wound. The report also noted a prior complaint survey in September 2025 had cited similar concerns about discrepancies between the wound physician's documentation and what was actually being provided.
Failure to Provide Ordered Double Portions
Penalty
Summary
The facility failed to ensure an underweight resident was provided the ordered diet. The resident’s record showed a dietitian note on 9/4/25 documenting a current weight of 102 lbs and recommending a regular consistency diet with double portions of vegetables and entree. A later dietitian note on 12/19/25 showed the resident’s weight had decreased to 94.6 lbs. On 1/7/26, surveyors observed the resident in bed with a lunch tray on the overbed table while the resident appeared asleep. When the tray was checked with the unit nurse manager, it contained rice and peas but no protein, and the meal ticket showed the resident should also have received 2 chicken salad sandwiches. There was no evidence the sandwiches had been delivered, and the resident confirmed they had not received the chicken salad. The unit nurse manager called the kitchen, which then sent the sandwiches up. The dietary manager later confirmed the resident was supposed to receive double portions of entree and vegetables and should have received two chicken salad sandwiches that day.
Failure to Document and Manage New-Onset Pain
Penalty
Summary
The facility failed to ensure pain management was provided in accordance with professional standards of practice for one resident who had an injury of unknown origin and later was found to have a right tibia and fibula fracture. The resident’s medical history included diabetes, heart failure, end stage renal disease, and memory deficit following a stroke, and a primary care note on 10/6/26 described the resident as in no acute distress, able to move all extremities, but with right-sided weakness and muscle wasting. The record showed pain assessments were documented every shift from 10/1 through 10/8/26 as 0, and the resident had an order for acetaminophen 500 mg, two tablets every 8 hours as needed for mild to severe pain. The incident investigation statement completed by Nurse #43 documented that the resident’s spouse reported the resident’s right knee was hurting to light touch, and the nurse applied Biofreeze that had been ordered for the resident’s left arm to the knee without documentation of an order for knee use. The nurse stated the resident later denied pain and declined acetaminophen, but there was no documentation that the new knee pain was reported to the PCP or that an order was obtained for Biofreeze use on the knee. The record also showed acetaminophen was administered on 10/8/25 with a documented pain level of 0 and effectiveness recorded, despite no documentation that the resident was experiencing pain or a rationale for the PRN medication. A physician later evaluated the resident for right lower extremity pain, noted knee swelling, ordered an x-ray, and the x-ray results were documented as an acute fracture of the right tibia and fibula before the resident was transferred to the hospital.
Pharmacy Recommendations Not Timely Reviewed by Provider
Penalty
Summary
The facility failed to have an effective process to ensure that pharmacy recommendations were reviewed by the resident's provider for one resident reviewed for unnecessary medications. Record review showed that a pharmacist completed an admission medication review for the resident, but the medical record did not show documentation that the provider received the pharmacist's recommendations. The admission pharmacy review dated 12/10/25 was not uploaded to the resident's electronic health record or hard chart when reviewed by the Administrator. The pharmacy review contained several recommendations, and the document showed the provider reviewed it and ordered labs and an EKG, but the provider signature was not dated. Review of orders did not show an EKG order before surveyor intervention; an EKG order for drug monitoring was later found dated 1/7/26 at 3:24 PM. The ADON stated the pharmacy review had not been sent to the provider before surveyor intervention and that the facility expected pharmacy recommendations to be sent to the nurse manager, who then communicates them to the provider. The ADON confirmed the recommendation had not been provided to the provider before that time and was signed by the provider on 1/7/26, which was not timely and did not meet the facility's 14-day policy.
Incomplete Electronic Medical Record
Penalty
Summary
The facility failed to maintain a complete and accurate medical record for Resident #202, who was deceased at the time of the closed record review. Surveyors found that no hard copy medical record was available, and the electronic record did not contain the resident’s MOLST form or death certificate, even though the electronic record indicated to see a new MOLST on [DATE]. During interview, Medical Record Staff #7 stated that every page of the medical record should be in the electronic record system. The Administrator was informed that the resident’s MOLST forms and death certificate were missing from the electronic record, and later stated that the death record had just been scanned in, but no last MOLST from [DATE] was found. The Administrator learned from the floor that the MOLST from [DATE] had been shredded mistakenly by the floor clerk.
