Manokin Nursing And Rehab
Inspection history, citations, penalties and survey trends for this long-term care facility in Princess Anne, Maryland.
- Location
- 11974 Edgehill Terrace, Princess Anne, Maryland 21853
- CMS Provider Number
- 215179
- Inspections on file
- 27
- Latest survey
- April 1, 2026
- Citations (last 12 mo.)
- 44 (2 serious)
Citation history
Health deficiencies cited at Manokin Nursing And Rehab during CMS and state inspections, most recent first.
A resident with dementia and PTSD, who had moderate cognitive impairment, was involved in an altercation with the facility Administrator during a smoking break. Witnesses, including staff and cognitively intact residents, reported that the Administrator blocked the door to prevent the resident from re-entering the building due to a cigarette, pushed the resident in the chest multiple times, and used a racial slur. The resident stated the Administrator was hitting them and calling racial slurs while they tried to return inside, leading the resident to choke the Administrator to get past her. These actions constituted physical and verbal abuse by the Administrator, in violation of the facility’s abuse policy and the resident’s right to be free from abuse, and were cited at an Immediate Jeopardy level under 42 CFR 483.12.
A facility failed to report an allegation of abuse to the state survey agency within the required two-hour timeframe after a resident with dementia and moderate cognitive impairment was involved in a physical altercation with the Administrator following a smoking break. The resident reported being pushed and yelled at by the Administrator after refusing to pick up a discarded cigarette and surrender an unlit cigarette, leading the resident to choke the Administrator. Two CNAs stated they saw the Administrator blocking the door, shoving the resident, and slamming the door shut when staff tried to deescalate the situation, which escalated the resident’s behavior. An LPN on duty received reports that the Administrator provoked the resident and that the resident alleged being pushed, and she notified the family, police, DON, and MD, but the required external report to the SSA was not submitted until several days later, contrary to facility policy and regulatory timeframes.
Staff failed to maintain an accurate medical record when a progress note documented a telehealth visit for a resident who was not present in the facility at the time. The entry lacked required annotations for late entry or error, and staff could not explain the discrepancy.
A resident with impaired vision and intact cognition reported a missing ring, but staff failed to maintain an inventory of the resident's belongings and did not document or investigate the loss according to facility policy. Interviews and record reviews confirmed the absence of an inventory list and grievance documentation related to the missing item.
Two residents experienced physical abuse by staff members, including a cognitively impaired resident who was struck in the face by a GNA and another resident who was hit on the head by an intoxicated maintenance assistant. Both incidents were witnessed or reported by staff and other residents, and the facility's policies prohibiting abuse were not upheld.
A resident with severe cognitive and physical impairments, identified as high risk for falls, experienced multiple unwitnessed falls despite an existing care plan with fall prevention measures. After each fall, incident reports were completed, but no new interventions or care plan updates were documented or implemented to address the repeated incidents, as confirmed by record review and staff interviews.
