Lorien Nursing & Rehab Ctr - Elkridge
Inspection history, citations, penalties and survey trends for this long-term care facility in Elkridge, Maryland.
- Location
- 7615 Washington Boulevard, Elkridge, Maryland 21075
- CMS Provider Number
- 215357
- Inspections on file
- 18
- Latest survey
- February 12, 2026
- Citations (last 12 mo.)
- 20
Citation history
Health deficiencies cited at Lorien Nursing & Rehab Ctr - Elkridge during CMS and state inspections, most recent first.
A resident’s family member reported that a GNA told her that residents and their representatives were not allowed to speak directly with state surveyors who were on site. Instead of bringing the family member to a surveyor, the GNA provided contact information for the state oversight agency to file a complaint. The family member subsequently filed a complaint, and record review confirmed the complaint submission, demonstrating that the resident’s representative was discouraged from and not permitted to communicate directly with surveyors.
A resident with hemiplegia, muscle weakness, impaired coordination, and documented need for one-person assistance with transfers and partial to moderate assistance for toilet transfers experienced prolonged delays in call bell response when requesting toileting help. The resident reported long waits, attempted to toilet without assistance, and had multiple falls. Review of call bell logs showed several response times exceeding the facility’s stated 20-minute expectation, including one response over 24 minutes. A GNA reported inadequate staffing to meet care needs, and the resident’s family reported new episodes of incontinence since admission, which they associated with prolonged call bell response times.
Facility staff did not conduct an investigation after a resident's family reported missing personal items, including a puzzle and an electronic sound amplifier device. The resident's medical record lacked an inventory sheet for these items, and the DON confirmed that no investigation was performed.
Nursing staff did not document ADL care for a resident on three separate shifts, as confirmed by the DON during a complaint survey. This lack of documentation was identified after a family complaint regarding care and the development of a preventable wound.
A resident with left-sided hemiparesis, requiring total care, fell from bed during ADL care due to inadequate assistance, resulting in a humeral neck fracture and hematoma. Despite care plans indicating the need for two-person assistance, a GNA attempted care alone, leading to the incident. Subsequent evaluations revealed the extent of injuries, and staff interviews confirmed the resident's dependency on two-person support for ADL care.
A resident with one-sided impairment and dependent on staff for toileting reported long wait times for call bell responses over a weekend. The facility's policy requires call bells to be answered within 20 minutes, but logs showed delays of 28 and 55 minutes. The Second Floor Supervisor confirmed the expectation for timely responses but could not explain the delays.
A resident with a history of ischemic CVA and requiring total care experienced a medical event involving excessive sweating and a distended abdomen. The physician was notified, and an x-ray was ordered, but the Responsible Party (RP) was not informed until after the resident's passing. The delay in notification was acknowledged by the DON, who confirmed that the RP should have been updated on changes in the plan of care.
A facility failed to thoroughly investigate a missing credit card incident reported by a resident. The investigative file lacked documentation of staff and resident interviews or evidence from the bank about fraudulent use. The DON confirmed no additional documentation was available, indicating an incomplete investigation.
A facility failed to document staff training on the application of a sling for a resident with a humeral fracture. Despite the family's concerns and the DON's acknowledgment of the need for training, there was no evidence of an in-service being conducted. Interviews revealed inconsistencies and lack of documentation regarding the training, contributing to the deficiency identified by the surveyor.
A resident experienced a delay in receiving necessary x-ray services after an incident where their legs slid out of bed, resulting in a bruise. Despite orders for x-rays of the left rib, humerus, and shoulder, the facility failed to obtain the services in a timely manner, leading to the resident being transferred to the hospital for evaluation. The facility has since changed its radiology service provider.
A facility failed to involve a resident's guardian in the initial care planning process, violating the resident's rights. The resident, with a history of schizophrenia, epilepsy, and edema, was incorrectly designated as their own representative. The baseline care plan lacked a written summary and signatures from the resident or their representative. Despite a hospital discharge summary indicating updated decision-making capacity, this information was not in the facility's records. The Social Work Director acknowledged speaking with the guardian, but the Nursing Home Administrator noted that staff should have been aware of the guardianship status.
The facility failed to assist two residents in formulating or obtaining advance directives, as revealed during an annual survey. Both residents lacked documentation indicating whether they had advance directives or were offered assistance in creating one. The social director confirmed the oversight, acknowledging that the residents were not provided with the opportunity to formulate advance directives.