Arbitration Agreement Signed by Unauthorized Party
Penalty
Summary
The facility failed to ensure that the appropriate party signed the arbitration agreement and failed to ensure that the resident received information about the agreement and understood it. During the survey, the administrator and the Chief Clinical Officer stated that the arbitration agreement was voluntary and not binding, and that residents had 30 days to rescind after signing. However, the agreement itself stated in bold, all-capital letters that by entering the agreement the parties were giving up and waiving their constitutional right to have any claim decided in court before a judge and jury. Review of the admission process showed that the Director of Admissions said the arbitration agreement was part of the admission packet and was completed by the person handling admission paperwork, with the resident asked to sign only if the hospital discharge summary showed the resident was alert and oriented. For one resident, the signed arbitration agreement was completed by a family member rather than the resident. The resident’s hospital discharge summary, MDS admission assessment, and physician certification all indicated the resident had no documented cognitive decline and was able to understand and sign admission documents and communicate decisions. The resident later stated not knowing what an arbitration agreement was and was unaware that a family member had signed it, and also stated not having an advance directive.
Failure to Provide and Accurately Administer Pressure Ulcer Care
Penalty
Summary
Facility staff failed to provide appropriate pressure ulcer care and prevention for three residents, as evidenced by medical record reviews and staff interviews. One resident with cerebrovascular disease, diabetes, and peripheral vascular disease was admitted with a sacral Stage IV pressure ulcer. After returning from the hospital with specific wound care instructions, the facility did not administer the required daily sacral wound treatments for nearly two weeks, a lapse confirmed by the Director of Nursing. Another resident, admitted for rehabilitation and wound care with multiple chronic conditions including cerebral palsy and diabetes, had a sacral pressure ulcer that progressed to Stage IV and extended to both buttocks. The treatment orders for this resident were incorrectly entered into the electronic medical record, resulting in wound care being performed three times daily instead of the intended once daily. Staff interviews revealed that treatments were performed according to what appeared in the eMAR, without questioning discrepancies, and the wound care physician confirmed the order was for once daily application only. A third resident, admitted for subacute rehabilitation, had deep tissue injuries (DTIs) on both heels. The treatment administration record showed that the wound care provided did not match the wound physician's orders, with incorrect dressings and delayed initiation of the prescribed treatment. The Director of Nursing acknowledged inconsistencies in following wound care orders on the unit. These findings demonstrate a failure to follow prescribed wound care protocols and ensure accurate implementation of physician orders for pressure ulcer management.
Failure to Obtain Consent for Wound Debridement by Outside Providers
Penalty
Summary
Facility staff failed to ensure that outside providers obtained consent from a resident's representative prior to performing a debridement procedure on a resident's right heel wound. The resident, who had a diagnosis of dementia and was assessed to have moderate cognitive impairment with a BIMS score of 8 out of 15, was admitted following a hospitalization and had a documented deep tissue injury (DTI) on the right heel. The facility's social worker communicated with the resident's assisted living staff and scheduled an assessment of the wound, with the resident's representative aware that an assessment would occur but not informed that a debridement would be performed or that consent would be needed for such a procedure. On the day of the incident, two nurse practitioners from the resident's assisted living arrived at the facility, identified themselves, and were escorted to the resident's room by a nurse. The nurse introduced them to the resident and informed the resident that the providers were there to assess the wound. The nurse then left the room but returned to find the providers performing a debridement without having obtained consent from the resident's representative. The nurse instructed the providers to stop the procedure and reported the incident to facility management. Interviews confirmed that consent was not obtained prior to the debridement.
Failure to Thoroughly Investigate Abuse Allegations
Penalty
Summary
The facility failed to provide documentation that allegations of abuse were thoroughly investigated for one resident who reported being mistreated by staff during activities of daily living (ADL) care. Specifically, a resident alleged to the social worker that a geriatric nursing assistant (GNA) pushed their head on the bed and that some nurses were rough during treatment, causing distress. The facility's documentation included a written statement from the social worker and a statement from one staff member, but lacked resident interviews or staff interviews regarding the care provided by the second staff member implicated in the allegation. Further review revealed that three other residents expressed concerns about the same staff member's treatment, describing her as rough, impatient, and displaying anger towards residents. Despite these concerns, the Director of Nursing (DON) was unaware of the residents' feedback, and the Nursing Home Administrator (NHA) acknowledged that the investigation focused solely on one staff member, overlooking the need to investigate the second staff member's conduct. The lack of comprehensive interviews and follow-up resulted in an incomplete investigation of the abuse allegations.