Administrator Physical and Verbal Abuse of Resident During Smoking Break
Penalty
Summary
The deficiency involves the facility’s failure to protect a resident from physical and verbal abuse by the Administrator during a smoking break. The facility’s abuse policy prohibited abuse, including physical abuse such as hitting, slapping, and pushing, and verbal abuse such as the use of disparaging and derogatory terms, including when residents are within hearing distance regardless of their cognitive status. Resident #3, who had dementia, post-traumatic stress disorder, generalized anxiety disorder, and moderate cognitive impairment (BIMS score of 10), was participating in a smoke break when an altercation occurred with the Administrator. The resident reported that the Administrator allowed more residents than usual to go out to smoke and then began calling the resident racial slurs while the resident was smoking and attempting to return inside. According to Resident #3, when they tried to re-enter the building, the Administrator repeatedly hit them and blocked their way, leading the resident to choke the Administrator to get her out of the way. Multiple witnesses, including staff and residents, described the Administrator physically blocking the door and preventing Resident #3 from entering the facility because of a cigarette. CNA #1 stated she saw the Administrator standing in front of the door, screaming "no" at the resident, blocking the door, and pushing Resident #3 in the chest twice while the resident tried to get around her. An activity aide reported seeing the Administrator and the resident shoving each other, and that when she attempted to open the door with the keypad, the Administrator yelled "no" and told her not to open it, after which the resident choked the Administrator. Several cognitively intact residents who witnessed the event provided consistent accounts that the Administrator pushed Resident #3 and used a racial slur before the resident placed hands on the Administrator. One resident witness stated the Administrator pushed the resident back from the door twice and then used the N-word, after which the resident grabbed the Administrator by the throat. Another resident reported that the Administrator shoved the resident in the chest multiple times, causing the resident to rock back, and then called the resident a racial slur, which led to the resident becoming angry and choking the Administrator. Additional witnesses described the Administrator blocking the keypad with her body and hand, shoving the resident in the chest with both hands, and engaging in a verbal argument with the resident. Collectively, these accounts show that the Administrator initiated physical contact and used a racial slur toward Resident #3, constituting physical and verbal abuse in violation of the facility’s abuse policy and the resident’s right to be free from abuse. The surveyors determined that this conduct by the Administrator toward Resident #3 constituted non-compliance with 42 CFR 483.12, Freedom from Abuse, Neglect, and Exploitation, at a scope and severity level J, indicating Immediate Jeopardy that began on 02/05/2026 when the Administrator verbally and physically abused the resident.
Failure to Timely Report Allegation of Staff-to-Resident Abuse to SSA
Penalty
Summary
The deficiency involves the facility’s failure to report an allegation of resident abuse to the state survey agency (SSA) within the required two-hour timeframe, as required by its own abuse, neglect, and exploitation policy. The policy specified that all alleged violations involving abuse or resulting in serious bodily injury must be reported immediately, but not later than two hours after the allegation is made, to the Administrator, state agency, adult protective services, and other required agencies. Despite this requirement, the facility did not submit the initial Facility Reported Incident (FRI) for an abuse allegation involving Resident #3 and the Administrator until several days after the incident. Resident #3, who had dementia, post-traumatic stress disorder, generalized anxiety disorder, and moderate cognitive impairment (BIMS score of 10), was involved in a physical altercation with the Administrator following a smoking break. According to the incident report and resident’s account, the resident stated they were outside smoking, discarded a cigarette in the snow, and refused the Administrator’s instruction to pick it up. The resident further reported that the Administrator pushed them and demanded an unlit cigarette the resident wished to keep, and when the resident again refused, the Administrator continued pushing and saying the resident was not listening, leading the resident to choke the Administrator. The incident report categorized this as physical aggression initiated by the resident toward a staff member. Witness statements from two CNAs described the Administrator blocking the door and preventing the resident from reentering the building, with both the Administrator and the resident shoving each other. One CNA reported that when she opened the door to deescalate the situation, the Administrator slammed it shut with her body and yelled "No," which further triggered the resident, after which the Administrator shoved the resident again and the resident choked the Administrator. The nurse on duty stated that staff were required to report any witnessed or alleged abuse immediately, within two hours, and confirmed she was informed that the Administrator had provoked the resident and that the resident alleged the Administrator yelled at and pushed them. Although the nurse notified the resident’s family, local police, DON, and MD, the initial abuse report to the SSA was not submitted until days later, and facility leadership acknowledged that the incident and witness statements constituted an allegation of abuse that should have been reported immediately.
Inaccurate Medical Record Entry for Absent Resident
Penalty
Summary
Facility staff failed to maintain an accurate medical record for one resident who had been transferred to the hospital for suicidal ideation. During a review of the resident's records, a progress note was found documenting a telehealth visit on a date when the resident was not present in the facility. The unit manager was unable to explain why this note was entered, and the medical record director confirmed that the note did not include any indication of being a late entry or written in error, as required by facility policy. The Director of Nursing also confirmed that the resident was not in the facility on the date the telehealth visit was documented.