A facility failed to complete a Significant Change in Status MDS within 14 days for a resident enrolled in hospice care. The resident was admitted to hospice, but the MDS did not reflect this change, as confirmed by the MDS Coordinator during a survey review.
The facility staff inaccurately coded the MDS assessments for two residents. One resident was incorrectly marked as having natural teeth, while another resident's Foley catheter was not documented, leading to inaccurate coding of urinary incontinence. The errors were acknowledged by the MDS Coordinator.
A facility failed to complete a comprehensive baseline care plan for a resident with a history of disorientation, malnutrition, and diabetes. The care plan lacked specific details in dietary and therapy sections, and there was no documentation of the resident's dietary preferences or goals. Interviews revealed that multiple disciplines did not document initial goals or care plans, leaving the resident uninformed about the services to be provided.
A facility failed to conduct timely care plan meetings for a resident following quarterly assessments, as required for effective care planning. Despite an audit identifying missing meetings for multiple residents, documentation for the resident in question remained incomplete, indicating a lapse in the facility's care planning process.
The facility failed to document and provide activities that meet the needs of two residents, as observed during an annual survey. One resident was unable to recall any activities and had no documentation of participation for several months, while another resident reported not being offered activities despite expressing interest. The Activities Director cited staffing shortages and admitted to incomplete assessments and documentation, leading to a deficiency in meeting the residents' needs for socialization and engagement.
A facility failed to have physician orders for a resident's foley catheter care, despite the resident's history of sepsis, UTIs, and obstructive uropathy. The absence of orders led to no documented foley care in the Treatment Administration Record. The DON confirmed the oversight, noting that without an order, the task was not assigned.
A resident with a stage 2 pressure ulcer on the heels was not consistently provided with protective boots as ordered, despite having a care plan indicating the need for pressure relief interventions. Observations showed the resident without boots in bed, and the TAR lacked documentation for these interventions. An LPN and the DON confirmed the boots should have been applied, highlighting a deficiency in pressure ulcer care.
A resident experienced issues with bowel regularity, and the facility failed to follow its bowel protocol. Despite having an order for MiraLax to treat constipation, it was not administered, and bowel movements were not documented on several days. The facility's protocol required specific steps to address constipation, which were not followed, leading to the deficiency.
The facility failed to ensure timely certification for nurse aides in training (NAITs), as three NAITs did not obtain Geriatric Nursing Assistant (GNA) licensure within the required timeframe. One NAIT was reassigned until licensure was obtained, another continued working until resignation, and a third was employed beyond the permissible period without proper enrollment records. The HR Director acknowledged the issue and confirmed discrepancies in employment status.
The facility failed to maintain professional standards in food service safety, with multiple instances of unlabeled and improperly stored food items observed. Unlabeled spices, cheese, meat, and eggs were found, along with missing dishwasher temperature log entries and improperly stored wet bowls. Further inspections revealed continued issues with unlabeled and undated food items, indicating non-compliance with food safety standards.
The facility failed to maintain medical records according to professional standards, as evidenced by incomplete documentation for two residents. One resident's COVID-19 test result lacked a date, and another resident's MOLST form was incomplete, with discrepancies in the code status between the electronic medical record and the care plan.
A facility failed to maintain infection control practices, including a foley catheter drainage bag left on the floor, discrepancies in PICC dressing change documentation, and a GNA handling soiled linen without gloves or hand sanitization.
Resident Representative Discouraged From Speaking Directly With State Surveyors
Penalty
Summary
The facility failed to permit a resident’s representative to speak directly with state surveyors during a recertification survey. During an interview, the family member of Resident #14 reported that a Geriatric Nursing Assistant (GNA #23) told her that residents and their representatives were not allowed to speak directly with state surveyors who were on site. Instead of facilitating contact with the surveyors, GNA #23 provided the family member with contact information for the Office of Health Care Quality (OHCQ) to file a complaint. Complaint record review confirmed that the family member subsequently filed a complaint with OHCQ. This conduct resulted in the resident’s representative being discouraged from and not permitted to communicate directly with the state surveyors who were present in the facility. No additional medical history or clinical condition for the resident was provided in the report.