Failure to Update Care Plan with Accurate Interventions for Skin Integrity
Penalty
Summary
Facility staff failed to review and revise the interdisciplinary care plan to accurately reflect interventions for a resident with significant medical needs. The resident, admitted with diagnoses including cardiac arrest resulting in anoxic brain damage, asthma, and ventilator dependence, developed a deep tissue injury (DTI) to the left heel, as documented in weekly skin assessments from late December through January. Additional wounds, including a Stage 2 pressure ulcer to the left ischium and a DTI to the right buttock, were also noted during this period. Despite these findings, the care plan created for the resident only included general interventions for skin integrity, such as incontinence checks, use of barrier cream, daily skin inspections, and weekly wound monitoring. The care plan was not updated to include specific interventions for the resident's heels, such as elevation or floating of heels, use of heel boots, application of skin prep to heels, or provision of an air mattress. The Director of Nursing confirmed during an interview that the care plan should have been updated to reflect these interventions.
Failure to Administer Physician-Ordered Treatments
Penalty
Summary
Facility staff failed to administer prescribed treatments according to physician orders for two residents. One resident was admitted with dermatitis and was prescribed Clotrimazole by the wound physician. Although the resident received the medication initially, there was a lapse in administration from the end of July through mid-August, despite ongoing physician orders and documentation that the rash had not resolved until later in August. The Director of Nursing confirmed that the treatment should have continued during this period. Another resident with a history of cerebrovascular disease, diabetes, and peripheral vascular disease was admitted with a right foot wound and later underwent a partial foot amputation. The wound physician provided specific treatment orders for the resident's right lateral foot wound. However, review of the treatment administration records revealed that staff failed to provide the ordered wound care during several periods over multiple months. The Director of Nursing acknowledged these lapses in treatment provision.
Failure to Follow Physician-Ordered Medication Parameters
Penalty
Summary
Surveyors identified that the facility failed to ensure residents' drug regimens were free from unnecessary drugs by not adhering to physician-ordered parameters for administering blood pressure and diabetic medications. For one resident with multiple complex diagnoses, including heart failure and diabetes, nursing staff administered Carvedilol even when the resident's heart rate was below the physician-ordered threshold, and failed to administer insulin as ordered when blood sugar was elevated, without documentation of physician notification or new orders. The Medication Administration Records (MAR) and nursing notes confirmed these deviations from prescribed parameters. Similar deficiencies were found for two other residents with significant medical histories, including neurological and cardiovascular conditions. In these cases, medications such as Propranolol, Hydralazine, and Metoprolol were administered or withheld contrary to specific physician orders based on blood pressure and heart rate readings. The Director of Nursing (DON) confirmed these findings during record reviews and acknowledged a recurring issue with staff not following physician-ordered medication parameters on the affected unit.
Failure to Prevent Resident Elopement Due to Inadequate Supervision
Penalty
Summary
The facility failed to provide adequate supervision and intervention for a resident known to have exit-seeking and elopement behaviors. This deficiency was identified during a survey when it was discovered that the resident, who had a history of wandering and removing their wanderguard, managed to elope from the facility. The resident had been displaying wandering behaviors since their admission, and despite having a wanderguard applied, they frequently removed it, including on the day of the elopement. On the day of the incident, the resident cut off their wanderguard and exited the facility through the main entrance by following a visitor. The resident was later returned to the facility by a good Samaritan. Interviews with facility staff revealed that the resident had been using a makeshift cutter, possibly a plastic knife from a food tray, to remove the wanderguard. The facility's staff were aware of the resident's behavior but failed to implement effective measures to prevent the elopement. The facility's failure to adequately supervise the resident and address the known risk of elopement led to the incident being classified as Immediate Jeopardy. The resident's ability to remove the wanderguard and exit the facility without detection highlighted a significant lapse in the facility's safety protocols and monitoring systems.
Removal Plan
- Assessment of the resident for injury on return and documented.
- Notified the Responsible Party and provider.
- The resident was placed on 1:1 sitter.
- Completed wandering/elopement risk assessment, pain, fall, Patient Health Questionnaire 9(PHq9), and Brief Interview of Mental Status(BIMS) assessment.
- Social work evaluation completed.
- The resident was started on plastic silverware.
- The room was changed to be on the other side of the nurse's station.
- Check the wanderguard system to ensure door alarms when the wanderguard is present.
- All wanderguards in the facility were checked for placement and tested.
- Elopement assessments for all residents will be reviewed to ensure accuracy and completion.
- Staff members received education on elopement policy and expectations. Staff will receive education on hire, annually, and as needed.
- Drills will serve as education and competency assessments.
- Education to families regarding signing out.
- Front desk drills for alertness.
- Photos of residents at risk of elopement are posted on the left upper wall inside the front desk station and photos of residents at risk of elopement posted at the nurses' station.
- Elopement binder located at the front desk.