Failure to Maintain Resident Property Inventory and Investigate Lost Item
Penalty
Summary
The facility failed to protect a resident's property and provide a safe environment by not maintaining an inventory of the resident's belongings and not investigating a reported lost item. A resident with intact cognition and impaired visual function reported a missing ring to both staff and family. The care plan for this resident directed staff to inform the resident where items were placed due to visual impairment. Documentation showed that staff searched the room and contacted laundry, and the resident's family involved the state police. However, there was no evidence that a formal inventory of the resident's belongings was completed at admission, nor was there documentation of a grievance or investigation into the missing ring. Interviews with current staff, including the Social Services Director and the Nursing Home Administrator, confirmed the absence of an inventory list and a lack of documentation regarding the grievance or its resolution. Staff recalled being notified about the missing ring and informing the previous Social Services Director, but could not confirm if any follow-up or formal grievance process occurred. The facility's policy required completion of an inventory list at admission and a documented grievance process for missing items, but these procedures were not followed in this case.
Failure to Prevent Staff-to-Resident Physical Abuse
Penalty
Summary
The facility failed to protect residents from staff-to-resident abuse, resulting in two separate incidents involving physical abuse by staff members. In one case, a resident with severe cognitive impairment and diagnoses including Alzheimer's disease and major depressive disorder was involved in an altercation where a Geriatric Nurse Aide (GNA) struck the resident in the face after the resident had first smacked the aide. The incident was reported to the administrator, and the resident was assessed for pain and injury, with no physical harm noted at the time. The resident did not recall the event and denied pain, but the event was corroborated by other staff who heard the altercation. In another incident, a cognitively intact resident with diagnoses including spinal stenosis, bipolar disorder, and chronic heart failure reported being physically assaulted by a Maintenance Assistant (MA) who was intoxicated while on duty. The MA used profane language, hit the resident on the back of the head, and poked the resident on the shoulder. Another resident witnessed the event and noted the smell of alcohol on the MA's breath. The MA was observed by staff to be intoxicated, refused to leave the facility when directed, and was later reported to have struck the resident. The resident expressed fear of the MA following the incident. Both incidents were documented in the facility's records and confirmed through interviews with staff and residents. The facility's abuse prevention policy prohibits such actions and requires immediate reporting of abuse allegations. Despite these policies, the facility did not maintain an environment free from staff-to-resident abuse, as evidenced by these two events involving physical harm to residents by staff members.
Failure to Implement Post-Fall Interventions for High-Risk Resident
Penalty
Summary
The facility failed to provide adequate supervision and implement interventions to prevent multiple falls for a resident identified as being at high risk for falls. The resident had severe intellectual disabilities, major depressive disorder, restlessness, agitation, and severely impaired cognitive skills, and was dependent on staff for hygiene and mobility. The care plan identified the resident as at risk for falls and included specific interventions such as placing the bed against the wall, keeping the bed in the lowest position, ensuring proper posture, using floor mats, and applying a perimeter mattress. Despite these measures, the resident experienced multiple unwitnessed falls, each time being found on the floor next to the bed, sometimes with minor injuries. After each fall, incident reports were completed, but no new interventions were documented or implemented to address the repeated falls. Record reviews and staff interviews confirmed that after each fall, there was no evidence of updated interventions or care plan modifications. The Minimum Data Set Coordinator, Nursing Home Administrator, and Director of Nursing—all of whom were not employed at the time of the incidents—were unable to find documentation of any interventions added after the falls. The staff involved in the incidents were no longer employed and did not respond to inquiries. The lack of follow-up interventions after each fall event constituted a failure to ensure the area was free from accident hazards and that adequate supervision was provided to prevent further accidents.
Latest citations in Maryland
Facility staff did not ensure that 2nd floor residents who could not use stairs were able to receive visitors when the only elevator was out of service for an extended period. Complaints indicated that some family members, who were themselves unable to ambulate stairs, could not visit their relatives on the 2nd floor during this time. The emergency plan directed non-ambulatory 2nd floor residents to remain on that floor unless there was an emergency and did not address how visitation would be maintained when the elevator was inoperable. The Administrator reported that visitors could use the stairs and that an emergency chair system could be used to move residents, but also stated that the chair system was not used for visitation and was unaware of any complaints, despite two having been filed.