Failure to Provide Timely Assistance With Toileting and Call Bell Response
Penalty
Summary
The facility failed to provide timely assistance with activities of daily living (ADLs), specifically toileting, to a resident who required staff help. The resident, admitted in January 2026 with hemiplegia and hemiparesis affecting the left non-dominant side, muscle weakness, difficulty walking, and lack of coordination, reported long wait times for staff to respond to the call bell when needing restroom assistance. Due to these delays, the resident stated they attempted to use the restroom without assistance and fell on multiple occasions. Record review showed the resident had unwitnessed falls in January and February 2026, and the baseline care plan from January 2026 documented a need for one-person assistance with transfers. An MDS from January 2026 indicated upper and lower extremity impairment and a need for partial to moderate assistance with toilet transfers. The care plan documented a fall on 01/21/2026 and included a goal initiated on 01/22/2026 for the resident to use the call bell and wait for staff assistance. During an interview, the Administrator stated that staff are expected to respond to call bells immediately, but no longer than 20 minutes. Review of the call bell response log for the resident’s room between January and February 2026 revealed multiple instances where response times exceeded 20 minutes. On 02/09/2026, the call bell was activated at 6:59 PM and staff responded 24.31 minutes later. A GNA reported that the facility was not adequately staffed to meet residents’ care needs. The resident’s family member reported that the resident, who was continent of bowel and bladder at admission, had episodes of incontinence attributed to prolonged call bell response times. These findings were reviewed with the Administrator on 02/11/2026.
Failure to Investigate Missing Personal Items Complaint
Penalty
Summary
Facility staff failed to thoroughly investigate a complaint regarding missing personal items belonging to a resident. The resident's family reported that an adult puzzle and an electronic sound amplifier device were missing from the resident's room. Upon review, there was no evidence in the resident's medical record of an inventory sheet listing these items. Additionally, the Director of Nursing confirmed that no investigation into the missing items had been conducted, despite the complaint being reported and the items being identified as missing during a room search.
Failure to Document ADL Care in Resident Medical Record
Penalty
Summary
Facility nursing staff failed to accurately document activities of daily living (ADL) care in the medical record for a resident on three separate shifts. Specifically, there was no documentation of ADL care provided on the day shift of 1/15/25, the evening shift of 1/20/25, and the night shift of 1/23/25. This deficiency was identified during a complaint survey following a family report that the resident did not receive necessary ADL care, which allegedly contributed to the development of a preventable wound. The Director of Nursing (DON) confirmed during an interview that the nursing staff did not document the required ADL care for the resident on the specified dates.
Failure to Provide Adequate Assistance Leads to Resident Fall and Injury
Penalty
Summary
The facility failed to adequately assess and assist a dependent resident during Activities of Daily Living (ADL) care, resulting in a fall from bed and actual harm to the resident. The resident, who was admitted in early 2023, had left-sided hemiparesis and required total care, being unable to participate in medical decision-making. The care plan initially required 1-2 staff for bed mobility, but was revised to require 2 staff by July 2023. Despite this, a Geriatric Nursing Assistant (GNA) attempted to perform care alone, leading to the resident's fall. The incident occurred when the GNA was providing afternoon care and attempted to roll the resident onto their side, causing the resident's legs to slide out of bed while the upper torso remained in bed. Although initially no injuries were noted, subsequent medical evaluations revealed a humeral neck fracture and a muscular hematoma, necessitating a blood transfusion due to anemia. The resident's care plan and assessments consistently indicated the need for extensive assistance and two-person support for bed mobility, which was not adhered to during the incident. Interviews with staff, including the GNA involved and the LPN responsible for care planning, confirmed that the resident required a two-person assist for all ADL care. The facility's investigation report highlighted that the Nursing Assistant in Training (NAT) involved in the incident had received training on safe resident lifting and transfers, which emphasized the need for two staff members for repositioning in bed. The Director of Nursing (DON) acknowledged the discrepancy in the care plan and confirmed that it was adjusted post-incident to reflect the need for two-person assistance for all ADL care.
Delayed Call Bell Response for Dependent Resident
Penalty
Summary
The facility failed to answer call bells in a timely manner to attend to the needs of dependent residents, specifically for one resident on the Second Floor Nursing Unit. During an interview, the resident reported that over the weekend, they used the call bell to request assistance to the bathroom, but it took a long time for the staff to respond. The resident expressed difficulty in waiting for assistance when needing to use the bathroom. A review of the resident's electronic medical record revealed that the resident has an impairment on one side and is dependent on staff for toileting and transferring needs. The surveyor requested and reviewed the call light response time log for the resident, which confirmed that on a specific date, the call light was on for 28 minutes and later for 55 minutes and 51 seconds. The facility's Call Light Policy states that call lights should not be ignored, and the Routine Resident Checks policy specifies that call bells should be answered within 20 minutes. The Second Floor Supervisor confirmed the expectation for call lights to be answered within 20 minutes and acknowledged the delay in response time but was unable to determine the reason for the prolonged wait.