Failure to Conduct Annual Performance Evaluations for GNAs
Penalty
Summary
The facility failed to conduct performance evaluations for five Geriatric Nursing Assistants (GNAs) within the required 12-month period. This deficiency was identified during a review of staff personnel records on July 3, 2024, which revealed that GNAs #26, #27, #28, #29, and #30 did not have any performance evaluations on file. An interview with the Nursing Home Administrator and the HR Director confirmed the absence of these evaluations and acknowledged the deficiency. The facility staff understood that this oversight constituted a failure to comply with regulatory requirements for regular performance reviews of nurse aides.
Food Safety and Sanitation Deficiencies
Penalty
Summary
The facility staff failed to prevent bare hand contact with ready-to-eat food, as observed during an in-room interview with a resident. A GNA was seen handling toast with bare hands while buttering it for the resident, which she later acknowledged was against protocol. This incident was discussed with the unit manager and the director of nursing. In the kitchen, several issues were noted, including improper use of hair coverings by staff, with some not covering their beard hair or wearing any hair covering at all. Additionally, there were concerns about the dating and storage of food items, with some items left unrefrigerated and others improperly labeled or stored. The kitchen equipment was not well-maintained, with broken thermometers and ice accumulation in cold storage areas, creating unsanitary conditions. The surveyor also observed inaccuracies in the tray line, with missing food items on residents' trays, and personal items on food prep surfaces. Furthermore, there was a lack of monitoring of required dishwashing sanitization temperature levels, with several instances of unrecorded temperatures. These practices potentially affected all residents in the facility.
Lack of Effective Communication Training for Staff
Penalty
Summary
The facility failed to ensure that all staff received training in effective communication, as identified during the Extended Survey investigation portion of the recertification survey. An interview with the Human Resources Director revealed that the annual training plan required by the corporate office for nurses and Geriatric Nursing Assistants (GNAs) did not include any training on effective communication. Training records for four GNAs were reviewed, and none showed evidence of such training. Further interviews with the Director of Nursing and the Chief Executive Officer confirmed that recent training materials also lacked effective communication content. Additional training records provided by the President of Clinical Services did not include evidence of effective communication training, and it was confirmed that the facility had no such training for any staff.
Lack of Behavioral Health Training Program
Penalty
Summary
The facility failed to implement a Behavioral Health Training Program, as required by regulations, which was identified during the Extended Survey portion of the recertification survey. On July 5, 2024, the Human Resources Director provided the annual training plan and training records for four Geriatric Nursing Assistants (GNAs), which lacked any information or evidence of a Behavioral Health Training Program. Further interviews with the Director of Nursing and the Chief Executive Officer, as well as a review of training materials from a recent skills day, confirmed the absence of such a program. On July 10, 2024, a review of the training records for the four GNAs again showed no evidence of behavioral health training. Despite additional training records being provided by the President of Clinical Services on July 11, 2024, there was still no evidence of a Behavioral Health Training Program. The President of Clinical Services confirmed that the facility did not have a Behavioral Health Training Program at that time, noting that a previous arrangement with a contracted behavioral health company had ended.
Failure to Provide Written Notification for Hospital Transfers
Penalty
Summary
The facility failed to provide written notification to residents and their representatives regarding transfers or discharges to the hospital, as required by regulations. This deficiency was identified during a recertification and complaint survey, affecting four out of six residents reviewed for hospitalization. The survey revealed that the facility's staff, including Licensed Practical Nurses and Unit Managers, consistently provided verbal notifications but did not follow up with written documentation, which is a regulatory requirement. For Resident #131, the surveyor found that the resident was transferred to the hospital for a change in mental status without receiving written notification. Interviews with the staff, including the LPN and Unit Manager, confirmed that the practice was to verbally inform residents and their representatives, with documentation only in the transfer packet sent to the hospital. The Director of Nursing also acknowledged the lack of written notification, despite verbal communication being documented in the change in condition form (SBAR). Similarly, Resident #49 was transferred to the hospital without written notification to the responsible party, as confirmed by interviews and medical record reviews. The same issue was noted for Residents #74 and #99, where medical records did not show evidence of written notification for hospital transfers. Staff interviews consistently revealed a practice of verbal notification only, with no written documentation provided to residents or their representatives, highlighting a systemic issue within the facility's transfer notification process.