Facility staff did not complete required quarterly smoking safety assessments for several residents identified as smokers, including some who had not been reassessed for many months and one who had never been assessed during their stay. This issue was discovered during a complaint survey after the facility’s only elevator was out of service for an extended period, affecting a group of residents on an upper floor who needed to reach a designated smoking area on a lower floor. Review of records and staff interviews, including with the DON and a unit manager, confirmed that the facility’s own practice of quarterly smoking safety assessments for smokers was not followed for half of the affected residents.
Facility staff failed to accurately code multiple MDS assessments for several residents, leading to discrepancies between MDS entries and MARs for pain management, falls, and high-risk drug classes. In several cases, scheduled pain management was coded as provided when MARs did not show daily pain medications, often because an LPN counted low-dose Aspirin ordered for cardiovascular prophylaxis or heart failure as pain medication, contrary to RAI guidance. One resident’s falls were underreported on the MDS despite two documented falls, and daily use of a topical analgesic and an antiplatelet (Aspirin) was not correctly captured. Other residents had MDS entries indicating use of hypnotic or antianxiety medications when MARs showed none, while actual antidepressant and hypoglycemic medications administered daily were omitted from Section N0415. These errors were confirmed by the involved LPNs during surveyor interviews.
Staff failed to conduct complete investigations into two residents’ abuse allegations. In one case, a resident reported that an employee poked their face and made an obscene gesture, but the investigation lacked a statement from the corporate representative who was first notified of the allegation. In another case, a resident reported that someone in blue clothing put a hand by their face and over their mouth, with a specific GNA identified as the alleged perpetrator; however, the investigation did not include statements from two GNAs who were on duty on the unit at the time of the alleged incident, despite leadership having the opportunity to ensure all relevant documents were present.
Staff failed to create person-centered care plans for two residents, one with mobility limitations and one receiving peritoneal dialysis. For the resident with mobility issues, the care plan did not address the resident’s refusal to use a Hoyer lift and preference for pivot transfers, despite therapy prohibiting pivot transfers and staff awareness of the resident’s resistance. For the resident on peritoneal dialysis, the care plan did not specify that the treatment was peritoneal dialysis, nor did it include the treatment schedule or cycle time frames; an LPN Unit Manager acknowledged using a generalized renal care plan without incorporating the specific dialysis prescription.
A resident’s medical record lacked documentation confirming that scheduled showers or bed baths were provided on multiple dates, and there was also no record of any refusals of care on those days. The DON and an LPN unit manager reported that showers were scheduled on specific shifts and that completed showers and refusals should be documented on shower/skin sheets and in the care plan, but the surveyor found gaps where no such entries existed. This resulted in incomplete ADL documentation and failure to maintain medical records according to accepted professional standards.
A resident with multiple fractures and chronic pain was receiving an opioid-based pain regimen, including PRN hydromorphone. The resident was later found unresponsive and "out of it" by an LPN, who located an order for Narcan and administered it, with the resident responding to the medication. A physician note documented an opioid overdose treated with Narcan. Review of the medical record showed no documentation that the resident’s representative was notified of this significant change in condition and emergency intervention, and staff interviews confirmed that notification likely did not occur, despite the DON’s expectation that the responsible party should have been informed.
Staff failed to follow updated wound care orders and to document an opioid overdose event and Narcan use for two residents. One resident with venous and arterial lower extremity wounds did not receive the prescribed change from oil emulsion to daily skin prep on one foot wound, and did not receive ordered skin prep on a new plantar wound for several days after the wound physician revised the treatment plan. Another resident with multiple fractures and chronic pain, receiving multiple opioid and adjunct analgesics, reportedly experienced an opioid overdose; an LPN found the resident unresponsive, located an existing Narcan order, administered Narcan, and observed the resident return to baseline, but did not complete or document a change-in-condition assessment, vital signs, or the Narcan administration in the medical record.