Failure to Timely Notify Responsible Party of Treatment Changes
Penalty
Summary
The facility failed to inform the Responsible Party (RP) of Resident #70 about the need to alter treatment in a timely manner. Resident #70, who had a history of ischemic CerebroVascular Accident (CVA) with left-sided hemiparesis and required total care, was admitted to the facility in early 2023. On a particular day, the resident was noted to have excessive sweating and a distended abdomen with hypoactive bowel sounds. The physician was notified, and an abdominal x-ray was ordered. However, the RP, identified as the resident's granddaughter, was not informed of these developments until later in the afternoon. The delay in notifying the RP was documented by LPN #28, who noted that the call to the RP was delayed due to pending abdominal x-ray results. Despite the physician being updated and an x-ray being ordered, the RP was not informed of the morning events until after Resident #70 had passed away at 3:10 PM. The Director of Nursing (DON) confirmed that the RP should have been notified of changes in the plan of care and acknowledged the delay in notification as documented by the LPN.
Incomplete Investigation of Missing Credit Card
Penalty
Summary
The facility failed to maintain documentation that a Facility Reported Incident (FRI) was thoroughly investigated for one resident out of thirteen during the annual survey. The deficiency was identified when a resident reported a missing credit card months prior, and the surveyor found that the facility's investigative file lacked comprehensive documentation. The file contained initial and follow-up report forms submitted to the Office of Health Care Quality, but there were no records of interviews with facility staff, other residents, or evidence from the bank regarding fraudulent use of the credit card. The Director of Nursing confirmed that no additional documentation was available, indicating an incomplete investigation into the reported incident.
Failure to Document Staff Training on Sling Application
Penalty
Summary
The facility failed to provide necessary education for the application of a sling device after a knowledge deficit was identified among staff. This deficiency was observed in the case of a resident who had been admitted to the facility in early 2023. The resident had suffered a fall resulting in a mildly impacted humeral neck fracture and a left pectoral muscular hematoma, requiring nonoperative management with a sling. Despite the physician's note indicating the family's concern about staff's ability to manage the sling and the Director of Nursing's (DON) acknowledgment of the need for an in-service training, there was no documentation to confirm that such training was conducted. Interviews with the DON and the Occupational Therapist (OT) revealed inconsistencies and lack of documentation regarding the in-service training. The OT recalled conducting an in-service on the standard sling but could not confirm the attendance or documentation of the training. The DON was unable to provide any evidence of the training being completed, and no documentation was found in the medical record or elsewhere to indicate that staff had been adequately trained to manage the resident's sling. This lack of documentation and follow-through on training contributed to the deficiency identified by the surveyor.
Failure to Provide Timely Radiology Services
Penalty
Summary
The facility failed to provide timely radiology services for Resident #70, who was admitted in early 2023. On July 15, 2023, a Licensed Practical Nurse (LPN) documented an incident where the resident's legs slid out of bed while a Geriatric Nursing Assistant (GNA) was providing care, resulting in a bruise. The LPN communicated this observation to a provider on July 17, 2023, who requested lab tests and clarification of the fall. On July 18, 2023, the Nurse Supervisor sought further clarification and inquired about the need for an x-ray. The resident's physician and Medical Director ordered x-rays for the left rib, humerus, and shoulder later that day. Despite the order, the x-ray was not completed at the facility. On July 19, 2023, the Medical Director noted that staff had been unable to obtain an estimated time of arrival from the radiology service. Due to the resident's pain and the possibility of a fracture, the resident was transferred to the hospital's emergency room for evaluation. The Director of Nursing confirmed that the x-ray order was placed on July 18, 2023, and was scheduled for completion on July 19, 2023, but the radiology company did not fulfill the order. The facility has since changed its radiology service provider.