Failure to Provide Written Bed-Hold Policy Notification
Penalty
Summary
The facility failed to notify residents or their representatives in writing of the bed-hold policy upon transfer to an acute care facility. This deficiency was identified during a recertification/complaint survey for four out of six residents reviewed for hospitalization. The bed-hold policy, which outlines the facility's procedure for reserving a resident's bed during therapeutic leave or hospitalization, was not provided in writing to the residents or their representatives, as required. For Resident #131, the facility staff confirmed that the bed-hold policy was included in the transfer packet sent to the hospital but was not given to the resident or their representative. The Licensed Practical Nurse (LPN) and Unit Manager (UM) both stated that they verbally informed the resident and their family about the bed-hold policy, but no written notification was provided. Similarly, for Resident #49, the facility staff did not provide written notification of the bed-hold policy, although it was included in the transfer packet sent to the hospital. The Director of Nursing (DON) confirmed that the facility did not send any written notification to the residents or their representatives. The same issue was observed for Residents #74 and #99, where there was no documentation of written notification of the bed-hold policy being provided to the residents or their representatives upon transfer to the hospital. Staff interviews revealed that the facility's practice was to verbally inform residents and their families about the bed-hold policy and include it in the transfer packet sent to the hospital, but not to provide a written copy to the residents or their representatives.
Deficiencies in Comprehensive Care Planning
Penalty
Summary
The facility staff failed to develop and initiate comprehensive person-centered care plans for several residents, leading to deficiencies in care. For Resident #131, who was dependent on renal dialysis due to End Stage Renal Disease, the care plan lacked critical details such as the type and location of dialysis access, specific dialysis days, and necessary monitoring instructions for the access site. Despite having physician orders for monitoring the AV fistula, these were not reflected in the care plan, which focused primarily on infection control without addressing other essential aspects of dialysis care. Resident #163, who was on psychotropic medications including Lorazepam and Seroquel, did not have a care plan that included monitoring for medication side effects or behavioral changes. The absence of medical orders for such monitoring was confirmed by both the resident's assigned nurse and the facility Administrator, indicating a gap in ensuring the safe administration of these medications. The care plan only included general instructions to administer medications as ordered and monitor for effects, without specific orders for side effect monitoring. For Resident #83, who had visible contractures in both hands, the care plan did not address the issue of contractures or include interventions such as the use of hand splints or palm protectors, despite these being listed in the resident's task list. Additionally, Resident #109, who was admitted to hospice care, did not have a hospice care plan developed since the start of hospice care. The facility staff, including the unit manager and DON, confirmed the absence of a hospice care plan, highlighting a failure to address the resident's change in condition and care needs.
Delayed Reporting of Injury and Alleged Abuse Incidents
Penalty
Summary
The facility failed to report allegations of injury of unknown origin and alleged abuse to the state agency within the required timeframe. In the first case, a resident was found with swelling and discoloration on the left arm, which was later diagnosed as an acute fracture. The incident was initially observed by a nurse, and an X-ray was ordered. However, there was a significant delay between the time the X-ray results were reported and when the facility staff became aware of the incident, leading to a delayed submission of the initial incident report to the state agency. In the second case, an alleged abuse incident occurred between two residents, but the facility did not report it to the Office of Health Care Quality within the required 2-hour timeframe. The incident was reported more than two days later, which was not compliant with the reporting requirements. The facility's investigation concluded that no abuse or injury occurred, but the delay in reporting was confirmed by the Assistant Administrator.
Failure to Investigate Injury and Elopement Incidents
Penalty
Summary
The facility failed to thoroughly investigate an injury of unknown origin involving a resident who was found with a bluish discoloration and swelling on the left arm, later diagnosed as an acute fracture. Despite notifying the physician and conducting staff education on safe transfers and positioning, the facility did not interview other residents to gather additional information about the incident. The administrator acknowledged the lack of interviews with other residents and mentioned that this practice was only recently adopted based on recommendations from a sister facility. In a separate incident, the facility did not adequately investigate an elopement involving a resident who cut off their wander guard and left the facility. Although the resident was returned by a good Samaritan without injury, the facility's investigation did not address how the resident managed to cut the wander guard or document the details of their return. The administrator admitted to the surveyor that the situation was a "perfect storm" and validated the concern about the lack of documentation and investigation into the resident's actions.
Failure to Address Resident's Elopement Risk
Penalty
Summary
The facility failed to provide appropriate behavioral health care and services to a resident with a history of exit-seeking and elopement behaviors. The resident, who had been residing in the facility since December 2023, was known to frequently remove or cut off their Wanderguard bracelet, a device intended to prevent elopement. Despite the resident's repeated actions of removing the Wanderguard, the facility did not implement effective interventions to address this behavior. The resident successfully eloped from the facility on one occasion, following a visitor out of the main entrance, and was returned an hour later. The facility's care plans and physician's progress notes did not adequately address the resident's behavior of cutting the Wanderguard. The care plans were updated but lacked specific interventions to prevent the resident from removing the device. Additionally, the Treatment Administration Record (TAR) did not include behavior monitoring after the first elopement incident. Interviews with staff revealed that the resident likely used plastic knives from food trays to cut the Wanderguard, yet no effective measures were taken to prevent access to these knives or to ensure the Wanderguard remained in place.