Surveyors substantiated a deficiency when disinfectant wipes, labeled for storage in areas inaccessible to children and not for personal cleansing, were observed sitting openly on a wire shelf in the dining room of a locked dementia unit while cognitively impaired residents waited for breakfast. A GNA and an LPN present on the unit stated that staff used the wipes to clean tables and that residents were never left alone in the dining room and had not been seen using the wipes. The ICP reported being unaware that the wipes’ placement in the dining room was a concern, and the NHA and DON stated they had not previously been informed about the issue, though the DON acknowledged understanding the concern.
A resident’s medical record showed multiple instances where Hydromorphone, a controlled narcotic, was documented as signed out and given on the Controlled Drug Administration Record but was not documented on the MAR on the same dates and times. An LPN reported signing only the narcotic sheet and not the MAR, while the DON acknowledged awareness that nurses were signing the narcotic sheet without completing the MAR, and a unit manager stated they were unaware this was occurring and that both records should be completed. The NHA and DON agreed with the surveyor’s findings after the issue was identified.
Failure to Ensure Visitation Rights During Elevator Outage
Penalty
Summary
Facility staff failed to ensure that residents residing on the 2nd floor who could not safely ambulate using stairs were able to exercise their right to have visitors when the facility’s only elevator malfunctioned. Complaint reviews showed that family members were unable to visit their relatives on the 2nd floor when the elevator was inoperative, and these family members themselves were unable to use the stairs. An incident report documented that the facility’s only elevator was malfunctioning for an extended period, from 3/28/26 to 4/23/26. During this time, residents who could not use the stairs remained on the 2nd floor, and some of their family members could not access them due to the lack of elevator service. Review of the facility’s emergency plan revealed that it instructed that 2nd floor residents who could not safely use the stairs should remain on the 2nd floor unless there was an emergency, and it did not include any provisions for maintaining visitation when the elevator was inoperable. In an interview, the Administrator stated that visitors could use the stairs to visit 2nd floor residents and that residents could be transported using an emergency chair system to meet visitors who could not use the stairs. However, the Administrator acknowledged that the emergency chair system was not used for visitation purposes during the elevator outage and reported being unaware of any complaints about the inoperative elevator, despite two complaints having been received by OHCQ. No additional documentation was provided to show a plan to support visitation for 2nd floor residents during the elevator malfunction.
Failure to Complete Required Quarterly Smoking Safety Assessments
Penalty
Summary
Facility staff failed to update smoking safety assessments at least once every three months for multiple residents identified as smokers. During a complaint survey focused on smoking safety, surveyors reviewed an incident involving the facility’s only elevator being inoperative for nearly a month, which affected residents who lived on the 2nd floor and needed to access the 1st-floor smoking area. The facility’s investigation identified a group of 10 residents on the 2nd floor who smoked and required additional accommodations to safely ambulate to the designated smoking area. Review of these residents’ medical records showed that 5 of the 10 did not receive quarterly smoking safety assessments as required by the facility’s practice. Specifically, four residents had not received a smoking assessment since May 2025, and one resident had no documented smoking assessment at any time during their stay. During interviews, the Unit Manager stated that residents identified as smokers are to be assessed quarterly for smoking safety. When the surveyor pointed out the missing assessments, the DON reviewed the records and confirmed that these residents had not received the required quarterly smoking assessments. This lack of timely reassessment occurred in the context of an extended elevator outage that necessitated special consideration for safe smoking access for residents residing on the 2nd floor.