Failure to Involve Guardian in Care Planning
Penalty
Summary
The facility failed to involve a resident's guardian in the initial care planning process, which is a violation of the resident's rights. The deficiency was identified during a review of the medical records and interviews conducted by the surveyor. Resident #162 was admitted to the facility with a history of schizophrenia, epilepsy, and edema. The baseline care plan incorrectly designated the resident as their own representative, and there was no written summary or signatures from the resident or their representative on the care plan. The Social Work Director and Nurse Supervisor signed the document, but the guardian's involvement was not documented. Further investigation revealed that a hospital discharge summary indicated the resident's capacity to make care decisions was updated prior to admission, but this information was not included in the facility's records. During interviews, the Social Work Director acknowledged speaking with the resident's guardian and requesting guardianship paperwork, but the Nursing Home Administrator stated that admissions and nursing staff should have been aware of the guardianship status. The incorrect assessment of the responsible party led to the failure to involve the guardian in the care planning process.
Failure to Assist Residents with Advance Directives
Penalty
Summary
The facility failed to assist residents in formulating or obtaining an advance directive, as evidenced by the cases of two residents during an annual survey. Resident #54 was admitted in late August 2024, and a social worker assessment was completed on August 22, 2024. However, the assessment did not indicate whether the resident had an advance directive or if they were offered assistance in formulating one. During an interview, the social director confirmed that the necessary documentation was missing, and the resident was not offered help in creating an advance directive. Similarly, Resident #162, admitted in early September 2024, also lacked documentation regarding advance directives. A social worker assessment completed on September 6, 2024, failed to show whether the resident had an advance directive or was offered assistance in formulating one. The social director acknowledged the oversight during an interview, confirming that the resident was not provided with the opportunity to create an advance directive. These findings highlight the facility's failure to comply with regulations regarding residents' rights to formulate advance directives.
Failure to Complete Significant Change MDS for Hospice Enrollment
Penalty
Summary
The facility failed to accurately assess and complete a Significant Change in Status Minimum Data Set (MDS) assessment within 14 days of a resident's enrollment into a hospice program. This deficiency was identified during an annual survey for one resident who was investigated for hospice care. The MDS is a comprehensive assessment tool used to evaluate a resident's functional, medical, psychosocial, and cognitive status to develop a personalized care plan. A Significant Change in Status MDS is required when a resident enrolls in a hospice program, which provides specialized care for individuals with a life expectancy of six months or less. The surveyor discovered that the resident was admitted to a hospice program on June 7, 2024, as indicated by a physician's order. However, during a review of the Significant Change in Status MDS with an assessment reference date of June 17, 2024, it was found that the enrollment into the hospice program was not addressed in the assessment. MDS Coordinator #5 confirmed that the resident's enrollment in hospice should have triggered a Significant Change in Status MDS, which was not completed as required. This oversight was confirmed during an interview with the MDS Coordinator and a review of the assessment documentation.
Inaccurate MDS Coding for Two Residents
Penalty
Summary
The facility staff failed to accurately code the Minimum Data Set (MDS) assessments for two residents during the annual survey. For one resident, the MDS assessment incorrectly indicated that the resident was not edentulous, despite observations confirming the resident had no natural teeth. The MDS Coordinator acknowledged the error during an interview and confirmed that the coding was incorrect. For another resident, the MDS assessment failed to document the presence of an indwelling Foley catheter, despite the resident's medical history and care plan indicating its use due to obstructive uropathy. The MDS Coordinator admitted to missing this detail, as he primarily relied on physician orders and nursing assessments, which did not include an order for the Foley catheter. This oversight led to the resident being inaccurately coded as always having urinary incontinence.
Failure to Complete Baseline Care Plan for Resident
Penalty
Summary
The facility failed to adequately include and review all initial healthcare information and goals in the baseline care plan for a resident. Upon admission in early July 2024, the resident had a medical history of disorientation, protein-calorie malnutrition, and diabetes. Despite being alert and oriented to self, the resident was not oriented to place or time. The baseline care plan, completed shortly after admission, lacked specific details in several sections, including dietary and therapy orders, functional goals, and therapy services. Additionally, there was no documentation of the resident's dietary preferences, risks, or goals, and the section for the resident or representative's signature was left blank. Interviews with the Social Work Director and the Nursing Home Administrator revealed that the responsibility for completing the baseline care plan was divided among different disciplines. However, several disciplines failed to document initial goals or the care to be provided, leaving the resident uninformed about the plans and services to be rendered. The lack of a comprehensive baseline care plan and the absence of a care plan meeting contributed to the deficiency identified by the surveyor.