Failure to Maintain Resident Dignity and Privacy
Penalty
Summary
The facility staff failed to treat a resident with dignity and respect by leaving them undressed and without assistance for an extended period. During a survey, it was observed that the resident was not appropriately dressed, with only a gown placed on their chest, and reported waiting for staff assistance for 40 minutes. The resident expressed a preference to be dressed and mentioned discomfort with the possibility of an opposite-gender resident entering the room. Despite this, an opposite-gender resident attempted to enter the room during the survey. Further observations revealed that the resident was again found undressed, covered only with a sheet and towel, and expressed a desire to be dressed but had not received assistance. The resident's medical records indicated a high cognitive status and a dependency on staff for dressing. The Director of Nursing acknowledged the importance of maintaining residents' privacy and dignity, stating that staff should knock, introduce themselves, and ensure privacy by closing curtains during care activities.
Ceiling Tile Disrepair in Resident Bathroom
Penalty
Summary
The facility failed to maintain a safe, clean, and well-repaired environment, as evidenced by the condition of the bathroom in a room on the Renaissance 1 Medical Surgical Unit. During an initial observation, two ceiling tiles above the shower were found to be falling down, with one tile showing brown discoloration over 75% of its surface around the ceiling fan. This issue was first noted on 6/20/24. On 7/03/24, the Maintenance Director acknowledged the problem, suggesting a possible water leak from the shower on the floor above. The Director of Nursing was also unaware of the issue until informed during the survey, validating the concern upon inspection.
Failure to Provide Baseline Care Plans to Residents
Penalty
Summary
The facility failed to provide a baseline care plan to residents or their representatives within 48 hours of admission, as required. This deficiency was identified during an annual survey and a recertification survey. Specifically, for one resident, there was no documentation that the baseline care plan was provided on three separate occasions, despite the Director of Nursing (DON) being aware of the issue and unable to provide evidence of compliance. Similarly, another resident's record showed no indication that the baseline care plan was shared with the resident or their representative, and the DON confirmed the absence of documentation. Interviews with the DON and the President of Clinical Services revealed acknowledgment of the deficiency, but no evidence was found to support that the baseline care plans were communicated to the residents or their representatives. The lack of documentation in the residents' records highlights the facility's failure to meet regulatory requirements for timely communication of care plans, which is essential for informing residents and their representatives about the care they will receive.
Failure to Update Care Plans After Incidents
Penalty
Summary
The facility failed to update or revise care plans for two residents following significant incidents. Resident #154, who was initially admitted in December 2023, experienced a fall on March 21, 2024, which required hospitalization. Upon readmission, the resident's care plan, which included interventions for fall risk, was not updated to reflect the new incident. Observations noted the resident's anxious behavior and attempts to get out of a geriatric chair, yet no additional interventions were documented. Interviews with nursing staff, including the Director of Nursing (DON), confirmed that care plans should be updated after such incidents, but it was revealed that the care plan for Resident #154 was not revised after the fall. Similarly, Resident #89 attempted to elope from the facility on October 31, 2022, but the care plan was not updated to address this incident. The last update to the resident's elopement care plan was on July 19, 2022, which included an intervention to engage the resident in purposeful activities. Despite prior elopement attempts, the care plan remained unchanged after the October incident. The DON confirmed the lack of updates to the care plan and acknowledged the surveyor's concerns about this deficiency.
Failure to Follow Medical Orders and Inconsistent Use of PPE
Penalty
Summary
The facility failed to ensure that medical orders were followed and that appropriate care interventions were in place for a resident with pressure injuries. The surveyor observed that the resident's feet were resting directly on the bed surface, contrary to the medical order to elevate or float the heels to prevent skin breakdown. Additionally, the resident's call bell was out of reach, and the resident reported needing assistance with repositioning, which was not addressed promptly. The facility also failed to communicate the reason for enhanced barrier precautions to the resident and their roommate, leading to confusion and concern. The surveyor noted inconsistencies in the use of personal protective equipment (PPE) for a resident on enhanced barrier precautions. Although a sign indicated the need for such precautions, staff did not consistently wear gowns during wound care and repositioning, as required. The resident's wound dressings were not changed daily as ordered, with one dressing observed to be two days old. The facility also failed to obtain a medical order for heel protector boots, despite a hospital discharge recommendation for their use. Interviews with staff revealed a lack of clarity regarding responsibilities for dressing changes and documentation. The wound nurse was performing dressing changes on certain days, but there was no clear process for ensuring all residents were seen or for documenting these changes. The Assistant Director of Nursing reported that precautions were implemented by whoever entered the orders first, indicating a lack of coordination between the Infection Control Nurse and Unit Managers.