Inaccurate MDS Coding for Pain Management, Falls, and High-Risk Drug Classes
Penalty
Summary
Facility staff failed to ensure that Minimum Data Set (MDS) assessments were accurately coded for multiple residents, based on medical record review and staff interviews. For one resident with cerebrovascular disease, an MDS with an Assessment Reference Date (ARD) of 3/2/26 coded Section J0100A (scheduled pain management) as "yes," but the March Medication Administration Record (MAR) did not show daily pain medication administration. An LPN stated she coded it that way because the resident received Aspirin 81 mg daily, although the physician’s order showed the Aspirin was prescribed as prophylaxis for cardiovascular events, and the RAI Manual specifies that medications not primarily intended for pain relief should not be coded as pain management. Another resident with cerebral infarction, congestive heart failure, and vascular dementia had two documented falls in progress notes between the prior assessment and the ARD of 2/4/26, but Section J1900 (number of falls since admission or prior assessment) captured only one fall. The same MDS coded Section J0100A (scheduled pain management) as "no" despite the February MAR documenting daily use of Diclofenac topical gel for pain. The MAR also showed daily Aspirin 81 mg for coronary artery disease, but Section N0415 (high-risk drug classes) did not capture the use of an antiplatelet medication. The responsible LPN confirmed missing the second fall and the Aspirin coding error. Additional residents had similar discrepancies: one resident’s MDS repeatedly coded use of hypnotic medications in Section N0415 when MARs showed no hypnotics administered, and failed to capture an antidepressant (Sertraline) that was given; the LPN reported coding Clonazepam as a hypnotic based on dual use, though reference guidelines did not classify it as such. Further inaccuracies were identified for other residents in pain management and high-risk drug class coding. One resident’s MDS with an ARD of 1/8/26 coded receipt of PRN pain medication in Section J0100A, but the January MAR showed no PRN pain medications given; a later MDS for the same resident coded use of an antianxiety medication in Section N0415, while the April MAR showed no such medication administered. Another resident with traumatic subarachnoid hemorrhage, type 2 diabetes with neuropathy, atrial fibrillation, and atherosclerotic heart disease had an MDS with an ARD of 2/3/26 that coded scheduled pain medication as "yes" and PRN pain medication as "no," although the MAR showed intermittent PRN Tylenol for pain and no daily pain medication, and also documented daily Aspirin 81 mg for heart failure and daily Rybelus for diabetes; the MDS failed to capture PRN pain use, incorrectly coded daily pain medication, and did not code hypoglycemic medication in Section N0415. Another resident with a history of stroke and right-sided hemiplegia/hemiparesis had two MDS assessments in February coded as receiving scheduled pain medication, but the February MAR did not show daily pain medication; the LPN reported coding based on daily prophylactic Aspirin 81 mg, which was not ordered for pain.
Incomplete Investigations of Resident Abuse Allegations
Penalty
Summary
Facility staff failed to complete thorough investigations of two separate resident allegations that were reported to the state agency. For the first incident, a resident alleged that on a specific date and time an employee poked two fingers into their face and showed them their middle finger. The five-day follow-up documented the allegation, but the investigation file did not clearly identify who was the first point of contact for the report. During interview, the Administrator stated that a corporate representative was initially made aware of the alleged incident, but there was no statement from this corporate representative included in the investigation file. The Administrator described their usual investigation process as interviewing involved parties, identifying and interviewing witnesses, reviewing staffing for the date of the alleged incident, and interviewing the resident’s roommate and other nearby residents if there were no direct witnesses. In the second incident, a resident reported that during a specific shift someone wearing blue put a hand by their face and over their mouth, and a particular GNA was identified as the alleged perpetrator. Review of the staffing sheet for the time of the alleged incident showed that two GNAs were working on the unit where the incident was reported to have occurred. However, the investigation file contained no statements or interviews from these two GNAs. Prior to the surveyor’s review of the investigation, the DON and a regional nurse were given the opportunity to review the investigation to ensure all necessary documents were available, yet the statements from the two GNAs remained absent. These omissions demonstrated that the facility did not conduct complete investigations into the reported allegations.