Failure to Conduct Timely Care Plan Meetings
Penalty
Summary
The facility failed to facilitate timely care plan meetings for a resident following their quarterly assessments, which is a requirement to ensure the resident and their representative can participate in the care planning process. This deficiency was identified during an annual survey, where it was found that care plan meetings were not held after several MDS assessments, including quarterly and annual assessments. Specifically, for one resident, care plan meetings were documented on only a few occasions, despite multiple assessments being conducted over the period. The Social Services Director confirmed the absence of timely care plan meetings and acknowledged that an audit had previously identified this issue for multiple residents. Despite the audit and efforts to rectify the situation, documentation for the resident in question was still lacking. The deficiency highlights a failure in the facility's process to ensure regular and documented care plan meetings, which are crucial for evaluating the effectiveness of the resident's care.
Deficiency in Meeting Residents' Activity Needs
Penalty
Summary
The facility failed to evaluate and document activities that meet the needs of residents, as evidenced by the cases of two residents during an annual survey. Resident #38 was observed in bed with outdated activity calendars and was unable to recall any activities provided by the facility. The resident's care plan indicated a need for assistance with activities and a preference for group activities, but there was no documentation of participation in activities for several months. The Activities Director acknowledged the lack of documentation due to staffing shortages and confirmed that no records showed the resident's engagement in activities. Resident #54 reported not being offered activities and expressed interest in participating. The resident's medical record showed an admission in late August 2024, but there was no documentation of activities being offered or provided. The MDS assessment indicated preferences for reading materials, music, and group activities, among others. However, the Activities Director admitted that no Home and Lifestyle Assessment was completed, and there was minimal documentation of activities offered, with only a beverage and nail care recorded for September 2024. The surveyor's investigation revealed significant gaps in the documentation and provision of activities for both residents, highlighting a deficiency in meeting the residents' needs for socialization and engagement. The lack of documentation and assessment of residents' preferences contributed to the failure to provide appropriate activities, as required by the residents' care plans and preferences.
Lack of Physician Orders for Foley Catheter Care
Penalty
Summary
The facility failed to have physician orders written to ensure proper care and treatments were in place for a resident with a foley catheter. This deficiency was identified during a survey when reviewing the medical records of a resident who was readmitted to the facility after a hospital stay. The resident had a history of sepsis due to MRSA, urinary tract infections, and obstructive uropathy, which necessitated the use of a foley catheter. Despite the presence of a care plan for bladder elimination issues, there were no physician orders documented for the foley catheter or its care. The surveyor's review of the Treatment Administration Record (TAR) for September 2024 revealed no documentation of foley care. During an interview, the Director of Nursing confirmed the absence of orders for the foley catheter and acknowledged that without an order, the task was not assigned to the TAR. This oversight resulted in the lack of documented care for the resident's foley catheter, highlighting a gap in the facility's process for ensuring necessary medical orders and care documentation.
Failure to Provide Adequate Pressure Ulcer Care
Penalty
Summary
The facility failed to ensure that a resident received appropriate services to promote the healing of a pressure ulcer. This deficiency was identified for one resident who was observed multiple times without protective boots while in bed, despite having orders to elevate and float heels and apply off-loading boots for pressure relief. The resident had a care plan indicating a risk for pressure ulcers, which was later revised to include a stage 2 pressure ulcer on the heels. However, the protective boots were not consistently applied as required. The surveyor noted that the Treatment Administration Record (TAR) for the resident did not include documentation for pressure relief interventions. During an interview, an LPN confirmed that the resident should have been wearing the boots while in bed and acknowledged the presence of wounds on the resident's feet. The Director of Nursing also confirmed that the boots should have been applied according to the orders and that any refusal by the resident should have been documented. This lack of adherence to the care plan and physician orders contributed to the deficiency in pressure ulcer care.
Failure to Follow Bowel Protocol for Resident
Penalty
Summary
The facility failed to provide appropriate treatment for constipation and maintain bowel continence for a resident. The resident, who was readmitted to the facility after a hospital stay, reported issues with bowel regularity. The medical record review revealed that the resident had an order for MiraLax to be administered as needed for constipation, but it was not given despite several days without a documented bowel movement. The facility's bowel protocol, which included steps to address constipation, was not followed. The surveyor noted that the resident's bowel movements were not recorded on multiple days, and the prescribed MiraLax was not administered according to the protocol. The facility's protocol required an abdominal assessment and the administration of prune juice and MiraLax if no bowel movement occurred within specified timeframes. However, these steps were not taken, leading to the deficiency. The Director of Nursing was informed of the concern that the bowel protocol was not adhered to for the resident.