Deficiencies in Respiratory Care Management
Penalty
Summary
The facility failed to adhere to physician's orders and care plans for the administration of oxygen to residents, as well as to maintain proper labeling and timely changing of respiratory equipment. Resident #49 was observed receiving oxygen at a rate of 4 liters per minute, contrary to the prescribed 2 liters per minute. The nurse on duty was unaware of the prescribed rate and confirmed that the oxygen order was not documented in the treatment administration record, leading to a lack of proper monitoring. Additionally, the oxygen tubing was not labeled with the date of the last change, indicating a failure in following the facility's policy for changing oxygen tubing. Resident #81 was found using unlabeled oxygen tubing and without the required humidification in place. The medical record indicated that the oxygen equipment should be changed weekly, and humidification should be used continuously. However, the tubing was overdue for a change, and the humidification bottle was not set up until the surveyor's intervention. The RN Unit Manager confirmed these discrepancies and acknowledged the oversight in maintaining the respiratory equipment as per the facility's protocol. Resident #163's oxygen setup lacked labeling on both the tubing and humidification bottle, and there was no active medical order for the humidification. The oxygen liter setting was observed to be at zero, and the family expressed concerns about the respiratory equipment. The LPN and RN involved were unaware of the last change of the tubing and the correct oxygen setting, highlighting a lack of communication and adherence to medical orders. The surveyor's observations and interviews with staff revealed significant lapses in the facility's management of respiratory care for these residents.
Delayed Entry of Visit Notes in Resident's Medical Record
Penalty
Summary
A facility agency provider failed to timely place visit notes into a resident's medical record, which was identified during a recertification survey investigating facility-reported incidents and complaints. The deficiency involved a resident for whom a pharmacist consultant recommended a gradual dose reduction (GDR) of Seroquel (Quetiapine Fumarate). The facility contracted an agency psychiatric nurse practitioner (NP) to assess the resident to ensure the GDR was safe. However, the NP did not assess the resident for a GDR because they could not locate Seroquel in the resident's medical orders. The NP's visit notes were not entered into the resident's chart until eight days after the visit, which the Director of Nursing (DON) acknowledged was not timely.
Medication Storage and Labeling Deficiencies
Penalty
Summary
The facility was found to have several deficiencies related to the storage and labeling of medications during a recertification survey. Firstly, a medication cart on the 2 South Nursing Unit was observed to be unattended and unlocked, allowing access to all medications within. This was confirmed by an LPN who acknowledged that the cart should have been locked when not in use. Additionally, multiple medication carts were found with multidose medications that lacked opening dates, which is necessary to determine their expiration. This was observed on both the first and second floors, with staff confirming the absence of opening dates on medications such as Fluticasone Propionate nasal spray, Acetaminophen solution, and various insulin injections. Furthermore, the facility failed to consistently monitor and document the refrigerator temperatures where residents' medications were stored. The temperature logbook for the first-floor refrigerator showed missing entries for several days in April 2024, indicating a lack of proper monitoring to ensure medication integrity. The unit manager acknowledged that the night shift nurses were responsible for maintaining the logbooks and recognized the need for re-education on this process.
Inaccurate Medical Records and Documentation Errors
Penalty
Summary
The facility failed to maintain complete and accurate medical records for two residents during a recertification and complaint survey. For one resident, there were discrepancies in the documentation of dialysis access sites. The medical record inaccurately indicated the presence of a right jugular tunneled dialysis catheter, which had been discontinued once the left arteriovenous fistula became functional. Additionally, there was a lack of documentation regarding the resident's fluid intake, despite an order for a 1.5 L/day fluid restriction. Furthermore, an audiology consult order remained active in the records even after the appointment had been scheduled, leading to inaccurate staff documentation. For another resident, the facility's records failed to include specific orders for water flushes during medication administration, as required by the resident's enteral feeding protocol. The active orders and the Medication Administration Record (MAR) and Treatment Administration Record (TAR) did not reflect the necessary water flushes during medication pass, which were outlined in an outdated enteral protocol form. The protocol form in the resident's paper chart was not updated to match the current tube feeding orders, leading to inconsistencies in the documentation. Interviews with staff, including unit managers and the Director of Nursing, confirmed the inaccuracies and omissions in the medical records. Staff acknowledged that the documentation did not accurately reflect the residents' current medical orders and protocols. The discrepancies in the records were attributed to outdated information and a lack of proper updates in the electronic and paper records, which resulted in staff following incorrect procedures.