Failure to Develop Person-Centered Care Plans for Mobility and Peritoneal Dialysis Needs
Penalty
Summary
Facility staff failed to develop and implement person-centered care plans that addressed all identified needs for two residents, one with mobility limitations and one receiving peritoneal dialysis. For the resident with mobility limitations, the care plan included interventions for resistance to care and adjustment issues, but did not address the resident’s specific resistance to use of a Hoyer lift and the resident’s insistence on pivot transfers from bed to wheelchair. The Unit Manager confirmed that the resident was resistant to care, did not like the Hoyer lift, and preferred pivot transfers, but also stated that physical therapy had prohibited pivot transfers. Despite this known conflict between the resident’s preferences and therapy restrictions, the care plan lacked individualized interventions related to the resident’s resistance to the Hoyer lift and continued request for pivot transfers. For the resident receiving peritoneal dialysis, review of the electronic health record showed an order for peritoneal dialysis, but the resident’s care plans did not include a person-centered care plan specific to this treatment. The existing dialysis care plan did not specify the type of dialysis treatment being provided, did not document when the resident was scheduled to receive the treatment, and did not include time frames for the dialysis cycles. During an interview, the LPN Unit Manager stated that they do not place the dialysis prescription details into the care plan and instead use a generalized renal care plan by selecting standard items, confirming that the care plan was not individualized to the resident’s ordered peritoneal dialysis regimen.
Failure to Document Resident Showers and Refusals
Penalty
Summary
Facility staff failed to maintain complete and accurate documentation of bathing care for a resident, specifically regarding showers and refusals of showers. During a complaint survey, the surveyor requested verification that Resident #5 was receiving scheduled showers. The DON stated that the resident was scheduled for showers on the 3 pm–11 pm shift on Tuesdays and Fridays, and provided shower sheets for several dates in October and early November. However, there was no documentation to verify that the resident received a shower or bed bath on 10/17/25, 10/21/25, and 10/24/25. The DON explained that when a resident receives a shower it is documented on a skin sheet, and that refusals of showers should be documented both in the plan of care and on the shower sheet. Despite this, the surveyor did not receive any documentation indicating that the resident either received bathing care or refused showers on the missing dates. This lack of documentation showed that the facility did not safeguard resident-identifiable information and maintain medical records in accordance with accepted professional standards, as there was no record confirming whether the resident’s scheduled showers or refusals occurred on the identified dates.
Failure to Notify Responsible Party After Narcan Administration for Suspected Opioid Overdose
Penalty
Summary
The deficiency involves the facility’s failure to notify a resident’s responsible party when there was a significant change in the resident’s medical status requiring emergency medication. A complaint alleged that there was no communication with the responsible party when Narcan (naloxone) was administered to a resident for an alleged opioid overdose. Medical record review showed the resident was admitted in March 2026 with multiple fractures, including a nondisplaced zone 1 sacral fracture, a nondisplaced fracture of the posterior column of the right acetabulum, a fracture of the right pubis, and other chronic pain. The resident’s pain regimen included multiple opioids and other pain medications, including Hydromorphone 6 mg every 4 hours PRN, Hydromorphone 4 mg every 4 hours PRN, Tylenol, Lidocaine cream, Methocarbamol, Celebrex, and Gabapentin. A physician’s note dated 4/8/26 documented that the resident reportedly had an opioid overdose earlier that morning and responded well to Narcan administration by nursing, with the note listing chronic pain and opioid overdose status post Narcan. Further review of the resident’s medical record did not show any documentation that the resident’s representative was notified of this overdose event and Narcan administration. During interviews, an agency LPN stated that the resident was “out of it and not responding” during rounds, prompting the LPN to check for and then administer Narcan, after which the resident responded. Another LPN reported that Narcan was given because the resident appeared to be having an overdose and that the physician saw the resident afterward, but stated, “I don’t think anyone was notified, but should have been.” The DON also stated that she would have expected the responsible party to be notified. These findings confirmed that the facility failed to notify the resident’s responsible party of a significant change in condition and emergency treatment.