Failure to Ensure Timely Certification for NAITs
Penalty
Summary
The facility failed to ensure that nurse aides in training (NAITs) obtained appropriate certification within the required timeframe, as evidenced by the cases of three NAITs. NAIT #24 was hired during the pandemic waiver period and was required to obtain Geriatric Nursing Assistant (GNA) licensure by the end of the waiver period. However, the licensure was not obtained in time, leading to her reassignment to the Assisted Living side of the facility until she obtained her licensure. NAIT #25 also did not obtain licensure within the required timeframe and continued to work as a NAIT until her resignation. The Human Resources (HR) Director acknowledged the issue and stated that a process is now in place to track educational progress for all NAITs. Additionally, NAIT #26 was hired as a dietary aide and there were no records indicating her enrollment in a nurse-in-training program. Despite completing her training and obtaining certification, she was employed as a NAIT beyond the permissible period and was incorrectly coded as a GNA for her last two days of employment. The HR Director confirmed these discrepancies, indicating a failure in the facility's process to ensure timely certification and proper employment status for NAITs.
Deficiency in Food Storage and Labeling Practices
Penalty
Summary
The facility failed to adhere to professional standards of food service safety, as observed during a survey. During an initial kitchen tour, several items, including bottles of Oregano, Italian Seasoning, and Old Bay, were found unlabeled regarding their opening and discard dates. Additionally, unlabeled cheese, a meat patty, a bag of meat, and an opened scrambled egg carton were identified. The Dietary Team Lead acknowledged that labeling might have been missed. A dishwasher temperature log was found with missing entries, and wet bowls were improperly stored upright, preventing proper drainage. Further observations revealed ongoing issues with food labeling and storage. On a subsequent visit, a refrigerator on the second floor contained an open pudding container and other resident food items that were unlabeled and undated. The process for labeling food was unclear among staff, as indicated by the responses from a Unit Secretary and a Registered Nurse. During a kitchen revisit, a container of egg salad was found past its labeled expiration date, and jars of mayonnaise and mustard were without labels or dates, indicating continued non-compliance with food safety standards.
Deficiencies in Medical Record Documentation
Penalty
Summary
The facility failed to maintain medical records in accordance with professional standards, as evidenced by deficiencies found in the records of two residents. For one resident, the surveyor discovered incomplete documentation related to a COVID-19 test. The paper medical record contained a point-of-care COVID antigen test result that was positive, but the form lacked a date indicating when the test was performed. This incomplete documentation was brought to the attention of the Director of Nursing. Another deficiency was identified in the medical records of a second resident, where the Maryland Medical Orders for Life-Sustaining Treatment (MOLST) form was incomplete. Although the first page of the MOLST form was filled out, signed, and dated with a Do Not Intubate (DNI) code status, the second page was incomplete. Additionally, there was a discrepancy in the resident's electronic medical record, which showed a care plan with a code status of Do Not Resuscitate, Intubate (DNR A-1), conflicting with the physician's order of DNI A-2. This inconsistency was confirmed by the Assistant Director of Nursing.
Infection Control Deficiencies in LTC Facility
Penalty
Summary
The facility failed to maintain infection prevention practices, as evidenced by several observations. In one instance, a resident's foley catheter drainage bag was observed lying on the floor, which could increase the risk of infection. Despite being informed by a Geriatric Nursing Assistant (GNA) that the clip was broken, the Licensed Practical Nurse (LPN) did not address the issue promptly, leaving the bag on the floor for approximately an hour. This delay in response was acknowledged by the Director of Nursing (DON) during a review of the concern. Another deficiency was noted when a Registered Nurse was observed changing a resident's Peripherally Inserted Central Catheter (PICC) dressing. The dressing was labeled with a date that did not match the documented change date in the Medication Administration Record (MAR). The DON confirmed that the dressing had not been changed as documented, due to the resident being at therapy, and acknowledged that the documentation was completed prior to the actual dressing change. Additionally, a GNA was observed handling soiled linen without gloves and subsequently touching a clean linen cart without sanitizing hands, which was later acknowledged by the GNA as a lapse in infection control practice.
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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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