Infection Control Deficiencies in PPE Use and Catheter Maintenance
Penalty
Summary
The facility failed to ensure staff donned appropriate personal protective equipment (PPE) for enhanced barrier precautions and did not timely implement and follow the medical order for these precautions. This was evident for a resident with pressure injuries. The resident was admitted with wounds, and the medical order for enhanced barrier precautions was implemented approximately nine days later. During this period, staff inconsistently used PPE, with some staff not wearing gowns during wound care and repositioning, despite the facility's expectations. The resident and their roommate expressed concerns about the lack of communication and inconsistent use of PPE. Additionally, the facility did not use appropriate infection control practices during urinary catheter maintenance for another resident. The urine collection bag for this resident was observed on the floor, which is against standard infection control practices. The Director of Nursing acknowledged that this was unacceptable. These deficiencies were identified during a recertification survey, highlighting lapses in infection prevention and control practices at the facility.
Failure to Document Flu Vaccine Education
Penalty
Summary
The facility staff failed to document that residents and/or their Responsible Parties (RPs) were provided education on the Influenza vaccine before requesting consent. This deficiency was identified during a survey when reviewing the immunization records of five randomly selected residents. Specifically, for one resident, who had been residing at the facility since December 2023 and refused the Flu vaccine, there was no documentation to support that the resident or their RP received education regarding the flu vaccine. During an interview, the Infection Control Preventionist (Staff #15) stated that they provide education on the Flu and Pneumonia vaccines and obtain consents, documenting these actions in the electronic medical record under the immunization tab. However, it was confirmed that for the resident in question, although verbal education was provided to a family member, it was not documented. This lack of documentation was acknowledged by the Nursing Home Administrator (NHA) and Director of Nursing (DON) when the surveyor shared the concern.
Inadequate Pressure Ulcer Management
Penalty
Summary
The facility failed to provide adequate pressure ulcer management for a resident who was admitted with a stage two sacral pressure wound. Over approximately eight weeks, the resident's condition worsened to a stage 4 sacral pressure wound. The medical record review revealed that the facility did not provide the necessary wound care treatments to prevent the deterioration of the resident's condition. The attending provider only ordered specialized wound care treatment after the wound had progressed to stage 4. An interview with the Director of Nursing confirmed the facility's failure to provide preventative wound care, acknowledging the deficiency in managing the resident's pressure wound.
Failure to Monitor Psychotropic Medication Use
Penalty
Summary
The facility failed to ensure residents remained free from unnecessary medications, as observed during a recertification survey. Resident #138 was found to have been prescribed psychotropic medications without comprehensive monitoring for side effects or behavior. The surveyor noted that the resident had been on trazodone, a psychotropic medication, with PRN orders not limited to 14 days, contrary to recommendations. The Director of Nursing (DON) and other staff acknowledged the lack of monitoring and the oversight in reordering monitoring upon the resident's readmission. Resident #163 was also found to have active orders for psychotropic medications, including Lorazepam and Seroquel, without corresponding orders for monitoring side effects or behavior. The resident's assigned nurse and the facility Administrator confirmed that such monitoring should have been in place but was not ordered. The facility's process for ensuring monitoring was described by the DON, but it was evident that the process was not effectively implemented for this resident. Additionally, Resident #545's case revealed a delay in implementing a recommended gradual dose reduction (GDR) for Seroquel. The facility's contracted agency psychiatric nurse practitioner failed to assess the resident for the GDR due to an oversight in locating the medication in the resident's orders. Consequently, the resident continued to receive the higher dose until the attending provider ordered the reduction. The DON acknowledged the delay and the surveyor expressed concern over the facility's handling of the GDR recommendation.
Failure to Provide Timely Dental Services
Penalty
Summary
The facility failed to ensure timely dental services for residents requiring routine or emergent care, as evidenced by the cases of two residents. One resident had a dental consult order for a loose tooth placed in April 2023, which was discontinued in February 2024 due to a hospital readmission. The resident expressed a desire to have missing teeth replaced, but there was no record of a dental appointment or consult being scheduled. The Unit Manager and Nursing Home Administrator were unaware of the resident's dental concerns until the surveyor's inquiry, and the resident had not been seen by a dentist since the initial order. Another resident's family member had requested a dental appointment for a cracked tooth and decay in March 2024, but no appointment was arranged. The social worker responsible for the Long-Term Care Unit was not aware of the request, as it was not communicated by the previous social worker or nursing staff. The family member reported multiple attempts to arrange the appointment through various staff members, including the administrator, but no action was taken. The deficiencies highlight a lack of communication and follow-through in scheduling necessary dental services for residents. The facility's processes for handling dental consults and appointments were inadequate, leading to delays in care and unmet needs for the residents involved.
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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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