Failure to Follow Wound Care Orders and Document Narcan Administration
Penalty
Summary
Facility staff failed to provide treatment and care in accordance with professional standards and physician orders for two residents. For one resident admitted after hospitalization with acute systolic heart failure and peripheral edema, a wound physician initially ordered daily oil emulsion dressings for venous wounds on the right shin, left medial foot, and left second toe. At a follow-up assessment, the wound physician changed the treatment for the left medial foot from oil emulsion to daily skin prep and ordered daily skin prep for a newly identified arterial wound on the left plantar foot. Review of the March 2026 medication and treatment administration records showed staff did not discontinue the oil emulsion or initiate the ordered skin prep to the left medial foot, and did not administer skin prep to the left plantar foot wound from the date of the new orders until the resident was sent to the hospital. The DON confirmed that treatments were not administered per the updated wound care orders during this period. For another resident admitted with multiple pelvic and sacral fractures and chronic pain, the record showed extensive opioid and adjunct pain medication orders, and a physician note documented that the resident reportedly experienced an opioid overdose and responded well to Narcan administration by nursing. However, the medical record contained no nursing assessment of the resident at the time of the event, no documentation of the resident’s condition or vital signs, and no record of Narcan administration or the resident’s response afterward. An agency LPN reported finding the resident unresponsive or "out of it" during rounds, knowing the resident was on significant pain medications, and, after checking for an existing order, administering Narcan, after which the resident returned to baseline. The LPN acknowledged not completing or documenting a change-in-condition assessment, and both the DON and unit manager stated they would have expected an assessment and vital signs to be documented in this situation.
Disinfectant Wipes Left Accessible in Dementia Unit Dining Room
Penalty
Summary
The deficiency involves the facility’s failure to keep the environment free from accident hazards on one locked dementia unit. During a complaint survey regarding unsecured cleaning supplies and the potential for residents to use cleaning wipes for personal use, a surveyor observed disinfectant wipes stored openly on a wire shelf in the dining room of the Seagull Unit, a locked dementia unit. The product labeling on the container directed that it be stored in areas inaccessible to children and specifically stated it was not to be used as a diaper wipe or for personal cleansing and that it was not a baby wipe. At the time of the observation, residents with cognitive impairment were present in the dining room awaiting breakfast. A GNA was in the dining room with the residents during the observation, and the unit manager, an LPN, accompanied the surveyor. The surveyor expressed concern about the wipes being accessible in a public area where cognitively impaired residents were present. The LPN reported she had never seen residents use or attempt to use the wipes and stated staff used them to wipe down tables before and after meals. The GNA stated she was always present when residents were in the dining room, that residents were never left alone there, and that she had never seen a resident use a wipe. The Infection Control Nurse stated she was not aware the disinfectant wipes in the dining room were a concern because no residents had gone near them and confirmed they were intended for staff use to clean tables. The NHA and DON reported they had not been made aware of the concern with the wipes, though the DON stated she understood the concern.
Incomplete Documentation of Narcotic Administration on MAR
Penalty
Summary
The deficiency involves the facility’s failure to maintain complete and accurate medical records in accordance with accepted professional standards for one resident. Review of the resident’s April 2026 Medication Administration Record (MAR) and the Controlled Drug Administration Record showed multiple discrepancies for Hydromorphone, a narcotic medication. On several specific dates in April, the Controlled Drug Administration Record documented that Hydromorphone doses were signed out and given by licensed nursing staff at various times, but the corresponding MAR entries for those same dates and times were left blank, indicating no documentation of administration on the MAR. During interviews, an LPN stated that they sign out the medication on the narcotic sheet but do not document it on the MAR. The DON acknowledged awareness that nurses were signing off on the narcotic sheet but not on the MAR, and a unit manager reported not being aware that nurses were failing to sign the MAR when also signing the narcotic sheet, stating that documentation should occur on both records. The NHA and DON later stated they were not aware of the concern until it was identified by the surveyor and agreed with the findings. These observations and interviews demonstrate that the facility did not ensure that all medication administrations were consistently and accurately documented on the MAR for this resident.
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